Is encapsulation of posterior glass-ionomer restoratives the solution to clinically induced variability introduced on mixing?

Retrospective Clinical Evaluation of RMGIC/GIC Class V Restorations

The aim of this retrospective study was to evaluate the clinical performance of glass-ionomer cement (GIC) and resin-modified glass-ionomer cement (RMGIC) materials in Class V carious cervical lesions restored by dental students. Ninety-six (96) restorations performed with either GIC (Fuji IX) (n = 39) or RMGIC (Fuji II LC) (n = 57) were evaluated using the modified USPHS criteria by two independent investigators at two follow-up evaluations (two years apart). The Fisher statistical test was used to compare USPHS criteria and examine significant differences, with a significance level set at p < 0.05. The Kaplan-Meier algorithm was used to calculate the survival probability. The overall success rate of Class V restorations was 72.9% at the second follow-up evaluation, with restorations ranging in age from 2.5 to 3.5 years. The RMGIC (Fuji II LC) restorations exhibited a significantly higher overall success rate compared to the GIC (Fuji IX) restorations (p = 0.0104). Significant differences were observed in retention (p = 0.0034) and color match (p = 0.0023).

Evaluation of the Mechanical Properties of Three Resin-Modified Glass-Ionomer Materials

This study is aimed at evaluating the flexural strength (FS), fracture toughness (FT), and diametral tensile strength (DTS) of three resin-modified glass-ionomer cements (RMGICs): Ketac Nano, Riva Light Cure, and Fuji II LC. One hundred twenty specimens were prepared from the RMGIC materials ( $n=10$ ). The cements were mixed and inserted into different mould sizes according to the test performed: FS: rectangular Teflon mould ( $32\text{mm}\times 3.15\text{mm}\times 2\text{mm}$ ); FT: notchless triangular prism (NTP) Teflon mould ( $6\text{mm}\times 6\text{mm}\times 6\text{mm}\times 12\text{mm}$ ); and DTS: ring road stainless steel mould ( $6\text{mm}\times 3\text{mm}$ ). Specimens were light cured for 20 seconds on each surface and stored in distilled water at ${37}^{°}\text{C}\pm 2^{°}\text{C}$ for seven days prior to tests. To evaluate the influence of storage in the mechanical properties of the RMGIs, specimens tested for DTS were stored in distilled water at ${37}^{°}\text{C}\pm 2^{°}\text{C}$ for 32 days prior to test. Data were analyzed by ANOVA and Tukey’s test ( $\alpha =0.05$ ). Fuji II LC presented significantly higher values for all tests employed when compared to Ketac Nano and Riva LC RMGIs. There was no significant difference on DTS before and after the 32-day storage for each material. Fuji II LC presented superior mechanical properties when compared to Ketac Nano, and Riva LC storage showed no influence on the mechanical properties of the RMGI materials tested.

Consensus on glass-ionomer cement thresholds for restorative indications

OBJECTIVE

The aim of this paper is to present the results of a consensus meeting on the threshold property requirements for the clinical use of conventional glass-ionomer cements (GICs) for restorative indications.

METHODS

Twenty-one experts on GICs evaluated the results of tests on mechanical and optical properties of 18 different brands of restorative GICs: Bioglass R [B], Chemfil Rock [CR], Equia Forte [EF], Gold Label 2 [GL2], Gold Label 9 [GL9], Glass Ionomer Cement II [GI], Ionglass [IG], Ion Z [IZ], Ionomaster [IM], Ionofil Plus [IP], Ionostar Plus [IS], Ketac Molar Easymix [KM], Magic Glass [MG], Maxxion R [MA], Riva Self Cure [R], Vidrion R [V], Vitro Fil [VF] and Vitro Molar [VM]. All experiments were carried out by a team of researchers from Brazil and England following strict protocols, under the same laboratory conditions throughout, and maintaining data integrity.

RESULTS

There was consensus on: determining as primary properties of the material: compressive strength, microhardness, acid erosion and fluoride release, and as secondary properties: contrast ratio and translucency parameter, in order to rank the materials. Seven brands were below the thresholds for restorative indications: IZ, IM, IG, MA, VF, B and MG.

