d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 551556

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

Compressive strength of two newly developed

glass-ionomer materials for use with the Atraumatic
Restorative Treatment (ART) approach in class II cavities
H. Koenraads a , G. Van der Kroon a , J.E. Frencken b,
a

Department of Preventive and Restorative Dentistry, Radboud University Nijmegen Medical Centre, College of Dental Sciences,
Nijmegen, The Netherlands
b Nijmegen International Centre for Oral Health, care planing and future scenarios, Radboud University Nijmegen Medical Centre,
College of Dental Sciences, Nijmegen, The Netherlands

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objectives. The null-hypotheses tested were that no difference in compressive strength of

Received 10 July 2008

ART class II cavities exists between those restored with (1) glass-carbomer and a com-

Accepted 12 December 2008

monly used glass-ionomer; (2) KMEM and the commonly used glass-ionomer and; (3)
glass-carbomer and KMEM.
Methods. 100 molar teeth, stratied by size, were randomly allocated to the four test groups.

Keywords:

Large ART class II cavities were drilled and restored with Clearl photoposterior (nega-

Atraumatic Restorative Treatment

tive control), Fuji IX (positive control), Glass-carbomer and KetacTM Molar Easymix (KMEM)

Glass-ionomer cement

(experimental groups). Half of the samples in each test group were 5000 times thermocycled

Class II restorations

between 5 C and 55 C, with a 30 s dwell time in each bath and a transfer time of 10 s. The

Compressive strength

restorations were statically tested at the marginal ridge until failure, using a rounded rectangular testing rod at crosshead speed of 1.0 mm/min. ANOVA and Students t-test were applied
to test for differences between the dependent variable (compressive strength at the nal
breaking point) and the independent variables (thermocycling and restorative material).
Results. Restorations of Clearl photoposterior had a statistically signicant higher mean
compressive strength value at nal breaking point than those of the three glass-ionomers
tested (p = 0.0001). No thermocycling effect was observed (p = 0.19). ANOVA between the three
glass-ionomer materials and mean compressive strength at nal breaking point showed no
statistically signicant difference (p = 0.09).
Signicance. Class II ART cavities restored with the newly launched Glass-carbomer and
KetacTM Molar Easymix were not signicantly more fracture resistant than comparable
restorations using the conventional glass-ionomer Fuji IX.
2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Recently published results of a meta-analysis on the survival

of ART restorations showed high survival percentages of

single-surface ART restorations using high-viscosity glassionomers in both primary, and permanent dentitions [1].
The meta-analysis also revealed an absence of survival
results of multiple-surface ART glass-ionomer restorations

Corresponding author at: Nijmegen International Centre for Oral Health, care planing and future scenarios, Radboud University Nijmegen
Medical Centre, College of Dental Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 361 4050; fax: +31 24 354 0265.
E-mail address: j.frencken@dent.umcn.nl (J.E. Frencken).
0109-5641/$ see front matter 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2008.12.008

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in permanent teeth. This was due to the nature of most

