Glass Ionomers in Contemporary Restorative Dentistry — A Clinical Update Edmond R. Hewlett, DDS, and Graham J. Mount, BDS, DDSe Apstract Glass ionomers are applicable to many restorative situations, both as stand-alone restoratives and in conjunction with composite resins. This article reviews the clin- cally relevant properties of glass ionomers, the differences between them and com- posite resins, and heir clinical applications. An understanding of these concepts is essential forthe optimal incorporation of these materials into common restorative procedures he glass-ionomer family of restorative materials has evolved during the past 30 years into a diverse group of products that includes ai- rect restoratives, luting agents, liners, and bases, as well as pit and fissure sealants, all available in both the con- ventional and resin-modified varieties (Table 1). Such a broad array of choices may pose a dilemma to the clinician with respect to selecting and utilizing these materials over their composite resin-based counterparts. Glass ionomers differ from composite resins on several fundamental levels, includ ing composition (water-based vs. resin- based), setting reaction (acid-base reac- tion vs. resin polymerization), and na- ‘ture of the tooth/restoration interface (chemical adhesion and ion exchange vs. micromechanical attachment to acid-demineralized enamel and dentin) These and other attributes of glass ionomers render them applicable to many restorative situations, both as stand-alone restoratives and in con- junetion with composite resins. This ar- ticle reviews the clinically relevant properties of glass ionomers, the afore- mentioned differences between them and composite resins, and thelr clinical applications, An understanding of these concepts is essential for the opti mal incorporation of these materials Into common restorative procedures, GL ternminovocy The use of the term “cement” in ret- erence to glass ionomers can be confus- ing. “Cement” as it applies to restora- tive dentistry typically connotes a lut- ing agent, ie,, an intermediary material that serves to bind two objects togeth- er. The term has also been used in ref erence to liners and bases, temporary restoratives, and certain permanent di- rect restoratives (silicate and glass- ionomer).”* A general definition ex- plains this multiple usage, describing cement as “any substance which sets to ‘a hard mass on being mixed with water or other medium." glass ionomer is thus appropriately referred to as a den: tal cement in the traditional sense and, like other cements, falls into several categories of clinical use. It is, however, the only dental cement currently repre- sented in the permanent direct restora- tive category of available materials. The term “cement” is nonetheless not al ‘ways necessary in common usage. ‘Author / Edmond R Hewett, DDS, i an associate professor and vice chatr of the Division of Restorative Dentistry at the University of California a Lo Ange ‘Graham J. Mount, BDS, DDS, is tn general ental practice ans 3 sng research fellow at the Unversity of Adelaide, Aust JUNE.2003.V0L.81.N0.6,CDA.JOURNAL 4830 Representative Samptinc oF Giass-ionomer Propucts Material ype Conventional glass ionomers Resin-modified glass ionomers Laing agent Fut Fu Ps! GlassionomerCV-Pus? Fu cam* Ketac-Cem? fey Luting Cement? Restoravecore bulldup Fy! Fulluc! Glssinomer Cement Type IF Fu ILC Cre! Ketac Aca P Viremer Coe BulduprRestratve* Lnerase lassionomer Lining ement® uj Lining LC’ Glassonomer Base Cament® —_Vitebond? Ling Cement? Keta- Bond Sivelss-onomer Ketac-Siver? carmel restorative ‘Sivergiass-onomer Miracle Mic actu esorative igh viscosity Ful I GPF x GP Fast! restorative Ketac- Molar lca? ‘isu sealant Fu Triage! Foot canal sealer Ketac Endo Apicap? ‘Composite bonding agent Fj Bond “camera a ase Conventionat Giass ionomers ‘The first glass-ionomer material \was introduced by Wilson and Kent in 1972 as a “new translucent dental fill: ing material” recommended for the restoration of cervical lesions.’ This original formulation was the product of efforts to develop a replacement for silicate cements, which had been used for decades in cervical restorations. The components of a glass ionomer are a powdered fluoroaluminosil slass similar to the one used cements and a polyalkenoic acid. The latter component is a complex poly- 4484. CDA.JOURNAL.VoL.31.NO.6.JUNE.2003 ‘meric blend of (primarily) acrylic, ita- conic, and maleic acids chosen for their ability to form a cement when mixed with glass and effect ion-ex- change adhesion to tooth structure.