Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2022  |  Volume : 40  |  Issue : 1  |  Page : 23--29

In vivo evaluation of clinical performance of Cention N and glass ionomer cement in proximal restorations of primary molars


Divya Arora, Mansi Jain, HP Suma Sogi, Prinka Shahi, Ishita Gupta, Meera Sandhu 
 Department of Pediatric and Preventive Dentistry, MMCDSR, Mullana, Haryana, India

Correspondence Address:
Dr. Mansi Jain
Department of Pediatric and Preventive Dentistry, MMCDSR, Mullana, Haryana
India

Abstract

Introduction: Restoring a proximal lesion in primary tooth has met with many challenges which has led to evolution of many materials. An alternative to Glass Ionomer Cements which has fluoride releasing capacity, offers good bond strength and is esthetic have been long looked for. Aim: This study aimed to compare the clinical performance of GIC and Cention N in proximal restorations of primary molars. Materials and Methodology: A prospective study was conducted on 154 primary molars in patients aged between 5 and 8 years using a split-mouth design. Patients were divided into two groups. Control group restored with GIC and study group received Cention N. Both groups were assessed at baseline 3, 6 and 9 months according to Ryge criteria and data was statistically analysed using Fisher's Exact. Results: Statistically significant difference was found between GIC and Cention N restorations for color match at baseline and color stability at 3 months (P < 0.001), while the other parameters did not show any significant difference among the two restorative materials. Conclusion: Cention N can be used as a suitable alternative to GIC for restoring Class II restorations in primary molars.



How to cite this article:
Arora D, Jain M, Suma Sogi H P, Shahi P, Gupta I, Sandhu M. In vivo evaluation of clinical performance of Cention N and glass ionomer cement in proximal restorations of primary molars.J Indian Soc Pedod Prev Dent 2022;40:23-29


How to cite this URL:
Arora D, Jain M, Suma Sogi H P, Shahi P, Gupta I, Sandhu M. In vivo evaluation of clinical performance of Cention N and glass ionomer cement in proximal restorations of primary molars. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Jul 5 ];40:23-29
Available from: https://www.jisppd.com/text.asp?2022/40/1/23/343005


Full Text



 Introduction



Oral health is an important component of general health. The impact of oral disease on people's lives is subtle and pervasive, influencing eating, sleeping, work, and social roles, and recurrences of these impacts constitute a silent epidemic. Dental caries is one of the major oral health problems,[1] and approximately 30% of total caries experience occurs mainly in primary teeth.[2] Restoring primary teeth is quite challenging due to small clinical crown, relatively large pulp chambers, and reduced thickness of enamel and dentin.[3] Proximal decay requires preparations that are conservative in depth, thereby avoiding pulpal exposure. Selection of restorative material is equally important in restoring proximal carious lesions as seepage from the materials can easily harm the pulpal tissue because of close proximity of pulp horns to interproximal surfaces.[3] Amalgam has been the most frequently used restorative material for primary teeth from many decades because of its long-term clinical performance and strength. However, its use has been declined due to poor esthetics and detrimental health effects caused by mercury release. The most frequently used alternative to amalgam is glass ionomer cement (GIC),[4] with the advantage of chemical adhesion to tooth structure, good biocompatibility, superior esthetics, and long-term fluoride release providing cariostatic effect but has the disadvantage of slow setting rate, low fracture toughness, susceptibility to moisture contamination, dehydration during initial phase of setting, and poor wear resistance.[5] Composite resins have also been widely used for restoring primary teeth as they provide better esthetics, high fracture, and wear resistance than GICs, but they do not provide any fluoride release and also show polymerization shrinkage after setting, leading to postoperative sensitivity, marginal discoloration, and secondary caries.[6],[7] Therefore, dentists have required an alternative to amalgam or GICs which should be cost-effective, fluoride releasing, easy to use, and should offer both strength and good esthetics.[8]

Recently, a new restorative material Cention N is being introduced which has calcium and fluoride-releasing properties comparable to conventional GIC and is quick and easy to use.

Thus, the present study was undertaken to compare the retention, marginal integrity, marginal discoloration, and secondary caries incidence of conventional GIC with Cention N in Class II restorations in primary molars.