of those studies that have investigated the survival of ART
restorations in permanent teeth in young children [2,3] and
in older children of a low caries risk group [4,5], both of which
groups exhibited a low number of multiple-surface cavities.
With the assurance that the Atraumatic Restorative
Treatment is a reliable preventive and restorative caries management approach in single-surface cavities, attention can
now be directed to its application in multiple-surface cavities in permanent teeth. The ART approach has traditionally
used high-viscosity glass-ionomers to restore cavities. One
of the disadvantages of glass-ionomer, however, is its low
fracture toughness, particularly when used in large class-II
cavities. Untreated large multiple-surface cavities are frequently found in adults in countries where ART would be
appropriate. However, if ART is applied in eld situations in
developing countries, without access to restorative materials
known to have higher fracture toughness, the question arises
as to whether the placement of a restoration with a potentially
short survival rate would be at all helpful for the patient. On
the other hand, materials suitable for use in conjunction with
ART should be developed.
Recently, two glass-ionomer-based restorative materials
with improved physical characteristics have been launched:
KetacTM Molar Easymix (KMEM) [6] and glass-carbomer. KMEM
is an improved version of an established high-viscosity
glass-ionomer with an increased powderliquid ratio of
25% compared to the commonly used high-viscosity glassionomers. Glass-carbomer is a kind of glass-ionomer and
is distinguished from it by its nano-sized powder particles
and its composition that contains uorapatite. The latter
component was added as it has been shown that glassionomer changed into a uorapatite-like material over time
[7]. The nano-sized particles should facilitate a strengthening
of the material through an increased particle surface in contact with the glass-carbomer liquid. Furthermore, for setting,
glass-carbomer requires energy that is applied by using a lightcuring source in the range of 1400 mW/cm2 . Application of an
ultrasonic device and a direct heat device to glass-ionomer
have been shown to result in higher mechanical property values than was achieved through the standard setting reaction
of the material in-vitro [8]. In particular, the initial setting reaction was increased, which increased the compressive strength
of glass-ionomer to enamel [9].
The aim of the present investigation was to test the compressive strength of the two newly launched materials in
comparison with that of the commonly used glass-ionomer
in ART class II cavities. The null-hypotheses tested were
that no difference in compressive strength at nal breaking
point exists between: (1) glass-carbomer and a commonly
used glass-ionomer; (2) KMEM and the commonly used glassionomer; (3) glass-carbomer and KMEM.

2.

Materials and method

2.1.

Pretest and power calculation

regarding glass-carbomer, a pretest on the compressive

strength of the materials under study was needed in
order to calculate the sample size. The restorative materials tested were Clearl photoposterior (composite resin,
negative control; Kuraray, Japan), handmixed Fuji IX (conventional high-viscosity glass-ionomer, positive control; GC
Europe, Belgium), KetacTM Molar Easymix (extra high-viscosity
glass-ionomer; 3MESPE, USA) and glass-carbomer (Glasscarbomer Products, The Netherlands). All materials were
treated according to the manufacturers Directions for Use
and placed in a mould of cylinders with a diameter of 4 mm
and a height of 9 mm each. After a setting period of 40 h,
an MTS 858, Mini Bionix II (MTS, USA) testing machine
was used to subject all the samples to axial pressure of
1.0 mm/min. The mean compressive strength and standard
error (SE) values of the on average seven samples per group,
were 290 44.4 MPa (Clearl photoposterior), 86.8 30.7 MPa
(Fuji IX), 79.8 19.2 MPa (glass-carbomer) and 73.6 16.7 MPa
(KetacTM Molar Easymix).
Using the compressive strength values of the pre-test,
accepting an of 0.05 and a power of 80%, and agreeing that
a difference in results between positive control and experimental materials of 35% is clinically signicant, the power
calculation resulted in 25 teeth per group.

2.2.

One hundred extracted, intact, non-carious, restoration-free

human mandibular 3rd molars were selected and stored in
tap water at room temperature. About eighty percent of these
ranged in size from 10.0 to 10.9 mm, measured at the widest
bucco-lingual dimension, whereas the remaining teeth were
between 11.0 and 12.0 mm. The teeth were stratied for tooth
size and randomly distributed over the eight study groups
(Table 1).

2.3.

Cavity preparation

After the roots were notched all specimens were imbedded

into polymethylmetacrylate blocks, leaving the enamelcement-line just visible. To assess specic dimensions of an
ART cavity preparation, both operators treated a few cavitated teeth with ART hand instruments. The resulting shape
of the cavity was used as a template for drilling the cavities in the teeth used in this experiment. To simulate a
large class II ART-preparation, the shape of the box consisted
entirely of curved surfaces and slightly undermined enamel.
The cavities were prepared with a spherical diamond bur
(diameter 2.9 mm, 001-033 HP, Horico, Germany), in a highspeed, water-cooled hand-piece, by two trained operators.
Finally, the cavity surface was smoothed with a medium-sized
excavator (153/154, Henry Schein, USA). The exact dimensions
of the Class II ART preparation are displayed in Table 2 and
Fig. 1.

