Clinical Performance of Glass Ionomer Cement in Load-Bearing Restorations: A Systematic Review

REVIEW ARTICLES
e-ISSN 1643-3750
© Med Sci Monit, 2024; 30: e943489
DOI: 10.12659/MSM.943489
Received:
Accepted:
2023.12.13
2024.01.17 Clinical Performance of Glass Ionomer Cement
Available online:
Published:
2024.01.24
2024.02.14 in Load-Bearing Restorations: A Systematic
Review
Authors’ Contribution: ABCDEF 1 Laura Durrant 1 Dental Academy, University of Portsmouth, Portsmouth, UK
Study Design A BCDEF 1 Mahdi Mutahar 2 Department of Restorative Dental Sciences, College of Dentistry, Jazan University,
Data Collection B Jazan, Saudi Arabia
Statistical Analysis C DFG 2 Arwa A. Daghrery 3 Department of Restorative Dental Science, College of Dentistry, King Khalid
Data Interpretation D DFG 2 Nassreen H. Albar University, Abha, Saudi Arabia
Manuscript Preparation E EG 3 Ghadeer Saleh Alwadai 4 Department of Restorative Dental Sciences, College of Dentistry,
Literature Search F Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Funds Collection G DG 3 Saleh Ali Alqahtani 5 Department of Prosthetic Dental Science, College of Dentistry, Jazan University,
DEG 4 Laila Adel Al Dehailan Jazan, Saudi Arabia
CG 3 Naif Nabel Abogazalah
DG 3 Nada Ahmad Alamoudi
CFG 5 Mohammed M. Al Moaleem
Corresponding Authors: Mahdi Mutahar, e-mail: Mahdi.mutahar@port.ac.uk, Mohammed M. Al Moaleem, e-mail: malmoaleem@jazanu.edu.sa
Financial support: None declared
Conflict of interest: None declared
Glass ionomer cement (GIC) is a self-adhesive dental restorative material composed of a polyacrylic acid liquid
and fluoro-aluminosilicate glass powder. It is commonly used for cementation during dental restoration. This
study aimed to systematically review the existing literature regarding the clinical performance of GIC in load-
bearing dental restorations.
A comprehensive literature search was conducted in EBSCO, PubMed, Embrace, and Cochrane databases. Only
randomized controlled trials (RCTs) were included in the search, and a broad search technique was used, where
inclusion and exclusion criteria were applied. After a thorough evaluation, 12 RCTs were extensively reviewed,
and whether GIC is suitable for load-bearing restorations was determined.
Significant variations in staining surface or margin, color match, translucency, esthetic anatomical form, reten-
tion, material fracture, marginal adaptation, surface luster, occlusal contour, wear, and approximal anatomi-
cal form indicated the unsuitability of GIC. By contrast, significance differences in patient view and periodon-
tal response indicated that GIC is suitable. No significant differences in postoperative sensitivity, recurrence of
caries, or tooth integrity were observed. Nevertheless, the results of the review demonstrated that the clinical
performance of GIC is comparable to that of traditional restorative materials with regard to the parameters
analyzed.
GIC is a suitable restorative material for load-bearing restorations regarding surface margin, esthetic anatom-
ical form, material retention and fracture, marginal adaptation, occlusal contour, wear, and approximal ana-
tomical form. It reduces other parameters, such as postoperative sensitivity, recurrence of caries, and tooth
integrity.
Keywords: Dental Materials • Glass Ionomer
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Durrant L. et al:
REVIEW ARTICLES Clinical performance of GIC in load-bearing restorations
© Med Sci Monit, 2024; 30: e943489
Background materials, hinders polishing or finishing, and needs to be pro-

tected from drying.
Before Wilson and Kent (1972) invented glass ionomer cement
(GIC) in England between 1969 and 1972, silicate cement was A load-bearing restoration is either a class I or class II accord-
often used as a filling material despite its deficiencies in some ing to Black’s classification [16]. Class I restoration is of the oc-
properties. The predecessor of GIC was an aluminum-contain- clusal surface of the premolars and molars, whereas class II is
ing fluorosilicate glass cement, from which fluoride ions are proximal, which may have more than 2 surfaces [17]. Amalgam
liberated [1,2]. John McLean played a crucial role in introduc- is the most clinically suitable material for load-bearing resto-
ing GIC to the field of dentistry. In 1972, the first commercially rations because of its excellent stress-bearing properties, such
available GIC, also known as alumino-silicate polyacrylic acid as wear resistance [18]. However, the growing prevalence of
cement, was produced. A year later, McLean was appointed as minimally invasive dentistry and decreased use of amalgam
a clinical consultant to the Government Chemist Laboratory [2]. have prompted the exploration of alternative materials [19].
He collaborated with Alan Wilson to carry out clinical trials on
GIC, playing a pivotal role in promoting the use of GIC and ad- The dental industry has made substantial efforts to explore
vancing its development [3,4]. materials that are suitable substitutes for amalgam in load-
bearing restorations. Although amalgam offers some benefits,
GIC is as an acid-based cement produced by the reaction be- including simplicity and low cost, it has esthetic limitations,
tween weak polymeric acids and essential powdered glass- cannot be applied through a minimally invasive technique,
es containing fluoro-aluminosilicate, glass particles, and ions and is toxic to the environment. The 2017 European Union
such as strontium, calcium, and lanthanum [5,6]. During set- Regulations and the 2013 Minamata Treaty have imposed re-
ting, which occurs in aqueous solutions at different concentra- strictions on its use for individuals under 15 years of age and
tions, acids corrode a powder particle’s surface, freeing calcium pregnant or breastfeeding patients [20].
and aluminum ions, resulting in adhesion between the pow-
der and a liquid [7]. The final structure comprises a significant Resin composite (RC) is a good alternative, which has a high
amount of unreacted glass acting as a filler that strengthens esthetic value and can be applied with a minimally invasive
the set cement, which has been named “GI” [8]. The formula technique, but it is expensive and hydrophobic; additionally,
has been improved by adding itaconic acid, which increases its application is time-consuming [21]. GIC provides numerous
the molecular weight and reactivity of polyacrylic acid and re- benefits that have been extensively documented in the liter-
duces viscosity [9]. Tartaric acid is also added, which enhanc- ature, including chemical bonding with the tooth structures
es setting characteristics by delaying the setting of cement through micromechanical retention, hydrophilicity, anticario-
through reactions with glass components [10,11]. genic effects, fluoride release, thermal compatibility, and bio-
compatibility. However, it possesses weak fracture toughness,
GIC is naturally adherent to the tooth structure primarily be- has moisture sensitivity, and promotes occlusal wear [22,23].
cause of polymeric acids [12,13]. Its hydrophilic nature moist- These limitations can cast doubt regarding the clinical viabil-
ens a freshly prepared tooth surface. After initial placement, ity of GIC for load-bearing restorations. Moreover, while sen-
adhesion is facilitated by ion–dipole interactions resulting sitive to moisture, it has a high solubility rate and moderate
from the formation of hydrogen bonds between free nega- compressive strength.
tively charged carboxylate ions and positively charged calci-
um ions [14]. The hydrogen bonds are gradually replaced by Nevertheless, some improvements have been achieved. For ex-
ionic bonds between the anionic functional groups in the ce- ample, GIC reinforced with 0.01 wt.% Ag-doped carbon nano-
ment and cations in the tooth; this process leads to formation tube fillers has been used as an alternative to conventional
of an ion exchange layer between the tooth and cement [15]. GIC dental fillings [24]. Hydroxyapatite improves the physical,
This robust and chemical-resistant interfacial layer provides mechanical, and structural properties of GIC [25]. Notably, all
a durable adhesive bond and prevents leakage to an under- forms of GIC and their modification result in a good reminer-
lying natural tooth [12,13]. Fluoride ions are released during alizing potential clinically [26].
acid–base reactions and can cross between the cement and
the tooth. Therefore, GIC restorations can function as fluo- Clinicians must adhere to evidence-based medicine when mak-
ride reservoirs, gradually releasing ions into the tooth and ing decisions, often referring to the hierarchy of evidence or
functioning as a defense mechanism against caries while in Oxford’s Level of Evidence (OLE) [27-30]. A brief literature search
the mouth [2,7,13]. The benefits of GIC apart from releasing only shows recent reviews that cannot answer the present re-
fluoride are self-adhesion, bioactivity, biocompatibility, and search question. Therefore, this study aimed to systematical-
thermal compatibility. However, it has lower fracture resis- ly review the existing literature on the clinical performance of
tance, flexural strength, and wear resistance than other filler GIC in load-bearing dental restorations.
Durrant L. et al:
Clinical performance of GIC in load-bearing restorations
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
Figure 1. PRISMA flow diagram [31,32].

