Clinical assessment of some physical and mechanical properties of different

restorative materials in primary molars

Farghlyi, El Bayoumy YSii,Barakat IBiii

Abstract
Purpose the present study will be directed to clinically assessment of bulk Fill composite,
multicolored compomer and bioactive restorative Materia in primary molars. Methods: The study
sample was divided equally into three groups group I comprises 20 primary molars received
multicolored compomer, group II comprises 20 primary molars received bulk fill composite ,group
III comprises 20 primary molars received bioactive materials . The clinical evaluation of all
restorations was carried out at baseline before preparation and directly after restoration, after 3 and
6 months . Results: comparing three groups there were About surface glass, Surface &Marginal
Staining and Anatomic form there were significance difference between groups at 6
mons.(P<0.05). Also, about Color match stability & translucency there were highly significance
difference between groups (P<0.000). As regard there were non-significance difference between
different groups at periods (P>0.05) in previous item of aesthetic properties. There was moderate
significance difference in Marginal adaptation & Proximal contact point & food impaction
between groups (P<0.001) at baseline. In proximal contact point food impaction there were
significance difference between different groups at 6mns. (P<0.05) . As regard about radiographic
examination there were significance difference in different periods. As regard there were non-
significance difference between different groups at periods (P>0.05) in previous item of functional
properties. There was significance difference between groups in Postoperative sensitivity & tooth
vitality, Tooth cracks &fractures (P<0.05) at baseline. As regard there were significance in periods
in group3 about Tooth cracks &fractures between different groups at 6mns. As regard there were
non significance difference between different groups at periods (P>0.05) in previous item of
biological properties. Conclusions: Better surface gloss, color match and stability better for bulk
fill and multicolored compomer.Major drawbacks of gingival margin of posterior class II
multicolored compomer is recurrence of caries than bulk fill and bioactive material.The advent of
bulk fill composites, would seem to be a significant turning point in posterior direct restorative
dentistry.
Introduction
Dental caries is a multifactorial chronic infectious disease that affects approximately 50% of
children less than 12 years old worldwide. Untreated dental caries is associated with pain,
difficulty eating, poor physical growth and development, difficulty sleeping, mood changes,
learning problems, hospitalization, and in rare cases, death (1)
Colored compomers have been available for use in the restoration of primary molars. In contrast
to conventional polyacid-modified resin composites, they contain a small amount of glitter
particles which produce a color effect in shades of red, blue or gold. The filler content is similar

i
Ahmed Farghly Abd-Elnaeem B.D.S 2009, Faculty of Dental Medicine, Al-Azhar University ( Assuit Branch )Dentist at
students’ hospital Assiut university
ii
Samy Youssef El Bayoumy, Professor and Head, Department of Pedodontics and Dental Public Health Faculty of Dental
Medicine,Boys,Cairo Al-Azhar University
iii
Ibrahim Farouk Barakat , Lecturer, Department of Pedodontics and Dental Public Health Faculty of Dental
Medicine,Boys,Cairo Al-Azhar University
to conventional compomers Germany). Twinky Star is a light-cured, colored, radiopaque and
fluoride releasing compomer filling system made specifically to be used in primary teeth.(2)
conventional RBC’s have typically been placed in layers not exceeding 2mm thick, the advent of
newer high intensity lights, and the recent introduction by manufacturers of modified resin systems
which claim bulk cure up to 4 mm may offer advantages to dentists in terms of simplicity and
speed of Class II RBC placement. It is important however with these new bulk fill systems, that
the physical properties, marginal adaptation and degree of conversion of the RBC restoration are
not negatively affected.(3)
Traditional materials are designed to be passive and do no harm. This is a negative approach and
does not take advantage of the benefits that can be achieved with active materials that play a
dynamic role in the mouth Bioactive Materials stimulate the natural remineralization process that
helps protect teeth against caries .Bioactive Materials are moisture friendly, transport water ,and
release and recharge essential minerals such as calcium ,phosphate, and fluoride .Bioactive
Materials are dynamic, not passive, and in the presence of saliva they elicit a biological response
that forms a layer of apatite and a natural bond between the material and the tooth.(4)
Patients, Materials and methods
In this study 225 children were examined and 40 were included to participate from the Pediatric
Dental Outpatients Clinic, Faculty of Dental Medicine, Al-Azhar University. The age of children
was ranged from 4 to 9 years.The study sample was divided equally into three groups :- group I
comprises 20 primary molars received multicolored compomer, group II comprises 20 primary
molars received bulk fill composite ,group III comprises 20 primary molars received bioactive
materials.