CONCLUSIONS

Based on the primary properties adopted as being essential for restorative indications, the conventional restorative GICs that met the thresholds and could be considered suitable as long-term restorative materials were: EF, GI, GL9, KM, IP, GL2, IS, CR, V, VM and R. A decision-making process to select the best GIC must also include results from clinical trials.

CLINICAL SIGNIFICANCE

This study provides a ranking of GICs that could be considered suitable as long-term restorative materials based on their main properties.

Effect of Mechanical Load Cycling on Microleakage of Restorative Glass Ionomers Compared to Flowable Composite Resin in Class V Cavities

Objectives:

Microleakage is the most important factor responsible for the destruction of restoration margins. The aim of this study was to assess the effect of mechanical load cycling on microleakage of four types of glass ionomer cement (GIC) in comparison with a flowable composite resin.

Materials and Methods:

In this in-vitro experimental study, 100 Class V cavities were prepared on the buccal and lingual surfaces of 50 intact premolars. The prepared cavities were divided into five groups of (A) Z350, (B) Equia Forte, (C) encapsulated Fuji II LC, (D) hand-mixed Fuji II LC, and (E) Ketac Molar. All the samples were thermocycled (×2,000, 5–55°C), and half of the samples in each group were load cycled. All the teeth were then immersed in 0.5% basic fuchsine for 24 hours, sectioned, and observed under a stereomicroscope. Data were analyzed with Kruskal-Wallis and Mann-Whitney-U tests. Comparison between the incisal and gingival microleakage was made with Wilcoxon test. P<0.05 was considered statistically significant.

Results:

Load cycling and type of restorative material had a significant effect on microleakage. Gingival microleakage was significantly higher than occlusal microleakage with Equia Forte, encapsulated Fuji II LC, hand-mixed Fuji II LC, and Ketac Molar in the absence of loading, and with Z350 after loading.

Conclusion:

The sealing ability of Z350 under load cycling was better than that of Equia Forte, hand-mixed Fuji II LC, and Ketac Molar. The marginal integrity of encapsulated Fuji II LC was not significantly different than that of Z350.

Variation in the Dispersions of Powder Liquid Ratios in Hand-Mix Glass Ionomers

Background

The Powder/Liquid Ratio (PLR) influence, and the literature regarding the handling and physical properties of Glass Ionomer restorative materials (GIC) were investigated.

Objective

The objective of the study was to compare the PLR variability and magnitude in hand-mix GICs, as dispensed for clinical use. From the recorded individual powder and liquid weights, additional comparisons could be made by pairing the various "extreme" outer observations in relation to the manufacturer's PLR.

Study Design

The materials assessed were Ketac Universal Hand-mix (KUH), Riva Self Cure Hand-mix (RSCH) and Fuji IX GP Hand-mix (FIXH). Twenty scoops of powder were paired with twenty drops of liquid, as would be the case in the clinical scenario. Statistical analysis was completed with the Kruskal Wallis H test, Intraclass Correlation (ICC) and straight line regressions with One-way ANOVA and the post-hoc Tukey HSD Test (p<0.05 was considered significant).

Results

The powder and liquid observations indicate a lack of consistency in both the powder and liquid dispersions. The volume remained "one drop" but the weights were much lower than the manufacturer's recommended drop weight for some observations, due to air in the liquid drop. The Kruskal-Wallis H test indicated significant differences (p=0.0001) between the three materials for the paired PLRs. The One-way ANOVA and post-hoc Tukey HSD Test were used to compare the recommended PLR to the results and the significant differences (p<0.01).

Conclusion

The recommended manufacturers' powder and liquid weights were KUH 0.150/0.05g; RSC 0.165/0.035; FIXH 0.18/0.05, respectively. KUH, FIXH and RSCH liquid had powder and liquid dispersions above the manufacturer's recommendations. FIXH had the most paired PLR observations within the ±10% range followed by KUH. Extreme powder and liquid combinations could occur in the clinical scenario and these combinations were considered.

Clinical Evaluation of Microhybrid Composite and Glass lonomer Restorative Material in Permanent Teeth

AIM

The aim of this study was to clinically compare glass ionomer cement (GIC) with microhybrid composite resin used in class I cavities on permanent teeth over a period of 9 months.