PRISMA 2020 flow diagram for new systemic review which included searches of database and register only
Identification of studies via databaases and registers
52,864 articles identified from

Boolean search phrases across all
three databases
Identification
1 article identified through

Records identified from*: another source
Databases (n=3)
PubMed (n=4,434)
EBSCO (n=32,030)
Google Scholar (n=16,400)
Records excluded according to

Records screened the exclusion criteria**
(n=37) (n=52,828)
Screening
Studies excluded based on title

Studies assessed for eligibility by and/or abstract
CCAT appraisal (n=24)
(n=13)
Studies excluded:
CCAT score <70% (n=1)
Included
Studies included in review for etc.

analysis
(n=12)
Study Design keywords, nesting methods, and Boolean operators. The nesting
search method uses synonyms to create themed phrases. The
This systematic review complied with the standards outlined keywords include (Glass Ionomer Cement OR GIC), Restoration
in the Preferred Reporting Items for Systematic Reviews and and Restorations as Class I and II ‘AND’ and ‘OR’ were used
Meta-Analysis (PRISMA) 2020 [31,32]. According to the hier- with the nesting method to broaden the search [36,37].
archy of evidence and OLE, the randomized controlled trial
(RCTs) is the most widely used study format. Therefore, this Inclusion Criterion
review only included results from RCTs.
Including studies published from 2018 and 2022 years ensures
Formulating the Research Question that the data collected is accurate and up to date. A Crowe
Critical Appraisal Tool (CCAT) of >70% was applied. We included
A total of 5585 studies on the use of GIC in load-bearing res- studies that examined dentition type (primary or permanent)
torations were obtained. The preliminary examination of the and used either GIC or resin-modified GIC. Articles written in a
research topic specified whether the research question (is GIC language other than English, systematic reviews, cohort stud-
clinically suitable for loading bearing restoration?) is appro- ies, case reports, case series, editorials, expert opinions, gray
priate for the topic of this review. This question was formu- literature, and restoration of endodontically-involved denti-
lated using the PICO framework, which considers the popula- tion were excluded.
tion (patients requiring load-bearing restoration), intervention
(GIC restorations), comparison (other dental restorations), and Databases Search
outcome (clinical direction for GIC use in load-bearing restora-
tions) [33,34]. This framework was selected because it is often EBSCOhost (https://library.port.ac.uk), PubMed (https://pubmed.
used for systematic reviews of clinical trials [35]. ncbi.nlm.nih.gov), and Embrace and Cochrane databases
(https://www.cochranelibrary.com/central/doi/10.1002/cen-
Key Terms tral/CN-00978608/full) were searched with the correspond-
ing search terms. The search was implemented in accordance
For each aspect of PICO, we generated key terms to have a with the PRISMA 2020 statement (Figure 1). An overwhelm-
structured and consistent search methodology for all data- ing result was achieved (52 864 studies), and another over-
bases. The existing literature underwent screening employing whelming result was found through the initial broad search.
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
Table 1. Included studies with their title, year, author (s), outcomes, and Crowe Critical Appraisal Tool score.
Research
Title Year Author(s) Findings CCAT
type
A 3-year study on the 2019 Fotiadou C, Frasheri I, RCT Both GIC tested 78
performance of two glass- Reymus M, Diegritz C, performed similarly in
ionomer cements in Class II Kessler A, Manhart J, Class II cavities with a
cavities of permanent teeth et al [45] moderate failure rate
after 3 years
Evaluation of glass-Ionomer 2022 Uzel İ, Aykut-Yetkiner A, RCT Both GIC and RC were 73
versus Bulk-Fill resin composite Ersin N, Ertuğrul F, Atila comparable, with good
E, Özcan M [46] clinical performance after
a 2-year recall
A five-year clinical trial to 2023 Wafaie RA, Ibrahim Ali A, RCT GIC provided successful 83
evaluate the clinical performance El-Negoly SAE, Mahmoud clinical performance in
of high-viscosity glass ionomer SH [47] small to medium-sized
restorative systems in small class class II cavities compared
II restorations to RC
Clinical evaluation of bulk- 2020 Akman H, Tosun G [48] RCT The EQUIA group 80
fill resins and glass ionomer exhibited minor changes
restorative materials: A 1-year after 1-year in marginal
follow-up in children adaptation and retention,
in contrast to the wholly
good performance from
RC
10 years follow up of a glass 2019 Gurgan S, Kutuk ZB, RCT Both GIC and RC were 78
ionomer restorative material in Yalcin Cakir F, Ergin E comparable, with an
class I and class II cavities [49] acceptable clinical
performance after a 10-
year recall.
Evaluating the effectiveness 2021 Menezes-Silva R, Velasco RCT ART GIC restorations 78
of ART restorations with high- SRM, BRESCIANi E, and RC conventional
viscosity glass-ionomer cement Bastos RDS, Navarro MFL restorations had high-
versus conventional restorations [50] survival rates in class II
with resin composite in Class II cavities over 2-years
cavities of permanent teeth: two-
year follow-up
Clinical evaluation of microhybrid 2018 Kharma K, Zogheib T, RCT GIC is an acceptable 78