* Depending on the product, the liquid component does not necessarily con- tain all of the acid. Polyacrylic acid is often incorporated into the powder in its dehydrated form, leaving the lig- uid to consist of water or an aqueous solution of tartaric acid. These vari- ous composition characteristics are re- flected in the more accurate and sci- ‘entific term for glass lonomers, name- ly “glass-polyalkenoate cements.” Mixing of the glass-ionomer pow= der and liquid generates an acid-base setting reaction (Figures 1 and 2) com- ‘mencing with partial dissolution of the surface of the glass particles by the acid. Positive ions (Ca®* and AI) re- leased into solution act to crosslink the acid polymer chains, forming an in- creasingly rigid matrix as the crosslinked network becomes tighter and more complex. Fluoride ion (F) Is, also released from the glass particles, becoming available for both uptake by adjacent tooth structure and release from the matrix into saliva, Fluoride neither plays a role in the glass- ionomer setting reaction nor Is it in- corporated into the matrix structure. Glass ionomer Is thus not weakened significantly by fluoride release. Limitations Since the Introduction of glass ionomers, numerous modifications have been made to the liquid and powder components to improve the handling and physical properties of the set material. As with all restorative materials, there are strict rules for the clinical handling and placement of glass ionomers. The powder-to-liquid ratio is specific for each application, and mixing techniques are demand: ing. Consequently, the use of capsu: lated materials is strongly recom: mended to guarantee routine success. The setting reaction is not unlike amalgam in that there is an initial “snap” set within three minutes for all glass-ionomers, but the chemical reac- tion continues thereafter for a pro- longed period. There is a tendency in the earliest stages for the material to take up additional water, but later the main risk becomes water loss leading to dehydration and cracking.Figure 4. Thcoretical diagram ofthe inital acid-base reaction between thelas power and polyac igua components of pas fonomers. Note attacked by ac, relessing Ca, AL and $nded Martin Dunit Publishers, London, 200 Foas (Repeated with peaniston from A Early sorption swelling (hygroscopic expansion) of the immature material and dissolu tion of reactive components, while dehydration allows loss of some of the water critical for continuation of the setting reaction. Both situations result in distuption of the setting reaction and resultant nonmature cement with ing, cracking, and loss of translucen- be prevented by sealing the restora- unacceptable properties such as These untoward occurrences can tion surface immediately afte ing the matrix to maintain the water balance using a light-polymerized un- filled resin enamel bonds The problem of water balance maintenance was most pronounced with the original glass-ionomer restorative materials but has been largely overcome in recent times, In fact, for the modern high-viscosity au. tocure materials, loss of water through dehydration is the greatest problem; and its prevention in the oral envi eta condensed {ng the paral iso mate leit wth ronment is not difficult. It Is never theless recommended that final pol ishing of glass-ionomer restorations be delayed for about 24 hours to allow further maturation of the material Other properties such as compressive and flexural strength and fracture toughness will limit glass-ionomer use as a restorative material to areas not subject to occlusal stress unless well: supported by surrounding tooth struc ture, Wear resistance improves markedly as the restoration matures, and clinical results suggest that wear isnot a problem? Advantages In spite of their limitations, glass- lonomer restoratives possess several compelling characteristics that merit their inclusion in the adhesive restora: tive armamentarlum, Ton Exchange It must be noted that ion migra tion within or through any material Figure 2. \ fay stand mata GLA can only occur in the presence of water. Since glass ionomer is water based, it is not surprising that numer- us studies have reported continuing release of fluoride from set glass ionomer over prolonged periods;!™ and higher levels of fluoride release from glass lonomers as compared to other fluoride-containing restorative Additionally, uptake of fluoride by enamel and dentin walls adjacent to glass-ionomer restorations has been demonstrated in both in vitro and in vivo!” studies. The high levels of fluoride release observed in the days immediately following restoration placement reflect release of fluoride from the exposed glass particles at the ‘outer surface of the restoration. Initial fluoride release levels also likely re- flect dissolution of small amounts of the material mass from the surface during the minimally mature stage when solubility of the material is highest. Furthermore, a recent studyFigure 3. 