Dental Cements USES OF DENTAL CEMENTS :

1-pulpal protection(liners, bases, varnishes) 2-luting cementation(crown, inlays, onlays, veneers) 3-restorations(temporary and permanent) 4-surgical dressing(eg. periodontal surgery): for example if the patient had a periodontal surgery where parts of the gingiva where removed for any reason, some versions of cements are mixed and placed on the wound site just to help it to heal and prevent any discomfort that can be felt after the operation its just when you cut your hand and place a banded. this table(slide 3) summarize the uses of dental cements , we will cover it briefly. In terms of providing protection to the pulp from injury or irritation that happens because of: 1) cavity prepration. 2) releasing of chemical components from filling materials. 3)thermal injury due to conductivity of the filling material like metallic fillings amalgam. 4) dental caries we want to prevent injury to the dental pulp because we want to maintain the vitality of the tooth , we dont want to do root canal treatment just because we did the cavity preparation in a wrong way for example: using a high speed handpeice without any water, this generates a lot of heat due to friction and can cause irreversible damage to the pulp so we have to know what causes the original irritation to avoid it or minimize it.

Pulpal Protection:
pulpal protection can be done using many things: 1)cavity varnishes ( like varnishes that we talked about in GIC) 2)liners 3)bases These things used underneath fillings before you place a filling, especially in deep cavities not in shallow cavities because in shallow cavities you will have enough thickness of dentin depth covering the pulp so you dont need anything to be placed underneath the filling because dentine can provide good insulation and protection, but if your cavity is very deep minimal dentin is left behind covering or overlaying the pulp you might need an extra layer of material to provide protection and insulation. This for example a deep class two cavity (slide 5 figure 10-1): => liner: placed in a thin layer 0.5 mm or less, and because the cavity is very deep we either place a base over the liner. =>base: up to 0.7mm so its thicker and therefore provide even better protection. =>on top we place the filling material.
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So this layer with the base will compensate for some of the dentin that was removed due to cavity preparation and provide protection to the pulp by keeping it isolated from the rest of the cavity and the oral cavity. Cavity Varnishes: as we explained before in GIC its a resin material that can be composed of: 1-natural resin(copal) 2-synthetic resin dissolved in solvent like alcohol or chloroform. As soon as you place it in the cavity on the floor and the walls the alcohol will evaporate and leaves a layer of resin that covers or seals the dentinal tubules which are the pathway to the pulp. *so varnishes is placed to protect the pulp by : 1-covering and sealing dentinal tubules 2-minimizing microleakage 3-miminzing sensitivity 4-reduce staining: because it will close dentinal tubule so any material coming in due to microleakage or corrosion of amalgam will not be able to enter the dentinal tubule so this will minimize staining of dentine all around. *Application methods (how we place varnishes in the cavity): 1-placed on the floor and the walls 2-placed it in more than one layer because its very thin, so we place one layer then 3- wait from 5-15 seconds for the solvent to evaporate and dry up and then 4- add a second layer just to make sure that you covered everything. *Despinsing and clinical considerations: usually when we buy it there is 2 bottles of : 1-varnish : 90%slovent , 10% resin (copal) 2-extra solvent because sometimes the solvent evaporates and the liquid become too viscous so you have to dilute it with extra solvent. 3-So the lid should be kept tightly closed. because varnish has high solubility( because they are light cured) and wash out quickly it will not provide as much protection as we want them to thats why they replaced by other materials such as bonding agents which has lower solubility . We some still use varnishes to protect GIC from dehydration but if you want to use it for this purpose some prefer to use bonding agents because of their higher stability.

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Liners/low strength base (type IV)

1-calcium hydroxide 2- ZnO/E (typeIV) type IV: type 4 liner, low strength ,very thin liner, weak material.

*Calcium hydroxide:
most famous liner has many desirable proprieties its available as two paste system base(white) and catalyst (light brown) mix them together to have a one homogenous color and then you apply it with applicator that you use in cons lab that called : Dycal applicator or calcium hydroxide applicator.