composite and glass ionomer Mehanna C [51] alternative to RC for
restorative material in permanent restoring Class I cavities
teeth
Atraumatic restorative treatment 2020 Araujo MP, Innes NP, RCT The GIC survival rate was 70
compared to the Hall Technique Bonifácio CC, Hesse D, three times lower than
for occluso-proximal carious Olegário IC, Mendes FM, the SSC group. However,
lesions in primary molars; Raggio DP [52] the GIC group were more
36-month follow-up greatly accepted by
participants and parents
Comparison of resin-modified 2018 Dermata A, Papageorgiou RCT Both RMGIC and RC were 70
glass ionomer cement and SN, Fragkou S, Kotsanos comparable, with good
composite resin in class II N [53] clinical performance after
primary molar restorations a 2-year recall
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
Table 1 continued. Included studies with their title, year, author (s), outcomes, and Crowe Critical Appraisal Tool score.
Research
Title Year Author(s) Findings CCAT
type
Long-term clinical performance 2019 Kupietzky A, Atia Joachim RCT Both GIC and RC were 75
of heat-cured high-viscosity glass D, Tal E, Moskovitz M clinically successful after
ionomer Class II restorations [54] a 3-year recall. However,
versus resin-based composites in GIC was described a s
primary molars an intermediate lasting
restoration for proximal
regions as RC showed
higher success rate
during same period
Class II ART high-viscosity 2020 Molina GF, Ulloque MJ, RCT ART GIC restorations 73
glass-ionomer cement and Mazzola I, Mulder J, and RC conventional
conventional resin-composite Frencken J [55] restorations had high-
restorations in permanent survival rates in class II
dentition: Two-year survival cavities over 2-years
Six-year results of a clinical trial 2020 Heck K, Frasheri I, RCT Both GIC showed 75
of two glass ionomer cements in Diegritz C, Manhart J, acceptable and
Class II cavities Hickel R, Fotiadou C [56] comparable survival
rates after 6 years
RCT – randomised control trials.
After applying the eligibility criteria and removing duplicates, The included studies used an alternative criterion, such as
we selected 37 studies for further screening. The studies were USPSH, and we made appropriate amendments to coincide
independently screened by reading their titles and abstracts. subgroups and achieve evidence-based comparison of homo-
Finally, 13 studies were deemed suitable for critical appraisal, geneous data. Each subgroup’s dichotomous results are pre-
but only 12 studies met the inclusion criteria (Table 1). sented in tables and narratively for a comprehensive summary.
Subgroups based on participant age, type of dentition (primary
Critical Appraisal or secondary), surface, and material that result in dichotomous
outcomes were established (Table 2). Furthermore, as recom-
The CCAT is a valid and dependable tool for evaluating the in- mended by the PRISMA 2020 statement, we used the WHO’s
tegrity of diverse research designs. It has multiple categories Grading and Recommendations Assessment, Development,
that conclude with a score for interpretation. The literature and Evaluation Framework to determine the subjective cer-
within the final screening was assessed using the CCAT be- tainty of evidence, which was rated as very low, low, moder-
cause it is a widely used tool for RCTs [38,39]. The CCAT score ate, or high (Table 2) [43,44].
for each appraisal was correlated to a percentage using the
CCAT instructions. Only studies with a CCAT score of >70% Risk of Bias Assessment
were included [38,39].
As this systematic review’s contents are RCTs, we indicated the
Critical Analysis Cochrane risk of bias, which was subjectively rated as “low,”
“some concerns,” and “high” and was assessed according to 4
Data collected were subjected to subgroup analysis according domains (Figure 2): D1, D2, D3, and D4. If a study was marked
to the FDI World Dental Federations’ Clinical Criteria for the as high in 1 of the domains, the study was deemed high overall.
Evaluation of Direct and Indirect Restorations [40-42]. These
criteria can be used in comprehensive procedures for evalu- Table 2 shows the 12 studies included in this review, showing
ating dental materials and can be divided into 3 groups: es- the characteristics of each study, such as comparison, commer-
thetic, functional, and biological properties. Each main group cial name, participant age group, number of participants, number
contain 16 subgroups, and each subgroup has scores of 1-5 of restorations, dentition, class, study length, preferred materi-
(1, clinically very good; 2, clinically good; 3, clinically sufficient/ al, COE, and authors. All the studies have a comparison: GIC ver-
satisfactory; 4, clinically unsatisfactory; 5, clinically poor). The sus RC, GIC versus stainless-steel crown, and GIC versus GIC. The
last 2 were classified as failures. outcomes were described as dichotomous outcomes because 2
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
Table 2. Characteristics of the 12 included studies.
Comparison between used Number of No. of

Commercial name Participant age group Dentition
materials participants restorations
ART HVGIC vs CRT RC EQUIA Fil, Filtek Z250 14-44 YOA (26.2m) 131 272 Permanent
ART HVGIC vs CRT RC EQUIA Fil, Z350-3M Children and 54 77 Permanent

adolescents
GIC vs GIC 1 Fuji IX GP Fast, EQUIA Fil 18-70 YOA (35.4m) 34 85 Permanent
GIC vs GIC 2 Fuji IX GP Fast, EQUIA Fil 18-70 YOA (35.4m) 34 44 Permanent
Bulk-Fil RC vs GIC EQUIA, Sonicfill, X-tra Fil, 6-10 YOA 30 160 Primary
Filtek Z550
Bulk-Fil vs GIC EQUIA, Tetric EvoCeram 10-12 YOA 35 70 Permanent
HVGIC vs RC EQUIA, Filtek P60 7 YOAm 45 131 Primary
RMGIC vs RC Vitremer 4-7.5 YOA 55 104 Primary

Filtek Z250
GIC vs RC Gradia Direct Posterior, 15-37 YOA (24m) 51 140 Permanent

EQUIA Fil
GIC vs RC Filtek Z250 (RC), EQUIA 20-40 YOA (25m) 40 160 Permanent
Forte (GIC), and Riva HV
(GIC), Ketac Universal
(GIC)
GIC vs RC EQUIA, Amelogen Plus 25-63 YOA (41.3m) 15 40 Permanent
GIC vs Hall Crown (HC) EQUIA Forte, Stainless- 5-10 YOA 124 131 Primary
Steel Crown
Comparison between used Class I/Class II/ Material Certainty of
Study length Authors
materials Mixed favoured evidence
ART HVGIC vs CRT RC Class II 2 years No difference Low Molina et al,

2020 [55]
ART HVGIC vs CRT RC Class II 2 years No difference Moderate Menezes-Silva et al,

2020 [50]
GIC vs GIC 1 Class II 3 years No difference Very low Fotiadou et al,

2019 [45]
GIC vs GIC 2 Class II 6 years No difference Moderate Heck et al, 2020 [56]
Bulk-Fil RC vs GIC Class II 12 months Bulk-Fil RC Moderate Akman and Tosun,

2020 [48]
Bulk-Fil vs GIC Mixed 2 years No difference Very low Uzel et al, 2022 [46]
HVGIC vs RC Class II 3 years RC Moderate Kupietzky et al,

