The atraumatic restorative treatment (ART) approach for primary teeth: review of literature

There is widespread interest in and increasing usage of the atraumatic restorative treatment (ART) technique or approach for the restoration of primary teeth, especially in developing countries. However, most of the published reports of the clinical performance of newer, more-viscous esthetic conventional glass ionomer restorative cements marketed for the technique have been from short-term studies, and there have been very few reports comparing different types of restorative materials and methods of cavity preparation. After 12 months, Class II/multisurface and Class III/IV ART restorations have generally shown success rates of approximately 55-75% and 35-55%, respectively. Failures were usually from restoration losses and fractures. Class I & V/single-surface ART restorations have had much better short-term success rates of approximately 80-90%. Recurrent caries was not a concern at this time, but occlusal wear was relatively high. Further improvements in the mechanical and adhesive properties of the newer cements are still required, together with further clinical investigations of the remineralization of shallow open preparations as an alternative to placing restorations. The ART approach is readily accepted by children and has resulted in the retention of many teeth that would otherwise have been extracted.     

Selection of restorative materials for the atraumatic restorative treatment (ART) approach: a review

The atraumatic restorative treatment (ART) technique or approach for the restoration of primary and permanent teeth has been widely adopted in, but not limited to, developing countries. However, the requirement for the placement of the restorative materials under often less-than-ideal conditions imposes significant restrictions on their selection; and there have been very few randomized clinical trials or reports comparing different types of restorative materials and treatments. Although conventional glass-ionomer cements (GICs) have relatively poor mechanical and adhesive strengths, their satisfactory biological features, ease of use, and low costs are distinct advantages. Most of the published reports of the clinical performance of the newer, high-strength esthetic conventional GICs specifically marketed for the ART approach have been from short-term studies. Satisfactory clinical performance has been demonstrated for single-surface posterior restorations only, over three years. Findings indicate that further improvements in restorative materials are still required for their use with the ART approach, together with further clinical investigations of the remineralization of shallow open caries lesions, as an alternative to placing definitive restorations.     

Comparison of atraumatic restorative treatment and conventional cavity preparations for glass-ionomer restorations in primary molars: one-year results.

OBJECTIVE: The purpose of this study was to compare the success rates of glass-ionomer cement restorations placed with the atraumatic restorative treatment approach and conventional cavity preparation methods. METHOD AND MATERIALS: Two encapsulated, high-strength, esthetic conventional glass-ionomer cements were placed in 82 Class I and 53 Class II atraumatic restorative treatment and conventional cavity preparations, and an encapsulated amalgam alloy was placed in 32 Class I conventional preparations, in vital primary molars of 60 Chinese children aged 7 to 9 years. RESULTS: The atraumatic restorative treatment preparations, made with hand instruments only, took approximately 50% longer to complete than did the preparations completed with conventional rotary instrumentation. After 1 year, there were no amalgam failures. For the glass-ionomer cement restorations, when the atraumatic restorative treatment method was used, significantly better survival rates were found for Class I (92.9%) than for Class II (64.7%) cavity preparations. There was also a strong trend for relatively better survival rates for the conventional cavity preparation method (86.7%) than for the atraumatic restorative treatment (64.7%) method for Class II cavity preparations. However, both the atraumatic restorative treatment and conventional methods appeared equally effective for Class I preparations. CONCLUSION: In a clinic setting, the use of atraumatic restorative treatment hand instruments for cavity preparation is more time consuming, and the method may also provide less mechanical retention and/or bulk of glass-ionomer cement for some Class II preparations in primary molars than does the use of conventional rotary instruments.     

Comparison of atraumatic restorative treatment and conventional restorative procedures in a hospital clinic: evaluation after 30 months.

