INTRODUCTION The term cement has been applied to powder / liquid materials which are mixed to a paste consistency.

The word luting is defined as the use of a moldable substance to seal joints and cement two substances together. Various cements are used for luting for example zinc phosphate, zinc silicophosphate, zinc polycarboxylate, glass ionomer, and zinc oxide eugenol and resin cements. The clinical success of fixed prosthesis is heavily dependant on the cementation process. For a restoration to accomplish its purpose, it must stay in place on the tooth. No cements that are compatible with living tooth structure and the biologic environment of the oral cavity possess adequate adhesive properties to hold a restoration in place solely through adhesion. Although the establishment of optimal resistance and retention forms in the tooth preparation are of primary importance, a dental cement must be used as a barrier against microbial leakage, sealing the interface between the tooth and restoration and holding them together through some form of surface attachment.

PRINCIPLES OF CEMENTATION Dental treatments necessitate attachment of indirect restorations and appliances to the teeth by means of a cement. These include metal, resin, metal-resin, metal ceramic, and ceramic restorations, provisional or interim restorations; laminate veneers for anterior teeth; orthodontic appliances, and pins and posts used for retention of restorations. The word luting is often used to describe the use of a moldable substance to seal a space or to cement two components together;. The properties of various cements differ from each other. Hence, the choice cement is mandated to a large degree by the functional and biologic demands of the particular clinical situation. If optimal performance is to be attained, the physical and biologic properties, and the handling characteristic, such as the working and setting times and ease of removing excess materials, must be considered in selecting a cement for a specific task.

CHARACTERISTICS OF ABUTMENT PROSTHESIS INTERFACE. When two relatively flat surfaces are brought into contact, analogous to a fixed prosthesis being placed on a prepared tooth, a space exists between the substrates on a microscopic scale. Typical prepared surfaces on a microscopic scale are rough, that is, there are peaks and valleys. When two surfaces are placed against each other, there are only point contacts along the peaks. The areas that are not in contact then become open space. The space created is substantial in terms of oral fluid flow and bacterial invasion. One of the main purposes of a cement is to fill this space completely. One can seal the space by placing a soft material, such as an elastomer, between the two surfaces that can conform under pressure to the roughness. The current approach is to use the technology of adhesives. Adhesive bonding involves the placement of a third material, often called a cement that flows within the rough surface and sets to a solid form within a few minutes. The solid matter not only seals the space but also retains the prosthesis. Materials used for this application are classified as Type I cements. If the third material is not fluid enough or is incompatible with the surfaces, voids can develop around deep, narrow valleys and undermine the effectiveness of the cement.

BONDING MECHANISM

Non adhesive luting Originally the luting agent served primarily to fill the gap and prevent entrance of fluids. Zinc phosphate for example exhibits no adhesion on the molecular level. It holds the restoration in place by engaging small irregularities on the surface of both tooth and the restoration. The nearly parallel opposing walls of a correctly prepared tooth make it impossible to remove the restoration without shearing or crushing the minute projections of cement extending into recesses in the surfaces.

Micromechanical bonding Resin cements have tensile strengths in the range of 30 -40 MPa, which is approximately five times that of zinc phosphate cement. When used on pitted surfaces, they can provide effective micromechanical bonding. The tensile strengths of such bonds can sometimes exceed the cohesive strength of enamel. This allows the use of less extensive tooth preparation for restorations such as ceramic veneers and resin bonded fixed partial dentures. The deep irregularities necessary for micromechanical bonding can be produced on enamel surfaces by etching with phosphoric acid solution or gel, on ceramics by etching with hydrofluoric acid and on metals by electrolytic etching, chemical etching, sandblasting or by incorporating salt crystals into preliminary resin pattern.

Molecular Adhesion Molecular Adhesion involves physical forces (bipolar, Vander Waals) and chemical bonds (ionic and covalent) between molecules of two different substances. Newer cements, such as polycarboxylate and glass ionomers, possess some adhesive capabilities, although this is limited by their relatively low cohesive strength. They still depend primarily on nearly parallel walls in the preparation to retain restorations. Limited success has been achieved in attempts to develop resin cements and coupling agents that will exhibit strong, durable molecular adhesion to tooth structure, base metals and ceramics. Noble metal alloys are not suited for direct molecular bonding. However, a thin layer of silane can be bonded to a gold alloy with special equipment (Silicoater, Kulzer, Irvine or Rocatec, ESPE-Premier) to serve as a 3

coupling agent by bonding chemically to resin cements. Equally effective is a layer of tin electroplated onto gold alloy. By applying a silane coupler to roughened porcelain, shear bond strengths in excess of the cohesive strength of the porcelain have been achieved. However such bonds tend to become weaker after thermo cycling in water. At this time, molecular adhesion should be looked upon only as a way to enhance mechanical and micromechanical retention and reduce micro leakage, rather than as an independent bonding mechanism.

DISLODGEMENT OF PROSTHESIS Fixed prostheses can debond because of biologic or physical reasons or a combination of the two. Recurrent caries results from a biologic origin. Disintegration of the cements can result from fracture or erosion of the cement. For brittle prostheses, such as glass-ceramic crowns, fracture of the prosthesis also occurs because of physical factors, including intraoral forces, flaws within the crown surfaces, and voids within the cement layer. In the oral environment cementation agents are immersed in an aqueous solution. In this environment the cement layer near the margin can dissolve and erode leaving a space. This space can be susceptible to plaque accumulation and recurrent caries; therefore, the margin should be protected with a coating (if possible) to allow continuous setting of the cement. There are two basic modes of failure associated with cements: cohesive fracture of the cement and separation along the interfaces. Because the cement layer is the weakest link of the entire assembly, one should favor higher strength cements to enhance retention and prevent prosthesis dislodgement by providing a firm support base against applied forces. Several factors have an influence on the retention of these fixed prostheses. First, the film thickness beneath the prosthesis should be thin. It is believed that a thinner film has fewer internal flaws compared with a thicker one. Second, the cement should have high strength values. Generally, greater forces are required to dislodge appliances cemented with cements that have higher tensile strength than with cements of low tensile strength. It is also well established that the stresses developed during mastication are exceedingly complex. Undoubtedly, properties other than tensile strength may be involved. These include compressive and shear strength of the cement, fracture toughness, and film thickness. Third, the dimensional changes occurring in the cement during setting should be minimized. Sources include gain or loss of water and differences in the coefficients of thermal expansion among the tooth, the prosthesis, and the cement. It is, therefore, important to isolate the cement immediately after removal of the excess. Fourth, a cement with the potential of chemically bonding to the tooth and prosthetic surfaces or bond- enhancing intermediate layers may be used to reduce the

potential of separation at the interface and maximize the effect of the inherent strength on the retention. When a mechanical undercut is the mechanism of retention, the failure often occurs along the interfaces. If chemical bonding is involved, the failure often occurs cohesively through the cement itself. The prosthesis becomes loose only when the cement fractures or dissolves.

IDEAL PROPERTIES OF LUTING CEMENT Described by McLean and Wilson 1. Low viscosity and film thickness 2. Long working time with rapid set at mouth temperature 3. Good resistance to aqueous or acid attack 4. High compressive and tensile strength 5. Resistance to plastic deformation 6. Adhesion to tooth structure and restoration 7. Cariostatic 8. Biologically compatible with pulp 9. Translucency 10. Radio opacity

CHOICE OF LUTING AGENT An ideal luting agent is one which has a long working time, adheres well to both tooth structure and cast alloys, provides a good seal, is non toxic to pulp, has adequate strength properties, is compressible into thin layers, has a low viscosity and solubility and exhibits good working and setting characteristics. In addition any excess can be easily removed. Unfortunately, no such product exists.

Zinc phosphate cement Is probably still the luting agent of choice. Cavity varnish can be used to protect against pulp irritation from phosphoric acid and appears to have little effect on the amount of retention of the cemented restoration.

Zinc polycarboxylate cement This agent is recommended on retentive preparation when minimal pulp irritation is important.

Glass ionomer cement This has become a popular cement for luting cast restoration. It has good working properties and because of its fluoride content, it may prevent recurrent caries. Resin modified glass ionomer cement Currently among the most popular luting agents, Resin modified glass ionomer cements have low solubility, adhesion and low micro leakage. The popularity it mainly due to perceived benefit of reduced post cementation sensitivity.

Adhesive resin Long-term evaluations of these materials are not yet available, so they cannot be recommended for routine use. Laboratory testing yields high retention strength values, but there is concern that stresses caused by polymerization shrinkage, magnified in thin films, leads to marginal leakage. Adhesive resin may be indicated when a casting has become displaced through lack of retention.

ZINC PHOSPHATE CEMENT Zinc phosphate cement is the oldest of the cementation agents and thus has the longest track record. It serves as a standard by which newer systems can be compared. It is a traditional crown and bridge cement used for the alloy restorations. It is supplied as a powder and liquid, both of which are carefully compounded to react with one another during mixing to develop a mass of cement possessing desirable physical properties.

Composition Powder The principal ingredient of the zinc phosphate cement is zinc oxide. Magnesium oxide, silicon dioxide, bismuth trioxide, and other minor ingredients are used in some products to alter the working characteristics and final properties of the mixed cement. Zinc oxide (ZnO) Magnesium oxide (MgO) Silicon dioxide (SiO2) Bismuth trioxide (Bi2O3) Miscellaneous (BaO, Ba2So4, CaO) 90.2 8.2 1.4 0.1 0.1

The magnesium oxide, usually in quantities of about 10%, are added to the zinc oxide to reduce the temperature of the calcinations process. The silicon dioxide is inactive filler in the powder and during manufacture aids in the calcinations process. Although bismuth is believed to impart smoothness to the freshly mixed cement mass, in large amounts it may also lengthen the setting time. Tannin fluoride may be added to provide a source of fluoride ions in some products. The ingredients of the powder are heated together at temperatures ranging from 1000 to 1300 C for 4 to 8 hours or longer, depending on the temperature. Calcinations results in a fused or a sintered mass. The mass is then ground and pulverized to a fine powder, which is sieved to recover selected particle sizes. The

degree of calcination, fineness of the particle size, and composition determine the reactivity of the powder with the liquid. The powder particle size influences the setting rate. Generally the smaller the particle size, the faster the set of the cement.

