GLASS IONOMERS: DIRECT TOOTH COLORED Todd C. Snyder, …d1ue90e5sp4tcv.cloudfront.net/1946/images/Asset306880_v1.pdf · 6/15/2017 1 todd c. snyder, dds, aaacd glass ionomers: direct

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Todd C. Snyder, DDS, AAACD

GLASS IONOMERS: DIRECT TOOTH

COLORED RESTORATIVE

MATERIALS

• PRIVATE PRACTICE IN LAGUNA NIGUEL, CALIFORNIA

• ACCREDITED, AMERICAN ACADEMY OF COSMETIC DENTISTRY

• FORMER FACULTY, UCLA CENTER FOR ESTHETIC DENTISTRY

• FACULTY, ESTHETIC PROFESSIONALS

• MEMBER OF CATAPULT EDUCATION

• F.A.C.E. GRADUATE

• CBDO, BLUX.COM

• DRIVENLECTURE.COM

Todd C. Snyder, DDS, AAACD

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RESTORING TEETH

Digital radiographs provide the ability to manipulate image size,

appearance and use algorithms to find decay.

67%

accuracy

CariVu

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BITEWINGS VERSUS CARIVU

(Courtesy of Dr Lou Graham)

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Canary

The Canary System Detects Cracks

& Cavities not Visible on X-rays

+ Around & beneath intact margins

of fillings & crowns

+ Under sealants (including opaque

sealants)

+ On proximal surfaces

+ On smooth surfaces, pits &

grooves

+ Around orthodontic brackets

Research claims validated by 60+ papers

15+ case reports & 2 FDA CFR 21 clinical

trials

THE SCIENCE BEHIND THE CANARY SYSTEM

• Pulses (2 Hz) of laser light hit the tooth surface.

• Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).

• Defective tooth crystal structure affects the retained heat and luminescence signatures.

➢Energy Conversion Technology Temperature

increase < 1oC

not harmful

• Detected signals reflect the tooth’s condition.

• Detects 50 micron lesion up to 5 mm below the surface.

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Demineralized

enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83% 64%

Specificity 79% 46%

• Canary Numbers >20 when scanning sealants (3M™ ESPE™ Clinpro™ Sealant) placed over pit & fissure caries.

• The caries detection ability of the Canary System was not affected by sealant & was more accurate than DIAGNOdent.

Sensitivities and specificities for

pit & fissure caries detection

after sealant placement.

Canary Number 66

Canary Number 37Caries into

dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

DETECTION OF CARIES BENEATH SEALANTS

PARADIGM SHIFTFinding pathology late by using a diagnostic tool from 1896 requires bigger restorations and invasive dentistry.

Find pathology earlier creates less damage and more tooth for ones life as well as better potential resin bond strengths and better resin material longevity due to superficial decay being found.

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?How are you restoring

these different preparations

What substrate are we treating?

Class I or II

:Composite Preparation

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding

%30 Degrease in Bond Strengths with most

bonding systems.

Problem

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• Direct Composite Restorations

..…are designed to minimize the shortcomings of resin restorative materials and their

interactions when used in large defects arising deep from within the tooth.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/

(RFA-DE-10-004) “Tooth-colored resin restorations have an

average replacement time of 5.7 years due to secondary caries precipitated by bond failure.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/

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Factors that compromise bond durability in restorative dentistry

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorptionPolymer swelling

Decline in mechanical propertiesLeaching of hydrolyzed resin components

MMP-8MMP-2MMP-9

Demineralizing dentin is like openingthe Pandora’s box, releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped withinthe mineralized dentin matrix.

In the presence of water (such as thatderived from water sorption or from

adhesives, MMPs (2,8 & 9) can breakdowncollagen fibrils that are not protected

by intrafibrillar minerals

Sukala et al. (2007)Mazzoni et al. (2007)


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Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially

disappeared after 6 months of intraoral function

Instability of hybrid layersproblem may be more severe than we realize


BOND LOCATION& DEGRADATION

• Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin bonds. CompendContin Educ Dent. 2011 Sep;32(7):60-4, 66.

