Received: 31 May 2022 Revised: 6 September 2022
DOI: 10.1111/jerd.12963
CLINICAL ARTICLE
The stamp technique for direct restoration in a ICDAS 4
carious lesion: A 4-year follow-up
Mariele Vertuan DDS, MS 1 |
Genine Moreira de Freitas Guimarães DDS, MS 2
2
Alyssa Teixeira Obeid DDS, MS | Juliana Fraga Soares Bombonatti DDS, MS, PhD 2 |
Sergio Kiyoshi Ishikiriama DDS, MS, PhD 2 |
1
Department of Biological Sciences, Bauru
School of Dentistry, University of São Paulo
(FOB-USP), Bauru, Brazil
2
Department of Operative Dentistry,
Endodontics and Dental Materials, Bauru
School of Dentistry, University of São Paulo
(FOB-USP), Bauru, Brazil
Correspondence
Adilson Yoshio Furuse, Department of
Operative Dentistry, Endodontics and Dental
Materials, Bauru School of Dentistry-FOB-
USP, Alameda Octávio Pinheiro Brisolla, 9-75,
Bauru, SP 17012-901, Brazil.
Email: furuse@usp.br
Funding information
Coordenação de Aperfeiçoamento de Pessoal
de Nível Superior, Grant/Award Number:
Finance Code 001
442 © 2022 Wiley Periodicals LLC.
Accepted: 7 September 2022
Victor Mosquim DDS, MS 2 |
|
Adilson Yoshio Furuse DDS, MS, PhD 2
Abstract
Objective: This case report described the use of a stamping technique associated
with a bulk fill composite to restore an ICDAS 4 carious lesion on a posterior tooth.
The 4-year follow-up is also presented.
Clinical Considerations: A 32-year-old patient presented a carious lesion on tooth
36 with an underlying dark shadow at the dentin seen from the noncavitated enamel
occlusal surface, which was compatible with an ICDAS 4 carious lesion. The lesion
was radiographically detected and the caries disease was treated with dietary and
hygiene habits orientations. Before accessing the lesion and selectively removing the
carious tissue, an occlusal stamp was made by applying a flowable resin composite to
copy the anatomy of the noncavitated enamel surface. The cavity was restored using
a bulk fill resin composite (Opus Bulk Fill, FGM) with 4-mm-thick increments. Before
curing the last increment, a Teflon band was adapted at the uncured bulk fill compos-
ite surface and the occlusal stamp made with the flowable composite was pressed
against it to reproduce the natural characteristics and initial occlusal anatomy. The
top surface was light-activated for 40 s. After 4 years, small wear could be seen in
the restoration, but still within clinically acceptable levels.
Conclusion: The occlusal stamp technique allows reproduction of the natural anat-
omy of teeth affected by ICDAS 4 carious lesions with good clinical longevity over
4 years.
Clinical Significance: This case report presents the use of the stamp technique to
restore a tooth affected by an ICDAS 4 lesion, in which a carious process reached the
dentin and the enamel anatomy was still preserved. The bulk fill resin composite
associated with the occlusal stamp was chosen to quickly restore the cavity with
clinical predictability. Bulk fill composites allow the insertion of up to 4-mm-thick
increments and offer lower shrinkage stress, good clinical longevity and a less time-
consuming procedure in cases of posterior teeth, especially if associated with the
stamp technique.
wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2023;35:442–448.
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VERTUAN ET AL. 443

KEYWORDS
conservative dentistry, dental caries, direct composite restoration, operative dentistry,
resin composite

1 | I N T RO DU CT I O N cavities. Nonetheless, when ICDAS 4 lesions are present with no