4 theorticaldagram showing ion exchange adhesion be id tooth structure. Polya chain penetrate enamel Figure 4. Detail ofa gaseionomer restoration placed in vio showing then exchange ayer between enamel al dentin and dentin surfaces dloplacng phorpate al calcu sons,atimately ro- Weed to remove the smear yer The lonenchange leer more ard fe dicing an on-enriched layer atthe passdonomer/ooth nkerace (Reprinted _Setanttan both the glass onomer andthe enamel Onignal magnification ‘sith permission from sn Aas of mer Cents: Claas Gude, _0}000x Repentd with person fom An rtm also implicates early permeability of some glass ionomers as an explana: tion for high initial fluoride levels Resin-modified glass ionomers exhib: ited significantly higher levels of ini tial fluoride release than their less per meable conventional counterparts Fluoride release levels drop after the first week and stabilize after two to three months, with continued release at these lower levels for many years.” This phenomenon reflects slow fluo- ride release from the glass particles and slower diffusion of released fluo- ride from deeper areas of the matrix. It is generally accepted that both the short- and long-term levels of fluoride release are nonetheless adequate to in. hibit demineralization in adjacent tooth structure!7.20252: and to in crease the fluoride concentration in saliva.*™” Fluoride release levels have also been shown to temporarily rise following exposure of glass-ionomer restorations to topical fluoride prepa: rations?!°2 suggesting a “recharge able” quality to the fluoride release \ Cnn ud and giving further credence to the no: tion of glass ionomer's inherent anti cariogenic properties tioned higher permeability of resin- modified glass ionomers likely ac- counts for the higher recharge poten- tial of these materials as compared with the conventional types.” There is gathering evidence that caries inhibition by glass ionomers not only is a question of fluoride re lease but also involves a continuing ion exchange among the restoration, the surrounding tooth structure, and the saliva. It has been shown that the steady improvement in wear resis. The aforemen. tance results from movement of fluo. ride ions out of the restoration surface followed by the uptake of calcium and phosphate ions from the saliva to maintain the electrolytic balance in the restoration. There is further e dence of the transfer of calcium, phos. phate, and strontium ions ftom the glass-lonomer restoration deep into demineralized dentin and surround: Ing enamel.” This remineralization capability renders ticularly useful as a long-term prov sional restoration in the presence of high-carles risk inasmuch as it will help to heal damaged tooth structure. These properties of glass ionomers give rise to a variety of clinical indica: tions not enjoyed by other restorative materials. Of course, no material can be regarded as a prevention or cure for caries. Once the etiologic factors for caries have been eliminated or con- trolled glass ionomer is most valuable in assisting the healing of remaining tooth structure that has been demineralized and damaged. however, Adhesion to Too! Unlike adhesive resins, which bond micromechanically to partially demineralized enamel and dentin. glass ionomers bond chemically to mineralized tooth structure through exchange mec! (Figures 3 and 4). The cavity surface must first be conditioned by applying a 10 percent solution of polyacrylic StructureFigure &. Scanning dectron micrograph showing dentin condi ue min dct he ce ety cle. Sean magni acid for 10 seconds. A thorough wash of the cavity with air/water spray then removes the smear layer and enhances the wettability of the cavity surface." 5 In contrast to the aggressive dem. Ineralization produced with phos. phoric acid, the action of this milder conditioning Is largely limited to smear layer removal’ (Figures 5 and 6). Mineral content of the underlying tooth surface will remain relatively in- tact, and there will be a more consis- tent and predictable substrate for ponding. Following conditioning and rinsing, cavity surfaces should be dried but not dessicated.s Insofar as a mineralized tooth substrate is essen: tial for chemical bonding with glass ionomers, and as these cements are unable to infiltrate and “hybridize” the exposed collagen fibers of acid: etched dentin, conditioning with phosphoric acid prior to glass ionomer placement is strictly con. traindicated, Ion exchange adhesion between tooth structure and the restoration de- ced Figure 6. velops because, in the presence of the polyalkenoic acid in the freshly mixed cement, ions are released from both the glass particles (calcium and alu- minum) and the tooth structure (cal- clum and phosphate). These released Ions serve to buffer the acid, effect the Initiation of setting, and produce an lon-enriched interfacial layer firmly attached to both the restoration and the tooth, Once the material has ma: tured, any failure will be cohesive within the glass ionomer (the weaker material), leaving behind the ion-en- riched layer bonded to the dentin and enamel at the restoration/tooth inter face. One Investigator has reported findings suggesting some degree of chemical adhesion to the collagen fibers.