COMMENTARY C

A review of orthodontic cements and adhesives

Nels Ewoldsen, DDS, MSD,a and Richard S. Demke, DDSb
Lincoln, Neb, and Lockport, Ill

Dental cements and resins are used intraorally to secure fixed orthodontic devices. Although cements are still
used, the popularity of resin and resin-cement hybrid materials is increasing because of their improved
physical properties and low solubility in oral fluids. Some cements bond chemically to enamel, but bond
strengths are low because cements are brittle and fracture cohesively. Resin adhesives penetrate micropores
in etched enamel and mechanical retentions in orthodontic devices, resulting in higher bond strengths
because resins are more fracture resistant than cements. Resins, however, do not bond well in the presence
of moisture, and their attachment to surfaces is primarily mechanical. Hybridized materials combine the
advantages of cements and resins but also have certain disadvantages. Optimal material selection and
application require an understanding of the chemical differences and physical limitations of today’s orthodontic
cements, resins, and hybrid materials. (Am J Orthod Dentofacial Orthop 2001;120:45-8)

O
rthodontic devices should interfere minimally
with the patient’s comfort, appearance, oral
function, and hygiene. Although various dental
cements and resin adhesives are used to attach ortho-
dontic devices to teeth, the higher-strength dental
cements and improved resin adhesives permit the use
of smaller, more patient-friendly orthodontic devices.
New orthodontic cements, adhesive resins, and hybrid
cement-resin combinations offer improved physical
properties and clinical benefits, but there are clear dif-
ferences in the clinical indications and contraindica-
tions for each class of material. With an understanding
of the features, benefits, and limitations, the practi-
tioner can choose the material wisely to obtain optimal
results. This article highlights the physical and chemi-
cal characteristics of cements, resins, resin-modified
glass ionomers, and polyacid-modified composite
resins, with emphasis on their clinical features, han-
dling, and physical characteristics (Table I).
Cements
Dental cements consist of an acid component and an
alkaline component that, when combined, result in the
hardening or setting of the mixture. Cements set by a
neutralization reaction.1 Typically, the hardened cement’s
microstructure shows partially reacted glass particles
aAdjunct Associate Professor, University of Nebraska Medical Center, College
of Dentistry, Lincoln, Neb.
bDental industry consultant.
(alkaline) suspended in a salt matrix formed when the
acid component reacts with the alkaline glass. Cements
are brittle, with relatively high compressive strength, low
tensile strength, and relatively low fracture resistance.2
Zinc-phosphate cement is the reaction product of
zinc oxide and a phosphoric acid solution. When set,
zinc-phosphate cement is dimensionally stable with
relatively good physical properties, including low solu-
bility in oral fluids. The cement components must be
mixed properly to ensure that the acid-base reaction
can proceed optimally, resulting in good physical char-
acteristics and minimal effects on oral tissues. Mixing
powder/liquid cement products is technique sensitive.
Ideally, zinc-phosphate cement should be kept cool
during mixing. Further control of setting is accom-
plished by slow incremental incorporation of the alka-
line component during mixing. The greatest drawback
to zinc-phosphate cement is that it does not bond to
enamel and metals and therefore cannot be used to
attach brackets to teeth. Nevertheless, it has been used
as a dental cement for more than a century.3
Polycarboxylate cement is the reaction product of
zinc oxide and a polycarboxylic acid solution. The car-
boxyl groups spaced along the polycarboxylic acid
chain chelate to calcium in enamel and dentin, result-
ing in a chemical bond between the cement and the
tooth. The chelation of carboxyl groups to divalent and
trivalent cations results in a chemical bond to tooth sur-
faces and metal surface oxides. Polycarboxylate

