414528 gc get connected equia e v11 ja30 03 17 by GC Europe

2017

EQUIA & EQUIA FORTE Special edition

10 YEARS

GC EQUIA Forte

New restorative system with glass hybrid technology GC takes yet another step into the future of modern restorative therapy by presenting GC EQUIA Forte, an innovative restorative system based on a new glass hybrid technology. Representing the next step in the evolution of the proven EQUIA concept, EQUIA Forte combines a filling component with a protective composite coating while additionally benefiting from a newly introduced hybrid filler technology. The resulting restorative offers further improved performance in tooth-coloured posterior restorations for patients of all generations. The Glass hybrid technology makes use of the advantages of combined different size filler technologies – in a way similar to hybrid composites. The more voluminous glass fillers of EQUIA Forte Fil were supplemented by smaller, highly reactive fillers that strengthen the restoration. Its impressive performance parameters can be documented not only descriptively but also quantitatively: The filling component EQUIA Forte Fil by itself achieves 10% more flexural strength than the standard combo of EQUIA Fil plus EQUIA Coat. In combination with the EQUIA Forte Coat composite coating, the flexural strength increases by 17% and flexural energy by almost 30%, compared to standard EQUIA. Adding a multifunctional monomer to EQUIA Forte Coat increases surface hardness by almost 35% and wear resistance by more than 40% compared to EQUIA Coat. But these naked figures are not an end in themselves. They indicate that handling has been optimised – a significant benefit for the dental practice. With EQUIA Forte, GC has added another powerful restorative material to the dentist’s armamentarium, with further improved performance while retaining the characteristic virtues of the EQUIA concept. Practitioners enjoy its simple and fast application, while patients receive a biocompatible tooth-coloured posterior restoration – minimally invasive treatment has become available to all age groups.

Contents

The new EQUIA Forte extends in comparison to the current EQUIA the recommendation of use in class II cavities (if the cusps are not affected). It is another innovative filling concept that, with its impressive performance parameters, is part of GC’s roadmap to the future of dentistry in general and restorative dentistry in particular. EQUIA Forte represents many decades of successful research and development by GC, a company that constantly strives to improve its products. The further improved properties of EQUIA Forte meet the needs of patients between 7 and 77 years – and beyond.

Scientific Sheet-Clinical Studies

10 years of GC EQUIA: Experts take stock: Significant progress in GI Technology

Professor Dr. Sevil Gurgan, Professor Elmar Reich, PD Dr. Falk Schwendicke and Professor Hervé Tassery

Micro-laminated GIC restorations: new perspective for geriatric patients

Assistant Professor Anja Baraba & Professor Ivana Miletić

Clinical evaluations confirm longevity of glass ionomer cements EQUIA by GC excels in long term studies as permanent posterior restorative

Professor L. Sebnem Turkun

Modern Solutions for Direct Posterior Restorations Professor Ivana Miletic

EQUIA Special

Scientific Sheet – Clinical Studies EQUIA® Title

Clinical performance of a new glass-ionomer based restoration system: A retrospective cohort study

Reference

K. FRIEDL, K.A. HILLER & K.H. FRIEDL Dent Mater (2011) 27(10):1031-7

Design

Retrospective cohort study with 151 restorations

What is being tested?

The suitability of a glass-ionomer system (EQUIA) as a permanent restoration material in posterior cavities.

After 2 years and about 150 restorations were evaluated, it was concluded that EQUIA may be used as a permanent restoration material for any size of Class I and in smaller Class II cavities. Title

7 Years, Multi-centre, Clinical Evaluation on 154 Permanent Restorations Made With a Glass ionomer-based Restorative System

Reference

M. BASSO, J. GONE BENITES, A. IONESCU, C. TASSERA IADR- APR abstract 0446, Seoul 2016

Design

154 restorations were performed in 124 patients. 149 restorations evaluated at 7 years (42 Class I, 70 Class II, 37 Class V; 9 incisors, 11 canines, 50 premolars and 79 molars)

What is being tested?

To evaluate the clinical performance of a restorative system based on a highviscosity, coated glass-ionomer cement (i.c. EQUIA) for Class I, II and V permanent dental restorations.

After 7 years, highest number of failures were reported in class II (21) in respect to Class I (no failures) and Class V (12). In molars, incidence of lost restorations seems to be influenced by numbers of walls involved by cavity preparation. Optimal performances for Class I (no failures over 42 restorations) suggest that EQUIA is a reliable choice for permanent dental restorations, even in load bearing tooth surfaces of molars and premolars. Title

Clinical performance during 48 months of two current glass ionomer restorative systems with coatings: a randomized clinical trial in the field.

Reference

T. KLINKE, A. DABOUL, A. TUREK, R. FRANKENBERGER, R. HICKEL AND R. BIFFAR. TRIALS (2016) 17(1):239

Design

Prospective, double blinded randomized control clinical trial

What is being tested?

The clinical performance of a GIC material (Fuji IX GP Fast, GC) versus a coated GIC system (EQUIA, GC).

After 4 years, 782 fillings in 510 patients were evaluated. EQUIA and Fuji IX GP fast were used to restore permanent teeth, Class I, Class II mo/od and Class II mod. Both systems performed similarly after 48 months in Class I cavities. For Class II mo/od fillings, EQUIA showed a better overal performance with fewer failures in the follow-up. This suggests that EQUIA is a worthy alternative for an aesthetic and economical long-term filling.

GC Fuji IX GP Fast, EQUIA, Gradia, G-Bond, Solare & G-Coat Plus are trademarks of GC. Riva is not a trademark of GC. GC Europe is not affiliated with any of the universities referenced and none of the trademarks of the universities are trademarks of GC.

EQUIA Special

EQUIA®

Scientific Sheet – Clinical Studies EQUIA® Title

Clinical performance of a glass ionomer restorative system: a 6-year evaluation

Reference

S. GURGAN, ZB. KUTUK, E. ERGIN, SS. OZTAS & FY. CAKIR Clin Oral Investig. 2016 Dec 20. doi: 10.1007/s00784-016-2028-4. [Epub ahead of print]

Design

Clinical trial with 140 (80 Cl1 and 60 Cl2) fillings in 59 patients

What is being tested?

The clinical performance of a glass-ionomer restorative system (EQUIA, GC), compared with a microhybrid composite resin (Gradia Direct Posterior, GC).

After 6 years 115 fillings (70CL I and 45 CL II) in 47patients were evaluated, both EQUIA and Gradia Direct Posterior showed significant differences regarding marginal adaptation and marginal discoloration (p<0.05). The study showed that there was a significant decrease in color match in EQUIA restorations (p=0.01). Only one Class 2 EQUIA restoration was missing at 3 years and one at 4, while there were no failures at 5- and 6-year controls.

Conclusion: both restorative materials exhibited a similar and clinically successful performance after 6 years. Title

The effect of a nano-filled resin coating on the 3-year clinical performance of a conventional high-viscosity glass-ionomer cement

Reference

V.T.K. DIEM, M.J. TYAS, H.C. NGO, L.H. PHUONG & N.D. KHANH Clin Oral Investig. 2014 18(3):753-9

Design

Clinical trial with 198 evaluated restorations

What is being tested?

The respective clinical performances of a conventional GIC (GC Fuji IX GP Extra, GC), a resin-coated GIC (GC Fuji IX GP Extra + G-Coat Plus, GC) and a resin composite (Solare, GC) as a comparison material.

This study shows that although both GC Fuji IX GP Extra and GC Fuji IX GP Extra with G-Coat Plus (EQUIA restorative system) showed acceptable clinical performance in occlusal cavities in children, the application of G-Coat Plus gave some protection against wear. Clinical Relevance: The application of G-Coat Plus to GC Fuji IX GP Extra glass-ionomer cement may be beneficial in reducing wear in occlusal cavities. Title A Prospective Six-Year Clinical Study Evaluating Reinforced Glass Ionomer Cements with Resin Coating on Posterior Teeth: Quo Vadis? Reference

L.S. TURKUN & O. KANIK Oper Dent. 2016;41(6):587-598

Design

Clinical trial with 256 restorations in 54 patients

What is being tested?