** If the glass ionomer is proper ly placed, microleakage between the restoration and the cavity walls will This in turn ensures ab- sence of post-insertion sensitivity when glass ionomer is used as a base under composite resin.*°** be decreased. Glass-ionomer restoratives under- GLA Figute The cavty hasbeen etched with 37 percent orhophosphoie aid ation of the callagen rendering go a small setting shrinkage; but, pro- viding the water balance is main: tained, the slow progression of the setting reaction combined with wate uptake from the oral environment will counteract the volumetric change and minimize shrinkage-induced stresses at the restoration/tooth inter face."? They also exhibit a low coeffi cient of thermal expansion that is similar to that of tooth structure Resin-Mopirieo Giass lonomers Historically, the first significant modification to glass ionomers came through the addition of small quanti ties of light-polymerizable resin ‘groups. This has proven to be a suc- cessful strategy for simplifying the water balance maintenance while pre- serving favorable characteristics and improving physical properties and translucency of glass ionomer. The re- sultant materials have been identified by several terms, including “resin but ionomers” and “hybrid ionomers,Figure 7. 4 thcortcal diagram showing the intuence ofthe resin ina resinmodiied lst ionomers. Th sins re lightactivaed to penetration Figure 8. rg o:he ton som in ge Chemin lepth ofthe curing light, providing protection forthe ongoing acid-base c= __polymeriaton. Resin polymerization sow complete and the steers action from immediate water upake/oss Hed chains tepresen aly poy _‘{acdtase) eomponent has matured tothe se Scie a that of coonea nerd ens to the depeh of penetration of the curing light (preted tional gas onomers (Figure 2) (Repented with permission frm An Aa of resin-modified glass ionomer ‘commonly used to differentiate these materials from those that set solely by acid-base reaction, tional autocure glass ionomers, “Resin-modified” specifically refers to the addition of polymerizable resin groups (usually 2-hydroxyethyl- methacrylate, or HEMA) by grafting them to molecules of the acidic liquid component. The result is a complex liquid that maintains acid reactivity independent of the newly acquired ability to be light polymerized. It is important to recognize that the tradi- tional acid/base setting reaction of the autocure glass ionomer is still present and will continue as normal." Only about S percent of the mixed cement will be resin, and when polymerized it will impart strength as well as protec: is most tion to the ongoing acid-base reaction from dehydration and water sorption (Figures 7 and 8). Resin-modified glass ionomers are thus occasionally referred to as “dual-cure to these two distinct setting modes. Some manufacturers additionally in- clude a chemic HEMA that, along with the usual pho- toinitiated and acid-base reactions, ‘tricure” terminology in reference 1 initiator for gives rise to the (Figure 8) Originally marketed in the form of cavity liners, resin-modified glass- omer product lines expanded to include restoratives and luting agents. All of these materials retain the most desirable qualities of conventional versions, namely fluoride release,*! fon exchange adhesion to conditioned enamel and dentin,** and low interfa- hance- ments over conventional types, partic ularly in the case of restoratives, in- clude significantly improved resis- tance to microleakge,** on-command hardening and immediate finishing as with composite resins,224° improved ‘mechanical properties and translucen- cial shrinkage stress." The ¢ cy," and reduced water sensitivity.** Despite the transient resistance to water movement in and out of the restoration, post-finishing sealing of a resin-modified glass-ionomer restora tion with light-polymerized unfilled resin is recommended to protect acid- base reactive components at the restoration’s outer surface.24® Recent studies additionally suggest that de- layed finishing/polishing of these ma- terials may improve resistance to mi- croleakage.