 Materials and Methodology



This randomized control trial was carried out in the Department of Pediatric and Preventive Dentistry, MMCDSR, Mullana. The study was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and was approved by the institutional ethical committee, and informed consent was obtained from parents or guardians before interventions were done.

Cooperative healthy children in the age group of 5–8 years ready to comply with the study protocol, with at least one pair of primary molars with Class II lesions, and without any sign and symptom of reversible and irreversible pulpitis were included for the study. One hundred and fifty-four carious primary molars fulfilling the inclusion and exclusion criteria were selected. After obtaining the list of patients fulfilling the study criteria from the outpatient department, patients were then randomly picked and allotted into two groups by simple random sampling.

Group A – Study group received 77 Class II restorations either in maxillary or mandibular teeth with Cention N (Ivoclar, Vivadent).

Group B – Control group in which 77 Class II restorations were done either in maxillary or mandibular teeth with GIC (Fuji Type II).

After caries excavation, Cention N and GIC were hand mixed on the paper pad as per the manufacturer's guidelines. For Cention N, powder/liquid ratio of 4.6:1 was maintained, while GIC was mixed in the ratio of 2:1. After proper isolation, Cention N was placed into the cavity, condensed, and sculpted by Teflon-coated instruments to remove any voids and allowed to set for 4 min followed by finishing and polishing. Cention N sets immediately, as it is an alkasite material which is a subgroup of Composite, so Vaseline was not applied after the restoration, whereas as the initial set of GIC is achieved within 3–5 min, but the ionic reaction continues for 24 h; therefore, Vaseline was applied to the restoration after the initial set of restoration [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

Clinical evaluation of the restorations was done at 3, 6, and 9 [Figure 3], [Figure 4], [Figure 5] months using Modified United States Public Health Service Ryge criteria [Table 1]. Outcomes were evaluated by two different evaluators who were well versed in the Ryge criteria. The kappa statistic had a high agreement level, with the values being 0.90.{Figure 3}{Figure 4}{Figure 5}{Table 1}

 Results



Obtained data were analyzed using Fisher's exact test, and the results were tabulated. Statistically significant difference with P < 0.001 was observed on comparison of color match between GIC and Cention N group at baseline and color stability at 3, 6, and 9 months [Table 2] and [Figure 6]. At baseline, in GIC group, 77 subject teeth were graded as Charlie code in color match grading, while in Cention N group, 77 subject teeth had Alpha code.{Table 2}{Figure 6}

There were 7 subjects lost to follow-up in further evaluation. At 3 months, in GIC group, 70 subject teeth had a Bravo code in color match grading, while in Cention N group, 70 subject teeth hd Alpha code. This difference was also statistically significant, with P < 0.001.

At 6 and 9 months, in GIC and Cention N group, Bravo code was graded in color match grading which was statistically insignificant.

GIC and Cention N group when compared for marginal discoloration, anatomic form, marginal integrity, surface texture and gross fracture at baseline 3, 6 and 9 months scored Alpha grading which was statistically insignificant [Table 3]. At 3, 6, and 9 months of follow-up, no secondary caries developed around the margins of restorations in both groups, so all the 70 subject teeth had Alpha code in secondary caries grading [Table 4].{Table 3}{Table 4}

 Discussion



Success of the restoration depends on various factors such as child's cooperation during treatment, primary tooth characteristics, clinical demand, and hygiene maintained by the patient; therefore, selection of an appropriate material for restoration of primary teeth is pivotal. Welbury et al. in 1991[9] reported a lower survival time for GIC (33 months) as compared to amalgam restorations (41 months), while Qvist et al. in 1997[4] reported a failure rate of 37% for GIC after 3 years and concluded that GIC is not an appropriate restorative material for Class II restorations in primary molars. Recently, a new material, i.e., Cention N available in the tooth shade A2 has been introduced in dentistry which belongs to the group of alkasites and has properties of both Amalgam and GIC and offers tooth-colored esthetics as well as high flexural strength with optional additional light-curing property.[8],[10] It utilizes an alkaline filler which is capable of releasing substantial levels of fluoride ions comparable to traditional GIC.[11] It also releases hydroxyl and calcium ions which aids in neutralizing the excess acidity during the acid attack by cariogenic flora, thus preventing demineralization.[8] The organic monomer is found in the liquid. It consists of four different dimethacrylates which represent 21.6% weight of the final mixed material. Cention N does not contain Bis-GMA, HEMA, or TEGDMA.[10] It contains a combination of UDMA, DCP, an aromatic aliphatic-UDMA, and PEG-400 DMA cross-links during polymerization resulting in strong mechanical properties and good long-term stability.[8] Due to the presence of photoinitiator Ivocerin and an acyl phosphine oxide initiator, Cention N has an optional light-curing property. The inorganic fillers found in powder with particle size between 0.1 μm and 35 μm comprise barium aluminium silicate glass filler, ytterbium trifluoride, a calcium barium aluminium fluorosilicate glass filler, a calcium fluorosilicate (alkaline) glass filler, and an Isofiller which is also being used in Tetric N-Ceram Bulk Fill Composites that act as a shrinkage stress reliever.[8],[10] Cention N is a full-volume replacement material, which can be applied quickly and conveniently in bulk.[8],[10]

