P E D IA TR IC D E N T IS TR Y

V 37

NO 2

MAR

APR 15

Conference Paper
Glass lonomer Restorative Cement Systems: An Update
Joel H. Berg, DDS, MS' Theodore P. Croll, DDS2

Abstract: Glass ionomer cements have been used in pediatric restorative dentistry fo r more than two decades. Their usefulness in clinical dentistry
is preferential to other materials because o f fluoride release from the glass component, biocompatibility, chemical adhesion to dentin and enamel,
coefficient o f therm al expansion similar to that o f tooth structure, and versatility. The purpose o f this paper was to review the uses o f glass
ionomer materials in pediatric dentistry, specifically as p it and fissure sealants, dentin and enamel replacement repair materials, and luting cements,
and fo r use in glass ionomer/resin-based composite stratification tooth restoration (the sandwich technique). This article can also be used as a
guide to research and clinical references regarding specific aspects o f the glass ionomer systems and how they are used fo r young patients.
(Pediatr Dent 20l5;37(2):li6-24)
KEYWORDS: GLASS IONOMER CEMENT, PEDIATRIC RESTORATIVE DENTISTRY

This paper reports on the November 2014 American Academy

of Pediatric Dentistry restorative dentistry consensus conference
regarding the clinical use of glass polyalkenoate (glass ionomer)
materials in children. Compared to other dental restorative and
luting materials, none combine so many advantages with so few
disadvantages. The various formulations of the glass ionomer
systems make for unprecedented versatility and clinical effective
ness. Restorative objectives for children include sealing noncarious pits and fissures, rendering the tooth and the tooth/
restoration interface caries resistant after tooth repair, providing
easy handling properties for the dentist and assistant, and keep
ing material costs reasonable. In addition, the material selected
for the procedure must endure the grueling intraoral environ
ment, without degradation, for as long as possible. Certain glass
ionomer systems meet those objectives remarkably well and
have become a standard of care in a variety of clinical applica
tions for children.
For the education of both children and parents, Croll de
fined glass ionomers as a type of filling material that bonds to
teeth...1because glass ionomers are self-adhesive materials2 and
are the only commonly used materials that chemically bond
to tooth structure.3,4 Thanks to continuing improvements in
products over the years, this category of products has gained
an extremely important role in modern clinical dentistry.
The purpose of this paper was to review the uses of glass
ionomer materials in pediatric dentistry, specifically as pit and
fissure sealants, dentin and enamel replacement repair materials,
and luting cements, and for use in glass ionomer/resin-based
composite stratification tooth restoration (the sandwich tech
nique). This article can also be used as a guide to research and
clinical references regarding specific aspects of the glass ionomer
systems and how they are used for young patients.

'Dr. Berg is Dean. University of Washington School of Dentistry, Seattle, Wash., U.S.A.
2Dr. Croll is a pediatric dentist in private practice, Doylestown, Pa., U.S.A.; an affili

ate professor. Department of Pediatric Dentistry, University of Washington School of Den

tistry': and an adjunct professor, pediatric dentistry. School of Dentistry. University of
Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A.
Correspond with Dr. Bergat joelberg@uw.edu

116

GLASS IO N O M E R RESTORATIVE C E M E N T SYSTEMS

Background

Glass polyalkenoate cements, more commonly known as glass

ionomers, are made of calcium or strontium alumino-fluorosilicate glass powder (base) combined with a water soluble
polymer (acid). Glass ionomers were invented in the United
Kingdom in 1969, and the earliest formulations became avail
able in the early 1970s. Glass ionomer cement components,
when blended together, undergo a hardening reaction that
involves neutralization of the acid groups by the powdered glass
base. Significant amounts of fluoride ions are released during
this reaction, which relies on the presence of water. Two varia
tions of true glass ionomer materials developed in the 1980s
and 1990s are those modified by inclusion of metal and those
with a light-polymerized liquid resin component that renders
the cement photocurable as part of the overall hardening
reaction. The latter are called resin-modified glass ionomer
cements.
The original glass ionomer commercial formulations intro
duced in the 1970s failed to gain widespread interest, especially
by dentists in North America. Those materials had long setting
times, were susceptible to dissolution and desiccation during
hardening, and had poor wear resistance and low fracture
strengths once set. Regardless of the advantages of the first glass
ionomersincluding fluoride ion release and uptake by enamel
and dentin, coefficients of thermal expansion similar to that of
tooth structure, chemical bonding to both enamel and dentin,
tooth color replication, and biocompatibilitydentists did not
readily adopt materials that were difficult to handle and un
reliable in the long term. As time went by, the status of glass
ionomers changed.
Clinical use of glass ionomer materials by category

This paper provides a position statement regarding each clinical

indication for glass ionomer materials in children. It is useful
to consider the matter in categories, because different clinical
challenges require varying solutions, and specific formulations of
glass ionomer materials are used for different clinical purposes.3
Glass ionomer materials, in general, have not approached
the esthetic appearance of resin-based composites (RBCs). How
ever, the resin-modified versions, particularly the nano-ionomer,
have improved in this regard, but RBCs are still more esthetically
desirable for imperceptible enamel repair of anterior teeth.

P E D IA T R IC D E N T IS T R Y

Sealants. Glass ionomers have been studied for use as pit

and fissure sealants.6'9 Prior to providing a position statement
regarding the use of glass ionomers as sealants, it must be noted
that resin-based sealants are known as the most effective ma
terials for pit and fissure sealants.10,11 Bonded resin sealants,
when used properly, work exceptionally well. In the most ex
tensive review of resin sealants in the dental literature, Simonsen
described every aspect of resin-bonded sealants, including:
laboratory studies; clinical technique and tooth preparation;
etching time; application of sealants by dental auxiliaries; re
tention of resin sealants and their preventive function; inclusion
o f fluoride in the resin, glass ionom er materials used as a
sealant; filler content and color of resin sealants; autocure versus
photopolymerized resin hardening; purposeful sealing of carious
pits or fissures; cost effectiveness; underuse of sealants; and the
controversy about estrogenicity of RBCs and sealants.10 Simonsen
pointed out the importance of perfect isolation of a tooth to be
sealed with resin, that the enamel acid etching must be com
pleted with no contamination of the tooth surface, and that
pits and fissures need to be free of debris so that hidden carious
lesions can be ruled out.
Even though bonded resin sealants are preferred, glass
ionomers offer an alternative and should be considered in cer
tain circumstances, such as:
1. Precooperative children with primary molars having
deeply pitted or fissured surfaces but with teeth that
are difficult to isolate.
2. Permanent first or second molars that are not yet fully
emerged into the mouth, but at-risk pits and fissures
are evident.
3. C onditions whereby a transitional sealant can be
considered prior to the placement of a standard long
term resin sealant.
Limitations of glass ionomer sealants include the:
1. Physical properties of glass ionomer materials.
2. Specific formulation of glass ionomer selected for the
procedure.
3. Longevity of glass ionomer cement used as a sealant.
Glass ionomers are brittle materials. Pure (traditional) glass
ionomers, when used as sealants, have been shown to exhibit a
high frequency of fracture within the pits and fissures, although
remnants of the material remain within the depths of the fis
sures as a result of their chemical bond to tooth structure and
some mechanical interlocking retention. Therefore, a preventive
effect remains, probably enhanced by the fluoride component
in the glass. To compensate for the brittleness of traditional
glass ionomers, resin-modified glass ionomer (RMGI) materials
have commonly been selected as alternatives.16'18 These materials
offer better physical properties and on-command initial hard
ening by photopolymerization but still lack the flowability and
retentiveness of resin sealants when used on a properly isolated
and acid etch-conditioned tooth surface.
For the primary dentition, there are some indications where
the longevity of glass ionomer as a sealant (especially the lighthardened resin-modified type) serves adequately until exfoliation
of the tooth. In the permanent dentition, the literature strongly
supports resin sealants as the material of choice for pits and
fissures at risk of Class I caries.10
Luting cement. Glass ionomer cements were first intro
duced as cavity lining materials; soon thereafter, these materials
were used as luting agents. Subsequently, specifically formulated