*Despenising:
its : 2 paste system Self-cured(chemical cured): base: Calcium phosphate, zinc oxide, glycol salicylate, calcium tngstate. catalyst: Calcium hydroxide, zinc oxide, zinc stearate in ethylene toluene sulfonamide Light-cured cement: which has photo initiator to make it sensitive to the light so interaction to light will cure it so we dont have to wait 5 min for the material to set. Composed of : UDMA+Ca hydroxide+barium sulfate filler and low viscosity monomer slightly different composition than self cured the problem of this material is that it has: 1-high solubility. 2-low compressive strength(sweep easily): if we start to condense amalgam on top of it it will start to crack. 3-weak thermal insulator: because we place it in a thin layer. Thats why nowadays we dont usually place Ca hydroxide as a liner we prefer to use better material that has a lower solubility and stronger. Which is basically resin modified GIC called vitrebond. but Ca hydroxide has many good advantages that make it very suitable for other applications,it has: high ph 9-11: makes it anti-bacterial, promotes calcium for tissue formation(dentine) so we basically use it when we expose the pulp during cavity preparation ,if you expose the pulp so : its a state that done by you, the rest of the cavity is clean the exposure is not very big, there is no contamination with saliva , no bleeding coming out of the pulp in these cases we can repair this damage, we dont go immediately and do root canal treatment we try to fix this exposure or injury so we use Ca hydroxide, this is what we call direct pulp capping.

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so as a rule in the clinics in the textbook the informations are slightly different because they are a bit older so nowadays as a rule we use Ca hydroxide only for direct pulp capping when we expose the pulp, there are certain criteria that need to be available before you decide to do direct pulp capping: 1-no contamination 2-small exposure 3-no caries around 4-no bleeding from the pulp: the pulp is not inflamed if this criteria are not available you go and do root canal treatment. There is another procedure called indirect pulp capping when your cavity is very deep and the last layer of dentin over the pulp its stained its not soft with caries but its stained, also its not completely healthy dentin there might be some bacteria, so you decide to keep it because if you remove it you will expose the pulp so some practitioners leave this final layer and place Ca hydroxide on top of it because Ca hydroxide has hight ph 9-11 (anti-bacterial) if there is any bacteria left it will kill it and caries will stop ,so instead of exposing the pulp this is a procedure that maybe done. so because we didnt expose the pulp and we put the Ca hydroxide on top of the bacterial infected layer of dentin we call this procedure indirect pulp capping. So some support Ca hydroxide in indirect pulp capping and some says that its not necessary because as soon as you place a liner(vitrebond) you cut the nutrition from this bacteria and it will die and you will stop caries. (slide11) So this is an example of basic Ca hydroxide there was an exposure in these two sides because usually you do the exposure at the pulp horn(upper most part of the pulp) so pit point exposure very small so we can proceed to direct pulp capping.

ZnO/E liner (type IV):

the advantage of this material is that its sedative its minimizes pain. since its weak and thin it doesnt provide really good insulation or protection from thermal changes, better material to provide protection from thermal changes its the base because it thicker. so this an example of a base placed on the dental filling made out of ZnO/E.(slide 14)

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High Strengt Bases:

because they are placed in thicker layers they provide : 1-better support for the restoration 2-better insulation, the material when its mix, its not going to be very flowable its going to be putty like, like a dough secondary consistency (liner is more flow because so it has a lower powder:water ratio if its powder:liquid system) now different materials can be used as a base: 1- GIC, 2-resin modified GIC 3- ZnO/E that is reinforced (typeIII) stronger than type IV. these material needs to have this properties: 1-strong enough that develop quickly: because we dont want to wait long time until we start place our filling, we want it to set quickly and become strong quickly. 2-low thermal conductivity: to insulate the pulp and protect it from any thermal changes. 3-moderate elastic modulus :it should be not too stiff and not too flexible (moderate stiffness) so it can provide support to the restoration.