MATERIALS AND METHODS

A total of 40 teeth with class I cavities were divided into two groups (n = 20) and restored with GIC (EQUIA; GC) and microhybrid resin composite (Amelogen Plus; Ultradent). Restorations were evaluated at ×4.5 magnification using the United States Public Health Service (USPHS) criteria every 3 months. Statistical analysis was performed using the Fisher's exact test (a < 0.05).

RESULTS

The data obtained reported no statistical significance difference between both groups in regard to anatomical shape, color, postoperative sensitivity, secondary caries, material handling, adaptation, and marginal staining.

CONCLUSION

The results of this clinical study showed that GIC (EQUIA; GC) can be used for the restoration of permanent teeth and may be more appropriate for certain clinical situations than the resin composite material.

CLINICAL SIGNIFICANCE

EQUIA (GIC) is a viable alternative to resin composite in restoring class I cavities in permanent teeth.

Randomized clinical trial of encapsulated and hand-mixed glass-ionomer ART restorations: one-year follow-up

Objective

This prospective, randomized, split-mouth clinical trial evaluated the clinical performance of conventional glass ionomer cement (GIC; Riva Self-Cure, SDI), supplied in capsules or in powder/liquid kits and placed in Class I cavities in permanent molars by the Atraumatic Restorative Treatment (ART) approach.

Material and Methods

A total of 80 restorations were randomly placed in 40 patients aged 11-15 years. Each patient received one restoration with each type of GIC. The restorations were evaluated after periods of 15 days (baseline), 6 months, and 1 year, according to ART criteria. Wilcoxon matched pairs, multivariate logistic regression, and Gehan-Wilcoxon tests were used for statistical analysis.

Results

Patients were evaluated after 15 days (n=40), 6 months (n=34), and 1 year (n=29). Encapsulated GICs showed significantly superior clinical performance compared with hand-mixed GICs at baseline (p=0.017), 6 months (p=0.001), and 1 year (p=0.026). For hand-mixed GIC, a statistically significant difference was only observed over the period of baseline to 1 year (p=0.001). Encapsulated GIC presented statistically significant differences for the following periods: 6 months to 1 year (p=0.028) and baseline to 1 year (p=0.002). Encapsulated GIC presented superior cumulative survival rate than hand-mixed GIC over one year. Importantly, both GICs exhibited decreased survival over time.

Conclusions

Encapsulated GIC promoted better ART performance, with an annual failure rate of 24%; in contrast, hand-mixed GIC demonstrated a failure rate of 42%.

The Repair of Furcal Perforations in Different Diameters with Biodentine, MTA, and IRM Repair Materials: A Laboratory Study Using an E. Faecalis Leakage Model

The aim of this study is to evaluate the microleakage of repair materials MTA, IRM, and Biodentine applied on furcal perforations with different diameters. One hundred and forty extracted human teeth were used in this study. The teeth were divided into 2 main groups (60 teeth in each) which were then divided into 3 subgroups (n = 20). The remaining 20 teeth were divided into 2 groups (10 in each) to serve as controls. The furcal areas of the teeth were perforated with #2 cylindrical burs in Group 1 whereas perforations were made using #4 cylindrical burs in Group 2. Each subgroup of both Groups 1 and 2 received ProRoot MTA (ProRoot, USA), Biodentine (Septodont), or IRM (Dentsply, USA) to repair the perforations. An experimental set-up was established to contaminate repaired perforations with E. Faecalis (ATCC29212). The turbidity of bacteria was observed on the 7th, 15th, 30th, and 45th days. The data was analysed by chi-square test (p > 0.05). The number of bacteria in the group perforated by bur #2 and closed by MTA was found to be lower than the other groups on the 7th day (p < 0.05). There was no statistical difference in the bacterial counts of other groups on the 15th, 30th, and 45th days (p > 0.05). ProRoot MTA was found to be more successful in the prevention of bacterial leakage compared to IRM and Biodentine in smaller perforations during the 1st week.

The properties of experimental resin-modified glass-ionomer luting cements (RMGICs) containing novel monomers

OBJECTIVES

To investigate working and setting times, compressive fracture strength (CFS), compressive modulus (CM), three-point flexure strength (TFS) and tensile flexure modulus (TFM) of commercial, control and experimental RMGICs.