V 37 I NO 2

M A R I A P R 15

luting agents have been developed for various purposes.19 Now,

the chief types of luting agents are the powder/liquid formu
lations and resin-modified versions. The resin-modified systems
have dom inated in recent years because o f their enhanced
physical properties and ease of use.20
Besides differences in physical properties between the tradi
tional chemically hardened glass ionomer luting cements and
the resin-modified types, one needs to remember that the
former requires acid removal of the smear layer for the best
bonding, and the resin-modified materials require a self-etching
adhesive prior to cement application to the tooth surface.
Crown cementation. Since their introduction, glass ionomer
cements have become the material of choice for cementation of
stainless steel crowns and stainless steel orthodontic bands (see
below).20'22 Stainless steel crowns differ from laboratory customfabricated metallic or ceramic crowns, because laboratory processed
crowns have a precision fit. In the stainless steel crown proce
dure, the luting cement acts not only as an interface between
the crown and the tooth, but also as a bulk filler for the voids
that inherently exist under a preformed crown. Therefore, the
clinician is relying on careful contouring, crimping, and finishing
of the crown form, along with adhesive and strength properties
of the cement, for long-term retention of a steel crown. Precision
laboratory fabricated crowns also require a luting cement that
is practical (i.e., excess is easily removed after crown cementa
tion) and biocompatible, has fluoride ion release and uptake by
dentin and enamel, is adhesive and insoluble in oral fluids, and
has high strengths in thin layers to withstand the daily impact
forces of occlusion and mastication. To a large extent, RMGI
luting cements have satisfied all these requirements for crown
cementation for children and adults.20,21'23'25
Resin luting cements, often selected as luting agents for
laboratory-fabricated permanent tooth crowns, are not preferred
for cementation of stainless steel crowns. They are not selfadhesive, are less biocompatible with cut dentin, and require a
more difficult and time-consuming procedure.
Orthodontic band cementation. Glass ionomers are ideal
for cementing orthodontic bands. Not only are their physical
strengths more than sufficient for that purpose, but the fluoride
ion release and uptake by enamel surfaces protects the teeth
from acid challenge from foodstuffs and from organic acids
produced by biofilm/plaque accum ulation.22,26'29 No matter
how extensive efforts are to instruct young orthodontic patients
about meticulous oral hygiene, complete daily removal of plaque
and debris, and use of fluoride dentifrices and mouth rinses,
an excellent preventive measure is to have band cement that
releases fluoride and renews itself with fluoride from oral health
care products. Clinicians should know that adhesion of glass
ionomer luting agents to tooth structure is greater than adhesive
strengths of the cements internal band surfaces.30 Therefore,
additional retention can be achieved by roughing those metal
surfaces with a diam ond bur or employing air particulate
abrasion.31,32
Orthodontic bracket adhesive. Several laboratory studies
have examined the bond strength o f orthodontic brackets
bonded to enamel smooth surfaces with glass ionomer cement
when subjected to forces commonly applied to bracket/tooth
interfaces during orthodontic tooth movement.33'35 Although
the bond strength measured with resin-modified varieties has
sometimes been deemed adequate to allow for orthodontic tooth
movement without detachment, these bond strengths are still
significantly lower than those using resin-based bracket ad
hesives. In the same way that resin-bonded sealants out perform

G L A S S IO N O M E R R E S T O R A T IV E C E M E N T S Y S T E M S

117

PEDIATRIC DENTISTRY

V 37

NO 2

MAR I APR 15

glass ionomer sealants, resin-bonded brackets have a better

attachment than those with glass ionomer material.36,37
There may be clinical circumstances for which a lower bond
strength bracket adhesive would be desirable. For example, if
brackets were placed for a short term to stabilize an injured
tooth, a RMGI may suffice and decrease the risk of enamel
damage when the brackets are removed. Another example is
when a short-term orthodontic goal is required in a local region
of the mouth and forces involved are minor, a RMGI system
may work well. At least one manufacturer has marketed its
RMGI specifically as an orthodontic adhesive.38'40 It may be pos
sible to create enhanced formulations of RMGI attachment
cements that could be strong enough to routinely be used as
bracket adhesives, allowing for retention during the entire
duration of orthodontic treatment, act as a fluoride source for
adjacent enamel, and facilitate bracket removal afterwards.41
Cavity liner/base. Glass ionomer products are ideal for use
as dentin replacement protective cavity liners. The fluoride con
tent of these formulations (and associated antimicrobial effect),
chemical bond to dentin, sealing ability, retentiveness, and lack
of postoperative tooth sensitivity make them ideal for internal
use in tooth repair, whether a thin liner or thicker dentin re
placement base is required.42,43 Flowable, low-viscosity versions
of traditional glass ionomer material as well as RMGIs have
been used effectively as cavity liners and bases since the 1970s.44
Glass ionomers provide a simple and effective choice for the
clinician to accomplish all of the objectives of cavity lining
simultaneously.
Dentinal adhesive. Using glass ionomer as a dentinal ad
hesive is a natural extension of the idea that glass ionomers are
ideal cavity liners. By using a glass ionomer material as an ad
hesive on dentin surfaces, above which resin composites are
applied as a surface restorative material, one can accomplish
several restorative objectives simultaneously.45,46 The cavity can
be sealed, the retention of the surface RBC can be achieved,
and resistance to further destruction can be avoided. One issue
that must be dealt with when considering using glass ionomer as
an adhesive on dentin surfaces is the enamel margin. Because
the appearance of glass ionomers (even the resin-modified
variety) still cant compare to the highly esthetic RBCs, glass
ionomers are best used as an adhesive only for the dentin sur
faces in anterior applications.
Because of the inherent adhesive properties of glass iono
mers and their biocompatibility, RMGIs can be use as adhe
sives in lieu o f the som etim es challenging placem ent of
resin-based adhesives.47,48 It is im portant to remember that
the chemical bond of glass ionomers to tooth structure over
time does not hydrolyze the way resin/dentin bonds do.
Sandwich technique/dentin replacement. It is perhaps
difficult to distinguish using glass ionomers as liners, dentinal
adhesives, and the sandwich technique.44 The sandwich tech
nique is tissue-specific tooth repair. Also known as stratifica
tion, the sandwich technique simply means that a suitable glass
ionomer (usually the resin-modified type) is used to replace
dentin, and an RBC is overlaid as a bonded enamel replacement.
The glass ionomer is sandwiched between the tooth surface and
the bonded RBC.50 There are a number of papers promoting
the use of this technique, with more limited exposure to clinical
testing of the technique with reported outcomes.50 Croll and
Swift reviewed RBC/RMGI stratification, and other writers have
documented the advantages of that restorative approach.51'53
Another example of a sandwich-type of technique using
glass ionomers is the tunnel preparation.54,5 This technique re