The clinical performance of two reinforced glass ionomer cements (EQUIA, GC and Riva SC, SDI) and two surface coating material (G-Coat Plus, and Varnish, GC) combinations after 6 years.

After a 6-year clinical evaluation period, the EQUIA Fil system was more successful than Riva SC regarding color match, marginal adaptation, anatomic form, and retention rate. Note: EQUIA Restorative Concept was launched in March 2007 bearing the components Fuji IX GP EXTRA + G-Coat PLUS. Since March 2011, it has been rebranded as a New Restorative System bearing the components EQUIA® Fil and EQUIA® Coat. All the products Fuji IX GP EXTRA, G-Coat PLUS and the EQUIA Restorative System co-exist in the market; These clinical papers are a selection of the available evidence on EQUIA. More supporting studies are available and can be delivered upon request. GC Fuji IX GP Fast, EQUIA, Gradia, G-Bond, Solare & G-Coat Plus are trademarks of GC. Riva is not a trademark of GC. GC Europe is not affiliated with any of the universities referenced and none of the trademarks of the universities are trademarks of GC.

EQUIA Special

Testimonials Coming from a country where composites are considered as the first choice, with EQUIA I found an easier, quicker and more reliable restorative alternative! Eight years’ results from Prof. Basso’s clinical trial evaluating EQUIA’s clinical performance show... The survival rate of Class I and Class II restorations is comparable to other long-term restorative materials. However, the number of remaining walls in Class II cavities seems to be crucial for the survival rate of EQUIA restorations. The technique of application of EQUIA, being quick and easy to learn, is reliable even in less expert hands. The stability of colour of EQUIA restorations is completely satisfactory for patients at every follow-up visit.

Prof. Matteo Basso, Milan University, Italy

My experience with EQUIA surprised me by the fact that the coat transforms the material of the underlying GI into a more definite restorative solution (as per the IFU). Four years’ results from Prof. Biffar’s 6

EQUIA Special

multi-centre clinical trial in Germany show... Quick and easy application in a clinical trial in the field. No statistical difference between the two evaluated materials could be found. Follow the manufacturer´s recommendations regarding cavity geometry.

Dr. Reiner Biffar, Greifswald University, Germany Since I started using EQUIA (10 years ago), my concern about marginal breakdown in Class II cavities does not exist. Moreover, it offers an ideal alternative to amalgams in our public dental healthcare system. Seven years’ results from Prof. Gurgan’s clinical trial comparing EQUIA against micro-filled composite show… The EQUIA restorative system and micro-hybrid resin composite exhibited similar and clinically successful performance after seven years. The EQUIA system in either Class I or Class II cavities exhibited a significantly good outcome over the seven years. Both restoratives evaluated in this long-term evaluation showed good longevity.

Prof. Sevil Gurgan, Hacettepe University, Turkey

I have found EQUIA Forte Fil and Coat to be invaluable asset in the minimally invasive management of root caries in the ageing patient. The combination of adhesion, root surface protection and durability make it an ideal restorative material for these patients.

Dr. Ian Meyers, private practitioner, Australia For more than 20 years the Fuji GICs have been part of my daily practice. Year after year, the products improved their performance, as we improved our experience in indications and settings. In our particular practice (high caries-risk patients, or noninvasive periodontal treatment) GIs have become THE solution. I am sure that using EQUIA or EQUIA Forte in daily dental practice is a clever alternative restorative solution as soon as the patient is caries-active, if the indications of the manufacturer are respected.

Dr. Michel Blique, Nancy University, France

10 years of GC EQUIA: Experts take stock

Significant progress in

GI Technology

Professor Dr. Sevil Gurgan (Turkey), Professor Elmar Reich (Germany), PD Dr. Falk Schwendicke (Germany) and Professor HervĂŠ Tassery (France) At the beginning of 2017, the question of the future of dental amalgam still remains the focus of widespread public attention: the EU Parliament, Commission and Member States had just reached a compromise on the continued use of the controversial material, which is likely to include, among other things, ceasing to use it on children under the age of 15 and on pregnant and breastfeeding women from July 2018. In this discussion leading dental experts outline how they see the future of amalgam and the role that modern glass ionomer-based filling solutions like EQUIA and EQUIA Forte (both GC) play in the search for alternative materials. The 10th anniversary of the EQUIA concept in 2017 offered an occasion for the discussion.

EQUIA Special

10 years of GC EQUIA: Experts take stock Significant progress in GIC

1. Where do you see the future trends in dentistry? Dr Falk Schwendicke: We can expect many trends: for one thing, digital procedures will play a greater role, not just with regard to CAD/CAM processes, but also in imaging, treatment supervision or in the form of apps for patient communication and health management. E-health is getting more and more important and patients welcome this development too, because for them, digital processes offer a great motivation to think about health issues on an ongoing basis at home. Furthermore, I can see a trend towards to even more prevention. Health management is very important here, too. These trends mainly become relevant in the context of epidemiology: more and more older people are keeping their natural teeth for longer. We need ideas in this area!

Professor Hervé Tassery: Actually, it’s mainly in the area of CAD/CAM processes that we can expect to see interesting developments. With regard to patients, too, social aspects will become increasingly significant. I would also expect, therefore, that going forward, health policy around dentistry will be increasingly focused on prevention. Professor Dr Elmar Reich: I think that tailored dentistry based on diagnoses of cariological and parodontological risk factors will become more important. I am also, like my colleagues, anticipating major developments in digitalisation. Digital dentistry brings challenges, but also a lot of opportunities for practitioners. In this area, I’m finding it particularly exciting to see how developments in the field of digital intraoral impression-taking will progress. A whole new topic is the fact that society’s ageing, and therefore patients are too. In this area, dentistry has an

obligation to offer treatment concepts for the increasing number of older patients - whether it’s in the practice, at home or in care facilities. Professor Sevil Gurgan: We’re already witnessing enormous changes and the 21st century will go even further than the recent past in producing developments of note for human existence. The decades ahead of us promise a multitude of scientific and technological discoveries and economic, social and political changes on a scale as yet unseen in the history of humanity. The biological and digital revolutions are converging more quickly in clinical dentistry than, for example, in general medicine and pharmacy. Fundamental improvements in health research, risk assessment and disease prevention, as well as in diagnosis, therapy, biomaterials and successful treatments in the healthcare sector will change healthcare worldwide. If you look back, you can clearly see

Case 1 1

Figure 1: Patient with high caries risk

Figure 2: Use of GC Tri-plaque ID gel for patient education and removal of soft carious lesion using MI approach

Figure 3: High fluoride releasing and moisture tolerant EQUIA Forte offers an ideal solution for such cases

Prof. Hervé Tassery, France

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10 years of GC EQUIA: Experts take stock Significant progress in GIC

from the progress in dentistry and in society that the dental profession has experienced impressive technological growth. The following is a list of areas in which digital dentistry has already arrived: CAD/CAM and intraoral imaging (both laboratory and practice-controlled), caries diagnosis, computer-assisted implantology including designing and manufacturing surgical guides, digital intra- and extraoral radiography including dental volume imaging, electronic and surgical hand-pieces, lasers, occlusion and jaw joint analyses and diagnostics, intra- and extraoral photography, practice and patient data management including digital patient communication and colour identification.