Reprint requests to: Richard Demke, 13543 South Parker Rd, Lockport, IL cement was the first chemically adhesive dental
60441; e-mail, RSDDDS@aol.com. cement. As with zinc-phosphate cement, the mixing
Submitted and accepted, May 2001. technique takes time to master because incorporating
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/117207 zinc-oxide powder into the relatively viscous polycar-
doi:10.1067/mod.2001.117207 boxylic acid is difficult. The resulting neutralization
45
46 Ewoldsen and Demke
Table I. Tooth preparation and conditions for optimal bonding by each class of material with their principal benefits
Cements Adhesion
Zinc phosphate* None
Glass ionomer* Chemical
Resin-modified glass ionomer* Chemical/mechanical
Resins Mechanical
Polyacid-modified composite resins Mechanical
*Acid-base setting reaction contributes to physical properties.
reaction between zinc oxide and polycarboxylic acid
has little effect on oral tissues; thus, it is considered a
biocompatible cement. Despite polycarboxylate
cement’s chemical bonding to dental and orthodontic
substrates, its relatively high solubility and relatively
low fracture resistance limit its clinical use.2
Glass ionomer cements (GICs) capitalize on car-
boxyl chelation to enamel, dentin, and most metals by
employing various mixtures of carboxyl-containing
acids (polyalkenoic acids) reacted with aluminosilicate
glass. Aluminosilicate glass fused in the presence of
fluoride fluxes results in an alkaline composition that
releases fluoride ions when reacted with acids. Fluo-
ride release has been measured during the GIC setting
reaction and after setting. Additional fluoride is
released when GICs are exposed to acids. Caries inhi-
bition has been associated with a sustained low-level
fluoride release from GICs. Furthermore, GICs contain
hydrogel phases, supporting the movement of calcium,
strontium, and other ions associated with the reminer-
alization of enamel and dentin. GIC hydrogel phases
are thought to be responsible for the uptake and re-
release of added environmental fluoride from topical
gels, rinses, and dentifrices. Compared with polycar-
boxylate cements, GICs show higher bond strengths to
enamel, dentin, and metals.4,5
Mixing GICs, however, is technique sensitive, and
the hydrogels desiccate and crack in dry environments.
Low fracture resistance limits their orthodontic use pri-
marily to band cementation; however, clinical use of
GICs for bracket bonding has been reported.6,7 The
development of capsulated GICs eliminated most mix-
ing variables. GIC’s inhibition of demineralization in
adjacent enamel and its improved band retention are
the chief reasons that it remains useful to orthodontists
for cementing bands in caries-prone patients.8-11 GICs
have been used for orthodontic bracket bonding, but
bracket retention was poor compared with resin con-
trols. There is agreement among orthodontists that con-
ventional GICs lack the physical properties necessary
to retain brackets throughout treatment.12 Despite the
low bracket-retention rates of GICs, their chemical
American Journal of Orthodontics and Dentofacial Orthopedics
July 2001
Tooth
Acid etching required surface moisture conditions Fluoride release/recharge
No Dry No
No Moist Yes
No Moist Yes
Yes Dry No
Yes Dry Yes, but low
adhesion and moisture tolerance eliminate the need for
acid etching and drying.
Resin-modified cements
The orthodontic use of GICs increased dramatically
with the development of resin-modified GICs (RMGIC).
The addition of 10% to 20% resin monomers to the
GICs resulted in a cement that is initially hardened with
the use of either light or chemical activators to polymer-
ize the monomers. RMGICs are adhesive cements with
improved physical properties and more stable hydrogels
compared with GICs. Capsulation of RMGIC powder
and liquid components simplified mixing procedures
with a triturator. Although a limited amount of resin
monomer can be added to the polyalkenoic acid solu-
tion, polymerization of the resin monomers hastens the
initial hardening of RMGICs without interfering signif-
icantly with the acid-base setting reaction, the fluoride
release, or the chelation of carboxyl groups to metal and
tooth surfaces.5,13 In addition to the chemical bonding of
RMGICs, resin monomers penetrate surface irregulari-
ties to produce a micromechanical interlock (bond) after
polymerization. In addition to the advantage of operator-
controlled setting, light-activated polymerization pro-
ceeds significantly faster than acid-base (cement form-
ing) reactions, resulting in improved early physical
properties, especially fracture resistance. Maturation
hardening, sustained fluoride release/recharge, and
caries inhibition are similar compared with conventional
GICs and RMGICs. Also similar are the abilities of both
GICs and RMGICs to chemically bond in the presence
of moisture.14,15
Resins
Resin adhesives consist of resin monomers and
inert fillers.16 As with RMGICs, polymerization can be
either light activated, chemically activated, or dual
cured with both light and chemical activation.17 Light-
activated resin adhesives are always single-component
materials stored in opaque packages. Single-component
