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*Clinical Applications of GIC: (from slide 26):

After being introduced to its composition and properties now we will talk about its clinical application. in composite fillings we need to prepare the surface of enamel and dentine and make it rough same thing goes for GIC, we need to prepare the surface make it clean, increase it's suitability before GIC is placed on it so that it can chemically bound to enamel and dentine to a very high degree. So the tooth surface should be clean and dry but not over dry, a conditioner is placed on enamel and dentine and it's made of acrylic acid the same acid that is mixed with the powder when GIC is prepared, this acid is prepared in a bottle and provided to the dentist, after this conditioner is placed it should be washed after 3 seconds and then GIC is placed on top after that we need to protect the surface of GIC without being dried or contaminated with moisture so a layer should be placed on the top of GIC this layer is made out of varnish (basically made of resin and alcohol) ,when it's placed (as a liquid ) alcohol evaporates and an isolating layer will remain on the top. So this layer will help the GIC while it's still setting from moisture contamination, saliva, blood and from being over dried

Sometimes bonding agents can be applied on the top of GIC. Some people placed vaseline but it's not a good idea because it's easily washed away and it will not stay for a long period of time. GIC is also used as luting agent or cementing agent, when you have a crown or bridge and your want to place it on a tooth that has been prepared previously GIC is used because its highly flowable so the cementing agent will help the crown to attach to the prepared tooth.

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Advantages of these agents (cementing agent) are similar to the general advantages of GIC which are: -they can release fluoride -they aren't harmful to the pulp unless your preparation is closed to the pulp in this case you need to place a base or a liner to protect it. -it has a low thickness (the thickness of the GIC between the tooth structure and the crown isn't high because lower thickness will help to bond the two surfaces better) Imagine a layer of water in between two glass slides, they bond very well when the thickness is thin between these two slides but when it's thick they can easily separate. - They bond chemically to tooth structure (you don't have to prepare the tooth in a specific way). Other type of cement that have been used instead like hybrid cement and resin cement that are based on resin because they have low solubility unlike the GIC which have a high solubility which is one of its disadvantages. Another use of GIC is to use it as a restorative material (filling material) but in placement that aren't subjected to high stress because they are weak material like in class 3 cavity ,class 5 and sometimes in primary teeth and class 1 ( in any area that isn't subjected to high stress). It can also be used as liner and base under filling to isolate the pulp from outside like transformation of heat in amalgam fillings and from acid itching that are used with composite (usually these liners have a lower P:L ratio compared to a restorative material because the restorative material needs to be viscous enough so that it will be strong enough )

So cementing agents usually have a lower P: L ratio to be more flowable so that they can spread all over the surface. And the manufacturers control this viscosity by controlling this P: L ratio.
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So as we said previously when we prepare the cavity to receive the GIC filling you need to be conservative, no need for under-cuts because they are chemically bonded to tooth structure . and isolation is necessary either by cotton rolls or rubber dam just like composite, and then preparation of the dentine surface by cleaning it using a conditioner, sometimes if you aren't preparing a cavity for example if there's a fracture in the surface you just need to clean it by using a brush, water and a certain material which is called pumice so no need to place a conditioner because there is no debris of enamel and dentine. If you have a patient with a sensitive teeth or we have a deep cavity you might need to place another material under GIC to prevent any pain (because we said it's acidic it start with a very low PH ( 2-4 ) and it need 24 hours to rise it's PH and become neutral)

An example of a liner that is used in prepared cavity is calcium hydroxide to ensure a good bonding for enamel and dentine with GIC. And remember you should only cover the area where the pulp is, no need to cover the whole area so .that the GIC could bind to the tooth structure

GIC can be either: Powder and liquid that you need to mix them together following the manufacturer instructions regarding to the ratio .. gradually the powder is incorporated with the liquid and then you make the whole material together and we need to stick to the mixing time otherwise you're working time would be too short
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some GIC are encapsulated