* Hich-Viscosity Avtocure Giass ionomers Other attempts at improvin glass-ionomer properties have in. volved metal reinforcement (additic am alloy powder) as well ng of silver particles to the glass component to form a cermet (ceramic-metal). Data on improve ments in physical properties! and clinical perfor of am 58 however, is,equivocal; while other reports suggest diminished caries resistance com- pared to conventional glass ionomer restoratives.545° More recently, high-viscosity, high-strength versions of convention- al autocure glass-ionomer restoratives have been introduced, Originally aimed at remote or underdeveloped regions lacking access to dental care,** these materials also have many applications in the traditional restora- tive setting. Improved physical prop- erties result from chemical modifica- tions and alterations to the heat his- tory of the glass powder that allow higher powder-liquid ratios than ear- lier conventional restoratives. Characteristics include the adhesion and ion exchange common to all glass fonomers as well as fast setting times, and high levels of compressive and tensile strength, surface hard- ness, and fluoride release.*? These at- ” tuibutes render these materials an ex- cellent choice for bases, emergency temporary restorations, long-term provisional restorations, and final restorations in nonstress-bearing areas, particularly in high-caries-risk patients.***? Contouring and finish- ng can begin five minutes after placement, using water spray to pre vent dehydration, followed by surface sealing with resin to protect the con- tinuing acid-base reaction. Potyacip-Mopirieo Composite Resins (Compomers) *Compomers,” originally intro- duced in Europe, have been available since 1993. The term "compomer” is an acronym derived from “composite” and “glass-ionomer,” and it reflects the intent to produce a restorative that combines components and prop- erties of both materials. Specifically, compomers purportedly possess the esthetic attributes of composite resins along with the fluoride-release advan- tage of glass ionomers. Unlike true glass ionomers, however, compomers are resin-based materials containing nno water; and the setting/polymeriza- tion of compomer restoratives in- volves neither mixing nor an acid- ¢ < FLUORIDE™I a LUORIDERELGASE, _ ADVANTAGE OF Gass ionomers. — - li base reaction, Compomers ate in fact light-polymerized composite resin restoratives, modified to contain ion- leachable glass particles and anhy- drous (freeze-dried) polyalkenoic acid. The term “polyacid-modified composite resins” was thus proposed by MeLean and colleagues"! and is ‘used commonly in the scientific liter- ature to distinguish these materials from glass ionomers. In the absence of water, the com- GL pomer composition prevents the aforementioned glass particles and anhydrous acid from reacting.® Eventual water uptake in the oral en- vironment, however, initiates an acid- base reaction between these compo- nents with resultant diffusion of low levels of fluoride ion from the restora- tion." Numerous in vitro studies have shown these fluoride release levels to be significantly lower than those mea- sured for conventional and resin. modified glass-lonomers.®® One re- cent study,* however, demonstrated equivalent rates of fluoride release for compomers and glass lonomers after three years. This finding, though, does not take into account the higher fluoride recharge/re-release capacity of glass ionomers compared with compomers.2!2 The resin bonding agents required for compomer-tooth adhesion act as barriers to fluoride uptake from compomers into cavity walls and margins. Mechanical properties of com- pomers tend to be somewhat inferior to those of conventional composite resins, thus limiting their use to areas Subjected to low stresses.*2*7.6* Specifically, compomers (and microfill composite resins) are often recom- mended for restoration of noncarious cervical lesions as their flexibility (cela tive to hybrid composite resins) pre- sumably renders them more resistant to detachment during tooth flexure.” Ctinicat Arrtications FoR Giass-ionomer Restoratives Resin-modified and highly viscous versions of glass-ionomer restorative ‘materials can be used alone or in com- bination with composite resins to ef- fectively treat many common restor tive situations. JUNE 2003.VOL.31.NO.6.CDA.JOURNAL 489ty replaced touring te cavity (Adapted from Feat, Sandwich Technique The term “sandwich technique"™ refers to a laminated restoration using glass lonomer to replace dentin and composite resin to replace enamel. This strategy combines the most fa- vorable attributes of the two materi als, Le,, caries resistance,"72°2S chemi cal adhesion to dentin,** fluoride re- lease* and remineralization, * and lower interfacial shrinkage stress!” of glass ionomer with the enamel bonding, surface finish, durability, and esthetic superiority of composite resin. Additionally, composite resin bonds micromechanically to set glass ionomers and