2. Where could the developments in restorative dentistry lead? Schwendicke: Prevention will play an even greater role in the care of elderly patients, especially those with a need for long-term care. A new mix of individual and group prophylactic approaches could appear. Traditional restorations work only in a limited way in such patients and precisely for the treatment of root caries; also here we will need alternative concepts. I also think that the number of sealants will increase, as will the use of bioactive materials. There will be a greater focus on biocompatibility and general health matters, too. Aesthetic aspects will remain extremely important here. Tassery: Today people are already trying to keep their teeth for longer. I don’t think we’ve reached the end of that process. Efforts to get patients actively involved in the treatment

process will also continue to increase. Reich: A major topic is actually the longevity of restorations: patients request these and modern materials in this area already perform very well. However, there is sure to be further progress. The number of preventative sealants will also increase. Chairside treatments are a major trend across the board, of course, as well as “green” dentistry. If you look at the risk of developing allergies, glass ionomer cements beat composites. That’s why I think that GICs will become even more significant. Gurgan: This brings to mind a few exciting questions: Will your dentist be able to “grow” you a real tooth one day, to replace one that you’ve lost? Will a medicine be tailored not just to your illness, but to your genetic code as well? And will you be able to protect babies against tooth decay before they even have teeth? This may not be as far off as we might think. The dental profession is entering a phase of astonishing new discoveries. If the right technologies are available, there will also be the challenge of getting people from all walks of life to profit from this extraordinary thrust of knowledge.

3. What restorative options does modern dentistry have to offer? Schwendicke: Holistic approaches offer new opportunities: Biologicallycontrolled cavity management will also impact on restorative dentistry. There will be a focus on materials which are biomimetic, remineralising, antibacterial or which affect biofilms. In addition, materials which allow a sealant procedure without grinding

the natural tooth will increase in importance, as well as materials which fits into modified restoration substrates: In the past, all carious dentin has traditionally been removed from a cavity. Modern excavation concepts for deep caries doesn’t foreseen that anymore. According to this, new materials will also have an improved adhesion to and bioactivity with remaining carious dentin. With that in mind we will probably see more materials which connect with the tooth, like glass ionomer cements (GICs) and composites, but which can also do even more. Especially, for the mechanical characteristic GIC’s still have more potential for development in this area. Tassery: The thinking in dentistry has really changed - with regard to treatment concepts, too: among other things, with the minimal invasion approach, we now have improved opportunities to provide adequate treatment while still preserving the substance of the tooth. Gurgan: A new type of dentistry has emerged - a new “restorative approach” called Modern Restorative Dentistry (MRD). MRD follows a minimal-invasion approach but, strictly speaking, has maximum coverage. The approach describes the concept that all healthy tooth structures are preserved during the procedure and that form and function are restored using modern adhesive materials. Reich: I also think that the direction of travel is towards tooth-preserving procedures and the corresponding restoration materials. Patients also want these materials to look as much like real teeth as possible. On the practitioner side I see a trend, in cases

EQUIA Special

10 years of GC EQUIA: Experts take stock Significant progress in GIC

where there’s any doubt, towards removing less caries in order to protect the pulp.

4. In your opinion, what effect will the Minamata Convention have on the use of amalgam in dentistry? Schwendicke: Whether it’s in the short or long term Amalgam will disappear and become unimportant. With regard to alternatives, there are currently two options: Composites, possibly bulk-fill materials, can be used, as can cementtype fillings like GICs, for example. Because politics has had a strong impact on this development, it’s difficult to predict the result. Nonetheless, GICs offer a good approach here, although, as already mentioned, the mechanical features still need improvement in comparison to amalgam. Tassery: I am also working on the assumption that we need to think more about restorative alternatives. I think, therefore, that it’s high time we made more effort to develop high-viscosity GICs. Gurgan: As we know, the Minamata Convention aimed to minimise the use of amalgam and to promote the use of cost-effective, clinically effective quicksilver-free alternatives for restorations. With regard to the environment, it’s desirable from a dental perspective that the use of dental amalgam is reduced. This can be achieved effectively by increasing cavity prevention and by promoting the use of high-quality alternatives to dental amalgam. The use of amalgam is prohibited in many countries. Glass ionomers and composites can be used as alternatives - however, the 10

EQUIA Special

choice of material ultimately depends on the tooth, its position and the size of the cavities. The type of healthcare, patients’ wishes, technological and financial aspects and environmental factors should also be considered. It is also important to ensure the “longevity” of the restoration and to preserve it and the natural structure of the tooth as well as possible. Our healthcare institutions must concentrate more on disease prevention and minimise potential interventions. Cost aspects should also not be underestimated, because cost effectiveness in countries with high incomes and with a low instance of dental diseases is not representative and cannot be extended to all countries worldwide. The challenges facing countries with medium and low incomes are considerable. Unfortunately the populations of many countries still have high demand for restorative procedures to treat cavities. In this regard, glass ionomers and composites have great potential for use as alternatives to dental amalgam. Reich: In many developing countries, amalgam is still a proven and reliable material for fillings. As an alternative, development aid is currently only providing GICs used in ART technology.

5. What alternatives are there to amalgam? Reich: Self-hardening adhesive restoration materials can offer an alternative. Schwendicke: As we’ve mentioned, GICs offer a good foundation. Their aesthetics and application are already convincing; the mechanical characteristics just need some

improvement. If we can achieve that, GICs could well become the new amalgam. Tassery: One important approach is certainly in prevention. In this area we still need a better understanding of how biofilm can be controlled and managed so that no cavities occur in the first place. Gurgan: In the past, glass ionomers looked like a relevant alternative in children’s dental care only. However, thanks to the continued developments they can now be used on adults in general and on older patients. The longevity and failure rate of restorations are important factors. Our clinical studies showed that restorations in small Class II cavities and in occlusal surfaces now have high longevity rates. That’s why it’s important to keep studying the long-term use of these materials in the permanent posterior region.

6. You have already discussed the progressive evolution in GICs. Could you elaborate? Schwendicke: EQUIA and EQUIA Forte represent significant progress in GICs. However, until now the indications were still limited. GICs are well-suited to restorations on occlusal cavities, but for larger occluso-proximal cavities I’m still not quite convinced. Restrictions in cavity size - key word: bucco-oral distance - are unfavourable in everyday dentistry: Here once again, we can see the need to develop the mechanical characteristics. Other than that, however, GICs work well in all areas - they are relatively aesthetically pleasing, easy to handle and bioactive. Reich: For me, GICs are an extremely

10 years of GC EQUIA: Experts take stock Significant progress in GIC

important material which still have interesting potential for development. Gurgan: Since the introduction of GICs, these materials have undergone many modifications over the years. Their physical characteristics - especially resistance to wear, reduced sensitivity with early water absorption, so that restorations could be positioned and polished in the same visit, and their translucency - were improved by increasing the viscosity and reducing the amount of filling material to achieve a certain texture. To improve the mechanical characteristics of GICs and enable their clinical use in the posterior region, studies have been carried out to strengthen their matrix by adding different types of filling material. A further development in strengthening GICs is the use of a surface protector. The “coating” should offer protection in the early setting phase and close any surface tears and porosity, which increases the GIC filling’s resistance to wear and fracture toughness.

7. What news is there on the performance of glass ionomer materials in in-vitro studies? Gurgan: There are a few in-vitro studies demonstrating the progress in glass ionomer technology. However, laboratory studies don’t always reflect the behaviour of materials in clinical practice due to the differences between laboratory and practice conditions. On the other hand, controlled clinical studies can provide the ultimate proof of clinical effectiveness. Reich: Clinical studies are an important way to ensure the effectiveness and safety of a material, although the test

conditions in in-vitro studies rarely correspond to the real-life clinical situation. Tassery: In reality we need lots of studies to be able to confirm the clinical effectiveness of a material. However, by their nature these take a long time and, to obtain meaningful results, need a lot of funding.