OBJECTIVE: The purpose of this study was to evaluate two glass-ionomer cements placed in the occlusal surfaces of permanent molar teeth, using two cavity preparation methods. METHOD AND MATERIALS: Three dentists placed 149 restorations for 68 patients in a hospital clinic. Atraumatic restorative treatment or conventional cavity preparation methods were used for two encapsulated, high-strength conventional glass-ionomer cements: Fuji IX GP and Ketac-Molar. Non-gamma 2 amalgam alloy was used in conventional preparations for comparison. RESULTS: The restorative procedures were uneventful, but cavity preparations made with atraumatic restorative treatment hand instruments took approximately twice as long as did conventional rotary instrumentation. After 30 months, only one glass-ionomer cement restoration had failed. Both glass-ionomer cements showed high early losses of sealant material, but caries was not detected in the exposed fissures. Both glass-ionomer cements also showed relatively high restoration wear. At 30 months, the mean cumulative net occlusal wear was 119 +/- 12 mm for Fuji IX GP and 96 +/- 13 mm for Ketac-Molar; the difference was not statistically significant. Color matching improved significantly by 6 months; there was no significant difference in color match between the two glass-ionomer cements by 12 months. Minor surface tarnishing and marginal discrepancies were present in the amalgam restorations and increased with time. CONCLUSION: The occlusal restorations performed satisfactorily over periods of up to 30 months. However, the continued deterioration of the cements requires longer-term studies to be undertaken.     

Glass ionomer cements used as fissure sealants with the atraumatic restorative treatment (ART) approach: review of literature

AIM: To review the success of newer, more-viscous aesthetic conventional glass ionomer cements (GICs), that have been marketed specifically for the atraumatic restorative (ART) technique or approach, when used as pit and fissure sealants. As part of this approach, enamel fissures adjacent to the ART restorations are conditioned with poly (acrylic) acid (PAA) and then usually sealed with a GIC, using the finger-press method. RESULTS: The newer GICs appear in vitro to penetrate adequately and seal occlusal fissures in permanent molar teeth, and clinical studies of the ART approach over three years have found sealant retention (full and partial) to be approximately 70%, with fissure caries approximately 0-4%. In two studies, fissure caries was significantly reduced in sealed as compared with unsealed teeth over three years. CONCLUSIONS: Although the results appear to be better with the newer than with earlier conventional GIC products, the ART studies have generally involved populations at low-risk to caries, and further improvements in the mechanical properties of the cements are required for optimal long-term clinical success. Etching the enamel fissures with phosphoric acid, instead of conditioning with PAA, before GIC sealant placement warrants clinical investigation.     

Clinical performance of resin-modified glass ionomer cement restorations in primary teeth. A retrospective evaluation

BACKGROUND: The authors retrospectively evaluated the clinical performance of one resin-modified glass ionomer cement as a restorative material in Class I, Class II, Class III and Class V restorations in primary teeth. METHODS: A total of 306 patients who had received a total of 864 resin-modified glass ionomer restorations, which had been in their mouths for a minimum of three years, were included in this evaluation. The authors assessed the clinical observations recorded in patients' records and used bitewing radiographs to assess Class II restorations. RESULTS: The authors found an overall restoration success rate of 93.0 percent, with Class I restorations having a 92.6 percent success rate, Class II restorations having a 93.3 percent success rate, Class III restorations having a 100 percent success rate, and Class V restorations having a 98.0 percent success rate. CONCLUSIONS: The resin-modified glass ionomer cement functioned well as a Class I, Class II, Class III and Class V restorative material in primary teeth. CLINICAL IMPLICATIONS: Resin-modified glass ionomer restorative cement is a durable and reliable material to use for Class I, Class II, Class III and Class V restorations in primary teeth. Therefore, dentists have a proven alternative to silver amalgam and resin-based composite for primary tooth restoration.     