Dental Cements:
we talked about some of them previously ,called luting cements (cements that are used in cementation of crown and bridges): 1- GIC 2-Risn cements 3-ZnO cements 4-Compomer cements 5-Hybrid ionomers 6-Zinc phosphate 7-Zinc polycarboxylate there are several desirable features that need to be available: 1-good flow 2-good wettability: to be able to flow and wet to surface of the tooth completely to provide good retention of the crown on top of the tooth. 3-thin film thickness: less than 25 micrometer so when you place the cement underneath the crown. (see slide 19 figure 10-2) this is the red line is the cement you want it flow very well in your prepared tooth(everywhere) and the thickness of this layer should not be more than 25 micrometer ,
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if its thicker it will : 1-prevent proper placement of the crown (restoration) 2- the excess can dissolve or wash out and this might lead to microleakage, irritation and caries so maximum film thickness underneath the crown should be 25micrometer or less . (slide 20) these cements are mixed to primary consistency : they are flowable, they have low viscosity so this is a crown after it is seated on a prepared tooth. so what happenes is: 1-ready crown 2-cement placed inside the crown spread it everywhere to cover all surfaces then it placed with some pressure on top of the prepared tooth, ideally excess cement should come out from the margins so that you are sure that there is no deficiency . now dental cements may be used as restorative material like GIC which used in areas with minimal stress(minimal occlusal forces) , other types of cements can be used as temporary filling material. now why we dont use cements as a permanent restoration: 1-low strength 2-low wear resistance 3-High solubility which is undesirable but as I said there is an exception here that GIC can be used in class V cavity when there is no stress or no high occlusal load. when you can use cements as filling material for a temporary period of time: 1-in root canal treatment for the patient and its going to take more than one visit you place a temporary material until the patient comes back again because you cant leave the tooth open. 2-if you dont have enough time to place permanent restoration you can just place a temporary filling and the patient come again. 3-in symptomatic teeth ,a sedative provisional restoration can be placed: when the patient is in pain you can place a cement that can relieve pain like ZnO/E until the symptoms minimize and then you bring back the patient again. but in general, in our clinics if you remove caries and there is no damage to the pulp even if the patient has symptoms you dont place temporary filling, but in private clinics they do that alot usually because they dont have enough time because they may have a lot of patients. but in our clinics in the center in the following year we dont place temporary filling, but in that case if the patient has symptoms of pain after removing caries you place a liner or base underneath a good filling and symptoms will stop.

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There are few cases that you really dont have enough time ( at the end of clinics) you do place a temporary filling but its not acceptable you should always try to place permanent filling immediately why?? because permanent filling provide a good seal and prevent microleakage while the temporary filling doesnt seal the cavity very well as good as permanent filling thats why its better to place a permanent filling immediately unless there are situations that you cant. (Slide 23) so this is intermediate restorative material IRM this is a very famous brand and the components of the material are zinc oxide eugenol, liquid+powder system we mix it putty like or secondary consistency and placed in the cavity to fill it up . IRM can last for few months there are versions of the material some of them are weaker than the others so for example if you cut one (?????) between appointments you dont need to place IRM you can place other version that its weaker or easier to remove in your next visit but if the patient want to go for month, two or even three months you need to place something strong that doesnt fall out easily so IRM is the material of choice . surgical dressing: this is an example of periodontal surgery was done here in this area in some anterior teeth (figure 10-3/10-4) so because there will be a wound we dont want to leave it open so we place something on top of it to: 1-protect and support it 2-to control bleeding 3-to provide comfort to the patient thats why we use cements as surgical dressing material

*composition:
2 pastes system mixed together putty like its adapted and then sutures can be used to maintain it in its place for retention until the patient comes back and everything is ok. Materials that is used is based of Non eugenol dressing because eugenol can be irritant and can cause burning sensation so we dont use eugenol containing material in surgical dressing. when surgical dressing is placed it should be: 1-smooth and not bulky should be retentive 2-covers surgery site with minimal overextension 3-interlocks interdentally to provide retention. again your surgical dressing material mustnt has eugenol because its an irritant material and can cause burning sensation.

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properties of dental cements (table slide 26) it depends on the material and the application in terms of strength for example for restorative material it depends on powder: liquid ratio if you got less powder: liquid ratio you got more consistent material which means better strength, If the cement is brittle it means it has high compressive strength and low tensile strength. As a rule the cements that are based on resin are stronger than other types of cements (polycaboxylate cements) because they have lower solubility. Solubility: influenced by powder ration, cements have high solubility so there will be microleakage, pulpal irritation, except in resin cements

