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C H A P T E R 13

Glass Ionomer Restoratives


Carlos A. Munoz-Viveros

RELEVANCE TO ESTHETIC ionomers can recharge any lost fluoride (i.e., add fluoride
DENTISTRY back into the restorations for subsequent release) by exposing
the surfaces to fluoride ion sources such as fluoride-containing
Although glass ionomer restoratives are not highly esthetic, they toothpastes, fluoride mouthrinses, or topical fluorides. This
are considered the material of choice for class V lesions in temporarily boosts the fluoride concentration, but unfortu-
patients at high risk for caries and erosion lesions. They are also nately the boosted levels are not high enough for even a
used in deciduous class I and II restorations. Glass ionomers in short time to be considered clinically efficacious as an anti-
general are tooth colored but rather opaque in appearance. caries therapy.
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-
Indications
rior to those of resin composites, so they cannot be used for large Glass ionomers are useful for posterior class II restorations, class
restorations or cavities that will be subjected to occlusal forces. II restorations prepared using the open sandwich technique
(placed in the proximal box of a preparation at the cementum
BRIEF HISTORY OF CLINICAL and dentin interface), and carious or noncarious class V restora-
tions. They also serve as pit and fissure sealants and in atraumatic
DEVELOPMENT AND EVOLUTION restorative technique (ART) restorations.
OF THE PROCEDURE
Glass ionomers were developed in the 1970s by mixing silicate
Contraindications
cement with polyacrylic acid. They set via an acid-base chemical Glass ionomers should not be used in stress-bearing restorations
reaction. They bond chemically to enamel and dentin. Glass or areas where esthetics is a concern. Large class II, class III, and
ionomers are supplied as a liquid and powder system. class IV restorations are better handled with other materials.
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 MATERIAL OPTIONS
polymerization, either light or chemically activated. These
refined materials (also called hybrid ionomer cements) offer better
Advantages
physical properties, are easier to finish, and set on demand. Conventional glass ionomers offer many biotherapeutic advan-
In the early 1990s compomers were developed to mimic tages (Table 13-1). They provide long term release of fluoride
resins. These can be used with conventional dental adhesive ions, ability to bond to tooth structure and are very biocompat-
systems. A liquid water-free polyacid monomer is used in place ible. Because they posses a coefficient of thermal expansion
of the polyacrylic acid. Compomers bond and set like composite similar to tooth structure, they are able to provide excellent mar-
systems. Initially they release fluoride but that diminishes with ginal seal around the preparation. They have adequate strength
time. Compomers are fairly popular in pediatric cases. In the and release fluoride. These materials are not very expensive.
late 1990s metal-reinforced glass ionomers were introduced for
use as core buildups. These contain a silver alloy admix.
Disadvantages
Despite the long term release of fluoride, glass ionomers have
CLINICAL CONSIDERATIONS limited clinical applications. Compared with other restorative
materials, glass ionomers are less durable, harder to finish,
Although the caries-inhibiting effect of glass ionomers has sensitive to changes in its water content and not very esthetic.
been established, their clinical effectiveness has been questioned It is also necessary to use a protective glazing coat over the
because of their relatively short clinical durability. Glass 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.
TREATMENT CONSIDERATIONS
INNOVATIVE ELEMENTS Preparation
The dentist begins with rubber dam isolation. A traditional
Scientific Elements preparation with no bevels is performed, including small reten-
The original glass ionomers developed in the 1970s are still on tive undercuts if needed. Otherwise no retention is needed. Any
the market. Over the years, several improved versions have been unsupported enamel is removed.
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
Procedure
and older aldults. 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.
Technological Elements
Encapsulated versions make this material easier to use. Auto
mix syringe versions have recently been introduced to the
Finishing
marketplace. 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
TREATMENT PLANNING glass ionomers should be used. Several manufacturers provide a
resin-based protective coating to be applied over the restoration
Options after finishing.
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, CLINICAL CONSERVATION
and in individuals who are a high risk for developing carious CONCEPTS
lesions.
As new materials are developed, it becomes increasingly difficult
to choose the most appropriate material for a particular clinical
Sequence situation. Currently there are no specific clinical guidelines, and
Case evaluation is very important. Traditionally, radiographic no long-term, evidence-based clinical studies are available. The
evidence of demineralization was the main decision process physical properties of current glass ionomers, especially their
for placing a restoration. Modern research has shown that the 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 The senior patient in Figure 13-1 had recurrent caries under
often than conventional resins. However, newer generation of restorations. Physical examination revealed poor oral hygiene
glass ionomers have shown to be successful after 10 years of and mild xerostomia. There were several recurrent lesions, some
clinical use. of which were located subgingivally. Esthetics was not an issue.
It was determined that amalgam, resins, and flowables were not
suitable for this situation.
CONTROVERSIES The treatment plan was to remove the old restorations
and any recurrent carious lesions. After removal of the old
There is insufficient clinical documentation to show that glass restoration and re-shaping the preparation, the cavity was
ionomers are a viable permanent option for long-term use. cleaned with a mild acid. The new restoration was placed,
Manufacturers are developing and introducing new materials contoured, and finished. A protective coating was applied.
with very little clinical evidence, which creates further confusion
among dentists. SUGGESTED READINGS
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and greater ability to recharge are being developed. 24:312-316, 1996.
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