Clinical inclusion criteria
i.Children having carious primary molars indicated for restoration. ii.Patients should be healthy
with no systemic disease. iii.Children with a behavior rating of 3 or 4 on the Frankl(5)
Restoration techniques
At the initial visit a complete health history questionnaire and parental consent form were
completed. Hard and soft tissues were examined.Make radiographic preapical x -ray for
evaluation,(6),According to ADA instructions.(7). Take photographic image.(8) Rubber dam
isolation and suction were used for moisture control .Carious dentin removal was evaluated
according to clinical criteria of Kidd et al (dental explorer should not stick in the dentine, it should
not give a tug-back sensation and the cavity must be stain-free),(9) Cavo- surface angles were not
beveled, and no retentive grooves were placed.The cavity was prepared with minimal invasive
technique Class II resin composite restorations not extend beyond the proximal line angles.(10).A
wedge and universal matrice system was placed interproximal.(11).Restorative materials were
applied according to the manufacturer’s directions.Following removal of the matrix band, diamond
finishing burs, yellow rubber cups and aluminum oxide discs were used for finishing and polishing
of the restorations .Post-operative imaging and preapical x ray.The restorations were assessed
according to the FDI criteria.(12)Repair of the restorations is recommended according to the FDI
criteria, the repaired restorations were also evaluated as a subgroup 4 (codes 41, 42, 43 and 44
represent the respective codes of 1, 2, 3 and 4 after the restoration has been repaired)
Statistical analysis:
Data collected and analyzed by computer program SPSS" ver. 23" Chicago. USA. Data expressed
as number, percentage. Mann-whitney was used to determine significant for numeric variable. Chi.
Square was used to determine significance for categorical variable
Results
Comparison between different groups according aesthetic properties
Compomer groupIThe mean Surface gloss was 1.0 ± 0.0 at baseline, 1.00 ± 0.00 after 3 months
and 1.2 ± 0.3 after 6 months. There was non-significance difference between different periods in
group I.The mean surface &Marginal Staining was 1.0 ± 0.0 at baseline, 1.0 ± 0.00 after 3 months
and 1.2 ± 0.3 after 6months. There was non-significance difference between different periods in
group II.The mean color matched stability &translucency was 1.0 ± 0.0 at baseline, 1.0 ± 0.0 after
3 months, 1.0 ± 0.0 after 6 months. There was non-significance difference between different
periods in group1.Bulk groupII The mean Surface gloss was 1.0 ± 0.0 at baseline, 1.00 ± 0.00 after
3 months and 1.0 ± 0.0 after 6 months. There was non-significance difference between different
periods in group II. The mean surface &Marginal Staining was 1.2 ± 0.4at baseline, 1.0 ± 0.00
after 3 months and 1.5 ± 0.6 after 6months. There was non-significance difference between
different periods in group II.The mean color matched stability &translucency was 1.5 ± 0.6 at
baseline, 1.17 ± 0.39 after 3 months, 1.0 ± 0.0 after 6 months. There was non-significance
difference between different periods in group II. Bioactive groupIII The mean Surface gloss was
1.0 ± 0.0 at baseline, 1.00 ± 0.00 after 3 months and 1.8 ± 0.3 after 6 months. There was none
significance difference between different periods but there were significance between baseline &
6mns. in group III.The mean surface &Marginal Staining was 1.0 ± 0.0at baseline, 1.0 ± 0.00 after
3 months and 1.0 ± 0.0 after 6months. There was none significance difference between different
periods in groupIII.The mean color matched stability &translucency was 2.54 ± 0.87 at baseline,
2.4 ± 0.2 after 3 months, 1.54 ± 0.55 after 6 months. There were significance difference between
baseline & each of 3mns., 6mns. (P<0.001),periods in group III.