8. Could you speak in more detail on the long-term clinical results of the glass ionomerbased restoration system EQUIA (GC)? Schwendicke: As we mentioned, EQUIA offers excellent results on smaller, mainly occlusal, cavities. This actually applies to GICs in general. Clinical studies also show an improvement and acceptable longevity on limited extended occluso-proximal cavities. However, dentists would like to be able to use GICs for any indication, e.g. on larger MOD cavities in molars as well. We still need better results in this area. Reich: A study by a research group at Greifswald University, headed by Professor Dr Reiner Biffar1 and a research done Prof. Dr. Gurgan2 showed that EQUIA performs so well clinically that the material could be used to place posterior fillings that would last for several years. Gurgan: In the context of our study2 a total of 140 posterior lesions (80 Class I and 60 Class II cavities) were restored in 59 patients, according to the manufacturer’s instructions, using EQUIA (EQUIA Fil and EQUIA Coat, GC) or a posterior composite (Gradia Direct Posterior in combination with G-Bond, both GC). The restorations were qualitatively assessed according

to the modified USPHS (US Public Health Service) criteria under the scanning electron microscope (REM) at the beginning of the study and then annually over a period of six years. After six years, a total of 115 restorations (70 Class I and 45 Class II cavities) had been evaluated in 47 patients, equal to a recall rate of 79.6%. Only two Class II fillings using EQUIA had to be changed after three and four years respectively due to a marginal fracture, while after five and six years there were no further problems with the fillings. After six years, both materials still showed similar and mainly clinically successful performance levels, while the REM evaluations matched the clinical findings. This shows that the glass ionomer-based EQUIA system performs to the same standard as a composite after a period of six years.

9. What notable developments are there in glass ionomer technology? Reich: There are certainly a lot of developments in glass ionomer technology at present. The EQUIA concept is already performing well and, depending on the indications, is a good option for posterior treatments. However, naturally I hope that the further potential for optimisation will be thoroughly exploited. Tassery: Compared to the older products, current GICs have become far more aesthetically pleasing. However, in larger cavities they reach their limits. Here, onlays are generally the better option. With regard to speed of setting and flexural strength, light-curing GICs are also an interesting development.

EQUIA Special

10 years of GC EQUIA: Experts take stock Significant progress in GIC

Gurgan: In March 2015, EQUIA Forte was launched, containing a new generation of glass fillers - called glass hybrids. In this system, the glass filler matrix combines fluor-alumino-silicates (FAS) of different sizes. Smaller, highly reactive fillers (ca. 4 μm) were added to the larger glass fillers from EQUIA Forte Fil (ca. 25 μm), strengthening the matrix. A highly molecular polyacrylic acid was added to EQUIA Forte Fil, making the cement matrix stronger and more stable. In addition to the physical characteristics, handling was optimised to make the material less sticky and more packable. In contrast, the coating is based on the same technology as EQUIA Coat, equipped with evenly distributed nanofillers and a new, multi-functional monomer which increases the coating’s surface hardness and resistance to wear. The new EQUIA Forte is, according to the use instructions and in comparison to EQUIA, recommended for expanded use in Class II cavities, so long as the cupids are not affected, and also for restorations in Class I, unloaded Class II restorations, interdental restorations, core build-ups, Class V restorations and root caries treatments. Studies are currently underway on the use of EQUIA Forte on larger Class II cavities and to restore non-carious, cervical lesions in bruxism patients - also in comparison here to a composite. We

will report on the results of the use of EQUIA Forte in larger Class II cavities at the 6-month point at the IADR 2017 in San Francisco.

10. In your opinion, what are the main reasons why materials like EQUIA and EQUIA Forte make ideal alternatives (to amalgam) for restorations? Schwendicke: GICs are impressively easy to work with. With their selfadhesive qualities, they are quick and uncomplicated to use in day-to-day clinical life. In my opinion we shouldn’t overstate the fluoride release and remineralising qualities, but with GICs patients benefit from an attractive aesthetic and the fact that hyper sensitivity only occur extremely rarely. Reich: The physical values, such as the thermal expansion and the modulus of elasticity of GIC-based materials, make them appear better than those of composites. If the strength and setting on the tooth can be optimised further - e.g. by continuing to develop the materials and improve clinical techniques - I foresee excellent prospects for GICs. Tassery: Depending on the indications, EQUIA and EQUIA Forte are promising options for the posterior region. Benefits include their “tooth-like” qualities and their good edge sealing.

Using GICs also means there is barely any post-operative sensitivity. Additional benefits are their remineralising qualities and, above all, the opportunity to offer GICs in the context of a minimally-invasive approach. Gurgan: Amalgam has been used for decades and is viewed by many as the best restoration material for the posterior area. However, in response to UNEP’s (United Nations Environmental Programme) Minamata Convention, many countries have now banned amalgam and both the World Dental Association (FDI) and the World Health Organisation (WHO) are promoting alternatives to amalgam. In comparison to other permanent filling materials, like composites for example, GICs have many benefits - such as their ability to adhere to wet enamel and dentin and their anti-cariogenic qualities, thanks to long-term fluoride release. Additional clinical benefits like biocompatible features and a low thermal expansion coefficient reinforce their great significance in everyday practice. The glass ionomer-based EQUIA system has excellent biocompatibility and it is further distinguished by its bulk fill technology, the lack of any need for etching and bonding procedures, easy handling and quick setting.

Literature 1. Biffar R, Klinke T, Daboul A, Frankenberger R, Hickel R (2015): 48 months clinical performance of two current glass-ionomer systems in a field study. Abstract Nr. 0039, ConsEuro 2015 2. Gurgan S (2015): 6 year clinical success of GI restorative comparing with composite resin in posterior teeth. J Dent Res 2015;94(Spec Iss B):[Abstract # 0220; CED-IADR; p 100]

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10 years of GC EQUIA: Experts take stock Significant progress in GIC

Prof. Dr. Sevil Gürgan (Turkey) graduated from the Hacettepe University School of Dentistry, Ankara, Turkey and got her PhD degree at the Department of Restorative Dentistry of the same school. She became Associate Professor in 1988 and Professor in 1995. She had been as a visiting Professor at the New York University School of Dentistry in New York in 1995 and at the Tufts University School of Dentistry in Boston in 2005. She is an active member of International Association for Dental Research, past board Member of International Association for Dental Research Continental European Division (2009-2012), board member of the European Academy of Operative Dentistry, and the World Federation for Laser Dentistry. She acted as the vice President of Hacettepe University between 2008-2012 and was head of the Department of Restorative Dentistry of the Dental Faculty between 2005-2011. Currently she is professor at the same department. She has published several articles on dental materials and dental bleaching and has been giving lectures and courses at national and international congresses and meetings for more than 20 years. Professor Elmar Reich (Germany) graduated from the University of Tübingen/Germany in 1979. Graduate program at the University of Ann Arbor/ Michigan 1980/81 in Restorative Dentistry and Periodontology. 1994-2000: Chairman of the Department for Periodontology and Conservative Dentistry at the University of Saarland, Homburg, GermanyFDI: Chairman of the FDI Science Commission (1997 – 2003).1997-2000: Head of the WHO-Centre for Standardisation in Dentistry, University of Saarland.October 2000-December 2003: Head of New Technologies, business unit of KaVo Co. Since January 2004 Pr. Reich is working in a private dental practice in Biberach/Germany and is professor at the Department of Conservative Dentistry and Periodontology, University of Cologne.Since 2008: member of FDI Education Committee 2010-2013: Chairman of FDI Education Committee

PD Dr. Falk Schwendicke (Germany) 2016 Deputy head of department 2015 Editorial Board, Journal of Dental Research 2013 Associate Professor for Caries Research and Preventive Dentistry, Department of Operative and Preventive Dentistry, Charité – Universitätsmedizin Berlin, Germany 2012-2013 Assistant Professor, Clinic for Conservative Dentistry and Periodontology, Christian-Albrechts-Universität Kiel, Germany 2009-2012 Associate Dentist, Banbury, Oxfordshire, United Kingdom 2009 Dental licence, German Dental Licence Board, Berlin, Germany 2009 Doctorate thesis, Institute for Biochemistry, Charité – Universitätsmedizin Berlin, Germany: “Peptidic Inhibitors of a filarial chitinase – exploration and characterisation” (magna cum laude) 2008 Dental exam, Charité – Universitätsmedizin Berlin (grade: excellent -1.0) Professor Hervé Tassery (France) team leader of LBN Laboratory Montpellier universitySpecialist in Preventive and minimally invasive dentistry Professor in conservative dentistry and endodontics at University of MarseilleLecturer and author on preventive dentistry and Minimum Intervention

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Testimonials I am truly impressed with the material after nine years of experience in my clinical practice. The material is strong, reliable and patients find the procedure quick and easy. I am using it besides composites for Class I, some Class II and many Class V cavities with good clinical success. But even today in Germany there is a lot of amalgam used, and I believe that EQUIA or EQUIA Forte can offer a good alternative restorative solution in the indications as recommended by the manufacturer.