Restoration of permanent teeth in young rural children in Cambodia using the atraumatic restorative treatment (ART) technique and Fuji II glass ionomer cement

Several recent studies have demonstrated the success of the ART (atraumatic restorative treatment) technique under field conditions in developing countries. The ART technique involves removal of caries using only hand instruments, and placing a glass ionomer cement (GIC) restoration.
Objectives. To estimate the longevity of Fuji II GIC ART restorations placed in permanent teeth by dental nurse students under field conditions in rural Cambodia.
Design . Clinical field trial.
Setting . One high school in rural Cambodia.
Sample and methods . 53 subjects between the ages of 12 and 17 who had dental caries were selected to participate. Subjects were randomly assigned to a dental nurse student for cavity preparation and placement of ART restorations (without cavity conditioning).
Results . 92·1% of the carious lesions required class I or class V restorations, and 85·4% were in the lower molars. 89 teeth were filled. At 1 and 3 years 86·4% and 79·5% of restorations were still present. Restorations were assessed by one dentist according to standard criteria. 76·3% of the restorations were judged to be successful at 1 year, and 57·9% at 3 years.
Conclusions . Factors which may have affected the success rates included: the material used, technical factors, failure to condition the cavity prior to restoration, and inexperience of the operators. The results suggest that ART restorations in permanent teeth using Fuji II GIC are only moderately successful after 3 years. Better results could be expected by using a dentine conditioner in conjunction with one of the newer stronger glass ionomer cements.     

Inhibition of artificial secondary caries in root by fluoride-releasing restorative materials

This investigation evaluated the fluoride-releasing properties of various fluoride-releasing restorative materials, including resin-modified glass-ionomer cements (Fuji ionomer TypeII LC, Photac-Fil Aplicap, Vitremer), compomers (Ionosit FIL, Compoglass, Dyract) and fluoride-releasing resin composites (Heliomolar radiopaque, Degufill mineral). The study also estimated the effects of those materials on the inhibition of artificial secondary caries around restorations using a bacterial caries-inducing system. The amount of fluoride released from the materials in deionized water was measured every one week for 10 weeks. Class V cavities with the gingival margin located in the root were prepared in extracted human premolars and restored with each of the materials. The restored teeth were incubated in the bacterial artificial caries chamber, and the artificial lesion created around the restoration was observed microradiographically. The resin-modified glass-ionomer cements released the largest amount of fluoride and created a thick radio-opaque zone in the artificial lesion along the restoration-dentin interface. These results indicated that the fluoride-releasing restorative materials have the potential to inhibit secondary caries formation around restorations. Resin-modified glass-ionomer cements presented a particularly strong effect, compared with compomers and fluoride-releasing resin composites.     

Glass-ionomer cements in Class V restorations

The aim of the present study was to evaluate the effect of two different techniques of glass-ionomer application on the marginal microleakage in Class V restorations. Two types of composite resins were also used. Nonretentive Class V cavities were prepared at the cementum enamel junction of human extracted third molars. Glass-ionomer cements were applied with a chamfer technique or as base in the floor of the cavity. After restoration, the samples were stored in dye solution, sectioned and observed under optical stereomicroscope. The base technique for glass-ionomer cements showed less microleakage than the other restorative methods.     

The effect of polishing systems on microleakage of tooth coloured restoratives: Part 1. Conventional and resin-modified glass-ionomer cements

The purpose of this in vitro study was to investigate the effect of polishing systems on the microleakage of conventional and resin-modified glass-ionomer cements. Class V cavities were prepared at the cemento-enamel junction of 80 freshly extracted posterior teeth. The prepared teeth were randomly divided into two groups and restored with conventional or resin-modified glass-ionomer cements. The restored teeth were stored in distilled water at 37 degrees C for 1 week after removal of excess restorative with diamond finishing burs. The restored teeth were then divided into four groups of 10 and finished and polished using the following systems: Two Striper MFS; Sof-Lex XT; Enhance Composite Finishing and Polishing System; Shofu Composite Finishing Kit. The finished restorations were subjected to dye penetration testing. Results showed that the microleakage at dentin margins of conventional glass-ionomer cements and enamel margins of resin-modified glass-ionomer cements are significantly affected by the different polishing systems.     

Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis

The purpose of this study is to perform a systematic investigation plus meta-analysis into survival of atraumatic restorative treatment (ART) sealants and restorations using high-viscosity glass ionomers and to compare the results with those from the 2005 ART meta-analysis. Until February 2010, four databases were searched. Two hundred four publications were found, and 66 reported on ART restorations or sealant survival. Based on five exclusion criteria, two independent reviewers selected the 29 publications that accounted for the meta-analysis. Confidence intervals (CI) and or standard errors were calculated and the heterogeneity variance of the survival rates was estimated. Location (school/clinic) was an independent variable. The survival rates of single-surface and multiple-surface ART restorations in primary teeth over the first 2 years were 93% (CI, 91–94%) and 62% (CI, 51–73%), respectively; for single-surface ART restorations in permanent teeth over the first 3 and 5 years it was 85% (CI, 77–91%) and 80% (CI, 76–83%), respectively and for multiple-surface ART restorations in permanent teeth over 1 year it was 86% (CI, 59–98%). The mean annual dentine lesion incidence rate, in pits and fissures previously sealed using ART, over the first 3 years was 1%. No location effect and no differences between the 2005 and 2010 survival rates of ART restorations and sealants were observed. The short-term survival rates of single-surface ART restorations in primary and permanent teeth, and the caries-preventive effect of ART sealants were high. Clinical relevance: ART can safely be used in single-surface cavities in both primary and permanent teeth. ART sealants have a high caries preventive effect.     

非创伤性充填技术治疗乳磨牙龋疗效观察

目的探讨非创伤性充填技术(ART)修复乳牙龋的疗效及儿童对ART的接受程度。方法选择患牙本质龋的乳牙580颗,分为3组,ART充填198颗,190颗牙作为对照进行银汞合金充填,192颗采用牙钻备洞,玻璃离子充填。1年及2年后复查。结果84.5%儿童使用ART治疗无不适感,91.2%的学生愿意使用ART方法进行治疗。ART组第1、2年的成功率(88.3%、76.0%)与银汞合金对照组(80.5%、71.3%)、牙钻玻璃离子组(89.9%,79.9%)无显著性差异。ART组及牙钻组2年继发龋发生率(10.55%与9.80%)低于银汞合金对照组(22.56%),差异有显著性。结论ART技术简单,效果较好,对于乳牙龋是一种有效的治疗方法。     

Restoration of primary anterior teeth: review of the literature

This paper reviews the published data on restorations of primary anterior teeth. The discussion includes Class III restorations, Class V restorations, various forms of full coronal restorations, atraumatic restorative technique (ART) and recommendations for future research.     

Six-year evaluation of the atraumatic restorative treatment approach in permanent-tooth Class III restorations

PURPOSE: The aim of this study was to assess the 6-year performance of the ART (atraumatic restorative treatment) approach in Class III restorations in permanent teeth. MATERIALS AND METHODS: A total of 127 ART Class III restorations, using Ketac-Molar (3M ESPE) ionomer cement, was performed in 58 adult patients by one experienced operator in 1998. After a 6 years, 34 patients and 65 restorations were evaluated according to ART criteria. Two calibrated examiners carried out the evaluation. Data were analyzed by exact 95% Confidence Interval and Survival Analysis using the Jackknife method for standard error determination. RESULTS: Among assessed restorations, 73.8% (95% CI = 61.5% to 86.2%) were in good condition and classified as successful, with a 67.6% (95% CI = 54.4% to 80.7%) cumulative survival rate. Failed restorations included 13.9% completely or partially missing restorations, 9.2% restorations that had been replaced by other treatment, 1.5% restorations with a large defect at the margin, and 1.5% restorations that presented high wear on the surface. No caries was observed even in those teeth in which restorations were absent. CONCLUSION: The 6-year success rate of the ART approach in anterior permanent teeth (Class III) was considered high.     

Clinical investigation of two glass-ionomer restoratives used with the atraumatic restorative treatment approach in China: two-years results.