2.4.

Because of the paucity of data on the physical characteristics of KMEM and the complete absence of data

Specimen selection

Restorative procedure

Information on the restorative materials used is presented in Table 3. The restorative procedures are described
below.

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Table 1 Specications of the different test groups.N = number of specimens analysed.

Group

Restoration material and its treatment

1A
1B
2A
2B
3A
3B
4A
4B

5
5
15
15
14
14
14
15

Composite (Clearl photoposterior), stored in tap water for one week

Composite (Clearl photoposterior), thermocycled for one week
Conventional high-viscosity GIC (Fuji IX), stored in tap water for one week
Conventional high-viscosity GIC (Fuji IX), thermocycled for one week
Glass-carbomer, stored in tap water for one week
Glass-carbomer, thermocycled for one week
KetacTM Molar Easymix, stored in tap water for one week
KetacTM Molar Easymix, thermocycled for one week

Table 2 Dimensions (mm) of the preparation to

simulate a large class II ART cavity.
Parameter
Largest bucco-lingual width
Width at occlusal plane
Height above enamelcement-junction
Axial depth, mesio-distal
Undermined enamel at the
entire enamel-dentinjunction

2.4.1.

Size, mean and

SD (mm)
5.80 (0.25) (twice the bur
width)
4.00 (0.25)
1.00 (0.25)
2.90 (0.25) (bur entirely
countersunk)
0.50

Composite resin

Clearl photoposterior (Group 1): The cavity was rinsed with

water and air-dried with an air/water syringe. After application of a Tofemire (1101C 0.035, Hawe-Neos, Italy) matrix
band, the cavity was acid-etched with phosphoric acid for
15 s, using a cotton pellet, rinsed with water and air-dried.
Clearl SA primer (Kuraray, Japan) was applied with a cotton bud and air-dried. Clearl Photobond (Kuraray, Japan) was
then applied, dispersed with pressed air and cured for 10 s
with UV light (Kulzer Translux CL, Heraeus Kulzer, USA). The
cavity was lled with syringable Clearl photoposterior, in
three layers. Each layer was light-cured for 20 s. Finally, the
Tofemire matrix band was removed and the restoration was
nished with a ne granular diamond burr (FG 7406-018, Jet
Diamonds, USA and FG 249-F012, Horico, Germany) and Soex
disks (3MESPE, USA) and was stored in tap water.

2.4.2.

Glass-ionomer

Fuji IX hand-mixed (Group 2) and KetacTM Molar Easymix

hand-mixed (Group 4): After application of a Tofemire matrix
band, the cavity was dried twice, using cotton pellets for 5 s

Fig. 1 Third mandibular molar, occlusal, mesial and

buccal view, preparation in red. (For interpretation of the
references to color in this gure legend, the reader is
referred to the web version of the article.)

each. Conditioning the cavities in Group 2 was achieved by

dipping a moist cotton pellet in the Fuji IX liquid and applying
it for 10 s, then washing the cavity with wet cotton pellets for
10 s and drying it with dry cotton pellets. A factory-produced

Table 3 The manufacturer, the LOT-number and the expiration date of the used restorative materials.
Restorative material

Manufacturer

LOT

Expiry date

Clearl photoposterior (composite resin)

Fuji IX (conventional high-viscosity
glass-ionomer)

Kuraray, Osaka, Japan

GC Corporation,
Osaka, Japan

00202B
Powder: 0611101
Liquid: 0611081

09-2008
Powder: 11-2009
Liquid: 11-2009

Glass-carbomer (new product)

Glass-carbomer Products, Leiden, The Netherlands

7612847

12-2008

KetacTM Molar Easymix (conventional

extra high-viscosity glass-ionomer)