enamel breakdown, bulk fill composites can be used associated with
The International Caries Detection and Assessment System (ICDAS) the “stamp” technique.
was developed to help clinicians to detect early onsets of caries activ- This technique consists of copying the pseudo-intact occlusal sur-
ity, becoming popular over the years.1,2 This system consists of coding face of the tooth before accessing the lesion, and then using this
the carious lesion's surface from 0 to 6 based on their characteristics, impression to sculpt the occlusal surface of the tooth in resin compos-
allowing the clinician to determine the progression of the lesion, dis- ite before light-curing. Despite requiring an additional step to copy
tinguishing initial lesions in enamel (ICDAS 1 and 2) from moderate the anatomy of the affected tooth, the main advantages of using the
(ICDAS 3 and 4) and extensive lesions in dentin (ICDAS 5 and 6).3 stamp technique associated with a bulk fill composite are the reduced
However, in occlusal ICDAS 4 lesions, where an underlying dark clinical time used to restore the cavities, reproduction of the occlusal
shadow in dentin is observed with or without localized enamel break- anatomy and occlusion without long finishing and polishing steps and
down, it is common that the occlusal anatomy is still preserved. This reduced voids present in the restoration.13
occurs because the lesion has progressed into dentin, but it has not
yet weakened the enamel enough to cause its fracture. When
detected at this stage, the dentist may treat the lesion more conserva-
tively when compared with when extensive lesions (ICDAS 5 and 6)
are being treated.
In their guide, the International Caries Classification and Manage-
ment System (ICCMS) states that active ICDAS 4 lesions ought to be
treated with tooth-preserving operative care,3 in which sound and
reversibly compromised structure should be preserved. According to a
previous study,4 the selective removal of carious tissue should be con-
ducted until leather-consistent dentin is reached. This allows the pres-
ervation of structure and causes the least damage to the surrounding
tissues.4
In these cases, resin composites are frequently used to restore
the anatomy and function of posterior teeth. Among all advantages of
these materials, they allow preservation of the dental tissue without
F I G U R E 1 Initial aspect of the left mandibular first molar (36).
requiring extensive preparations due to their bonding to tooth struc- The occlusal surface was not cavitated, but an underlying dark
ture.5 However, despite advances made in the adhesive dentistry shadow was observed from the occlusal surface, indicating an ICDAS
field, these materials still have some limitations like predisposition to code 4
marginal infiltration due to their polymerization shrinkage, leading to
postoperative sensitivity, bacterial invasion and secondary caries,
TABLE 1 ICDAS summary classification according to Ismail et al.2
reducing the restoration's clinical longevity.6
Score Definition
To avoid or reduce these drawbacks imposed by the inherent
characteristics of the material, the 2-mm-thick incremental technique ICDAS 0 Sound tooth surface (no sign of demineralization).

is recommended.7,8 Despite the fact that this technique allows better ICDAS 1 White spot visible after drying of the tooth, without
loss of surface continuity or pigmentation
marginal integrity and reduces the polymerization stress, it is a sensi-
restricted to the bottom of the sulcus.
tive and time-consuming procedure,5 especially in box-shaped cavities
ICDAS 2 White spot visible on wet surface of the tooth.
with higher configuration factor (C-factor), such as extensive Class I
ICDAS 3 Occurrence of a discontinuity in the enamel, without
cavities.9,10
exposing the dentin, and may present as a typical
Thus, as an attempt to reduce clinical time with the possibility of microcavity or as a sulcus loss of contour.
filling cavities with 4-mm increments, bulk fill resin composites were
ICDAS 4 Presence of shading in underlying dentin, with or
developed.7 These materials have increased translucency, which without localized enamel breakdown.
allows them to be used in larger increments (≈4 mm), and lower poly- ICDAS 5 Clear cavity with visible dentin (less than ½ of the
merization shrinkage, which leads to lower stresses in the cavity11,12 affected surface).
with similar bond strength values.7 For these reasons, bulk fill com- ICDAS 6 Extensive cavity with visible dentin (at least ½ of the
posites can be a good alternative material to be used in Class I affected surface).

444
Therefore, this case report aimed to describe a case in which an
ICDAS 4 carious lesion was restored using a bulk fill composite associated
with the “stamp” technique, and to report its follow-up after 4 years.
2 | CLINICAL CASE REPORT
A 32-year-old patient sought the local clinic for a regular
appointment to analyze the presence of carious lesions. After
F I G U R E 2 The bitewing radiographical aspect of the left
mandibular first molar (36). It is possible to observe a discrete
radiolucent area below the distal cusp
FIGURE 3 Before accessing the lesion, the stamp created using flowable resin on the occlusal surface of the affected tooth
17088240, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12963 by Guatemala - OARE Access, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VERTUAN ET AL.
clinical examination, a carious lesion was detected on the left
mandibular first molar (36) (Figure 1). The tooth presented a
noncavitated occlusal surface, but with an underlying dark
shadow from dentin seen from the occlusal surface. Based on
the ICDAS classification2 (Table 1), this lesion was classified as
ICDAS 4.
The bitewing radiograph (Figure 2) showed a discrete radiolucent
area below the distal cusp, extending to the outer third of dentin,
according to the ICDAS and ICCMS scoring systems.
Pulp health status was assessed using the cold pulp test, where
dichlorodifluoromethane (Roeko EndoFrost; Coltene/Whaledent,
F I G U R E 4 Carious tissue removal with spoon excavator until
leathery-consistent dentin
 17088240, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12963 by Guatemala - OARE Access, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VERTUAN ET AL. 445

