A Library Dissertation on

GLASS IONOMER CEMENT

By
Dr.AISWARYA LEKSHMI .R
(POST GRADUATE STUDENT 2021 - 2024)

Submitted to

DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS

PUSHPAGIRI COLLEGE OF DENTAL SCIENCES, THIRUVALLA
AFFILIATED TO KERALA UNIVERSITY OF HEALTH SCIENCES,
THRISSUR, KERALA

In partial fulfilment of the requirement for the degree of

MASTER OF DENTAL SURGERY

IN
CONSERVATIVE DENTISTRY & ENDODONTICS

UNDER THE GUIDANCE OF

Dr. A. DEVADATHAN

Professor and Head of the Department

Department of Conservative Dentistry & Endodontics
Pushpagiri College of Dental Sciences, Thiruvalla, Kerala 689107

2021 – 2024
 CERTIFICATE

This is to certify that the library dissertation entitled “GLASS IONOMER

CEMENT” is a bonafide work done by Dr. AISWARYA LEKSHMI.R under
my guidance during her post graduate training period in this department. The work
was carried out as a requirement of partial fulfilment for the degree of Master of
Dental Surgery in Conservative Dentistry & Endodontics. It has not been
submitted (partial or full) for the award of any other degree or diploma.

Dr. A. DEVADATHAN

PROFESSOR & HEAD OF THE DEPARTMENT

DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS

PUSHPAGIRI COLLEGE OF DENTAL SCIENCES

Place: THIRUVALLA

Date:
 ACKNOWLEDGEMENT

The work presented in this library dissertation would not be possible without my close
association with many people. I take this opportunity to extend my sincere gratitude
and appreciation to all those who made this dissertation possible.

My respectful gratitude to the almighty who accompanied me with blessings in

bringing out this dissertation work so successfully.

At this moment of accomplishment, I am greatly indebted to my guide,

Dr. A Devadathan, Professor and HOD, Department of Conservative Dentistry &
Endodontics, Pushpagiri College of Dental Sciences, Thiruvalla for his guidance and
support in completion of dissertation. Without his guidance, this work would not have
been possible and I shall eternally be grateful for his assistance..

I have great pleasure in acknowledging my gratitude to Dr. Jose Jacob, Associate

Professor, Department of Conservative Dentistry and Endodontics for the support &
encouragement, which have been a great contribution in the completion of
dissertation.

I am grateful to Dr.Manuja Nair, Reader, Department of Conservative Dentistry &

Endodontics for her constant guidance and support. I owe a lot of gratitude to her for
always being there for me and I feel privileged to be associated with a person like her
during my life.

I am grateful to Dr. Minimol. K Johny, Reader, Department of Conservative

Dentistry & Endodontics who had in her own way, for helping me out with all the
queries regarding my dissertation.

I would also like to thank to Dr. Amal Fathima, for her guidance and valuable
suggestions.

My heartfelt thanks to my fellow batchmates Dr. Arya senan and Dr. G e o r g e

a b r a h a m for their guidance and moral support.

Date: Dr. AISWARYA LEKSHMI.R

Thiruvalla
 SL. PAGE
CONTENTS
NO NO.
1 INTRODUCTION 1-2

2 HISTORY AND BACKGROUND OF GLASS 3-11

IONOMER CEMENT
3 CLASSIFICATION 13-15

4 COMPOSITION & MANUFACTURE 16-18

5 MANIPULATION 19-21

6 SETTING REACTION 22-25

7 STRUCTURE OF SET CEMENT 26-28

8 PHYSICOMECHANICAL PROPERTIES 29-32

9 INDICATIONS AND CONTRAINDICATIONS 33-36

10 ADVANTAGES AND DISADVANTAGES 36

11 MODIFICATIONS OF GIC 37-42

12 CLINICAL APPLICATIONS 43-48

13 CLINICAL APPLICATIONS IN CONSERVATIVE 48-49

DENTISTRY
14 CLINICAL APPLICATION IN ENDODONTICS 50-54
15 RECEN ADVANCES 55-61

16 STUDIES ON GIC 62-70

17 CONCLUSION 71

18 REFRENCES 72-89
 Introduction

A substantial part of modern dentistry is con cerned with the restoration of

function and increasingly the appearance of the teeth follow ing damage by

caries, non-carious tooth surface loss or occasionally through trauma.The topic

of dental materials is a critical aspect of restorative dentistry (Wilson 1978). It

is a complicated subject, as it is not only concerned with mechanical and

chemical function, i.e. strength and toxicity/biocompatibility. It also includes

considerations of aesthetics, as increasingly good matches for the appearance of

the natural tooth are required as patients are concerned about the cosmetic

aspects of tooth repair at least as much as function (Mount and Hume 2005).For

much of the history of restorative dentistry, functional repair was considered

paramount, and aesthetic considerations simply did not feature in the process of

foil (Skinner and Phillips 1960). The former was more economical, and silver

amalgam has remained until now a widely used material within restorative

dentistry throughout the world, particularly in certain geographical locations

(Kovarick 2009) .However, for well over a hundred years, dental cements have

been available to the profession which, if not fully matching the appearance of

the natural tooth, were at least white and less obtrusive than either gold foil or

silver amalgam. 1

Glass Ionomer cements Invented by Wilson and Kent and developed by

Mc Lean and Wilson in 1971, Glass Ionomer cements  have been available for

cementation for more than 30 years. The development of these cements was

1
announced in a 1972 article in the British Dental Journal written by Wilson and

Kent. 2

They are hybrids of the silicate cements and the polycarboxylate cements.

By developing the glass-ionomer cements in this way, it was hoped that they

nwould possess the advantages of both the silicate cements (translucency and

fluoride release) and the polycarboxylate cements (kindness to the pulp and

chemical adhesion to tooth structure) 3 .

This library dissertation is about glass ionomer cement.This library

dissertation mainly emphasis on history,composition,physical

properties,setting ,and clinical application of glass ionomer cement.

2
 HISTORY AND BACKGROUND OF GLASS IONOMER CEMENT

The first of th e cements in the lutting cement cate was the zinc

oxychloride cement invented by Sorel in 1855 (Sorel1855) 7 . It was prepared by

reaction of zinc oxide powder with aqueous solutions of zinc chloride.The

concentration of zinc chloride was quite high, typically of the order of 40–50 %

by mass,so that reaction with zinc oxide powder was rapid and quickly led to the

formation of a solid ceramic-like mass of reasonable strength and insolubility in

oral fluids. This cement was pioneered in dentistry in 1858, but proved

unsuccessful (Wilson 1978). It was difficult to manipulate and subject to erosion

within the mouth; hence, its overall clinical performance was poor. 2 0

Next came the zinc phosphate cement, which was invented around 1878 (Pierce 1879) 25.

It was not particularly successful as first formulated, but was refined by Fleck in 1902 (Fleck

1902), as a result of which it was much easier to use and capable of satisfactory service in

clinical dentistry. The refinements introduced by Fleck were necessary in order to reduce the

excessively vigorous setting reaction between the components, zinc oxide and aqueous

phosphoric acid. The modifications involved changes to both components to slow down the

setting reaction and to reduce the exotherm. The zinc oxide powder was deactivated by heat

treatment in the range 1100–1200 °C. This causes a degree of sintering between the particles of

the powder and also a slight loss of the oxygen to form a non stoichiometric compound Zn(1 +

x)O, where x is up to 70 ppm (Dollimore and Spooner 1971). The resulting solid is pale yellow

in colour and reacts much more slowly with the phosphoric acid solution than untreated zinc

oxide, so that a satisfactory paste can be mixed and placed prior to setting. The phosphoric acid

3
solution was also deactivated to prevent the reaction with zinc oxide occurring too quickly. This

was achieved by incorporation of controlled amounts of aluminium and zinc salts. They have the

effect of pre-reacting with a small portion of the acid to form salts of the type which make up the

matrix of the set cement and hence can be readily incorporated as the cement solidifies. The

overall effect of these additives is to reduce reactivity and contribute to the ease of mixing of the

final cement formulation. The resulting cement has excellent properties and is still widely used

in clinical dentistry, notably for luting crowns (Hill and Lott 2011) 34. The cement is easy to mix,

forms a smooth off-white paste and hardens at an appropriate rate to give a strong solid with

good dimensional stability. The third cement in this group is the now obsolete dental silicate

cement. Of the three cements, it attained the highest degree of clinical importance and was also

critical to the development of the glass-ionomer cement. Although successful, it was a material

with deficiencies in clinical service, and it was because of these deficiencies that the Laboratory

of the Government Chemist in the UK was called upon to investigate these materials.(Wilson

1996a). A small group was established under the leadership of Dr. Alan Wilson, whose

pioneering work in understanding the setting and structure of the dental silicate cement paved the

way for the invention of the far superior glassionomer cement (Wilson and Kent 1971). The early

history of the dental silicate cement is obscure (Wilson 1978) though there is evidence that it

may date back as far as the zinc phosphate cement. However, it was not until 1908 that a

successful version appeared (Schoenbeck 1980). This cement, like the others already described,

is a two-component material. The powder was a glass based on calcium aluminosilicate with

added fluoride flux, and the liquid was a concentrated solution of phosphoric acid. Like the zinc

phosphate cement, the dental silicate cement was improved considerably by the inclusion of salts

in the aqueous phosphoric acid component, as this reduced the vigour of the setting reaction and

4
allowed workable pastes to be mixed and placed. The paste that was formed was off-white and

set rapidly to form a solid, strong material with a degree of translucency. This translucency gave

an appearance that was superior to that of the zinc phosphate cement, and this made the cement

suitable for the aesthetic repair of the anterior teeth (Wilson 1978). Another advantage of the

dental silicate cement was that the strength was high, of the order of 250–300 MPa in

compression at 24 h. This was also a superior property of these cements compared with the zinc

phosphate cement.It is important to understand the nature of the invention of the glass-ionomer

cement. It did not consist of simply mixing the glass powder of the dental silicate cement with

the poly(acrylic acid) solution of the zinc polycarboxylate and finding that an excellent cement

was the result (Wilson 1996a). It is true that early attempts to improve the dental silicate cement

did involve experiments with aqueous solutions of organic acids, though these acids were

monomeric and the results, while interesting, were not successful in producing cements with

significantly improved properties (Wilson 1968). Poly(acrylic acid) was considered in those

early experiments, but the results were so disappointing that they were not reported at the time

(Wilson 1968). Instead, they were hinted at some years later (Wilson and McLean 1988) and not

described in detail until Wilson published his personal accounts of the invention of glass-

ionomers (Wilson 1996a). It turned out that these early glass-polyacrylate cements were

disappointing in the extreme. They formed an intractable paste which underwent a sluggish

reaction, as observed by an increase in the viscosity of the paste; hardening was very slow and

the product was hydrolytically unstable. This cement was clearly of no use as a potential dental

material (Wilson 1996a). The invention of the glass-ionomer cement was, in fact, not a single act

but rather a series of innovative steps. One key step was the finding that the alumina/silica ratio

of the glass controlled the resulting basicity and hence the readiness with which a glass powder

5
would react with an acid solution. This pointed the way towards the first successful glass for a

glass-ionomer cement, one with sufficient basicity to react with aqueous poly(acrylic acid).

Controlling the alumina/silica ratio allowed the glasses to set much more rapidly than the

original glass-poly(acrylic acid) mixture, where the glass was of relatively low basicity. These

improved mixtures not only set more rapidly; they were also hydrolytically stable when placed in

water (Wilson and Kent 1971; Kent et al. 1973). The first glass to give at least moderately

satisfactory cements was designated G200 and contained alumina and silica in the appropriate

ratio to give a high basicity; it was also high in fluoride. The resulting cement was known as

ASPA 1, the term ASPA being an acronym for aluminosilicate poly(acrylic acid). ASPA was

also the brand name of the very first commercial glass-ionomer cement, launched in 1975

(Wilson and McLean).Component % by mass SiO2 30.1 Al2O3 19.9 AlF3 2.6 CaF2 34.5 NaF

3.7 AlPO4 10.0 Based on data from Wilson and McLean The first glass-ionomer, based on

G200, was far from the finished article, in that it set relatively slowly and retained a high degree

of water sensitivity for a considerable time after setting, which was a distinct drawback. In

addition, the glass itself was not particularly translucent, and therefore, the resulting cement had

poor aesthetics. The next inventive step along the path to creating a satisfactory glass-ionomer

cement was the discovery of the effect of (+)-tartaric acid on the setting reaction. This discovery

came about from a consideration of the nature of the G200 glass. It was exceptionally high in

fluoride, a factor that seemed to be important as G200 was the only glass capable of forming a

usable cement with poly(acrylic acid) solution (Wilson 1996a). Wilson and his team inferred that

fluoride ions must play an important part in controlling the setting reaction, suggesting in

particular that they interacted with aluminium ions released from the glass and prevented them

from prematurely cross-linking the poly(acrylate) polymer chains. This, they postulated, was

6
because of the high affinity of aluminium for fluoride ions and the formation of complex ions of

the type AlF2+ and AlF2 +, which had been proposed to occur during the setting of dental

silicate cements (Wilson and Kent 1968). Slowing the reaction of aluminium via chelation

seemed to be a way forward. In the gravimetric analysis of rocks, the established method to

prevent premature precipitation of aluminium as the phosphate was to include either citric acid or

(+)-tartaric acid, both of which were known to form water-soluble complex ions with Al3+

(Lundall and Hoffman 1938). These two acids were therefore examined as potential additives in

the glass-ionomer cement. The results were striking, especially with (+)-tartaric acid. The

resulting cements had longer working times and sharper setting, seemingly contradictory

properties, both of which made the cement mixture easier to mix and to manipulate (Crisp et al.

