Is Resin Infiltration A Microinvasive Approach To White Lesions of Calcified Tooth Structures - A Systemic Review
Is Resin Infiltration A Microinvasive Approach To White Lesions of Calcified Tooth Structures - A Systemic Review
Is Resin Infiltration A Microinvasive Approach To White Lesions of Calcified Tooth Structures - A Systemic Review
A b s t r ac t
Aim: The treatment of white lesions should aim at arresting the lesion progression of carious lesions and improving the esthetics by diminishing
the opacity of the developmental disturbances of a tooth. The objective of this review was to present the scientific basis, the principles of resin
infiltration and to discuss its inherent clinical applications.
Data sources: Data were identified by PubMed searches. Papers published in English between 2010 and 2015 were selected and most up-to-
date or relevant references were chosen.
Conclusion: The resin infiltration technique, while promising, needed more clinical evidence for conclusive findings. However, based on available
laboratory and clinical studies, it seems convincing that resin infiltration of enamel lesions should aim at arresting the progression of white
spot lesions. Combining this microinvasive approach with a substantial caries remineralization program may provide therapeutic benefits and
significantly reduce both long term restorative needs and costs, thus complementing the concept of minimum intervention dentistry.
Keywords: Icon, Minimum intervention dentistry, Resin infiltration, Subsurface caries lesion.
International Journal of Clinical Pediatric Dentistry (2019): 10.5005/jp-journals-10005-1579
Introduction 1
Department of Pedodontics and Preventive Dentistry, Royal Dental
In recent years, a dramatic change has evolved in the management College, Palakkad, Kerala, India
of dental caries from the traditional restorative treatment approach 2
Department of Public Health Dentistry, Educare Institute of Dental
to a more preventive approach, namely non-invasion or minimal Sciences, Malappuram, Kerala, India
invasion.1Enamel carious lesions are characterized by mineral loss 3
Department of Paediatric and Preventive Dentistry, Indira Gandhi
in the body of the lesion, resulting in greater visual enamel opacity Institute of Dental Sciences, Puducherry, India
due to alteration of the refractive index of the affected area. 2,3 4
Department of Pedodontics and Preventive Dentistry, Tagore Dental
Great attention has been devoted to the noninvasive treatment College, Chennai, Tamil Nadu, India
of enamel carious lesions, which includes remineralization of 5
Department of Pedodontics and Preventive Dentistry, Sathyabama
the lesion with fluoride and casein phosphopeptide-amorphous Dental College, Chennai, Tamil Nadu, India
calcium phosphate, or the use of therapeutic sealants for occlusal 6
Department of Pedodontics and Preventive Dentistry, Annoor Dental
lesions. Fluoride and casein phosphopeptide-amorphous calcium College, Muvattupuzha, Kerala, India
phosphate play a key role in the remineralization of superficial white Corresponding Author: Vidya Manoharan, Department of Pedodontics
spot lesions. However, this approach is not always successful as it and Preventive Dentistry, Royal Dental College, Palakkad, Kerala, India,
requires good compliance of the patient, with a change in harmful Phone: +91 9645090658, e-mail: [email protected]
habits, and with many of the patients abandoning the treatment How to cite this article: Manoharan V, Kumar AS, et al.Is Resin Infiltration
before completion. Sealants have been used therapeutically a Micro invasive Approach to White Lesions of Calcified Tooth Structures?:
on non-cavitated enamel caries as an attempt to reduce lesion A Systemic Review. Int J Clin Pediatr Dent 2019;12(1):53–58.
progression. The pores within the body of enamel caries provide Source of support: Nil
diffusion pathways for acids and dissolved minerals.4 Therefore, Conflict of interest: None
an alternative approach for superficial sealing might be based on
experiments conducted by Robinson et al.5to arrest carious lesions
by the infiltration of these pores with resorcinol-formaldehyde
patches, white line/stripes, faint white lines, and white speckled
resins. This concept has been modified and commercially developed
lesions (Table 1).