METHODS

RelyX Luting (RX, 3M-ESPE) and Fuji Plus (FP, GC), two control home liquids and eight new liquid compositions (F1-F4 and R1-R4) comprising different percentages of the monomer HPM (hydroxypropyl-methacrylate) and/or THFM (tetrahydrofurfuryl-methacrylate) with the original monomer HEMA (2-hydroxyethyl-methacrylate) were used in this study. The polymerization was initiated chemically (using benzene sulfonic acid sodium-salt in FP powder and potassium persulfate/ascorbic acid in RX powder). Home and experimental liquids were mixed with the corresponding commercial powder. An oscillating rheometer was used to measure the working and setting times (n=6). 20 cylinders per material (6.0±0.1mm height, 4.0±0.1mm diameter) were fabricated for CFS and CM testing, 20bars per material (25.0±0.1mm length, 2.0±0.1mm width, 2.0±0.1mm thickness) were made for TFS and TFM testing.

RESULTS

All RX compositions showed longer setting times (p≤0.0001) and lower CFS values compared to their FP counterparts (p≤0.0001). The TFS testing showed that commercial and home RMGICs behaved as brittle materials with linear load/deflection curve while experimental materials showed plastic ductile deformation before fracture. F3, F4 and F2 showed significantly higher CFS values compared to the corresponding home material (p≤0.0001).

SIGNIFICANCE

All new experimental compositions demonstrated working and setting times that are clinically acceptable. The new experimental FP compositions containing THFM (especially F3 and F4) demonstrated improved mechanical properties compared to their corresponding home material.

How mobile are protons in the structure of dental glass ionomer cements?

The development of dental materials with improved properties and increased longevity can save costs and minimize discomfort for patients. Due to their good biocompatibility, glass ionomer cements are an interesting restorative option. However, these cements have limited mechanical strength to survive in the challenging oral environment. Therefore, a better understanding of the structure and hydration process of these cements can bring the necessary understanding to further developments. Neutrons and X-rays have been used to investigate the highly complex pore structure, as well as to assess the hydrogen mobility within these cements. Our findings suggest that the lower mechanical strength in glass ionomer cements results not only from the presence of pores, but also from the increased hydrogen mobility within the material. The relationship between microstructure, hydrogen mobility and strength brings insights into the material's durability, also demonstrating the need and opening the possibility for further research in these dental cements.

Calcium phosphate cements for bone substitution: chemistry, handling and mechanical properties

Since their initial formulation in the 1980s, calcium phosphate cements (CPCs) have been increasingly used as bone substitutes. This article provides an overview on the chemistry, kinetics of setting and handling properties (setting time, cohesion and injectability) of CPCs for bone substitution, with a focus on their mechanical properties. Many processing parameters, such as particle size, composition of cement reactants and additives, can be adjusted to control the setting process of CPCs, concomitantly influencing their handling and mechanical performance. Moreover, this review shows that, although the mechanical strength of CPCs is generally low, it is not a critical issue for their application for bone repair--an observation not often realized by researchers and clinicians. CPCs with compressive strengths comparable to those of cortical bones can be produced through densification and/or homogenization of the cement matrix. The real limitation for CPCs appears to be their low fracture toughness and poor mechanical reliability (Weibull modulus), which have so far been only rarely studied.

Effect of antiasthmatic medication on the surface roughness and color stability of dental restorative materials

OBJECTIVE

This study evaluated the effect of antiasthmatic medication on the surface roughness and color stability of dental restorative materials.

MATERIALS AND METHODS

A total of 60 disc-shaped specimens were fabricated from glass ionomer (n = 20), composite resin (n = 20) and feldspathic porcelain (n = 20). Each material group was randomly divided into two subgroups (n = 10): (1) control group and (2) test group. Control groups of the specimens were kept in artificial saliva. Test groups were exposed to salbutamol sulfate (Ventolin Nebules) using an inhaler machine. Surface roughness measurements were done using a profilometry and color measurements were done with digital colorimetry at baseline and after inhalation and storing in artificial saliva. A two-way analysis of variance (ANOVA) and post-hoc Fisher's least significant difference test were used to compare the change in surface roughness and color. The confidence level was set at 95%.