2019 [54]
RMGIC vs RC Class II 2 years No difference Very low Dermata et al,

2018 [53]
GIC vs RC Mixed 10 years No difference Moderate Gurgan et al, 2020 [49]
GIC vs RC Class II 5 years No difference Moderate Wafaie et al. 2023 [47]
GIC vs RC Class II 9 months No difference Moderate Kharma et al, 2018 [51]
GIC vs Hall Crown (HC) Class II 3 years HC Very low Araujo et al,
2020 [52]
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
D1 D2 D3 D4 D5 Overall
Molina et al 2020 – – X X – X
Heck et al 2020 + – – + – –
Fotiadou et al 2020 + + – + + –
Akman and Tosun et al 2020 – – + + – –
Menesez-Silva et al 2021 + – – + – –
Dermata et al 2018 + – + X + X
Gurgan et al 2020 + – + + + –
Kupietzky et al 2019 – – + + + –
Uzel et al 2022 + + X + + X
Wafaie et al 2022 + + + + – –
Kharma et al 2022 – – + + – –
Araujo et al 2020 + – + X + X
Domains: Judgement
D1: bias arising from the randomization process
D2: bias due to deviations from intended intervention X High
D3: boas due to missing outcome data
D4: bias in measurement in outcome – Some concerns
D5: bias in selection of the reported results + Low
Figure 2. Cochrane risk of bias.
groups were compared. The investigated GIC materials included Color Match and Translucency
in the 12 studies are shown in Table 3, with information on their
composition and indications. Some studies were not included in Three of the included studies found statically significant re-
each table because they did not explore all the 16 FDI criteria. Only sults regarding color match. The results ranged from good col-
the studies that produced results for the criterion were included or match to distinct deviation, and the latter only affected GIC.
in the table. The top row is the recall period that the results cor- One study observed that Filtek Z250 outperformed other GIC
relate to. It can be used to interpret the results in the tables. For materials in terms of color match (P<0.001). EQUIA Forte res-
example, a score of 2 for surface luster indicates that the materi- toration’s color match was superior to that of Ketac Universal
al is slightly dull and contains isolated pores. Fotiadou et al found or Riva HV restorations at 5-year recall [47]. Similarly, Gurgan
that 87.5% of EQUIA restorations had an FDI score of 2 for surface et al [49] observed that Gradia DP outperformed EQUIA Fil.
luster at 12-month recall. When the difference in results between Menezes Silva et al [50] compared Z350-3M with EQUIA Fil
the baseline and recall periods was insignificant, the column was (P<0.05). Three studies found no clinical significance in recalls
filled with NA. A P>0.05 indicated that a study explored this crite- for the materials investigated and no significant differences
rion [45]. Table 4 shows the parameters evaluated during different among dichotomous outcomes (P>0.05) [46,48,51].
recall periods in relation to the type of material used and authors.
Esthetic Anatomical Form
Staining Surface or Margin
Two of the included studies found statistical significance re-
Six studies investigated the staining surface [46-51], but only garding the esthetic anatomical form of GIC [47,49], and most
2 of them found statically significant results regarding stain- of the materials were esthetically acceptable. Menezes et al [50]
ing surface and margin when GIC was compared with RC found a statistically significant difference in esthetic anatomi-
(P<0.05) [47,48]. The effect was observed only in minor sur- cal form between EQUIA Fil and Z350-3M. After 5 years, Ketac
face staining, which was easily removed and did not exert a Universal and Riva HV restorations displayed a substantial
detrimental effect. None of the studies found a clinically sig- change in esthetic anatomic form relative to the baseline [47].
nificant difference in recalls for the materials investigated, and Two studies found no clinical significance in recalls for the ma-
no significant differences in dichotomous outcomes were ob- terials investigated and no significant differences in dichoto-
served (P>0.05) [49]. mous outcomes [48,49].
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
Table 3. Included materials and their types, indications, composition, and authors.
Material Type Indications Composition Authors
EQUIA Bulk-filled 1. Class I restorations 95% strontium Molina et al, 2020 [55];
Fil radiopaque 2. S
tress bearing Class II restorations fluoroaluminosilicate Menezes-Silva et al, 2020 [50];
posterior (see separate technique guide for glass, highly reactive Fotiadou et al, 2019 [45];
restorative suggested cavity preparations) small particles, and 5% Heck et al, 2020 [56];
3. N
on-stress bearing Class II polyacrylic acid. Akman & Tosun, 2020 [48];
restorations Uzel et al, 2022 [46];
4. Intermediate restorative Kupietzky et al, 2019 [54];
5. C
lass V and root surface Gurgan et al, 2020 [49];
restorations Kharma et al, 2019 [51];
6. Core build up Araujo et al, 2020 [52]
EQUIA Bulk-filled 1. Class I restorations Surface-treated fluoro Wafaie et al, 2023 [47]
Forte glass hybrid 2. S
tress bearing Class II restorations aluminosilicate
restorative (see separate technique guide for glass, ultrafine-highly
suggested cavity preparations) reactive glass, higher-
3. N
on-stress bearing Class II molecular weight
restorations polyacrylic acid, iron
4. Intermediate restorative (III) oxide. Polybasic
5. C
lass V and root surface carboxylic acid (tartaric
restorations acid) 5-10% by wt.
6. Core build up
Fuji IX FAST 1. C lass I and Class II Restorations in Alumino fluoro silicate Fotiadou et al, 2019 [44];
GP Fast Packable deciduous teeth. glass, polyacrylic acid, Heck et al, 2020 [56]
Posterior 2. E mergency or Intermediate distilled water, polybasic
Restorative Restorative (I.R.M.) carboxylic acid
3. L ong-term temporary (Posterior
fillings)
4. F inal restoration for non-stress
areas
5. C ore build-up and dentin
substitute in Sandwich Technique
Ketac Bulk-fill, 1. L inings for single- and multi- Oxide glass chemicals Wafaie et al, 2023 [47]
Universal radiopaque surface composite fillings >95% by wt. Water
Aplicap glass 2. C ore build-up prior to crown 40-60%, copolymer of
ionomer placement acrylic acid – maleic acid
restorative 3. Primary tooth fillings 30-50%, tartaric acid
material 4. R estricted stress-bearing Class I 1-10%, benzoic acid
and Class II restorations* <0.2% by wt.
5. Cervical fillings
6. S ingle- and multi-surface
temporary fillings
7. Fissure sealing
Riva Self Bulk-fill, 1. Minimal Class I and II restorations Fluoro aluminosilicate Wafaie et al, 2023 [47]
Cure HV radiopaque, 2. Restorations in deciduous teeth glass 90-95%, acrylic
high 3. Geriatric restorations acid homopolymer
viscosity 4. Intermediate restorations and as 5-10% by wt. acrylic acid
glass a base material for class I and homopolymer 20-30%,
ionomer II cavities, using the sandwich tartaric acid 10-15%
restorative technique by wt.
material 5. Cervical restorations (Class V)
6. Stump reconstruction
7. Temporary fillings
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
Table 3 continued. Included materials and their types, indications, composition, and authors.
Material Type Indications Composition Authors
Vitremer Tri-Cure 1. Class III and Class V restorations Fluor aluminosilicate Dermata et al, 2018 [53]
Glass 2. R
estoration of cervical erosion/ glass. It also contains
Ionomer abrasion lesions microencapsulated
System 3. Restoration of root caries lesions. potassium persulfate
(Resin- 4. C
lass I and Class II restorations in and ascorbic acid,
Modified) primary teeth aqueous polycarboxylic
5. T
emporary repair of fractured acid modified with
teeth pendant methacrylate,
water, HEMA and
photoinitiators
Retention and Fracture of Material from baseline to 6 years of recall for EQUIA Fil and Fuji IX GP
Fast Set (P 0.017 and P 0.011, respectively) [56]. Two studies
The results regarding retention or fracture and retention found no clinical significance in recalls for materials investi-
showed that GIC is frequently minimally retentive with re- gated and for dichotomous outcomes [49,51].
gard to dichotomous outcomes (Table 4) [46-50,52-55]. The 2
studies of dichotomous outcomes showed that EQUIA Fil was Approximal Anatomical Form, Postoperative Sensitivity,
superior to Fuji IX GP Fast Set at each recall period [45,56]. and Tooth Vitality
Similarly, EQUIA Fil exhibited higher retention performance that
Riva Self Cure HV and Ketac Universal Aplicap at 1, 3, and 5 The results ranged from clinically excellent to clinically poor.
years of recall [47]. Only 1 study yielded significant results re- There was a significantly greater incidence of loss of contact
garding fracture alone for EQUIA Fil and Fuji IX Fast Set [45]. point integrity in Vitremer compared with Filtek Z250 (P=0.03)
Another study found fracture to be the leading cause of fail- [53]. Five studies found no clinical significance in recalls for
ure for EQUIA Fil and Fuji IX Fast Set [56]. However, 5 stud- the materials investigated, and no significant differences in
ies found no clinical significance in recalls for the materials dichotomous outcome were observed [45,47,50,54]. In rela-
investigated and in dichotomous outcomes [47,49,51,52,54]. tion to postoperative sensitivity and tooth vitality, no clinical
Focusing on the average retention of GIC, a study found that at significance was observed at recalls for each material, and no
a 3-month recall, the retention of GIC restorations was 97.06% significant differences was found for dichotomous outcomes
[48]. At a 6-month recall, the retention of GIC averaged 95.6% [45,49,51,56].
[46,48,50]. At 12-month recall, the retention of GIC averaged
93.35% [45-50,53]. At 2-year recall, the retention of GIC av- Surface Luster/Texture
eraged 91.1% [45-46,50,53,54]. At 3-year recall, the retention
of GIC averaged 83.35% [44,47,49,52,54]. One study reported Six of the included studies found deterioration of surface lus-
the retention of GIC at a 4-year recall [49]. ter as an outcome of GIC at 6-year recall [45-47,50-51,56]. The
deterioration varied from slight deviation from enamel to dull
Marginal Adaptation surfaces with pores. The most common outcome was a slight-
ly dull appearance. Compared with RC, the results were sta-
Four of the included studies found statistically significant mar- tistically significant (P<0.05). One study found no significant
ginal adaptation results. The results ranged from harmonious differences for dichotomous outcomes in recalls for materials
outlines to partial or complete looseness of the restoration investigated with regard to surface luster [49].
and significant gaps and irregularities, and only the last result
affected GIC. One study observed irregularities in the EQUIA Recurrence of Caries Erosion Abfraction and Tooth Integrity
Fil group. However, the RC groups remained similar at 6 and
12 months of recall (P=0.029 and P=0.034, respectively) [48]. No clinically significant differences were observed at recalls for
Wafaie et al [47] found that Filtek Z250 underwent no signifi- each of the materials with regard to dichotomous outcomes
cant change from the baseline to the recall periods, but all GIC (P>0.05) in relation to the recurrence of caries and erosion ab-
groups did (P<0.05). One study found that EQUIA showed sta- fraction [45-49,51-54,56] or tooth integrity [45,47,56].
tistically significant changes from baseline to 3 years of recall
(P=0.039), whereas the changes in Fuji IX GP Fast Set was less
notable [45]. However, another study found significant changes
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
Table 4. Characteristics of the studies during different recall periods and their relation to esthetics, functions, and biological behavior
(n=12).
3- 6- 9- 12- 2- 3- 4- 5- 6- 10-
Materials used Authors
month month month month year year year year year year
1. Staining surface/margin
EQUIA / NA / NA NA / / / / / Uzel et al,