Prof. Dr. Elmar Reich, private practitioner, Germany In my country, amalgam is still very much used. With EQUIA Fil I finally found a good long-term alternative even in moderate sized two-surface restorations. Six years’ results from Prof. Türkün’s clinical trial comparing EQUIA Fil with Riva SC show... Excellent long-term colour match with EQUIA Fil. Significantly better marginal adaptation and anatomic form even in large two-surface restorations with EQUIA Fil. 14

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More partial or total loss with Riva SC while even large EQUIA Fil cases could be refurbished or repaired.

Prof. L. Sebnem Türkün, Ege University, Turkey EQUIA allows me to place restorations that chemically fuse to teeth, with a simple two-step technique (prepare and condition), bulk filling my preparations and creating margins that resist future decay. With the complimentary EQUIA Forte and EQUIA Forte Coat in unit dosing, the system is close to perfection. I don’t understand how anyone can practice without it, and I can’t imagine a more versatile material.”

Dr. Brian B. Nový, DDS President, DentaQuest Oral Health Center, Director of Practice Improvement, USA EQUIA Forte is a remarkable, innovative biomimetic restorative material and a great advancement on its predecessor, Fuji IX Extra. Having grown up with the Fuji family for the past 18 years, it is my key material for cores, dentine substitute and as a final restoration

for many posterior cavity configurations. It is easy to handle, use, adapt and sculpt, making placement faster with great results. Its high strength, coupled with its ability to chemically bond to tooth structures, gives me the confidence and predictability in providing successful direct restorations.

Dr. Akit Patel, private practitioner, UK The microlaminated EQUIA Restorative System was developed with the idea to create options for economical yet durable fillings and as an alternative for amalgam. It was received with great interest and acceptance amongst the dental profession throughout the world. Furthermore, we can say that there is scientific evidence presented at International conferences and published in the International Journals showing that EQUIA can be used as long-term restorative alternative for the posterior region when it is used according manufacturer instructions. The development of this material opens the option to the dentist to save time and cost for the patients.

Mr. Henri Lenn, Executive Vice President, GC International AG

Microlaminated GIC restorations new perspective for geriatric patients Assistant Professor Anja Baraba, Professor Ivana MiletiÄ&#x2021; Department of Endodontics and Restorative Dentistry, School of Dental Medicine University of Zagreb, Croatia Due to increased life expectancy, there is an explosion of the aging population nowadays. Over the years, teeth are exposed to both physiological wear and tear and various pathological conditions which are even more pronounced at an older ager. Old age is usually associated with certain risk factors regarding the health of dentition, both general and those related to oral cavity. General risk factors include various medical problems like medications and psychological problems. Interestingly, more than 50% of patients over 60 are taking

medications because they are medically compromised (Nadig et al. 2011). Medications may result in different side effects, especially medications such as anti-depressants, anti-hypertensive and anti-cholinergic which often lead to salivary hypofunction and dry mouth. Furthermore, many elderly patients may suffer from depression due to loneliness or feeling of neglect, which might lead to lack of motivation to maintain good oral hygiene and seek regular dental care. Risk factors related to oral cavity include gingival recession, previous restorations, fixed bridges or

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Micro-laminated GIC restorations: new perspective for geriatric patients

removable partial dentures. Gingival recession leads to food impaction and plaque accumulation on the rough surface of tooth cement. Additional problem is the fact that the root caries lesion may progress twice as fast as than the one in enamel (Featherstone, 1994). Present restorations with non adequate margins may lead to occurrence of secondary caries while any prosthodontics appliances can act as retention sites for food and plaque. Due to all aforementioned risk factors and high incidence of caries lesions, especially root caries lesions, (Sumney et al. 1973; Katz et al. 1982), elderly patients are high risk patients and restorative care should be based on bioactive materials with remineralising potential, like glass-ionomer cements (GIC). GIC are biocompatible and adhesive materials, first developed in 1971

(Wilson & Kent, 1971). Chemical adhesion of GIC to hard dental tissues is strong and it is achieved through an ionenriched layer firmly attached to the tooth (Mount 1991, Wilson et al. 1983). Another advantage of GIC is the ability to release fluoride ions, which allows remineralization and provides antimicrobial effect. These materials are also moisture tolerant, offering low solubility and good translucency (Billington et al. 2006). In order to improve qualities and avoid certain disadvantages of traditional GIC, different modifications of these materials were released on the market. One of these modifications were micro-laminated GIC which combined GIC and protective composite based coat. These were the first GIC materials recommended for permanent aesthetic restorations in posterior region. First micro-laminated GIC was

EQUIA restorative system introduced in 2007 in Europe. Different studies have confirmed the longevity of this material for restorations in the posterior region with clinical success even after six years (Gurgan et al. 2015; Friedl et al. 2012; Klinke et al.; Diem et al. 2014; Basso et al. 2014; Turkun & Karik 2015). Recently a new generation of glass ionomers has been introduced by GC, EQUIA Forte restorative system which combines the use of EQUIA Forte Fil with EQUIA Forte Coat. This new material is based on glass-hybrid technology, combining different sizes of glass particles and has even better physico-mechanical properties in comparison to EQUIA Fil. These improvements of GIC, offer new possibilities for aesthetic, functional and bioactive restorations, especially for high risk patients.

Ivana MiletiÄ&#x2021;, DMD, PhD was born in 1971. in Zagreb. She graduated at the School of Dental Medicine, University of Zagreb in 1995. Since then, she has been working at the Department of Endodontics and Restorative Dentistry in the University of Zagreb, where she gradually became full Professor (in 2008) and actively participates in teaching in clinic, pre-clinic and continuous education. She is also head of postgraduate and PhD courses. She got her master degree in 1998, PhD in 2000; and passed the specialist exam in endodontics and restorative dentistry in 2004. She is an author and co-author of four course books and more many scientific, review, educative and specialized articles in extenso which are also cited in many international journals and course books. She is particularly specialised in the field of Endodontics, where she actively worked on various scientific projects from 1996 till today. She has been participating on many national and international congresses, and has held many lectures. She is an active member of Croatian Chamber of Dental Medicine, Croatian Endodontic Society, Croatian Medical Association, European Endodontic Society, ORCA and IADR. She is the president of the Croatian Society for Minimum Intervention Dentistry. Anja Baraba is assistant professor at the Department of Endodontics and Restorative Dentistry at the University of Zagreb in Croatia. She graduated from the School of Dental Medicine, University of Zagreb, was a student assistant at the Department of Histology and Embriology and received Dean Awards as well as two national scholarships. She has worked as a young researcher and a senior assistant at the Department of Endodontics and Restorative Dentistry since 2007. She obtained her PhD degree in 2011 and became assistant professor in 2014. She completed her specialty training in endodontology and restorative dentistry in 2013. She has published scientific and other articles in journals indexed in Current Contents and other journals. She is a member of Croatian Chamber of Dental Medicine, Croatian Endodontic Society, Croatian Medical Association, European Endodontic Society and IADR. She is the secretary of the Croatian Society for Minimum Intervention Dentistry.