resins are convenient because no mixing is required,
thus eliminating technique variables. However, be-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 120, Number 1
cause resins harden solely through a polymerization
reaction, they neither contain nor form hydrogels, and
water is not a significant component. Although some
resin adhesives release fluoride, the amount is quite
low and most likely has no effect on caries. Certainly,
without an acid-base reaction, the release of remineral-
ization ions other than fluoride is unlikely unless the
resin contains a soluble glass filler. Soluble fillers are
subject to dissolution and ion release. However, with-
out hydrogel formation, there is little fluoride recharge
and movement of remineralization ions.
Resin adhesives attach to dry, etched enamel by the
same mechanical bonding mechanism as do RMGICs.
Because resin monomers contain few, if any, carboxyl
groups, chelation to enamel, dentin, and metal surfaces
does not occur.14 Optimal adhesion with resins requires
acid etching or other surface treatments and a dry oper-
ating field.17,18 Resin polymerization with light activa-
tion is operator controlled, and resin adhesives acquire
their optimal physical properties quickly. Generally,
resins are less brittle and more fracture-resistant than
cements.
Polyacid-modified composite resins
Polyacid-modified composite resins, also known as
compomers, were developed to bring the features of
caries inhibition and carboxyl chelation to resins. Com-
pomers are single-component systems consisting of
aluminosilicate glass in the presence of carboxyl-
modified resin monomers and light-activated conven-
tional resin monomers. Although the alkaline glass and
acidic carboxyl components are packaged in the same
container, allegedly no acid-base setting reaction
occurs because water is absent from the composition.
However, after light-activation of the compomer, it is
postulated that water sorbs into the compomer, allow-
ing a delayed acid-base reaction that may release fluo-
ride and other remineralizing ions from the aluminosil-
icate glass.19 The relatively weak acid-base reaction
does not result in increased physical properties of the
compomer. The absence of hydrogels restricts ion
uptake and release, although fluoride recharging of
compomers has been reported and can be explained by
water sorption and diffusion dynamics.20-25 Com-
pomers have been linked to caries inhibition in vitro
because of fluoride release from the aluminosilicate
glass filler at low pH.
Acid etching or other surface treatment is required
before compomer orthodontic adhesives are used, and
bonding surfaces must be dry.21 Carboxyl chelation
with cations on enamel, dentin, and metallic surfaces
has not been shown to occur with compomer adhesives.
Physical properties are acquired quickly as compomers
Ewoldsen and Demke 47
polymerize, and their early setting strengths are supe-
rior to those of the RMGICs but inferior to those of the
resin adhesives.22,26
Summary
Cements differ from resins in that cements are 2-
component systems that harden because of acid-base
reactions between components. Cements contain water
and, in the case of carboxyl-containing cements, will
bond to moist surfaces. The water in hardened dental
cements in the form of hydrogels supports ion move-
ment within the cement and ion exchange between the
cement and its environment. Ionically active cements
are associated with caries inhibition, remineralization,
and chemical bonding to enamel, dentin, and many
metals.
Orthodontic resin adhesives do not inherently con-
tain water and therefore bond best to acid-etched or
roughened, dry surfaces through mechanical retention
rather than chemical bonding. Light-activated resin
adhesives are single-component materials, are easier to
manipulate than cements, and have better physical
properties. Resins harden through a polymerization
reaction and have limited ionic activity. Water-soluble
elements added to resins will diffuse into the environ-
ment, but their effect on caries inhibition and reminer-
alization appears to be insignificant.
Compomers behave much like resin adhesives; they
bond primarily through physical interaction with dry
surfaces. Although compomers contain carboxyl-
modified resin monomers, they are packaged as single-
component materials, suggesting limited reactivity
between alkaline glass and acidic monomers. Studies
characterizing the setting reaction of compomers con-
firm that little setting occurs after light activation,
despite the acid-base reaction. Compomer bonding
studies have failed to confirm the chelation of carboxyl
groups to enamel or dentin. The fluoride release from
compomers is lower than that from GICs but higher
than that from resins. Fluoride recharging and caries
inhibition of compomers have been reported.
This information is intended to clarify the chemical
and physical distinctions among various orthodontic
bonding materials. Clinicians need to be knowledge-
able about the various cements and orthodontic bond-
ing adhesives so that they may select and use these
materials appropriately.
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