chemically to the HEMA in resin-modified versions. Either resin-modified or highly vis- ccous glass ionomers may be used, de- pending upon anticipated mechanical sttesses and esthetic considerations. The sandwich technique is applic able to Class I lesions in particular using either the “open” or “closed” variations (Figures 9 and 10). The 490. COA.JOUANAL.VOL.21.NO,6,JUNE.2008 Closed sandwich technique, Mising dentin ina Clas av ith ether esn-moded ox high-visconity glass onomer. ‘Compt ein used to replace enamels eal the enced margin sr Sande is lized in Clas cas lacing enamel athe cervical meg ‘glass lonemer wed pest ofthe protimal box i ie eomposteresn to stor the evil 6 puting optima esiance to micocalage and Seconda aves long dentin marge (Adapted from Fea" open sandwich ts specifically useful for deep Class I proximal box forms ‘where the cervical margin lacks enam- el. Numerous in vitro studies have re- ported improved resistance to mi roleakage and caries with this tech- nique as opposed to resin bonding at dentin margins." Additionally, re- placement of dentin in either the open or closed technique with glass ionomer minimizes the complexity of incremental build-up with composite resin, It will also eliminate acid etch- ing of dentin and thus has potential to reduce or eliminate postoperative sensitivity caused by incomplete seal- Ing of etched dentin. Class II and Class V Lesions Simple one-surface restorations that are not under occlusal load can be successfully restored with a glass ionomer alone, generally without lamination. The original autocure materials are very suitable, producing satisfactory esthetic results provided that water balance is maintained at insertion.7* * Fissure Sealing Long-term success with fissure sealing has been demonstrated using normal restorative glass ionomers. Proper conditioning prior to place- ment will ensure the ion exchange adhesion, and maturation over time allows acceptable longevity. The modern high-viscosity glass ionomers are now the preferred materials, and these can be placed under finger pres- sure to adapt the cement into the depths of the fissure 2° Root Caries Glass ionomer, given its afore- mentioned attributes, is clearly the material of choice for root caries restorations. In particular, excellent Ion exchange adhesion to dentin, caries inhibition, and simplified placement protocol as compared with ‘composite resin render glass ionomerideally suited to these situations. Relative esthetic limitations of glass jonomer tend to be inconsequential in root caries sites, and longevity of glass-ionomer restorations in these sites is excellent.® High Caries Risk High-viscosity glass-ionomer restoratives lend themselves well to short- and long-term management of patients at high risk for developing, caries. In addition to seating ability and lon exchange, these materials have abrasion resistance adequate for provisional restoration of occlusal and proximal surfaces. Frequent fluo- ride recharge of such restorations will likely occur via the topical fluoride regimens typically prescribed for such. patients, and calcium and phosphate ions are constantly available from the saliva. There is a glass ionomer de- signed as a lining for high-caries-risk patients that exhibits a very high flu- ride release, making It useful when demineralized dentin is to be left on the cavity floor. Emergency Temporary Restorations Fractured cusps/restorations can be quickly and predictably stabilized with glass ionomers pending defini- tive restoration. Adhesion properties of glass ionomer impart adequate re- tention even if mechanical undercuts, are absent. Coverage of exposed dentin and sharp margins to provide enduring patient comfort is accom- plished with minimal chair time. Summary Glass ionomers have evolved to become more user-friendly while re- taining unique characteristics applic~ able to many contemporary restora tive situations. An overview of glass ionomers is presented in an effort to acquaint the clinician with the mater- laY's attributes and utilization. HIN References / 1, Academy of Prosthodontics, ‘Glowary of prosihsnti terms, 70 ed] Paster Dent 81394110, 1988. "2 Jablonski 8, ablanskt's Dictionary of Dentin: Kreger, Malabar. Fs, 1992, pp 138 3, zwemer 1, Bowcher'’ Clinical Dental Taming, th ed! Mosbyear Book, St. Lows, 1008, ps0 “A! Harty Fl, Concise ttustrated Dental Dictionary, 2nd ed.” Wright/Butterworth- Heinemann Le, Oxford, 1998, 7. ‘Sr Wilon AD, Kent RE, A few translacent ce sment for dentistry The gossionomer cement. DDeaey 13212188", 1972 6. Mount G), An Atlas of Glass-ionomer mont Cnca’'s Guide, ed 8. Matin Dre ‘Vondon, 2002 7 Anusavice KJ, Dental cements for restora tion and pulp protection in Philips Science of Dental Materials, 10th ed. WB Saunders Co, Philadephia, 1996 ‘fa MSA, Mount GJ, Hume WR, The ef fect of varnishes and other surfee treatments fom water movement across the surface of & {lussionomer cement. Austra! Dene 1989, Sis3209. 