118

GLASS IONOMER RESTORATIVE CEMENT SYSTEMS

quires occlusal preparation and angulated access to the contact

point, wherein glass ionomer is injected to completely fill the
tunnel section, and the occlusal opening is restored with bonded
RBC.
Restorations
The earliest glass ionomers had a slow chemical setting reaction
and were subject to washout or desiccation. Once hardened,
their physical properties could not rival those of the RBC. How
ever, the remarkable advantages of the glass ionomer systems
encouraged manufacturers to progress with improvements such
that certain materials became suitable for both dentin and ena
mel replacement.56'59 In the mid 1980s, metal-modified glass
ionomers were introduced; however, although wear resistance
was improved, fracture strengths were not, and the gray color
was an additional disadvantage. In the late 1980s, light-hardened
liners/bases were introduced, followed by RMGI restorative
cements in the early 1990s. Physical properties and handling
characteristics of these resin-modified glass ionomers have made
them a standard restorative material for use in young patients.60
An additional beneficial property of certain RMGI restora
tive cements is triple hardening.61 Initially, the visible light
beam cures the light sensitive resin, followed by a chemical resin
cure. Then, over an extended period, the glass ionomer acid/base
neutralization reaction matures for additional hardening. The
chemical resin cure is important in times when depth of light
penetration is uncertain. The early RMGI restorative cements
had such good durability and reliability that several are still on
the market almost 25 years later.62
It should be noted that, even with addition of the lighthardened resin component, the resin-modified glass ionomer still
maintains the properties and advantages of other glass ionomer
systems. They are hydrophilic and biocompatible, release and
take up fluoride ions, have a coefficient of thermal expansion
similar to that of tooth structure, are tooth colored, and chem
ically bond to dentin and enamel. No other dental restorative
material has such an array of positive attributes. Wear resis
tance and physical strengths, although much improved from the
original cements (and sufficient for m any applications in
primary teeth), still lag behind RBCs.
Glass ionomer materials are excellent for repair of defective
margins of prior restorations and for interim use. For example,
they serve as temporary endodontic access fillings during cal
cium hydroxide apexification or internal tooth bleaching pro
cedures, or as fillings of small marginal defects of RBC or silver
amalgam restorations.
Class I restorations. The C-factor is a way to describe the
effect the number of bonded surfaces have on RBCs as they
shrink during photopolym erization. Such shrinkage is im
portant, as it can open margins during the hardening process.
Because glass ionomers have significantly less shrinkage, their
use for Class I restorations in primary teeth is particularly ad
vantageous.63,64
In the permanent dentition, small, minimally invasive pre
parations can be restored with RMGI; however, if RBC can be
used alone or as an overlay in the stratification method, its
greater wear resistance and fracture strength make it the prefer
able material.65,66
Class II restorations. For primary molars, RMGI restorative
cement is a good material for small- to medium-sized Class I
restorations.67,68 Traditional glass ionomer material can be used,
but preparations must be larger to accommodate a bigger bulk
of cement that is more resistant to fracture.69,70

PED IA T R IC D EN TIS T R Y

Studies have shown excellent results when using RMGI

restorative cement for Class II repair of primary molars.71'82 Many
clinicians have abandoned the use of silver amalgam in chil
dren in favor of RMGIs for tooth repair, which formerly would
have been done with amalgam. By doing so, dentists avoid
explaining the silver appearance of the restoration and also
the ongoing false controversy about mercury in dental filling
material.
For permanent teeth, resin composite is still preferred for
Class II direct restorations and the sandwich technique, the
latter for its wear resistance and fracture strength.
Class III restorations. Glass ionomer cement is an ideal
choice for small Class III restorations. The proximal contact
point is a prime location to take advantage of the unique fluoride
releasing properties of glass ionomer.83 For permanent teeth,
resin-modified glass ionomer materials are ideal from the lingual
approach, but RBCs replicate enamel appearance more ideally.
Class V restorations. Class V caries lesions in infants,
toddlers, and preschoolers are common in the primary denti
tion. Nursing bottle and sippy cup use and early childhood
caries from all causes characteristically result in cervical decal
cification and caries.84 The self-adhesive properties, easy hand
ling, and acceptable tooth-colored appearance of glass ionomers
greatly simplify Class V tooth repair for the youngest patients.8'"
Likewise, permanent teeth with Class V caries lesions are
also ideally treated with RMGI cement. Children and teens
who overindulge in soda pop and high acid fruit drinks often
develop Class V caries and erosion lesions, and the fluoridecontaining glass ionomers are therapeutic in that regard, because
they provide long-term reliable results.88,85
Buildup after pulp treatment
After pulpotomy or pulpectomy in primary teeth, in lieu of full
coronal coverage, glass ionomers are useful in a type of sandwich
procedure. The lost dentin is entirely replaced, the pulp space
is filled with RMGI, and the surface above it is restored with
RBC.90,91 Although there is not a good long-term clinical trial
reporting on outcomes of this procedure, there is much anec
dotal information reported by practitioners, seemingly all favor
able. It is logical that the key to success is completely sealing
off access of salivary-borne bacteria to the pulp space. This
requires complete seal of cavosurface margins, which is probably
achievable. Regardless, depending on the patients ages and
length of time required for retention of primary teeth, stainless
steel crowns or full-coverage anterior crowns may not always be
necessary.
ART technique
The ART technique (atraumatic restorative treatment) has been
introduced using traditional glass ionomer materials. In this
technique, the dentist (or other operator) uses hand instruments,
such as spoon excavators, to remove tooth structure affected by
caries. The traditional glass ionomer is then hand mixed and
placed into the cavity preparation, with the glass ionomer acid/
base reaction setting the material. The technique was introduced
first in Thailand and is now used in many Third World areas,
allowing large numbers of children affected by caries but lacking
resources sometimes even without electricity and w ater-to
have their teeth treated in traditional ways.92 Specifically for
m ulated glass ionomers have been developed for the ART
technique. These are high powder/liquid ratio traditional glass
ionomer materials, with enhanced physical properties developed
by m anipulation of glass particle size and distribution and

