Restorative Dentistry

Glass-ionomer cements in restorative dentistry

John W. Nicholson. PhD*/Theodore P Croll. DDS**
Abstract This anide reviews ihe eurreni sUiHis aiitijiirure prospeclsfor glass-ionomer malerials. Tliese muieriuls are of wo eheuiicai lypes: ihe older, selfhardeiiing cemeiils. which sei by an uviil-base iieiiii-alLalioii reaeHon to give relalively bri/rle luaierials: and he newer, re.sin-modified cemeiU.s. which separtly hy polymerizaiion and panly by neinraUzaiioii. Compared with he self-hardening cements, he lauer materials have improved esthetics, improved resistance to moisture, and greater toughness. Both types qfgla.s.s-ionomer cement bond well o enatnel and dentin and release a clinically useful amount of fluoride. Thev have been used in a variety of applications: as liners or bases, for luting of stainless steel eroiins. for Class V restorations in permanent teeth, and for Class 11 and Class HI restorations in primar}- teeth. The resin-modicd glass-ionomers are particularly promising for these latter uses, ahhough it is too early to be sure whether heir long-term dnrabilHy is sufficient. Self-hardening glass-ionomer materials are likely to retain specific niches of clinical applicaHon. including in their metalreinforced and cermet-containing fortns. (Quintessence Int }997;2S:705-74.)

^linical relevance

Introduction In recent years, there has been considerable confusion about what type of material should be called a glass-ionomer cement. Strictly, the term should be applied only to a material that involves a significant acid-base reaction as part of its setting reaction, where the acid is a water-soluble polymer and the base is a special glass.' Other materials, for example those that some manufacturers have marketed as "light-cured glass-ionomers." are essentially resin composites, although they do contain the fluoroaluminosilicate glass of a conventional glass ionomer material. However, these materials lack the characteristic good adhesion of glass ionomer cements, tend to release little fiuoride. and undergo polymerization contraction on setting. A further source of confusion has been the development of materials that set by polymerization but are based on resins modified to include acid functional groups on them and also contain basic glasses. These materials, such as Dyract (Dentsply), Compoglass (Ivoclar), and Hytac (ESPE), show interesting properties, and are promising as restoratives, but are ceriainly not glass-ionomer materials. The term compomerh^.^ been applied to them by the manufacturers, but this
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IKS review of the glass-ionomer genre updates the atist about glass-ionomer and polyacid-modified sin materials, describes their chemistry' and poten\. and advises the dinician about methods and jionale for their use in restorative and prosthetic
islry.

ad. Departmem of Dental Biomaterials Science. King's Denial itLlute, Universily of London. London. England pvate Practice, Pdiatrie Dentjstrj', Doylesloivn. Pennsylvania; lical Professor. Departmem ol Pdiatrie Dentistry. University of nsylvania. School ofDental Medieine; Clinical Professor, Craniofial Growth and Development (Pcdiatrie Dentiitry), University of as, Health Science Center at Hojston (Dental Branch); Adjunc! Assistant Professor, Department of Pdiatrie Dentistry. Univer( of Iowa. Coliege of Dentistry. |lrequEsts; Dr J. W. Nicholson. Dental Biomaterials Department, Dental Institute. Caldecot Road, London SES9RW, United . E-mail: j . nie hols on@kd.ac.Lk.

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term has already been incorrectly applied by clinicians to glass-ionomer-resin hybrid materials that sel substantially by an acid-base reaction.--' The term polyacid-iiioifd resin coiiiposiie has been recommended lor these materials, ' although Ihe word aimpoiner is a useftil everyday name. Those glass-ionomer malerials that are modified by Che inclusion of resin, generally lo make them partly photocurable, are recommended to be called resin-inodified glass-ionomer materials, the term used here.