Liquid Adding aluminum and sometimes zinc, or their compounds, to a solution of orthophosphoric acid, produces zinc phosphate cement liquids. Although the original acid solution contains about 85% phosphoric acid and is a syrupy fluid, the resulting cement liquid usually contains about one third water H3PO4 (free acid) H3PO4 (combined with aluminum and zinc) Aluminum (Al) Zinc (Zn) Water (H2O) 38.2 16.2 2.5 7.1 36.0

The partial neutralization of phosphoric acid by aluminum and zinc tempers the reactivity of the liquid and is described as buffering. The reduced rate of the reaction helps establish a smooth, non-granular, workable cement mass during the mixing procedure. Both partial neutralizing or buffering and dilution adjust the zinc phosphate cement liquid so it reacts with its powder to produce a cement mass with proper setting time and mechanical qualities. The composition of the liquid should be preserved to ensure a consistent reaction, as water is critical to the reaction. Changes in composition and reaction rate may occur either because of self-degradation or by water evaporation from the liquid. Self-degradation of the liquid is best detected by clouding of the liquid over time.

Setting Reaction When the powder is mixed with the liquid the phosphoric acid attacks the surface of the particles and releases zinc ions into the liquid. The aluminum, which already forms a complex with the phosphoric acid, reacts with zinc and yields a zinc aluminophosphate gel on the surface of the remaining portion of the particles. Thus the set cement is a cored structure consisting primarily of unreacted zinc oxide particles embedded in a cohesive amorphous matrix of zinc aluminophosphate. The set zinc phosphate cement is amorphous and is extremely porous. 9

The surface of alkaline powder is dissolved by the acid liquid, resulting in an exothermic reaction.

Manipulation The manner in which the reaction between zinc phosphate cement powder and liquid is permitted to occur determines to a large extent the working characteristics and properties of the cement mass. Incorporate the proper amount of powder into the liquid slowly on a cool slab (about 21 C) to attain the desired consistency of the cement.

Powder Liquid Ratio Reducing the powder liquid ratio can increase working and setting times. This procedure is however not acceptable means of extending setting time because it impairs the physical properties and results in a lower initial pH of the cement. The powder liquid ratio is 1.4gm/0.5ml.

Rate Of Powder Incorporation Introduction of small quantity of powder into the liquid for the first few increments increases working and setting times by reducing the amount of heat generated and permits more powder to be incorporated into the mix.

Care Of The Liquid When zinc phosphate cement is exposed to a humid atmosphere it will absorb water, whereas exposure to dry air tends to result in a loss of water. The addition of water causes more rapid reaction with the powder, resulting in a shorter setting time. A loss of water from the liquid results in a lengthened setting time. Therefore keep the bottle tightly closed when not dispensing the material. Polyethylene squeeze bottles do not require removal of a dropper and therefore eliminate the tendency for gain or loss of water from the liquid.

Mixing Slab A properly cooled thick glass slab will dissipate the heat of the reaction. The mixing slab temperature should be low enough to effectively cool the cement mass but must not be below the dew point unless the frozen slab technique is used. A 10

temperature of 18 to 24 C is indicated when room humidity permits. The moisture condensation on a slab cooled below dew point contaminates the mix, diluting the liquid and shortening the setting time. The ability of the mixing slab to be cooled and yet be free of moisture greatly influences proper control of the reaction rate of zinc phosphate cement.

Mixing Procedure By incorporating small portions of the powder into the liquid, minimal heat is liberated and easily dissipated. The heat of the reaction is most effectively dissipated when the cement is mixed over a large area of the cooled slab. Use a relatively long narrow bladed stainless steel spatula to spread the cement across this large area to control the temperature of the mass and its setting time. During neutralization of the liquid by the powder, the temperature of the mixing site is inversely proportional to the time consumed in mixing. Thus a large volume of the powder is carried to the liquid all at once rather than spatulated over a large area of the slab for a sufficient time, the temperature at the site of the reaction becomes higher. This temperature rise speeds the reaction and hinders control over the consistency. During the middle of the mixing period, larger amounts of powder may be incorporated to further saturate the liquid with the newly forming complex zinc phosphates. The quantity of the unreacted acid is less at this time because of the prior neutralization gained from initially adding small increments of powder. The amount of heat liberated will likewise be less, and it can be dissipated adequately by the cooled slab. Finally smaller increments of powder are again incorporated, so the desired ultimate consistency of the cement is not exceeded. Thus the mixing procedure begins and ends with small increments, first to achieve slow neutralization of the liquid with the attendant control of the reaction and last to gain a critical consistency. Depending on the product 60 to 90 seconds of mixing appears adequate to accomplish a proper zinc phosphate cementing mass.

11

Contact With Moisture The area near the cement must be kept dry while the powder and liquid is mixed, during insertion into the mouth and during hardening. If the cement is allowed to harden in the presence of saliva some of the phosphoric acid is leaked out and the surface of the cement will be dull and easily dissolved by oral fluids. After the cement sets it should not be allowed to dry. Drying of the cement results in shrinkage and crazing of the surface. A coating of varnish should minimize dehydration as well as prevent premature contact with oral fluids.

Working Time And Setting Time Working time is the time measured from the start of the mixing during which the viscosity (consistency) of the mix is low enough to flow readily under pressure to form a thin film. Adequate working time is expressed between 2.5 to 8 minutes at a body temperature of 37 C. The first 60 to 90 seconds are consumed by mixing the powder and liquid. Setting time is the time elapsed from the start of the mixing until the point of the needle no longer penetrates the cement as the needle is lowered onto the surface. Practically, it is the time at which the zinc phosphate cement flash (excess) should be removed from the margins of the restoration. The setting time can be measured with a 4.5 N (1 pound) Gillmore needle at a temperature of 37 C and relative humidity of 100%. A reasonable setting time for zinc phosphate cement is between 5 to 9 minutes, as specified in ADA specification no. 8.

Frozen Slab Method The frozen slab method is a way to substantially increase the working time (411 minutes) of the mix on the slab and shorten the setting time (20 to 40% less) of the mix after placement into the mouth. In this method, a glass slab is cooled in a refrigerator at 6 C or in a freezer at 10C . No attempt is made to prevent moisture from condensing on the slab when it is brought to room temperature. A mix of cement is made on the cold slab by adding the powder until the correct consistency is reached. The amount of powder incorporated with the frozen slab method is 50% to 75% more than with the normal procedures. The compressive strength and tensile strength prepared by the frozen slab method are 12

not significantly different from those prepared for normal mixes, however, because incorporation of condensed moisture into the mix in the frozen slab method counteracts the higher powder liquid ratio. This method has been advocated for cementation of bridges with multiple pins.

Mechanical Interlocking Whenever an inlay is seated in a prepared cavity the surfaces of both the inlay and the tooth have slight roughness and serrations into which the cement is forced. Film thickness is a factor for retention. Thinner the cement better is the cementing action. Zinc phosphate cements are irritating to the pulp. Although the pH of the cement approaches neutral at 24 hours. Thinner mixes are more acidic and remain so for a longer period of time than the standard mixes. Berk, H. Stanely said that thin mix Zinc phosphate cements have more pulp response than thick mix because Zinc phosphate cements is pushed into dentinal tubules and it destroys the odontoblast right in place. The application of a cavity varnish to a cut tooth structure can act as a barrier to the penetration of the acid. A recent animal study involving cementation of crowns reported pulp response to none when a cavity varnish was applied to the teeth prior to cementation of crowns. With respect to the effect of retention, Fetton showed a coat of varnish to have no influence in crown retention. Molta JP said that cavity varnish has been shown to reduce the retention of cemented pins and decrease tensile bond between two opposed dentinal surface when Zinc phosphate cement is used for luting.

Characteristics Properties Physical and biologic properties Two physical properties of the cement that are relevant to the retention of the fixed prostheses are the mechanical properties and the solubilitys. The prosthesis can get dislodged if the underlying cement is stressed beyond its strength. High solubility can induce loss of the cement needed for the retention and may create plaque retention sites. Zinc phosphate cement when properly manipulated exhibits a compressive strength of 104MPa and a diametral tensile strength of 5.5 MPa.

13

Zinc phosphate cement has a modulus of elasticity of approximately 13 GPa. Thus it is quite stiff and should be resistant to elastic deformation even when it is employed for cementation of restorations that are subjected to high masticatory stress. A reduction in the powder liquid ratio of the mix produces a markedly weaker cement. A loss or gain in the water content of the liquid reduces the compressive and tensile strengths of the cement.

Retention Whenever a casting is seated in the prepared tooth, the surfaces of both the casting and the tooth structure have slight roughness and irregularities into which the plastic cement is forced. Such extensions many times act as undercuts in providing retention of the inlay. The thickness of the film between the casting and the tooth is also a factor in the retention. The thinner the film, the better is the cementing action.

Solubility and disintegration The premature contact of the incompletely set cement with water results in dissolution and leaching of that surface. Prolonged contact even of well-hardened cement, with moisture demonstrates that some erosion and extraction of soluble material does occur from the cement. Even the filling cement mixes show considerable loss of material in the mouth over a period of time, indicating that zinc phosphate can be regarded only as a temporary filling material. Wear abrasion and attack of food decomposition products accelerate the disintegration of zinc phosphate cements. Greater resistance to disintegration is achieved by increasing the powder liquid ratio. A thicker mix of cement exhibits less solubility than a thinner mix.

Dimensional stability Zinc phosphate cement exhibits shrinkage on hardening. The normal dimensional change when properly mixed cement is brought into contact with water after it has set is that of slight initial expansion, apparently from water absorption. This expansion is then followed by slight shrinkage on the order of 0.04% to 0.06% in 7 days. 14

Consistency and film thickness Two arbitrary consistencies of the cement are used based on their use. Inlay seating or luting and cement base or filling. A third consistency which lies midway between inlay seating and the cement base, is band seating consistency used for retention of orthodontic bands. The inlay seating consistency is used to retain alloy restorations. Although the unhardened zinc phosphate cement is somewhat tenacious, the retaining action in its hardened state is one of mechanical interlocking between the surface irregularities of the tooth and the restoration. The film thickness of the zinc phosphate cement greatly determines the adaptation of the casting to the tooth and also determines the strength of the retention bond. The maximum film thickness is 25 m. the heavier the consistency; the greater the film thickness and the less complete the seating of the restoration. The ultimate film thickness that a well-mixed, non-granular cement attains depends first on the particle size of the powder and second on the concentration of the liquid. The film thickness also varies with the amount of force and the manner in which this force is applied to a casting during cementation. An increased amount of powder incorporated into the liquid will increase the consistency of the cement mass. The operator must frequently test each mass as the end of mixing time approaches. The final consistency will be fluid, yet will string up from the slab on the spatula about 2-3cm as the spatula is lifted away from the mass. A heavy putty like consistency of zinc phosphate cement is used as a thermal and chemical insulating barrier over thin dentin and a high strength base.