V 3 7 I NO 2

M A R I APR 15

content of the polyacid component. In addition, several highly

refined and finely sharpened hand instrum ents have been
developed to allow rapid excavation of damaged tooth structure,
simultaneously preparing the cavity for some mechanical inter
locking retention of the cement.93,94
Results of many different long-term clinical trials have
examined the effectiveness of ART fillings.95,100 Most of these
studies have reported on retention of the restoration as the
primary outcome measure of the treatment. Some have looked
at new caries lesions beside the surface of the restoration; none
has developed a protocol comparing the ART technique to a
control, such as a traditional in-chair technique. In spite of this,
many have touted the attributes of the ART technique because
of good outcomes measured in terms of restoration retention
and the ability to treat large numbers of children in inaccessible
and isolated areas, sometimes by practitioners who might not
be able to perform standard procedures.101
The ART technique will likely be further tested and ex
panded, and some are looking into ways of treating dental caries
lesions medicinally, prior to restoring the teeth with the glass
ionomer material.
Summary
Glass ionomers have been a mainstay of restorative dentistry for
children for several decades. Their many formulations, clinical
uses, and unique advantages have made these materials an essen
tial part of everyday practice for dentists who treat children.
The fluoride-releasing properties of glass ionomers will
become even more important as caries diagnostic devices, now
available for clinical use, become more sophisticated and pro
vide better sensitivity (on proximal axial surfaces) and speci
ficity.102,103 Awareness about the value of fluoride-releasing
materials will certainly be enhanced when the localized effects
of their use can be more precisely measured.
Udpate since 2002 consensus position paper as presented
in November 2014
Glass ionomer cement systems for use in pediatric dentistry
were extensively reviewed in 2002 as part of the AAPD Pediatric
Restorative Dentistry Consensus Conference.104,106 Since the
1970s, glass ionomer cements have proven to be the best direct
application dentin replacement materials available. RMGIs have
overcome most of the major disadvantages of the original chemi
cally hardened glass ionomers. These materials harden initially
by photopolymerization, and the setting process continues by
completion of the acid/base neutralization reaction as the poly
acid component reacts with the glass particles. Inclusion of the
light sensitive resin not only provides for on command harden
ing, but also makes for a filling material (or luting cement)
with enhanced physical properties compared to traditional glass
ionomers. RMGI cements are clinically practical materials with
all the advantages of glass ionomer systems as well as the bene
fits of better handling and physical strength (wear resistance,
fracture resistance, fracture toughness, etc.) and greater durability
over time.
A continuum of adhesive tooth restorative materials was
described by Burgess et al.105 and Berg.106 This continuum
focuses on advantages and disadvantages of the RMGIs and
RBCs. For years, dental manufacturers research and development
teams have been working to create a dental restorative material
that has all the advantages of hydrophilic RMGIs and hydrophobic RBCs w ithout any disadvantages. Croll and Berg107
noted that such a material would:

GLASS IO N O M E R RESTORATIVE CE M E N T SYSTEM S

119

P EDIATRIC D EN TIS T R Y

1.
2.

3.
4.

5.
6.
7.

8.
9.

V 3 7 / NO 2

M A R I APR 15

Chemically bond to enamel and dentin.

Be therapeutic by releasing fluoride ions that are
incorporated into adjacent dentin and enamel, ren
dering th a t to o th stru ctu re less soluble to acid
challenge.
Have an antimicrobial effect by virtue of its fluoride
content.
Have equivalent coefficient of thermal expansion to
that of tooth structure so that the mass of material had
sufficient dimensional stability, minimizing marginal
breakdown.
Not shrink or expand during the hardening reaction.
Be insoluble in oral fluids and acid foodstuffs (erosion
resistance).
Have high resistance to wear from im pact forces,
stresses from occlusion and mastication, and wear and
tear from toothbrushing.
Have high cohesive strength and resistance to both
initial fracturing and propogation of fractures.
Be tooth colored, highly polishable, and have easy
handling characteristics, including on com m and
hardening (photopolymerization).

Much effort has been expended in developing bonding

agents and appropriate methods of directly bonding RBC to
acid-etched dentin, not just enamel. To this date, a resin-dentin
bond that does not hydrolyze over time has not been perfected.
One school of thought is that RMGf material and RBC should
be stratified to achieve the best biomimetic restorative result.108'110
This approach takes advantage of all the positive properties of
both materials, significantly decreases marginal leakage, virtually
eliminates post-operative tooth sensitivity, capitalizes on the
fluoride component of the glass particles, and helps to overcome
the effects of resin polymerizaton shrinkage.110 There has been
much academic debate offered on the subject, but we have not
encountered any cogent rationale refuting the value of adhe
sively bonded tooth repair involving stratification of an RBC
over an RMGI liner/base.
In 2007, a new advance was achieved on the continuum
when a nano-ionomer was introduced. Ketac Nano (3M ESPE,
St. Paul, Minn., USA) is a two-paste RMGI system described
by the manufacturer in its technical product profile as such:
Paste A is resin based and contains fluoroaluminosilicate glass, silane treated silica and zirconia silica
nanofillers, methacrylate and dimethacrylate resins,
and photoinitiators. Paste B is water based and contains
polyalkenoic acid copolymer (Vitrebond Copolymer),
silane treated zirconia silica nanoclusters, silane
treated silica nanofiller, and hyroxyethylmethacrylate
(HEMA). Ketac Nano Primer contains water, HEM A,
polyalkenoic acid copolymer, and photoinitiators.
Killian and Croll reported on the clinical use of the nanoionomer and their experiences with the material over three
years.111 Their unpublished eight-year observations regarding
Ketac Nano are as follows:
1. RMGIs, such as Fuji II LC (GC America, Inc., Alsip,
111., USA) and Vitremer Core Buildup/Restorative (3M
ESPE), perform very well over many years, with only
two disadvantages: they have less wear resistance and
lower fracture strengths than RBCs. Experiences with
Ketac Nano from 2007 to 2014 show improvement in
these properties.

120

GLASS IO N O M E R RESTORATIVE CEM EN T SYSTEMS

2.

3.

4.

5.
6.

7.

8.

9.

It is essential to use syringe injection of the nano-iono

mer to avoid air incorporation into the restoration.
The orange thin lumen AccuDose Low Viscosity tips
(Centrix, Inc., Shelton, Conn., USA) work especially
well for that purpose.
Once the two pastes of the material are blended and
placed into the syringe tip, a delay of approximately
30 seconds before injecting is useful to make time for
an initial congealing of the cement. That makes for
easier placement of the material.
Finishing and polishing can be achieved in the same
manner as one completes an RBC restoration. Polished
nano-ionomer surfaces are smooth and lustrous, like RBC
surfaces, due to the nanofillers and nanofilled clusters.
In some mouths, the material yellows slightly over
the years.
For Class I and II repairs of primary molars, the nanoionomer appears to be very reliable for five to eight
years until the treated tooth is lost to exfoliation. Some
isthmus fractures have occurred in Class II restorations
with larger bucco-lingual widths. Blunting opposing
jack-hammer-like cusp tips is helpful to avoid harsh
concentrated forces on the cement and enamel surfaces.
The resin chemistry of the nano-ionomer only provides
for photopolymerization. There is no chemical resin
cure; hence, through-and-through light beam penetra
tion is critical for optimum hardening of the cement.
In regions of masticatory impact and occlusal contact,
the nano-ionomer does not wear as well as an RBC.
However, significant wear, perhaps in combination
with erosion from oral fluids over time, rarely occurs
within five years to the extent that renewed treatment
is needed.
The nano-ionomer is very useful for interim repair
of certain permanent posterior teeth (e.g., those with
enamel hypoplasia or enamel hypocalcification, with
or without associated dental caries).112