Resin-dentin bonds are not as durable as was previously thought. Microtensile bond strengths often fall 30% to 40% in 6 to 12 months.

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding

%30 Degrease in Bond Strengths with most

bonding systems.


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Courtesy Pacific University (Dr Marc Guisberger)

IMMEDIATE BOND STRENGTH STUDY

Maximum/Minimum Shear Bond Strength per Bonding Material

SHEAR BOND TEST RESULTS - 2012

Courtesy Pacific University (Dr Marc Guisberger)

IMMEDIATE BOND STRENGTH STUDY

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BOND STRENGTHS RELATED TO TOOTH STRUCTURE

0

5

10

15

20

25

30

35

40

45

50

DEJ Superficial

(Sound)

Dentin

Beveled

Enamel

Deep

Dentin

Affected

Carious

Dentin

Infected

Carious

Dentin

45 45

30 30 30

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Irie m, suzuki k, watts dc, 2004, marginal gap formation of light activated restorative materials, affects of immediate setting shrinkage and bond strength. Dent Mat 18, 2002; 203-210

DRAWBACKS OF ANY COMPOSITE RESIN

• Material placement techniques

• Variable substrate

• Infected carious dentin

• Polymerization stress & shrinkage

• Water absorption

• Hydrophobic bonding agents

• Decreased adhesive bond strength over time

• MMPs and Cathepsins

• Microleakage

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Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

“C-FACTOR” DEFINITION

Configuration Factor:

“The ratio of bonded to un-bonded (free) surfaces”

Feilzer, DeGee, Davidson (1987), Universtiy of Amsterdam, ACTA

Internal (Polymerization) Stresses of Composites

“A Simple Pain-Free Adhesive

Restorative System by Minimal

Reduction & Total-Etching (1993)

Takao Fusayma DDS,

Tokyo Medical & Dental University

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Tokyo Medical & Dental University, 2010 J. Tagami et al

FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W/ 71%/WT FLOWABLE ON DENTIN ONLY)

RESIN TO DENTIN HYBRID ZONE

“Adhesive dentistry could be expressed as a simple relationship between bonds and stress. If the bonds can withstand the

stress, the restorative technique will be successful.”

Unterbrink & Liebenberg (1999)

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?How are you restoring

these different preparations

• Bioactive material

• affinity to tooth structure. when placing a glass ionomer a weak acid or conditioner is used to aid in releasing calcium and phosphate ions from the tooth structure. These calcium and phosphate ions combine into the surface layer of the glass ionomerand form an intermediate layer called the interdiffusion zone. This bond layer can be very strong and significantly reduce the microleakage that would occur at the margins of the restoration.

• Very good fluoride and ion release helps remineralize tooth structure in the remineralization–demineralization process that naturally occurs in the oral cavity.

• They bond to enamel, dentin, and metals.

Why Glass Ionomers?

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GLASS IONOMER INTERFACEIn

terfa

ce

An

aly

sis (TEM

)

CARDOSO et al. J Dent 2010

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• They produce good marginal integrity.

• They shrink only one ninth the amount of composite material.

• They are fluoride-rechargeable.

• There are no free monomers in the material.

• The cavity preparation can be bulk-filled, making the materials easy to place.

• They exhibit excellent biocompatibility.

Why Glass Ionomers?

CONVENTIONAL GLASS IONOMER COMPRESSIVE STRENGTHS

• Resin Modified Glass Ionomer (Fuji II LC) 170mpa compressive strength

• GC EquiaFil compressive strength 255mpa

• Equia Forte is reported as higher with Class II indications

• Riva SC compressive strength 271mpa

• Surefil SDR flowable resin compressive strength 220mpa

• Dentin 280mpa-297mpa

• Enamel 384mpa

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GLASS IONOMER MATERIALS

• SDI-Riva LC, light cure HV, Riva SC, self cure HV

• G.C. America-Fuji II LC, Equia Forte

• VOCO-Ionolux, Ionofil Molar AC

• 3M/ESPE-Ketac Nano, Photac Fil Quick, Vitremer, Ketac Molar Quick, Ketac Fil Plus

• Shofu- FX II

RIVA SELF CURE/SC HV (SDI)

• No adhesive is required, and sensitivity is non-existent. Like dentin, Riva Self Cure has a very high compressive strength, ensuring it will withstand long term mastication forces.