Viscosity The consistency of cements can be quantified by measuring viscosity. A small but significant increase in viscosity is seen at higher temperatures. A rapid increase in viscosity demonstrates that restorations should be cemented promptly after completion of the mixing to take advantage of the lower viscosity of the cement. Delays in cementation can result in considerably thick film and insufficient seating of the restoration. 15

Acidity During the formation of zinc phosphate cement, the union of zinc oxide powder with phosphoric acid liquid is accompanied by a change in pH. In the early stages the pH increases rapidly, with a standard mix reaching the pH of 4.2 within 3 minutes after mixing has started. At the end of one hour this value increases to about 6 and is nearly neutral at 48 hours. Investigations have shown that the initial acidity of zinc phosphate cement at the time of placement into the tooth may excite pulpal response, especially where only a thin layer of dentin exists, between cement and pulp.

Thermal and electrical conductivity One of the primary uses of zinc phosphate cement is an insulating base under metallic restorations.

Applications Zinc phosphate cement is used most commonly for luting permanent metal restorations and as abase. Other applications include cementation of orthodontic bands and the use of cement as a provisional restoration.

Advantages 1. Adequate strength to maintain the restoration 2. Relatively good manufacturer properties 3. Mixed easily and that they set sharply to a relatively strong mass from a fluid consistency.

Disadvantages 1. Irritating effect on the pulp 2. Lack of anticariogenic properties 3. Lack of adhesion to the tooth 4. Vulnerability to acid attack 5. Brittleness 6. Solubility in acid fluids.

16

Reaction Of Pulp To Cement The phosphoric acid in Zinc phosphate cement can be the cause of the pulpal reaction. The closer it approaches the pulp, the greater is the intensity of the response. Also the ratio of powder to liquid is important consideration. A thick mix of Zinc phosphate cement used as a base will generate a moderate localized response, whereas a thin mix used to cement on a crown that is placed under great pressure by patients biting on a tongue blade can cause a very severe reaction.

17

ZINC SILICOPHOSPHATE CEMENT They are also called as Zinc silicate, Silicate zinc cement. Zinc silicophosphate cement is a hybrid resulting from the combination of zinc phosphate cement and silicate powders.

Types Of Zinc Silicophosphate Cements According to ADA no 28 (1969) there are three types Type I as a cementing media Type II temporary posterior filling material Type III dual purpose cementing media and temporary posterior filling material.

Properties Zinc silicophosphate cements (ZSP) consist of mixture of silicate glass, a small percentage of zinc oxide powder and phosphoric acid. They are used as luting agents for restorations and orthodontic bands, intermediate restorations and as die material. Its strength is somewhat superior to that of zinc phosphate cement, and the major difference is that Zinc silicophosphate cement appears somewhat translucent and releases fluoride by virtue of silicate glass. Clinical observation has shown that silicophosphate is less soluble in the mouth than zinc phosphate cement. The fluoride content should give some antocariogenic action. Therefore it is recommended for cementation of restoration in patients with high caries rate. The flow property of the mix is not as good as zinc phosphate cement, leading to higher film thickness. The cement does not bound to tooth structure; hence retention is by mechanical interlocking. Esthetically it is superior to the more opaque zinc phosphate cement for cementation of ceramic restorations. The use of Zinc silicophosphate cement is declining, as practitioners have choice of other more esthetically pleasing materials such as resin and glass ionomer cements.

18

Advantages 1. Zinc silicophosphate cements have a better strength and toughness than zinc phosphate cements 2. Shows considerable fluoride release hence anticariogenic 3. Translucent 4. Under clinical conditions lower solubility and better bonding 5. Best suited to cement of ortho bars and restoration on non-vital teeth.

Disadvantages 1. Less satisfactory mixing 2. Higher film thickness 3. Greater pulpal irritation

Trade Names Flourathin and Lucent ( type I)

19

ZINC POLYCARBOXYLATE CEMENT In the quest for an adhesive cement that can bond strongly to the tooth structure, Zinc polycarboxylate cement was the first cement system that developed an adhesive bond to tooth structure in 1960.

Composition Zinc polycarboxylate cement or zinc polyacrylate cements are supplied as a powder and liquid or as a powder that is mixed with water. The cement powder is essentially zinc oxide and magnesium oxide that have been sintered and ground to reduce the reactivity of zinc oxide. Stannic acid may be substituted for magnesium oxide. Other oxides such as bismuth and aluminum can be added. The powder may also contain small quantities of stannous fluoride, which modify setting time and enhance manipulative properties. It is an important additive because it increases strength. However, the fluoride released from this cement is only a fraction. The cement powder that is mixed with water contains 15 % to 18% polyacrylic acid coated on the oxide particles. The liquid is a water solution of polyacrylic acid. Most commercial liquids are supplied as 32% to 42% solution of polyacrylic acid having molecular weight of 25,000 to 50,000. The manufactures control the viscosity of the cement liquid by varying the molecular weight of the polymer or by adjusting the pH by adding sodium hydroxide. Itaconic and tartaric may be present to stabilize the liquid, which can gel on extended storage.

Setting Reaction The setting reaction of this cement involves particle surface dissolution by acid that releases zinc, magnesium, and tin ions, which bind to the polymer chain via the carboxyl groups. These ions react with carboxyl groups of adjacent polyacid chains so that a cross-linked salt is formed as the cement sets. The hardened cement consists of an amorphous gel matrix in which unreacted particles are dispersed. The microstructure resembles that of zinc phosphate cement in appearance. Water settable versions of this cement are available. The polyacid is a freezedried powder that is then mixed with the cement powder. The liquid is water or a weak solution of NaH2PO4. However the setting reaction is the same whether the

20

polyacid is freeze dried and subsequently mixed with water or if the conventional aqueous solution of polyacid is used as the liquid.

Manipulation Mixing The cement liquids are quite viscous. The viscosity is a function of the molecular weight and the concentration of the polyacrylic acid thereby varies. Generally the powder liquid ratio is 1.5 parts of powder to 1 part of liquid by weight. The consistency of the mixes is creamy compared with that of zinc phosphate cements. The mixes cement is pseudoplastic that is the viscosity decreases as the shear rate increases, or in other terms, the flow increases as spatulation increases or as force is placed on the material. The correct consistency is found in a mix that is viscous but that will flow back under its own weight when drawn up with a spatula. The cement liquid should be mixed on a surface that does not absorb liquid. A glass slab affords the advantage over paper pads supplied by the manufacturers because once it is cooled it maintains the temperature longer. The cool slab and powder provides for longer working time, but under no circumstances should the liquid be cooled in a refrigerator. Mix polyacrylate cements within 30 to 60 seconds, with half to all of the powder incorporated at once to provide the maximum length of working time 2.5 to 6 minutes. Working time can be extended to 10-15 minutes by using a cool slab chilled to 4C. The liquid should not be dispensed before the time when the mix is to be made. It loses water to the atmosphere rapidly and this results in marked increase in viscosity. Use the mixed cement only as long as it appears glossy on the surface. Once the surface becomes dull, the cement develops stringiness and the film thickness becomes too great to seat a casting completely. If good bonding to tooth structure is to be achieved, the cement must be placed on the tooth surface before it loses its glossy appearance. The glossy appearance indicates a sufficient number of free carboxylic acid groups on the surface of the mixture that are vital for bonding to tooth structure.

21

Surface penetration and retention Despite the adhesion of the cement to tooth structure, polycarboxylate cements are not superior to zinc phosphate cement in the retention of cast noble metal restorations. A comparable force is required to remove gold inlays cemented either with zinc phosphate cement or with polycarboxylate cement. Examination of fractured surfaces shows that failure usually occurs at the cement tooth interface with zinc phosphate cement. In the case of polycarboxylate cements, the failure occurs usually at the cement metal interface. The cement does not bond to the metal in the chemically contaminated condition. Thus it is essential that this contaminated surface on the casting be removed to improve wettability and the mechanical bond at the cement metal interface. The surface can be carefully abraded with a small stone, or it can be sandblasted with high-pressure air and alumina abrasives. Because this type of cement affords an opportunity to obtain adhesion to tooth structure, a clean cavity surface is necessary to ensure intimate contact and interaction between cement and the tooth. A recommended procedure is to apply a 10% polyacrylic acid solution for 10 to 15 seconds followed by rinsing with water.

Removal of excess cement During setting the polycarboxylate cement passes through a rubbery stage that makes the removal of the excess cement quite difficult. The excess cement that has extruded beyond the margins of the casting should not be removed while the cement is in this stage, because some of the cement may be pulled out from beneath the margins leaving a void. The excess should be removed when the cement becomes hard. The outer surface of the prosthesis should be coated with a separating medium like petroleum jelly, to prevent excess from adhering. Another approach is to start removing excess cement as soon as seating is completed.

22

Properties Viscosity The initial viscosity of zinc polycarboxylate cement is higher than zinc phosphate cements and a delay of 2 minutes in cementation reverses the situation.

Film thickness When polycarboxylate cements are mixed they appear to be much viscous than zinc phosphate cement. Since zinc polycarboxylate cement is pseudoplastic cement it undergoes thinning at an increase shear rate. Clinically, this means that the action of spatulation and seating with a vibratory action will reduce the viscosity and yield a film thickness of 25- m or less.

Working time and setting time The working time for polycarboxylate cement is much shorter than phosphate cement that is 2.5 minutes. Lowering the temperature of the reaction can increase the working time that may be necessary for fixed bridges. Unfortunately, the temperature of the cool slab can cause the polyacrylic acid to thicken. The increased viscosity makes the mixing procedure more difficult. It has been suggested that only the powder should be refrigerated before mixing. The setting time ranges from 6 to 9 minutes.

Mechanical properties 1. The compressive strength of polycarboxylate cement is 55 Mpa. 2. The diametrical tensile strength is slightly higher than that of zinc phosphate cement. 3. Its modulus of elasticity is less than half. 4. Brown stated that an increse in the compressive and tensile strength of polycarboxylate cement can be obtained with the addtion of stainless steel powder or fibers . 5. Zinc polycarboxylate cement is not as brittle as zinc phosphate cement. 6. Thus it is more difficult to remove the excess after the cement has set.

23

Solubility The solubility of the cement in water is low, but when it is exposed to organic acids with a pH of 4.5 or less, the solubility markedly increases. Also a reduction in the powder liquid ratio results in significantly higher solubility and disintegration rate in the oral cavity.

Bond strength An interesting feature of polyacrylate cement is its bonding to enamel and dentin, which is attributed to the ability of the carboxylate groups in the polymer molecule to chelate to calcium. The bond strength to enamel has been reported to be from 3.4 to 13 MPa and to that of dentin is 2.1 MPa. Optimum bonding requires clean tooth surface. Sand blasting or electrolytic etching of the gold alloy surface is necessary to achieve optimum bonding.