comparison between different groups according aesthetic properties :
Compomer group I The mean Surface gloss was 1.0 ± 0.0 at baseline, 1.00 ± 0.00 after 3 months
and 1.2 ± 0.3 after 6 months. There was non-significance difference between different periods in
group I. The mean surface &Marginal Staining was 1.0 ± 0.0 at baseline, 1.0 ± 0.00 after 3 months
and 1.2 ± 0.3 after 6months. There was non-significance difference between different periods in
group II.The mean color matched stability &translucency was 1.0 ± 0.0 at baseline, 1.0 ± 0.0 after
3 months, 1.0 ± 0.0 after 6 months. There was non-significance difference between different
periods in group1.Bulk group The mean Surface gloss was 1.0 ± 0.0 at baseline, 1.00 ± 0.00 after
3 months and 1.0 ± 0.0 after 6 months. There was non-significance difference between different
periods in group II. The mean surface &Marginal Staining was 1.2 ± 0.4at baseline, 1.0 ± 0.00
after 3 months and 1.5 ± 0.6 after 6months. There was non-significance difference between
different periods in group II. The mean color matched stability &translucency was 1.5 ± 0.6 at
baseline, 1.17 ± 0.39 after 3 months, 1.0 ± 0.0 after 6 months. There was non-significance
difference between different periods in group II. Bioactive groupIII The mean Surface gloss was
1.0 ± 0.0 at baseline, 1.00 ± 0.00 after 3 months and 1.8 ± 0.3 after 6 months. There was none
significance difference between different periods but there were significance between baseline &
6mns. in group III. The mean surface &Marginal Staining was 1.0 ± 0.0at baseline, 1.0 ± 0.00 after
3 months and 1.0 ± 0.0 after 6months. There was none significance difference between different
periods in groupIII. The mean color matched stability &translucency was 2.54 ± 0.87 at baseline,
2.4 ± 0.2 after 3 months, 1.54 ± 0.55 after 6 months. There were significance difference between
baseline & each of 3mns., 6mns. (P<0.001),periods in group III.
comparison between different groups according functional properties :
Compomer group I The mean Fracture of restorative material &restoration retention was 1.0 ± 0.0
at baseline, 1.00 ± 0.00 after 3 months and 1.8 ± 0.7 after 6 months. There was non-significance
difference between different periods in group I. The mean Marginal adaptation was 1.0 ± 0.0 at
baseline, 1.0 ± 0.00 after 3 months and 1.0 ± 0.0 after 6months. There was non-significance
difference between different periods in group I. The mean proximal contact point food impaction
was 1.0 ± 0.0 at baseline, 1.2 ± 0.3 after 3 months, 1.9 ± 0.7 after 6 months. There were non-
significance difference between baseline&3mns. And between 3mns. & 6mns. But there was non-
significance difference (P>0.05) between baseline &6mns. periods in group I. The mean
Radiographic examination was 1.0 ± 0.0 at baseline, 1.0 ± 0.0 after 3 months, 2.1 ± 0.2 after 6
months. There was significance difference between baseline & 3mns. And between 3mns. &6mns.
As regard there were non-significance difference between baseline & 3mns. in group I Bulk fill
group.The mean Fracture of restorative material &restoration retention was 1.0 ± 0.0 at baseline,
1.00 ± 0.00 after 3 months and 1.2 ± 0.3 after 6 months. There was non-significance difference
between different periods in groupII.The mean Marginal adaptation was 1.2 ± 0.3at baseline, 1.0
± 0.00 after 3 months and 2.4 ± 0.8 after 6months. There was non-significance difference between
different periods in group II.The mean proximal contact point food impaction was 1.5 ± 0.6 at
baseline, 1.17 ± 0.39 after 3 months, 1.0 ± 0.0 after 6 months. There was non-significance
difference between different periods in group IIThemeanRadiographic examination was 1.08 ± 0.2
at baseline, 1.08 ± 0.2 after 3 months, 1.08 ± 0.2 after 6 months. There was non-significance
difference between different periods in group II.Bioactive group IIIThe mean Fracture of
restorative material &restoration retention was 1.2 ± 0.3 at baseline, 1.00 ± 0.00 after 3 months
and 2.4 ± 0.8 after 6 months. There were non-significance difference between baseline & 3mns
and between 3mns. & 6mns. (P>0.05). But there was significance difference between baseline &
6mns. in group3. The mean Marginal adaptation was 2.7 ± 0.75 at baseline, 1.2 ± 0.3 after 3 months
and 1.2 ± 0.3 after 6months. There was non-significance difference between baseline & 3mns. But
significance difference between baseline & 3mns. (P<0.05). And non-significance difference
between other periods in group3.The mean proximal contact point food impaction was 1.0 ± 0.0
at baseline, 1.4 ± 0.3 after 3 months, 2.6 ± 0.76 after 6 months. There was significance difference
between baseline & each of 3mns., 6mns. (P<0.05), but non-significance difference between
baseline&3mns. But there was significance difference between baseline&6mns. And non-
significance difference between 3mns. & 6mns. (P>0.05) periods in group III. The mean
Radiographic examination was 1.5 ± 0.4 at baseline, 1.3 ± 0.3 after 3 months, 1.08 ± 0.2after 6
months. But there none significance difference between different periods in group III.