• No shrinkage

• Riva Self Cure does not contain resin eliminating the problem of volumetric shrinkage after curing. Sensitivity, resulting from microleakage associated with shrinkage does not occur.

• BPA and HEMA Free

• Riva Self Cure does not contain Bisphenol A (including it’s derivatives) or HEMA. Use this product on your patients with confidence and peace of mind.

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SDI

GC

VOCO

• Polyacrylic acid conditioner

• 10 second application to the enamel and dentin

• Developed to partially remove the smear layer of dentin and enamel

• Optimizes adhesion of the glass ionomer cement to tooth structure

DENTIN CONDITIONER

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RIVA SELF CURE HV (SDI)

CARIES DETECTOR 86% ACCURACY:

• As noted by Southern Illinois Dental School in-vitro research,

“Caries Detector Solution Identified 86% of Subsequently Confirmed Caries Lesions After Sectioning”.

• Reference: Caries Detection Accuracy by Multiple Clinicians & Techniques, Thomas, Land, Wilson & Gregory Stewart DDS, Southern Illinois University School of Dental Medicine, IADR Abstract 3127, 1998.

https://www.sdi.com.au/au/product/rivastar/RIVA STAR (SDI)

https://www.sdi.com.au/au/product/rivastar/

https://www.sdi.com.au/au/product/rivastar/

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Deep Preparations Caries Indicator, Conventional Glass Ionomer, Bonding

Agent & Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation & C Factor

Coefficient thermal expansion similar to

dentin

• Glass Ionomer + Bonding Agent + Composite

• Lack of enamel, deep prep or if preparation is on dentin & cementum interproximally

• Close proximity to gingiva

• Subgingival

• Moisture control poses an issue

• Close pulpal proximity

DIRECT RESTORATION LAYERING

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• Glass Ionomer + Bonding Agent + Composite• Dentin Conditioner 10 seconds• Rinse and lightly dry (keep tooth moist, due not

desiccate)• Mix Conventional Glass Ionomer and syringe into

preparation.• Manipulate to place• Wait for material to setup• Use fine diamonds under water spray to adjust if

necessary• Etch Enamel• Rinse & dry w/o desiccating, keep moist• Apply bonding agent• Evaporate off volatile solvents• Cure• Place composite• Cure• Adjust & Check bite

DIRECT RESTORATION LAYERING

Open sandwich, glass ionomer & nanohybrid composite

Enamel ReplacementModern NanoHybrid CompositeCR April 2014 NanoHybrid offers best results

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STOCK LESS

• Eliminate the guesswork from finding the right shade for your restorations by having to choose from just 4 universal shades.

• aura eASY shades easily equate to a Vita shade, making it simpler for you to customize shades for the majority of your daily needs.

GLASS IONOMER SANDWICH

•Class I & II (non-stress bearing) III &

V posterior restorations

•Open & Closed Sandwich

techniques

•Composite replacement

•Amalgam replacement

•High caries risk patients

•Pediatric patients

•Geriatric patients

•Special needs patients

•Long term resistance to

microleakage

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GLASS IONOMER VS. OPEN SANDWICH

GLASS IONOMER VS. OPEN SANDWICH8 years later.

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BULKFIL / Large Core Buildups

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CONVENTIONAL GLASS IONOMER

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RIVA SELF CURE HV (SDI)

A3.5 A3 A2

Glass Ionomer Bulk Fill

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Todd Snyder, DDS, AAACD

Caries control/quadrant dentistry(Class I, II, III, V & core buildup)

Class II Conventional Glass Ionomer BULKFIL

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WHAT DOES A RESIN COATING DO?