Dimensional stability The zinc polyacrylate cement shows a linear contraction when setting at 37 C. the amount of contraction varies from 1 % for a wet specimen at 1 day to 6 % for a dry specimen at 14 days. These contractions are more pronounced than those observed for zinc phosphate cements and start earlier.

Acidity Zinc polyacrylate cements are slightly more acidic than zinc phosphate cements when first mixed but the acid is only weakly dissociated, and penetration of the highly molecular weight polymer molecules toward pulpal tissue is minimal. Mortiner noted that film thickness is thicker than zinc phosphate cement. According to Wilson and Paddon the cement remains much less brittle and is tougher than silicate, zinc phosphate and glass ionomer cement. Abelson said that the retention of full crown was similar to zinc phosphate.

Applications Zinc polyacrylate cements are used primarily for luting permanent alloy restorations and as bases. Theses cements have also been used in orthodontics for cementation of bands. 24

Advantages 1. Biocompatibility with the pulp is excellent. Postoperative sensitivity is negligible when used as a luting agent 2. Adhesion to tooth and alloy 3. Easy manipulation.

Disadvantages 1. Need for accurate proportioning required for optimal properties 2. Greater viscoelasticity 3. Shorter working time 4. Low compressive strength 5. More critical manipulation.

Trade Names Dertelon (Premier dental products) PCA (S.S. White) Cermaco (Johnson & Johnson)

25

GLASS IONOMER CEMENT Glass ionomer is the generic name of a group of materials that use silicate glass powder and an aqueous solution of polyacrylic acid. The material acquires its name from its formulation of a glass powder and an ionomeric acid that contains carboxyl groups. It is also referred to as polyalkeonate cement. Originally, the cement was designed for the esthetic restoration of anterior teeth and it was recommended for use in restoring teeth with class III and V cavity preparations. Also because the cement produces a truly adhesive bond to tooth structure.

Applications The use of GIC has broadened to encompass formulations as luting agents, liners, restorative materials, core build-ups and pit and fissure sealants.

Types Of Glass Ionomer Cement There are three types based on their formulations and their potential uses Type I Type II Restorative material Powder liquid ratio 3:1 Must protect for 24 hours for best results Reduced fluoride content to improve translucency Luting applications Powder liquid ratio is generally 1.5 : 1 Grain size 15 m or less High early resistance to water contamination Radiopaque for easy detection of excess Limited extension of working time thru chilling glass slab.

26

Type III Liner and base. Powder liquid ratio varies according to use Lining requires 1.5:1 for easy Base requires 3:1 or greater for strength Light activated varieties available

Type IV Metal modified glass ionomer cement Miracle mix Cermet cement

Light curable versions of GIC are also available. (HEMA added to liquid) Hybrid glass ionomer \ resin modified

Composition The glass ionomer powder is an acid soluble calcium fluroaluminosilicate glass. The raw materials are fused to a uniform glass by heating them to a temperature of 1100 C to 1500 C. Lanthanum, strontium, barium or zinc oxide additions provide radiopacity. The glass is ground into a powder having particles in the range 20 to 50 m. SiO2 Al2O3 AlF3 CaF2 AlPO4 29.0 16.6 5.3 34.3 9.8

Fluoride is an essential constituent of glass ionomer cement. It lowers the temperature of fusion, increases the strength and improves the working characteristics of the cement paste.

27

The liquid for GIC was aqueous solutions of polyacrylic acid in a concentration of about 50 %. The liquid was quite viscous and tended to gel over time. The acid is form of a copolymer with itaconic, maleic, or tricaboxylic acid. Theses acids tend to increase the reactivity of the liquid, decreases the viscosity, and reduce the tendency for gelation. The copolymeric acids used in modern glass ionomer liquids are more irregularly arranged than in the homopolymer of acrylic acid. This configuration reduces hydrogen bonding between acid molecules and thus reduces the degree of gelling. Tartaric acid present in the liquid improves the handling characteristics and increases the working time however it shortens the setting time. One of the glass ionomer formulations consist of freeze dried acid powder and glass powder in one bottle and water or water with tartaric acid in another bottle as the liquid component. When the powders are mixed with water, the acid dissolves to reconstitute the liquid acid. The chemical reaction then proceeds in the same manner as that demonstrated by the powder liquid system. This is usually done to extend the working time. These cements have a longer working time with a shorter setting time. They are referred to as water settable GICs or as anhydrous GICs. Simmons and Murray et al say that compressive strength has been found to be significantly increased with the addition of silver alloy powder. McLean showed that a simple matrix of metal powder and alumino silicate glass ionomer powder failed to form a sufficient bond at metal/ polyacrylate interface. The glass ionomer cement is capable of establishing a bond with the dentin substrate before development start, but the composite start only after stress is started

Chemistry Of Setting Glass ionomer cement is an acid base reaction cement as defined by Wilson and Wygant. When the powder and liquid are mixed to form a paste, the surface of the glass particles is attacked by the acid. Calcium, aluminium, sodium and fluorine ions are leached into the aqueous medium. The polyacrylic acid chains are cross-linked by the calcium ions and form a solid mass. Within the next 24 hours a new phase forms in which aluminum ions become bound within the cement mix. This leads to more rigid cement. Sodium and fluorine ions do not participate in the cross linking of the cement. Some of the sodium ions may replace the hydrogen ions of carboxylic group, where 28

as the rest combines with fluorine ions, forming sodium fluoride uniformly dispersed within the set cement. During the maturing process, the cross-linked phase is also hydrated by the same water used as the medium. The unreacted portion of glass particles are sheathed by silica gel that develops during removal of the cations from the surface of the particles. Thus, the set cement consists of an agglomeration of unreacted powder particles surrounded by a silica gel in an amorphous matrix of hydrated calcium and aluminum polysalts.

Role Of Water In The Setting Process Water is a most important constituent of the cement liquid. It serves as the reaction medium initially, and then it slowly hydrates the cross linked matrix, thereby increasing the material strength. During the initial reaction period, this water can readily be removed by desiccation and is called loosely bound water. As the setting continues, the same water hydrates the matrix and cannot be removed by desiccation and is then called tightly bound water. This hydration is critical in yielding a stable gel structure and building the strength of the cement. If freshly mixed cements are kept from the ambient air, the loosely held water will slowly become tightly bound water over time. This phenomenon results in cement that is stronger and less susceptible to moisture. If the same mixes are exposed to ambient air without any covering, the surfaces will craze and crack as a result of desiccation. Any contamination by water that occurs at this stage can cause dissolution of the matrix forming cations and anions to the surrounding areas. This process results in weak and more soluble cement. Although the dissolution susceptibility tends to decrease over time, the minimum time at which the danger of cracking from the exposure to air no longer exists has not been established. The ionomer cement must be protected against water changes in the structure during placement and for a few weeks after placement if possible.

Role Of Fluoride Glass ionomer cements are bioactive. They form permanent adhesive bonds to dentin and enamel, hence preventing the development of secondary caries. They also release fluoride over a prolonged period and so can arrest the progress of caries.

29

Of all dental cements they are the most resistant to erosion in the acidic stagnation regions of the mouth.

Manipulations To achieve a long lasting restoration several conditions need to be satisfied like appropriate cavity surface preparation to achieve the bonding, proper mixing to obtain a workable mixture.

Surface Preparation Clean surfaces are essential to promote adhesion. A pumice wash can be used to remove the smear layer that is produced during cavity preparation. On the other hand organic acids such as polyacrylic acids of various concentrations can remove the smear layer but still leave the collagenous tubule plug in place. These plugs inhibit the penetration of the cement constituents and affect the hydrodynamic fluid pressure within dentin. One workable method is to apply a 10 % of polyacrylic acid solution to the surface for 10 to 15 seconds, followed by a 30 second water rinse.t5he smear layer will be removed but the tubules remain plugged. This procedure of removing the smear layer is called conditioning. The purpose of pumice debridement is to remove the fluoride rich layer surface that may compromise the surface conditioning process. After conditioning and rinsing of the preparation, the surface should be dried but it should not be unduly desiccated. It must remain clean because any further contamination by saliva or blood impairs bonding of the cement.

Preparation Of The Material Glass ionomer cements mixed with carboxylic acid liquids have a powder liquid ratio of 1.3: 1 or 1.35: 1, but it is the range of 1.25 to 1.5 g of powder per 1 ml of liquid. The powder and liquid are dispensed on a paper or a glass slab. A cool dry glass slab may be used to slow down the reaction and extend the working time .the slab should not be used if the temperature is below dew point, that is, at temperatures that enhance moisture condensation on the glass slab that can alter the acid water

30

balance needed for a proper reaction. By waiting for a few minutes, the temperature of the slab will rise sufficiently until water vapor no longer condenses on its surface. The powder and liquid should not be dispensed onto the slab until just before the mixing procedure is to be started. Prolonged exposure to the office atmosphere alters the precise acid water ratio of the liquid. The powder is divided into two equal portions. The first portion is incorporated into the liquid with a stiff spatula before the second portion is added. The mixing time is 30 to 60 seconds. At this time the mix should have a glossy surface. The shiny surface indicates the presence of polyacid that has not participated in the setting reaction. The residual acid ensures adhesive bonding to the tooth. If the mixing process is prolonged, a dull surface develops, and adhesion will not be achieved. Encapsulated products are typically mixed for 10 seconds in a mechanical mixer and dispensed directly onto the tooth and restoration. The cement must be used immediately because the working time after mixing is about 2 minutes at room temperature. An extension of the working time to 9 minutes can be achieved by mixing on a cool slab, (3 C), but because a reduction in compressive strength and modulus of elasticity is observed, this technique is not recommended. Do not use the cement once a skin forms on the surface or when the viscosity increases. Glass ionomer cements are very sensitive to contact with water during setting. The filed must be isolated completely. Once the cement has achieved its initial set (7 minutes), coat the cement margins with the coating agents supplied with the cement. It is important to prevent excess cement from spreading to the tooth structure or to the prosthesis. This cement is particularly susceptible to attack by water during setting. Therefore, the accessible margins of the restoration should be coated to protect the cement from premature exposure to moisture.

Properties Film thickness The glass ionomer cement is capable of forming films of 25m or less.

Working time and setting time The working time ranges from about 3 to 5 minutes the water settable cements tend to have somewhat longer working time. 31

The setting time is usually between 5 to 9 minutes. The water added cements have a more rapid initial set than those that use the polyacid liquid. Both working time and setting time can be determined by indentation tests. The oscillating rheometer of Wilson gives more information and is a better measure of working time. Its dynamic nature is closer to the clinical than is static indentation test.