Tetric EvoCeram p>0.05 p>0.05 p>0.05 2022 [42]
EQUIA / / / NA / 7.7% 2 / 5.4% 2 / / Wafaie

Riva Self Cure (HV) p>0.05 5.3% 2 2.6% 2 et al,
Ketac Universal 7.9% 2 7.9% 2 2023 [43]
Aplicap 2.6% 2 5.1% 2
Filtek Z250
EQUIA NA 5.88% 2 11.76% 2 / / / / / / / Akman and

Filtek Z550 p>0.05 3.12% 2 6.75% 2 Tosun
SonicFil 2.94% 2 5.88% 2 2020 [44]
X-tra Fil 2.94% 2 5.88% 2
EQUIA Fil / / / NA / NA NA / NA NA Gurgan

Gradia Direct p>0.05 p>0.05 p>0.05 p>0.05 p>0.05 et al,
Posterior 2020 [45]
EQUIA Fil / NA / NA NA / / / / / Menezes-

Z350-3M p>0.05 p>0.05 p>0.05 Silva et al,
2020 [46]
EQUIA NA NA NA / / / / / / / Kharma
Amelogen Plus p>0.05 p>0.05 p>0.05 et al,
2018 [47]
2. Colour match and translucency

EQUIA / / / 85% 2 / 84.6% 2 / 100% 2 / / Wafai

Riva Self Cure (HV) 15% 3 15.4% 3 84.2% 2 et al,
Ketac Universal 70% 2 81.6% 2 15.8% 3 2023 [43]
Aplicap 30% 3 18.4% 3 78.9% 2
Filtek Z250 62.5% 2 73.7% 2 21.1% 3
37.5% 3 26.3% 3 15.4% 2
10% 2 10.3% 2
EQUIA NA NA NA / / / / / / / Akman and

Filtek Z550 p>0.05 p>0.05 p>0.05 Tosun,
SonicFil 2020 [44]
X-tra Fil
EQUIA Fil / / / NA / 2.6% 2 2.1% 2 / 14.3% 2 13.4% 2 Gurgan

Gradia Direct p>0.05 100% 1 100% 1 13.7% 2 (15.8% 2) et al,
Posterior 4% 2 2020 [45]
(2.6% 2)
EQUIA Fil / 56.6% 2 / NA NA / / / / / Menezes-

Z350-3M 28.6% 2 p>0.05 p>0.05 Silva et al,
2020 [46]
2018 [47]
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
Table 4 continued. Characteristics of the studies during different recall periods and their relation to esthetics, functions, and biological
behavior (n=12).
3- 6- 9- 12- 2- 3- 4- 5- 6- 10-
3. Aesthetic anatomical form
EQUIA / / / NA / NA / 8.1% 2 / / Wafaie

Riva Self Cure (HV) >0.05 >0.05 5.4% 3 et al,
Ketac Universal 13.2% 2 2023 [43]
Aplicap 7.9% 3
Filtek Z250 13.2% 2
7.9% 3
5.1% 2
EQUIA NA NA / NA / / / / / / Akman and

Filtek Z550 >0.05 >0.05 >0.05 Tosun,
SonicFil 2020 [44]
X-tra Fil

Gradia Direct >0.05 >0.05 >0.05 >0.05 >0.05 et al,
Posterior 2020 [45]
EQUIA Fil / 43.4% 2 / 32.4% 2 46.8% 2 / / / / / Menezes-

Z350-3M 9.1% 2 10.8% 2 15.2% 2 Silva et al,
2020 [46]
4. Retention and fracture of material
EQUIA / NA / 94.286% 97.1% / / / / / Uzel et al,

Tetric EvoCeram p>0.05 100% 100% 2022 [42]
EQUIA / / / 92.5 / 89.7% / 89.7% / / Wafaie et al,

Riva Self Cure (HV) 87.5 87.2% 89.5% 2023 [43]
Ketac Universal 90% 89.7% 88.6%
Aplicap 95% 92.3% 92.3%
Filtek Z250
EQUIA 97.06% 88.24% / 82.35% / / / / / / Akman and

Filtek Z550 100% 100% 100% Tosun,
SonicFil 100% 100% 100% 2020 [44]
X-tra Fil 100% 100% 100%
EQUIA Fil / / / / / / / / 86.5% / Heck et al,

Fuji IX GP Fast 86.8% 2020 [52]
EQUIA Fil / / / / 97% / / / / / Molina et al,

Filtek Z250 98.5% 2020 [51]
EQUIA Fil / 98.7% / 95.8% 90.3% / / / / / Menezes-

Z350-3M 100% 98.7% 91.5% Silva et al,
2020 [46]
EQUIA Forte / / / / / 35% / / / / Araujo

Stainless Steel 82% et al,
Crown (Hall 2020 [48]
Technique)
EQUIA Fil / / / NA / 96.1% 96% / NA NA Gurgan

Gradia Direct p>0.05 (100%) (100%) p>0.05 p>0.05 et al,
Posterior 100% 100% 2020 [45]
(100%) (100%)
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
behavior (n=12).
3- 6- 9- 12- 2- 3- 4- 5- 6- 10-
EQUIA / / / 100% 94.6% 86.2% / / / / Fotiadou
Fuji IX GP Fast 93.1% 93.9% 74% et al,
2019 [41]
EQUIA / / / / / 82.9% / / / / Kupietzky

Filtek P60 95.1% et al,
2019 [50]
Vitremer / / / 98% 74% / / / / / Dermata

Filtek Z250 96% 74% et al,
2018 [49]
5. Approximal anatomical form
EQUIA / / / NA NA NA / / / / Fotiadou
Fuji IX GP Fast p>0.05 p>0.05 p>0.05 et al,
2019 [41]