RESULTS

Inhaler treatment significantly increased the surface roughness and color change of glass ionomer and composite resin materials (p < 0.05), while the surface roughness and color of feldspathic porcelain was not changed after inhaler treatment (p > 0.05).

CONCLUSION

The antiasthmatic inhaler medication (salbutamol sulfate) affected the surface roughness and color of composite resin and glass ionomer restorative materials.

Mechanical performance of encapsulated restorative glass-ionomer cements for use with Atraumatic Restorative Treatment (ART)

The Atraumatic Restorative Treatment (ART) approach was suggested to be a suitable method to treat enamel and dentine carious lesions in patients with disabilities. The use of a restorative glass-ionomer with optimal mechanical properties is, therefore, very important.

Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)--a minimum intervention and minimally invasive approach for the management of dental caries

While originally developed in response to a need to provide effective restorative and preventive treatment in underserved communities where running water and electricity might not always be available, over the past two decades, the atraumatic restorative treatment (ART) approach has become a worldwide phenomenon; used not only in some of the poorest developing countries but also in some of the most wealthy. The ART approach involves the removal of infected dentine with hand-instruments followed by the placement of a restoration where the adjacent pits and fissures are sealed simultaneously using high viscosity glass-ionomer inserted under finger pressure. Reliable results can only be obtained if the treatment protocol, as described in this article, is closely followed. ART should be considered as a therapeutic option especially in children, anxious patients and those with special needs.

Hertzian indentation testing of glass-ionomer restoratives: A reliable and clinically relevant testing approach

OBJECTIVES

To investigate the load to failure of encapsulated posterior glass-ionomer (GI) restoratives tested under Hertzian indentation and to explore the validity and reproducibility of the test results achieved for consideration of inclusion as an ISO testing protocol.

METHODS

Groups of 20 disc-shaped specimens (10.0±0.1mm diameter, 3.10±0.03mm thickness) were prepared (in batches of four) from three encapsulated posterior GI restoratives. Discs were tested while resting freely on a dentine analogue material at 24h under Hertzian indentation at a rate of 1mm/min delivered through a 20mm diameter hard steel ball. The failure mode and fracture origin of the GI specimens was assessed by fractography. Statistical analyses of the load to failure data were conducted using SPSS software (p<0.05) with the normality and homogeneity of variance of the load to failure data assessed using the Shapiro-Wilk and Levene's test, respectively. Data was also analysed using regression analyses to identify trends within the load to failure data sets.

RESULTS

The load to failure data for the GI restorative groups investigated were normally distributed (p>0.05), homogenous (p>0.05) and not significantly influenced by batch (p>0.780) or specimen number (p>0.447) although significant differences (p<0.05) between the GI restorative materials were evident. Fractographic analysis identified smooth fracture surfaces parallel to the loading axis where the failure mode was bottom initiated radial cracking. The mean coefficient of variation (CoV) for the GI restorative load to failure data sets achieved using Hertzian indentation testing was 7%.

SIGNIFICANCE

The failure mode and fracture origin of the GI restoratives tested using Hertzian indentation is representative of the clinical situation in vivo. The reliability of the load to failure data sets produced were improved compared with routinely employed mechanical testing approaches suggesting the possibility of inclusion as an ISO testing protocol.

The effect of variability in the powder/liquid ratio on the strength of zinc phosphate cement

Aim. To investigate (a) variability in powder/liquid proportioning and (b) effect of variability on diametral tensile strength (DTS), in a zinc phosphate cement. Statistical analyses (α = 0.05) were by Student's t-test in the case of powder/liquid ratio and one-way ANOVA and Tukey HSD for pair-wise comparisons of mean DTS. The Null hypotheses were that (a) the powder-liquid mixing ratios would not differ from the manufacturer's recommended ratio (b) DTS of the set cement samples using the extreme powder/liquid ratios would not differ from those made using the recommended ratio. Methodology. 34 dental students dispensed the components according to the manufacturer's instructions. The maximum and minimum powder/liquid ratios, together with the manufacturer's recommended ratio, were used to prepare samples for DTS testing. Results. Powder/liquid ratios ranged from 2.386 to 1.018. The mean ratio (1.644) was not significantly different from the recommended value of 1.718 (P = 0.189). DTS values for the maximum and minimum ratios were both significantly different from each other (P < 0.001) and from the mean value obtained from the recommended ratio (P < 0.001). Conclusions. Variability exists in powder/liquid ratio for hand dispensed zinc phosphate cement. This variability can affect the DTS of the set material.