1975; Wilson et al. 1976). The cements also had improved compressive strength and were more

resistant to acid attack. Wilson considered this to be the most important discovery made in the

whole process of inventing and developing the glass-ionomer cement (Wilson 1996a). The new

formulation was named ASPA II, and it can be considered to be the first really practical glass-

ionomer cement. 26

Pioneering Studies of GlassIonomer Cements

Following the preliminary reports announcing the development of the glass-ionomer cement

(Wilson and Kent 1971; Kent et al. 1973), detailed scientific publications on these cements

began to appear in 1974. As well as scientific studies, the first clinical report appeared that year

(McLean and Wilson 1974). It covered fissure sealing and restoration with glass-ionomers and

was the report of a 2-year clinical study undertaken with the original ASPA formulation of glass-

ionomer. The initial scientific studies were concerned with the setting reaction of these materials

(Crisp and Wilson 1974a, b; Crisp et al. 1974). They broke the reaction down into two stages: the

7
decomposition of the glass powder (Crisp and Wilson 1974a) and the reaction of the ions

released to cross-link the polyacid, which was incorrectly termed “precipitation” (Crisp and

Wilson 1974b). Gelation would have been a better term for this part of the setting process. The

remaining paper in this important series describes the application of infrared spectroscopy to the

study of the setting reaction (Crisp et al. 1974) and was important in showing that the main

products are calcium and aluminium polyacrylates. These two possible products can be

distinguished on the basis of their infrared spectra. Calcium polyacrylate shows a carboxylate

band at 1540 cm−1, indicating a highly ionic structure, whereas aluminium polyacrylate shows

an equivalent band at about 1600 cm−1, indicating a degree of covalent character with distinct

chelation of the central Al3+ ions by the surrounding carboxylate groups (Crisp et al. 1974). This

paper also showed that the fully set cement contained some residual unreacted carboxylic acid

groups, trapped within the cement as it hardened and unable to react for steric reacions.1.6 Early

Research on Glass-Ionomers 1.6.1 The Composition and Structure of the Glasses The first

practical glasses for use in glass-ionomer cements were calcium aluminosilicates with added

fluoride (Wilson and Kent 1971; Kent et al. 1979; Wilson et al. 1980). Their alumina/ silica ratio

was adjusted to make them sufficiently basic to set on reaction with aqueous poly(acrylic acid).

Although numerous other glass systems have been investigated since these early studies, the

glasses developed by Wilson and Kent remain the basis of all practical glassionomer cements

used clinically. The one substantial change has been the development of strontium-containing

ionomer glasses (Guida et al. 2003), where the element strontium is used in place of calcium in

the formulation. Fluoride is an essential component of the glasses (Wilson and McLean 1988).

This element has several functions within the glass. It lowers the fusion temperature, it improves

the working behaviour of the freshly mixed cement paste by preventing premature gelation and it

8
improves the strength of the set cement. Fluoridecontaining glasses are much less opaque than

pure oxide ones, and this in turn means that cements prepared from them have improved

translucency. The essential property of glasses for use in glass-ionomer cements is that they are

basic and can react with aqueous solutions of acid (Hill and Wilson 1988). This property arises

from the ratio of alumina to silica in the glass. Right from the start of research into workable

glasses for these cements, this need for basicity and how it could be achieved were well

understood. The theoretical framework for this understanding was the random network model of

glass as advanced by Zachariasen in 1932 (Zachariasen 1932). This model considers the glass

structure to be a random assembly of oxygen polyhedral, each comprising a small central cation

surrounded by a number of negatively charged oxygen ions. A typical polyhedron is (SiO4).

These structures are linked at the corners via the oxygen ions to form an array of chains and

interconnected units. The overall concept thus views a glass as consisting essentially of a

polymer based on (SiO4) tetrahedra joined at the corners and exhibiting varying degrees of

cross-linking. The reactivity of such glass structures towards aqueous acids can be increased by

including cations such as calcium that can break up the continuous Si–O–Si structural units to

form non-bridging oxygen. These ions are described as “network modifying”: − − − − + → − − −

− − + − Si O Si CaO Si O Ca O Si 2 The inclusion of aluminium has more complex effects than

the inclusion of simpler chemical species such as calcium or sodium. Aluminium can act as a

network modifier in an analogous way to calcium, but it can also be a network former. In the

latter case, the presence of reasonable amounts of silica as tetrahedral building blocks of (SiO4)

forces the aluminium to adopt a similar tetrahedral geometry and to form species equivalent to

(AlO4). Although these tetrahedra are the same size as the (SiO4) ones, they carry more formal

charge. This is because the central cation is a 3+ ion, compared to the formal 4+ charge on the

9
central silicon in (SiO4). The presence of the (AlO4) tetrahedra therefore has to be balanced by

additional cations (e.g. Na+, Ca2+) in the structure close to the main oxide network (Lowenstein

1954). These ideas show that the aluminosilicate glass structure of ionomer glasses can be

regarded as consisting of linked (SiO4) and (AlO4) tetrahedral, with additional cations to balance

the charge deficiency due to aluminium. It is the alumina units and their associated cations that

serve as the point of reaction with aqueous acid solution, and reaction of the acid involves

removal of the charge-balancing cations, followed by rupture of the aluminosilicate network

(Wilson and McLean 1988). The Al/Si ratio cannot apparently be greater than 1:1; otherwise

there are insufficient (SiO4) tetrahedral to force the aluminium into fourfold co-ordination, and

high basicity does not develop (Lowenstein 1954).21

10
GLASS IONOMER CLASSIFICATION

The generally accepted classification for GICs is outlined below, and it still relates closely to the

viscosity of the unset cement.

Type 1: Luting and Bonding (RM-GIC Adhesive) Materials

These materials are used for the cementation of indirect restorations including crowns, bridges

and orthodontic brackets. They are delivered as either conventional or resin-modified materials.

The resin-modified materials can set with or without light polymerisation. These materials are

either delivered as separate powder and liquid systems, encapsulated materials or nowadays

even a paste/paste system (only the resinmodified materials). The luting cements are able

to achieve a good thin fifi lm thickness in the order of 20 μm. The powder/liquid ratio can be in

the order of 1.7:1 or increased to as much as 3.8:1 when the acid has been dehydrated to a

powder form. The other material in this group can be termed a RM-GIC adhesive. This material

has only been available since the mid-1990s and has shown to be a useful alternative for bonding

resin composite to tooth structure instead of with resin- based adhesives (Burrow and Tyas ).

Only a couple of these adhesives are commercially available (Fuji Bond LC, GC Corporation,

Japan; Riva Bond LC, SDI Ltd, Australia). Delivery can nowbe in the form of a hand-mixed

powder and liquid or encapsulated. The mixed material is applied to the tooth as a thin layer

using a micro-brush, similar to a resin- based adhesive.25

Type 2: Restorative Materials

This group was originally classified into ‘aesthetic’ and ‘non aesthetic’ materials and either

conventional or resin-modififi ed. More recently,many of these materials could be classified as

11
being only Type 2, with the exception of the socalled reinforced materials that contain silver and

are not tooth-coloured. The aesthetic and non aesthetic subgroups are now almost eliminated,

The powder/liquid (P:L) ratio varies slightly amongst the currently available materials rang

ing from about 3.1:1 up to 3.6:1. The capsulated materials tend to have a higher powder/liquid

ratio. The P:L ratio shows little variation whether the GIC is a conventional or resin-modified

material.The older classification included a second subgroup of a higher P:L ratio. These

cements were stronger, set faster and could be trimmed and polished immediately after setting.

It could be argued that some of the current GICs should still be placed in this subgroup.

However, there are now other materials that set quickly and can be finished early and have good

aesthetics but also a higher viscosity. Hence, the divisions of this classification have become less

well defi ned.The lower P:L ratio conventional GICs have all but been replaced by the high-

viscosity materials or by RM-GICs which provide the best aesthetics and acceptable strength. All

of the restorative cements are radiopaque.26

Type 3: Lining or Base Cements

These are either conventional or resin-modified and are either auto- or light-cured. More recent

materials are presented in a paste/paste form for easier dispensing and application. These paste/

paste materials are usually light-cured and resin-modified. The original powder/liquid materials

still exist and are widely available. These lining/base cements are most often used as a thin layer

beneath restorations and serve as a thermal insulator or dentine replacement. However, the recent

trend for dentine replacement is to use a restorative material (Type 2) in larger cavities due to

their greater strength in association with the fast set allowing the restoration to be completed

quickly.Exceptions to the above materials now exist. Fissure sealant cements are usually low-

viscosity,fast-setting and are typically conventional autocure materials. One manufacturer

12
produces a high fluoride-releasing conventional GIC (Fuji VII, GC Corp, Japan) recommended

for what hasbeen termed as ‘fissure protection’ and has been reported in several research papers

(Ganesh and Tandon ; Chen and Liu ). It has a powder/liquid ratio of 2:1. This GIC has also

been recommended for use as a base due to its low viscosity and high strength. Its initial

introduction was aimed at stabilising caries lesions in patients with high risk of caries, i.e. as a

‘temporary’ cement. A number of the newer materials that are claimed to be RM-GICs tend to

have a very high resin content. Hence, the debate continues on what constitutes a true GIC,

which led to the Mount et al. paper. The general consensus is that the mixed cement must be able

to set in a dark environment to demonstrate the existence of an acid–base reaction which forms

the matrix of the set cement. Those that do not meet this criterion are more like a resin composite

with GIC 27

Classification According to uses

Type I- For Luting

Type II- For restorations

Type III- Liners and bases

Type IV- Metal modified

Type V- Light cure

Type VI- Pit and fissure

Type VII- Core build up

Type VIII- Orthodontic

Type IX- Atraumatic restorative treatment (ART)

Newer Classification

1. Traditional Glass Ionomer

13
Type I – Luting cement

Type II – Restorative Cements

Type III – Liners and Bases

2. Metal Modified Glass Ionomer

a. Miracle mix

b. Cermet cement

3. Light cure glass ionomer HEMA added to liquid

4. Hybrid Glass Ionomer

a. Pre-cured glasses blended into composites

According to McLean et al in 1994

1.Glass Ionomer Cements (Traditional)

2. Resin Modified Glass Ionomer Cements.

3. Poly Acid Modified Composite Resins.

Supplied as

Powder/ Liquid bottles

Preproportioned capsules (hand mixing formulations)

Light cure system

Water settable types

14
COMPOSITION

Glass ionomer (GI) materials are a powder-liquid product where the

powder is a silicate glass that contains calcium, aluminium, and fluoride. The

liquid is polyacrylic acid. Walls A. G., in 1986 has stated that the basic powder

and liquid components that are mixed to yield glass ionomers consist of an

aluminosilicate glass and polycarboxylic acid, respectively 5 2 .

POWDER

Comp on en t % Function

S il i ca (S i O 2 ) 41.9 % Filler

Alumina (Al 2 O 3 ) 28.6%

Alumina fluoride (AlF 3 ) 1.6% Ceramic Flux

Calcium fluoride (CaF 2 ) 15.7% Ceramic Flux

Sodium fluoride (NaF) 9.3% Ceramic Flux

Aluminium phosphate 3.8%

(AlPO 4 )

Lanthanum, Strontium, Radiopacity

Barium or Zinc Oxide

LIQUID

15
Component Function

Aqueous sol ut i on of P ol yacryl i c aci d (i e. a Increases reactivity of the

copol ym er of acryl i c aci d wi t h ot her
liquid, decrease viscosity and
unsat urat ed pol ycarboxyl i c aci ds i e. it aconi c,
reduce tendency for gelation
m al ei c and t ri carbal l yl i c aci d

Tart ari c Aci d Improves handling

characteristics, increases

working time and shortens

setting time

Wat er It is the most important

component of the liquid as it

acts as a medium for the

reaction to take place and

hydrates the reaction products

Several types of glasses with very complex structures have been used in

commercial products. The glass controls the setting rate, strength and

translucency of the cement. Franklin Garcia-Godoy, Jerry W. Nicholson and

John W. Mc Lean justified in 1983 that additions of tartaric acid improved the

working and setting characteristics 1 1 .