Fill porosities to increase physical properties of the restoration and offers a much smoother surface…

(SEM

im

ag

es

x1000)

100um 100um

Some voids are observed A smooth surface is obtained

Polished by using siliconcarbide paper (#600)

After coating


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ENDODONTIC SANDWICH TECHNIQUE


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MINIMALLY INVASIVE PREPARATIONS

KAVO SONICSYS

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ABFRACTION LESIONS

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ABFRACTION LESIONS

• Sometimes it presents as single teeth due to excursive interferences or as a pivot, fulcrum or “teeter totter” tooth.

• Other times there are more in a quadrant and there is severe wear to the occlusion.

• Other times it maybe on the facials of anterior teeth, where there is wear on the incisaledges or wear facets on the linguals, however little to no wear on posteriors.

• Occlusal guards should be fabricated along with an occlusal analysis in CR on models.

Flowables?

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Microleakage and missing fillings from high occlusal loads on teeth can cause large cervical stress concentrations resulting in disruption of the bonds between the hydroxyapatite crystals and the eventual loss of cervical enamel and dentin.

ABFRACTION LESIONS & CLASS V RESTORATIONSLATIN WORDS, AB – “AWAY”, FRACTION – “BREAKING”

• Pathological loss of tooth structure caused by biomechanical loading forces.

• Static and cyclic flexural overloading of tooth structure ultimately leading to fatigue and failure of tooth structure away from the point of loading.

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RESIN MODIFIED GLASS IONOMERS (RMGI)

• Light/Dual cured

• High flexural strength

• Lower compressive strength than conventional G.I.

• Good polishability

• Excellent wear

• Hydrophillic

• Fluoride release

• No microleakage

• No adhesives

• Acid resistant layer

• Reduces sensitivity

• True chemical adhesion

RESIN MODIFIED GLASS IONOMER RESTORATION

Post-Op Photo – notice unlike typical class V composite RMGI restorative material.

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Fig. 15 – Graph representing the

mean annual failure rates

per adhesive class, determined

according to a systematic

review of Class-V clinical trials

of adhesives during the

period 1998–2004 [2].

Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent

Mater (2009), doi:10.1016/j.dental.2009.11.148

Typical treatment involves the placement of a #00 retraction cord on each tooth followed by a shade selection. Roughen tooth structure with air abrasion. Place cavity conditioner on all areas to be restored for 10 seconds, then wash and dry.

Restorative Therapy- Case

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Mix RMGI and syringe into place. Utilize hand instruments to shape and remove gross excess. Cure each tooth for 20 seconds. Remove excess and contour using a handpiece with fine diamond burs. Teeth should be isolated from saliva.


After contouring the restorations can be coated with a self etch adhesive coating, and cure for 10 seconds.


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Six year post-op photos show the integrity of the material is still excellent. Note the lack of marginal microleakage stain often present with composite restorations.


RESIN MODIFIED GLASS IONOMER PLACEMENT

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REVIEWGlass Ionomers

• Modern Diagnostic Tools

• Deep dentin bonding is difficult, unreliable, and short lived

• Conventional glass ionomers have better margins and less microleakage

• Conventional glass ionomers like moisture and help remineralizethe tooth

• Dentin is hypermineralized from glass ionomers making it less susceptible to acid attacks from bacteria

• In shallow preparations thin layer of RMGI as first incremental layer on floor only

• Resin Modified Glass Ionomers as a restorative option with excellent long term benefits to patients in class V defects.

Lots of options

What works best for your practice and skills?

What substrate & how deep is the cavity?

How much time do you have?

Risks and Longevity?

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DRIVENTHE FIRST OF ITS

KIND LECTURE SERIES

www.DrivenLecture.com

THANK YOU!

Todd C. Snyder, DDS, AAACDHandout at www.Dentoolz.com

GLASS IONOMERS: DIRECT TOOTH COLORED Todd C. Snyder, …d1ue90e5sp4tcv.cloudfront.net/1946/images/Asset306880_v1.pdf · 6/15/2017 1 todd c. snyder, dds, aaacd glass ionomers: direct

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