9. Mount GJ, Longevity in glas-ionomer restorations: review of successful technigue (Guimessece nt 204 50,1097, 10. Wikon AD, Geen DM, Kubn AT, the release of horde and other chemical spect fom {glussslonomer cement. omateialy 6431-3, is, i. Swartz MC, Philips RW, Clark HE, Long team fluoride rls rom lasvionomer cements Dent Res 68:158-20, 1984, 12. Forsten L, Shor- and longterm fuoride telease from glas Jonomers and other thiorie containing fling mates in ito, Saal 7 Den Hes 9879.85, 1990. 13. Yap AU, Tham SY, eta, short-term Auc- rie flee fom various aesthetic restorative ma Aedals. Oper Dent 27 3.2808, 2002 1a, Assen f, Peutaedt A, Long-term Nvo- re release fom a glasslonomer cement, a com- Promer, and from experimental resin composites ‘etn Ort Ss 42)987, 2002 YS. Mulier U, Kitbasa AM, eta, void re lease rom lghtecurng restorative materials J Dnt 1346):30-4, 2008 ‘Hos Wesnberg , alls E The in vito sss Jonomer cement on deine and snare (ells J Oral Rehab 735-42 1980 17. Tsanidis V, Koulourides , An in vitro model for ssessment of fluoride uptake fom flassionomer cements by dentin and effet on SStvesttance,J Dent Res 71.712, 1992 16 Tatn LE, Cha GP, Yn; n vito caries in ison elles by conventional and ein sie fsstonemer stration. Oper Do 224-14, 1987, GL 19, StarvetL, Tet AB, a In v0 More tuptats in enamel and dentin from forge come inn mae /Dewt Chl 5797-10, 1990 126, Shimokobe H, Komatst Hy Matt J, ore content im humsn enamel ater removal ‘Of the applied cement. Dent Res 6oopectal fue) abet 96), 1982 21. Preston AJ, Agalamanyi EA, ct al The recharge of esthetic dental restorative tata tt lure itrotwo ear ress Dont Mater Toa, 2008 22. Mount G} and Bryant RY, Glssonomer materials in, Mount cf, Hume WR. eds, Pretevation and Restoration of Tooth Stracture ‘Mosby Intemational Ld, London, 1938. 2a Tor¥, Hota Te a Inoton of ant cia secondary caries rot by fase. sr trtve mata, Oper Det 241 3643, 2001 "A Donly Ki, Separa Aye Clink formance and caves nibiton of esin-modtfied ims-lonomer cement and amalgam restora: {ions jm Dent Aso 130.105 1859696, 19, "35. Donly n), Grandgenett C, Dentin dem. Inematation ttition at restoration margins of Vitremer, Dyract nd Compoglas, Am} Dent Tisy2ass, 995 Zo. Tereira PN, tnokosbi $, et al Microhardness of in vio cates Inhibition zone Adjacent to conventional and rst mode gs enone cements Dent Mater 14) 05585, 1538 27, Randall Re, Wilon NH, Glasyionomer restorative review of 4 econ cates {rete etek | Dt Rex 7228-9, 198. BE, Koch ©, Hatibovie-Kofman 5, Glass ‘onomer cements a8 a flurie release system ‘vo, Scand Dent Rs 1367-75, 1990 29, Hatab TN. el Mowafy OM eta, An in vivo atidy on the feleae of ode rom gla Tonomer cement. Quintessence ne 22221-4199, "fo. rorsten 1, Plunge release an uptake by stasclonomers Scand Dnt Res 982415, 191. "Hamar NOnen A, Flute fleas and up take tracert of aesthetic estorative mst Sh 7 na Reb 290) 7918, 2002. '32 tote 1, Ohstoto Metal, Release and recharge of uosde by restorative mates: Det ‘Nat 154)347-53, 1988, "ss, Nicholson JW, Ceamecka 8, Limanowska- Shaw i fet of gnsonomer and related dental ements on the pi of lactic aid storage soltions. Fates 21888, 199. 34" Ngo Hl, Maino V, Mount GJ, Caleiam, stronthin,suminum, sodium and rie lease from four las lonomers./ Det Res 77264 (Abst 33) 198, 3S, Mount G), Adhesion of eassionome iment inthe clinical envionment. Oper Dow 1: Tar, 1991 “Jo. Ngo Hf, Mount Gj, Peters MCRB, A study of plase-onomer cement and its interface Sl he enamel a deta wing ome ature, high-resolution scanning skecton mi Efoscope techmique. Quintessence In 28:63, 1097 “7. Powis DR ollerasT, tal. mprone a: beso oft glseionomer cement 0 dentin and (ShamcL T Dot Res 611416221982 "TR Hewett ER Caputo AA, Wrobel DC, Casetonomer bond stength and testment of TUNE.2003.¥0L.21.NO.6.CDA.JOURNAL 491dentin with potyacryllc acd. 1 Prosth Dent ‘(6960-72 1981 39. Akinmade A, Adhesion of glass. polyaltenoate cement to collagen, j Deat Res Special suc I81(Abt 633), 1994. “40. Chistemen O), Preventing postoperative tooth sensi in clas Land festortons ‘A Bent hoe 1332) 22931, 2002 “4 Mctean NW, Dentinal bonding agents ver sus slasstonomer cement. Quinteenet It 25: Sse 190, “42, e Gee A, Physical properties of las lonomer cement sting shitiage ard wea. Bavidson CL, Mor IA eds, Advances by Clas Tonomer Cenients. Quintessence Publishing, ing, 1999 45, Momot ¥, MeCabe JF, Fluoride release ftom lghrativated glasvsonomer restorative Ce sents Dent Mater 184,198, 44. Sato 5, Tosa 5, Hirota K,Characteasties of gla onomer cements In, Davidson CL. Mor Taveds, Advances in Glaselonomer