Survival of smart restoratives in pediatric dentistry: a PRISMA-guided meta-analysis of randomized trials

Background: Smart and ion-releasing restorative systems are widely used for pediatric posterior restorations, yet their survival compared with resin composites remains uncertain. This review synthesized randomized clinical evidence on restoration survival and failure in children. Methods: PubMed (MEDLINE), Embase (Ovid), and Cochrane CENTRAL were searched from inception to 18 September 2025 without language or year restrictions. Eligible studies were randomized controlled trials using parallel, split-mouth, or cluster designs in children receiving direct posterior restorations. The primary comparison was smart materials versus resin composites in primary teeth. Outcomes followed Atraumatic Restorative Treatment or United States Public Health Service Ryge failure criteria at the longest follow-up. Random-effects meta-analyses were performed when at least two studies contributed, using DerSimonian-Laird tau-squared and Hartung-Knapp confidence intervals. Time-to-event outcomes were synthesized separately. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Results: Of 380 records identified, 16 trials met inclusion criteria. For primary teeth, two trials pooled at 12 to 24 months showed a non-significant trend favoring resin composites, with a risk ratio of 1.74 and a 95 percent confidence interval of 0.67 to 4.57, and low heterogeneity. Technique-related signals suggested that retentive grooves reduced failure compared with no grooves in Class II Atraumatic Restorative Treatment restorations in a single randomized trial. Effects of rotary excavation and medicated liners were imprecise and based on single studies. In pediatric permanent teeth, two trials comparing smart materials showed no clear difference in survival. Conclusions: At 12 to 24 months, smart ion-releasing materials do not outperform resin composites for primary posterior restorations. Operative technique, particularly retentive features in Atraumatic Restorative Treatment restorations, may be more influential than material choice. Evidence in pediatric permanent teeth remains limited and inconclusive. Larger, well-reported trials with longer follow-up and standardized outcomes are required. The PROSPERO Registration: CRD420251090030.

Atraumatic restorative treatment; Glass-ionomer cement; Ion-releasing restorative materials; Meta-analysis; Pediatric dentistry; Primary teeth; Randomized controlled trial; Resin composite

[1] Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of untreated caries: a systematic review and metaregression. Journal of Dental Research. 2015; 94: 650–658.

[2] Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. The Lancet. 2019; 394: 249–260.

[3] Opdam NJ, Loomans BA, Roeters FJ, Bronkhorst EM. Five-year clinical performance of posterior resin composite restorations placed by dental students. Journal of Dentistry. 2004; 32: 379–383.

[4] de Medeiros Serpa EB, Clementino MA, Granville-Garcia AF, Rosenblatt A. The effect of atraumatic restorative treatment on adhesive restorations for dental caries in deciduous molars. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2017; 35: 167–173.

[5] Nicholson JW, Croll TP. Glass-ionomer cements in restorative dentistry. Quintessence International. 1997; 28: 705–714.

[6] Sikka N, Brizuela M. Glass ionomer cement. StatPearls Publishing: Treasure Island (FL). 2025.

[7] Krishnakumar K, Kalaskar R, Kalaskar A, Bhadule S, Joshi S. Clinical effectiveness of high-viscosity glass ionomer cement and composite resin as a restorative material in primary teeth: a systematic review of clinical trials. International Journal of Clinical Pediatric Dentistry. 2024; 17: 221–228.

[8] Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview. Clinical Oral Investigations. 2012; 16: 1337–1346.

[9] Pesaressi E, Zelada-Lopez D, Cosme T, Diaz J, Huanqui M, Fidela de Lima Navarro M, et al. Randomised clinical trial of class II ART restoration in primary teeth with and without retentive grooves after 12 months. European Journal of Paediatric Dentistry. 2024; 25: 42–49.

[10] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. The BMJ. 2021; 372: n71.

[11] Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. The BMJ. 2019; 366: l4898.

[12] Akman H, Tosun G. Clinical evaluation of bulk-fill resins and glass ionomer restorative materials: a 1-year follow-up randomized clinical trial in children. Nigerian Journal of Clinical Practice. 2020; 23: 489–497.

[13] Maru VP, Kulkarni P, Chauhan R, Bapat SS. Evaluation and comparison of silorane resin composite to glass ionomer in occluso-proximal restorations of primary molars. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2022; 40: 281–287.

[14] Deepika U, Sahoo PK, Dash JK, Baliarsingh RR, Ray P, Sharma G. Clinical evaluation of bioactive resin-modified glass ionomer and giomer in restoring primary molars. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2022; 40: 288–296.