Too much of water results in weak cement and too little water impairs the

reaction and the subsequent hydration.

Water settable cements:

16
 These type of cements were developed and put forward as “Water

hardening” cements by Wilson A.D and J. W.Mc Lean in 1984 1 1 . The polyacrylic

copolymer is freeze dried, and then added to the glass ionomer powder. The

liquid is water or water with tartaric acid. When the powder is mixed with water,

the polyacrylic acid powder goes into solution to form liquid acid. Then the

chemical reaction takes place as for powder and liquid. These cements are

known as water settable cements and they set faster than those with polyacrylic

acid. 5 3

MANUFACTURE

The components are sintered at 1100°C to 1500°C. The glass is then

ground to particle sizes ranging from 20 to 50µm.

MANIPULATION

 Conditioning of the tooth surface

 Manipulation of the cement

 Protection of cement during setting

17
  Finishing

Conditioning of the tooth surface:

The tooth should be clean, free of debris or any temporary cement from

the interim restoration. The tooth surface can be cleaned with pumice or with

10% polyacrylic acid for 10-15 seconds and then washing it off with water. This

removes the smear layer from the prepared tooth surface. However this will act

as a plug over the dentinal tubules preventing penetration of acid and hence

affecting the setting. The surface must be dry but not dessicated and it should be

protected from blood or saliva contamination. This can be achieved by proper

isolation of the prepared tooth surface with the help of cotton rolls or rubber

dam. 5 6

Proportioning and Mixing:

P/L ratio: Generally 3:1 by weight. A lower P/L ratio reduces the mechanical

properties and increases the chances of cement degradation. Moisture

contamination alters acid-base balance. 5 7

Spatula used: Agate spatula

Manual mixing: The powder bottle is tumbled gently and the powder and liquid

are dispensed right before mixing. A cool and dry glass slab is preferred as it

18
allows all the powder to be incorporated into the mix and yet maintain its

plasticity.

As with ZOP and ZPC materials, glass ionomers can be mixed on a cold

glass slab in order to slow the setting time. However, this can have an adverse

effect on the strength of the final mix. Clinicians need to remember that when

mixing GI as a luting cement, the powder-to-liquid ratio will be reduced

compared to when this material is mixed as a restorative cement.  This will result

in a lower pH for a longer period of time, possibly leading to short-term

postoperative sensitivity.

The powder is divided into 2 increments. The 1 s t increment is added to the

liquid rapidly with a stiff bladed spatula to produce a homogenous milky

consistency. The remainder of the powder is added and mixed with a folding

method in order to preserve the gel structure.

Mixing time: 45 seconds

Preparation of the restoration: The inner surface of the restoration must also be

cleaned off any debris for loading of the cement prior to cementation.

Setting Reaction

19
Leaching: When the powder and liquid are mixed together, the acid attacks the

glass particles. Thus calcium, aluminium, sodium and fluoride ions leach out

into the aqueous medium.

Calcium Cross-links: the initial set occurs when the calcium ions cross-links

with polyacrylic acid chains. This forms a solid mass.

Aluminium cross-links: in the next phase (24hours), the aluminium also begins

to cross link with polyacrylic acid chains.

Sodium and Fluoride ions: These ions do not take part in the cross linkin. Some

sodium ions replace the hydrogen ions in the carboxylic groups. The rest

combine with fluorine to form sodium fluoride which is uniformly distributed

within the cement.

Hydration: Water plays a very important role in the se3tting reaction of the

cement. Initially it serves as the medium, but later it slowly hydrates the matrix,

adding strength to the cement.

Silica gel sheath: the unreacted glass powder particle is sheathed by a silica gel.

It is formed by the leaching of ions from the outer portion of the matrix.

Hence, on mixing the two components, hydrated protons from the liquid

penetrate the surface layers of the powder particles. Cations (mainly Al and Ca)

20
are displaced and aluminosilicate network is degraded to a hydrated siliceous

gel. Cations of fluoride complexes migrate into the aqueous phase of the cement

phase, where metallic salt bridges are formed between the long chains of

charged polycarboxylate ions, cross-linking them and causing the aqueous phase

to gel and the cement to set. Toxic monomers are not involved.

The setting reaction is represented as:

Glass (base) + Polyelectrolyte (acid)= Polyhydrogel (salt) + Silica Gel

Calcium ions are more rapidly bound to the polyacrylate chains than the

aluminium ions and are responsible for the cement’s initial set. Later,

aluminium salt bridges form and the cement hardens; the high ionic potential of

the trivalent aluminium ion ensures a stronger cross-linking than with divalent

ions alone. Water is the reaction medium, and additions of tartaric acid improve

working and setting characteristics.

The glass ionomer cements have a double setting reaction that confers

interesting rheological properties on the hardening paste. Initially, the cement

sets enough to permit carving similar to amalgam (calcium-ion exchange), later

it sets hard (aluminium ion-exchange).

The glass ionomers adhere to wet dentin because they are polar polymers

that compete with water for polar enamel surface. Glass ionomer is a highly

21
ionic polymer with a multiplicity of COOH groups that form strong hydrogen

bonds to enamel apatite.

Hybrid = SC(P) and PCC(L), Polymer-Based Dental Cement (Fig-24)

POLYACRYLATE GEL

(initially Ca polyacrylate gel and later Al

polyacrylate gel) Si +4, Al+3, Ca+2, Na+, F- Ions

RESIDUAL GLASS PARTICLE

Fig : Glass ionomer hybrid cements

STRUCTURE OF SET CEMENT

22
 The set cement contains agglomerates of unreacted powder particles

surrounded by silica gel and embedded in an amorphous matrix of hydrated

calcium and aluminium polysalts.

Post hardening Precipitation

Even after the cement sets, continuous precipitation of poly salts occur.

However with time, the slower formed aluminium poly salts becomes the

dominant phase of the cement matrix.

Exposure of the cement to water before hardening reaction is complete,

leads to loss of cations and anions which form the matrix as they can be

23
dissolved. Thus it is very important to protect the margins of the restoration

after the restoration has been cemented.

One must be careful when using GI as a cement, specifically when the

margins of fixed prostheses are susceptible to contact with moisture during the

period of set. GI materials are known to be sensitive to moisture and should be

protected from water and saliva contamination for at least 15 minutes after

placement. It has also been suggested that a resin adhesive be used as a surface

protection agent to reduce marginal microleakage during the initial setting

period.

It has been reported that glass ionomer-based materials (which are

hydrophilic) expand when they come in contact with water. Therefore, the

marginal seal of castings luted with these materials may be improved due to this

hygroscopic expansion and may also exhibit greater bond strength. However,

this expansion is the most likely cause of fracture of all-ceramic restorations

luted with glass ionomer cement and may explain why some manufacturers are

developing GI cements with lower expansion properties.

Loosely bound and Tightly bound water

Water which is easily removed by dessication and decreases with time is

loosely bound water. Loosely bound water gradually hydrates and binds with the

matrix, becoming tightly bound. Tightly bound water increases with time and is

not easily removed by drying.

24
Bonding to tooth structure:

Wilson considered the attachment to collagen in dentin via NH2 or COOH

on pendant side chains is possible. Recently, it has been demonstrated that

phosphate and calcium ions are displaced from synthetic apatite by sodium

polyacrylate solution, forming a calcium phosphate-polyacrylate crystalline

structure acting as an interface between tooth enamel and the set cement. Glass

ionomer cements bond to enamel and dentin because they adhere to substrates by

polar and ionic attractions (physicochemical adhesion). They are based on the

hardening reaction between ion-leachable glasses and aqueous solutions of

homopolymers or copolymers of acrylic acid.

Bonding to the restoration

When using glass-ionomer cements, researchers have found that increasing

the roughness of the internal surfaces of castings using coarse-grit aluminum

oxide in an air abrader significantly increases the retention of the castings

compared to using fine-grit aluminum oxide. The roughness of the preparation

also affects retention. In another, retention was significantly greater for castings

cemented to preparations made with a diamond bur than to those prepared with a

carbide bur. One way to reduce the potential for post-cementation sensitivity

with glass-ionomer cements is to use a resin based desensitizer on the prepared

tooth prior to luting. Recent research has found that this type of desensitizer

does not adversely affect crown retention.

25
PROPERTIES

26
 The physicomechanical properties of GICs vary widely among the

different commercial products and among the types of cements. Variations in the

powder-liquid ratio, glass powder, degree of cement hydration and porosity all

affect the properties of a cement.

A remarkable increase in strength is apparent as the cement undergoes

setting. However, the final strength of the set GIC remains low compared with

resin composite restorative materials. In contrast, the glass ionomer luting

cements are stronger than zinc phosphate and zinc polycarboxylate cements.

Glass ionomer cements possess impressive compressive strength of 140 to

200 MPa, but are weak in flexural strength (10 to 40 MPa). They are adhesive

and, with the fluoride leach, possess cariostatic properties. The matrix of the

glass ionomer cement contains sheathed droplets of calcium fluoride, so the

hardened cement paste continually releases fluoride ions. Because the cement

becomes attached via ionic and polar bonds to the enamel and dentin, the

intimate molecular contact facilitates fluride ion exchange with the hydroxyl

ions in the apatite of the surrounding enamel. Glass ionomers are also

biologically compatible with the tooth structure and pulp if placed over dentin.

In deep carious lesions or in direct contact with the pulp, glass ionomers are

irritants. The particle size of the glass is of great importance for governing the

setting time, film thickness and essential powder-liquid ratio.

27
FLUORIDE RELEASE, ADHESION AND BIOCOMPATIBILTY:

The glass particles in the glass ionomer cements contain fluoride, which

may be released mainly in the form of sodium fluoride. Although the fluoride

release varies for various forms of glass ionomers, the release pattern is almost

similar. A high rate of fluoride release is recorded during the first days, and a

gradual continuous decline occurs thereafter. It has been shown that the fluoride

can be recharged with uptake from the oral environment, thus acting as fluoride

devices with slow release rates into the oral cavity. GIC is believed to have a

cariostatic effect due to this fluoride release. Resin modified GIC releases lesser

fluoride compared to conventional GIC yet present similar release rate profile.

GIC can bond with enamel, dentin and base metals. An ion-exchange

process between the cement and the tooth substrate leads to the development of

an ion-enriched intermediate layer of new material at the cement-tooth interface.

This means stronger the GIC, greater the adhesion. Thus, the significantly

higher bond established between the resin-modified glass ionomers and the tooth

surface maybe derived from the enhanced strength of the cements.

Residual polycarboxylic acid in the set cement may have an adverse effect

on the pulp integrity. However, the higher molecular mass of the acids and the

dentin buffer capacity seem to cause only a mild irreversible pulpal

inflammation in the absence of bacteria .

28
Fluoride release in glass ionomer cements

29
 To summarise the typical Properties of Glass Ionomer

Cement

Fig-27 : Glass ionomer luting cement

Prop erty IS O 9917 : 1991 Cl ass 4.2.1 T ypi cal Prop erti es

Worki ng Tim e - -- 3 m i ns 20 secs

Net S et t i ng Ti m e 2.5 m i ns - 5 m i ns 3 m i ns 40 secs

C om pressi ve S t rengt h 70 MP a Mi nim um 128 MP a

Lact i c Aci d Jet Erosi on 0.05 m m / hr Maxi m um 0.0038 Mpa

F il m Thi ckness 25 µ m Maxim um 20 µ m

R adi opaci t y - -- 2.0 m m Al

30
INDICATIONS,CONTRAINDICATIONS,ADVANTAGES AND DISADVANTAGES

INDICATIONS

Restorative Material

Glass ionomer cement is popularly used in pediatric restorations thanks to its easy placement and

better marginal adaptation. It is also indicated for restoring permanent teeth in low stress-bearing

areas like class III and class V lesions. It is the material of choice in high-caries-risk patients due

to the fluoride release.[1-5]

Luting Agent

GIC can be used for luting of indirect restorations (metal and metal-ceramic) post and core and

orthodontic bands and brackets.[4][8]

Pulp Protection

GIC is used as a liner or bases beneath metallic and composite restorations (sandwich technique).

