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Cements and Adhesives in Orthodontics - An Update

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Biological and Biomedical Reports, 2012, 2(5), 342-347

Editorial

Cements and Adhesives in Orthodontics - An Update

Renuka L Pawar1, Yusuf A Ronad1, Chanamallappa R Ganiger1, Suresh K V2,*, Sandesh Phaphe1,
Pratap Mane1

1 Department of Orthodontics and Dentifacial Orthopaedics, School of Dental Sciences, Krishna

Institute of Medical Sciences, Deemed University, Karad, Satara, Maharashtra, India
2 Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of
Medical Sciences, Deemed University, Karad, Satara, Maharashtra, India

Corresponding authors*: dr.suri88@gmail.com

__________________________________________________________________________________

ABSTRACT materials offer improved physical properties and

Success of orthodontic treatment is greatly
dependent upon the adhesion or mechanical
bonding characteristics of the cements and
adhesives. In the recent years, the popularity of
resin and resin hybrid materials is increasing
because of their improved physical properties
and low solubility in oral fluids. Though the
newer cements, adhesive resins and hybrid
cement resin combinations offer improved
physical properties and clinical benefits, they
also have some short comings. Therefore a clear
understanding of the features, benefits and
limitations is required to choose materials
wisely and obtain optimal results. This review
article highlights the various cements and
adhesive materials used in orthodontics.
Keywords: adhesives; cements; orthodontics;
hybrid materials
Introduction
Cementation of orthodontic bands and
appliances has been in use for at least about a
hundred years and has a wide spread clinical
acceptance. In the recent years greater emphasis
have been given to patients comfort,
appearance, function and hygiene. Newer
orthodontic cements, adhesives and hybrid
clinical benefits. Selection of the right materials
requires a proper understanding of the chemical
properties and physical limitations. These
properties have been highlighted in the article.
Cements
Most dental cements are supplied as two
components, a powder and a liquid. The liquids
are acidic solution or proton donors and the
powders are basic in nature. The reaction
between the powders and liquids is essentially
an acid-base reaction. Upon setting, these
cements gain sufficient strength for use as a
base, permanent restoration or as luting agent. 1
Zinc Phosphate Cement
One of the oldest luting cement and has been
widely used for band cementation in the last
century. 2, 3 This cement is a reaction product of
zinc oxide powder and aqueous solution of
phosphoric acid. This cement show relatively
high compressive strength, convenient setting
time and easy removal of excess cement, thus
more preferable for routine cementation of
orthodontic bands. 4 They also have some
disadvantages like low tensile strength and high
solubility resulting in micro leakage and
demineralization. 5 They fail to bond chemically

Research Article/Biological and Biomedical Reports (ISSN: 2162-4186), 2012, 2(5), 342-347

with either stainless steel or enamel, relying
entirely on mechanical means for their retentive
effect. 6, 7
Zinc Polycarboxylate Cement
In the quest for an adhesive luting agent that
bond strongly to tooth structure, zinc
polycarboxylate cements evolved as an adhesive
bond to tooth structure .These cements are
powder liquid systems and is a reaction product
of zinc oxide and polycarboxylic acid solution.
The polycarboxylic acid is believed to react
with calcium ions via carboxyl groups on the
surface of enamel, dentin or metal surface
resulting in a chemical bond between cement
and tooth. 1, 8 These cements react with both
enamel and stainless steel and were found to be
suitable clinically for band cementation.9 They
also exhibit poor tensile bond strength, poor
solubility, high viscosity and short working time
and thus have reduced in popularity. 5, 7
Glass Ionomer Cements
Introduced by Wilson and Kent in 1972 as a
restorative material and subsequently as luting
agent, the first generation glass ionomer cement
consists of aluminosilicate glass powder and
alkeonic acid liquids which undergo acid-base
reaction. The second generation glass ionomer
cements have freeze-dried powder blended with
glass and mixed with distilled water. 5 The set
cement contains hydro gel phases supporting the
movement of calcium, strontium and other ions
associated with remineralisation of enamel and
dentin. They are also responsible for uptake and
release of added fluorides from topical gels,
rinses and dentifrices. Thus glass ionomer
cements act as a reservoir for fluoride ions. 8
The leaching of fluorides over prolonged
periods, reduce the potential for
demineralization.10
Glass ionomer cements have significantly
higher compressive and tensile strength when
compared to zinc phosphate or zinc
polycarboxylates. They show better adhesion to
Research Article/Biological and Biomedical Reports (ISSN: 2162-4186), 2012, 2(5), 342-347
enamel and metal5. Studies have shown superior
clinical performance due to reduced band
failure. Moisture contamination does not affect
band cementation.11 Glass ionomer cements are
therefore preferable for cementation of
appliances or bands that remain in the mouth for
extended period of time, cementation of
appliances that are under exceptional
mechanical strain or for cementation of bands to
teeth with unusual crown morphology.4 Use of
glass ionomer cements for bracket bonding has
also been reported, but bracket retention is poor
in comparison to composite.12-14
Mixing of glass ionomer cements is technique
sensitive. Inaccurate powder-liquid ratio,
moisture contamination of the powder can
adversely affect the properties of set material. 5
Resin Modified Cements
Resin modified glass ionomer cements are
hybrid materials of traditional glass ionomer
cements with small addition of light curing resin
or self curing resin and hence exhibit properties
superior to conventional glass ionomer
materials. They have the advantage of both
adhesion to tooth structure, fluoride release and
rapid hardening by visible light. 15, 16 The initial
hardening of the cement takes place due to
either light or chemical activators that
polymerise the monomers. The slow acid-base
reaction ultimately brings about the final
strength. 1 In addition to chemical bonding, the
resin monomers penetrate surface irregularities
to produce micromechanical interlocks after
polymerization. These cements have the
advantages of controlled setting reaction, early
improved physical properties, further hardening
on maturation, sustained fluoride release, caries
inhibition and chemical bonding in presence of
moisture. The resin modified glass ionomer
cement powder and liquid components are
encapsulated and the mixing is done by
trituration.