greater than the value at 24 hours. The ratio of bound to unbound water increases, this being defined as the ratio of water that may be removed by chemical desiccation ( eg. by storage for 24 hours over silica gel at elevated temperature) to water that is retained in the cement during this treatment. Finally, translucency also changes, gradually becoming greater and more like natural tooth material as the cement ages.^ Tlie seiting reactions in glass-ionomer materials are as follows: 1. Decomposition of the glass under the influence of the aqueous polyacid. leading to the release of Ca^* and Al'* ions. The latter are probably released in the form of complex oxyanions containing several aluminum atoms.'* a structure that reflects the form they have occupied within the glass prior to acid attack.^ 2. Rapid reaction of the Cn'* ions with ihe polyacid chains, followed by slower reaction of Al^"* species gradually released from the anionic complex. This reaction displaces water from some of the hydration sites'" and leads to some ionic crosslinkitig of the polyacid chains; both effects lead to insolubilization of the polymer and stiffening of the material. 3. Gradual hydration of the inorganic fragments released in step I, to yield a matrix of increasing strength, greater resistance to desiccation, and improved translucency."'-

Se If-h arden ing glass-ionomer materials Glass-ioQomer materials in their original, self-hardening form, became available in the last quarter of the 20th century. They belong to the class of material known as acid-base cemeiiis,* and their setting involves neutralization of acid groups on a waler-soluble polymer whh a powdered, solid base. The base is a special calcium aluminosilicate glass that also contains tluoride, an important feature, because it causes the cement to release clinically useful amounts of this ion and thereby to prevent the development of secondary caries around restorations.- The glasses act as bases in the sense that they are proton-acceptors, even though they are not soluble in water. As the cements set, water becomes incorporated into the material, and there is no phase separation. In fact, water has been identified as having a number of roles: (!) it is the solvent for the setting reaction, because, without it. the polymeric acid would be unable to exhibit its full properties as an acid. (2) il is one of the reaction products. (3) it acts as both coordinating species to the metal ions released from the glass and as hydrating species at well-defined sites around the polyanion, and finally (4) it may act as a plasticizer and reduce the rigidity of the bulk polymeric structure.*' A number of factors are known to influence the speed of the setting reaction and the Tmal strength of the cement. These include the molar mass of the polyacid concentration of the acid solution, the powder-liquid ratio, and the presence of chelating agents, such as (+) - tartaric acid,' which reduces the setting time and increases the compressive strength of the cement once set. Glass-ionomer cements undergo gradual maturation processes that are pooriy understood. For example, in cements prepared from polyiacrylic acid), compressive strength gradually rises over the first 3 months or so of the cement"s life to a maximum value some magnitude

Improvements in the strength and durability of glass-ionomer cements have been sought by such means as the inclusion of finely divided silver alloy or of a silver-cermet formed from the glass plus silver ina fusion process. Fibers have also been used lo reinforce experimental cements.'-* A disadvantage of glass-ionomers is that they are sensitive to moisture in the early stages following , placement.^ This may result in either the washing out of reacting ions from the immature cement by saliva or, in patients who tend to breathe through the mouth, in , desiccation and arrest of the setting reaction. Both, effects are undesirable, and. to overcome the problems,._ dentists are advised to cover freshly placed cemenl with an impervious layer of varnish, petroleum jelly, . or liquid resin bonding agent. ^. Glass-ionomers are able to form true adhesive bonds to dentin and enamel^ and for this reason have, found a wider range of applications than other dentai cements. These uses are considered in more detail later ;, in this article. .