FIGURE 5 Cavity lining with resin-modified glass-ionomer F I G U R E 6 Thread seal tape on the surface of the affected tooth
cement to prevent the stamp to attach to the restoration

FIGURE 7 Occlusal stamp in position for dental anatomy F I G U R E 8 Final aspect after immediate finishing and polishing
refinement and after occlusal checking

Clinically, the patient presented biofilm at the cervical region and

FIGURE 9 Aspect of the restoration after 4 years
Langenau, Germany) was sprayed on a cotton roll, which was pressed
against the buccal cervical area the tooth for 5 s.14 The tooth pre-
sented normal sensibility, suggesting normal pulp vitality.
on the occlusal surface of some teeth, and previous resin composite
restorations were detected. Thus, the first step was dental cleaning
and hygiene and dietary instruction, aiming to treat the caries disease.
For the carious lesion on the left mandibular first molar, given that the
occlusal anatomy was still preserved, the occlusal “stamp” technique
was selected.13
After isolation with rubber dam, a thin layer of solid Vaseline was
spread on the occlusal surface of the tooth and a flowable resin com-
posite (Opallis Flow, FGM, Joinville, SC, Brazil) was used to copy the
external anatomy of the tooth. This layer of flowable resin was light
cured for 20 s and a microbrush (Cavibrush, FGM, Joinville, SC, Brazil)
was fixed on that layer to be used as a handle (Figure 3). After
light-curing for another 20 s, the layer of flowable resin with the
microbrush was detached from the tooth surface. This allowed the
acquisition of an impression of the occlusal surface (Figure 3).
The carious lesion was accessed with a diamond bur (#1090, KG
Sorensen, Cotia, SP, Brazil) and the tissue was selectively removed
until leathery dentin4 was reached using a low-speed carbide bur