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Micro-laminated GIC restorations: new perspective for geriatric patients

Case report Male patient, aged 60, came to the dental office because of sensitivity to cold stimuli and while brushing of cervical areas of anterior and premolar teeth in his lower jaw. After clinical examination, caries lesions were diagnosed on exposed roots of anterior teeth and premolar teeth in the lower jaw (figure 1). In the first visit, after application of local anesthesia, caries lesions were removed using round steel burs on the teeth on the right side. After conditioning the cavities with Dentin conditioner (GC, Tokyo, Japan) for 20 seconds, EQUIA Forte (GC, Tokyo, Japan) material (shade A3) was placed. After finishing the restoration, EQUIA Forte Coat (GC, Tokyo, Japan) was applied on the surface and light-cured for 20 seconds with a D-Light DUO LED curing device. The same procedure was carried out in the second visit for the teeth on the left side. Figure 2 shows the

appearance of the restorations in the second visit while figure 3 shows the final appearance of the GIC restorations after six months.

Figure 2 Appearance of the EQUIA Forte restorations

Figure 3 Appearance of the EQUIA Forte restorations after six months

References Nadig RR, Usha G, Kumar V, Rao R, Bugalla A. Geriatric restorative care- the need, the demand and the challenges. J Conserv Dent 2011;14:208-14. Featherstone. Fluoride, remineralization and root caries. Am J Dent. 1994;7:271–4. Sumney DL, Jordan HV, Englander HR. The prevalence of root surface caries in selected population. J Periodontol 1973;44:500–8. Katz RV, Hazen SP, Chitton NW, Mumma RD. Prevalence and intraoral distribution of root caries in adult populations. Caries Res 1982;16:265–71. Wilson AD, Kent BE. The glass-ionomer

Figure 1 Caries lesions on exposed roots of anterior teeth and premolar teeth in the lower jaw

cement. A new translucent cement for dentistry. J App Chem Biotech 1971;21:313. Wilson AD, Prosser HJ, Powis DM. Mechanism of adhesion of polyelec- trolyte cements to hydroxyapatite. J Dent Res 1983;62:590-2. Mount G. Making the most of glass ionomer cements. Dent Update 1991;18:276-9. Billington RW, Williams JA, Pearson GJ. Ion processes in glass ionomer cements. J Dent 2006;34:544–55. Gurgan S et.al, Six-year randomized clinical trial to evaluate the clinical performance of a glass ionomer restorative system. CED-IADR, Antalya abstract 2015. Friedl K, Hiller KA, Friedl KH. Clinical performance of a new glass ionomer-based restoration system. Dent Mater 2012:27:1031-7.

Klinke TU, Daboul AA, Biffar RH. Randomized clinical trial in the field: longevity after 48 months. Klinke et. al, P39 abstract Conseuro, London. Diem VTK, Tyas MJ, Hien CN, Phuong LH, Khanh ND. The effect of a nano-filled coating on the 3-year clinical performance of a conventional high-viscosity glass ionomer cement. Clin Oral Investig 2014;18:753-9. Basso M, Ionescu A, Gone Benites M. 48-month, multicenter, clinical evaluation on 304 glass ionomer permanent restorations. Abstract 192686, IADR-PER, Dubrovnik 2014. Turkun LS, Kanik O. Clinical evaluation of reinforced glass ionomer systems after 6 years. CED IADR, Antalya Turkey, 2015 (Abstr).

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Clinical evaluations confirm

longevity of glass ionomer cements EQUIA by GC excels in long term studies as permanent posterior restorative L. Sebnem Turkun Professor Sebnem Turkun graduated from Ege University School of Dentistry in 1991. In 1998 she obtained her PhD degree in Restorative Dentistry, became an Associate Professor in 2004 and a Professor in 2009. She is currently working in Ege University School of Dentistry in the Department of Restorative Dentistry as a full time Professor and head of the Restorative Dentistry Department. Her principal areas of interest are adhesive dentistry, aesthetic restorative materials and their clinical performance, antibacterial restorative materials, glass ionomer restoratives and minimal invasive dentistry. She has published many international and national papers in her fields of interest, participates as keynote speaker in many international and national congresses and presents numerous workshops and hands-on courses. She is a member of the IADR, EDAD, Turkish Restorative Dentistry Association, MI European Board and serves on the European Federation of Conservative Dentistry (EFCD) executive committee. Since 2007, she is the translating editor of the journal Quintessence Turkey and the board member of many international and national dental journals.

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By Professor L. Sebnem Turkun, Ege University School of Dentistry, Turkey For more than three decades, thousands of clinical studies have been conducted comparing the clinical performance of aesthetic resin based materials. Thanks to these, we now know that if done properly, resin composites perform as well as amalgam restorations in the timeframe of 8 to 10 years. However, with some high caries risk patients, it is literally a crime to place posterior resin restorations before stabilizing the oral environment. What is needed in cases like these is a high wear resistant, long-lasting and fluoride releasing dental material for posterior restorations.

Clinical evaluations confirm longevity of glass ionomer cements

A few years ago, when GC launched its new reinforced glass ionomer material, EQUIA, we wanted to test its long-term clinical performance in comparison to another reinforced and encapsulated glass ionomer, Riva (SDI, Australia). We believed that comparing two materials in the same group would expedite our ultimate goal of successfully using minimum intervention materials in posterior restorations. So in 2008 we decided to conduct a PhD thesis comparing the clinical performance and some mechanical properties of the two encapsulated and reinforced glass ionomer cements.

Important outcomes The study revealed that the EQUIA Fil system was more successful than Riva when it came to colormatch and retention rate after a 6-year clinical period. Despite minor reparable defects, the overall clinical performance of EQUIA Fil was excellent, even in large posterior two-surfaces restorations after a period of 6 years. As we know very well, conventional glass ionomer cements have a chalky appearance, wear quickly and are easily fractured from the marginal ridges in multi-surface restorations. With the improvement in glass ionomer technology, reinforced and encapsulated glass ionomers were launched in the market, eliminating the problem of wear. However, aesthetics and fracture resistance remained a great problem which limited the clinical indications

of the glass ionomer cement restorations. At that time, EQUIA was developed by GC in combination with a light curing resin coating placed over the restoration immediately after setting. This unique coating protects the glass ionomer material from wear until it fully matures and gives it a shiny, aesthetic look. The most important concern then was its clinical longevity, especially in moderate to large two-surface restorations. So the most important outcome of this long-term clinical study is that we could destroy the myth that glass ionomer cements wear quickly and therefore were only suitable as provisional posterior restorative materials.

6 years

The overall clinical performance of EQUIA Fil was excellent even in large posterior two-surfaces restorations after a period of 6 years.

The impact on day-to-day dentistry The long-term clinical findings of our study in combination with many others already published, proved that glass ionomer cements are not provisional restorative materials but a bona fide permanent material of choice even in large proximal restorations. These restorations are placed very quickly in bulk and without the need for adhesive systems. When the patient is at high caries risk or isolation of the cavity poses a problem, now the material of choice is a reliable reinforced glass ionomer with resin coating. In Turkey, the government covers most of the basic dental treatments in dental hospitals or university clinics for insured employees. We have a large amount of patients attending our clinics every day for

many reasons, but mostly for caries and periodontal problems. For the past two years, national social security has not reimbursed hospitals for glass ionomer restorations because it considers them to be provisional restorations instead of permanent. However, these patients are in need of a fluoride-releasing restorative material to stabilize their oral environment. For that purpose and for convincing the Ministry of Health that this material is now a proven permanent restorative material, we needed evidence based research and long-term clinical trials. With the published data that are now available in the literature, I think that we will be successful very soon.