3M ESPE, St. Paul,

MN, USA

Powder: 277193
Liquid: 275416

Powder: 03-2009
Liquid: 08-2009

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dentin conditioner (3MESPE, USA) was used to condition the

cavities in Group 4. The powder and liquid ratio were mixed
according to the Directions for Use until a homogeneous mixture was achieved within 30 s at room temperature (21 C).
The mixture was placed into the cavity in increments, using
an applier/carver instrument (ART 102-6508; Henry Schein,
USA) and an Ash 6 instrument (1052/6, Martin, Germany),
and pushed into position with a medium sized excavator
(153/154, Henry Schein, USA). After placement of the nal
layer a petroleum jelly gloved nger held the glass-ionomer
under pressure for 10 s. The excess material was removed with
the applier/carver instrument and a medium-sized excavator.
The restorative procedure was completed by placing a layer of
petroleum jelly over the glass-ionomer to maintain the correct
water balance within the restoration. The teeth were stored in
tap water.

2.4.3.

Glass-carbomer

Glass-carbomer (Group 3): The cavity was rinsed with water

and air-dried, using a water/air syringe. After application of a
Tofemire matrix band, the tooth surfaces were prepared with
a cotton pellet dipped in Tooth Cleaner (Glass-Carbomer
Products, The Netherlands) for 15 s, rinsed with water and
air-dried with a water/air syringe. The glass-carbomer capsule
was activated, using the CapActivator (Glass-Carbomer Products, The Netherlands), and mixed in a RotoMix (3MESPE, USA)
for 20 s. The mixed capsule was placed in a universal applicator and, after the stop was removed from the nozzle and bent
slightly, the cavity was lled in one go. A cotton pellet was
used to cover the surface of the restoration with Surface Gloss
(Glass-carbomer Products, The Netherlands). The restoration surface was then placed under light nger-pressure and
light-cured with a high energy lamp (1400 mW/cm2 , FlashLite 1401, Discus Dental, USA) for 90 s. The restorations were
nished with a ne granular diamond burr (FG 7406-018
and FG 249-F012) and Soex disks and nally, stored in tap
water.
The restorations were performed by two trained operators;
each producing half of the restorations of each group, with the
other assisting.

2.5.

Testing

Half of the samples in each test group were thermocycled

(Haake S/N A 1006, Thermo Fisher Scientic Inc., USA) 5000
times, between 5 C and 55 C, with a dwell time of 30 s in
each bath and a transfer time of 10 s. Teeth were stored in
water at room temperature before being subjected to load testing, as presented in Fig. 2. On each resin block a line was
drawn at an angle of 13.5 , to ensure the right positioning in
the testing machine. The restorations were statically tested at
the marginal ridge until failure. A rounded rectangular testing rod (type CR 1.5, width 10 mm, radius 1.5 mm) was used
at a crosshead speed of 1.0 mm/min. The total time between
restoring and testing of the molars was three weeks.

2.6.

Evaluation

To ensure that preparations complied with the specied

dimensions, an impression of the cavities of eight prepara-

Fig. 2 Schematic representation of the positioning of the

specimen in the testing machine.

tions (one from every group, randomly chosen) were made,

using Express (3MESPE, USA), and dimensions were measured
with sliding callipers. All thus tested preparations fell within
the set limits (Table 4).
As failures occurred in different ways, a distinction was
made between adhesive and cohesive failure. The latter was
further divided into failure within the tooth and failure within
the restoration.

2.7.

Statistical analysis

The compression strength was registered in Newtons. The

dependent variable was compressive strength at the nal
breaking point (fracture of restoration or tooth). The independent variables tested were thermocycling (yes/no) and
restorative material (four groups). As the data were randomly
distributed, a logarithmic transformation preceded the statistical tests between dependent and independent variables
using a twofold analysis of variance with interaction. Students
t-test was used to determine differences between restorative
material groups. A statistically signicant difference was set
at p < 0.05.

3.

