C H A P T E R 13
Glass Ionomer Restoratives
RELEVANCE TO ESTHETIC
DENTISTRY
Although glass ionomer restoratives are not highly esthetic, they
are considered the material of choice for class V lesions in
patients at high risk for caries and erosion lesions. They are also
used in deciduous class I and II restorations. Glass ionomers in
general are tooth colored but rather opaque in appearance.
Esthetically they are inferior to conventional resin composites,
but they offer the advantages of providing adhesion and fluoride
release. The physical properties of glass ionomers tend to be infe-
rior to those of resin composites, so they cannot be used for large
restorations or cavities that will be subjected to occlusal forces.
BRIEF HISTORY OF CLINICAL
DEVELOPMENT AND EVOLUTION
OF THE PROCEDURE
Glass ionomers were developed in the 1970s by mixing silicate
cement with polyacrylic acid. They set via an acid-base chemical
reaction. They bond chemically to enamel and dentin. Glass
ionomers are supplied as a liquid and powder system.
Because of the poor physical properties of glass ionomers, in
the late 1980s resin-modified glass ionomers were introduced.
They have an acid-base reaction in addition to free radical
polymerization, either light or chemically activated. These
refined materials (also called hybrid ionomer cements) offer better
physical properties, are easier to finish, and set on demand.
In the early 1990s compomers were developed to mimic
resins. These can be used with conventional dental adhesive
systems. A liquid water-free polyacid monomer is used in place
of the polyacrylic acid. Compomers bond and set like composite
systems. Initially they release fluoride but that diminishes with
time. Compomers are fairly popular in pediatric cases. In the
late 1990s metal-reinforced glass ionomers were introduced for
use as core buildups. These contain a silver alloy admix.
CLINICAL CONSIDERATIONS
Although the caries-inhibiting effect of glass ionomers has
been established, their clinical effectiveness has been questioned
because of their relatively short clinical durability. Glass
Carlos A. Munoz-Viveros
ionomers can recharge any lost fluoride (i.e., add fluoride
back into the restorations for subsequent release) by exposing
the surfaces to fluoride ion sources such as fluoride-containing
toothpastes, fluoride mouthrinses, or topical fluorides. This
temporarily boosts the fluoride concentration, but unfortu-
nately the boosted levels are not high enough for even a
short time to be considered clinically efficacious as an anti-
caries therapy.
Indications
Glass ionomers are useful for posterior class II restorations, class
II restorations prepared using the open sandwich technique
(placed in the proximal box of a preparation at the cementum
and dentin interface), and carious or noncarious class V restora-
tions. They also serve as pit and fissure sealants and in atraumatic
restorative technique (ART) restorations.
Contraindications
Glass ionomers should not be used in stress-bearing restorations
or areas where esthetics is a concern. Large class II, class III, and
class IV restorations are better handled with other materials.
MATERIAL OPTIONS
Advantages
Conventional glass ionomers offer many biotherapeutic advan-
tages (Table 13-1). They provide long term release of fluoride
ions, ability to bond to tooth structure and are very biocompat-
ible. Because they posses a coefficient of thermal expansion
similar to tooth structure, they are able to provide excellent mar-
ginal seal around the preparation. They have adequate strength
and release fluoride. These materials are not very expensive.
Disadvantages
Despite the long term release of fluoride, glass ionomers have
limited clinical applications. Compared with other restorative
materials, glass ionomers are less durable, harder to finish,
sensitive to changes in its water content and not very esthetic.
It is also necessary to use a protective glazing coat over the
surface.
337
338 Glass Ionomer Restoratives

TABLE 13-1 Representative Glass Ionomers and Modified Glass Ionomers

RESIN-MODIFIED POLYACID-MODIFIED RESIN METAL-REINFORCED
GLASS IONOMERS GLASS IONOMER COMPOSITES (i.e., COMPOMERS) GLASS IONOMERS LINERS
Ketac-Fil+ Fuji II LC Dyract eXtra (DENTSPLY Caulk) Ketac Silver Vitrebond Plus
Ketac-Molar Fuji Filling LC Hytac Aplitip (3M ESPE) (3M ESPE)
(3M ESPE) (GC America) (3M ESPE) Fuji Lining LC
Fuji II Vitremer Compoglass F (Ivoclar Vivadent) (GC America)
Fuji IX Photac-Fil Quick
Fuji Triage Ketac Nano
(GC America) (3M ESPE)