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Clinical evaluations confirm longevity of glass ionomer cements

6 years

The EQUIA Fil system Nowadays, most of the reinforced and encapsulated glass ionomer materials can be used for a minimum of two years without any problems in posterior teeth with small to moderate cavities.1 However, if color match is a concern for the patient, or if we need a more resistant permanent material for medium to large cavities and if we are looking for a long-term restoration, a more sophisticated brand like EQUIA Fil with a resin coating should be used.2 The EQUIA Fil system is different to other reinforced and encapsulated glass ionomer materials on the market

6 years

due to its reliable color matching properties and easy handling. The other materials, including Riva, have a chalky appearance, similar to conventional powder liquid glass ionomer cements after placement. EQUIA Fil matures under the resin coating and develops a very hard and resistant consistency as time passes. This fracture resistance is crucial as

the material needs to function in the mouth for a long period of time. Even in larger two-sided restorations, its longevity is better than other glass ionomers and similar to resin composites, as proved in a 4-year clinical study published by my colleagues from Hacettepe University/Turkey [include reference]. 3

Further research

6 years

A new version of EQUIA Fil has been launched earlier this year, EQUIA Forte, with further improved color matching and resistance. We are excited to be taking part in a multi-center long-term clinical study alongside universities in Croatia, Italy and Bulgaria to test the clinical efficacy of this material.

References 1. Clinical Evaluation Of New Encapsulated Glass Ionomers And Surface Coating Combinations For 24-Months. Ozgur KANIK, L. Sebnem TURKUN 2. Clinical Evaluation Of Reinforced Glass Ionomer Systems After 6 Years LS TURKUN and O KANIK, 1Ege University School of Dentistry, Izmir, Turkey; 2 Kocatepe University School of Dentistry, Afyon, Turkey, CED-IADR 2015 Antalya. 3. Gurgan S, Kutuk ZB, Ergin E, Oztas SS, Cakir FY. Four-year randomized clinical trial to evaluate the clinical performance of a glass ionomer restorative system. Oper Dent. 2015 Mar-Apr;40(2):134-43.

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Modern Solutions for Direct Posterior Restorations Ivana MiletiÄ&#x2021;, DMD, PhD was born in 1971. in Zagreb. She graduated at the School of Dental Medicine, University of Zagreb in 1995. Since then, she has been working at the Department of Endodontics and Restorative Dentistry in the University of Zagreb, where she gradually became full Professor (in 2008) and actively participates in teaching in clinic, pre-clinic and continuous education. She is also head of postgraduate and PhD courses. She got her master degree in 1998, PhD in 2000; and passed the specialist exam in endodontics and restorative dentistry in 2004. She is an author and co-author of four course books and more many scientific, review, educative and specialized articles in extenso which are also cited in many international journals and course books. She is particularly specialised in the field of Endodontics, where she actively worked on various scientific projects from 1996 till today. She has been participating on many national and international congresses, and has held many lectures. She is an active member of Croatian Chamber of Dental Medicine, Croatian Endodontic Society, Croatian Medical Association, European Endodontic Society, ORCA and IADR. She is the president of the Croatian Society for Minimum Intervention Dentistry.

Professor Ivana Miletic, Department of Endodontics and Restorative Dentistry, School of Dental Medicine, University of Zagreb, Croatia In order to restore effectively lost tooth structure, the chosen restorative material should demonstrate properties similar to natural tooth together with good adhesion, low polymerization shrinkage, high load bearing capacity and anticariogenic effect. The choice of a material also has to be adapted to the clinical situation, taking into account the patientâ&#x20AC;&#x2122;s age, caries risk and aesthetic requirements, the possibility to isolate the tooth, the functional demands placed on restorations(1) and some economic considerations. The most popular posterior restorative materials are resin-based composite, which are a combination of an organic part (matrix), an inorganic part (fillers) and coupling agents. Since their introduction on the market in the beginning of the 1960â&#x20AC;&#x2122;s, lots of attempts have been made to improve their composition in order to overcome two key shortcomings: lack of mechanical strength and high

polymerisation shrinkage(2). Improvements in composite materials have been especially focused on reinforcing the inorganic part, which is responsible for physical and mechanical properties like hardness, flexural strength, modulus of elasticity, coefficient of thermal expansion and wear resistance. The filler size in composite materials is directly connected to the mechanical

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Modern Solutions for Direct Posterior Restorations

properties of the material. Nanofilled composites are developed to offer materials that are more easily polished and have greater wear resistance(3). This high wear resistance will be particularly important in the posterior region. When using nano-sized inorganic particles, the percentage of fillers in the material is increased, particles are uniformly dispersed in the organic matrix and the space between the particles is reduced, which reinforces and protects the organic matrix(4,5,6). These nano fillers can be used in conventional composite materials, but also in flowable The most popular posterior restorative materials are resin-based composite, which are a combination of an organic part (matrix), an inorganic part (fillers) and coupling agents. Since their introduction on the market in the beginning of the 1960’s, lots of attempts have been made to improve their composition in order to overcome two key shortcomings: lack of

Fig. 1 Old amalgam restoration

mechanical strength and high polymerisation shrinkage(2). Improvements in composite materials have been especially focused on reinforcing the inorganic part, which is responsible for physical and mechanical properties like hardness, flexural strength, modulus of elasticity, coefficient of thermal expansion and wear resistance. The filler size in composite materials is directly connected to the mechanical properties of the material. Nanofilled composites are developed to offer materials that are more easily polished and have greater wear resistance(3). This high wear resistance will be particularly important in the posterior region. When using nano-sized inorganic particles, the percentage of fillers in the material is increased, particles are uniformly dispersed in the organic matrix and the space between the particles is reduced, which reinforces and protects the organic matrix(4,5,6). These nano fillers can be used in

conventional composite materials, but also in flowable composites. Conventional composites based on this technology can be categorized according to nanomer or nanocluster filler particles(7). Nanomers are isolated discrete particles, with dimensions ranging from 5 to 100 nm, while the size of nanocluster filler particles may significantly exceed 100 nm(8). Nanohybrid composites contain finely ground glass fillers and nanofillers in a prepolymerized filler form(9). An example of nanohybrid composite material is G-ænial (GC, Tokyo, Japan) which consists of 400 nm strontium glass, 100 nm lanthanoid fluoride and 16 nm silica in prepolymerized forms. This composite is available in Anterior and Posterior versions. The variation of particle sizes and interfaces within the G-ænial material enables the reflection of light on the restoration in a similar way as within the tooth structure. For this reason, a very nice aesthetic result can be achieved even when using

Fig. 2 Cavity after removal of amalgam filling and secondary caries Fig. 3 Dentin adhesive Fig. 4 Application of adhesive Fig. 5 Flowable composite Fig. 6 Restoration with G-ænial (shade A1)

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Modern Solutions for Direct Posterior Restorations

Fig. 7 and 8 Restoration with G-ĂŚnial Universal Flo

Fig. 9 and 10 Restoration with G-ĂŚnial Universal Flo

Fig. 11 and 12 Removal of old filling and application of EQUIA Forte Fil Fig. 13 Coating of the surface with EQUIA Forte Coat Fig. 14 Light polymerization for 20 sec. Fig. 15 Final restoration with EQUIA Forte

EQUIA Forte is especially useful when complete dry field cannot be achieved. Fig. 16 and 17 Replacement of old amalgam filling with EQUIA Forte system

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Modern Solutions for Direct Posterior Restorations

only one color of this material (Fig. 1-6). The advantages of flowable composite materials are their good adaptation and adherence to the cavity margins and the fact that they are more elastic when compared to conventional composite resin materials, thereby capable of buffering some of the stress applied onto the restoration. The main disadvantages of flowable composite are generally considered to be their lower physical and mechanical properties. Bayn et al.(10) emphasized that flowable composites from the first generation, due to the lower inorganic part in their composition, exhibit a higher polymerization shrinkage in comparison to conventional composite materials. Recently, a new composite material (G-ænial Universal Flo, GC, Tokyo, Japan) was introduced, featuring improved physical, mechanical and optical properties. The inorganic part of the material is based on strontium glass particles with a size of 200 nm, which are the smallest particles

that have been added to a flowable composite material. The adhesion between the inorganic and organic parts is improved as well as its elasticity, saturation of colour and futhermore, the material features excellent wear resistance and polishability and is offered in a broad spectrum of shades. Thanks to these improvements, this material can be used for posterior restorations of occlusal and approximal cavities using a standard procedure (Fig. 7, 8). According to the manufacturer, G-ænial Universal Flo is a thixotropic material which stays in place after application, unlike other flowable composites. This characteristic is especially desirable when restoring cervical parts of teeth (Fig. 9, 10). In light of Minimum Intervention concepts for restoring teeth, a new promising material for posterior restorations is a micro laminated GIC with adhesive and bioactive properties, enabling hard dental tissue preservation

and remineralisation. This new material has shown long-term clinical success, which is supported by scientific data(11, 12). The main disadvantage of glass-ionomers has been until recently their low mechanical strength, which made them unsuitable for use in high stress areas, such as occlusal and approximal areas. The new EQUIA Forte system consists of EQUIA Forte Fil and EQUIA Forte Coat. According to the manufacturer, its physical properties are superior to the existing EQUIA restorative system introduced in 2007. The highly reactive small glass particles added to the new material contribute to improving its flexural strength, by releasing metal ions which support the crosslinking of polyacrylic acid. Additionally, EQUIA Forte Fil adopted high-molecular-weight polyacrylic acid, which makes the cement matrix stronger and chemically more stable. EQUIA Forte Fil is placed easily in “bulk” directly in a cavity (Fig. 11, 12). After the hardening of the