viscosity: which is a propriety which affect luting cements, we want a luting cement or cementing agent that have secondary consistency(low viscosity) so it will have high powder:liquid ratio compared to restorative cements. Biocompatibility: it depends on many things: 1-Ph of the cement : if you have a material that has a low ph(acidic ph) this decreases the biocompatibility of the material because low ph can cause irritation to the pulp. some cements have initial acidic ph that becomes neutral within 24 hours, other cements take longer to become neutral up to 48 hours which makes them less biocompatible. 2-cements that contain eugenol are sedative and may cause pain and irritation. 3-cements that release fluoride less caries (high compatibility) Retention: 1-chemical: GIC 2-micromechanical :resin cements esthetics: cements like resin cements or resin modified GIC can be available in shades so if we talk about anterior crowns or veneers we have an option to choose the shade that is sutable so we have optimum esthetic result. so we can choose the shade of the most of the crown or veneer in addition to choose the shade of the cement underneath to get optimum esthetic results. and there are also try in cements: they are temporary cements can be used for cementation of crowns or veneers we can try them with the shade that we have selected for one week to see what the patient thinks if he is pleased you can remove the temporary crown or the veneer, and clean the surface then you place the permanent crown or veneer and place them try in cements are too expensive.
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manipulation of cements: -follow manufacturer instruction. each type of cements is manipulated differently, some types are powder-liquid system you in cooperate the powder immediately with the liquid, other types you need to cooperate most of the cement in liquid and leave a little bit of the powder to be mixed at the end if you want the material to be more viscous, some cements are divided into different portions, several portions and gradually mix it with the liquid so it depends on the type an properties of cements. you have to pay attention when you do your mixing ,you have to know how is your mixing skill, you have to be quick because you dont want the cement to start to set while you are still mixing, you have to pay attention if you have to cements more than one crown at the same time, you have to pay attention if you got a long span bridge means you have bridge that is made of five minutes covering five or four teeth so you got another crowns to be filled with cemenet, so in some cases you or you assistant have to be skillful to mix it as quickly as possible to have a longer working time to place the cements. setting could be: chemical , light or dual cured.

Removing the excess: after we place the crown or the bridge or the cement we need to remove the excess now when to remove the excess, immediately, or to wait or at the very end again it depends in the cement itself for example : GIC- It goes to three steps in setting: 1- dissolution 2-gelation 3-hardening now from dissolution to gelation before it comes hard its come to slightly rubbery, like a gel this is the time when you remove the excess so you dont remove GIC excess immediately you have to wait until it initially sets and becomes gel like or rubber like and it will be easy to remove the excess with plastic instrument. Some cements set very quickly and very hardly so you need to remove excess almost immediately ,so it depend on the type of the cement, and usually after removing the excess bucally and lingually you have to remove the excess in between teeth, how we do that?? we use dental floss we tie it like a node and we make it pass between the teeth so any excess interdentally will be removed by dental floss, some students forget to do that and its very annoying to the patient to feel like there is a rock in between the teeth or underneath the bridge there are special processes that can be used for that.

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Zinc oxide eugenol:

uses: 1-impression material 2-temporary and intermediate filling material 3-base(low strength base/high strength base) 4-temporary cementation 5-root canal sealers: during filling of root canals 6-new reinforced cements are used for permanent cementation(type II) several advantages: 1-a wide variety of uses 2-sedative to the pulp 3-easily manipulated disadvantages: 1-low strength 2-high solubility 3-you cant use underneath composite because it prevent setting of composite. Composition: several types are available: 1- type I: zinc oxide, eugenol, resin to reduce brittleness, zinc acetate as accelerator. 2- typee II: its slightly different its reinforced (stronger) either by adding: a.20% acrylic resin b.ethoxybenoic acid (EBA)-alumina-reinforced cement contains 30% alumina in powder. liquid is eugenol and EBA to form stronger crystalline matrix. These materials will reinforced zinc oxide eugenol and make it stronger and less soluble. 3- some versions of zinc oxide are non eugenol they use another oil, other versions of zinc oxide material uses another type of oil instead of eugenol. 4- dispensed as powder& liquid, and two paste system mixed together. Properties: 1-sedative effect on pulp and antibacterial so it relieves pain.(pain killer) 2-neutral ph (=7), biocompatible. 3-can be irritant in direct contact with pulp 5-moderate strength 6-chemical retention 7-water and temperature accelerate the setting of the material

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Manipulation: 1-Type I: two pastes mixed together (base and catalyst ) Solvent: if you use it as an impression material there is a solvent that can remove excess called (oil of orange). 2-type II: powder and liquid, powder is immediately incorporated into liquid and mix it for 30 seconds and sometimes you can add slightly extra powder if you want it to be more viscous (putty like consistency) because it makes it easier to place it as temporary filling in the cavity. how to mix it?? immediately start mixing the powder into the liquid to get one homogenous color, usually in the lab we do the mixing on a glass using a metal spatula. Until we get dough or the putty.