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Resin-modified glass-ionomer materials These materials, the majority of which are cured by visible light, are hybrids that involve the incorporation of polymerizable components into an acid-base glassionomer cement. They were first described in the late 1980s.'"* The use of visible light to cure these materials, at least as far as the initial development of structure is concerned, limits the depth of individual layers of cement that can be used, because of limitations in the extent to which light can penetrate these materials. Typically, this depth is of the order of 2 to 3 mm. a feature which restricts the use of these materials to certain areas, such as cavity lining or incisai edges. Resin-modified glass-ionomer materials consist ofa complex mixnire of components,'-' including poly( acrylic acid) or a graft-copolymer of poiy(acrylic) in which a photocurabie side chain has been added; photocurable monomers, such as hydroxyethyl methacrylate (HEMA); calcium aluminosilicate glass: and water. These materials set by a number of competing reactions and have complex structures. There is evidence of slight swelling ofthe cured cement in aqueous media,"^ but. to date, there is only one account of this leading to a catastrophic clinical failure, when a tooth filled with an inappropriately formulated material thai underwent phase separation prior to use was split by the osmotic pressure in a HEMA-rich cement. '^ In general, however, clinical indications for their use has been promising, and good adaptation"* and adhesion,''' acceptable fluoride release.-" and excellent esthetics,"'-" have been reported. The data available to date on long-term durability and esthetics will be discussed later in this article.

without a lining or a base.-^ -'' although moderate inflammatory responses in the pulp have been reported in some human studies,-'-** The use of certain glass-ionomers extracoronaily, however, as luting cements, has been shown to be associated with pulpal hypersensitivity.'^ -"" The particular cements that cause this are the so-called anhydrous cements, which are formulated by mixing glass and polymer powders and activated by the addition of the appropriate amount of water. The reason that these cements cause pulpal sensitivity was initially thought to be due to the slow dissolution ofthe polyacid, which was assumed to maintain the local pH at low levels for longer than in conventionally formulated glass ionomers," However, a study of pH change in setting cements showed that the anhydrous cements underwent a slightly more rapid neutralization than conventional ones and that their setting profile was almost the same as that of anhydrous zinc polycarboxylate. - - No pulpal sensitivity has ever been reported for this latter material. It thus seems likely that pH is not the cause ofthe reported sensitivity. Biologic studies have shown that different glassionomers differ in their ability to develop and sustain a marginal seal that excludes bacteria from the region close to the pulp,-'-'""'^ Moreover, beneath certain glass-ionomer restorations, including experimental crowns luted with this material, bacteria have been found in an active state of metabolism. Moderate pulpal infiammation has always been associated with them,-'-'"'-'' It thus seems that glass-ionomers are not directly responsible for this adverse pulpal reaction, but certain brands, by not forming an adequate seal, are responsible indirectly, because bacteria can be admitted to cause the adverse biologic effects.

fiiocompatibillty JiJ Biocompaiibi/Hyis defined as the ability ofa material to -jjftis perform with an appropriate host response in a ijiJiS specific application.-^ It is thus distinct from inertness. ^0 which would imply no response from the host. More0'$ over, biocompatibility is not a single phenomenon, but ir&t' ^'^^'' ^^ ^ collection of processes involving different ,li,fi but interdependent mechanisms of interaction be^^, Iween a material and the tissue. It is also specific to a ' ;j particular application and location in the body, ' Glass-ionomer cements are generally biocompatible with oral tissues and. as restorative materials, result in ",.<only mild pulpal irritation at a level similar to that ' ^ produced by zinc polycarboxylate and zinc phosphate ^ I""'', cements.-'' TTiis reaction is so mild that giass-ionomers " * <^n generally be used as intracoronal restoratives *
Clinical applications

Original glass-ionomer restorative cements did not receive widespread acceptance by dentists in the early and mid 1980s, particularly in the LJnited States. These materials had low wear resistance, fractured easily, and required unusuai handling by the dentist to avoid overhydration or desiccation during the extended initial hardening time. Regardless ofthe benefits of fluoride ion release and uptake by adjacent enamel and dentin, chemical bonding, and favorable thermal expansion/contraction properties, glass-ionomer restorative cements were simply impractical for use other than for short-term restorations or for people with exceptional susceptibility to caries.

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Fig 1 Sliver amalgam (mesial fossa) and silver-cermet resloralions o a primary second molar, 8.5 years after placement.