EQUIA / / / NA / NA / NA / / Wafaie
Riva Self Cure (HV) p>0.05 p>0.05 p>0.05 et al,
Ketac Universal 2023 [43]
Aplicap
Filtek Z250
Vitremer / / / NA 12% 2 / / / / / Dermata

Filtek Z250 p>0.05 4% 5 et al,
2% 5 2018 [49]
EQUIA / / / / / NA / / / / Kupietzky
Filtek P60 p>0.05 et al,
2019 [50]
EQUIA Fil / NA / NA NA / / / / / Menezes-

Z350-3M p>0.05 p>0.05 p>0.05 Silva et al,
2020 [46]
6. Post operative sensitivity and tooth vitality

Aplicap
Filtek Z250

SonicFil 2020 [44]
X-tra Fil
EQUIA Fil / / / / / / / / NA / Heck et al,

Fuji IX GP Fast p>0.05 202 [52]

Posterior 2020 [45]
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
behavior (n=12).
3- 6- 9- 12- 2- 3- 4- 5- 6- 10-
2019 [41]
2018 [47]
7. Recurrence of caries erosion abfraction

Aplicap
Filtek Z250

SonicFil 2020 [44]
X-tra Fil


Posterior 2020 [45]
EQUIA Forte / / / / / NA / / / / Araujo

Stainless Steel p>0.05 et al,
Crown (Hall 2020 [48]
Technique)
EQUIA / / / / / NA / / / / Kupietzky
Filtek P60 p>0.05 et al,
2019 [50]
2019 [41]
Vitremer / / / NA NA / / / / / Dermata
Filtek Z250 p>0.05 p>0.05 et al,
2018 [49]
2018 [47]
8. Tooth integrity
Aplicap
Filtek Z250
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
behavior (n=12).
3- 6- 9- 12- 2- 3- 4- 5- 6- 10-
2019 [41]
9. Periodontal response/gingival health
Aplicap
Filtek Z250
Vitremer / / / 100% 1 6% 2 / / / / / Dermata
Filtek Z250 15% 2 26% 2 et al,
2018 [49]
Materials used 3-month 6-month 9-month 12-month 2-year 3-year 5-year 6-year 10-year Authors
10. Surface lustre/texture
EQUIA / 100% 1 / 5.71% 2 25.71% 2 / / / / Uzel et al,

Tetric EvoCeram 100% 1 100% 1 5.17% 3 2022 [42]
8.57% 2
EQUIA / / / 85% 2 / 97.4% 2 97.3% 2 / / Wafaie

Riva Self Cure (HV) 95% 2 2.6% 3 2.7% 3 et al,
Ketac Universal 5% 3 92.1% 2 86.8% 2 2023 [43]
Aplicap 90% 2 7.9% 3 13.2% 3
Filtek Z250 10% 3 89.5% 2 86.8% 2
12.5% 2 10.5% 3 13.2% 3
17.9% 2 20.5% 2
2.6% 3
EQUIA Fil / / / / / / / 100% 2 / Heck et al,

Fuji IX GP Fast 90% 2 2020 [52]
10% 3
EQUIA Fil / / / NA / NA / NA NA Gurgan

Gradia Direct p>0.05 p>0.05 p>0.05 p>0.05 et al,
Posterior 2020 [45]
EQUIA Fil / 44.7% 2 / 54.9% 2 48.4% 2 / / / / Menezes-

Z350-3M 18.2% 2 24.3% 2 27.3% 2 Silva et al,
2020 [46]
EQUIA / / / 87.5% 2 91.4% 2 92.3% 2 / / / Fotiadou

Fuji IX GP Fast 96.5% 2 5.71% 3 3.84% 3 et al,
93.9% 2 87.5% 2 2019 [41]
6.06% 3 4.16% 3
EQUIA 5% 2 30% 2 30% 2 / / / / / / Kharma

Amelogen Plus 100% 1 10% 2 10% 2 et al,
2018 [47]
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
behavior (n=12).
Materials used 6-month 12-month 2-year 3-year 5-year 6-year 10-year Authors
11. Marginal adaptation
EQUIA / NA / NA 2.7% 2 / / Wafaie
Riva Self Cure (HV) p>0.05 p>0.05 5.4% 3 et al,
Ketac Universal Aplicap 5.3% 2 2023 [43]
Filtek Z250 5.3% 3
7.9% 2
2.6% 3
5.1% 2
2.6% 3
EQUIA 11.76% 2 14.71% 2 / / / / / Akman and
Filtek Z550 100% 1 2.94% 3 Tosun,
SonicFil 100% 1 100% 1 2020 [44]
X-tra Fil 100% 1 100% 1
100% 1
EQUIA Fil / / / / / 10% 2 / Heck et al,
Fuji IX GP Fast 15% 3 2020 [52]
5% 4
5% 5
9.5% 2
4.8% 3
4.8% 4
14.3% 5
EQUIA Fil / NA / NA / NA NA Gurgan
Gradia Direct Posterior p>0.05 p>0.05 p>0.05 p>0.05 et al,
2020 [45]
EQUIA / NA NA 3.4% 2 / / / Fotiadou
Fuji IX GP Fast p>0.05 p>0.05 3.4% 3 et al,
10.3% 5 2019 [41]
8.3% 2
4.2% 4
4.2% 5
EQUIA NA NA NA / / / / Kharma
2018 [47]
Materials used 3-month 6-month 12-month 2-year 3-year 5-year Authors
12. Patient view
EQUIA NA NA NA / / / Akman and Tosun,

Filtek Z550 p>0.05 p>0.05 p>0.05 2020 [44]
SonicFil
X-tra Fil
EQUIA / / NA NA NA / Fotiadou et al,
Fuji IX GP Fast p>0.05 p>0.05 p>0.05 2019 [41]
EQUIA Forte / / / / 4.5% 3 / Araujo et al,
Stainless Steel Crown (Hall 23.4% 3 2020 [48]
Technique)
EQUIA / / 5% 2 / 5.1% 3 2.6% 2 Wafaie et al,
Riva Self Cure (HV) 7.5% 2 7.7% 2 2.6% 3 2023 [43]
Ketac Universal Aplicap 2.5% 3 2.6% 5 5.1% 5
Filtek Z250 5% 2 5.1% 2 2.6% 2
2.5% 3 2.6% 5 5.3% 3
5% 2 5.1% 2 2.6% 5
5.3% 3
5.1% 2
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
behavior (n=12).
Materials used 12-month 2-year 3-year 5-year 6-year Authors
13. Occlusal contour and wear
EQUIA Fil / / / / 25% 2 Heck et al,

Fuji IX GP Fast 5.6% 2 |2020 [52]
5.6% 3
EQUIA 25.5% 2 / 10.3% 2 10.8% 2 / Wafaie et al,

Riva Self Cure (HV) 15% 2 5.1% 3 8.1% 3 2023 [43]
Ketac Universal Aplicap 2.5% 3 13.2%% 2 18.4% 2
Filtek Z250 20% 2 10.5% 3 13.2% 3
2.5% 2 13.2% 2 15.8% 2
7.9% 3 10.5% 3
7.7% 2 10.3% 2
Vitremer NA 22% 2 / / / Dermata et al,

Filtek Z250 p>0.05 2% 3 2018 [49]
100% 1
EQUIA / / 6.9% 2 / / Kupietzky et al,

Filtek P60 94.8% 3 2019 [50]
51% 3
Materials used 12-month 3-year 5-year Authors

14. Radiographic examination
EQUIA NA NA 2.6% 2 Wafaie et al

Riva Self Cure (HV) p>0.05 p>0.05 5.1% 3 2023 [43]
Ketac Universal Aplicap 5.3% 2
Filtek Z250 2.6% 3
5.3% 2
2.6% 3
5.1% 2
2.6% 3
15. Adjacent mucosa
EQUIA NA NA NA Wafaie et al,