OBJECTIVE: To compare the clinical performance of two glass-ionomer cements, ChemFlex (Dentsply DeTrey) and Fuji IX GP (GC), when used with the atraumatic restorative treatment (ART) approach in China. METHODS: Eighty-nine school children aged between 6 and 14 years who had bilateral matched pairs of carious posterior teeth were included. A split-mouth design was used in which the two materials were randomly placed on contralateral sides. The performance of the restorations was assessed directly and also indirectly from die-stone replicas at baseline and after 6, 12, and 24 months. RESULTS: The 24-month cumulative survival rates of ART restorations in the primary teeth were 93 and 90% for the ChemFlex and Fuji IX GP class I restorations, respectively, while 40 and 46% of class II restorations placed with the respective materials were satisfactory. In the permanent dentition, only class I restorations were involved and the cumulative survival rates were 95 and 96% for ChemFlex and Fuji IX GP. For the primary teeth after 24 months, net mean occlusal wear was 87 microm for ChemFlex and 85 microm for Fuji IX GP. The occlusal wear in the permanent teeth was 75 microm for ChemFlex and 79 microm for Fuji IX GP. CONCLUSION: The clinical performance of both materials over a 24-month period was similar and the survival rates of class I ART restorations in both primary and permanent teeth were high.     

The atraumatic restorative treatment (ART) approach for managing dental caries: a meta-analysis

The number of publications reporting on the survival of ART sealants and ART restorations has increased considerably in recent years. A systematic investigation of their longevity is therefore warranted. Based on three exclusion criteria, a literature search in the electronic libraries Pubmed and Medline revealed 28 eligible publications for inclusion in a meta-analysis. High mean survival rates for single-surface ART restorations using high-viscosity glass-ionomer in primary dentitions over 3 years were found (95% after 1 year to 86% after 3 years). These rates were statistically significantly higher than for those of multiple-surface ART restorations in primary dentitions (p<0.0001). High mean survival rates for single-surface ART restorations using high-viscosity glass-ionomer in permanent dentitions over 6 years were found (97% after 1 year to 72% after 6 years). The mean annual failure rates for single-surface ART restorations using high-viscosity glass-ionomer in primary and permanent dentitions and for multiple-surface ART restorations in primary dentitions are 4.7%, 4.7% and 17%, respectively. The number of studies reporting on the retention and caries preventive effect of ART sealants was low. It is concluded that single-surface ART restorations using high-viscosity glass-ionomer in both primary and permanent dentitions show high survival rates. Medium-viscosity glass-ionomer should not be used for ART restorations.     

Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition: results after 3 years

This study compared the survival of restorations produced through the atraumatic restorative treatment (ART) approach using glass-ionomer with those produced through the traditional approach using amalgam (MTA) in deciduous dentitions over a period of 3 years. Using a parallel group design, 835 grade 1 children, aged 6-7 years, participated. A total of 482 children were treated through the ART and 353 children through the MTA approach. Eight dentists produced a total of 1891 single- and multiple-surface restorations. After 3 years, 22.1% of the restorations were lost for evaluation. There was a statistically significant difference in the combined survival of all single- and multiple-surface restorations between the two approaches in favour of the ART approach (p = 0.04). The study revealed a 3-year cumulative survival percentage of single-surface ART and MTA restorations of 86.1 and 79.6%, respectively. The difference was statistically significant (p = 0.03). The main reasons for both single-surface ART and MTA restorations to fail was 'restoration missing' followed by 'gross marginal defect'. The 3-year cumulative survival percentages of multiple-surface ART and MTA restorations were 48.7 and 42.9%, respectively. The difference was not statistically significant (p > 0.05). The 3-year survival percentages of single- and multiple- surface ART and MTA restorations varied widely amongst the 8 operators with an operator effect (p = 0.001) for multiple-surface MTA restorations. It can be concluded that the ART approach using glass-ionomer yielded better results in treating dentinal lesions in deciduous teeth than did the traditional approach using amalgam after 3 years. It is recommended to select the ART approach to complement the other activities of the school oral health programme.     