Clinical experiences echo research findings about the nanoionomer. Studies have verified that nano-filled adhesive mate
rials in general, and Ketac Nano in particular, resist biodegrada
tion and abrasive wear better than conventional materials.113,114
It has also been verified that adhesion of the nano-ionomer to
dentin and enamel is the same as other glass ionomer systems,
and there are two hardening mechanisms, as for other RMGIs.115
In addition, fluoride ion kinetics of the nano-ionomer have
been tested, and it was concluded that the new RMGI KN
exhibits fluoride ion release behavior similar to typical conven
tional glass ionomers and RMGIs and that the primer does not
impede the release of fluoride.116
In the past few years, there has been an extraordinary
amount of emphasis placed on bioactive dental restorative ma
terials.117'120 Many products are coming to market touting their
ability to remineralize dentin and enamel and rejuvenate tooth
structure in biomimetic fashion so that not only is there a repair
process at work but also a preventive aspect to the restorative
results. In February 2014, two new products were introduced
that show exceptional properties in m anufacturers testing.
ACTIVA BioACTIVE-Restorative and ACTIVA BioACTIVEBase/Liner (Pulpdent Corporation, Watertown, Mass., USA)
were introduced in February 2014. The companys product
description states that ACTIVA products are the first bioactive
dental materials with an ionic resin matrix, a shock-absorbing

P E D IA TR IC D E N TIS T R Y

resin component, and bioactive fillers that mimic the physical

and chemical properties of natural teeth. They are durable, wear
and fracture resistant, chemically bond to teeth, seal against
bacterial microleakage, and release and recharge with calcium,
phosphate and more fluoride ions than glass ionomers. ACTIVA
contains no Bisphenol A, no Bis-GMA and no BPA derivatives.
(Pulpdent publication XF-VWP REV: 05/2014).
For the restorative material, the following physical pro
perties are defined by the manufacturer:
1. Light cure setting time: 20 seconds.
2. Depth of light cure: four mm.
3. Self-cure setting time at 37 degrees Celsius: two minutes.
4. Percent filler by weight: 56 percent.
5. Percent of reactive glass by weight: 21.8 percent.
6. Fluoride release (one day): 230 ppm.
7. Fluoride release (28 days; cumulative): 940 ppm.
8. Flexural strength: 102 MPa/14,790 psi.
9. Flexural modulus: 4.3 GPA.
10. Compressive strength: 280 MPa/40,6000 psi.
11. Diametrile tensile strength: 42 MPa/6,090 psi.
12. Water sorption (one week): 1.65 percent.
13. Polymerization shrinkage: 1.7 percent.
The base/liner is filled 45 percent by weight; therefore, it
does not have quite the physical strengths of the restorative
material. Both materials have excellent flowability and are easily
spread into a cavity preparation with full assurance that all
regions are covered and the preparation is saturated.
The manufacturer provides a pistol grip mixer/dispensing
system with a number of injection tips for placement of the
ACTIVA pastes. Another option of delivery into cavity prepara
tions is expression of the two pastes onto a mixing pad, spatulation in the usual manner, and use of syringe delivery with
Centrix AccuDose tips, just as with the nano-ionomer. The
manufacturers disperser/mixer eliminates incorporation of air
bubbles into the blended paste; however, with care, an ideal
mixture can be achieved by hand blending with a spatula.
Pulpdent was granted 510(K) approval by the Food and
Drug A dm inistration in March of 2013 for ACTIVA to be
marketed as an RMGI dental filling material. However, since
March 2014, one of the authors (TPC) has placed more than
300 primary tooth restorations and more than 300 permanent
tooth restorations using ACTIVA BioACTIVE Restorative.
The material handles, finishes, and polishes like RBCs. After
12 months in the mouth, these restorations are indistinguish
able from RBCs. The clinician may wonder if ACTIVA BioACTIVE-Restorative is a RBC with RMGI properties or a
RMGI that has resin-based composite physical strengths. Both
designations could be correct, but dentists need verification of
that possibility.
Results of some studies about these unusual new materi
als are currently in press in dentistry journals, and some have
already been published.121,122 However, more independent
laboratory and clinical studies are needed to fully determine all
properties and long-term clinical performance of the ACTIVA
materials regarding biocompatibility, polymerization shrinkage,
fracture strengths, wear resistance, solubility in oral fluids, mois
ture absorption, fluoride release and take-up, antimicrobial
properties, microleakage, and color stability.
Currently, we believe that the ACTIVA products could be
the latest major advancement on the adhesive dental restorative
materials continuum 105,106 but acknowledge that much more
needs to be learned about these innovative new products.123

V 3 7 / NO 2

M A R / APR 15

R ecom m endations

The dental literature supports the use of glass ionomer and

resin modified glass ionomer cement systems in the following
situations:
1. Luting cement:
a. stainless steel crowns;
b. orthodontic bands; and
c. orthodontic brackets (limited).
2. Cavity base/liner.
3. Class I restorations in primary teeth and, in certain
cases, permanent teeth.
4. Class II restorations in primary teeth.
5. Class III restorations in primary teeth.
6. Class III restorations in permanent teeth in high-risk
patients or teeth that cannot be isolated.
7. Class V restorations in primary teeth.
8. Class V restorations in permanent teeth in high cariesrisk patients or teeth that cannot be isolated ideally.
9. Caries control:
a. high caries-risk patients;
b. restoration repair; and
c. ART (atraumatic restorative treatment) and interim
therapeutic restorations.
Acknowledgm ents
The authors wish to thank John W. Nicholson, PhD, who at the
time of the original writing was a professor of Biomaterials
Ch emistry, D epartm ent of Chemical, Environm ental and
Pharmaceutical Sciences, School of Science University of Green
wich, Medway Campus, Chatham, Kent, United Kingdom for
his original and erudite contributions to the 2002 glass ionomer
position paper and the science of glass polyalkenoates.
References
1. Croll TP. The ASDC Kids Mouth Book. 2nd ed. Chicago,
111.: American Society of Dentistry for Children Publica
tions; 1999.
2. Wilson NH. Conference report. Direct adhesive materials:
current perceptions and evidence future solutions. J
Dent 2001;29:307-16.
3. Kielbassa AM, Wrbas KT, Hellwig E. Initial tensile bond
strength of resin-modified glass ionomers and polyacidmodified resins on perfused primary dentin. J Dent Child
1997;64:165, 183-7.
4. Croll TP. Glass ionomers and esthetic dentistry: what
the new properties mean to dentistry. J Am Dent Assoc
1992;123:51-4.
5. Berg JH. The continuum of restorative materials in pedi
atric dentistry: a review for the clinician. Pediatr Dent
1998;20:93-100.
6. Pereira AC, Pardi V, Basting RT, et al. Clinical evaluation
of glass ionomers used as fissure sealants: twenty-fourmonth results. J Dent Child 2001 ;68:15, 168-74.
7. Isen S, Beiruti N, Sadat N. A comparison of retention and
the effect on caries of fissure sealing with a glass ionomer
and a resin-based sealant. Com m unity Dent Oral Epi
demiol 2001;29:298-301.
8. de Luca-Fraga LR, Freire Pimenta LA. Clinical evaluation
of glass ionomer/resin-based hybrid materials used as pitand-fissure-sealants. Quintessence Int 2001;32:463-8.
9. Kervanto-Seppala S, Lavonius E, Kerosuo E, Pietila 1.
Can glass ionomer sealants be cost-effective? J Clin Dent
2000;11:1-3.