Fig. 18 Application of everX Posterior Fig. 19 Adaptation of material with instrument to the cavity walls and cavity bottom and undercuts Fig. 20 everX Posterior in the cavity Fig. 21 Final layer of light-cured restorative composite G-ænial

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Modern Solutions for Direct Posterior Restorations

material and the finishing procedure, a thin layer of EQUIA Forte Coat is applied (Fig. 13) and polymerized for 20 sec. (Fig. 14 & 15). EQUIA Forte Coat is based on the same technology as EQUIA Coat, featuring nanofillers uniformly dispersed in the coating liquid, together with the addition of a new multifunctional monomer with efficient reactivity. This monomer makes the coating layer harder and smoother. Thanks to its moisture tolerance, EQUIA Forte is especially useful when complete dry field cannot be achieved (Fig. 16, 17). A major concern is still how to restore endodontically treated teeth. Endodontic treatment is usually performed on teeth with severe loss of tooth substance. Previous carious lesions, pre-existing restorations and access cavities are factors responsible for reducing the amount of healthy dentin and thus increasing the probability of fracture under functional forces. Panitivisai and Messer(13) showed that cuspal deflection increased while adding more extensions to the cavity preparations. When an access cavity was incorporated into a preparation, cuspal deflection was the greatest. Therefore, it is essential to develop new materials helping to prevent the fracture of endodontically treated teeth. Recently, a fibre-reinforced composite has been introduced as a new material for dentin replacement, with a composition incorporating glass fibres into the organic matrix of the composite. By combining fibres and composite materials, it is possible to overcome some of the limitations of conventional composites such as high polymerization shrinkage, brittleness

and low fracture toughness(14). Garoushi et al.(15) concluded that by adding continuous bidirectional or short random fibre-reinforced composite substructures under the particulate filler composite resin, the load-bearing capacity and compressive fatigue limit of restorations could be increased. everX Posterior (GC, Tokyo, Japan) is a material based on this fibre-reinforcement technology. It is based on the combination of an organic resin matrix (bis-GMA, TEGDMA and PMMA) forming an Interpenetrating Polymer Network (IPN) and randomly orientated E-glass fibres and inorganic filler particles. IPN means that the material consists of two independent polymer networks (linear and crosslinked), which are not connected by chemical bond. Another advantage of fibre-reinforced composites is that the polymerization shrinkage is controlled by the direction and orientation of fibres(17, 18). everX Posterior has anisotropic properties because fibres are mainly oriented randomly (Fig. 16). However when placing the material in a cavity using instruments, fibres are mainly oriented in the horizontal plan (Fig. 17, 18). As a result, shrinkage has different values in the horizontal direction, causing less stress on cavity walls.

from its properties, as fibres have the ability to slow down, arrest or redirect crack propagation, thus reducing the risk of catastrophic failures. New developments in dental materials continue to offer innovative modern solutions to all clinical situations and enable to challenge the usual treatment approaches by providing alternative materials or methods which bring novel benefits. Continuous learning about these new materialsâ&#x20AC;&#x2122; properties and indications is crucial for practitioners to be able to offer tailor-made solutions to patients, which match their requirements and give the best possible prognosis of success.

everX Posterior should always be covered with a layer of one to two millimeters of particulate composite resin (Fig. 19). According to the manufacturer, everX Posterior is indicated as a reinforcing base material for direct composite restorations especially in deep, large posterior cavities. Endodontically treated teeth can also strongly benefit

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Modern Solutions for Direct Posterior Restorations

References 1. Burgess JO & Cakir D. Material selection for direct posterior restoratives. www. ineedce.com. 2. Garoushi S, Vallittu PK, Watts DC, Lassila LV. Effect of nanofiller fractions and temperature on polymerization shrinkage on glass fiber reinforced filling material. Dent Mater. 2008; 24:606-10. 3. Ferracane JL.  Resin composite—State of the art. Dent Mater. 2011; 27:29-38. 4. Bayne SC, Taylor DF, Heymann HO. Protection hypothesis for composite wear. Dent Mater 1992;8:305-9. 5. Turssi CP, Ferracane JL, Vogel K. Filler features and their effects on wear and degree of conversion of particulate dental resin composites. Biomaterials. 2005;26:4932-7. 6. Lim BS, Ferracane JL, Condon JR, Adey JD. Effect of filler fraction and filler surface treatment on wear of microfilled composites. Dent Mater. 2002;18:1-11. 7. Endo T, Finger WJ, Kanehira M, Utterodt A, Komatsu M. Surface texture and roughness

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of polished nanofill and nanohybrid resin composites. Dent Mat J. 2010; 29:213-23. 8. Cramer NB, Stansbury JW, Bowman CN. Recent advances and developments in composite dental restorative Materials. J Dent Res. 2011; 90:402-16. 9. Senawongse P, Pongprueksa P. Surface roughness of nanofill and nanohybrid resin composite after polishing and brushing. J Esthet Restor Dent. 2007; 19:265-75. 10. Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilkerson M. A characterization of first-generation of flowable composites. J Am Dent Assoc. 1998;129:567-77. 11. Gurgan S, Kutuk Z, Ergin E, Cakir F. Four-year randomized clinical trial to evaluate the clinical performance of a glass ionomer restorative system. Oper Dent. 2015; 12. Diem VT, Tyas MJ, Ngo HC, Phuong LH, Khanh ND. The effect of a nano-filled resin coating on the 3-year clinical performance of a conventional high-viscosity glassionomer cement. Clin Oral Invest 2014; 18:753-9.

13. Panitvisai P, Messer HH. Cuspal deflection in molars in relation to endodontic and restorative procedures. J Endod. 1995; 21:57-61. 14. Wolff D, Geiger S, Ding P, Staehle HJ, Frese C. Analysis of the interdiffusion of resin monomers into pre-polymerized fiber-reinforced composites. Dent Mater. 2012; 28:541-7. 15. Garoushi S, Vallittu PK, Lassila LV. Short glass fiber reinforced restorative composite resin with semi-inter penetrating polymer network matrix. Dent Mater. 2007; 23:1356-62. 16. Vallittu PK. Interpenetrating polymer networks (IPNs) in dental polymers and composites. J Adhes Sci Technol. 2009; 23:961-72. 17. El-Mowafy O. Polymerization shrinkage of restorative composite resins. Pract Proced Aesthet Dent. 2004;16:452-3. 18. Tezvergil A, Lassila LV, Vallittu PK. The effect of fiber orientation on the polymerization shrinkage strain of fiber-reinforced composites. Dent Mater. 2006; 22:610-6.

Taking glass ionomer to

glass hybrid: the next restorative innovation

EQUIA - clinical step-by-step

Chairtime comparison: EQUIA Forte vs. composite

Setting reaction of Glass ionomers and EQUIA

EQUIA Forte Resistance to fracture on compression

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