Riva Self Cure (HV) p>0.05 p>0.05 p>0.05 2023 [43]
Ketac Universal Aplicap
Filtek Z250
16. Oral and general health
EQUIA NA NA NA Wafaie et al,

Riva Self Cure (HV) p>0.05 p>0.05 p>0.05 2023 [43]
Ketac Universal Aplicap
Filtek Z250
NA – non-significant. Retention success rate% displayed. Class II and Mixed are outside of parenthesis (). Class I results are within
parenthesis ().
Periodontal Response/Gingival Health dichotomous comparison of stainless-steel Hall Crown versus

EQUIA Forte indicated a preference for EQUIA Forte [52]. Two
Two of the included studies found statically significant results included studies found no clinical significance observed at re-
regarding patient satisfaction. The results varied from clini- calls for each of the materials investigated, and no significant
cally excellent to clinically poor. One study found a significant differences were found for dichotomous outcomes [41,44].
decline in patient satisfaction with EQUIA Forte and Riva HV One study found statistically significant results regarding peri-
restorations from baseline to 5-year recall [47]. However, the odontal response [47]. At 12-month recall, Filtek Z250 was
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
associated with significantly more bleeding on probing BOP [65]. Surface staining may be influenced by the combination of
compared with Vitremer (P=0.005), and no clinical significance extrinsic stimulus and surface roughness, which correlates with
observed at recalls for each material investigated, and no sig- wear [66]. Additionally, fractures, defects, gaps at the margins,
nificant differences were found for dichotomous outcomes [53]. and marginal staining in the crevice between the restoration
and the cavity wall can be related to pigment absorption [47].
Marginal staining was observed in few cases during 6-year re-
Discussion call period [60]. Despite the minor statistical significance of the
results, no GIC was significantly affected by staining or margin
This study collated the results of 12 RCTs, focusing on the criteria because stains can be easily removed by polishing [40].
clinical suitability of GIC for load-bearing restorations accord-
ing to the FDI criteria. After analyzing the results, we found In relation to color matching of GIC restorations at different re-
significant differences in surface luster, staining surface/mar- calls, GIC groups performed worse than the RC groups in 3 stud-
gin, color match and translucency, esthetic anatomical form, ies. This result may be related to GIC’s optical properties, which
retention and fracture of material, marginal adaptation, oc- were outperformed by RC because of GIC’s lack of translucency
clusal contour, and approximal anatomical form. No statisti- [67,68]. This conclusion contrasts with the findings of other in-
cally significant differences were found in postoperative sen- vestigations, which found that neither GIC nor RC restorations
sitivity and recurrence of caries. The present results generally have a significant color mismatch with the surrounding tooth
demonstrate that the clinical performance of the GIC materi- structure. In 1 study, EQUIA Forte had a better color match with
als were similar for most of the above-mentioned parameters. adjacent tooth structures than the other GIC groups because
This finding may influence clinicians’ decision-making when of the small highly reactive glass particles within EQUIA Forte
considering restoration placement in class II restorations, sug- and the coating [47,69]. Two studies revealed an improvement
gesting that GIC is clinically suitable in appropriate systems. in color matching for the GIC group at 5- and 10-year recall,
GIC exhibited acceptable performance for posterior teeth af- which may be connected to GIC’s maturation over time [47,49].
ter 24 and 36 months [57]. This result is congruent with the findings of a 3-year clinical
study conducted by Diem et al [70], who found that the color
Surface luster, which indicates the ability of a surface to re- match of GIC restorations improved during the study period.
flect light, is fundamental to the esthetic appearance of resto-
rations and is inversely proportional to surface roughness. The Esthetic anatomic form is the acceptability of the esthetics of a
clinical success of a restoration is greatly influenced by the sur- restoration [40]. Significant results for GIC’s esthetic anatomical
face texture of a dental material [58]. All surfaces within the form were found in studies that compared GIC with RC, rang-
oral cavity are covered by the acquired pellicle and undergo ing from an ideal form to a form that deviates from the norm
biofilm adhesion. Bacteria are associated with dental diseas- but is still acceptable. This deviation can be related to the high
es, such as periodontal disease and dental caries. Accordingly, wear rate or material fracture for GIC [71]. By contrast, 2 stud-
surface roughness affects a surface’s ability to modulate and ies found no appreciable deviation in the form of the anatomi-
limit bacterial attachment and propagate microorganisms [59]. cal esthetic [47,49], which is supported by a systematic review
GIC is inferior to RC, but the surface luster of GIC is compara- by Dias et al [28], who found no deficiency for this parameter.
ble to that of the enamel. GIC exhibits slight deviation to dull
surfaces but can be enhanced by covering it with a film of sa- In relation to fracture and retention of GIC materials, only 1
liva or multiple pores on more than one-third of its surface. study found significant differences I fracture rates, and another
Therefore, no GIC failed for this purpose according to the FDI found fracture as the leading cause of failure, despite yielding
criteria (4 and 5). Many of the studies used surface coatings no significant results. The remaining studies investigating ma-
and recorded improved surface luster [47,60-62], indicating that terial fracture found no significant difference from baseline to
resin coatings are effective in transforming restoration surface recall periods and in comparisons with RC. These findings con-
texture without excessive polishing. However, extended recall tradict the existing literature, which suggests that CGIC is highly
periods revealed that the coatings degrade after enduring mas- prone to fracture, especially compared with RC [72]. The studies
tication and show a dull appearance [63]. Therefore, surface included in this review used reinforced restorative systems indi-
texture deterioration may be attributed to the positive corre- cated for load-bearing restorations (Table 3). This may increase
lation between surface roughness and wear [64]. the fracture toughness and durability of the restorations we ex-
plored. These restorative systems frequently included a paired
Few GIC groups showed significant differences from RC in sur- surface coating, such as EQUIA Fil and EQUIA COAT, improving
face staining from baseline to recall periods. The lack of pro- mechanical properties, such as fracture resistance. Increased
found staining may be due to GIC’s self-adhesion properties fracture resistance and high strength were observed after the
to enamel and dentin, eliminating the need for bonding agents application of coating agents, which prevented contamination
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
caused by intra-oral fluids before hardening. This type of con- in approximal anatomical form occurred in Vitremer and Filtek
tamination can lead to loss of matrix-forming ions, weakens a after a 2-year recall [53]. Cyclic loads generated occlusal-prox-
material, and degrades reinforcing properties within a coating’s imal marginal fractures and damaged the proximal point [84].
matrix [73-75]. A review of material longevity shows that GIC Given that only 1 study produced significant results, GIC may
typically has a success rate of 93-98% within the primary den- fit the requirements for approximal anatomical shape. However,
tition for the tooth’s lifespan and 5 years within the adult den- a recent RCT identified approximal anatomical shape as one
tition [76]. Therefore, the result from this study exceeds this of the primary causes of a class II GIC restoration failure [85].
expectation because many restorations have been retained for
up to 10 years. The existing literature regarding the lifespan In relation to periodontal response, a single study found a sig-
of GIC within load-bearing restorations was created 13 years nificant difference in gingival health between Vitremer and
ago. Therefore, developments in the composition of different Z250. At 12- and 24-month recalls, Santos et al [86] found that
brands of GIC may account for the improvement in retention. RMGIC positively affected subgingival biofilm composition more
than RC. According to Atieh, open-sandwich restorations expos-
Concerning marginal adaptation, an acid- or base-resistant layer ing Vitremer in their proximal aspect resulted in considerable
is created by the chemical adhesion of GIC to the tooth struc- improvement in gingival health when compared to SSC [87].
ture, creating a long-lasting marginal seal [77]. Furthermore,
the dimensional stability of GIC is due to its hydrophilicity, Despite the success of outcomes regarding GIC within this re-
which promotes the absorption of any fluid produced from the view, most of the included studies covered less than 5 years of
cavity prep, and adhesion to enamel ensures that the seal is recall. Therefore, large studies with long follow-up times are
fixed [13]. Additionally, GIC has the same coefficient of ther- required. Attention should be placed on approximal restora-
mal expansion as the tooth structure, and the microgap be- tions. In addition, the guidelines in the WHO’s Prevention and
tween a restoration and a tooth is small [78]. Coatings reduce Treatment of Dental Caries with Mercury-Free Products and
the formation of marginal gaps and were applied in the includ- Minimal Interventions have recommended GIC for single-sur-
ed studies [79]. Reducing the risk of marginal gaps is neces- face occlusal restorations [88]. The heterogeneity of the stud-
sary, as the dentin pulp complex is exposed to the oral envi- ies can be considered another limitation of this review, and the
ronment by restorations with poor marginal adaptation, and GIC and RMGIC have distinct compositions and microstructures.
restorations are vulnerable to microleakage and plaque reten-
tion [80]. These results varied, and 2 studies showed failures This review did not focus on surface coatings within GIC sys-
for this subgroup; both compared Fuji IX and EQUIA, but re- tems. However, the GIC and surface coating are promising ma-
ported contradictory results. Thus, both materials may be at terials at appropriate indications and cavity geometries when
risk of marginal gaps after 3-year recall [70]. mechanical factors are considered. Further research may be
required, especially long-term clinical studies that evaluate
Clinical evaluation of wear is performed to determine how mate- the efficacy of surface coatings in enhancing the mechanical
rials behave when subjected to challenging masticatory chang- properties of GIC in load-bearing restorations.
es in the mouth. All the restorations were clinically acceptable in
terms of wear resistance according to the findings of this study.
This might be explained by the modern GIC’s increased flexural Conclusions
strength and wear resistance. Additionally, the coating agent per-
meates the pores and stops cracks in restorations from spread- Our study found that GIC is suitable for load-bearing restora-
ing [81]. Only 1 study stated that the participant’s occlusion was tions. Notably, RC is superior to most subgroups with regard
normal, preventing excessive wear rates caused by clenching or to dichotomous outcomes. However, the differences were con-
bruxism habits [70]. Progressive occlusal wear was reported in siderable. Notable differences in surface luster, color match,
all studies despite the absence of failure. The impact of coarse translucency, and marginal adaptation were observed.
particles in dietary components and the strong occlusal forces in
the posterior region may reflect pitting and wear [82]. Declaration of Figures’ Authenticity
The tightness and durability of the proximal contact points of All figures submitted have been created by the authors, who
restorations are crucial because poor contact results in food im- confirm that the images are original with no duplication and
paction and discomfort during mastication [83]. Small changes have not been previously published in whole or in part.
Durrant L. et al:
© Med Sci Monit, 2024; 30: e943489
REVIEW ARTICLES
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Clinical Performance of Glass Ionomer Cement in Load-Bearing Restorations: A Systematic Review