Fjg 2 "interim" silver-cermet restoration of maxillary firsi molar, 9 years after placement.

Glass-ionomcr luting cements, however, were more successful. They are used for cementing stainless steel crowns for primary teeth, precision casi crowns and fixed prostheses for permanent teeth, space maintainers. and single orlhodontic bands. Dentists treating caries-prone patients are particularly pleased with a luting cement that has leachable fluoride ions and associated preventive dentistry implications. Glassionomer luting cements of all types have become quite popular, and their use continues to increase. Introduction of the glass-ionomer-silver-cermet, Ketac-Silver (ESPE), in 19S4 gave dentists an attractive alternative to silver amalgam for Class I restoration of primary' teeth."'"^'' Although fracture strengths remained too low for the material to replace cusps or marginal ridges. Ketac-Silvcr made a large impact on restorative dentistry for children (Fig 1 ). A surprising development was that Class I silver-cermet restorations, originally placed for "interim" use in permanent teeth,""'have routinely lasted for 10 years or more (Fig 2). Ketiic-Silver has also been used for "lunneP restorations."""'^ other restorations using unconventional preparations conserving of tooth structure,"'''"'"' as an endodontic filling materiai. and to serve as a core buildup material prior to complete-crown preparation. More recently ihe profession has seen the development of resin-modified glass-ionomer materials. These combine advantages of glass-ionomer systems and visible light-polymerized resin technology and are a significant development in restorative dentistry. The set cement has the main advantages of conventional glass-ionomers, ie. fluoride release and adhesion to dentin and enamel, but also improved fracture resistance and better wear characteristics. Introduced

originally as liner/base materials feg. Baseline VLC, Dcntsply/Caulk; Vitrebond, 3M Dental), they are now available as restorative cemenis. Current commercial materials for this latter application include Fuji II LC ( G O , Photac-Fil (ESPE), and Vitremer Tri-Cure ( 3M Dental ), all of which have been useful for Class II andClassV restorations in primary (Figs 3a to 3c) and permanent (Figs 4a and 4b) teeth. For Class ! restorations of primarj' molars intended to last more than 3 years, initial clinical observation is that Vitrenier Tri-Cure appears to have the besi durability. One author (TPC) has now had more than 5 years' experience using these materials for the repair of primary teeth and confidently states that the resitimodified glass-ionomer cements will become a mainstay restorative material for pdiatrie dentistry'*'"^" (Fig 5). Having been found to be satisfactory in the primary dentition, resin-modified glass-ionomers are now being used to restore permanent teeth-'-' (Figs 4, 6, and 7). However, brand selection and material handling are important (Fig 8). VitremerTri-Cure restorative cement, mixed at high powder-liquid ratio so that all of the powder is wetted during mixing, appears to perform the best on the occiusal surfaces of permanent teeth. This may be the result of the high powder-liquid ratio, or it may be that Vitremer Tri Cure has better wear resistance, is less soluble, or both. All three brands of resin-modified glass-ionomer material perform well in Class III and Class V restorations, in many cases holding up well for more than 4 years in permanent leeth. The use of self-hardening resin-modified glassionomer luting cements is growing rapidly. These

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Fig 3a Sixteen-month-old cfiild with severe lingual caries of the maxillary primary incisors.

Fig 3b Caries debnded wilh an inverted cone bur, used in a slow-speed handpiece.

Fig 3c Resin-modified glass-ionomer restorations, 26 months after placement.

Fig 4a Sensitive decalcitication/carious lesion associated with poor oral hygiene during orlhodontic therapy

Fig 4b Resin-modified glass-ionomer cement restoration. ; 1 yearpostoperatiuely.

Fig 5 Four-year postoperative view ct primary second molar (mesio-occlusohngual) restoration; primary first molar (disto-occlusal) restoration. (Vitremer Tri-Cure Resforative Cement).

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Fig 6a Occlusal and occlusolingual carious lesions ot ihe maxillary permanenl first molar in a caries-prone child.