Results

One sample was lost during thermocycling. Results of two

samples (one glass-carbomer and one KMEM) were considered
invalid, owing to incorrect positioning in the testing device.
This resulted in a data set of 97 correctly performed tests.
The mean compressive strength and standard errors at
nal breaking point are presented in Fig. 3, by thermocycling and restorative material. Only a restorative material
effect (p = 0.0001) in mean compressive strength value at
nal breaking point was observed. Restorations of Clearl
photoposterior had a statistically signicant higher mean
compressive strength value at nal breaking point than

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Table 4 Width, height and depth of the impressions made of the cavity preparations randomly chosen from the test
groups.
Specimen from
test group

Width (mm) (specied

width = 6.8 0.25 mm)

1
2
3
4
5
6
7
8

Height (mm) (specied height

depends on the crown height)

6.6
6.7
6.6
7.0
6.9
6.6
6.7
6.9

Depth (mm) (specied

depth = 2.9 0.25 mm)

4.5
4.2
4.9
5.0
4.8
4.3
4.5
4.6

4.

Fig. 3 Mean compressive strength values and standard

errors of the four test groups, measured at the highest
breaking point by thermocycling (T). C.P. = Clearl
photoposterior; Fuji = Fuji IX; G.C. = Glass-carbomer;
K.M.E. = KetacTM Molar Easymix.

those of the three glass-ionomers tested. As no thermocycling effect was observed (p = 0.19), ANOVA between the three
glass-ionomer materials and mean compressive strength at
nal breaking point was carried out, using all the available
glass-ionomer restorations (n = 87). No statistically signicant
difference was found amongst the three glass-ionomer materials (p = 0.09).
The failure behavior of all restorative materials is presented
in Table 5. All Clearl photoposterior restorations showed a
combined adhesive and cohesive failure of the tooth, whereas
all glass-ionomer restorations showed cohesive failure of the
restoration, in some cases combined with a cohesive failure
of the tooth.

3.0
3.0
3.1
2.9
2.7
2.7
2.9
2.8

Discussion

In order to make the cavities as standardized and realistic as

possible, both size and shape of the ART class II preparations
were prepared, to calculated dimensions. As no signicant difference in size and shape was found in the subsamples tested,
all cavity preparations were considered standardized and in
accord with ART-shaped cavity preparations.
A higher powder-to-liquid ratio would, in theory, lead to a
stronger restoration [10]. However, this assumption was not
conrmed in the present in-vitro study. Restorations with
KetacTM Molar Easymix (highest powderliquid ratio) were
not found to be signicantly stronger than those of Fuji
IX and glass-carbomer. Therefore, all three null-hypotheses
were accepted. The compressive strength of both Fuji IX and
KetacTM Molar Easymix in the present study were similar to
those reported by Peez and Frank [6].
Both operators experienced, even after long and intensive training, difculties in mixing KetacTM Molar Easymix. It
was especially difcult to produce a good mixture constantly
within the 30 s recommended by the manufacturer. To the contrary, the conventional glass-ionomer Fuji IX, having a 25%
lower powder-to-liquid ratio, was easier to mix and resulted
in a more homogeneous mixture. Another practical difculty
experienced by the operators was the displacement of small
parts of the restorative material at the time of removing the
matrix band. This occurred most often with glass-carbomer,
a few times with KetacTM Molar Easymix and Fuji IX, but
never with Clearl photoposterior as the restorative material. Furthermore, it was observed that not all glass-carbomer
restorations were fully hardened; some not even after 40 h. In

Table 5 Failure behavior of the restorations by adhesive and cohesive failure by the tested groups.

Clearl photoposterior
C.P Clearl photoposterior Thermo
Fuji IX
Fuji IX Thermo
Glass-carbomer
Glass-carbomer Thermo
KMEM
KMEM Thermo

CR

A and CR

60%
33%
79%
79%
86%
40%

20%

A and CT
100%
100%

CR and CT

13%
60%
21%
21%
14%
60%

A, CT and CR

7%
7%

A = adhesive failure, CR = cohesive failure of the restoration, CT = cohesive failure of the tooth. KMEM = KetacTM Molar Easymix.
Thermo = thermocycled.