Color match

Esthetics being the utmost priority in modern restorative dentistry has led to the rapid development of various new dental materials and techniques. Color change of the restorative material with the passage of time is still one of the greatest concerns. To ensure excellent esthetics, it is necessary for tooth-colored material to maintain intrinsic color stability and resistance to surface staining. In this study, at baseline, Cention N group was given Alpha score, while GIC group was given Charlie score for color match grading. This mismatch of color between GIC and Cention N could be due to the difference in the translucency of these two materials as the translucency of Cention N is 11%[8] while translucency of Fuji II is 4%[8] so that the Cention N blends more naturally with the surrounding tooth structure than GIC.[8] Dedania et al., in 2018, stated that chameleon effect further increased the color matching of Cention N restorations with tooth.[12] The present study showed a higher percentage of mismatch in the GIC group at baseline that could be due to an increase in the opacity and the larger size of glass particles present in the powder of Fuji II, i.e., in the range of 5 μm (5000 nm)[13] which is much more than the wavelength of light (350–750 nm), so these particles scatter light and give restoration opaque and whitish appearance.[14] Color match between GIC and Cention N at baseline was statistically significant with P < 0.001 [Table 2] and [Figure 6]. With due course of time, restorations took up the staining from the oral environment depending on the differences in eating, drinking, and brushing habits and thus decreased the whitish hue slightly and blended with other tooth.

Marginal discoloration

Marginal discoloration occurs due to microleakage and marginal discrepancies between restorative material and tooth that could be due to poor marginal adaptation, polymerization shrinkage, and incorporation of any air bubble while mixing and inappropriate clinical placement of restorative material. Low elastic modulus (10 Mpa)[8] of Isofiller present in Cention N acts like a spring among the standard glass fillers which have a higher elastic modulus of 71 GPa.[8] It reduces polymerization shrinkage and microleakage[7] that can lead to marginal discoloration, marginal gaps, cracking, and hypersensitivity.[15] In the current study, no marginal discoloration was seen in any of the restorative materials till 9 months and Alpha score was given to both the restorative materials [Table 3].

Secondary caries

Secondary caries is the development of carious lesions around the restoration margins. Since fluoride has been used in various forms for the prevention and remineralization of incipient carious lesions, it is also incorporated in restorative materials to prevent secondary caries. In our study, no secondary caries was observed in any of the restorative materials till 9 months [Table 4]. GIC is well known for its fluoride release, which is 5.11 ppm after 7 days postoperatively.[16] Cention N also releases a substantial amount of fluoride which is 7.94 ppm in acidic medium after 7 days[15],[16] that is higher than traditional GIC.[8] The alkaline glass component of Cention N also releases hydroxide and calcium ions which further prevent demineralization of tooth structure.[8] The release of ions depends on pH of oral cavity as when pH of oral cavity is below critical pH i.e 5.5, Cention N releases a significantly larger amount of ions than when pH value is neutral.[8] Donly and Liu in 2018 examined the in vitro caries inhibition of restorative margins of Vitremer, Z 100 Composite, and Cention N and concluded that Cention N as well as Vitremer can clinically inhibit caries at restoration margins.[17]