Fig 6b Initial outline form cut with water-cooled highspeed bur, followed by complete debrjdement ot carious substance

Fig 6c VJtremer Tri-Cure Restorative Cement mixed with high powder-liquid ratio and syringe injected into the cavity preparation.

Fig 6d Excess cement purposely left over the cavosurface margins acts as an adhesive sealant

Fig 6e Enamel and cemenf surfaces, etched, rinsed, dried, and coated with unfilled resin sealant.

Fig 6f

Resforation 17 months after placement.

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Fig 7 Class I resJn-moditied glass-ionomer restoration 34 months after placement

Fig 8 Failure ot a Class I resin-modified glass-ionomer restoration as a result of incorporation of air bubbles during syringing, degradation of the material, and, perhaps, brand of maferial.

Fig 9 Excess resin-mod i tied glass-ionomer luling cemenl exuding at the margins during placemeni of a stainless steel crown

Fig 10 Resin-modified glass-ionomer luting cement used for a band and soldered wire loop space mainfainer

materials are not light-activated but contain the necessary monomers to undergo polymerization, together with initiators of the same type as used in cold-cure acrylics, eg. bcnzoyi peroxide and amine accelerator. The commercial materials of this type are Advance (Dentsply/Caulk), Fuji Pius (GC; originally called Fuji Duet) and Vitremer Luting ( 3M Dental ).^' These cements are easily handled, cause no significant postcementation sensitivity when luted to dentinal surfaces, and have significant fluoride release and high impressive and fracture strengths. A report pubiished in February 1996 confirmed these observalions and predicted that the resin-modified glass-ionomer 'uling cement wiil soon dominate the market for routine crown and fixed prosthetic ce menta tion. ^"' In

pdiatrie dentistry, these luting cements are becoming the material of choice for stainless steel crowns {Fig 9). space maintainers (Fig 10), and individual orthodontic bands. Band cementation can also be carried out with light-curable resin-modified glass-ionomer cements where the radiant light is transmitted through the tooth to bring about the polymerization part of the curing process.""

The future

What does the future hoid for the clinical use of glass-ionomer systems? Clearly, the new resin-modified malerials will have a major role to play. Although it is

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too early to be sure ofthe long-term durability and reliability of these materials, some predictions can be made. If they prove to have adequate wear resistance and fracture strengths so that a Class II restoration in a primary molar can survive for 6 to years, they will replace silver amalgam for the treatment of such teeth. The logic of this becomes even more compelling considering that resin composite can be used in cosmetically prominent teeth and stainless steel crown restorations are available for severely involved primary molars and canine teeth. The history of glass-ionomersilver-cermet restorations over the past 10 years also lends credence to predictions of an optimistic future for resin-modified glass-ionomer materials, given their better physical properties and handling characteristics. Resin-modified glass-ionomer luling cements give every indication of becoming the materials of choice for cementation of stainless steel crowns, space maintainers, and individual orthodontic bands. This could also be true for cementation of precision cast crowns and fixed prostheses to prepared permanent teeth. Although more long-term data are needed concerning resin-modified glass-ionomers, they show remarkable promise for materials at such an early stage in their development. With all this development on the resin-modified glass-ionomers, it might be tempting to conclude that the original self-hardening glass-ionomer cements are obsolete. However, this is far from the case. These materials, too, are undergoing exciting developments of their own. For example, new restorative-grade materials have been launched recently, such as KetacMolar (ESPE) and Euji IX( GC), which set only by a conventional neutralization reaction but have properties that rival or exceed those of the resin-modilied systems. Setting is rapid, early moisture sensitivity is considerably reduced, and solubility in oral fiuids is very low.-"**" These results have been obtained by altering the particle size and particle size distribution ofthe glass powder, so that setting occurs more rapidly than in the older formulations. These developments seem likely to be of particular importance in Third World countries, where there is an alarming growth in the incidence of dental caries but where, because supplies of electricity are sparse or nonexistent, sophisticated dental facilities, such as power handpieces and dental curing lamps, cannot be relied on.^^ Another subgroup ofthe self-hardening systems is that involving the inclusion of silver metal particles (as opposed to silver fused with glass as a cermet), a strategy that gives cements of good properties, ie. high