Zinc Phosphate
Another type of cement that used to be very famous and used alot as permanent luting agent. composition: 1-powder: zinc oxide 2-liquid: phosphoric acid and water buffered by Al+Zn to slow setting. this cement has low ph at the beginning and needs 48 hours to become neutral so when its placed or used for cementation of crown can lead to irritation and sensitivity due to acidity. setting reaction:5-9 minutes but usually its less and sets quickly specially with the temperature around now another problem with the material in addition to acidity, it exothermic (releases heat) which can lead to more irritation to the pulp, so in some cases when the preparation is deep you need to place something underneath(usually resin modified GIC) before you place zinc phosphate cement. properties: 1-initial acidity of 4.2, becomes neutral after 48 hours. 2-retentive by mechanical retention: thats why usually if you use it to cement a crown we made inside the crown rough by sand plastic by hitting the internal surface of the crown by sand particles to make it rough for better mechanical retention. 3-low solubility once set 4-sets quickly 5-you have to maintain a dry field because moisture affects (bad) cement. usually now we use other cements for cementation, in the clinic we will be using GIC cements because they are easier to use they dont cause irritation to the pulp compared to zinc phosphate.
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Manipulation: powder is not completely incorporated with liquid immediately its devided into 4-6 portions and gradually mixed with the liquid this will minimize the exothermic reaction and heat production during setting which is a good thing. So the mixing of zinc oxide is incremental (gradual), and there is 15 seconds between mixing each portion for one- two minutes.

zinc polycarboxylate:
another type of cements that is similar to GIC, now if you see the composition of zinc polycarboxylate you will notice that its similar to GIC Composition: powder: zinc oxide liquid: polyacrylic acid The liquid is the same but the powder is different in zinc polycarboxylate than GIC. Uses: 1-hight strength base 2-final cementation for indirect restorations. Propreties (slide 40): now it can bond mechanically and chemically , as a cementing agent the problem of the material that it has higher viscosity than other cements so it is not your best choice, acidity is mild its not as acidic as phosphate so biocompatibility is better ,it has lower compressive strength than other cements, its not commonly used and the most go for GIC cements. Manipulation: powder &liquid system, usually 90% of powder added first then the rest 10% is mixed with liquid to adjust the consistency if we want to make it more viscous. but usually most of the powder is mixed immediately with the liquid.

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Glass Ionomer Cement

we talked about it before so we are not going to talk about them again. we said that GIC can used in multiple reason: 1-low/high strength bases(in deep cavities use calcium hydroxide instead) 2-luting agents 3-core build up 4-restorative material( for class V) Manipulation: we said that it depends whether it is capsule or powder&liquid , and we said that we need to use a conditioner if we want to use it as restorative material and we apply the varnish on top to protect it from dehydration and contamination .

Resin Modified-GIC
can be used for : 1-permenant cementation for crowns and bridges 2-core pulp 3-liners 4-bonding of orthodontic brackets properties: 1-flouride release 2-low solubility 3-early low ph then increase to become neutral 4-high fracture toughness but lower than resin cements 5-problem of water sorption(contraindicated for all ceramic restorations, may cause cracking due to expansion): it can absorb some water over a period of time so you cant use them underneath porcelain veneers or crowns. crowns can made from porcelain completely or from porcelain with a metal layer beneath it we called it porcelain fused to metal, now you can use Resin Modified-GIC underneath porcelain fused to metal thats fine but if you only had a ceramic(porcelain) crown especially anteriorly or a veneer made from porcelain you cant use Resin Modified-GIC for cementation because it absorbs water and if it absorbs water it will expand and cause cracks. other option to use is resin cements. Manipulation: capsule, powder&liquid system. now this is example of Resin Modified-GIC called : vitrebond linerlight cured material (slide 44)