*finishing and polishing:

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It should be delayed for 24 hours until we are sure that the material is fully set so you remove gross excess (major excess) while the material is still soft enough and if there are a small excess remaining we delayed it for 24 hours. Sometimes while the material is set we place cellulose strip on the surface of GIC to make it smooth and protect it from moisture contamination. We can use a diamond bur to finish the material they are slightly abrasive so that they can remove excess material and give you a nice shinny smooth surface because rough surface helps to retain plaque, debris and irritation to the mucosa and may cause caries again. GIC can be used in a combination with composite. if you have a deep cavity and it's difficult to isolate completely we can use GIC as a base (sub-gingivally under composite, because composite is more sensitive to moisture so if you're not sure that you have a complete isolate for the tooth GIC is better to use as a base in this case and even if there are minimum amount of moisture it's acceptable to place GIC and after that we start putting composite layer by layer. Composite can micromechanically bond to GIC not only to enamel and dentine because GIC make a rough surface when phosphoric acid is put on it. So there is no need to place anything between them. This technique is called (sandwich technique) or lamination technique you have the tooth structure at bottom then GIC and at the top of it we have composite and this technique is just with composite and has nothing to do with amalgam So sandwich technique is used to prepare a very deep cavities sub gingivally like calss 2 cavities.

-Modifications of conventional GIC:

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They modify the material to become more resistance to abrasion and become strong like adding: silver particles to approve its toughness contain titanium oxide which is a whiting agent that prevent them from being so dark
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The liquid is (the acrylic acid, the maleic, the tartaric acid) are similar in composition, the only different is that there are metal particles incorporated to make the material tougher and more abrasion resistant so .(they called them (cermets Cement or metal reinforce GIC this is one modification provided as capsule and they are also provided as powder and liquid , they are slightly grayish in color they are not white why? Because they contain metal particles. They can be used for very small occlusal cavity but again not recommended in permanent teeth, just . in primary teeth .. In permanent teeth they are still weak Some of them are available as core build material, if you dont have composite or if you cant place amalgam because you dont have enough tooth structure for mechanical retention, you can use the GIC because .they can bound but again they are not your first choice Amalgam is your first choice followed by composite followed by GIC as a core build up material, and later on of coarse .you place your crown

Some materials are available as pit and fissure sealants, some pit and fissure sealants are made of resin, these pit and fissure sealant are based of GIC, same material but no powder- liquid ratio so that they can flow into pits and fissures to fill them and protect them from pain As you see in the picture in slide 36 so it's a little representation of fissure you can see the black spots at the base of the fissure
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These are bacteria, food debris that were not cleaned by tooth brush so we need to seal these to prevent any packing of debris and caries in pits . and fissures

?when do we use sealants in general *

When we need to have deep pits and fissures, young children that are susceptible to caries especially there first molar (they are the first (permanent teeth to erupt along with the incisors They have pits and fissures they want to protect them because children cant practice good oral hygiene because they are too young they havent develop their manual skill properly so you want to protect the first molar with pit and fissure sealants so its always a good idea to .place it Now your first choice is the resin based sealants because they bound better or they are stronger but if you cant isolate the tooth from saliva you cant place resin sealant, your alternative is GIC sealant because they .are not as sensitive to moisture as resin sealants First choice for us when we put pit and fissure sealant is resin- based .sealants because its stronger than GIC But if we cant make isolation for the tooth because of the saliva in this situation the second choice is the GIC sealants, we can put it directly at the surface of the tooth, so GIC doesnt really need a specific preparation like a resin, they dont need 100% isolation like resin so they are another options if we cant place a resin sealant So if patients have high caries risk or poor oral hygiene again this It . is an indication to place pit and fissure sealants

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So they can be GIC based or resin based , which are similar to composite but they dont have as many fillers as regular composite materials, they can have an opaque color (white color ) or transparent color so you cant actually see them or they can be colored