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practice this observation means that a glass-carbomer restoration runs a high risk of being damaged by the patient even
before it has hardened completely. The authors, therefore, recommend the use of Fuji IX and KetacTM Molar Easymix in
further clinical trials on ART restoration; such as testing the
compressive strength under incremental dynamic forces.
Although Clearl photoposterior is stronger than the glassionomers tested in the present study, its fracture mode
resulted in sacricing surrounding enamel and/or dentin. This
was in contrast to the glass-ionomers that showed fracture
lines within the material, which has been a characteristic of
glass-ionomer cement [11]. In a clinical situation, the latter
fracture mode is to be preferred to the former, as it permits
easier repair.
In conclusion: class II ART restorations with the newly
launched Glass-carbomer and KetacTM Molar Easymix were
not signicantly more fracture-resistant than comparable
restorations made with the conventional glass-ionomer Fuji
IX. ART restorations with Clearl photoposterior were most
fracture-resistant. This means that the conventional glassionomer Fuji IX, currently used in ART restorations, does not
need to be replaced by either of the two newly launched glassionomer materials. However, the search needs to continue for
a material that incorporates the positive properties of glassionomer (chemical adhesion, easy application and moulding,
independence from electricity and piped water supply) and
the best quality of composite, its physical strength, in order to
improve ART restorations in class II cavities.

Acknowledgements
The authors thank Ing. J. Mulder for analysing the data and Dr.
J. Wolke for assistance in testing.
The authors are also grateful to GC Europe NV, Belgium;
Glass Carbomer Products NV, The Netherlands and 3MESPE,
The Netherlands for supplying the restorative materials.

references

[1] Vant Hof MA, Frencken JE, van Palenstein Helderman WH,
Holmgren CJ. The ART approach for managing dental caries:
a meta-analysis. Int Dent J 2006;56:34551.
[2] Mandari GJ, Frencken JE, vant Hof MA. Six-year success
rates of occlusal amalgam and glass-ionomer restorations
placed using three minimal intervention approaches. Caries
Res 2003;37:24653.
[3] Frencken JE, Taifour D, vant Hof MA. Survival of ART and
amalgam restorations in permanent teeth after 6.3 years. J
Dent Res 2006;85:6226.
[4] Frencken JE, Makoni F, Sithole WD. ART restorations and
glass ionomer sealants in Zimbabwe: survival after 3 years.
Community Dent Oral Epidemiol 1998;26:37281.
[5] Lo EC, Holmgren CJ, Hu D, van Palenstein Helderman W.
Six-year follow up of Atraumatic Restorative Treatment
restorations placed in Chinese school children. Community
Dent Oral Epidemiol 2007;35:38792.
[6] Peez R, Frank S. The physical-mechanical performance of
the new KetacTM Molar Easymix compared to commercially
available glass ionomer restoratives. J Dent 2006;34:5827.
[7] Van Duinen RN, Davidson CL, De Gee AJ, Feilzer AJ. In situ
transformation of glass-ionomer into an enamel-like
material. Am J Dent 2004;17:2237.
[8] Kleverlaan CJ, van Duinen RNB, Feilzer AJ. Mechanical
properties of glass ionomer cements affected by curing
methods. Dent Mater 2004;20:4550.
[9] Algera TJ, Kleverlaan CJ, Prahl-Andersen B, Feilzer AJ. The
inuence of environmental conditions on the material
properties of setting glass-ionomer cements. Dent Mater
2006;22:8526.
[10] Aratani M, Pereira AC, Correr-Sobrinho L, et al. Compressive
strength of resin-modied glass ionomer restorative
material: effect of P/L ratio and storage time. J Appl Oral Sci
2005;13:3569.
[11] Watson TF. Bonding glass-ionomer cements to tooth
structure. In: Davidson CL, Mjor IA, editors. Advances in
glass-ionomer cements. USA: Quintessence Publishing Co,
Inc; 1999. p. 132.