in Germany for the management of smooth surface and proximal
non-cavitated caries lesions in which the porosities of enamel
lesion are infiltrated with a low viscosity resin, a technique known Etiology of White Marks
as “resin infiltration” creating a diffusion barrier within the lesion There is a wide array of treatments available including whitening as
without establishing any material on the enamel surface.1,6 Thus, the first choice by Greenwall7and bonding over the mark as the last
resin infiltration can delay the time for restoration placement. option, a technique using resin infiltration has been introduced by
White marks on anterior teeth can be unsightly and patients Munoz et al.8The low viscosity resin infiltrant was used to occlude
often seek treatment to have these marks eradicated. White marks the pores within the hypomineralised lesion, which acts as diffusion
associated with the presence of tissue porosity can appear as white pathways for acids and dissolved minerals, thus sealing these
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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Is Resin Infiltration a Microinvasive Approach to White Lesions of Calcified Tooth Structures?: A Systemic Review
Table 1: Etiology of white marks similar to the surrounding sound enamel. As a result, this treatment
Type of white mark Etiology may be used not only to arrest enamel lesions but also to improve
1. White patches Trauma to the primary dentition
the esthetic appearance of buccal white spots. 38,39
2. Multiple lesions: brown and Fluorosis Resin Infiltration Technique
white Discolourations
Icon® is marketed in two different forms: proximal surface and
3. White speckled lesions: Fever during development
vestibular surface kits. The usage for both is similar except for
mottled enamel
the need for separation in the case of proximal lesion treatment.
4. Faint white lesions, some Demineralization lesions after
Since the surface layer of enamel caries lesions has a lower pore
black edges removal of orthodontic brackets
volume compared to that of the lesion body underneath, it forms
5. Enamel defects and white Ceoliac disease, molar incisor
a barrier that might hamper the infiltration of resin into the lesion
lesions in deciduous incisors hypoplasia
body. Therefore, a preparation phase is required where the surface
and molars
of the teeth is cleaned and prepared with 15% hydrochloric acid
6. White spot or enamel Preterm birth
(icon etch) for 2 minutes and stirring the gel from time to time
hypoplasia
during application with a microbrush. 15% hydrochloric acid gel
has been demonstrated to be superior to 37% phosphoric acid gel
pathways. Thus, the caries infiltration can also be used to camouflage in removing the mineralized surface layer of natural enamel lesions
aesthetically disfiguring white spot lesions on buccal surfaces.9 when applied for 120 seconds. 15% HCL produces a penetration
depth of 58 μm, which is more than twice that of phosphoric acid
M at e r ia l s and Methods (25 μm), enabling penetration into the deepest part of the lesion,
The PubMed database research of relevant scientific articles on the thus eliminating the decalcified areas, preventing further attacks.40
effect of resin infiltration on caries lesion progression and esthetics. Ethanol wet bonding technique is used to desiccate the surface
The search was undertaken with the following keywords: “resin by applying 99% ethanol (Icon Dry) for 30 seconds followed by air
infiltration, dental caries”, “resin infiltration, caries lesions”, “resin drying. It is based on the assumption that it will coax hydrophobic
infiltration, esthetics,” and “Icon DMG.” The search was limited to monomers to infiltrate into demineralized wet enamel or dentine,
articles published in English between the years 2010 and 2015 (Table 2). and improve the efficacy of penetration of the hydrophobic
infiltrate (TEGDMA) to get a well-defined, resin-infiltrated layer. This
R e s u lts technique involves slowly replacing water within the demineralized
collagen matrix with ascending concentrations of ethanol, allowing
Resin Infiltration Concept the latter to penetrate the collagen matrix without causing
Resin infiltration technique is a novel technology that bridges the gap additional shrinkage of the interfibrillar spaces, thus preventing the
between prevention and restoration of carious lesions up to the first phase separation of hydrophobic resin monomers.41,42
third of dentin (D-1) and can camouflage aesthetically disfiguring white Icon resin, composed of tetraethylene glycol dimethacrylate,
lesions on the buccal surface. It is marketed under the name Icon® (DMG is applied on the lesion surface using a microbrush and allowed to
America Company, Englewood, NJ) and is described as a micro-invasive penetrate for three minutes. The excess is removed using a cotton
technology that fills, reinforces, and stabilizes demineralized enamel roll and light cured. Repeated application for another one minute
without sacrificing the healthy tooth structure.34,35 is performed and then the resin is light cured again. The resin is
The principle of resin infiltration is to perfuse the porous enamel applied twice because of the shrinkage of the material after the
with resin by capillary action, thereby arresting lesion progression by first application, resulting in the generation of space that can be
occluding the microporosities that provide diffusion pathways for the then occluded by a second application. The excess resin is then
acids and dissolved materials. This technique aims to create a diffusion removed and the surface is polished.13,43
barrier inside the lesion and not on the lesion surface.36 Robinson The practitioner should select the cases carefully. Resin
et al. reported that about 60 ± 10% of the lesion’s pore volume had infiltration technique can treat a smaller white mark much easier
been occupied by resin.5According to Kielbassa et al., resin infiltrates than a larger patch. Medium-to-large size patches may require two
into subsurface lesions and produces resin infiltrated parts of the treatments. If the lesion is very deep, then it is advisable to sandblast
lesion and the depth of resin infiltration was over 100 μm.37 the white area prior to applying the hydrochloric acid as an etch to
A positive side effect of resin infiltration is that enamel lesions the tooth. The sandblasting helps to open up the enamel tubules so
lose their whitish appearance when their microporosities are filled that better penetration of the hydrochloric acid can be achieved.44
with the resin and look similar to sound enamel. The principle of Teeth with brown discoloration may not be good candidates for
masking enamel lesions by resin infiltration is based on changes in resin infiltration, since the later will not mask the brown color and,
light scattering within the lesions. Sound enamel has a refractive in fact, it may saturate the color and make it look worse clinically.