compressive strength, radiopacity, and excellent clinical wear.^' Materials ofthis type currently on the market include Miracle Mix (GC) and Hi-Dense (Shofti). Also wilhin the dental field, se If-hardening glassionomers have been used in bone contact applications. In particular, this has involved their use in augmentation ofthe alveolar ridge in edentulous patients.^^'^^ Such studies have shown thai glass-ionomer materials form intimate bioactive bonds with bone cells and become fully integrated into the bone. It is an excellent material for this application and performs better than, for example, hydroxyapatite, which has been used to date for this purpose. Self-harden ing glass-ionomers have also been used in maxillofacial and craniofacial reconstruction surgery.''"''' The technique involves the fabrication of custom-made preset implants, cured outside the body to develop their full mechanical strength, and then cemented into place with a selfcuring glass-ionomer cement. The material has excellent biocompatibility, and early applications of this technique have been encouraging.

Conclusion Overall, glass-ionomer cements, both self-hardened and resin-modified, are important materials for modem clinical dentistry and will remain so for years to come. The development of rcsin-modifled materials has opened up new dimensions in restorative dentistry, while the development of metal-reinforced and rapidsetting self-hardening cements has enhanced the properties and extended the usefulness of the wellestablished original materials. Glass-ionomers of all types continue to combine fiuoride release, adhesion, good marginal seal, and reasonable esthetics.^^ No material is perfect, but. with the current level of intensive research on glass-ionomers. the deficiencies that exist seem certain to be eliminated, or at least reduced, resulting in an ever-improving range of materials ofthis type.

References
1. McLean JW, Nicholson JW, Wilson AD. Suggested nomendalurefol" glass.ionomer cements and related malerials |eili[orial|. Quinlessencelnl I994;15:S87-SS9. 2. Mjor I. Marketing vs responsibility, and more I letterl. Quintessence Int 1995:26:665-666, 3. Walson TF, Bartlctt DW! Adhesive systems, composites, dentine bonding agents and glass-ionomers. Br Dent J 1994; 176:227-231.