Anatomic contour

The main reason for loss of anatomic form is wear.[18] In our study, acceptable anatomic form with optimal approximal contact was observed till 9 months for both of the restorative materials [Table 3]. Similar results were obtained for GIC restorations by Hübel and Mejàre in 2003.[5] Cention N includes a special patented filler, partially functionalized by silanes, which keeps shrinkage stress to a minimum.[8],[15] Roulet in 2019[19] conducted a study to measure the wear of Activa, Cention N, and the GIC and observed that the wear behavior of Cention N was in the same range as of Composites and they concluded that Cention N can be used as a restorative material for posterior teeth.[19]

Marginal integrity

The marginal integrity of the restoration refers to its marginal fit and marginal adaptation which maintains the anatomic form of tooth, thereby increasing the longevity of the restorative material.[20] Poor marginal adaptation can lead to marginal deterioration which may produce marginal discoloration, postoperative sensitivity, and secondary caries.[20] In case of GIC and Cention N, bonding is achieved through chemical means. In the present study, both groups scored Alpha score and none of the restorative material showed any clinically significant gap between restorative and cavosurface margin [Table 3] till 9 months of follow-up.

Surface texture

Surface texture is the characteristic of any restorative material which maintains the cleanliness of the restoration, thereby inhibiting the growth of oral microflora. The surface finishing further depends on the microstructure of restorative material.[21] Surface roughness of GIC and Cention N scored Alpha till 9 months of study period [Table 3]. Amith Setty et al.[21] compared the surface roughness of Cention N and Filtek Z350 XT resin Composite and concluded that values of all the groups were either below or approximating baseline value for bacterial or plaque retention.[21]

Gross fracture

Longevity of the direct posterior restorative material depends on its compressive strength which is the most important mechanical property.[22] A material with low compressive strength than tooth tends to fracture under occlusal loads and ends with periodontal problems or even extraction of the tooth.[23],[24],[25] In our study, none of the restorations showed partial or complete dislodgement till 9 months, and Alpha score was given for both the restorative materials [Table 3].

Both the materials showed equal and acceptable clinical performance at the end of 9 months. However, most of the children complained of bitter taste after restoration with Cention N. Based on the results of the study, Cention N can be used as a suitable alternative to GIC for restoring Class II restorations in primary molars, as high failure rates has been observed in various studies previously.[15] The technological advances that have occurred in the past few years for using dental materials in children need constant re-evaluation of treatment techniques.[26] Thus, use of newer materials such as Cention N can reduce the impact of oral disease which is subtle and pervasive, influencing work and social roles.[27]