index (RI) of 1.62. The microporosities of enamel caries lesions Microabrasion or conventional resin restorations may be better
are filled with either a watery medium (RI 1.33) or air (RI 1.0). The options for treating teeth with brown discoloration. 39
difference in the refractive indices between the enamel crystals and
medium inside the porosities causes light scattering that results Resin Infiltration in Primary Teeth
in a whitish opaque appearance of these lesions, especially when The management of non-cavitated caries lesions using the
they are desiccated.38,39The microporosities of infiltrated lesions resin infiltration technique in primary teeth differs from that in
are filled with resin (RI 1.46) that, in contrast to the watery medium, permanent teeth. Firstly, primary enamel is less mineralized, more
cannot evaporate. Therefore, the difference in the refractive indices porous and aprismatic when compared to permanent enamel. As
between porosities and enamel is negligible and lesions appear a result, the diffusion coefficient seems to be greater in primary
Contd...
Reference Type of study Type of teeth Condition Follow-up Outcome
Tirlet G et al. In vivo Permanent anterior Fluorosis and 19 months Resin infiltration could be a promising
201327 teeth traumatic minimally invasive treatment in fluorosis and
hypomineralization traumatic hypomineralization
Munoz et al. In vivo Permanent anterior Fluorosis and 4 months Resin infiltration can be considered a
201328 teeth traumatic minimally invasive procedure for
hypomineralization mild-to-moderate fluorosis and hypoplasia
stains related to traumatic dental injuries
Liu Yonghong In vitro primary molars and Proximal lesions – Better penetration abilities of resin
et al. 201329 permanent posterior infiltration in primary molars are shown in
teeth lesions confined to the outer half of enamel
than those in permanent posterior teeth.
Wolfgang H In vitro Permanent posterior Hypomineralization – Artificial lesions were completely penetrated
Arnold et al., teeth by the resin and that artificial caries-like
201430 lesions can be used, within the limits of
the shallow artificial lesions, to perform
experimental studies on resin infiltration into
lesions
M. B. Altarabulsi In vivo Deciduous and Proximal lesion in 12 months Caries infiltration hampers the
et al. 201431 permanent teeth enamel or in the progression of initial proximal lesion
outer third of dentin extending radiographically in the enamel or
the outer third of dentin
Priya In vitro Sound premolars Hypomineralization – The maximum depth of penetration of the
Subramaniam resin material was 6.06 ± 3.32 μm
et al. 201432
Monica Almeida In vitro Bovine teeth Hypomineralization – The untreated lesion showed lower
Tostes et al. hardness values using a nanoindenter
201433 equipment for distances near the outer
surface of enamel
Soley Arslan In vitro Sound permanent Hypomineralization – Resin infiltration technique showed an
et al. 201534 incisors increase in microhardness and a decrease in
roughness of demineralized enamel surfaces,
coupled with low bacterial adhesion and thus
capable of arresting initial enamel carious
lesions
enamel. Secondly, the proximal surface layer is less mineralized and Advantages of Resin Infiltration
thinner in primary molars compared to the permanent ones and Resin infiltration has made possible an innovative way of treating
thus, the rate of progression of proximal caries in primary molars is initial carious lesions that fits perfectly with the concept of minimal
significantly higher than that in the permanent ones.44 intervention dentistry. Infiltration of carious lesions represents a
In an in vitrostudy by Paris S et al., primary teeth exhibited new approach to the treatment of non-cavitated lesions of proximal
better infiltrant penetration than permanent teeth, after 1 minute and smooth surfaces of deciduous and permanent teeth up to the
application of resin.45On the other hand, 3–5 minutes are required first third of dentin (D-1 level). From the foregoing review, it seems
to almost completely infiltrate a natural lesion in permanent teeth clear that the resin infiltration technique bears several advantages
with a lesion extended to the inner half of enamel, whereas, one- as follows:
minute application resulted in only superficial infiltration.14
Following 5 minute resin application, Liu et al. found no • Noninvasive treatment, preserving tooth structure;
significant differences in the overall penetration between primary • Achieved in a single visit;
and permanent molar lesions but the penetration abilities of • Mechanical stabilization of demineralized enamel;
primary molars were slightly higher than those of permanent teeth • Deeper penetration into porous demineralized areas;
in lesions confined to the outer half of enamel.29Ekstrand et al. • Arrest/retardation of lesion progress;
conducted a split-mouth study for one year to assess the efficacy • Minimized risk of secondary caries;
of resin infiltrated lesions covered by fluoride varnish vs fluoride • No risk of postoperative sensitivity and pulpal inflammation;
varnish treatment only on the proximal lesions of deciduous molars. • Reduced risk of gingivitis and periodontitis;
Lesion progression was assessed clinically and radiographically. • Rmproved esthetic outcome when used as a “masking” resin
Proximal caries in primary molars treated by resin infiltration and on demineralized labial surfaces (white spot lesions, i.e. with
fluoride varnish progressed significantly lesser (23%) than those orthodontic patients);
treated with fluoride varnish only (61%) after one year.10 • High patient acceptance.