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4. Wilson A D . Nk-holsoii JW. Acitl-Basc Cemtnli; Their Biamedic.ii and [ndiistrial AppliciUions. Ciimbridse, Siiglaiitl: C'anihrid;i; Univeraily Press. 199,1. 5. Swait M L , Phillips RW, C\aik H E. Long-lenii Hiioride relejse l"rom glass icinomer t-emems. J Denl Res l984i6,l:15S-IhO 6. Nicholson JW. Polyeleclrolsl niiiLerials: Reflceliunh iin a hijitily chacged (opjc. Chem Soc Rev I994;2J:53-5I. 7. Wilson A D , McLean JW. Glas5.|nnomer Cornent. Chicago: QiJintessence, t988. 8. Wasson EA, NicholsiinJW. A sludy of the relationsliip bemeen Ihc setting chemistry Jiid properties of modified glass polyalkenoiite cemenis. Br Polym J I99O;23; 179-IS. 9. Hill RG, Wilson A D . Some structural aspects of g lasse 5 used in ionomer cements. Glass Technol I98S;?9:15O-1SS. 10. Ikegami A. ImaiN. Preeipilalion of polyeleclrolyles by sails. J Polym Sei t962;56:l3.1-15i. i t . MalsuyaS, Maeda T, Ohta M. IR and NMR analyses of hardening and maturation ofglass ionomer cement J Dem Res 1996;75:192II1927, 12. WasEon E.^, Nicholson JW. New aspecls of the setting of glassLononier cements. J Dem Res 199J;72:481-48,1. 13 OldHeld CWB, Ellis B. Fibrous reinforeemenl of glass.ionomer cements. Clin Mater 1993;7;."il.l-J22. H. Miira SB Eut Patent applieation. .i:."!|20A2, 1989; Antonucci JM, MeKjnneyJE. StansburyJW. US Patent application. 160,856. 19S. t5. Anstice H M . Recent developments in restorative dental materials. Chem Ind (London) 1994;899-9U2. 16. AnstieeHM. Nicholson JW, Studies on the structure of ligbt-cured glass ionomer eements. J Mater Sei Mater Med 1992;."t:447-45l, 17. Nicholson JW, Anstice H M , Light eurable glass-iunomer cemenib for dentistr>'. Trends Polym Sei l994;2:272-275. 18. Waison TF. A confocal microscopic study of some factors afiecLing the adaptation of a light-cured glass ionomer to tooth tissue J Dent Res 1990:69:15.11-1538. 19. Mitra SB. Adhesion to dentin and physical properties of a light-cured glass ionomer liner/base. J Dent Res 1991;7O:72-74. 20. Forss H. Release of fluoride and other elements from light cured glass-ionomers in neutral and acidic conditions. J Dent Res t993;72:l257-1262, 11. Croli TP, Killian C M . Restoration of Class It carious lesions in primaiy molars using light-hardening glass-ionomer-re s in cements. Quintessence [nt l 9 9 J ; 2 4 : 5 6 l - 3 6 9 . 32, Croll TP, Light-hardened Class I glass-ionomer-resin cement restoration of a permanent molar. Quintessence Int I993;24:iO9113, 23, Williams DF. DeH 1987. in Biomatcrials, Amslerda

ChrisicnsenG Glassionomerasa lutingmalcrial. J A m Dent Assoc 1990:120:62-69, Johnson G H , Powell LV, Dcroven TV: Evaluation iind control of post cementation pulpal sensitivity, J A m Denl Assoc 1993-124 3 9 46. Smith D C , Rtise N D , Acidity of glass ionomer cements during setting and its relation to puip sensitivity, J A m Dent Assoc l9S6;ll2:654-657. Wassou E A , Nicholson JW. Change in p H during setting of polyelectrolyte detital cements. J Dent I993;21:122-126, Tobias RS, Plant C G , Rippin JW, Browne R M . Pulpal response ti> an anhydrous glass-ionomer luting cement, Endod Dent Traumatol 34. PameijerCH, Stanley HR.Biocompatibilityofa glass ionomer luting agent in primates. Part I. A m J Dent l 9 ! i 8 ; h 7 l - 7 5 , 35 Plant C G , Tobias RS, Rippin .rW, Brooks JW, Browne R M . A study of the relationship among pulpal response, mierobial leakage and particle heterogeneity in a glass-ionomer base material. Dent Mater McLean JW, Gasser O. Glass-cermet cements. Quintessence lut [985:i6:333-34.. MeLeanJW, Gasser O. Powdered dental material and process for the preparation thereof. US patent 4,527,979, 1985. Croll TP, Phillips RW. Glass ionomer-siiver cermet restorations for primarj'teeth. Quintessence i n t 1985; 17:607-615. Croll TP, Phillips RW, Six years' ciperience with glass-ionomersilver cermet Quintessence Int 1991:22:783-793, Croll TP, iCillian C M . G lass-ionomer-siiver cermet interim Class i restorations for perniiinent teeth. Quintessence Int iy92:2J:731-73J. Knight G M . The use of adhesive matenals in conservative restoration of selected posterior teeth. Aunt Dent J 1984:29:324-331, Hunt PR, A modiried Class i i cavity preparation for glass-ionomer restorative materials. Quintessence int I9S4; 15:1011-1018. Baratieri L N , et al. The tunnel preparation and restoration. In: Baratieri, et al (eds), Advaneed Operative Dentistry, ed 2. Sao Paulo: Quintessence. 1993:295-312. Mount GJ. A n Atlas o f G lass-ionomer Cements, ed 2. London: Martin Dunitz, 1994:99-122. Hunt PR. Micro conservative restorations fur approximal carious lesion:i, J A m Dent Assoc 1990:120:37-40 Croli TP Lateral access Ciass I i restoration using res in-mod i Fied glass-ionomer nr silver-cermet cement. Quintessence int 1995: 26:121-126 Croll TP, Killian C M Visible i ig ht-hardened g lass-ionomer-resin cement restorations for primary teeth: New developments. Quintessence Int 1992:23:679-682. Croll TP, Killian C M , Glass-ionomer-resin restoration of primary molars with adjacent Class i i tarious lesions Quintessence int 1992:24 723-717. C r o i i TP, iiillian C M , Hclpin M L , A restoraU\e dentistry renaissance for children: Light-hardened glass ionomer/resin cement, J Dent Child 1993,60 89-94. Croll TP. Restorative dentistry for preschool children. Dem Clin N o n h A m 1995:.19:737-770. C r o l l TP, Kilhan C M . Class i and Class i i Ugh [.hardened glass lonomer/resin restorations. Compend Contin Educ Dent 1993; 14-908-918. Croll TP, Cavanaugh RR. Vitremer cement for Class i restoration o f permanent teeth. Pract Periodont Acsthet Dent 1994:6:25-34.