Strength The 24-hour compressive strength of Glass ionomer cements ranges from 90 to 230 MPa and is greater than that of zinc phosphate cement. Tensile strength is similar to those of zinc phosphate cement. Glass ionomer cements show brittle failure in diametral compression tests. The elastic modulus of glass ionomer cements is less than that of zinc phosphate but more than that of zinc polycarboxylate cement. The rigidity of glass ionomer cements is improved by the glass particles and the iononic nature of the bonding between polymer chains.

Bond strength Glass ionomer cements bond to dentin with values of tensile bond strength reported between 1 and 3 MPa. The bond strength of glass ionomer cements to dentin is somewhat lower than that of zinc polyacrylate cement, perhaps because of the sensitivity of glass ionomer cements to moisture during setting. The bond strength has been improved by treating the dentin with an acidic conditioner followed by an application of a dilute aqueous solution of ferric chloride. Glass ionomer cements bond well to enamel, stainless steel, and tin oxide plated platinum and gold alloy.

Solubility The solubility in water for the first 24 hours is high. It is important that the cement should be protected from any moisture contamination during this period. After the cement has been allowed to mature fully, it becomes one of the most resistant of the nonresin cements to solubility and disintegration in the oral cavity.

32

Biologic properties The glass ionomer cements bond adhesively to tooth structure and they inhibit infiltration of oral fluids at the cement tooth interface. This particular property plus the less irritating nature of the acid should reduce the frequency of postoperative sensitivity. There are several factors contributing to the irritant nature. One is the pH and the length of time that this acidity persists. Another factor may be the viscosity. The pH relate to the thinner mixes used for cementation and do not apply to the higher powder liquid ratio. Glass ionomer luting cements may cause prolonged hypersensitivity, varying form mild to severe, micro leakage has been suggested as an explanation, but a recent study showed no increase in bacterial counts 56 days after cementation of crowns with a glass ionomer cements. These cements may be bacteriostatic or bactericidal because of fluoride release. Graver says that post-cemented micro leakage is the cause of tooth sensitivity. Smith D.C. states the cause of post cemented sensitivity as bacterial invasion, hydraulic pressure, acidity in the early setting stage and wash out of thin mix. Taywn stated that the higher the powder liquid ratio the greater is the thermal diffusivity.

Adhesion Glass ionomer has the property of permanent adhesion to untreated enamel and dentin under moist conditions of the mouth. It reacts with the smear layer on cut dentin (more for a filling material than for a luting agent). Glass ionomer also bonds to other reactive polar substrates such as the base metals. Bonding is of a chemical rather than a micro mechanical nature. Therefore, no acid etching or surface roughening procedures is deprecated. several days after that. About 80% of maximum bond strength is developed in 15 minutes but strength slowly increases for

Mechanism Of Adhesion To Enamel And Dentine Chemically, tooth material consists of apatite, which makes up 98% of enamel and 70% of dentin by weight and collagen, which is found in dentin alone. The bond

33

of glass ionomer cements is better to enamel than to dentine, because bonding to apatite is the principal mode of adhesion. Beech proposed that the interaction between apatite and polyacrylic acid produced polyacrylate ions, which then formed strong ionic bonds with the surface calcium ions of apatite in enamel and dentine. Wilson suggested that initially, when the cement paste is applied to tooth material and is fluid, wetting and initial adhesion is by hydrogen bonding provided by free carboxyl groups present in the fresh paste. As the cement ages, the hydrogen bonds are progressively replaced by ionic bonds. The cations coming either from the cement or the hydroxyapatite. Polymeric polar chains of polyacid are essential for the achievement of adhesion. Their role is thought to be one of bridging the interface between the cement and the substrate. Wilson et al postulated that during absorption polyacrylate entered the molecular surface of hydroxyapatite, displacing and replacing the surface phosphate. Also calcium ions are displaced from hydoxypatite along with phosphate during this ionic exchange. Therefore, an intermediate layer of calcium and aluminium phosphates and polyacrylates would form at the interface between the cement and apatite. Chain length is also an important factor in adhesion. The polymer chains capable of bridging gaps between the cement body and substrate. Bonding to enamel, which is mostly apatite is due to ionic and polar forces and bonding to dentine is only to the apatite constituent of the dentine. Therefore, the adhesion of glass ionomer to dentine is weaker. Collagen contains both amino and carboxylic acid groups, so adhesion could be due to hydrogen bonding or cationic bridges. However, recent absorption studies show that polyacrylic acid and polyacrylate are not absorbed on collagen. Cements based on polyacrylic acid appear to bond more strongly than those based on copolymers of acrylic acid with itaconic or maleic acids. Evidence is only accumulating that bond strength to tooth substances depends on the nature of the polyacid used. If it were proved, then the molecular configuration of the polyacid would become an important factor in controlling adhesion.

34

Improving Adhesion When the cement tooth bonds fractures, it is by cohesive failure within the cement rather than adhesive failure at the interface. Therefore, the strength of the bond is limited by the cohesive strength of the cement used. The smear layer is considered to be beneficial. However, salivary contamination of a freshly prepared dentine surface reduces bond strength, but whether this was because of its water contact or contamination of the dentin surface is uncertain.

Surface Conditioning A number of research workers have sought to improve adhesion of glass ionomer cements. One way that is common to nearly all adhesive technologies is by pretreatment of the surface. Mclean and Wilson first used the term surface conditioning for this treatment in order to differentiate it from acid etching. Surface conditioning is needed in order to eliminate the wide variation found in the structures of the tooth surfaces following cutting. Rough tooth surfaces are contraindicated. In general, the smoother the surface, the stronger is the bond. Good interfacial contact is important for adhesion. Smoothening is necessary to prevent air entrapment and to minimize sites where stress concentration could occur.

Fluoride Release Both enamel and cementum can absorb fluoride. Fluoride is incorporated within the mineral structure as fluoridated hydroxy apatite. Plentiful fluoride is released in the early life of the restoration and it gradually decreases over a period. Fluoride is released for at least 18 months. Thickly mixed cements released more fluoride because they contain proportionately more glasses and therefore more fluoride. Not all the fluoride is available for release. It is released as sodium fluoride and is restricted by the sodium and the calcium content of the glass and not by the total fluoride content of the glass. Sodium fluoride is released preferentially from the matrix rather than the filler. The rate of release is proportional to the inverse of the square root of time. Aluminum ions are also released, temporarily and ceases once the cement has fully hardened. Aluminum ions absorbed by enamel confer acid resistance upon the tooth. 35

Action Of Fluoride In Prevention Of Caries The anticaries effect can be due to the uptake of fluoride ions by enamel apatite at hydroxyl sites, and high fluoride level at enamel surfaces increases resistance to plaque acids. Surface energy of apatite is decreased, therefore, the dental plaque does not adhere to tooth enamel surfaces.

Reaction Of Cement On Pulp Several reasons have been postulated as to why Glass ionomer cement does not have the same damaging effect on the pulp than Zinc phosphate cement. 1. First being the polycarboxylic acid used is much weaker than phosphoric acid. 2. Second, the acid is a polymer, means that it will have a much higher molecular weight and this will limit diffusion along the dentinal tubules towards the pulp. 3. Thirdly, there is a strong electrostatic attraction between hydrogen ions and negatively charged polymer chain and dissociation will less readily take place than with simple anions.

Applications Glass ionomer cements are primarily used for permanent cement, as a base, and as a class V filling material. The cement has been evaluated as a pit and fissure sealant and an endodontic sealer. Glass ionomer cements are being used clinically for cementation of orthodontic bands because of their ability to minimize decalcification of enamel by means of fluoride release.

36

HYBRID IONOMER CEMENTS Self cured and light cured ionomers (or resin modified glass ionomers) are available for cementation.

Composition One self-cured hybrid ionomer cement powder contains a radiopaque, fluroaluminosilicate glass and a micro encapsulated potassium persulfate and ascorbic acid catalyst system. The liquid is an aqueous solution of polycarboxylic acid modified with pendant methacrylate groups. It also contains 2 hydroxyethylmethacrylate (HEMA) and tartaric acid. Another self-cured cement contains a mixture of fluroaluminosilicate and borosilicate glasses in the powder. Its liquid is a complex monomer containing carboxylic acid groups that can undergo an acid base reaction with glass and vinyl groups that can polymerize when chemically activated. A light cured hybrid ionomer cement contains fluroaluminosilicate glass powder and a copolymer of acrylic and maleic acids, HEMA, water, camphoroquinone and an activator in the liquid.

Setting Reaction Setting of hybrid ionomer cements usually results from an acid base glass ionomer reaction and self-cured or light cured polymerization of the pendant methacrylate groups. Some cements are only light cured.

Manipulation The powder is fluffed before dispensing. The liquid is dispensed by keeping the vial vertical to the mixing pad. The powder liquid ration is 1.6 g of powder to 1.0 g of liquid, and the powder is incorporated into the liquid within 30 seconds to give a mousse like consistency. The working time is 2.5 minutes. The cement is applied to a clean dry tooth that is not desiccated. Some products recommend the use of a conditioner for enhanced bonding to dentin. No coating agent is needed. HEMA is known as a contact allergen therefore the use protective gloves and a no touch technique are recommended. 37

Properties The compressive and tensile strengths of hybrid ionomer cement are similar to glass ionomer cements. The fracture toughness is higher than that of other water based cements but lower than composite cements. The bond strength to moist dentin ranges from 10 to 14 MPa and is much higher than that of most water based cements. Hybrid ionomer cement have very low solubility when tested by lactic acid erosion. Water sorption is higher than resin cements. Fluoride release is similar to glass ionomer cements. The early pH is about 3.5 and gradually rises.

Applications Self cured hybrid ionomer cement are indicated for permanent cementation of porcelain fuse to metal crowns, bridges, metal inlays, on lays, and crowns, post cementation and luting of orthodontic appliances. Additional uses include adhesive liners for amalgam, bases, provisional restorations and cementation of specific ceramic restorations.

38

ZINC OXIDE EUGENOL CEMENT This material has been used to a wide range applications in dentistry including its use as an impression material for edentulous arches, a surgical dressing, a bite registration paste, a temporary filling material, root canal filling, a cementing medium, and as a temporary relining material for dentures. ZOE cement is one of the least irritating of all the dental materials and provides an excellent seal against leakage.