[15] Phonghanyudh A, Phantumvanit P, Songpaisan Y, Petersen PE. Clinical evaluation of three caries removal approaches in primary teeth: a randomised controlled trial. Community Dental Health. 2012; 29: 173–178.

[16] Ferreira JM, Pinheiro SL, Sampaio FC, Menezes VA. Use of glass ionomer cement containing antibiotics to seal off infected dentin: a randomized clinical trial. Brazilian Dental Journal. 2013; 24: 68–73.

[17] D’Costa VG, Singhal DK, Acharya S. Efficacy of GC Gold Label 9 and GC Miracle Mix® restorations using atraumatic restorative treatment (ART) in rural settings: a randomized controlled trial. Journal of Clinical Pediatric Dentistry. 2020; 44: 148–153.

[18] Mahfouz RA, Hanno AG, Rahman AMAE. Zirconia-reinforced glass ionomer restorations in molar incisor hypomineralization: a randomized controlled clinical trial. Clinical Oral Investigations. 2025; 29: 290.

[19] Garbim JR, Saihara CS, Olegário IC, Hesse D, Araujo MP, Bonifácio CC, et al. 2-year survival and cost analysis of occlusoproximal ART restorations using encapsulated glass ionomer cement in primary molars: a randomized controlled trial. BMC Oral Health. 2024; 24: 647.

[20] Lam PPY, Lo ECM, Yiu CKY. Effectiveness of glass-ionomer sealant versus fluoride varnish application to prevent occlusal caries among preschool children over 18–24 months—a randomised controlled trial. Journal of Dentistry. 2024; 150: 105356.

[21] Guler C, Yilmaz Y. A two-year clinical evaluation of glass ionomer and ormocer based fissure sealants. Journal of Clinical Pediatric Dentistry. 2013; 37: 263–268.

[22] Schraverus MS, Olegário IC, Bonifácio CC, González APR, Pedroza M, Hesse D. Glass ionomer sealants can prevent dental caries but cannot prevent posteruptive breakdown on molars affected by molar incisor hypomineralization: one-year results of a randomized clinical trial. Caries Research. 2021; 55: 301–309.

[23] Rodrigues JA, Santos NM, Azevedo CB, Haas AN, Lenzi TL. Non-invasive and micro-invasive treatments to arrest active occlusal carious lesions in erupting permanent molars: a randomized clinical trial. Brazilian Oral Research. 2021; 35: e058.

[24] Sharma H, Suprabha BS, Shenoy R, Rao A, Kotian H. Clinical effectiveness of alkasite versus nanofilled resin composite in the restoration of occlusal carious lesions in permanent molar teeth of children: a randomized clinical trial. European Archives of Paediatric Dentistry. 2023; 24: 301–311.

[25] Moura MS, Sousa GP, Brito MHSF, Silva MCC, Lima MDM, Moura LFAD, et al. Does low-cost GIC have the same survival rate as high-viscosity GIC in atraumatic restorative treatments? A RCT. Brazilian Oral Research. 2020; 33: e125.

[26] Silva GSD, Raggio DP, Mello-Moura ACV, Gimenez T, Montagner AF, Floriano I, et al. Pulp vitality of primary molars with deep caries treated with ART restorations: 2-year RCT. Brazilian Oral Research. 2022; 36: e061.

[27] Faustino-Silva DD, Figueiredo MC. Atraumatic restorative treatment—ART in early childhood caries in babies: 4 years of randomized clinical trial. Clinical Oral Investigations. 2019; 23: 3721–3729.

[28] Frencken JE, Liang S, Zhang Q. Survival estimates of atraumatic restorative treatment versus traditional restorative treatment: a systematic review with meta-analyses. British Dental Journal. 2021. PMID: 33883705.

[29] Chaudhari HG, Patil RU, Jathar PN, Jain CA. A systematic review of randomized controlled trials on survival rate of atraumatic restorative treatment compared with conventional treatment on primary dentition. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2022; 40: 112–117.

[30] Banon R, Vandenbulcke J, Van Acker J, Martens L, De Coster P, Rajasekharan S. Two-year clinical and radiographic evaluation of ACTIVA BioACTIVE versus Compomer (Dyract® eXtra) in the restoration of class-2 cavities of primary molars: a non-inferior split-mouth randomised clinical trial. BMC Oral Health. 2024; 24: 437.

[31] Kashbour W, Gupta P, Worthington HV, Boyers D. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews. 2020; 11: CD003067.