446
(Jota, Switzerland) and spoon excavator (Golgran, São Caetano do Sul,
SP, Brazil) (Figure 4). Then, a lining resin-modified glass-ionomer
cement (Vitrebond, 3 M ESPE, Saint Paul, MN, USA) was applied on
the pulp wall and light cured for 20 s (Figure 5). The enamel was selec-
tively etched with 37% phosphoric acid for 30 s, rinsed, and the cavity
was dried with absorbent paper. The universal adhesive system
(Ambar Universal, FGM, Joinville, SC, Brazil) was used in the self-
etching mode, following the manufacturer's recommendations.
The restorative step was executed using the Opus Bulk Fill A3
(FGM, Joinville, SC, Brazil) resin composite inserted in increments of
4-mm. The last increment was inserted in the cavity and a strip of
thread seal tape was placed on it, so the negative impression could be
pressed against the tooth (Figure 6) to reproduce the natural dental
structure characteristics. The strip of thread seal tape was carefully
removed and excesses of resin were removed. Then, the negative
impression was isolated with solid Vaseline and pressed against the
uncured resin to refine the dental anatomy (Figure 7), followed by
light-curing for 40 s. Minimal occlusion adjustments were necessary.
Figure 8 shows the final restoration after finishing and polishing
procedures.
After 4 years, the patient remains motivated for oral hygiene and
returned to the clinic for follow-up. Clinically, the restoration pre-
sented small wear, but without fractures and marginal discolorations
(Figure 9).
3 | DISCUSSION
Despite the multiple methods of prevention, dental caries has not yet
been entirely controlled, and it is still considered the main oral health
15
problem around the world, especially in low-income countries.
Described as a dynamic and continuous process, dental caries is a
multifactorial disease mediated by dental biofilm, which, when in sym-
biosis (balance) with the host, brings little consequences to the dental
structure. On the other hand, upon local environmental changes, a
modification in the biofilm's microbiota may occur. This process is
known as dysbiosis (imbalance) and leads to the development of the
caries disease.16 Therefore, it is important to state that restorative
treatments are used to restore carious lesions, while the caries disease
is treated with hygiene and dietary instructions, as well as with the
use of remineralizing agents, such as fluoride.
First described in 1986, “hidden caries” was the term used to
describe a carious lesion affecting dentin under a sound or minimally
demineralized enamel.17 Some theories over the years tried to explain
its development, such as the fluoride syndrome or presence of defects
in the occlusal pit and fissure surface.17,18 Lynch and Ten Cate evi-
denced that dentin presented a different demineralization rate com-
pared with the one of enamel, and the progression of hidden caries
could be explained by the fact that minerals lost by dentin could be
reprecipitated in enamel, which clinically could mean that caries pro-
19
gressed in dentin while enamel was supposedly preserved.
To aid in the detection of carious lesions, radiographic examina-
tion is a useful clinical tool, given that radiographic examination
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VERTUAN ET AL.
evidences areas of demineralization in dentin and a high correlation
between the histological and radiographic analysis of carious lesions
has been previously reported.20 However, studies also reported that
radiographic examination of ICDAS 4 carious lesions might not exhibit
obvious radiolucency, which might compromise the diagnosis by these
images.21,22 Nonetheless, with the development of detection systems
such as the ICDAS and the ICCMS, the clinical signs of carious lesions
reaching dentin but under the preserved enamel surface started being
detected clinically more frequently. This led to the disuse of the term
“hidden caries,” and these lesions started being described as ICDAS
4 lesions.2,3
These detection systems help the clinician to diagnose dental car-
ies based on the lesions' clinical signs,2,3 and also increased the accu-
racy of the visual examination,23 which resulted in the ICDAS
showing promising results in reproducibility and in identifying lesions
from its earliest onsets to the most advanced situations.2,3,24 Thus,
despite several technologies being developed to help clinicians to
diagnose dental caries in its early onsets, the best method available is
still the visual-tactile examination.25 Yet, it is important to state that
ICDAS 4 lesions, as the one in this case report, are not considered ini-
tial lesions, so detection systems such as the ICDAS and ICCMS
helped clinicians to detect and intervene in carious lesions even
before a restorative treatment is necessary, also following the princi-
ples of minimally invasive dentistry but leading to an even better
treatment prognosis.2,3 In addition, ICCMS instructs the clinicians to
manage the dental caries risk factors through the whole caries treat-
ment, which is the key to long-term success.3
Moreover, to treat these ICDAS 4 lesions, the ICCMS endorses a
tooth-preserving operative care, which consists in the selective
removal of the carious tissue. In this technique, all carious tissue in
the surrounding walls is removed, and the selective removal is con-
ducted in the pulp wall until a leathery-consistent dentin is reached.4
This technique reduces the chances of pulp exposure and a systematic
review concluded that the maintenance of bacteria under restorations
does not lead to lesion progression nor to other adverse effects such
as pulpitis or pulp necrosis.26
To restore Class I cavities, conventional resin composites have
shown good results over the years,27 however, due to their polymeri-
zation contraction, evidences of postoperative sensitivity, marginal
gap, and secondary caries are not unusual.6 To overcome this issue,
the lesion could be restored using a conventional resin composite
associated with the incremental technique. Nonetheless, this tech-
nique might lead to the incorporation of voids or contamination
between layers, and it can be time consuming due to several filling
and light-curing steps.7
For these Class I cavities, bulk fill composites might be a good alter-
native, especially if associated with the stamp technique. This technique
allows the placement of a restoration in a relatively short period of time
because it reproduces the natural anatomy of the occlusal surface,13,28
and it has shown good results after 40 months.13,28 To do so, the use of
flowable composites to copy the natural anatomy of the enamel's pits
and fissures is recommended. Other materials, such as transparent
silicone-based materials could also be used to copy the enamel surface,