GLASS IO N O M E R RESTORATIVE CE M E N T SYSTEM S

121

PEDIATRIC DENTISTRY

V 37 I NO 2

MAR I APR 15

10. Simonsen RJ. Pit and fissure sealant: a review of the litera
ture. Pediatr Dent 2002;24:393-414.
11. Gray GB, Paterson RC. Management of fissure caries in
the community dental services using sealant restorations:
a field trial. Eur J Prosthodont Restor Dent 1998;6:
33-40.
12. Pereira AC, Basting RT, Pinelli C, de Castro Meneghim
M, Werner CW. Retention and caries prevention of
Vitremer and Ketac-bond used as occlusal sealants. Am J
Dent 1999;12:62-4.
13. Smales RJ, Wong KC. Two-year clinical performance of
a resin-modified glass ionomer sealant. Am J Dent 1999;
12:59-61.
14. Smales RJ, Lee YK, Lo FW, Tse CC, Chung MS. Handling
and clinical performance of a glass ionomer sealant. Am
J Dent 1996;9:203-5.
15. Forss H, Halme E. Retention of a glass ionomer cement
and a resin-based fissure sealant and effect on carious
outcome after 7 years. Community Dent Oral Epidemiol
1998;26:21-5.
16. Raadal M, Utkilen AB, Nilsen OL. Fissure sealing with
a light-cured resin-reinforced glass ionomer cement
(Vitrebond) compared with a resin sealant. Int J Paediatr
Dent 1996;6:235-9.
17. Kilpatrick NM, Murray JJ, McCabe JF. A clinical com
parison of a light cured glass ionomer sealant restoration
with a composite sealant restoration. J Dent 1996;24:
399-405.
18. Winkler MM, Deschepper EJ, Dean JA, Moore BK, Cochran
MA, Ewoldsen N. Using a resin-modified glass ionomer
as an occlusal sealant: a one-year clinical study. J Am
Dent Assoc 1996;127:1508-14.
19. Gillgrass TJ, Benington PC, Millett DT, Newell J, Gilmour
WH. Modified composite or conventional glass ionomer
for band cementation? A comparative clinical trial. Am J
Orthod Dentofacial Orthop 2001;120:49-53.
20. Garcia-Godoy F, Bugg JL. Clinical evaluation of glass
cementation on stainless steel crown retention. J Pedod
1987;11:339-44.
21. Garcia-Godoy F, Landry JK. Evaluation of stainless steel
crowns luted with a glass ionomer cement. J Pedod 1989;
13:328-30.
22. Donly KJ, Istre S, Istre T. In vitro enamel remineralization
at orthodontic band margins cemented with glass ionomer
cement. Am J Orthod Dentofacial Orthop 1995; 107:
461-4.
23. Lacy AM, Young DA. Modern concepts and materials for
the pediatric dentist. Pediatr Dent 1996;18:469-78.
24. Kilpatrick NM. Glass ionomer cements: their application
in children. Part 1. Dent Update 1996;23:236-8.
25. Kopel HM. Use of glass ionomer cements in pediatric
dentistry. J Calif Dent Assoc 1991;19:35-40.
26. Hse KM, Leung SK, Wei SH. Resin ionomer restorative
materials for children: review. Aust Dent J 1999;44:1-11.
27. Marcusson A, Norevall LI, Persson M. White spot re
duction when using glass ionomer cement for bonding
in orthodontics: a longitudinal and comparative study.
Eur J Orthod 1997;19:233-42.
28. Akkaya S, Uner O, Alacam A, Degim T. Enamel fluoride
levels after orthodontic band cementation with glass iono
mer cement. Eur J Orthod 1996;18:81-7.

122

GLASS IONOMER RESTORATIVE CEMENT SYSTEMS

29. Wilson RM, Donly KJ. Demineralization around ortho

dontic brackets bonded with resin-modified glass ionomer
cement and fluoride-releasing resin composite. Pediatr
Dent 2001;23:255-9.
30. Jansson AW, Donly KJ. A one-visit composite post-crown
restoration: case report. Am J Dent 1990;3:299-301.
31. Millett DT, McCabe JF, Bennett TG, Carter NE, Gordon
PH. The effect of sandblasting on the retention of first
molar orthodontic bands cemented with glass ionomer
cement. Br J Orthod 1995;22:161-9.
32. Millett D, McCabe JF, Gordon PH. The role of sand
blasting on the retention of metallic brackets applied
with glass ionomer cement. Br J Orthod 1993;20:117-22.
33. Shammaa I, Ngan P, Kim H, et al. Comparison of bracket
debonding force between two conventional resin adhe
sives and a resin-reinforced glass ionomer cement: an in
vitro and in vivo study. Angle Orthod 1999;69:463-9.
34. Cohen M, Silverman E. A new resin-reinforced glass
ionomer cement for use with orthodontic attachments.
Compend Contin Educ Dent 1997;18:821-5.
35. Hitmi L, Muller C, Mujajic M, Attal JP. An 18-month
clinical study of bond failures with resin-modified glass
ionomer cement in orthodontic practice. Am J Orthod
Dentofacial Orthop 2001;120:406-15.
36. Norevall LI, Marcusson A, Persson M. A clinical evaluation
of a glass ionomer cement as an orthodontic bonding
adhesive compared with an acrylic resin. Eur J Orthod
1996;18:373-84.
37. Cook PA, Luther F, Youngson CC. An in vitro study of
the bond strength of light-cured glass ionomer cement in
the bonding of orthodontic brackets. Eur J Orthod 1996;
18:199-204.
38. Croll TP. Light-hardened luting cement for orthodontic
bands and appliances. Pediatr Dent 1999;21:121-3.
39. Millett DT, Nunn JH, Welbury RR, Gordon PH. De
calcification in relation to brackets bonded with glass
ionomer cement or a resin adhesive. Angle Orthod 1999;
69:65-70.
40. Twetman S, McWilliam JS, Hallgren A, Oliveby A. Cariostatic effect of glass ionomer retained orthodontic appli
ances: an in vivo study. Swed Dent J 1997;21:169-75.
41. Miller JR, Mancl L, Arbuckle G, Baldwin J, Phillips RW.
A 3-year clinical trial using a glass ionomer cement for the
bonding of orthodontic brackets. Angle Orthod 1996;66:
309-12.
42. Weerheijm KL, de Soet JJ, van Amerongen WE, de Graaff
J. The effect of glass ionomer cement on carious dentine:
an in vivo study. Caries Res 1993;27:417-23.
43. Donly KJ. Dental materials in pediatric dentistry. Curr
Opin Dent 1991;1:551-5.
44. Rabchinsky J, Donly KJ. A comparison of glass ionomer
cement and calcium hydroxide liners in amalgam restora
tions. Int J Periodont Rest Dent 1993;13:379-83.
45. Tandon S, Shetty KV. In vitro evaluation of tensile bond
strength of composite to glass ionomer cement. J Indian
Soc Pedod Prev Dent 1991;9:38-40.
46. Croll TP. Visible light-hardened glass ionomer cement
base/liner as an interim restorative material. Quintessence
Int 1991;22:137-41.
47. Croll TP. Rapid reattachment of fractured crown segment:
an update. J Esthet Dent 1990;2:1-5.