 Conclusion



Color match of Cention N restorations was similar to adjacent tooth structure at baseline while a mismatch was observed between GIC restorations and adjacent tooth structure. No marginal discoloration and break in the marginal integrity or surface roughness was observed for both the restorations group. Further, none of the restorations in both the groups showed secondary caries after 3, 6, and 9 months of follow-up. Cention N restorations were performed satisfactorily over 9 months. Thus, they can be considered as a clinically suitable option for restoration in primary molars. As there is a demand for tooth-colored restorations, this material can deliver high-quality, predictable, and less time-consuming restoration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mouradian WE, Wehr E, Crall JJ. Disparities in children's oral health and access to dental care. JAMA 2000;284:2625-31.
2Murray JJ, Rugg-Gunn AJ, Jenkins GN. Water fluoridation and child dental health. In: Fluorides in Caries Prevention. 3rd ed. Mumbai: Varghese Publishing House; 1999. p. 39-63.
3Mohan Das U, Viswanath D, Azher U. Clinical evaluation of resin composite and resin modified glass ionomer in class III restorations of primary maxillary incisors: A comparative in vivo study. Int J Clin Pediatr Dent 2009;2:13-9.
4Qvist V, Laurberg L, Poulsen A, Teglers PT. Longevity and cariostatic effects of everyday conventional glass-ionomer and amalgam restorations in primary teeth: Three-year results. J Dent Res 1997;76:1387-96.
5Hübel S, Mejàre I. Conventional versus resin-modified glass-ionomer cement for Class II restorations in primary molars. A 3-year clinical study. Int J Paediatr Dent 2003;13:2-8.
6Pascon FM, Kantovitz KR, Caldo-Teixeira AS, Borges AF, Silva TN, Puppin-Rontani RM, et al. Clinical evaluation of composite and compomer restorations in primary teeth: 24-month results. J Dent 2006;34:381-8.
7Samanta S, Das U, Mitra A. Comparison of Microleakage in Class V Cavity Restored with Flowable Composite Resin, Glass Ionomer Cement and Cention N. Imp J Interdiscip Res 2017;3:180-83.
8Todd JC. In: Schaan CN, editor. Scientific Documentation. Liechtenstein: Ivoclar Vivadent Press; 2016.
9Welbury RR, Walls AW, Murray JJ, McCabe JF. The 5-year results of a clinical trial comparing a glass polyalkenoate (ionomer) cement restoration with an Amalgam restoration. Br Dent J 1991;170:177-81.
10Manuja N, Pandit IK, Srivastava N, Gugnani N, Nagpal R. Comparative evaluation of shear bond strength of various esthetic restorative materials to dentin: An in vitro study. J Indian Soc Pedod Prev Dent 2011;29:7-13.
11Joshi RS, Gokhale NS, Hugar SM, Soneta SP, Badakar CM, Patil VH. Comparative evaluation of antibacterial efficacy of conventional glass-ionomer cement and bulk-fill alkasite material when combined with doxycycline and double antibiotic paste containing ciprofloxacin and metronidazole against Streptococcus mutans and Lactobacillus spp: An in vitro study. J Indian Soc Pedod Prev Dent 2020;38:361-6.
12Dedania M, Shah N, Bhadra D, Bajpai N, Sapariya K. Comparative evaluation of clinical performance of silver amalgam and Cention N in simple class I carious lesions in permanent molars – A split mouth randomized clinical study. Int J Curr Res 2018;10:72993-6.
13Bala O, Arisu HD, Yikilgan I, Arslan S, Gullu A. Evaluation of surface roughness and hardness of different glass ionomer cements. Eur J Dent 2012;6:79-86.
14Onal B, Pamir T. The two-year clinical performance of esthetic lesions restorative materials in non-carious cervical. J Am Dent Assoc 2005;136:1547-55.
15Sujith R, Yadav TG, Pitalia D, Babaji P, Apoorva K, Sharma A. Comparative evaluation of mechanical and microleakage properties of Cention-N, composite, and glass ionomer cement restorative materials. J Contemp Dent Pract 2020;21:691-5.
16Gupta N, Jaiswal S, Nikhil V, Gupta S, Jha P, Bansal P. Comparison of fluoride ion release and alkalizing potential of a new bulk-fill alkasite. J Conserv Dent 2019;22:296-9.
17Donly KJ, Liu JA. Dentin and enamel demineralization inhibition at restoration margins of Vitremer, Z 100 and Cention N. Am J Dent 2018;31:166-8.
18McKinney JE, Antonucci JM, Rupp NW. Wear and microhardness of glass-ionomer cements. J Dent Res 1987;66:1134-9.
19Roulet JF, Hussein H, Abdulhameed NF, Shen C. In vitro wear of two bioactive composites and a glass ionomer cement. Dtsch Zahnarztl Z Int 2019;1:24-30.
20Priyalakshmi S, Ranjan M. A review on marginal deterioration of composite restoration. IOSR J Dent Med Sci 2014;13:06-9.
21Setty A, Nagesh J, Marigowda JC, Shivanna AK, Paluvary SK, Ashwathappa GS. Comparative evaluation of surface roughness of novel resin Composite Cention N with Filtek Z350 XT: In vitro study. Int J Oral Care Res 2019;7:15-7.
22Sharma A, Mishra P, Mishra SK. Time-dependent variation in compressive strengths of three posterior esthetic restorative materials: An in vitro study. Int J Prosthodont Restor Dent 2016;6:63-5.
23Klapdohr S, Moszner N. New inorganic components for dental filling Composites. Monatshefte für Chemie Chem Mon 2005;136:21-45.
24Chen MH. Update on dental nano composites. J Dent Res 2010;89:549-60.
25Jandt KD, Sigusch BW. Future perspectives of resin-based dental materials. Dent Mater 2009;25:1001-6.
26Jain M, Garg S, Dhindsa A, Kaur M, Kumar S, Singh R. Management of neglected severe early childhood caries in a six year old female child: A three year follow up. EC Dent Sci 2014;1:11-6.
27Jain M, Chhabra C, Sogi S, Shahi P, Dhir S, Rana S. Effect of School-based oral health awareness lecture on knowledge, attitude, and practice toward oral health among primary school teachers of Barara, Ambala, Haryana. World J Dent 2021;12:322-7.