[9]

Pit and Fissure Sealant

GIC-based fissure sealants offer less retention than resin-based fissure sealants; therefore, they

are only indicated as a temporary sealant in newly erupted permanent teeth. The caries

31
preventive action of GIC-based pit and fissure sealants is comparable to resin-based pit and

fissure sealants.[10]

Atraumatic Restorative Technique (ART)

ART is a minimally invasive procedure that involves removing carious tissue with hand

instruments without anesthesia. The restoration of the cavity is done with an adhesive material

like glass ionomer cement (GIC). ART is performed in those cases where routine dental

treatment cannot be done because of a lack of facilities or accessibility to the dental clinic.[11]

Advantages

 Chemical bonding to the tooth structure[5]

 Caries preventive action[8]

 Thermal compatibility with tooth structure

 Mild pulp response[5]

 Tooth-colored restorative material[14]

The first advantage is the ability to bond to tooth structure 5 0 . This is an

ionic bond between the carboxyl groups of the GI and the calcium ions in the

tooth. With respect to fluoride release, when a glass ionomer is placed at the

margin (as in the sandwich technique) or as a cement, it has been found that

there is a reduction in recurrent caries due to the release of fluoride 5 1 . The

32
fluoride in GI allows for the remineralization of the adjacent tooth structure.

When a GI is used as a luting cement, there is a reduction in the problems

associated with microleakage. This has been attributed to its antimicrobial

properties.

Another advantage of GI is that the use of a resin-modified glass ionomer

as a liner significantly reduces volumetric polymerization contraction for light-

cured resin restorations. Resin-modified glass ionomer cement (eg,

FujiCem, GC America) has the added advantage of fluoride release (especially

important for patients with increased caries risk), moderate strength, and ease of

use. Additionally, GI cements exhibit significantly less solubility than either

zinc phosphate or zinc polycarboxylate cement.

The main advantages of these cements, which set through an acid-base

reaction, are an ability to bond chemically to enamel and dentin, a long term

fluoride release and a coefficient of thermal expansion similar to tooth tissues.

The glass ionomer cements have strength characteristics similar to those of

silicate cements, but they are more resistant to acid attack like the

polycarboxylate cements. They are only mildly irritating to the pulpal tissue,

and the extent of the inflammatory response is moderated by any residual dentin.

The glass ionomer cements have the added advantage of translucency.

33
 The hand-mixed formulations have been shown to have a significantly

greater compressive strength.

Disadvantages

 Poor mechanical properties, e.g., low compressive strength, low abrasion resistance, and

fracture resistance, make its use restricted to low stress-bearing areas[5][7]

 Poor esthetics due to lack of translucency

 Moisture sensitive while setting[7]

The longevity of glass ionomer cement restorations is affected by occlusal forces, porosities in

set cement, desiccation or water absorption during initial setting, and use of the mixed cement

after the loss of gloss. Furthermore, larger GIC particles decrease the rate of wear; the solubility

of the cement depends on the amount of cement at the margins.

Several disadvantages of GIC has been enlisted by Mount G.J. in 1999 5 1 :

low strength and wear resistance, relatively poor esthetic appearance, and

technique sensitivity to moisture during the early setting phase. Conventional GI

has a lower sealing ability than the light-cured (resin-modified) materials.

34
MODIFICATIONS OF GIC:

Continuous modifications in conventional glass ionomers have led to the

introduction of new formulations. In 1985, the first report of glass cermet

cements was published. Metal ions were incorporated into the glass particles to

enhance the strength of the cements. The resin modified glass ionomers

represent the latest generation of glass ionomers, in which the fundamental acid-

base reaction is supplemented by a light-curing and/or chemical-curing

polymerisation reaction. These cements were developed chiefly to provide

improved mechanical strength, solubility, wear resistance, moisture sensitivity,

and esthetic performance compared with conventional glass ionomers .

Modifications of Glass Ionomer Cement

35
STRUCTURAL CHARACTERISTICS

Composition: Small metallic particles, such as silver, may be incorporated

into the glass during fusion, creating metal-reinforced glass-cermet cements.

The composition of the powder for resin-modified glass ionomers is basically

similar to that of conventional glass ionomers. Strontium aluminosilicate or

barium aluminosilicate glasses are used in some products to provide radiopacity.

Fluoride glasses produce stronger cements than oxide glasses with improved

handling properties and a potential cariostatic effect.

The basic composition of the liquid component for resin-modified glass

ionomer cements is polycarboxylic acid, water and 2-hydroxyethyl methacrylate

(HEMA). Some products contain metavrylate-based monomers or methyl

metharcylate modified polycarboxylic acids. Photoinitiators and/ or chemical

initiators of a free radical polymerisation mechanism are added to the liquid.

The type, molecular weight and concentarion of the polycarboxylic acid

affect the acid reactivity, setting rate and strength of the cement. The

polyacrylic acid may be vacuum dried form incorporated into the glass powder

to yield a water hardening cement 5 2 .

36
Setting Reaction and structure: The setting reaction is based on a dual

mechanism in the resin-modified glass ionomers. Wilson A. D. Has discussed

about resin modified glass ionomer cements in 1990 5 3 .

The acid-base reaction is first induced after mixing the powder and liquid,

followed by a free radical polymerisation reaction while the acid base reaction

is continued. Finally a metal polycarboxylate salt hydrogel and a polymer

network are formed. The polycarboxylate salt matrix plays a crucial role in

strengthening the cement, while the polymer matrix provides the initial set.

Some resin-modified glass ionomer products cannot be characterised as true

glass ionomer cements because an acid base reaction has not been identified.

RESIN MODIFIED GLASS IONOMER CEMENT

Indications:

 Metal crowns, inlays and onlays (including stainless steel crowns) 5 4

 Porcelain-fused-to-metal crowns and bridges

 All-zirconia or all-alumina strengthened core-ceramic restorations

37
  Endodontic pins and posts

 Orthodontic appliances

Manipulation

Advantages

 Easy and hygienic handling with Clicker Dispenser

 Consistent mix ratios

 Paste-paste formulation for easy mixing

 Strong adhesion

 Easy removal of excess material

 Very low post-operative sensitivity

 Enhanced marginal integrity

 Sustained fluoride release

38
  Strong Adhesion: RelyX Luting 2 provides excellent adhesion to a wide

range of restoration materials and high bond strength to dentin and

enamel.

Enam el

Dent i n

Data: Shear Bond Strength Comparison

 Very Low Post-operative Sensitivity: There are virtually no post-operative

sensitivities caused by RelyX Luting 2.

 Easy Removal of Excess Material: Excess material of RelyX Luting 2 can

easily be removed after the seating of the restoration.

 Low Film Thickness: The low film thickness of RelyX Luting 2 allows a very

tight fitting indirect restoration to seat completely.

39
 Integrity of Margin, Low Solubility: The low solubility ensures the long-term

integrity of the margin and helps to prevent wash-out of luting cement under

indirect restorations.

 Fluoride Release: The fluoride release of RelyX Luting 2 is even higher than

with the conventional glass ionomer cement RelyX Luting 2.

STEPS IN LUTING RESTORATIONS

Fig – : A fractured Fig – : Crown preparation

amalgam restoration done

40
Fig – : Manipulation Fig – : Coating the crown

of Cement with cement

Fig : Removal of Fig – : Final result

Excess cement

41
PHYSICOMECHANICAL PROPERTIES

The inclusion of metal ions in glass-cermet cements achieved no

significant increase in strength or dissolution resistance of cements.

Resin modified GIC exhibit more rapid development of strength and

greater resistance to early moisture contamination than conventional GIC. The

compressive strength, diametral tensile strength, flexural strength, and fracture

toughness of the resin-modified cements have been dramatically improved

compared to conventional GIC.

42
CLINICAL APPLICATIONS:

As stated by Rosensteil in 1998, fine grained types of GIC have been used

as luting agents in fixed prosthodontics for luting of crowns, partial dentures

and inlays. The adhesive capacity and the anticariogenic potential of GIC are

considered to be particularly beneficial properties for luting agents.

These luting cements provide the link between the fixed prostheses and

the prepared tooth structure, thus playing an important role in the longevity of

restorations as said by Land MF, Crispin BJ 5 4 .

The major drawbacks of the most commonly used luting cements such as

zinc phosphate cements, are associated with a lack of adhesion and a low

resistance to dissolution in oral fluids. Despite these disadvantages, an overall

survival rate of 74.0 + 2.1% was found for fixed partial dentures after 15years in

the oral cavity. However alternative materials have been introduced because of

increased esthetic demands, along with an attempt to improve clinical

performance over that achieved with use of zinc phosphate cements.

The conventional glass ionomer luting cements were introduced in the mid

1980s and resin modified glass ionomers have been available since 1995. The in

vitro performance of glass ionomer luting cements has been assessed in term of

their mechanical properties, wear resistance, solubility and water sorption,

43
adhesive efficiency, biocompatibility and colour stability. However there is

concern that these in vitro evaluations cannot predict the clinical outcome when

the glass ionomer luting cements are subjected to clinical conditions,

particularly for metal and ceramic onlays/inlays, full crowns and muti unit

prostheses.

Although glass ionomers have been used as luting cements for over 15

years, no reliable long-term investigations on the in vivo aging of these cements

is presently available. The retention rates of various fixed prostheses cemented

with glass ionomers have been selected as criteria to define the in vivo longevity

of the cements as luting agents.

Brackett WW, Metz JE.in 1992 and 1994 have commented over the

performance of glass ionomer luting cement over 5 years and 8years in a general

practice 5 5 , 5 6 .

MPameijer CH, Nilner K. have performed a long term clinical evaluation of

three luting materials and gave their opinions in 1994. They said the luting

agent may have only a minimal impact on the resulting retention rates achieved.

Moreover the inherent difficulties in standardisation of the in vivo assessment

do not allow valid conclusions 5 7 .

One shortcoming in the use of glass ionomers as luting cements is the

occurrence of tooth sensitivity as stated by Bebermeyer RD, Berg JH. In 1994

44
after they did a patient survey post cementation. Studies found that within the 1 s t

2 weeks, postcementation hypersensitivity was manifested in 11% to 34% of the

teeth that received crowns 5 8 .

Kern M, Kleimeier B, Schaller HG, Strub JR. performed a clinical comparison

of postoperative sensitivity for a glass ionomer and a zinc phosphate luting

cement and concluded that glass ionomer contributes to patient sensitivity more

than Zinc Phosphate cement 5 9 .

It is assumed that this postoperative sensitivity may be induced by tooth

dessication during crown preparation, bacterial contamination, or irritation from

the cement per se. The absence of evidence for in vivo bacterial leakage in

cemented crowns upto 3 months postcementation excludes bacterial penetration

as a possible cause of tooth sensitivity in the early stages of oral function. In

addition, a remarkable reduction (2.1% to 4.0%) in the occurrence of pulp

sensitivity was over a 5 to 8 year follow up period.

Thus, tooth sensitivity seems to be eliminated during the aging of glass

ionomers. These observations suggest that the tooth sensitivity that has been

characterised as irreversible pulpitis is instead a short term phenomenon related

to the setting characteristics of glass ionomer cements. The prolonged setting

time of the cements, which is necessary for the optimum fitting of the

45
prostheses, is likely to maintain the low acidity of the cements for a long time,

thus causing the sensitivity presented.

Glass ionomer luting cements, apart from the cementation of fixed partial

dentures, have also been recently used for the cementation of ceramic inlays. In

order to prevent the bulk fracture of the brittle ceramic inlays, adhesive

cementation is necessary to ensure good adaptation to the prepared tooth

structure. Because of the adhesive capacity of glass ionomers, these cements are

the materials of choice, along with the traditional resin cements. A series of

controlled clinical studies has examined the aging performance of the glass

ionomer luting cements at the margins of ceramic inlays. This was confirmed by

studies conducted by van Dijken JW, Ormin A, Olofsson AL in 1999 6 0 .

The cement seems to be subjected to gradual degradation vertically and

horizontally, which leads to marginal ditching. Consequently, partial fracture or

total loss of the ceramic inlay may be caused by adhesive bond failure, which

mostly occurs at the ceramic-cement interface. The cement is separated from the

inlay and remains at the interface with the prepared tooth structure. The brittle

nature of the cements, their high dissolution rate and low wear resistance, and

the relatively poor bond between the cement and the rough ceramic surface,

account for the cement deterioration at the occlusal margins of the restorations,

where there is substantial stress from functional forces in vivo. The high

prevalence of fractures at the cement-ceramic interface for the inlays luted with

glass ionomers confirms in vivo results with different prostheses designs. The in

46
vivo performance of the glass ionomers was determined from clinical criteria or

by evaluating casts of the ceramic inlay restorations with the scanning electron

microscope. However, the use of retrieval analysis of teeth to assess the margins

and the interfaces in restorations luted with glass ionomers after specific periods

of oral service should offer the possibility for the most reliable and detailed

characterisation.

Identification of GIC adaptation at crown margins, using a dye to reveal

microleakage for extracted teeth that had been aged in vivo, is a questionable

approach because it is not clear whether the observed leakage is due to a gap at

the margins or to diffusion through the glass ionomer 6 1 .