PEDIATRIC DENTISTRY

48. Boghosian AA. Restoration of a traumatized dentition

using an experimental light-cured glass ionomer liner.
Northwest Dent Res 1989;1:12-4.
49. Welbury RR, Murray JJ. A clinical trial of the glass iono
mer cem ent-com posite resin sandwich technique in
Class II cavities in permanent premolar and molar teeth.
Quintessence Int 1990;21:507-12.
50. Rao V, Reddy W . An in vitro comparative evaluation of
the tensile bond strength at the two interfaces of the
sandwich technique. J Indian Soc Pedod Prev Dent 1995;
13:10-2.
51. Croll TP, Swift EJ. Tissue-specific, biomimetic, directapplication tooth repair. Contemporary Issues. J Esthet
Restor Dent 2012;25:156-8.
52. van Dijken JW, Kieri C, Carlen M. Longevity of extensive
Class II open-sandwich restorations with a resin-modified
glass ionomer cement. J Dent Res 1999;78:1319-25.
53. Cho SY, Cheng AC. A review of glass ionomer restora
tions in the primary dentition. J Can Dent Assoc 1999;
65:491-5.
54. Strand GV, Nordbo H, Tveit AB, Espelid I, Wikstrand
K, Eide GE. A 3-year clinical study of tunnel restora
tions. Eur J Oral Sci 1996;104:384-9.
55. Jones SE. The theory and practice of internal tunnel
restorations: a review of the literature and observations
on clinical performance over eight years in practice. Prim
Dent Care 1999;6:93-100.
56. Croll TP. Restorative dentistry for preschool children.
Dent Clin North Am 1995;39:737-70.
57. Vann WF Jr. Restoration of primary molars using a new
material. Pract Periodontics Aesthet Dent 1995;7:25-30.
58. Christensen GJ. Restoration of pediatric posterior teeth. J
Am Dent Assoc 1996;127:106-8.
59. Titley KC. Restorative materials in paediatric dentistry.
Oral Health 1996;86:5.
60. Croll TP. Alternatives to silver amalgam and resin com
posite in pediatric dentistry. Quintessence Int 1998;29:
697-703.
61. Espelid I, Tveit AB, Tornes KH, Alvheim H. Clinical
behavior of glass ionomer restorations in primary teeth. J
Dent 1999;27:437-42.
62. Croll FP, Helpin ML. Class II Vitremer restoration of
primary molars. J Dent Child 1995;62:17-21.
63. Vaikuntam J. Resin-modified glass ionom er cements
(RMGICs) implications for use in pediatric dentistry. J
Dent Child 1997;64:131-4.
64. Curzon ME, Pollard MA, Duggal MS. Restoration of
primary molars. Br D entJ 1996; 180:246.
65. Croll TP, Killian CM. Glass ionomer-silver-cermet in
terim Class I restorations for permanent teeth. Quintes
sence Int 1992;23:731-3.
66. Knibbs PJ, Phant CG, Pearson GJ. A clinical assessment
of an anhydrous glass ionomer cement. Br Dent J 1996;
161:99-103.
67. Wang NJ. Is amalgam in child dental care on its way out?
Restorative materials used in children and adolescents in
1978 and 1995 in Norway. C om m unity D ent Health
2000;17:97-101.
68. Croll TP, Helpin ML, Donly KJ. Vitremer restorative ce
ment for children: three clinicians observations in three
pediatric dental practices. J Dent Child 2000;67:391-8.

V 37 I NO 2

MAR / APR 15

69. Croll TP, Phillips RW. Glass ionomer-silver cermet re

storations for primary teeth. Quintessence Int 1986; 17:
607-15.
70. Rutar J, McAllan L, Tyas MJ. Clinical evaluation of a
glass ionomer cement in primary molars. Pediatr Dent
2000;22:486-8.
71. Fuks AB, Araujo FB, Osorio LB, Hadani PE, Pinto AS.
Clinical and radiographic assessment of Class II esthetic
restorations in primary molars. Pediatr D ent 2000;22:
479-85.
72. Donly KJ, Wild TW, Jensen ME. Posterior composite Class
II restorations: in vitro comparison of preparation designs
and restoration techniques. Dent Mater 1990;6:88-93.
73. Vilkinis V, Horsted-Bindslev P, Baelum V. Two-year
evaluation of Class II resin-m odified glass ionom er
cement/composite open sandwich and composite restora
tions. Clin Oral Investig 2000;4:133-9.
74. Welbury RR, Shaw AJ, Murray JJ, Gordon PH, McCabe
JF. Clinical evaluation of paired compomer and glass
ionomer restorations in primary molars: final results after
42 months. Br D entJ 2000;189:93-7.
75. Carranza F, Garcla-Godoy F. Esthetic restoration of pri
mary incisors. Am J Dent 1999;12:55-8.
76. Weerheijm KL, Kreulen CM, de Soet JJ, Groen HJ, van
Amerongen WE. Bacterial counts in carious dentine
under restorations: 2-year in vivo effects. Caries Res 1999;
33:130-4.
77. Ortendahl T, Thilander B, Svanberg M. Mutans strepto
cocci and incipient caries adjacent to glass ionomer ce
ment or resin-based composite in orthodontics. Am J
Orthod Dentofacial Orthop 1997;112:271-4.
78. Souto M, Donly KJ. Caries inhibition of glass ionomers.
Am J Dent 1994;7:122-4.
79. Donly KJ, Ingram C. An in vitro caries inhibition of photopolymerized glass ionomer liners. J Dent Child 1997;
64:128-30.
80. Marinelli CB, Donly KJ, Wefel JS, Jakobsen JR, Denehy
GE. An in vitro comparison of three fluoride regimens on
enamel remineralization. Caries Res 1997;31:418-22.
81. Bynum AM, Donly KJ. Enamel de/remineralization on
teeth adjacent to fluoride releasing materials w ithout
dentifrice exposure. J Dent Child 1999;66:89-92.
82. Donly KJ, Segura A, Wefel JS, Hogan MM. Evaluating
the effects of fluoride-releasing dental materials on adja
cent interproximal caries. J Am Dent Assoc 1999; 130:
817-25.
83. Rutar J, McAllan L, Tyas MJ. Three-year clinical perform
ance of glass ionomer cement in primary molars. Int J
Pediatr Dent 2002;12:146-7.
84. Donly KJ, Segura A, Kanellis M, Erickson RL. Clinical
performance and caries inhibition of resin-modified glass
ionomer cement and amalgam restorations. J Am Dent
Assoc 1999;130:1459-66.
85. Croll TP, Bar-Zion Y, Segura A, Donly, KJ. Clinical per
formance of resin-modified glass ionomer cement re
storations in primary teeth. J Am Dent Assoc 2001; 132:
1110- 6 .
86. Qvist V, Laurberg L, Poulsen A, Teglers PT. Longevity and
cariostatic effects of everyday conventional glass ionomer
and amalgam restorations in primary teeth: 3-year results.
J Dent Res 1997;76:1387-96.