Discussion
In present study we selected of class II type cavity because one of the primary challenges for the
dentist when restoring posterior teeth using composite resin includes the establishment of
anatomically correct proximal contacts, test of materials properties, There are particular sites on
the tooth that favour plaque retention and are therefore prone to decay. These are enamel pits and
fissures, approximal enamel surfaces, enamel at the cervical margin just coronal to the gingival
margin, (13)and open (light) proximal contacts can lead to food impaction, which, in turn, interrupts
the natural cleansing process and advances the breakdown and failure of the periodontal
components as well as the restoration .(14)
In the present study there was no significance difference between different periods in surface gloss
measurements in the two groups, group I(multicolored compomer) and group II (bulk fill) and this
result was agreement with Arora,and et al ;(15) who reported that after evaluation of multicolored
compomer for anatomical shape, marginal integrity, marginal discoloration, surface quality,
approximal contacts, secondary caries and postoperative sensitivity it was excellent after 12
months. .And agreement with Lassila and et al ,(16)reported that flowable bulk-filling resin
composites have different masking abilities than conventional universal filling resin materials,
which clinicians should take into account to achieve optimum color matching ,surface gloss and
aesthetic results.However, Van Dijken and Pallesen;(17)compared conventional (Ceram-X mono +)
and flowable bulk-fill RCs (SDR) in Class I and II, and reported no significant differences between
the materials in terms of the criteria assessed (retention, marginal staining, recurrent caries,
marginal adaptation, gingival recession, color change, and wear) up to 3 years post restoration
.There were significance between baseline & 6mns in group III (bioactive material), This
interpreted as surface gloss might be affected by the type of the composition of the monomer,(18)
and the degree of conversion of the resin.Non significance difference between different periods in
surface Marginal staining in the three groups, Similar to result study for Mjör et al; (19) reported
that composite resin, GIC, RMGIC and compomer did not show marginal staining of the primary
teeth and Similar findings were also reported in study for sengul and et al ;(20) no colour change
was recorded for restorative materials by the end of the 24th month in the present study. And
different to study for Demic et al (21) found that found that all Ryge criteria were good, except
those relating to color change, i.e. color stability and marginal discoloration. In both of these there
were significant changes in twinky star.
In this study color matched stability &translucency were non-significance difference between
different periods in group I and group II. it is come with result of sengul et al; (20) reported that no
color change was recorded for restorative materials by the end of the 24th month for compomer
and composite resine and disagreement with Hugar ,and et al;(22)reported that examination of the
margins showed discoloration with loss of glitter particles there was no incidence of secondary
caries.
In group III there was significance difference at baseline due to using single shade (A2) for all
cases and changes of color after 6mns in group III this may be due to the structure of the analyzed
composite resin, the organic matrix prevails, in volumetric ratios, comparatively with the
anorganic compound, which renders the material more susceptible to the abrasive action of the
finishing and polishing systems. An organic compound contains a mixture of non-
agglomerated/non-aggregated particles of silicium oxide and zirconium oxide with nanometric
size, dispersed among the clusters of particles with micrometric size. Possibly, the nanometric
particles from the surface layer had been the first one to be eliminated during finishing and
polishing and more reliable for future staining.(23)
functional properties
in the present study there were none significance difference between different periods in three
groups For Fracture of restorative material &restoration retention it comes agreement with study
to Ertugrul et al ;(24) reported that The 12-month mean cumulative survival rate of Compoglass F
was 95.7% and, for the Twinky Star group, it was 93% in class II restorations, with no significant
difference between the groups for either material. and also agreement with Ilie, Nicoleta Stark,
Katharina(25)reported that easy and fast manipulation of bulk fill lead to further success of
restoration for all physical and esthetical properties. And agreement with Pameijer et al;
(26)
reported that the Activa-enhanced RMGIs demonstrated comparable flexural strength and
flexural fatigue more than flowable composites.Marginal integrity found non-significant found
between groups , this come in agreement with study to Ertugrul F, et al (24)reported that the
marginal integrity in our study for colored compomer was acceptable and where the clinical
success of Twinky star was found to be 93 %. Our findings are consistent also with the literature
data in Alkurdi, Rahaf M Abboud, Souad A; (27) bulkfill restorations can overcome the difficulties
with multi-layer technique, saving time and efforts with satisfactory clinical outcome and due to
the low viscosity and marginal integrity.Proximal contact point and food impaction after 3 months