Two decades of ART: improving on success through further research

Since the introduction of the Atraumatic Restorative Treatment (ART) approach over twenty years ago, more than 190 research publications have appeared. The last research agenda defining research priorities for ART was published in 1999. The objective of the present work was to review existing research in the context of future research priorities for ART. Material and Methods: An internet survey was conducted amongst those who had published on ART or were known to be working on the ART approach, to solicit their views as to areas of future ART research. Three broad categories were defined, namely: 1. Basic and laboratory research; 2. Clinical research, and, 3. Community, Public Health, Health Services Research. Results: A 31% response rate was achieved. The study identified a number of new areas of research as well as areas where additional research is required. These are expressed as recommendations for future ART research. Conclusions: The ART approach is based on a robust, reliable and ever-growing evidence base concerning its clinical applications which indicates that it is a reliable and quality treatment approach. In common with all other oral health care procedures, targeted applied research is required to improve the oral health care offered.

The ART approach: clinical aspects reviewed

The success of ART as a caries management approach is supported by more than 20 years of scientific evidence. ART follows the contemporary concepts of modern cariology and restorative dentistry. It challenges treatment concepts such as step-wise excavation and the need for complete removal of affected dentine. The ART approach so far has mainly used high-viscosity glass-ionomer as the sealant and restorative material. Cariostatic and remineralization properties have been ascribed to this material which requires further research to establish its clinical relevance. The adhesion of high-viscosity glass-ionomer to enamel in pits and fissures is apparently strong, as its remnants, blocking the pits and fissures, have been considered a possible reason for the low prevalence of carious lesion development after the glass-ionomer has clinically disappeared from it. Encapsulated high-viscosity glass-ionomers may lead to higher restoration survival results than those of the hand-mixed version and should, therefore, not be neglected when using ART. Similarly, the use of resin-modified glass-ionomer with ART should be researched. The effectiveness of ART when compared to conventional caries management approaches has been shown in numerous studies. Proper case selection is an important factor for long-lasting ART restoration survival. This is based on the caries risk situation of the individual, the size of the cavity opening, the strategic position of the cavitated tooth and the presence of adequate caries control measures. As the operator is one of the main causes for failure of ART restorations, attending a well-conducted ART training course is mandatory for successful implementation of ART.

Are encapsulated anterior glass-ionomer restoratives better than their hand-mixed equivalents?

OBJECTIVES

The performance of encapsulated anterior GI restoratives were compared with their hand-mixed equivalents for the range of powder to liquid mixing ratios routinely encountered clinically. The clinically induced variability of powder to liquid mixing variations of an anhydrous GI restorative formulation was also compared with conventional GI restorative formulations that contained a polyalkenoic acidic liquid.

METHODS

Mean compressive fracture strengths, mean elastic moduli and mean total volumetric wear were determined for the encapsulated anterior GI restoratives mechanically mixed in a Capmix or Rotomix machine and the hand-mixed GI restoratives prepared with powder contents reduced from that recommended by the manufacturer (100%) in 10% increments to 50% for a constant weight of liquid. Multiple comparisons of the group means were made using a one-way analysis of variance (ANOVA) and Tukey's multiple range tests employed at P<0.05.

RESULTS

For the encapsulated GI restoratives, the mean compressive fracture strength, mean elastic modulus and in-vitro wear resistance were significantly increased compared with their hand-mixed equivalents prepared with powder contents below that recommended by the manufacturers. The conventional GI restoratives resulted in a linear deterioration (R2>0.95) of the mean compressive fracture strength and mean elastic modulus with powder content compared with the bi-modal deterioration for the anhydrous GI restorative.

CONCLUSIONS

Encapsulated anterior GI restoratives outperform their hand-mixed equivalents for the range of powder to liquid mixing ratios routinely encountered clinically such that they are advocated for use in clinical practice. Anhydrous GI restorative formulations are more susceptible to clinically induced variability on mixing compared with conventional GI restorative formulations that contained a polyalkenoic acidic liquid.