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Resin base cements:

the strongest, least soluble material because they are made out of resin you need some treatment for the tooth surface because the retention is micromechanical. now they can used for: 1-temporary and permanent cementation of crowns and bridges. 2-bond ceramic indirect restoration 3-orthodontic bands Setting: 1-chemical cure 2-light cure 3-dual cure: most versatile for example if you use them to bond veneers, veneers thickness is usually 0.5mm its very thin so you use light cure material underneath it and the light will penetrate through the veneer and set the cement , but if you are using a crown the thickness of porcelain is too much dont allow enough light to reach so you use either chemical or dual cure materials composition and properties: 1-similar to composite resin : acid etching+ bonding agent same principle as filling material but the difference is with filler and some other components. 2-usually microfill or microhybrid : small filler size to make it more flowable. properties: 1-insoluble and high wear resistant 2-high bond strength when primer, etching is used . 3-good esthetic(available in shades) under all-ceramic crowns 4-bonded by etching and bonding, sandblasting(in the lab to promote micromechanical retention) of internal surface of restorations 5-temporary cements (also available in shades): easy to mix and clean up, low-medium strength 6-new self adhesive resin: no etching or priming needed(Relyx Unicem,3M ESPE)

so this is an example of a cement (slide 48) that provided as a capsule so it is mixed and then this gun is used to express or inject this cement inside the crown which seems very easy thats why capsulated material is more expensive, easier to use but the manufacturer it cost him more money to make so it will be more expensive for you. and this is what I walk about excess coming out from periphery this means that you have placed enough material so there will be no deficiency along the margins of the crown so this excess can be removed depending on the type of the material sometimes with plastic instruments, sometimes with cotton.
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compomer cements:
which are modification of resin cements, similar to the compomer that we talk about in the composite lecture. composition and reaction: powder &liquid system powder: fluorosilicate glass in addition to resin material, sodium fluoride, self-cured and light-cured initiator. liquid: polymerized-methacrylate-carboxylic acid monomer, water, acrylate- phosphate monomer, diacrylate monomer. properties: can release fluoride, low solubility, high bond strength, high fracture toughness and strength similar to resin we need to treat the surface by etching because the retention is micromechanical . similar uses for :crown and bridges cementation. manipulation: 1-paste-paste system 2-powder-liquid system: rapid mixing is needed 3-dry but not desiccated tooth surface ( we dont want to dehydrate the tooth because we want the material to be able to flow very well we dont want to damage any collagen fibers) 4-gelation after 1 minute, here we can remove the excess similar to GIC (the material become like a gel). 5- light cure is done around the margins of the material.. special applications of cements: mostly when we talked about bonding applications we talked about crowns ,bridges and veneers this can also applied in : -bonding of orthodontic brackets: resin cements, GIC, Resin Modified-GIC -cementation of orthodontic bands: 1-glass ionomer 2-zinc phosphate with added fluoride 3-hybrid ionomers 4-resin cements -root canal sealers: endodontic sealers they are basically material that you need to combine with the filling material that you use inside the canal now when you do a cavity preparation in the crown you use a liner or base then you place a filling material( amalgam, GIC, composite) , now for root canal the filling material is called MTA its a rubbery material cone shaped placed inside the canal after its cleaned and pulp is removed, now this material cant chemically bond to the canal there will be small places around so a paste needs to be placed inside so it will cover and completely block any spaces that are present, this material or paste is what we call a sealer,
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now this sealer that is used in root canal can either be made from GIC material or Zinc oxide material or resin material, rubber, Ca hydroxide material so all of these can be used for this application but it will not be like the restorative material it will have some different components like particles maybe smaller to make the material more flowable or low viscous. but its another application of cements with different versions to fill root canal we will talk about them when we talk about endodontic materials after the mid exam. this material also should be biocompatible, it needs to have long working time because it takes you a long time to do filling to root canal its not as quickly as placing a filling material in the crown ,especially when you are working on molars you have to seal 3 or 4 root canal , you need it to be very radiopaque to be able to do radiograph and see if the sealer comes out from the apex or if it deficient.

Done by: Gewanna J. Ghazal

sorry if there are any mistakes 26/10/2012

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