Resins
Newman (1965) was the first person to use
epoxy resin for bonding stainless steel brackets
to enamel. Resin cements are essentially
flowable composites of low viscosity. They
consist of resin monomers and inert fillers.
Polymerization is achieved by conventional
chemical cure system or by light activation. The
chemically cured systems are available as two
pastes or as powder and liquid. The light cured
system is single component material available in
opaque syringes and convenient to use because
of no mix and longer working time. Studies
have shown that the shear bond strength of the
no mix bonding resin are adequate for direct
bonding. 16, 17 Several systems use both
mechanisms that is chemical cure as well as
light cure and are referred as dual cure systems.
Resin cements are insoluble in oral fluid. They
do not contain any hydro gel and do not show
any fluoride release or recharge. 8 Bonding of
resins to tooth surface and brackets takes place
by mechanical interlock. The bond strength
between enamel and brackets depends upon
various factors including the type of enamel
conditioners, acid concentrations, duration of
etching, the bonding agent (primer), the bracket
material, base design and the oral environment.
Most of the times bond failures results due to
moisture contamination. Recently, improved
adhesive bonding formulation are available in
wide range of products such as self etch primer
solutions and moisture insensitive primers. The
self etch primers are referred as sixth generation
bonding agents and contains methacrylated
phosphoric acid esters that etches and primes
the tooth surface simultaneously. This reduces
the technique sensitivity and chair side time.
Higher shear bond strength were observed when
compared to chemically cured systems. The self
etched primers also contain fluorides and
encourage ion exchange. 18
The introduction of moisture insensitive primers
has enhanced the performance of bonding
systems in presence of moisture. Moisture
Research Article/Biological and Biomedical Reports (ISSN: 2162-4186), 2012, 2(5), 342-347
insensitive primer is hydrophylic and contains
2-hydroxyethylmethacrylate, polyalkeonate
copolymers with carboxylate groups and
ethanol. This primer provides adequate bond
strength in wet environment when used with
light activated resins.
Compomers or Polyacid-modified Composite
Resins
These resin materials have dual features of
caries inhibition and carboxyl chelation. It has
the ability to release fluorides and undergo acid-
base reaction in presence of saliva. Compomers
are single component systems consisting of
aluminosilicate glass in the presence of carboxy
modified resin monomer and light activated
conventional resin monomers. 8
This material is moisture sensitive and packed
in moisture proof packages. Setting is initiated
after light activation (photo polymerization) of
the acidic monomers to change to rigid
materials. The set material absorbs water from
the saliva, allowing a delayed acid-base
reaction. This reaction releases fluorides and
other remineralising ions from aluminosilicate
glass.1,5,8 It has been reported that compomers
showed some amount of caries inhibition and
decalcification when used as orthodontic
adhesive. 19
Because of absence of water in the formula, the
material is not self adhesive like the
conventional glass ionomer or hybrid glass
ionomers. 1 Bonding to tooth surface is by
mechanical interlock. Acid etching and other
surface treatments are required before bonding,
and the bonding surfaces must be dry. 8 As the
compomers polymerize, physical properties are
achieved quickly with early setting strengths
which are superior to the resin modified glass
ionomer but inferior to resin adhesives. 20
Compomers also have the advantage of good
handling characteristics and command setting.