White SN, Yu Z, Tom JF, Sangsurasak S have described this fact in 1994 and

commented on the in vivo microleakage of luting cement for cast crowns 6 1 .

The hydrophilic nature and porosity of the glass ionomer cements strongly

favour the dye absorption mechanism, suggesting that the findings of White et al

for use of a resin modified glass ionomer luting agent are not valid. The short

time (6 months) that the crowns were in the oral cavity further limits the

validity of the study. The marginal integrity of cast crowns cemented with resin

modified glass ionomer was verified on extracted teeth after 6 months in vivo,

and the origin of the marginal discrepancies was found to be degradation of the

cement 6 2 .

47
However, the short time period of the study and the high standard deviations

obtained do not permit conclusions about the clinical performance of glass

ionomer cements.

The potential longevity of a prostheses is, to a large extent, determined by

the solubility of the cement and its resistance to disintegration in the oral

cavity. From a clinical point of view, long term solubility is a crucial factor that

leads to marginal ditching and microbial penetration. In vitro solubility cannot

resemble the dynamic and complex in vivo conditions 6 3 .

On the other hand, in vivo assessment of solubility has been obtained only

with the use of in situ models consisting of intra oral appliances that can be

removed from the mouth for subsequent measurement of material loss 6 4 .

The results obtained by the in situ models have two important limitations:

First, the dissolution is determined as a result of physicochemical erosion, not

mechanical fatigue in crowns and fixed partial dentures; and second, a large

cement surface is exposed directly to the oral fluids, whereas a thin layer of

cement is subjected to the oral environment under clinical conditions 6 5 .

Glass ionomer luting cements seem to undergo homogenous dissolution of

their elements upon aging 6 6 . Their resistance to dissolution is higher than for

zinc phosphate and polycarboxylate cements used commonly as luting materials.

48
Despite the cement dissolution found, no incidence of secondary caries has been

detected over an 8-year period in cast restorations luted with glass ionomer.

The results of this one study, where the extent of secondary caries was

assigned using clinical criteria, cannot substantiate the in vivo anticariogenic

potential of glass ionomer luting cements.

Clinical Applications of Glass-Ionomer Cements in conservaive dentistry.

Glass-ionomers have various uses within dentistry. They are used as full restorative materials,

especially in the primary dentition, and also as liners and bases, as fissure sealants and as

bonding agents for orthodontic brackets. They can be classified into three types, depending on

the intended clinical use, as follows:

Type I: Luting and bonding cements.

 For cementation of crowns, bridges, inlays, onlays and orthodontic appliances.

 Use relatively low powder:liquid ratio (1.5:1 to 3.8:1), leading to moderate strength only.

 Fast setting with good early resistance to water.

 Are radio-opaque.

Type II: Restorative cements.

There are two sub-divisions of Type II cements, depending on the importance of appearance.

For anterior repairs where appearance matters, Type II (i):

49
  Use high powder:liquid ratio (at least 3:1, and up to 6.8:1).

 Have a good colour match and translucency.

 Need protection from moisture for at least 24 hours with varnish or petroleum jelly.

 Are usually radio-opaque.

For use where appearance is not important (posterior restoration or repairs), Type II (ii):

 Also use high powder:liquid ratio (3:1 to 4:1).

 Fast set and early resistance to water uptake.

 Radio-opaque.

Type III: Lining or base cements

 Low powder:liquid ratio for liners (1.5:1) to allow good adaptation to the cavity walls.

 Higher powder:liquid ratio for bases (3:1 to 6.8:1), where the base acts as a dentine

substitute in the “open sandwich” technique in association with a composite resin.

 Radio-opaque.

Much of the work reported on the clinical effectiveness of glass-ionomers has been anecdotal,

and decisions on clinical applications have relied on the judgment and experience of clinicians.

Recent attempts to review all of the published evidence have confirmed that glass-ionomers do

have a measurable anti-caries effect. However, evidence to date is less clear about whether their

fluoride release is beneficial in practice].

50
CLINICAL APPLICATIONS OF GLASS-IONOMER CEMENTS IN ENDODONTICS

Root Canal Sealers

Root canal sealer properties have to comply with ANSI/ADA Specififi cation 57 and ISO

6876 . Regardless of the extensive use ofglass-ionomers as root canal sealers, there is very

limited research on the material properties and compliance to the specififi cations for root canal

sealers. Only the compliance of glass-ionomer materials for radiopacity (Shah et al. ;

Tanomaru-Filho et al. ) has been reported. Unfortunately, glass-ionomer sealers have also

shown high solubility and disintegration (Carvalho-Júnior et al. ), which is not in

compliance with the ADA specififi cations for root canal sealers (ADA Specififi cations No.

57, ). The main scope of a root canal sealer is to bind the gutta-percha to the dentine walls. Thus,

the ideal sealer should adhere to both the guttapercha and also to the dentine. Glass-ionomer

sealers have shown poor adhesive properties toboth root dentine and gutta-percha. This lack of

adhesion would imply a potential for increased microleakage if glass-ionomer is used as a

sealer. Studies evaluating microleakage of glassionomer sealers show that they consistently per

form worse than epoxy-based resin sealers and were comparable or even worse than zinc oxide

based root canal sealers. These evaluations were performed using dye leakage with methylene

blue (Smith and Steiman ; Rohde et al. ; Oliver and Abbott ; Kumar and Shruthi ), India ink

(Goldberg et al. ; Leonard et al. ), dye leakage with three dimensional reconstruction (Lyroudia

et al. ), salivary bacterial leakage (Malone and Donnelly ) and the flfl uid transport model

(Cobankara et al. ; Miletić et al. ; Economides et al. ). Glass-ionomer sealer provided adequate

51
sealing of the root canal and was comparable to a number of commercial sealers (Miletić et al. ).

The apical seal exhibited by glassionomer cement was not signififi cantly differ

ent from that provided by zinc oxide-eugenol cement regardless of the presence or absence of

a smear layer (Timpawat and Sripanaratanakul ), but inferior to that of a resin-based sealer

used in conjunction with a dentine bonding agent (Leonard et al. ) and a polydimeth

ylsiloxane-based root canal sealer (Cobankara et al. ). Epoxy resin-based sealers invari

ably exhibited a better seal than glass-ionomer sealers (De Almeida et al. ). In a previous

study, both a glass- ionomer sealer (Ketac Endo)and a zinc oxide-eugenol- based sealer

prevented coronal microleakage in the absence of a coronal restoration (Malone and Donnelly ).

In the Oliver and Abbott( study, interestinglyenough, coronal gutta-percha was removed and the

coronal 3 mm fifi lled with Ketac Endo only but not in the AH 26 (Dentsply, DeTrey, Konstanz,

Germany) group which served as the control. The study found comparable coronal leakage of

Ketac Endo specimens to the control group (AH 26), regardless of the different methodolo gies

used to obturate the root canals (Oliver and Abbott ).

Intra-orififi ce Barrier and Restorative Material

The use of glass-ionomer cement as an intraorififi ce barrier material and as an interim

dressingrelies on the material’s sealing ability, antimicrobial properties and adhesion. The use of

glassionomer cements to block the root canal orififice used in conjunction with gutta-percha

obturations is shown diagrammatically in Glass-ionomer signififi cantly reduced coronal

microleakage compared to a previously available thermoplastic synthetic polymer-based root

canal fifi lling, Resilon (resin-based solid cones) (Epiphany, Pentron Clinical Technologies,

Wallingford, CT, USA), used without sealer and the glass-ionomer intra-orififi ce barrier (Jack

52
and Goodell ). When used as a coronal barrier in cases of nonvital bleaching, glass-ionomer

provided adequate seal comparable to that of white MTA (Vosoughhosseini et al. ).

However,another research has shown a high degree of leakage when glass-ionomer was used as

an intracanal orififi ce barrier during tooth bleaching with sodium perborate and peroxide gel

(Canogluet al. ). Glass-ionomer used as a restorative material after root canal treatment is not

affected by the presence of other endodontic materials used for temporary fifi lling or sealers

present on dentine which are left from previous endodontic visits.The bond strength of dentine

with and without the presence of other endodontic materials was the same.

Root-End Filling Material

Root-end (retrograde) fifi lling materials should exhibit an adequate seal and also encourage cell

growth and differentiation particularly with periodontal ligament cells. The sealing ability of

glassionomer root-end fifi lling materials was reported to be comparable to that of amalgam, and

it was preferable to use a root-end fifi lling material rather than leave the tooth unfifi lled at the

root-end (Olsonet al. 1990 ). In several studies, conventional glassonomer cement used as a root-

end fifi lling material exhibited better sealing ability; it was shown to be better thanamalgam

(Chong et al. 1991 ; Ozata et al. 1993 ), silver- reinforced glass-ionomer (Ozata et al. 1993 ),

amalgam applied with varnish or amalgam applied with a dentine bonding agent Sutimuntanakul

et al. 2000 ). Both amalgam and glass-ionomer cement leaked signififi cantly more than a

calcium hydroxide-based sealer and composite resin when used as root-end fifi lling materials

(Danin et al. 1992 ). Glass-ionomer cementcan also be placed as a root-end fifi lling material

without a root-end cavity preparation. The resin modififi ed version of glass-ionomer materials

exhibits particularly good adaptation to the root canal walls (Chong et al. 1993 ).In more recent

studies, glass-ionomer root end fifi lling materials exhibited high levels of marginal gaps when

53
compared to Biodentine and MTA, which are both tricalcium silicate-based materials (Xavier et

al. 2005 ; Ravichandra et al.2014 ). In contrast, good marginal adaptation was observed with

glass-ionomer cements when measured directly and on resin replicas (Costa et al.2009 ) and

using capillary flfl ow porometry (DeBruyne et al. 2005 ). No correlation was observed between

marginal adaptation and apical sealing ability (Xavier et al. 2005 ; Costa et al. 2008 ). Glass-

ionomers were shown to be biocompatible as cells seeded on the materials were dense and

conflfl uent; the biocompatibility was similar to that of calcium silicate-based materials (Lee

et al. 2012 ). In contrast, in another study, poor cellular attachment was demonstrated in contrast

to that of MTA (Al-Hiyasat et al. 2012 ), with cellular apoptosis of periodontal ligament cells

(Lin et al. 2004 ).

Perforation Repair

Glass-ionomer cement has also been suggested for use as a perforation repair material. It is not

the ideal material for perforation repair as it does not preserve the integrity of the periodontal tis

sues (Vanni et al. 2011 ). In fact, glass-ionomer cement suppressed the growth of human peri

odontal ligament fifi broblast cells (Vajrabhayaet al. 2006 ), and its extracts were worse than

Super EBA, amalgam and MTA in inhibiting cell proliferation (Souza et al. 2006 ). However, it

was better than composite resin (Tai and Chang 2000 ) and leaked signififi cantly less (Lodiene

et al. 2011 ) but is not as effective as MTA for perforation repair (Bellam et al. 2009 ). A clinical

case showing the use of glass-ionomer cement to repair a lateral root perforation nonsurgically is

shown in , and a case of surgical perforation repair is shown in Although glass-ionomer cements

have been used for endodontic applications for a number of years, clinical studies to assess their

performance are scarce.

54
RECENT ADVANCES

Several efforts have been made to enhance the properties of GIC while maintaining the

bioactivity gained by releasing the ion. However, it was necessary to develop a “smart” material

that can overcome the adverse effects of the resin monomer and further induce remineralization

on the defective dentin. Efforts have also recently been underway to improve physical properties

and biocompatibility by using both BAG and HA as fillers.81

1. Glass ionomer cement containing bioactive glass

In some recent studies BAG has been used with GIC to improve bioactivity and induce tooth

regeneration. The use of bioactive materials has attracted attention in dentistry, particularly for

the purpose of dentin remineralization. The main inorganic component of the GIC comprises Si,

Al, and Ca and is ionized with polyacid, so it does not exhibit decomposition performance

Meanwhile, BAG contains specific weight percentages of Si, Na, Ca, and P and was introduced

by Hench in 1969 as 45S5 Bioglass with the following chemical composition and weight

percentages: 45 wt% SiO2, 24.5 wt% CaO, 24.5 wt% Na 2O, and 6.0 wt% P2O5. BAGs are

amorphous silicate-based materials which are compatible with the human body and can stimulate

new bone growth while dissolving over time83

In clinical situations, BAG was first used as a biomaterial to replace the loss of osseous tissues.