GLASS IONOMER RESTORATIVE CEMENT SYSTEMS

123

P E D IA T R IC D E N T IS T R Y

V 37 I NO 2

M A R I A P R 15

87. Duperon DF. Early childhood caries: a continuing dilem

ma. J Calif Dent Assoc 1995;23:15-6, 18, 20-2.
88. Hallgren A, Oliveby A, Twetman S. Caries associated
microflora in plaque from orthodontic appliances retained
with glass ionomer cement. Scand J Dent Res 1992; 100:
140-3.
89. Yamamoto H, Iwami Y, Unezaki T, Tomii Y, Tuchitani Y.
Fluoride uptake around cavity walls: two- dimensional
m apping by electron probe microanalysis. O per Dent
2000;25:104-12.
90. Donly KJ, Berg JH . The glass ionomer/composite sand
wich restoration for primary incisors after pulpectomy.
Am J Dent 1998;1:135-7.
91. Berg JH, Donly KJ. Conservative technique for restoring
primary molars after pulpotomy treatment. J Dent Child
1998;55:463-4.
92. Frencken JE, Songpaisan Y, Phantumvanit P, Pilot T. An
atraumatic restorative treatment (ART) technique: evalu
ation after one year. Int Dent J 1994;44:460-4.
93. Frencken JE, Makoni F, Sithole W D. Atraumatic restora
tive treatment and glass ionomer sealants in a school oral
health programme in Zimbabwe: evaluation after one
year. Caries Res 1996;30:428-33.
94. Phantum vanit P, Songpaisan Y, Pilot T, Frencken JE.
Atraumatic restorative treatment (ART): a three-year com
m unity field trial in Thailand survival of one-surface
restorations in the permanent dentition. J Public Health
Dent 1996;56(special issue):l4l-5,161-3(discussion).
95. Frencken JE, Makoni F, Sithole WD, Hackenitz E. Threeyear survival of one-surface ART restorations and glass
ionomer sealants in a school oral health programme in
Zimbabwe. Caries Res 1998;32:119-26.
96. Mallow PK, D urw ard CS, Klaipo M. Restoration of
perm anent teeth in young rural children in Cambodia
using the atraumatic restorative treatment (ART) techni
que and Fuji II glass ionom er cement. Int J Paediatr
Dent 1998;8:35-40.
97. Frencken JE, Makoni F, Sithole W D. ART restorations
and glass ionomer sealants in Zimbabwe: survival after
3 years. C om m unity D ent Oral Epidem iol 1998;26:
372-81.
98. Frencken JE, Holmgren CJ. How effective is ART in the
management of dental caries? C om m unity D ent Oral
Epidemiol 1999;27:423-30.
99. Luo Y, Wei SH, Fan MW, Lo EC. Clinical investigation
of a high-strength glass ionomer restorative used with the
ART technique in Wuhan, China: 1-year results. Chin J
Dent Res 1999;2:73-8.
100. Holmgren CJ, Lo EC, Hu D, Wan H. ART restorations
and sealants placed in Chinese school children: results
after three years. Community Dent Oral Epidemiol 2000;
28:314-20.
101. Cole BO, Welbury RR. The atraumatic restorative treat
ment (ART) technique: does it have a place in everyday
practice? Dent Update 2000;27:118-20,122-3.
102. Bilgin Z, Ozalp N. Fluoride release from 3 different types
of glass ionomer cements after exposure to NaF solution
and APF gel. J Clin Pediatr Dent 1998;22:237-41.
103. Gregory RL, el-Rahman AM, Avery DR. Effect of re
storative treatment on mutans streptococci and IgA anti
bodies. Pediatr Dent 1998;20:273-237.

124

G LASS IO N O M E R R E S TO R A TIV E C E M E N T S Y S T E M S

104. Croll TP, Nicholson JW. Glass ionomer cements in pedi

atric dentistry: review of the literature. Pediatr Dent 2002;
24:423-9.
105. Burgess JO , Norling BK, Rawls HR, Ong JL. Directly
placed esthetic restorative materials: the continuum. Com
pendium Ed Dent 1996;17:731-48.
106. Berg JH. Glass ionomer cements. Pediatr Dent 2002;24:
430-8.
107. Croll TP, Berg JH . Nano ionomer restorative cement:
ob-servations after two years of use. Inside Dent 2009;5:
60-7.
108. Croll TP, Cavanaugh RR. Posterior resin-based composite
restorations: a second opinion. J Esthet Restor Dent 2002;
14:303-12.
109. Croll TP. Tissue-specific, biomimetic, direct-application
tooth repair. J Esthet Restor Dent 2013;25:156-8.
110. Ruiz JL, Mitra S. Using cavity liners with direct posterior
composite restorations. Com pend C ontin Educ Dent
2006;27:347-51.
111. Killian CM, Croll TP. Nano ionomer tooth repair in pedi
atric dentistry. Pediatr Dent 2010;32:530-5.
112. Croll TP. Treatment options for hypoplastic and hypocalcified permanent molars in children. Inside Dent 2014;
10:58-66.
113. de Paula AB1, Fucio SB, Ambrosano GM, Alonso RC,
Sardi JC, Puppin-Rontani RM. Biodegradation and abra
sive wear of nano restorative materials. Oper Dent 2011;
36:670-7.
114. Fucio SB, de Paula AB, de Carvalho FG, Feitosa VP, Am
brosano GM, Puppin-Rontani RM. Biomechanical de
gradation of the nano-filled resin-modified glass ionomer
surface. Am J Dent 2012;25:315-20.
115- Falsafi A, Mitra SB, Oxman JD, Ton TT, Bui HT. Mecha
nisms of setting reactions and interfacial behavior of a
nano-filled resin-modified glass ionomer. D ent Mater
2014;30:632-43.
116. Mitra SB1, Oxman JD, Falsafi A, Ton TT. Fluoride release
and recharge behavior of a nano-filled resin-modified glass
ionomer compared with that of other fluoride releasing
materials. Am J Dent 2011;24:372-8.
117. Gjorgievska E l, Nicholson JW, Iljovska S, Slipper IJ.
Marginal adaptation and performance of bioactive dental
restorative materials in deciduous and young permanent
teeth. J Appl Oral Sci 2008;16:1-6.
118. Chen L, Shen H, Suh BI. Bioactive dental restorative
materials: a review. Am J Dent 2013;26:219-27.
119. Jefferies SR. Bioactive and biomimetic restorative ma
terials: a comprehensive review. Part I. J Esthet Restor
Dent 2014;26:14-26.
120. Jefferies S. Bioactive and biomimetic restorative materials:
a comprehensive review. Part II. J Esthet Restor Dent
2014;26:27-39.
121. Garcia-Godoy F, M orrow BR, Pameijer CH. Flexural
strength and fatigue of new Activa RMGICs. J Dent Res
20l4;93(special issue A):254.
122. Zmener O, Pameijer CH, Hernandez S. Resistance against
bacterial leakage of four luting agents used for cementa
tion of complete cast crowns. Am J Dent 2014;27:51-5.
123. Croll TP, Berg JH, Donly KJ. Dental repair material: a
resin-modified glass ionomer bioactive ionic resin-based
composite. Compend Cont Educ Dent 2015;36:602-7.

Copyright of Pediatric Dentistry is the property of American Society of Dentistry for Children
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.