Provision of Atraumatic Restorative Treatment (ART) restorations to Chinese pre-school children--a 30-month evaluation

Summary. Objectives . The objectives of this study were: to provide restorations using the ART approach to pre-school children in Southern China in a kindergarten environ-ment, using a high-strength glass-ionomer restorative material; to assess the accept-ability of this approach and to evaluate on a longitudinal basis the restorations placed.
Sample and methods. A total of 170 ART restorations were placed in 95 children, aged 5·1 ± 0·7 years, by seven final-year dental students using standard ART procedures and hand instruments. The restorations were evaluated every six months thereafter by two calibrated independent examiners using explorers and mouth-mirrors.
Results . 93% of the children reported that they did not feel pain during treatment and 86% were willing to receive ART restorations again. The cumulative 12- and 30-month survival rates of Class I restorations were 91% and 79%, respectively. The corresponding figures for Class V restorations were 79% and 70%, while those for Class II restorations were 75% and 51%. The failure rates of Class III and IV restor-ations were high with more than half of them scored as missing within the first year.
Conclusions . The ART approach was shown to be acceptable to Chinese pre-school children for providing restorative dental care outside the traditional clinical setting. The success rates were high for Class I and V restorations in primary teeth, modest for Class II, and low for Class III and IV restorations.     

In vitro caries inhibition at the enamel margins of glass ionomer restoratives developed for the ART approach

OBJECTIVES: To assess the ability of conventional glass ionomer cements manufactured specifically for the atraumatic restorative treatment (ART) approach to inhibit the in vitro demineralization of enamel. METHODS: Twenty-four sound permanent premolar teeth, extracted for orthodontic reasons, had cervical cavities (4x2x1. 5mm(3)) prepared in enamel. These were restored with Fuji IX, Fuji IX GP, Ketac-Molar and Compoglass, and then thermocycled 300 times between 5-55 degrees C before being placed in a demineralizing solution (0.1M lactic acid with 1g/l dissolved hydroxyapatite at pH 4.7) for four weeks. Buccolingual planoparallel sections were cut axially through the restorations, and subsequently lapped to approximately 100 microm thickness. The sections were examined with a polarized light microscope, and lesion measurements made using image analysis software. ANOVA and coefficients of variance were used to compare the findings. RESULTS: Compoglass and Ketac-Molar showed significantly less surface erosion than did the other two cements (p<0.0001). Inhibition of enamel demineralization immediately adjacent to the restoration margins was more frequent with the glass ionomer cements (20.5-25.0%) than with Compoglass (13.0%). However, the widths of the inhibition zones varied between materials and sites. CONCLUSIONS: Fluoride ion release from the restorative materials afforded some degree of protection to the adjacent enamel against in vitro demineralization.     

学龄儿童恒牙非创伤性充填远期疗效的临床观察

目的　评价非创伤性充填 (ART)治疗恒牙龋的长期效果。方法　采用ART标准器械和步骤 ,用高强度玻璃离子材料对 197名 12～ 13岁儿童完成充填。连续 6年进行临床评价 ,用美国公共卫生服务标准 (USPHS)同时验证。并用标准Rheinberger测量器评价充填的磨损程度。 结果第 6年小Ⅰ类洞充填的保留率为 75 % ,大Ⅰ类洞充填保留率为 6 1% ,差异有统计学意义 (P <0 0 1)。USPHS评价结果表明大、小Ⅰ类洞充填的边缘完整性的满意度各占 80 %和 93%。充填后第 1年Ⅰ类洞磨损值为 4 8μm ,明显高于以后每年的磨损值 2 0～ 2 5 μm(P <0 0 5 )。 结论　ART充填恒牙龋是适合、有效和可接受的 ,其保留率与洞型大小有关 ,是一种有前途的治疗方法 ,但应注意掌握适应证