BAG is able to bind strongly to bone via the formation of HA and firm bonding between the

collagen and HA, and the body therefore tolerates the material well This material was initially

used in the reconstruction of bone loss due to periodontal diseases in bony defects BAG has

55
recently been used in the treatment of dentinal hypersensitivity; fine BAG particles are

incorporated into toothpaste or applied to tooth surfaces. BAG attaches to the dentin surface and

quickly forms a hydroxycarbonapatite layer, which seals the tubules and relieves pain

Some researchers have studied the physical and chemical properties to evaluate the effect of

BAG materials on tooth structure. There are several studies on the effect of BAG addition on the

physical properties of RMGI Although the compressive strength of the composition is reportedly

slightly reduced, it is much higher than that of the GIC containing BAG.

Adding BAG particles to GIC decreases compressive strength and the modulus of elasticity. This

suggests that the BAG particles might be only loosely attached to the GIC matrix. Thus, BAG

particles probably acted as fillers that had not been adhered into the GIC matrix, leading to

decreased compressive strength and modulus of elasticity Therefore, the development of

bioactive GICs, that does not involve a deterioration in mechanical properties, seems to be

needed. Main research has been specifically focused on the application of nanoparticles to dental

materials, including GICs, to improve the mechanical properties of the matrix and strengthen

communication with cells derived from dental tissue to facilitate regeneration Several

nanomaterials such as hydroxyl- (or fluoro-) apatite, titanium oxide, zirconia, and resin and

combinations thereof have been incorporated into the existing GIC. One of the nanoparticles

indicated for use in GIC is a BAG nanoparticle The BAG nanoparticle, combined with the matrix

of GIC, increases surface area and biological activity and greatly improves mechanical/biological

properties as an additive per particle weight over that of conventional micro-sized BAG particles

56
2. Glass ionomer cement containing hydroxyapatite

HA has been beneficial in the field of dentistry due to its unique radiopacity and other properties

The application of current nano-sized biomaterials is known to be potentially more useful in

dentistry. They have wide applications because of greater strength, polishability, and aesthetic

value than commercial modifiers Recent advances in the synthesis of HA in various sizes and

forms have enabled HA to be used as a biocompatible filler for natural tooth materials. In

addition, HA showed excellent biological activity and played an important role in orthopedics

because of its bone-inducing and bioactive properties 84

Nanotechnology involves the use or modification of 1 to 100-nm materials Major applications of

nanotechnology in dentistry include surface modification of implants enhanced polymer

composites with nano-sized particles and caries prevention .Recent research shows that the

addition of nanoparticles or nanoclusters increases the mechanical strength of tooth fillers such

as resin composites Similar attempts have been made to improve the mechanical properties of the

GIC using nanotechnology Introduction of nano-sized apatite not only maintains the mechanical

properties of the GIC at all times, but also increases the release of fluoride ions Studies have also

reported that GIC containing nano-sized apatite has better biocompatibility than conventional

GIC 86

57
A schematic diagram that binds the nanorod hydroxyapatite (nHA) to the silicate surface.

Aminopropyltriethoxysilane (A) is a coupling agent used to conjugate amino groups to the glass

surface. The amino acids introduced on the surface of the silicate can react with nHA fixed

carboxylic acid to produce silicate-nHA.

Apatite crystals increase the crystallinity of cured matrix, further stabilizing the hardening

cement and improving the bond strength with the tooth structure Increasing fluoride release can

reduce secondary caries around the restoration site However, the possibility of interfacial failure

of glass and bioceramic can be a problem that can affect the physical properties of the cured

58
cement The crystals of nano-HA preferentially remineralize enamel Recent reports suggest that

the nano-HA-modified resin composite has improved mechanical properties over the unmodified

resin composite Similarly, adding nano-HA or nano-fluoroapatite to the powder content of GIC

had a positive effect on compressive, tensile, and flexural strength of the cured cement Fourier-

transform infrared spectroscopy showed that adding apatite to GIC powder has been found to

increase the crystallinity of cured GICs, which in turn improves chemical stability and water

insolubility This results in a better survival rate than that observed with commercialized GICs

The improved mechanical properties of GIC modified by HA are due to ionic bonds of

polyacrylic acid and HA crystals As a strong ionic bond is formed between the calcium ion of

the tooth structure and the crystal of the apatite of the cement, the GIC containing nano-HA is

expected to strongly bond to the surface of teeth In addition, reducing the particle size of HA

from a micrometer scale to a nanometer scale significantly increases the surface area, and

improves infiltration into dentin and enamel pores where crystals have been demineralized; this

can improve bonding at the tooth-ionomer interface 87

HA infiltered GIC, called glass carbomer, includes substances that are established by the acid-

base reaction between the aqueous polymer acid and the ion leaching base glass, but they also

include substances not commonly included in glass ionomer formulations As such, the bioactive

component acts as a secondary filler. According to solid state nuclear magnetic resonance

spectroscopy, this filler is actually HA and is included to promote the formation of enamel-like

substances in contact with the tooth, as previously studied with GIC used as fissure sealants.

Since glass carbomers contain a higher proportion of glass than that in conventional GIC, as well

as HA fillers, the set glass carbomers are brittle. Silicone oil is added to overcome this problem It

59
strengthens the material and remains bound by hydrogen bonding. The setting of glass carbomer

involves two parallel reactions, one involving the glass plus polyacid and the other involving HA

plus polyacid. Both are acid-base reactions, resulting in an ionic crosslinking polyacid matrix

containing embedded filler. However, the filler is not only ion-depleted glass, but in this case

also contains a partially reactive HA. Thus, the matrix is similar to that obtained using

conventional GIC, except that it contains polydimethylsiloxane oil 89

There are only preliminary studies on the clinical use of glass carbomer thus far; however, no

long-term studies have been conducted for this material. Consequently, the durability of this

material in the oral cavity of patients is not yet known

60
STUDIES ON GIC

John W. Osborne, Marjorie L. Swartz, Charles J. Goodacre, Ralph W.

Phillips, Elliot N. Gale devised a method for assessing the clinical solubility

and disintegration of luting cements in 1978. Silicophosphate, polycarboxylate,

Zinc Phosphate and EBA-Alumina were taken for the tests. No correlation was

observed between the clinical data on loss of material and the solubility of the

cements as measured by conventional in vitro tests 1 0 .

John W. Mc Lean, Alan D. Wilson, Samuel E. Guyer, William Lefkowitz,

William P. Malone and John E. Rhodes in 1984 have described the

development and uses of water-hardening glass ionomer luting cements. The

ideal properties of luting cements were described by Wilson et al& Mc Lean as

low viscosity and film thickness, long working time with rapid set at mouth

temperature, good resistance to aqueous or acid attack, high compressive &

tensile strength, resistance to plastic deformation, adhesion to tooth structure

and restoration, cariostatic, biologic compatibility with pulp, translucency and

radiopacity. Glass Ionomer cements are more resistant to plastic deformation

than zinc polycarboxylate cements and are therefore useful materials for

cementation of post crowns constructed with cast gold posts and cores or

61
prefabricated posts. The objective of their article was to develop cement that

meets the ideal requirements listed by Wilson & Mc Lean 1 1 .

Pluim LJ, Arends J, Havinga P, Jongebloed WL, Stokroos I. conducted a

study, in 1984, for the assessment of solubility which has been obtained only

with the use of in situ models consisting of intra oral appliances that can be

removed from the mouth for subsequent measurement of material loss. The

results obtained by the in situ models have two important limitations: First, the

dissolution is determined as a result of physicochemical erosion, not mechanical

fatigue in crowns and fixed partial dentures; and second, a large cement surface

is exposed directly to the oral fluids, whereas a thin layer of cement is subjected

to the oral environment under clinical conditions 1 2 .

B.W.Bertenshaw, V.Piddock, studied, in 1993, the deleterious effects of

porosity in glass ionomer, zinc polycarboxylate and zinc phosphate dental

cements under an optical microscope. It has been postulated that larger pores are

due to entrapment of air during mixing and the finer porosity results from the

loss of excess water. Pores of approximately 20µm diameter were observed in all

materials and finer pores were seen in zinc oxide containing cements 1 3 .

Shane N. White and Zhaokun Yu, in 1993, considered compressive strength as

a critical indicator for the success of luting agents as it is a necessary parameter

to tolerate masticatory forces. Their study showed that compressive and

62
diametral tensile strengths of composite resins and glass ionomer is greater than

that of zinc phosphate cements. the compressive and diametral tensile strengths

of adhesive luting agents varied widely 1 4 .

Watid Sadig, Emad Al-Qudami, in 1995, evaluated the film thickness of five

relatively new adhesive luting composite resins in comparison to Zinc Phosphate

cement, since it is the most "tried and proven" material for permanent

conventional cementation. However, the chemical components, filler particle

size, viscosities, diluting monomers, and setting reactions were reformulated to

result in a lower film thickness of the various new adhesive luting resins. The

film thickness of all the resin-based cements investigated in this study ranged

between 22 and 27 µm. The mean film thickness of All-Bond resin cement was

approximately 60µm. Therefore, according to the ADA Specification No. 8 it is

recommended for all uses, except for cementing precision appliances 1 5 .

Khamis Hassan, Salwa Khier, in 1997, investigated the effects of gamma

radiation at three therapeutic dosage levels on the diametral tensile strength

(DTS) and microhardness of three photo-cured glass ionomer cements. It was

also the objective of this study to compare the materials before and after

irradiation using infrared spectroscopy for detection of any possible alterations

in their chemical structure. Oral cancer patients, receiving gamma radiation as

primary or supplementary treatment, commonly have a variety of dental

restorations including resin-containing glass ionomer cements. The results of

63
this study showed, in general, a significant increase in the DTS values for the

investigated photo-cured (resin-modified) glass ionomer restorative materials

after gamma radiation at three dosage level. This increase in DTS could be

attributed to the possible effect of the incident therapeutic radiation beam on the

carbon-to-carbon bond in the organic monomeric additives, incorporated to

modify the conventional glass ionomer restorative materials. The carbon-to-

carbon bond, an essential chemical structure component in these organic resin

additives which connects the polymeric molecules in a chain reaction, would

bear a postradiation high energy that would result in an increased DTS 1 6 .

Andree Piwowarczyk, Peter Ottl, Hans- Christoph Lauer, in 2001, conducted

an in vitro study to examine 3 mechanical properties , namely compressive,

flexural and diametral tensile strength of various commercially available

cements and core materials as a function of time after mixing. Commercially

available cements used were 2 cermet cements, 1 metal-reinforced glass ionomer

cement, 2 conventional glass ionomer cements and 1 standard cure zinc

phosphate cement. This study affirmed that setting time influences the

mechanical properties of the materials tested. Glass ionomer cement reinforced

with sintered glass silver particles (Cermet Cement) showed the highest

mechanical properties of the examined materials 1 7 .

Jose C. de la Macorra, Guillermo Pradies in 2002 have given a detailed

description of conventional and adhesive luting cements. Thay have stated that

64
for the success of a restoration the quality and choice of luting cement is of

prime importance. He has concluded that There is no ideal luting material

available on the market today. The interested dentist has several options for

luting indirect restorations and should use specific selection criteria. Alleged

improvements in the physical properties of newer materials do not necessarily

result in better clinical performance 1 8 .

Hiraishi N, Kitasako Y, Nikaido T, Foxton RM, Tagami J, Nomura S.

examined the changes in pH of luting cements through bovine dentin using a pH-

imaging microscope, in 2003. They concluded that glass ionomer exhibited a

lower setting pH than zinc phosphate and zinc polycarboxylate, and acid

diffusions from glass ionomer and zinc phosphate cements were observed when

placed on 0.25mm-thick-dentin disks 1 9 .

Nathaniel C. Lawson, John O. Burgesss, Donald Mercante in 2007 conducted

a study related to the retention of cast crowns with eight different provisional

luting cements and correlate the retention to their flexural strength. Their results

proved that resin based cements provide more retention compared to zinc oxide

eugenol. Desired amount of retention is based on crown preparation and the

choice of cement 2 0 .

Keishi Tsubota, Kentarou Mori, Genta Yasuda, Ryo Kawamoto, Takeshi

Yoshida, Kanako Yamaguchi monitored the setting behaviour and modulus of

elasticity of luting cements using an ultrasonic device in 2008. This study

65
showed that there is an initial increase in the elastic modulus of cements and a

gradual drop after a month’s time 2 1 .

AG in 1986 has listed the main advantages of glass ionomer cements, which set

through an acid-base reaction, are an ability to bond chemically to enamel and

dentin, a long term fluoride release and a coefficient of thermal expansion

similar to tooth tissues 3 7 .

H. Al-Munif, R.L. Cooley, J.W. Robbins, in 1989, studied the bond strength of

two glass ionomer restora tive materials (Ketac-Fil and Fuji II) to recently

extracted teeth and extracted teeth stored in forma lin. The bond strengths of

Ketac-Fil to aged extracted and recently extracted teeth was essentially the

same. The bond strength of Fuji II to recently extracted teeth was statistically

stronger than to aged extracted teeth, but this difference was not thought to be

of practical significance 3 8 (Fig-28).