Current Best Approach treatment should be based on the interpretation of the activity
of the lesion and risk assessment. For example, patients are living
It is best to use resin-modified glass ionomers for general restor- longer, and an increasingly larger number are taking medications
ative procedures. that decrease salivary flow. This increases the potential for
rampant caries: a thorough assessment of the caries activity, oral
hygiene, and risk assessment should be fully evaluated before
OTHER CONSIDERATIONS deciding on a non-invasive or invasive restorative option.

Highly viscous glass ionomer materials are useful for ART

restorations.
INNOVATIVE ELEMENTS
Scientific Elements
The original glass ionomers developed in the 1970s are still on
the market. Over the years, several improved versions have been
introduced during the past 30 years. More recently a new gen-
eration of high-strength glass ionomers has been developed.
These materials are very popular especially for use on children
and older aldults.
Technological Elements
Encapsulated versions make this material easier to use. Auto
mix syringe versions have recently been introduced to the
marketplace.
TREATMENT PLANNING
Options
Glass ionomers are the ideal materials for older individuals with
decreased salivary flow, individuals with poor oral hygiene, and
persons with disabilities. These materials are also being used as
a liner under resin composite restorations, a base, a core build-up,
and in individuals who are a high risk for developing carious
lesions.
Sequence
Case evaluation is very important. Traditionally, radiographic
evidence of demineralization was the main decision process
for placing a restoration. Modern research has shown that the
TREATMENT CONSIDERATIONS
Preparation
The dentist begins with rubber dam isolation. A traditional
preparation with no bevels is performed, including small reten-
tive undercuts if needed. Otherwise no retention is needed. Any
unsupported enamel is removed.
Procedure
The cavity is cleaned with polyacrylic acid and rinsed. The
matrix is applied, followed by the restorative material. The res-
toration can be either light cured or allowed to harden.
Finishing
is the new generation of glass ionomers allows the practitioner
to contour and polish the material immediately. However, place-
ment procedures that minimize the need to finish and polish
glass ionomers should be used. Several manufacturers provide a
resin-based protective coating to be applied over the restoration
after finishing.
CLINICAL CONSERVATION
CONCEPTS
As new materials are developed, it becomes increasingly difficult
to choose the most appropriate material for a particular clinical
situation. Currently there are no specific clinical guidelines, and
no long-term, evidence-based clinical studies are available. The
physical properties of current glass ionomers, especially their
poor wear resistance, limit the use of these materials.
 Contemporary Esthetic Dentistry 339

A B

FIGURE 13-1 A, Microleakage observed on class II restorations in a high-risk caries patient. B, Removal of existing restoration
and preparation. C, One-year postoperative view of glass ionomer restoration. D, Glass ionomer class V restorations after 1 year.
Note the loss of gloss on the restoration surface.

MAINTENANCE CLINICAL TECHNIQUES

In general, glass ionomer cements need to be replaced more
often than conventional resins. However, newer generation of
glass ionomers have shown to be successful after 10 years of
clinical use.
CONTROVERSIES
There is insufficient clinical documentation to show that glass
ionomers are a viable permanent option for long-term use.
Manufacturers are developing and introducing new materials
with very little clinical evidence, which creates further confusion
among dentists.
NEAR-FUTURE DEVELOPMENTS
Glass ionomers with higher viscosity, higher fluoride content,
and greater ability to recharge are being developed.
The senior patient in Figure 13-1 had recurrent caries under
restorations. Physical examination revealed poor oral hygiene
and mild xerostomia. There were several recurrent lesions, some
of which were located subgingivally. Esthetics was not an issue.
It was determined that amalgam, resins, and flowables were not
suitable for this situation.
The treatment plan was to remove the old restorations
and any recurrent carious lesions. After removal of the old
restoration and re-shaping the preparation, the cavity was
cleaned with a mild acid. The new restoration was placed,
contoured, and finished. A protective coating was applied.
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