While this therapy can rightly be categorized as minimum by Ekstrand et al. composed of only children with moderate to high
intervention dentistry, clinical experience is limited and further risk, which may partially explain the results.10
controlled clinical trials are required to assess its long-term results.46
17. Hammad SM, El Banna M, et al. Effect of resin infiltration on white 33. Tostes MA, Santos Jr E, et al. Effect of resin infiltration on the
spot lesions after debonding orthodontic brackets. Am J Dent 2012 nanomechanical properties of demineralized bovine enamel. Indian
Feb;25(1):3–8. J Dent July–September 2014;5(3):161–165.
18. Meyer-Lueckel H, Bitter K, et al. Randomized controlled clinical trial 34. Arslan S, Zorba YO, et al. Effect of resin infiltration on enamel surface
on proximal caries infiltration: three-year follow-up. Caries Res 2012 properties and Streptococcusmutans adhesion to artificial enamel
Aug;46(6):544–548. DOI: 10.1159/000341807. lesions. Dent Mater J 2015 Jan;34(1):25–30. DOI: 10.4012/dmj.2014-078.
19. Martignon S, Ekstrand KR, et al. Infiltrating/sealing proximal 35. Kugel G, Arsenault P, et al. Treatment modalities for caries
caries lesions: a 3-year randomized clinical trial. J Dent Res 2012 management, including a new resin infiltration system. Compend
Mar;91(3):288–292. DOI: 10.1177/0022034511435328. Contin Educ Dent 2009 Oct;30(3):1–10.
20. Taher NM, Alkhamis HA, et al. The influence of resin infiltration 36. Weisrock G, Terrer E, et al. Naturally aesthetic restorations and
system on enamel microhardness and surface roughness: an in vitro minimally invasive dentistry. J Minim Interv. Dent 2011 Mar;4(2):23–30.
study. Saudi Dent J 2012 Apr;24(2):79–84. DOI: 10.1016/j.sdentj.2011. 37. Kielbassa AM, Gernhardt CR. Closing the gap between oral hygiene
10.003. and minimally invasive dentistry: a review on the resin infiltration
21. Paris S, Schwendicke F, et al. Masking of white spot lesions by technique of incipient (proximal) enamel lesions. Quintessence Int
resin infiltration in vitro. J Dent 2013 Nov;41(Suppl 5):e28–e34. DOI: 2009 Jul;40(8):663–681.
10.1016/j.jdent.2013.04.003. 38. Kidd EA, Fejerskov O. What constitutes dental caries? Histopathology
22. Jia L, Stawarczyk B, et al. Influence of caries infiltrant contamination of carious enamel and dentin related to the action of cariogenic
on shear bond strength of different adhesives to dentin. Clin Oral biofilms. J Dent Res 2004 Apr;83(Spec Iss C):C35–C38. DOI:
Investig 2013 Mar;17(2):643–648. DOI: 10.1007/s00784-012-0727-z. 10.1177/154405910408301s07.
23. Paris S, Schwendicke F, et al. Microhardness and mineral loss of 39. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot
enamel lesions after infiltration with various resins: influence of lesions by resin infiltration – a clinical report. Quintessence Int 2009
infiltrant composition and application frequency in vitro. J Dent 2013 Oct;40(9):713–718.