Types According to ADA specification 30 Type I - ZOE cement temporary cementation Type II - ZOE cements permanent cementation of restorations or appliances fabricated outside of the mouth Type III - ZOE cements temporary restoration and thermal insulating bases Type IV - ZOE cements cavity liner

Composition These materials are dispensed in two separate pastes. One tube contains zinc oxide and fixed vegetable or mineral oil acts as a plasticizer and aids in off setting the action of the eugenol as an irritant. The zinc oxide should be finely divided and it should contain only a slight amount of water. Oil of cloves, which contains 70 % to 85% eugenol, is sometimes used in preference to eugenol because it reduces the burning sensation experienced by patients when it contacts the soft tissues. The addition of rosin to the paste in the second tube apparently facilitates the speed of the reaction, and it yields a smoother, more homogenous product. Canada balsam and Peru balsam are often used to increase flow and improve mixing properties. If the mixed paste is too thin or it lacks body before it sets, a filler (such as wax) or an inert powder (such as kaolin, talc, diatomaceous earth) may be added to one or both of the original pastes. There are many soluble salts that may act as accelerators. Chemicals commonly used are zinc acetate, calcium chloride, primary alcohols and glacial acetic acid. The accelerator can be incorporated in either one or both pastes.

39

Tube no 1 (base) Zinc oxide Fixed vegetable or mineral oil 13 87

Tube no 2 (catalyst) Oil of cloves or eugenol Gum or polymerized resin Filler (silica type) Lanolin Resinous balsam 12 50 20 3 10

Accelerator solution and color 5

Chemistry The setting mechanism for ZOE material consists of zinc oxide hydrolysis and a subsequent reaction between zinc hydroxide and eugenol to form a chelate. Water is needed to initiate the reaction and it is also a by-product of the reaction. This type of reaction is called autocatalytic. This is the reaction why the reaction proceeds more rapidly in a humid environment. The setting reaction is accelerated by the presence of zinc acetate dihydrate, which is more soluble than zinc hydroxide and which can supply zinc ions more rapidly. Acetic acid is a more catalyst for setting reaction than is water, because it increases the formation rate of zinc hydroxide. High atmospheric temperature also accelerates the setting reaction. The free eugenol cement of the set cement is probably extremely low. It appears to be much higher than it actually is, because the chelate hydrolyzes readily, forming free eugenol and zinc ions.

Manipulation The mixing of the two pastes is generally accomplished on an oil impervious paper, although a glass-mixing slab can be used. The proper proportion of the two pastes is generally achieved by squeezing two strips of the paste of the same length, one from each tube, onto the mixing slab. A flexible stainless steel spatula is satisfactory for the mixing. The two strips are combined with the first sweep of the

40

spatula, and the mixing is continued for approximately 1 minute until a uniform color is observed. Cements intended for final cementation of restorations carry manufacturers directions and measuring devices that are important to use, because of the deceptive flow qualities of these cements, adding powder until the operator feels the mix is of suitable consistency for cementing a restoration will lead to a cement deficient in powder and a lowered strength in the set cement.

Properties Setting time The initial setting time may vary between 3 to 6 minutes. The final setting time is the time at which the material is hard enough to resist penetration under a load. It can occur within 10 minutes for type I pastes and 15 minutes for type II. The actual setting time is shorter when the setting occurs in the mouth.

Film thickness The film thickness should not be more than 25 m for cements used for permanent cementation and not more than 40 m for cements used for temporary cementation.

Compressive strength A maximum value of 35MPa is required for cements intended for temporary cementation. A minimum of 35 MPa is required for cements intended for permanent cementation. The strength of the cement for temporary cementation is selected in relation to the retentive characteristics of the restoration and the expected problems of removing the restoration when the time arrives.

Disintegration A maximum value of 2.5% is acceptable for provisional cementing materials but a value of 1.5 % is required for the other cements.

41

Provisional Cementation On many occasions, cementing a restoration provisionally is advised not that the patient and dentist can assess its appearance and function over a longer time than a single visit. However, this trial cementation should be managed cautiously. On one hand, removing the restoration for definitive cementation may be difficult, even when temporary ZnOE is used. To avoid this problem, the provisional cement can be mixed with little petroleum or silicone grease and applied only to margins of restoration to seal them while allowing subsequent removal without difficulty. On the other hand, a provisionally cemented restoration may come loose during function. If a single unit is displaced, it can be embarrassing or uncomfortable for the patient. If one abutment of a FPD becomes loose, the consequences can be more severe. If the patient does not promptly return for recementation caries may develop very rapidly. Provisional cementation should not be undertaken unless the patient is given clear instructions about the objective of the procedures, the intended duration of the trial cementation and the importance of returning if an abutment loosens.

Temporary Cementation Unmodified ZOE cements are used as a luting material for provisional restorations in crown and bridge prosthodontics. Unmodified cements are available in the compressive strengths of 1.4MPa to 21MPa. Studies proved that luting cements with a compressive strength of 15 to 24 MPa was the most appropriate cement based on retention; taste; ease of removal; ease of cleaning.

Non-Eugenol Paste One of the chief disadvantages of the ZOE pastes is the possible stinging or burning sensation caused by eugenol when it contacts soft tissues. Furthermore the ZOE reaction is never completed, with the result that the free eugenol may leach out. Some patients find the taste of eugenol extremely disagreeable and in patients who wear a surgical pack for several weeks; a chronic gastric disturbance may result.

42

A material similar to ZOE reaction product can be formed by a saponification reaction to produce an insoluble soap, if the zinc oxide is reacted with a carboxylic acid. The reaction is ZnO + 2RCOOH (RCOO) 2Zn + H2O Almost any carboxylic acid reacts with zinc oxide, but only a few such acids provide compounds of dental interest. Orthoethoxybenzoic acid, (EBA), is used in this regard. The carboxylic acid is not necessarily a liquid. Powdered acids can be dissolved or dispersed in a liquid carrying agent, such as ethyl alcohol. The non-eugenol cements do not adhere well to preformed metal crowns as the eugenol containing cements, and they are slower setting. The non-eugenol cements however do not soften provisional acrylic crowns.

43

RESIN BASED CEMENT Resin luting cements have been in existence since the 1950s. The early formulations were lightly filled methyl methacrylate resins. Because of their high polymerization shrinkage, tendency for pulpal irritation, penchant for micro leakage and poor handling characteristics, these resins had only limited use. However , with the development of composite direct filling resins with improved properties acceptance to acid etch and potential to bond to dentin, a variety of resin cements have become available.

ISO 4049 Describes three classes of composites for polymer based filling, restoration and luting materials Class 1 self cured materials Class 2 light cured materials Class 3 dual cured materials

Requirements Based On ISO 4049 Class 1,2,3: maximum film thickness 50 m Class 1,3: minimum-working time 60 seconds Class 1,3: maximum setting time 10 minutes Class 2: depth cure 0.5mm (opaque) 1.5mm (others) Class 1,2, 3: water sorption 40 g/mm Class 1,2,3: solubility 7.5 g/mm

Composition The basic composition of the most modern resin based cements is similar to that of resin based composite filling material. The resin cement consists of a resin matrix (bis-GMA or diurethane methacrylate) with inorganic fillers that are bonded to the matrix via coating with an organosilane coupling agent. The filler particle provides strength. The fillers are those used in composites (silica or glass particles, 10 to 15 m in diameter) and the colloidal silica is that used in micro filled resins. The resin matrix binds them together and bonds them to the tooth structure. Because most of a prepared tooth surface is dentin, monomers with functional groups that have been used to induce bonding to dentin are often incorporated in these resin cements. They 44

have

organophosphates,

hydroxyethyl

methacrylate

(HEMA),

and

the

4-

methacyrlethyl-trimellitic anhydride (4-META) system. Bonding of the cement to enamel can be attained through the acid tech technique. Polymerization can be achieved by the conventional peroxide amine induction system or by light activation. Some cements are autopolymerising for use under light blocking metallic restorations, while others are either entirely photo cured or dual cured (light activated) for use under translucent ceramic veneers and inlays. In dual cured cements, a catalyst is mixed into the cement so that it will eventually harden within shadowed recesses after a rapid initial hardening is achieved with a curing light. Dual cured cements come in a base catalyst form and must be mixed before use. Light cured composites are photo initiated in the presence of a camphoroquinone amine system. They provide a wide selection of shades, tints and opaquers.

Properties Resin based cements are virtually insoluble in oral fluids. They are formulated to provide the handling characteristics required for the particular application for e.g., cements recommended for cementation of indirect restorations have a film thickness of 25 m or less. With respect to bonding to dentin, the so-called adhesive cements, which incorporate the phosphonate, HEMA or 4-META adhesion systems, generally develop reasonably good bond strengths to dentin. Bonding to tooth structure may be more critical for resin based cements than for some other types of cement, because they possess no anticariogenicity potential. These cements differ from restorative composites primarily in their lower filler content and lower viscosity. Resin cements are virtually insoluble and are much stronger than conventional cements. It is their high tensile strength that makes them useful for micromechanically bonding etched ceramic veneers and pitted partial denture retainers to etched enamel on tooth preparations that would not be retentive enough to succeed with conventional cements.

45

Biologic Properties Resin based cements, just like composite cements are irritating to the pulp. Thus, pulp protection via a calcium hydroxide or glass ionomer liner is important when one is cementing an indirect restoration that involves bonding to dentin.

Manipulation The chemically activated versions of theses cements are supplied as two component systems a powder and a liquid or two pastes. The peroxide initiator is contained in one component and the amine activator is contained in the other. The two components are combined by mixing on a treated paper pad for 20 to 30 seconds. The time of excess removal is critical. If it is done while the cement is in a rubbery state, the cement may be pulled from beneath the margin of the restoration, leaving a void that increases the risk of plaque buildup and secondary caries. Removal of the excess cement is difficult if it is delayed until the cement has polymerized. It is best to remove the excess cement immediately after the restoration is seated. Light cured cements are single component systems just as are the light cured filling resins. They are widely used for cementation of porcelain and glass ceramic restorations and for direct bonding of ceramic orthodontic brackets. The time of exposure to the light that is needed for polymerization of the resin cement is dependant on the light transmitted through the ceramic restoration and the layer of polymeric cement. However the time of exposure to the light should never be less than 40 seconds. The dual cure cements are two component systems and require mixing that is similar to that for the chemically activated systems. The chemical activation is slow and provides extended working time until the cement is exposed to the curing light, at which point the cement solidifies rapidly. It then continues to gain strength over an extended period because of the chemically activated polymerization.

Disadvantages 1. Excessive cement film thickness 2. Marginal leakage because of setting shrinkage 3. Severe pulpal reactions when applied to cut vital dentin 46

4. Dentin bonding agents have been reported to reduce pulpal response, presumably by sealing the dentinal tubules and reducing micro leakage. Adhesive resin was found to produce better marginal seal than zinc phosphate cement.