and 6 months; there was no statistically significant difference between proximal contact point and
food impaction measurements in three groups. this come in agreement with study of Andrade; (28)
who compared bulk fill for sonic type composite parameters, and this is refer to using of
appropriate isolation and matricing, and also refer to good finishing for the proximal surface. And
with agreement to Pameijer and et al (26) reported that the Activa-enhanced RMGIs demonstrated
comparable flexural strength and flexural fatigue more than flowable composites. And in
harmony with study for Croll and et al ,(29) evaluated a second deciduous molar restored in a 8-
year-old girl with colored compomer (Magicfil), and reported that the restoration was intact and
served its purpose 10 months after its placement
In radiographic examination there non significance difference between different periods in group
II and group III in all periods and significant after 6 min. for group I showed statistically
significantly lower mean pathological changes this comes with result for Sengul & F Gurbuz, T
reported that; (20) According to the radiographic evaluation results, RMGIC was the best and
compomer was the worst material .and in another hand for our study Pascon et al ,(30) it was found
that compomer materials (Dyract AP, F2000) showed a better clinical performance in comparison
with a resin composite (Heliomolar) in primary molars at 2 years
Biological properties:
after 3 months and 6 months; there was no statistically significant difference in effect of the
restoration on the periodontium between effects of the restorations on the periodontium
measurements in the three groups.as no fracture of restoration at contact area, good restorations
contour and no food impaction and no any periapical pathologic chages.(11).In the present study
after 3 months and 6 months; there was no statistically significant difference between effects of
the restoration on the periodontium measurements in the three groups as reported in study for El-
Kalla, Ibrahim H García-Godoy, Franklin;(31)The bonded restorations preserve tooth structure,
normal contact area and provide an esthetic restoration, It also provides a unique feature in certain
cases in which there was migration of adjacent teeth into the proximal carious cavity.For
Recurrence of initial pathology after 3 months and 6 months; there was no statistically significant
difference between Effects of the restoration on the periodontium measurements in the three
groups .as no marginal staining ,and good marginal integrity, as reported that Marginal staining
results from seepage or leakage of oral fluids between the restoration and tooth structure and initial
cause for secondary caries.(32)
no significant for Postoperative sensitivity & tooth vitality in group II and group III this agreement
with study for Jefferies, Steven.(33)Bioactive materials have evolved over the past three decades
from relatively specialized, highly biocompatible, but low-strength dental materials to now emerge
in product compositions for expanded clinical uses in restorative dentistry but in group I there is
significant between base line and after three month this postoperative sensitivity relieved might
be for expansion of restoration and seal gap like what reported in study for Alves dos Santos et
al;(34)reported better marginal adaptation of compomers than composites, result to the chemical
composition, which allows the compomers undergo more hygroscopic expansion than the
composites, rather than the wear characteristics of the material. non-significant for three groups
in Oral & somatic/psychiatric symptoms this come with harmony to many study , Ping C et al ;(35)
evaluated the biological safety of the new Twinky Star compomer samples were tested with the
cytotoxicity test, in vitro hemolytic test and acute general toxicity test. The result of cytotoxicity
test shows that the samples had no cytotoxicity .And Barabanti,(36)also reported a survival rate of
100% for posterior Tetric EvoCeram restorations studied in a five-year trial and Arora et al;
(15)
conducted a study at University of Ankara, Turkey. 80 restorations were placed in 36 children
to treat class II cavities with different shades of Twinky star and examined after 12 months using
modified criteria of USPHS for anatomical shape, marginal integrity, marginal discoloration,
surface quality, approximal contacts, secondary caries and postoperative sensitivity. Three
restorations were replaced after one year. Rest of the restorations exhibited excellent results after
12 months of wear. In addition to this, color selection was also correlated with sex of the patient.
Boys favored blue color followed by lemon, silver and gold whereas girls exclusively selected
pink followed by silver, lemon, gold and blue.
Conclusions
1) Better surface gloss, color match and stability better for bulk fill and multicolored compomer.
2) Major drawbacks of gingival margin of posterior Class II multicolored compomer is recurrence
of caries than bulk fill and bioactive material
3) The advent of bulk fill composites, would seem to be a significant turning point in posterior
direct restorative dentistry.
Recommendations
1) More clinical data is required regarding parental satisfaction with such restorations especially
for bioactive materials.
2) Clinical study for ability of bioactive material for remineralization of tooth structure.
3) Clinical assessment for more long- time for bioactive material

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