66
 Fig-28

P. Mojon, E. B. Howbolt, Mac Entee in 1989 found out the bond strengths of 3

different luting cements viz. Glass ionomer. Adhesive resin and zinc phosphate

to amalgam alloy which is quite often used under artificial crowns for

restoration of severely damaged teeth. Weibull analysis demonstrated that the

adhesive resin cement provided a stronger and more predictable bond than either

glass ionomer or zinc phosphate cement 3 9 .

F. Salama, D.R. Myers in 1992 , reviewed the indications, modifications of the

basic technique of stainless steel crowns, related common errors, retention of

crowns, and gingival condition surrounding restored teeth, from various

literature and articles. They stated that Berg et al evaluated microleakage of

three luting agents used with stainless steel crowns. They found that glass

67
ionomer cement provides comparable protection to that of polycarboxylate and

zinc phosphate cements. Myers et al reported that crown retention with cement

was significantly higher than mechanical retention alone. Stainless steel crown

retention with polycarboxylate or zinc phosphate cement was significantly

greater than crown retention with zinc oxide eugenol cement. Savide et al

confirmed that mechanical retention does not contribute significantly to crown

retention and that cement significantly increases crown retention with all

preparations. Noffsinger et al observed no significant difference in crown

retention between polycarboxylate cement and glass ionomer cement 4 0 .

Shane White and Zhaokun Yu stated in 1993 that strength parameters greatly

influence the selection of luting cements. They compared the compressive and

diametral tensile strengths of six classes of new adhesive luting agents with zinc

phosphate as the controls and concluded that conventional glass ionomer, resin-

glass ionomer hybrid, encapsulated glass ionomer adhesive luting agent and

composite resins have significantly greater compressive and diametral strengths

than the zinc phosphate cements. Hence these newer adhesive luting agents can

tolerate masticatory forces better than zinc phosphates 4 1 .

Iman A.AI Badry, Faten M.Kamel have published a review literature in 1994

enlisting the clinical use of Glass Ionomer Cement and its composition, setting

reaction, types and properties which make it suitable as a restorative and luting

cement 4 2 .

68
Laila A. Saleh, Moustafa F. Khaiil, in 1994, evaluated the effect of 5

different protective coatings on the surface hardness of Glass Ionomer Cements.

They concluded that none of the protective coatings used in this study were able

to maintain the original surface hardness of the unprotected glass ionomer

restorative. Cocoa butter, Ketac varnish and nail polish were the least effective

in reducing the surface hardness of Ketac-Fil compared to Copalite varnish and

unfilled light-cured resin 4 3 .

Iman A.AI-Badry, Faten M. Kamel, in 1996 demonstrated the various clinical

uses of Glass ionomer cement. Glass ionomer cement, introduced 21 years ago,

was the first adhesive restorative material with cariostatic property. The

currently accepted classification of GICs includes: luting, restorative, reinforced

and lining cements. These cements permit a wide variety of clinical applications

including: cementation of castings, restoration of minimal lesions, crown

buildups and cavity lining. GICs have been recognized by pediatric dentists as

being well suited to preventive dentistry demands 4 4 .

Khamis Hassan, Salwa Khier, in 1997, investigated the effects of gamma

radiation at three therapeutic dosage levels on the diametral tensile strength

(DTS) and microhardness of three photo-cured glass ionomer cements. It was

also the objective of this study to compare the materials before and after

irradiation using infrared spectroscopy for detection of any possible alterations

in their chemical structure. Oral cancer patients, receiving gamma radiation as

69
primary or supplementary treatment, commonly have a variety of dental

restorations including resin-containing glass ionomer cements. The results of

this study showed, in general, a significant increase in the DTS values for the

investigated photo-cured (resin-modified) glass ionomer restorative materials

after gamma radiation at three dosage level. This increase in DTS could be

attributed to the possible effect of the incident therapeutic radiation beam on the

carbon-to-carbon bond in the organic monomeric additives, incorporated to

modify the conventional glass ionomer restorative materials. The carbon-to-

carbon bond, an essential chemical structure component in these organic resin

additives which connects the polymeric molecules in a chain reaction, would

bear a postradiation high energy that would result in an increased DTS 1 6 .

Zhen Chu Li and Shane N. White evaluated mechanical properties of certain

cements in 1999. Glass ionomer cements provide superior resistance to marginal

gap formation and crown dislodgement. Their study stated that cements varied

with respect to compressive proportional limit, elastic moduli, compressive

strength, resilience and toughness, diametral tensile strength, flexural strength

and toughness. Storage time affected the elastic moduli in different ways.

Elastic moduli of polycarboxylate and glass ionomer cements increased over

time, whereas the other materials changed little after the first day 4 5 .

70
Simonides Consani; Julie Guzela dos Santos; Lourenço Correr Sobrinho I ;

Mário Alexandre Coelho Sinhoreti I ; Manoel Damião Sousa-Neto in 2003,

studied the relationship between metallic cast crowns and tensile strength

according to cement types submitted to thermocycling. Difference in finish line

was introduced and each of the castings were cemented with zinc phosphate and

resin bonded GIC showing that independent of finish lines, increased tensile

strength was observed in those metallic restorations cemented with resin bonded

GIC 4 6 .

Zhuoqun Yan, Sharanbir K. Sidhu, Thomas E. Carrick, John McCabe, in

2007, designed a study to determine the dimensional changes of glass ionomers

(conventional, high viscosity, resin modified GIC) caused by thermal stimuli

under both dry and wet conditions. All materials showed contraction on heating

in dry condition but in wet condition they maintained their original dimension.

However resin modified glass ionomer showed expansion on heating in wet and

dry conditions. This is considered as their “smart” behaviour in which the

material can respond to a particular stimulus in a specific and controlled way

which is beneficial to their function 4 7 .

Ajaykumar Ashokkumar Nayak, in 2008, describes a simple method to protect

crown margins from moisture, during cementation, using petroleum jelly. Glass

ionomer is a commonly used luting cement, owing to its excellent bond to tooth

structure and metal, strength, radiopacity and handling properties.

71
Contamination with water or saliva is considered an important clinical

problem 4 8 .

James L. Sheets, Charles Wilcox & Terry Wilwerding in 2008, assessed and

compared the retentive nature of common glass ionomer cements that have been

used in the implant abutment cement retained crown technique with those

specifically formulated for this purpose. Within the limitations of this in vitro

study, it is not suggested that any one cement is better than another at retaining

cement-retained crowns (CRCs) to implant abutments or that a threshold value

must be accomplished to ensure retention. The rankings of cements presented is

a discretionary guide for the clinician in deciding the amount of desired

retention between castings and implant abutments 4 9 .

72
CONCLUSION

Glass ionomer cements are amongst the most widely used cements of the day

owing to their favourable physical, mechanical, biological and esthetic

properties. They are appealing both to the operator and to the patient. Glass

ionomer modified cements are much stronger than conventional glass ionomers

and can be compared to resin cements 6 7 .Future developments in GICs are likely to

deliver improvements in strength, wear resistance and aesthetic properties. These improve

ments will allow the material to increase its longevity in load-bearing situations, thus

allowing the material to become a viable alternative to amalgam restorations. Other new

features likely to be focused on include optimising biomimetic, biomineralising or antimi

crobial properties to provide new-generation GICs. Glass-ionomer cements will continue to

be considered as “smart” materials due to their dynamic interaction with tooth structure and

the surrounding.

REFERENCES

73
1. Anusavice, Phillips’ Science of Dental Materials; Chiayi Shen, Dental

Cements; 11 t h Edition, Elsevier Publication; 443-92

2. Clifford M. Sturdevant, John R. Sturdevant; Art & Science of Operative

Dentistry; Edward J Swift, John R Sturdevant, Andre V Ritter; Classes I and

II Indirect Tooth coloured restorations; 4 t h Edition, Mosby Publication; 569-

74

3. Ana M. Diaz-Arnold, Marcos A. Vargas and Debra R. Haselton. Current

status of luting agents for fixed prosthodontics. J Prosthet Dent. 1999; 81:

135-141

4. Stephen C Bayne, Dental Cements for Luting and Bonding, UNC School of

Dentistry publication; 2004

5. The Glossary of Prosthodontic terms; J Prosthet Dent. 2005;94: 10-92

6. Thomas M. Schulein ; Significant Events in the History of Operative

Dentistry. Journal of the History of Dentistry. 2005; 53: 67-70

7. Clifford M. Sturdevant, John R. Sturdevant; Art & Science of Operative

Dentistry; Theodore M. Roberson; Introduction to operative Dentistry; 4 t h

Edition, Mosby Publication; 3-4

8. Bandar M. A. Al-Makramani, A. A. A. Razak, M. I. Abu Hassan. Effect of

different luting agents on the fracture resistance of Procera All Ceram

copings. J Prosthodont. 2008; 17: 120-124

9. Pascal Magne. Immediate Dentin Sealing: A Fundamental Procedure for

Indirect Bonded Restorations. J Esthet Restor Dent. 2005; 17:144–155

74
10. John W. Osborne, Marjorie L. Swartz, Charles J. Goodacre, Ralph W.

Phillips, Elliot N. A method of assessing clinical solubility and

disintegration of luting cements. J Prosthet Dent 1978; 40: 413-417

11. John W. Mc Lean, Alan D. Wilson, Samuel E. Guyer, William Lefkowitz,

William P. Malone, John E. Rhodes. Development and uses of water-

hardening glass ionomer luting cements. J Prosthet Dent. 1984; 52:

175-181

12. Pluim LJ, Arends J, Havinga P, Jongebloed WL, Stokroos I. Quantitative

cement solubility experiments in vivo. J Oral Rehabil 1984; 11:171-179

13. B.W.Bertenshaw, V.Piddock. Porosity in water-based dental luting cements.

J Mater Sci. 1993; 4: 415-417

14. Shane N. White and Zhaokun Yu. Compressive and diametral tensile

strengths of current adhesive luting agents. J Prosthet Dent. 1993; 69: 568-72

15. Watid Sadig, Emad Al-Qudami. Evaluation Of The Film Thickness Of New

Adhesive Luting Resins. SDJ. 1995; 7: 77-81

16. Khamis Hassan, Salwa Khier. Effect Of Therapeutic Gamma Radiation On

Diametral  Tensile Strength And Microhardness Of Photo-cured Glass

Ionomer Cements. SDJ. 1997; 9: 120-124

17. Andree Piwowarczyk, Peter Ottl, Hans- Christoph Lauer. Laboratory

strength of Glass Ionomer and Zinc Phosphate cements. J Prosthodont. 2001;

10: 140-147

18. Jose C. de la Macorra, Guillermo Pradies. Conventional and adhesive

luting cements. Clin Oral Invest. 2002; 6: 198-204

75
19. Hiraishi N, Kitasako Y, Nikaido T, Foxton RM, Tagami J, Nomura S.

Acidity of conventional luting cements and their diffusion through bovine

dentin. Int Endo J. 2003; 36: 622-628

20. Nathaniel C. Lawson, John O. Burgesss, Donald Mercante. Crown

retention and Flexural Strength of eight provisional cements. J Prosthet Dent.

2007; 98: 455-460

21. Keishi Tsubota, Kentarou Mori, Genta Yasuda, Ryo Kawamoto, Takeshi

Yoshida, Kanako Yamaguchi. Setting behaviour of luting cements

monitored by an ultrasonic method. J Oral Sci. 2008; 50: 117-121

22. A.D. Wilson, J.W. Nicholson; Chemistry of solid state materials; Acid Base

Cements; A. R. West, H. Baxter; Page 5-314

23. Rita Virmani, Richard D. Norman, Marjori Swartz. The pH of setting

cements. III. In vivo. J Prosthet Dent. 1970; 23: 66-72

24. Martin Bransstrom, Hilding Nyborg . Bacterial growth and pulpal changes

under inlays cemented with zinc phosphate cement and Epoxylite CBA 9080.

J Prosthet Dent; 1974; 31: 556-564

25. Ralph G.Silvey, George E.Myers. Clinical Studies of dental cements: V.

Recall Evaluation of restorations Cemented with a Zinc Oxide-Eugenol

Cement and a Zinc Phosphate Cement. J Dent Res. 1976; 55: 289-291

26. Matthias Kern, Brigitte Kleimeir, Scghaller, Rudolf Strub. Clinical

comparison of postoperative sensitivity for a glass ionomer and a zinc

phosphate luting cement. J prsothet Dent. 1996; 75: 159-162

76
27. Shane White and Zhaokun Yu. Film thickness of new adhesive luting

agents. J Prosthet Dent. 1992; 67: 782-785

28. William J. O’ Brien. Dental Materials and their Selection; Dental Cements;

4 t h Edition Quintessence Publication, 134-159

29. Kaare Langeland and Leena Langeland. Pulp reactions to crown

preparation, impression, temporary crown fixation and permanent

cementation. J Prosthet Dent. 1965; 15: 129-143

30. R. W. Philips, M. L. Swartz, R. D. Norman, R. J. Scnell, B. F. Black.

Zinc oxide and eugenol cements for permanent cementation. J Prosthet Dent.