Self-Etching Primer
It combines etching and priming into one step.
Active ingredient is Methacrylated phosphoric
acid ester. Eg: prompt L-pop.
Mechanism
Methacrylated phosphoric acid ester dissolves
calcium from hydroxyapatite. The released
calcium then forms a complex and is
incorporated into network when the primer
polymerizes. Etching and monomer penetration
to exposed enamel rods are simultaneous and
depth of etch and primer penetration are
identical. 21-23
Moisture Insensitive/Resistant Primers
Despite moisture control steps and measures
available, orthodontist often faces problem of
bonding in an environment with increased risk
of contamination. This happens during bonding
of partially erupted premolars because of
proximity of adhesive to cervical portion of
crown and presence of crevicular fluid. 24
To overcome these 2 primers were developed –
Moisture resistant adhesive and Moisture active
adhesive:
Moisture Resistant Adhesive
They are available in a primer formulation and
are based on hydrophilic attraction of its
constituents. Eg: Transbond MIP.
The main reactive component is: Methacrylate
functionalized poly alkenioc acid copolymer
originally used in dentin bonding system.
Excess interfacial water ionises corboxylic
groups forming hydrogen bonded dimers. A
reversible breaking and reforming of calcium-
polyalkenoic acid complexes with enamel is
established, providing some stress relaxation
capacity. With this a dynamic equilibrium
occurs at the interface, incorporating water in
the bonding mechanism that minimizes
detrimental plasticity effect of water that occurs
with moisture contamination of conventional
bonding agent. 23
Research Article/Biological and Biomedical Reports (ISSN: 2162-4186), 2012, 2(5), 342-347
Moisture Active Adhesive
They require presence of moisture for proper
polymerization. They are available as pastes and
have entirely different composition and
polymerization mode. Eg: smart bond. Surface
here must be intentionally wetted prior to
application of it. They are based on cyano-
acrylate formulations. Setting reaction occurs in
2 steps:
1. Organo-Silane (gamma-methacryloxy propyl
trimethoxy silane).
Mechanism: in presence of water, methoxy
groups are hydrolyzed to silanol groups that can
bond with other silanols on the filler surfaces by
formation of siloxane bond.
Iso-cyanate group reacts with water, forming
unstable carbamic acid compound which rapidly
decomposes to CO2 and corresponding amine.
Amine reacts with residual iso-cyanate groups,
cross linking the adhesive through substituted
urea groups. 24
Disadvantages: First step occurs only in
presence of excess water. Release of CO2 during
prolonged setting reaction. It undergoes limited
diffusion through adhesive film as
polymerization proceeds and may become
entrapped, forming voids with detrimental effect
on interfacial strength. It has good in-vitro
performance and acts in presence of water, but
inside oral cavity, contamination is with saliva
rather than water, this adversely affects the
setting process and performance of material. 24
Study done by Zepprie et al found that the shear
bond strength of moisture insensitive primer in
presence of saliva produced lesser bond strength
than when they were bonded in dry fields. But
the values were in clinically acceptable range
13.7 Mpa. 24
Bonding to Non-Enamel Surfaces
Many adult patients have crown, bridge
restorations or amalgam restorations. Banding

becomes difficult if not impossible on abutment
teeth of fixed bridges. Recent advances in
materials and techniques however can help in
achieving effective bonding of orthodontic
attachments to non-enamel surfaces
Bonding to feldspathic porcelain: 2 different
techniques
Hydrofluoric acid (9.6% for 2 mins) gel
treatment, and Sand blasting and silane (Eg:
Scotch prime). 23
Bonding to high allumina porcelains
Hydrofluoric acid is not effective for bonding to
high allumina and glass ceramics. A newly
introduced technique for these teeth is silica
coating but clinical trials are needed. 23
Techniques for Bonding to Amalgam
Modification of metal surface (sand blasting,
diamond bur roughening) Use of adhesion
boosters (enhance) and New adhesive resin that
bonds chemically to non-precious and precious
metals eg: 4-methacryloxyethyl trimethyl
anhydrid (4-META). 24
Bonding to Gold
Use of different intermediate primers and new
adhesives that bond chemically to precious
metals (panavia). 24
Conclusion
Most cement is supplied as two component
systems, powder and liquid. The reaction
between the two is essentially an acid-base
reaction. The zinc phosphate cement has long
served as universal luting cement but has the
dual disadvantage of lack of adhesion to tooth
surface and lack of anti-cariogenic properties.
The properties of zinc polyarboxylate cement
are better when compared to zinc phosphate
cement. They bond chemically to tooth surface
but has limited working time and limited
capability of fluoride release.
Research Article/Biological and Biomedical Reports (ISSN: 2162-4186), 2012, 2(5), 342-347
The glass ionomer luting cements bond
chemically to tooth surface and release
fluorides. The fluoride realising capabilities
makes glass ionomer cement the material of
choice for orthodontic band cementation.
The orthodontic resin adhesives bond to the acid
etched or roughened tooth surface through
mechanical retention. Resin cements are
insoluble in oral fluids and there fracture
toughness is higher than that of other cements.
21
The light activated resin adhesives are single
component systems that are easier to manipulate
than cements and have better physical
properties. They harden with polymerization
reactions and they have reduced or no ionic
activity. They show reduced or insignificant
effect on caries inhibition and remineralisation.
Recently, the self-etch adhesives and moisture
insensitive primers are also available with shear
bond strength comparable with etch and rinse
adhesives. This system has reduced the chair
side time and has increased in popularity. 21
Compomers bond similar to resin adhesives by
mechanical interlock on the acid etched surface
of the enamel. The fluoride released from the
compomer is lesser than glass ionomer cement
but higher than the resin adhesives. Their early
setting strengths are inferior to resin adhesives.
It is thus apparent that no single type of cement
satisfies all the ideal characteristics. It is
therefore required that each situation should be
evaluated on the basis of significant
environmental, mechanical and biological
factors so that material may be selected and
used appropriately. This article provides a frame
work for making proper clinical decisions for
the use of the cement system that is best suited
for each specific case.
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