Cettents ‘Quintessence Publishing Chicago 1999 "25. Marin PE O'Rourke M, Marginal seal of ‘cervical tooth-olowred restorations. & labora Investigation of placement techniques. usta! ae): 199% 46. Chuang fin YT, ea, tet of various surface protections onthe maran miroleakage of {esin-mosdiied glas-tonomer cements Postiet Dest 86.):308-1, 20 AZ Sap AU Yap Wy ot ate of Sinise Ang/polishing techniques om mlcroleskage of tesismedifedsassdoaomer cement restorations (Oper ent 280541, 2008 ‘48. Than Al, Morgan DL, Metal reinforced slaslonomers thet etal St bond strengths {oath substrate f Pst Dew S8137-a, 1988 39. Beyls HME" Verbeek RM Compressive strength of some polyatkenats With or without deatal amalgam soy Incompor. Mion, Bow Mater isi, 1998 ‘30. Keby RE, Blaholder RF, Physical prope ties of stalnlesssiel and siverseinforced sss Tonomer cements. / Den kes 7:1388-61, 1994 ‘SL Williams Ja bllington RW, Increase in compresie strength of gassfonomer cements ‘wi respect to time perade of 24 hours 10 four ‘Months Oral Real 181638, 1991 82. Kramer N, Franrberget R Cline per formance ofa condnsable meal-inkree Rls ‘onomer cement in primary molars. BP Dent 1317-91, 20 5 83. Yap AU, Teo JC, Teoh SH, Comparative wear resistance of reinforced glas-tonomer ‘stortive materials Oper Dent 264} 34-8, 200 54. Dionysopoulos f, Kotsanos N, etal Arif cates formation siound forge seas ing stration soot | Oral Roh 251) 2 198 55, ifeera M, Casto A, et al, Antbscteriah axtivity of glasonomerretosive cements ex posed to cavity-producing mlcrooganisas. Oper Dent 24(8)28631, 1999 = 56, Freeken JE, Pilot T, etal, Ateaumatic Restorative Treatnient (ARD} rationale, tecnigue and development. Pub Heath Dent $1351, aseusson tots, i930 S37. Yap AU, Pek ¥S, Chang P,Phystoxme: ‘chanical propenies of asset highly viscous IC festortive JO Reb 3) 18, 208, "8, Sales), Guo W, In vio cas inhib tion at the enamel margins of glasvonomer Festoatives developed forthe ART tecgue, 7 Bent 26348-56200. 19. HUY. 1 VO et al Restoration of teeth with moreiscousplasedonomer cements ol Ing adiaton-nduced care int Dene 820144 sient. “0. Mount GJ, Glasdonomers: Advantages, disadvantages, and farure implications in Davidson cl, Mor tA. eds, Admnce br las Tonumer Cements. Quistessence Publishing, Cheng, 1999. G1. MeLean JW, Nichokon JW, Wilson AD, ‘Proposed nomenclature fr ga-onomer dental ements and elated mates: Cuntesente Ia SS54739, 1958 62. Catan Lorente MA, Dupe Va CCompative sty oft pial propeies of olysclbmodiied compote rs and a esn. foaled glass-ionomer cement. Dent hater Tayataz ooo 13, Hevatjolu-Antoniaes M, Karantais P, tal, Fore release fom restorative materials Sd hting cement. 7 Poste Den 8615664, Soon 4, Yp HK, Sales Rh, Horie reas from a potyacdtmoied resin compote and resins Ino glas-ononner mater Chins Int 31201, 200, 15, Karantai P,Helvatjoglow Antoniades M, et a Faorde release fom thre las onomers 4 ompomer, anda composite rei in water ai ‘Gal alive, and late Sed Oper Den 25(1):205, S00 "6, Asmusen E, Peta A, Longterm fuo- tide release from a lassionomer cement. com ‘Pome, and from experimental rs compose ett tio cont 62) 93-7, 2008 67. Gladys 5, Van Meerbeck Bt al Comparative physconmecharal chatactezaton otra hpi rave metas wh Sonne tonal ghsstonomer and ean composite restr tive mater J Det fe ToUaySAE Ny, 1997 68. Meyer DM, CatantLorente MA, Dupuis V, Ccompormers: beeen gas-tonome cements and ompoates tomate 190/505-1998 "68. starr CB, Class V Restorations. In summict TB, Robbins JW. etal, eds, Fundamentals of Operative Dentistry Contemporary Approach, 2nded. Quintessence Publishing Chiago, 2001 70, Dail BS, Felis A tal, Viscotasc parameters of dental restorative materials during feting) Bent Res 793) 81823, 2000. i Hage MS, Lindemath J ea, tect ot four Intermediate ayer treatments on ncoleake sage of Class I compote restorations. Gen Dent SepOct49(9,489.9, 200 72: Loguercio AD, Alessandra B, et a ‘Mlcoleakage In clas I composite rsa reson tons: total bonding and open sandwich tech. igu, Adis tt pr 7044 2000 33. Wibowo 6, Stockion 1, Micoleahage of Class it composite restorations. am J Dent 1Gya77.83 201 4. Diewich, Losche AC, eal, Marginal adaptation of direct composite and sandwich Fesortions in Class I eats with cereal mar {ins i dentine, Dent Fe, 27 2119.28, 1999 er atom in: ] Beat 27(6)468-4, 1999), 78. Gladys 5, Van Meerbeck B, et al, ‘Microleaage of adhesive restorative mates. Am Dent 1431706, 2001 76. Mount Gi, Cina! performance of hss sonomers, Boma: 195739, 1998 77. Fett M, Use of glss ionomers as bond ings. nings, oF bases. in, Davidwon Cl Mjor 1, ‘ds, Adorn Glnfonanar Comes, Quinteenee Publishing Chicago, 1999 “To request a printed copy of this article, please ‘contact Edmond R Hetlete, DDS, UCLA Schoo! ‘of Dentistry, ex 331668, Las Angels, CA 0098.