Composite Resin System Three types of composite resin materials are available for use in indirect techniques: microfilled resins, small particle composite resins and hybrid resins. All show excellent wear resistance, but small particle composite resins and hybrid resins can be etched to produce micromechanical retention. They can also be silanted to increase the bond strength further. One manufacturer of a reinforced microfilled resin inlay/ onlay system provides a special bonding agent to increase the bond strength of its material.

Resin Bonded Bridges Theses prosthesis are widely employed as alternatives to metal ceramic bridges. In this procedure, the preparation of the abutment teeth is minimal and is confined to enamel of the lingual surface and proximal surfaces. The tissue surfaces of the abutments are roughened by electrochemical etching or other means and the surfaces of the prepared tooth enamel are acid etched to provide mechanical retention areas for the resin cements.

Glass Ceramic Restorations These restorations are often translucent and require specific shades of cementation agent to maximize their esthetic appearance. Resin cements have been the cementation agents of choice recently for all ceramic inlays, crowns and bridges because of their ability to reduce fracture of the ceramic structures. To achieve the best retention, the undersurface of the glass ceramic restorations is usually etched and a silane coating is applied before cementation.

47

Resin Metal Bonding Bonding composites to the metal framework of a bridge and denture acrylic to a partial denture framework can be improved by the use of silica coating. Presently there are three methods of applying silica to either noble or base metal alloys. One method applies pyrogenic silica using a propane flame. Other method s use heat in an oven or ceramic blasting to coat the restoration or appliance. Bond strengths of composites to silica coated Au-Pd-Cr-Be alloys from 16 to 22 MPa. Silica coating of noble alloys eliminates the need for tin-plating these alloys to improve adhesion of composites. The bond strength of denture acrylics to Ni-Cr-Be alloys range from 7 to 23 MPa when alloy is treated with a silica coating or primed with adhesive resin cement. Liquid cements based on thiosulfates have recently become available for treatment of alloys. Recently, metal primers based on thiophosphate chemistry have been introduced as a treatment for resin metal bonding.

48

COMPOMERS Compomer is the resin based cement indicated for cementation of cast alloy crowns and bridges, porcelain fused to metal crown and bridges and gold cast inlays and onlays. Cementation of all ceramic crowns, inlays onlays and veneers The cement should not be used as a core or filling material. Compomers are also known as poly acid modified composites.

Composition The cement powder contains strontium aluminum fluorosilicate glass, sodium fluoride and self and light cured initiators. The liquid contains polymerizable methacrylate / carboxylic acid monomer, multifunctional acrylate / phosphate monomer, diacrylate monomer and water.

Setting Reaction Setting is the result of self and light cured polymerization. Once the cement comes into contact oral fluids an acid - base reaction may occur. The carboxylic acid groups contribute to the adhesive capability of the cement.

Manipulation Dry the tooth to be cemented but do not desiccate. The powder liquid ratio is 2 scoops to 2 drops. Tumble the powder before dispensing. Mix the powder and the liquid rapidly for 30 seconds. Place the mixed cement in the crown only and then seat the crown. A gel state is reached after 1 minute, at which time the excess cement is removed with floss and a scaler. Light cure the exposed margins to stabilize the restoration. Setting occurs 3 minutes after start of mix. Once set, compomer cement is very hard.

Properties Compomer cement has higher values of retention, bond strength, compressive strength, flexural strength and fracture toughness. The cement has low solubility and sustained fluoride release.

49

CEMENTATION PROCEDURE The permanent cementation of the restoration is the final clinical procedure that marks the success of our efforts. Our interest is that the permanent cementation should be performed without long periods of temporary cementation. Otherwise the patient may be exposed to a series of unpleasant complications such as separation of the teeth, difficulty in achieving a satisfactory level of oral hygiene, problems in removal of the restoration, and the possibility of infiltration because the thickness of the temporary cement is without doubt greater than the thickness of the permanent cement and is much less fluid. In immediate cementations the conditions of the healthy periodontium are ideal and especially in conditions of complete visibility of the entire preparation, cases in which the provisional restoration has been constructed properly, the only practice we follow is one of isolating the area, cleaning the preparation and protecting the prepared surface of vital teeth.

Isolation The performance of all luting agents is degraded if the material is contaminated with water, blood, or saliva. Therefore the restoration and the tooth must be carefully cleaned and dried after the try in procedure, although excessive drying of the tooth must be avoided to prevent damage to the odontoblasts. The casting is best prepared by air- brading the fitting surface with 50m alumina. This should be done carefully to avoid abrading the polished surfaces or margins. Alternative cleaning methods include steam cleaning, ultrasonic and organic solvents. Before initiation of cement mixing, isolating the area of cementation and cleaning and drying the tooth is mandatory. However the tooth should never be excessively desiccated. Over drying the prepared tooth will lead to postoperative sensitivity.

Saliva Control Depending on the location of the preparation in the dental arch, several techniques can be used to create the necessary dry filed of operation. In areas where only supragingival margins are present, moisture control with a rubber dam is probably the most appropriate method. However, in most instances a rubber dam 50

cannot be used and absorbent cotton rolls must be placed at the source of the saliva; an evacuator must be placed where the saliva pools. In the maxillary arch, placing a single cotton roll in the vestibule immediately buccal to the preparation and a saliva evacuator in the opposing lingual sulcus is generally sufficient. When working on a maxillary second or third molar, multiple cotton rolls must be placed immediately buccal to the preparation and slightly anterior to block off the parotid duct. If a maxillary roll does not stay in position but slips down, it can be retained with a finger or the mouth mirror. An alternative to multiple cotton rolls is placement of one long roll horseshoe fashion in the maxillary and mandibular muccobuccal folds. The use of moisture absorbent cards is another method for controlling saliva flow. These cards are pressed paper wafers covered with a reflective foil on one side. The paper side is placed against the dried buccal tissue and adheres to it. In addition two cotton rolls should be placed in the maxillary and mandibular vestibules to control saliva and displace the cheek laterally. Svedopter and Speejector for isolation and evacuation of the mandibular teeth, the metal saliva ejector with attached tongue deflector is excellent. By adding facial and lingual cotton rolls, excellent tongue control and isolation is provided. Excessive forces are not necessary to make crowns seat during the phase of cementation. If the space for the cement has been provided by the use of die spacer, it is not necessary to exert a great deal force, which can determine a permanent alteration of the integrity of the marginal fit. It should be kept in mind that the cementation load should not exceed 5-7 kg.

51

The technique used is known as the brush technique and consists of the application of a small quantity of cement on the incisal edge of the preparation using a brush for the application.

The interior of the crown in the area of the margins is painted with a small quantity of cement, and the crown is placed along its path of insertion.

The insertional technique is as follows: the crown is inserted slowly to about one half the distances; it is then withdrawn by a few millimeters and is reinserted to almost the full extent of its length. The process is then repeated. We use a slight up and down movement along this path to assist the layering of the cement. When the operator no longer feels any resistance, the crown is pushed to the finish line and thus

52

to its final seating. It is necessary to avoid rotational movements to find the correct seating position. This can be damaging if porcelain margins are present.

Once the crown has been inserted the patient is provided with an occlusal support and is asked to close to maintain the position of the crown during the setting of the cement. In professional practice we prefer to cement one crown at a time, or at the most two adjacent crowns.

Once the cement has hardened we follow this procedure: after immersion of the P.K. Thomas no. 2 waxing instrument in a silicone lubricant we enter the junctional area and remove the excess cement by following the anatomy of that area. We prefer to use this instrument because it has a rounded tip and a curvature that are ideal for following the anatomic contour. We place it against the coronal surface and 53

insert it in the gingival sulcus in the junctional area. By applying light pressure we follow the junction and remove the cement. The purpose of this cement is this technique is to remove the cement following the contour without causing scratches in the area of crown margin. The same procedure is repeated on the lingual surface and on the interproximal surfaces, and because of the instrument curvature; it results as being efficient and easy to perform.

Some cements like polycarboxylate or resin, tend to pull away from the margins if excess removal is performed too early. Dental floss with a small knot in it can be used to remove any irritating residual cement interproximally and from the gingival sulcus. The sulcus should contain no cement. After the excess has been removed. The occlusion can be checked once more with Mylar shim stock.

54

Cements take at least 24 hours to develop their final strength. Therefore the patient should be cautioned to chew carefully for a day or two.

Post-Cementation Aqueous based cements continue to mature over time well after they have passed the defined setting time. If they are allowed to mature in an isolated environment, that is, free of contamination from surrounding moisture and free from loss of water through evaporation, the cements will acquire additional strength and become more resistant to dissolution. It is recommended that coats of varnish or a bonding agent should be placed around the margin before the patient is discharged.

55

LUTING OF VENEERS All ceramic restorations may be cemented with zinc phosphate, glass ionomer or dual polymerizing resin cement. The cement comes in four shades (A2, C2, B1 & B3) permitting some influence on the final shade of translucent restorations. This not only provides better retention and colour control but it makes the ceramic material less fragile than if it were cemented with non resin cement. Clean the prepared tooth with non fluoride pumice and try in the porcelain veneers. Verify the marginal fit. A drop of water or glycerin will help the veneer stay in place. The restoration should be internally clean, etched and silaned. Remove any organic debris with ethanol or acetone. Acid etch the internal surface of the restoration with hydrofluoric acid (for feldspathic porcelain etching time is 5 minutes). The gel is carefully rinsed under running water (this hydrofluoric acid acts as an organic solvent and helps to remove any residual investment) Dry the ceramic with oil free air. The silane coupling agent is applied to internal surface of restorations. Dispense one drop of silane primer and drop of silane activator into dappen dish. Stir the liquid in the dish for 10-15 seconds with a brush. Apply to etched porcelain for 1 min and air dry after it. These silane coupling agents are organosilones which help to form covalent bonds (methacrylate group) with the resin when it is polymerized. Alternate to it titanates and zirconates can also be used as coupling agents. Etch the enamel surface with 37% phosphoric acid rinsed for 20 seconds and air dry the tooth. The bonding agent is then applied to the tooth for 30 seconds with a brush and compressed air is used for 5-10 seconds to remove the excess adhesive Polymerize the adhesive for 20 seconds with a light source. Dispense equal amounts of base and catalyst from dual cure resin. Mix for 10-20 seconds with plastic mixing stick. Apply a thin layer of cement to the internal surface of the crown. Seat the crown and remove excess cement from the marginal areas with an explorer and clean brush. Continue polymerizing for an additional 45-60 seconds, directing the light from the lingual (through the tooth) so that shrinkage will occur toward the tooth. Then direct the light from the labial (through the veneer). activation is not utilized, allow 6 minutes for auto polymerization. When light

56

Once the luting agent is polymerized trim the excess cement and check the occlusion. Final finishing procedures can be accomplished with porcelain polishing agents.