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Keywords: Dental Materials • Glass Ionomer

Full-text PDF: https://www.medscimonit.com/abstract/index/idArt/943489

4424 4 2 88

Background materials, hinders polishing or finishing, and needs to be pro-

Figure 1. PRISMA flow diagram [31,32].

52,864 articles identified from

1 article identified through

Records excluded according to

Studies excluded based on title

Studies included in review for etc.

Clinical evaluation of microhybrid 2018 Kharma K, Zogheib T, RCT GIC is an acceptable 78

RCT – randomised control trials.

Table 2. Characteristics of the 12 included studies.

Comparison between used Number of No. of

ART HVGIC vs CRT RC EQUIA Fil, Z350-3M Children and 54 77 Permanent

Bulk-Fil vs GIC EQUIA, Tetric EvoCeram 10-12 YOA 35 70 Permanent

HVGIC vs RC EQUIA, Filtek P60 7 YOAm 45 131 Primary

RMGIC vs RC Vitremer 4-7.5 YOA 55 104 Primary

GIC vs RC Gradia Direct Posterior, 15-37 YOA (24m) 51 140 Permanent

GIC vs RC EQUIA, Amelogen Plus 25-63 YOA (41.3m) 15 40 Permanent

ART HVGIC vs CRT RC Class II 2 years No difference Low Molina et al,

ART HVGIC vs CRT RC Class II 2 years No difference Moderate Menezes-Silva et al,

GIC vs GIC 1 Class II 3 years No difference Very low Fotiadou et al,

Bulk-Fil RC vs GIC Class II 12 months Bulk-Fil RC Moderate Akman and Tosun,

HVGIC vs RC Class II 3 years RC Moderate Kupietzky et al,

RMGIC vs RC Class II 2 years No difference Very low Dermata et al,

GIC vs RC Mixed 10 years No difference Moderate Gurgan et al, 2020 [49]

GIC vs RC Class II 5 years No difference Moderate Wafaie et al. 2023 [47]

GIC vs RC Class II 9 months No difference Moderate Kharma et al, 2018 [51]

Figure 2. Cochrane risk of bias.

Material Type Indications Composition Authors

Material Type Indications Composition Authors

EQUIA / NA / NA NA / / / / / Uzel et al,

EQUIA / / / NA / 7.7% 2 / 5.4% 2 / / Wafaie

EQUIA NA 5.88% 2 11.76% 2 / / / / / / / Akman and

EQUIA Fil / / / NA / NA NA / NA NA Gurgan

EQUIA Fil / NA / NA NA / / / / / Menezes-

2. Colour match and translucency

EQUIA / NA / NA NA / / / / / Uzel et al,

EQUIA / / / 85% 2 / 84.6% 2 / 100% 2 / / Wafai

EQUIA NA NA NA / / / / / / / Akman and

EQUIA Fil / / / NA / 2.6% 2 2.1% 2 / 14.3% 2 13.4% 2 Gurgan

EQUIA Fil / 56.6% 2 / NA NA / / / / / Menezes-

3. Aesthetic anatomical form

EQUIA / / / NA / NA / 8.1% 2 / / Wafaie

EQUIA NA NA / NA / / / / / / Akman and

EQUIA Fil / / / NA / NA NA / NA NA Gurgan

EQUIA Fil / 43.4% 2 / 32.4% 2 46.8% 2 / / / / / Menezes-

4. Retention and fracture of material

EQUIA / NA / 94.286% 97.1% / / / / / Uzel et al,

EQUIA / / / 92.5 / 89.7% / 89.7% / / Wafaie et al,

EQUIA 97.06% 88.24% / 82.35% / / / / / / Akman and

EQUIA Fil / / / / / / / / 86.5% / Heck et al,

EQUIA Fil / / / / 97% / / / / / Molina et al,

EQUIA Fil / 98.7% / 95.8% 90.3% / / / / / Menezes-

EQUIA Forte / / / / / 35% / / / / Araujo

EQUIA Fil / / / NA / 96.1% 96% / NA NA Gurgan

EQUIA / / / / / 82.9% / / / / Kupietzky

Vitremer / / / 98% 74% / / / / / Dermata

5. Approximal anatomical form

EQUIA / NA / NA NA / / / / / Uzel et al,

Vitremer / / / NA 12% 2 / / / / / Dermata

EQUIA Fil / NA / NA NA / / / / / Menezes-