?Which one is better? transparent or colored

colored of coarse , you want to know if it is still there or not because youneed to reexamine your patient or child every now and then , you want to make sure if the sealant is still covering pits and fissures , if its transparent you cant see it actually ,,, so a colored or an opaque sealant is a better choice so that when you review your patients you bring him back to your clinic to review the condition of the sealant you can see . it you can check if part of it is loss or not Again resin sealants can be light-cured or self- cured similar to the restorative material so they are not heavily filled because when you increase the filler you make it more viscous , we want it to be reflowable so if we want it to flow better the filler needs to be less so that it can .go inside the pit and fissure resin sealants are usually more flowable than GIC sealants and this is . another advantages of resin sealants over GIC .They have better flow, lower viscosity, so its easier for them to flow But there are advantages of GIC sealants again, fluoride release, adhesion to moist tooth structure , but they are do not always have the ability to fully penetrate , there are brittle and low-wear resistant , that's why resin . sealants are better So some researches say: even if clinically you cant see your GIC sealant because it was weak and lost but microscopically they will become (????) which will release fluoride and provide protection , other say no if you . lose it thats a bad thing you need to place resin sealants on top Clinical application: ( using varnish and acrylic acid conditioner same applications while using them to help in a better bound strength so they . are both same chemically
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The picture in slide 41 shows pits and fissures before placement and on the right this is the white material within pit and fissure so they are sealed protected from any accumulation of debris and colonization of bacteria

:(Hybrid (resin-modified GIC) final modification of GIC They are modified by adding a resin component and then photo initiator which make them light-cured so your working time is extended and your setting time is becoming shorter, its command set when you want to make it set you can subjected to light but you cant wait for a long period of time because in addition to be light cured, the setting reaction involves the acid-base reaction as well So even the material is left mixed without light-curing, it will start to set by the acid-base reaction.. Just like the conventional GIC and after a short time it will be hard . But there is a good thing about this material, you can make it set within 40 seconds just like composite so it will not be available to be contaminated for a long period of time (5 minutes) like a .chemical cured material So in light-cured material, you can start the setting by using light(major part of the cement is set by light which will protect it from any saliva contamination so we don't have to place a varnish on top ) after that it .will continue to set by acid-base reaction These materials (hybrid) have better ware resistance, less solubility ,can be polished easily, they have a better shape so they have a better properties than conventional GIC .they are also able to release fluoride An example of these material that we will use commonly in the clinic which is vetra bond liner so we can put it near the pulp because it's made out of GIC and it sets by light (within 40 seconds) so the acid will not .harm the pulp and it will not accumulate :The composition of Resin modified GIC

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Liquid component: contains poly acrylic acid but a resin is also added it's called HEMA (Hydroxy ethyl methacrylate), this component makes the .material stronger and has lower solubility In addition to these component it will have tartaric acid and a photo initiator which will make it sensitive to blue light (the resin component cause setting and then acid-base reaction will continue and end the setting .(of the material .Rapid set by light and slow set will continue with acid-base reaction So even if it's not exposed to light it will need a longer time to set but it (will set and take a longer time (20 minutes Again because it contains resin which can shrink, incremental placement .is necessary (just like composite) to minimize shrinkage

properties:

Long working time and short setting time Finishing and polishing can be done immediately, it's a hard material More resistance to acid attack and dehydration *Some of it are available as a restorative materials which are called ??? Usually used in primary teeth because of fluoride to protect the children teeth, other types as a liner or a base under composite and amalgam, it can be used as a luting agent. Q) do we have to check occlusion in pit and fissure sealants ? Yes, we need to check occlusion so that it will not interfere with occlusion of the upper and lower teeth .although pit and fissure sealants aren't that strong it's better to check the occlusion. Wish you all the beststudy well Please forgive me for any mistake Done by: Lamees Nimri Raya Hijazi: thank you my lovely twin for helping me in this script I really appreciate it ..God bless you

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