VERTUAN ET AL.
however, they may not be readily available on a general dental practice
and also may be retained in deep pits and fissures, tearing apart when
13,28
removed from the surface. In addition, flowable resins are much more
resistant than silicone-based materials, so they can be pressed against the
tooth surface without suffering deformation.
Since a resin-based material was used to produce the stamp, the
possibility of bonding between the stamp and the uncured underlying
bulk fill composite should not be overlooked. For this reason, Vaseline
may be applied on the stamp to act as a lubricant clinically. Some con-
cerns regarding the adaptation of the resin composite at the cavo-
surface margin if such a lubricant is used may be raised, especially if
there is lack of restorative material in any area of the final composite
layer. For this reason, in the present case report a thread seal tape
was used as a first protective barrier so the excess of composite could
flow to provide better adaptation of the cavo-surface margin without
the risk of contamination with Vaseline. After the first use of the
thread seal tape, the tape was removed and then the stamp was lubri-
cated with Vaseline and pressed against the surface. However, since
Vaseline was also used as an isolation agent during the preparation of
stamp, it could have filled the pit and fissures areas and not allowed
the flowable composite to flux within them, generating an impression
with continuous surface without clear delimitation of the occlusal
13
grooves. This may explain why the pit and fissures are not as clear
as the natural tooth anatomy on the final aspect of the restoration
(Figure 8), despite it being functional and without primary occlusal
trauma.
To restore the cavities, bulk fill composites can be a good alterna-
tive because they are less time consuming than conventional
composites. Bulk fill resins may present modified resin matrix and
light-activation system, increased filler size and/or reduced amount of
pigments/opacifiers. Despite this modification reducing the material's
mechanical properties,29,30 it is also responsible for increasing the
depth of light penetration (i.e., translucency), improving the material's
depth of cure.31–33 Due to the increased translucency, bulk fill com-
posites may show slight differences in color, which could be a problem
in some esthetic regions. However, considering that in the present
case report a Class I cavity in a mandibular molar is shown, the slight
difference in color and translucency was not an important concern
that would jeopardize the esthetic outcome and acceptance by the
patient.
In addition, bulk fill composites are normally formulated with a com-
bination of different monomers with a high molecular weight34 and differ-
ent photoinitiator systems, such as the “Advanced Polymerization
System,” which amplify the polymerization capacity of the material.35
These modifications interfere with the modulation of polymerization
kinetics and promote a relatively slower reaction, prolonging the pregel
phase of the resin and delaying the gelation phase of the material.31,32,36
This phenomenon allows more time for the molecules to compensate
and, thus, reduces the material's volumetric shrinkage.11
Due to these properties, bulk fill materials offer lower shrinkage
stress and less cusp strain and deflection than conventional
composites,31,37 thus serving as a good resource to be used in cavities
with a high configuration factor (C-factor), such as Class I cavities.
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447
Therefore, given these mentioned advantages, this technique seems to be
a good resource to be used in ICDAS 4 lesions, where the occlusal anat-
omy is preserved. Yet, further clinical trials evaluating the stamp tech-
nique's time-consumption and cost-effectiveness over the years
compared with the incremental technique with and without bulk fill com-
posites are necessary to evidence the life-spam of restorations placed
using it. In addition, it is imperative to state that the success of the restor-
ative treatment must also be conducted along with controlling the
patient's dietary and hygiene habits to properly treat the caries disease.
4 | CONC LU SION
The occlusal stamp technique allows to reproduce the natural anat-
omy of teeth affected by ICDAS code 4 carious lesions. When associ-
ated with a bulk fill composite, and with hygiene and dietary
instructions, the restorations seem to present clinical longevity over
more than 4 years.
DISCLOS URE
This study was financed in part by the Coordenação de Aperfeiçoa-
mento Pessoal de Nível Superior—Brazil (CAPES)—Finance Code 001.
The authors do not have any financial interest in the companies
whose materials are included in this article.
DATA AVAILABILITY STAT EMEN T
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
OR CID
Genine Moreira de Freitas Guimarães https://orcid.org/0000-0002-
4415-850X
Alyssa Teixeira Obeid https://orcid.org/0000-0001-9298-1114
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How to cite this article: Vertuan M, Mosquim V,
Guimarães GMF, et al. The stamp technique for direct
restoration in a ICDAS 4 carious lesion: A 4-year follow-up.
J Esthet Restor Dent. 2023;35(3):442‐448. doi:10.1111/jerd.
12963