34, Plant C O . Knibbs PJ, Tobias RS, Britton A S , Rippin JW. Pulpai response l o a glass-ionomer luting cement. Br Dent J (988:165:5458. 25. McLean JW.Aiternatives to amalgam. Br Dent J iyS4:i57:432-4."tJ. 26. Feilon D A . Cox CF, Odom M , Kanoy BE. Pulpal response to chemically cured and exprimentai light-eured glass-ionomer cavity Lners. J Pmsthet Dent 1991;65:7O4-7I2. -' Cooper i R. The response o f the human dental pulp to glas 5-iono mer cements. Int Endod J 1980.13:76-88, 8, Plani C G , Bro^ne R M , K n i b b i PJ, Bntton A S , Sorahen T. Piilpal effects of glass ionomer cements, i n t Endod J i 9 8 4 ; 1 7 : 5 l - 5 9 .

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5.1. Glass ionDmec-resin cements (G[-R). Clin Rts Assot Newsletter 1995:191 Mar);l-2. 54. Cemenl for fixed prosthodomiL-s-upJjIc '96. Clin Res ASSUL Newslellcr l996;20(Feb); I-?. 55. Croll TP, Helpin ML. Space mainlainer cemcnlalion using IL|3|Uhardenecl glass in no me r/resin reslomtivc cemenl J Denl Cliilil 56. Moiinl GJ. Glass ionomcr cemenls and future research. Am J Dcnl 57. Wasson EA. Metal reinforced gtass-ionomer cemeni: A review f prcip^nies ;ind L-linicl jse. Clin M;iler 199.1; I ! lit I-190

SK, Bronk I M , Craig GT. Lamb DJ. Initial in vivo evaluation of glass-ionoiner ccmcnls for use as alveolar bone substitutes. Clin Maler 1991 ;7:295-.!nn. 59. Brijuk IM. Craig GT, Lamb DJ. In viLro inleraetions between primary bone organ culiures. glass-lonomtr cemenis and hydroxyapatile/ LritaluLum phosphate ceramius. Biomalerials I99t;l2:l79-INfi. M). Helm!. J. Geyer G. kinomcr based bone subsliliite in otologic surgery, t j r Arch Olorbinolaryngol l993i25O:25J-256. 61. Geyer G. Hetms J. Reconilruclion of Ihe posterior audilory canal wall and oblileraticn of ihe maslojd cavity using glass-ionomer temenl. Transplants and Implants in Olology I49hl U165-I70. D

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