57

LUTING OF CERAMIC RESTORATIONS WITH RESIN BASED CEMENTS The crown should be cleaned, etched and silaned. Remove any organic debris with ethanol or acetone, followed by placing the restoration in an ultrasonic cleaner. Further cleaning can be accomplished by applying liquid phosphoric acid etchant. The crown is silaned with a silane coupling agent. Dispense one drop of silane primer and one drop of silane activator into a dappen dish. Stir the liquid in the dish for 10 -15 seconds with a brush. Apply it to the internal surface of the crown; avoid application on the external surface of the crown by covering the outside of the crown with wax. Rinse the crown and dry it with compressed air. Clean the tooth preparation with a rubber cup and flour of pumice. Ten wash and air dry. Etch the enamel for 30 seconds. Rinse and air dry the tooth. Apply bond adhesive over the entire preparation with a brush. Thin the bonding agent with compressed air for 15 seconds. Polymerize the adhesive. Dispense equal amount of base from the syringe and catalyst from the tube. Mix for 10 -20 seconds with a flat ended plastic mixing stick. Apply a thin layer of cement to the internal surface of the crown. Seat the crown and remove the excess to avoid ditching the cement at the margin. Aim the light cure at the marginal areas from facial, lingual and occlusal directions for 40 -60 seconds. Adjust the bulky margins and check for premature contacts. Polish the crown using porcelain finishing kit.

58

CONCLUSION Luting agents possess varied, complex chemistries that affect their physical properties, longevity and suitability in clinical situations. It appears a single adhesive will not suffice in modern day practice. To date, no adhesive can completely compensate for the shortcomings of the preparation retention and resistance forms or ill fitting, low strength restorations. Prosthdontics must be aware of the virtues and shortcomings of each cement type and select them appropriately.

59

REVIEW OF LITERATURE Edwin. V (1951) in his study on mechanism of dental structure said that the dental cements act as a bond by keying action. Roughness of interface between the inlay and the tooth area involved (pitch or taper between opposing walls of cavity) thickness of the bond. John E. Johnston (1954) did a evaluation of an acrylic cement for one year. He concluded that acrylic cement is more difficult to remove then ZnPO4 from cervically, a complete dehydrated surface is desirable, ability to with stand expansion and contraction due to temperature charge is not determined yet if the marginal cement is removed and before polymerization, leaking will occur. R.W.Phillips (1968) in his article ZNO and Eugenol cements for permanent restoration in his conclusion was ZNOE was inferior to ZnPO4 in terms of compressive strength. Wendi A. Levine (1969) did an evaluation of film thickness of resin luting agents. Most of the commercially available resin luting cements have films thin enough to allow to successful placement of etched cast metal retainer. Restorative resins which have grater film thickness are unsatisfactory for use as luting agents. W.A. Richter (1970) did a study on predictability of retentive values of dental cements. He concluded that by comparing the tensile strength of ZnPO4 , hydrophosphate and ZOE are equal and carboxylate is at least one third stronger. In retentive evaluation the carboxylate, ZnPO4 and Hydrophosphate cements are equal and ZOE is as retentive. Oilo G (1978) The influence of surface roughness on the retentive ability of two dental luting cements.Two series of brass cones and two series of dentine posts with varying surface roughness were produced. Maximum roughness value and arithmetical mean roughness were recorded for each cone. A tensile stress was applied until the crown and cone separated. The retentive force is relation to retentive area was measured. The results showed that the retentive ability of both cements 60

increased with increasing surface roughness. The increase in retention was greater for bras than for dentine. Dorothy McComb (1982) did a comparison of glass ionomer cement with other cement of retention of castings. She concluded that G.I. have the greater retentive strength and Zinc Phosphate has the weakest strength. Michael L. Myers (1983) conducted a study on marginal leakage of contemporary cementing agents, he concluded that the least amount of leakage were shown by ZnPO4, than followed by glass ionomer cement with protective varnish and last is polycarboxylate. Gudbrand Oilo (1984) did a clinical study of two luting cements used on student treated patient. In his 6 to 18 months observation there was no difference in both ZnPO4 and Polycarboxylate cement, both cement was seen equally suitable as a luting material. W.R. Lacefield (1985) did a study of tensile bond strength of a glass ionomer cement, he concluded that the tensile bond strength of G.I. cement to enamel was significantly greater than to dentin (etched with phosphoric and citric acid has no significantly effect on temporary bond strength. G.L.Button (1985) in his article on surface preparation and shear bond strength of the casting cement interface accounted that air blasting with 60 m aluminium oxide particles provided the surface roughness and topography with the greatest resistance to shear stress. Antony H.L. Tjan (1987) did a comparison of effect of various cementation methods on the retention of prefabricated posts according to his study the post cemented with composite recorded the greatest retention, then the ZnPO4 and glass ionomer. C.L. Davidson (1991) made a study on destructive stresses in adhesive luting cements. He said that nature and magnitude of the stress development, depend greatly on the formulation and film thickness of the luting cement. The thicker the layer, the 61

faster the stress development in the G.I.

and slower in the composite.

The

contraction stress has a detrimental effect on the corrosive strength of the glass ionomer and on the adhesive strength of the composite. R.E. Kerby (1991) compared physical properties of stainless steel and silver reinforced G.I. Cement, he suggested that the stainless steel reinforced G.I. cement possess strength properties that should lead to a stronger, more # resistant restorative when compared with the presently available one. De Schepper E.J. (1991). Fluoride release form G.I. Cements .This study compared the amounts and patterns of fluoride release form 11 commercially available glass ionomer cements into artificial salvia over an 84 day period. The results indicated that the materials differed in the amount of fluoride released, and that Miracle Mix released the highest cumulative total of fluoride over the test period. Along with old Fuji II, Miracle Mix also released the most fluoride during the last time interval (56 to 84 days). All of the materials released the greatest proportion of their cumulative total fluoride in the first 24 hours after mixing. Zakia Fakiha (1992) experimented the rapid mixing of ZnPO4 for F.P.Ds., he experimented mixing of ZnPO4 rapidly in ordinary and frozen glass and compared their properties. Mixing in frozen glass showed increase in PH, slightly increase in film thickness, increase in working time and decrease in setting time compared with the mixing in ordinary glass slab. satisfactory better for F.P.Ds. Chung Moonum (1992) experimented the effect of early water contract on G.I., ZnPO4, Polycarboxylate luting agents. He found out that the time between start of mixing and immersion in water decreased the width of both zones in all cements and markedly lowered the loss of the surface of regular glass ionomer cement than other. William W. Bracket (1992) analyzed the performance of a glass luting cement over 5 years in a general practice. In 5 years period 1435 received cast restoration luted with G.I. cement. The material has demonstrated an exceptionally low rate of secondary So frozen glass slab mixing appear to be

62

caries, excellent retention of castings and acceptable compatibility with the dental pulp. Johnson H, Powell .L.V (1993). Evaluation and control of post-cementation pulpal sensitivity : zinc phosphate and glass ionomer luting cements.Many studies have documented pulpal sensitivity after crown cementation, but non have determined its cause. By controlling technique variable in a large scale clinical trial, the authors evaluated the contribution of the zinc phosphate and glass ionomer luting cements in causing pulpal sensitivity or necrosis. James E. Metz, William. W. Brackett (1994) in their study on performance of G.I. luting cement over 8 years in a general practice reported as follows 1230 cast restorations luted with G.I. cement were followed up for 8 years. The result showed :a. b. c. Absence of secondary caries 99% retention of restorations 4 % incidence of irreversible pulpitis

Wu-J.C., Wilson (1994) Optimal cement space for resin luting cements..Stainless steel dies, simulating 0 to 80 microns of die spacing, were seated into a machined brass crown with phosphacap, Panavia EX, and C and B metabond. The seating discrepancy after 60 seconds was measured to determine the optimal cement space for best seating for each agent. The most complete seating for crowns luted with zinc phosphate cement was observed when at least 40 microns of cement space was provided. C and B Metabond and Panavia required 30 microns of die spacing.

63

REFERENCES 1. Antony H. L. Tjan: - Effect of various cementation methods on the retention of prefabricated - J.P.D. 1987; 58,3; 309 2. Button G.L. Surface preparation and bond strength of casting cement interface. J.P.D 1985; 53; 134-8. 3. Chung Moonum: - The effect of early water contact on G. I. Cements. Quint. Int.1992; 23; 209. 4. Dorothy McComb Retention of castings with G.I. cements J.P.D.1982; 48-3; 285. 5. Davidson C.L.- Destructive stress in luting cements. J. Dent Res: 1991; 70-5, 880 6. De Schepper E.J. Fluoride release from G.I. cements Quint: 1991; 22; 3; 2157. Edwin V. - Mechanism of dental structures. J.P.D. 1951,2, 306-10 8. G.H. Johnson Evaluation and control of post cementation pulpal sensitivity J.A.D.A. 1993; 124; 11; 38-46 9. Gudbrand Oilo Clinical study of two luting cements used on students treated patients J.P.D. 1984; 52-4; 518 10. G.Oilo- The influence of surface roughness on the retentive ability of two dental luting cements. J.Oral.Rehab; 1978 5(4) 372-89 11. John F. Johnston- Evaluation of acrylic cements.- J.P.D. 1959-5-200-4 12. James E Metz Performance of a G.I. luting cement over 8 yrs in a general practice J.P.D. 1978; 40; 4; 413-17 13. Kerby R.E.- Physical properties of stainless steel and silver forced G.I. cements J.Dent.Res. 1991; 70; 1350 14. Lace Field W.R.- Tensile bond strength of G.I. cement J.P.D. 1985; 532; 194 15. Michael L. Myers Marginal leakage of temporary cementing agents. J.P.D.1983; 50;4;513 16. Phillips R.W.- ZnOE cements for permanent restoration.- J.P.D. 1968 ;19;2;144-50 17. Richter W.A.- Predictability of retentive values of dental cements. J.P.D. ; 1970 24 3-298

64

18. William W. Brackett Performance of G.I. luting cements over a period of 5 yrs. J.P.D. 1992; 6,7-1, 59-62 19. Wendi A Levine An evaluation of the thickness of resin luting agents. J.P.D. 1989 62-2; 175 20. Wu. . JC Optimal cement space for resin luting cements I.J.P. 1994 7(3) 209-15. 21. Zakia Fakiha Rapid mixing of zinc phosphate cement --J.P.D. 1992; 67-1, 52

65