1968; 19: 144-150

31. S. E. Sorensen, M. A. Bingeman, J. D. Eick. The effects of mechanical

mixing on some physical properties of zinc cements. J Prosthet Dent. 1970;

23: 73-80

32. Takio Tsubaraya, Norimasa Kurosaki, Toshio Tukatsu, Masato

Nakamura. Surface adhesion and retentive force of cements. J Prosthet Dent.

1984; 52: 57-60

33. Kai Chiu Chan, Daniel B. Boyer, Gerald E. Denehy, Douglas C. Aunan.

Effect of metal etching on crown retention. J Prosthet Dent. 1986; 55: 18-20

34. Shane White, Zhaokun Yu, Victor Kipnis. Effect of seating force on film

thickness of new adhesive luting agents. J Prosthet Dent. 1992; 68: 476-81

35. Steven O. Hondrum. Storage stability of dental luting agents. J Prosthet

Dent. 1999; 81: 464-468

77
36. Aleksandra D. Milutinovic, Vesna B. Medic, Zorica M. Vukovic. Porosity

of different luting cements. Dent Mater. 2007; 23: 674-678

37. Walls AG. Glass polyalkeonate (glass ionomer) cements: A review. J Dent

1986; 14: 231-246

38. H. Al-Munif, R.L. Cooley, J.W. Robbins. Bond strength of glass ionomers

as restorative materials. SDJ. 1989; 1: 74-77

39. P. Mojon, E. B. Howbolt, Mac Entee. Maximum bond strength of Dental

Luting Cement to amalgam alloy. J Dent Res. 1989; 68: 1545-1549

40. F. Salama, D.R. Myers in 1992. Stainless steel crown in clinical

pedodontics: A review. SDJ.1992; 4:70-74

41. Shane White and Zhaokun Yu. Compressive and diametral tensile strengths

of current adhesive luting agents. J Prosthet Dent. 1993; 69:568-572

42. Iman A.AI Badry, Faten M.Kamel. Clinical Use of Glass Ionomer Cement:

A Literature review. SDJ (Saudi Dental Journal). 1994; 6: 107-116

43. Laila A. Saleh, Moustafa F. Khaiil. The Effect of Different Protective

Coatings on the Surface Hardness of Glass Ionomer Cements. SDJ. 1994; 6:

3-7

44. Iman A.AI-Badry, Faten M. Kamel. Clinical Use Of Glass Ionomer Cement:

A Review. SDJ. 1996; 4: 7-16

45. Zhen Chu Li, Shane N. White. Mechanical properties of dental luting

cements. J Prosthet Dent. 1999; 81: 597-609

46. Simonides Consani; Julie Guzela dos Santos; Lourenço Correr Sobrinho I ;

Mário Alexandre Coelho Sinhoreti I ; Manoel Damião Sousa-Neto. Effect

78
 of cement types on the tensile strength of metallic crowns submitted to

thermocycling. Braz Dent J.  2003. 14: 110-120

47. Zhuoqun Yan, Sharanbir K. Sidhu, Thomas E. Carrick, John McCabe.

Response to thermal stimuli of glass ionomer cements. Dent Mater. 2007; 23:

597-600

48. Ajaykumar Ashokkumar Nayak. A simple method to protect crown margins

from moisture during cementation. JIPS. 2008; 8: 154-155

49. James L. Sheets, Charles Wilcox & Terry Wilwerding. Cement selection

for cement-retained crown technique with dental implants. J Prosthodont.

2008; 17: 92-96

50. Wilson AD, Kent BE . A new transluscent cement for dentistry. The glass

ionomer cement. Br Dent J 1972; 132:133-135

51. Mount GJ. Glass ionomers: A review of their current status. Oper Dent

1999; 24: 115-124

52. McLean JW, Wilson AD, Prosser HJ. Development and use of water-

hardening glass ionomer luting cements. J Prosthet Dent 1984; 52: 175-181

53. Wilson AD. Resin modified glass ionomer cements. Int J Prosthodont 1990;

3: 425-429

54. Rosenstiel SF, Land MF, Crispin BJ . Dental luting agents: A review of

current literature. J Prosthet Dent 1998; 80: 280-301

55. Brackett WW, Metz JE. Performance of glass ionomer luting cement over 5

years in a general practice. J Prosthet dent 1992; 67: 59-61

79
56. Metz JE, Brackett WW . Performance of glass ionomer luting cement over 8

years in a general practice. J Prosthet dent 1994;71:13-15.

57. Pameijer CH, Nilner K. Long term clinical evaluation of three luting

materials. Swed Dent J 1994; 18: 59-67

58. Bebermeyer RD, Berg JH. Comparison of patient-perceived postcementation

sensitivity with glass ionomer and zinc phosphate cements. Quintessence Int

1994; 25: 209-241

59. Kern M, Kleimeier B, Schaller HG, Strub JR . Clinical comparison of

postoperative sensitivity for a glass ionomer and a zinc phosphate luting

cement. J Prosthet Dent 1996; 75: 159-162

60. van Dijken JW, Ormin A, Olofsson AL. Clinical performance of pressed

ceramic inlays luted with resin-modified glass ionomer and autopolymerising

resin composite cements. J Prosthet Dent 1999; 82: 529-535

61. White SN, Yu Z, Tom JF, Sangsurasak S. In vivo microleakage of luting

cement for cast crowns. J Prosthet Dent 1994; 71: 333-338

62. White SN, Yu Z, Tom JF, Sangsurasak S. In vivo marginal adaptation of

cast crowns luted with different cements. J Prosthet Dent 1995; 74 :25-32

63. Phillips RW, Swartz ML, Lund MS, Moore BK, Vickery J. In vivo

disintegration of luting cements. J Am Dent Assoc 1987; 114: 489-492

64. Hersek NE, Canay S. In vivo solubility of three types of luting cement.

Quientessence Int 1996; 27: 211-216

65. Bernard G. N. Smith, Leslie C. Howe; Planning and Making Crowns and

Bridges; Clinical techniques for making crowns; Fourth Edition; Informa

80
 Healthcare publishers, 2007; 157, 171 (Cementation of temporary crowns and

definitive placement)

66. Aphrodite I. Kakaboura; Aging of Glass Ionomer Cements; Eliades/

Brantley & Watts; Dental Materials in Vivo: Aging and related phenomena;

Quintessence Publishing

67. John J. Manappallil ; Basic Dental Materials; Dental Cements; 2 n d edition;

Jaypee Publication; 214-262

68. Wilson AD. Glass-ionomer cement--origins, development and future. Clin Mater.

1991;7(4):275-82. [PubMed]

69. Ching HS, Luddin N, Kannan TP, Ab Rahman I, Abdul Ghani NRN. Modification of glass

ionomer cements on their physical-mechanical and antimicrobial properties. J Esthet Restor

Dent. 2018 Nov;30(6):557-571. [PubMed]

70. Nicholson JW. Maturation processes in glass-ionomer dental cements. Acta Biomater

Odontol Scand. 2018;4(1):63-71. [PMC free article] [PubMed]

71. Sidhu SK, Nicholson JW. A Review of Glass-Ionomer Cements for Clinical Dentistry. J

Funct Biomater. 2016 Jun 28;7(3) [PMC free article] [PubMed]

72. Khoroushi M, Keshani F. A review of glass-ionomers: From conventional glass-ionomer to

bioactive glass-ionomer. Dent Res J (Isfahan). 2013 Jul;10(4):411-20. [PMC free article]

[PubMed]

73. Tay WM, Lynch E. Glass-ionomer (Polyalkenoate) cements. Part 1. Development, setting

reaction, structure and types. J Ir Dent Assoc. 1989 Jun;35(2):53-7. [PubMed]

81
74. Francisconi LF, Scaffa PM, de Barros VR, Coutinho M, Francisconi PA. Glass ionomer

cements and their role in the restoration of non-carious cervical lesions. J Appl Oral Sci.

2009 Sep-Oct;17(5):364-9. [PMC free article] [PubMed]

75. Hill EE, Lott J. A clinically focused discussion of luting materials. Aust Dent J. 2011 Jun;56

Suppl 1:67-76. [PubMed]

76. Manihani AKDS, Mulay S, Beri L, Shetty R, Gulati S, Dalsania R. Effect of total-etch and

self-etch adhesives on the bond strength of composite to glass-ionomer cement/resin-

modified glass-ionomer cement in the sandwich technique - A systematic review. Dent Res J

(Isfahan). 2021;18:72. [PMC free article] [PubMed]

77. Yengopal V, Mickenautsch S, Bezerra AC, Leal SC. Caries-preventive effect of glass

ionomer and resin-based fissure sealants on permanent teeth: a meta analysis. J Oral Sci.

2009 Sep;51(3):373-82. [PubMed]

78. Saber AM, El-Housseiny AA, Alamoudi NM. Atraumatic Restorative Treatment and

Interim Therapeutic Restoration: A Review of the Literature. Dent J (Basel). 2019 Mar

07;7(1) [PMC free article] [PubMed]

79. Wiegand A, Buchalla W, Attin T. Review on fluoride-releasing restorative materials--

fluoride release and uptake characteristics, antibacterial activity and influence on caries

formation. Dent Mater. 2007 Mar;23(3):343-62. [PubMed]

80. Mousavinasab SM, Meyers I. Fluoride release by glass ionomer cements, compomer and

giomer. Dent Res J (Isfahan). 2009 Fall;6(2):75-81. [PMC free article] [PubMed]

81. Lad PP, Kamath M, Tarale K, Kusugal PB. Practical clinical considerations of luting

cements: A review. J Int Oral Health. 2014 Feb;6(1):116-20. [PMC free article] [PubMed]

82
82. Lee JH, El-Fiqi A, Jo JK, Kim DA, Kim SC, Jun SK, et al. Development of long-term

antimicrobial poly(methyl methacrylate) by incorporating mesoporous silica nanocarriers.

Dent Mater. 2016;32:1564–74. [PubMed] [Google Scholar]

83. Padovani GC, Feitosa VP, Sauro S, Tay FR, Duran G, Paula AJ, et al. Advances in dental

materials through nanotechnology: facts, perspectives and toxicological aspects. Trends

Biotechnol. 2015;33:621–36. [PubMed] [Google Scholar]

84. Oliveira-Ogliari A, Collares FM, Feitosa VP, Sauro S, Ogliari FA, Moraes RR.

Methacrylate bonding to zirconia by in situ silica nanoparticle surface deposition. Dent

Mater. 2015;31:68–76. [PubMed] [Google Scholar]

85. Mabrouk M, Selim MM, Beherei H, El-Gohary MI. Effect of incorporation of nano

bioactive silica into commercial glassionomer cement (GIC) J Genet Eng Biotechnol.

2012;10:113–9. [Google Scholar]

86. Choi JY, Lee HH, Kim HW. Bioactive sol-gel glass added ionomer cement for the

regeneration of tooth structure. J Mater Sci Mater Med. 2008;19:3287–94. [PubMed]

[Google Scholar]

87. Saravana KR, Vijayalakshmi R. Nanotechnology in dentistry. Indian J Dent Res.

2006;17:62–5. [PubMed] [Google Scholar]

88. Lee JH, Seo SJ, Kim HW. Bioactive glass-based nanocomposites for personalized dental

tissue regeneration. Dent Mater J. 2016;35:710–20. [PubMed] [Google Scholar]

89. Park SJ, Gupta KC, Kim H, Kim S, Kang IK. Osteoblast behaviours on nanorod

hydroxyapatite-grafted glass surfaces. Biomater Res. 2019;23:28. [PMC free article]

[PubMed] [Google Scholar]

83
90. Moshaverinia A, Ansari S, Moshaverinia M, Roohpour N, Darr JA, Rehman I. Effects of

incorporation of hydroxyapatite and fluoroapatite nanobioceramics into conventional glass

ionomer cements (GIC) Acta Biomater. 2008;4:432–40. [PubMed] [Google Scholar] Arita

K, Yamamoto A, Shinonaga Y, Harada K, Abe Y, Nakagawa K, et al. Hydroxyapatite

particle characteristics influence the enhancement of the mechanical and chemical properties

of conventional restorative glass ionomer cement. Dent Mater J. 2011;30:672–83. [PubMed]

[Google Scholar]

84