Jun;41(6):543–548. DOI: 10.1016/j.jdent.2013.03.006. 40. Meyer-Lueckel H, Paris S, et al. Surface layer erosion of natural caries
24. Araujo GS, Sfalcin RA, et al. Evaluation of polymerization lesions with phosphoric and hydrochloric acid gels in preparation
characteristics and penetration into enamel caries lesions of for resin infiltration. Caries Res 2007 Apr;41(3):223–230. DOI:
experimental infiltrants. J Dent 2013 Nov;41(11):1014–1019. DOI: 10.1159/000099323.
10.1016/j.jdent.2013.08.019. 41. De Barros L, Apolonio FM, et al. Resin-dentin bonds of etch-and-rinse
25. Paris S, Soviero VM, et al. Pretreatment of natural caries lesions adhesives to alcohol-saturated acid-etched dentin. J Adhes Dent 2013
affects penetration depth of infiltrants in vitro. Clin Oral Investig 2013 Aug;15(4):333–340.
Dec;17(9):2085–2089. DOI: 10.1007/s00784-012-0909-8. 42. Li F, Liu XY, et al. Ethanol-wet bonding technique may enhance
26. Knosel M, Eckstein A, et al. Durability of esthetic improvement the bonding performance of contemporary etch-and-rinse dental
following Icon resin infiltration of multibracket-induced white spot adhesives. J Adhes Dent 2012 Apr;14(2):113–120.
lesions compared with no therapy over 6 months: a single-center, 43. Lasfargues JJ, Bonte E, et al. Minimal intervention dentistry: part 6.
split-mouth, randomized clinical trial. Am J Orthod Dentofacial Caries inhibition by resin infiltration. Br Dent J 2013 Jan;214(2):53–59.
Orthop 2013 Jul;144(1):86–96. DOI: 10.1016/j.ajodo.2013.02.029. DOI: 10.1038/sj.bdj.2013.54.
27. Naidu E, Stawarczyk B, et al. Shear bond strength of orthodontic 44. Vanderas AP, Manetas C, et al. Progression of proximal caries in the
resins after caries infiltrant preconditioning. Angle Orthod 2013 mixed dentition: a 4-year prospective study. Pediatr Dent 2003 May-
Mar;83(2):306–312. DOI: 10.2319/052112-409.1. Jun;25(3):229–234.
28. Munoz MA, Arana Gordillo LA, et al. Alternative esthetic management 45. Paris S, Soviero VM, et al. Penetration depths of an infiltrant into
of fluorosis and hypoplasia stains: blending effect obtained with resin proximal caries lesions in primary molars after different application
infiltration techniques. J Esthet Restor Dent 2013 Feb;25(1):32–39. times in vitro. Int J Paediatr Dent 2012 Sep;22(5):349–355. DOI:
29. Liu Y, Ge L, et al. Comparative study on the penetration abilities 10.1111/j.1365-263X.2011.01204.x.
of resin infiltration into proximal initial caries lesions in primary 46. Kielbassa AM, Muller J, et al. Closing the gap between oral hygiene
molars and permanent posterior teeth. West China J Stomatol 2013 and minimally invasive dentistry: a review on the resin infiltration
Apr;31(2):161. technique of incipient (proximal) enamel lesions. Quintessence Int
30. Arnold WH, Bachstaedter L, et al. Resin infiltration into differentially 2009 Sep;40(8):663–681.
extended experimental carious lesions. Open Dent J 2014 Dec;8: 47. de Freitas Santos LFT, Rego HMC, et al. Efficacy of bleaching treatment
251–256. DOI: 10.2174/1874210601408010251. on demineralized enamel treated with resin infiltration technique.
31. Altarabulsi MB, Alkilzy M, et al. Clinical safety, quality and effect World J Dent Oct–Dec 2012;3(4):279–283.
of resin infiltration for proximal caries. Eur J Paediatr Dent 2014 48. Lee JH, Kim DG, et al. Minimally invasive treatment for esthetic
Mar;15(1):39–44. enhancement of white spot lesion in adjacent tooth. J Adv
32. Subramaniam P, Girish Babu KL, et al. Evaluation of penetration depth Prosthodont 2013 Aug;5(3):359–363. DOI: 10.4047/jap.2013.5.3.359.
of a commercially available resin infiltrate into artificially created 49. Ekstrand K, Martignon S, et al. The non-operative resin treatment of
enamel lesions: an in vitrostudy. J Conserv Dent Mar 2014;17(2): proximal caries lesions. Dent Update 2012 Nov;39(9):614–616. DOI:
146–149. DOI: 10.4103/0972-0707.128054. 10.12968/denu.2012.39.9.614, 618–620, 622.Q2