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Systematic Review

Comparative Survival of Restorations in MIH-Affected Pediatric Teeth Using Total-Etch Versus Self-Etch Adhesive Systems: A Systematic Review and Meta-Analysis

by
Maurizio D’Amario
1,*,†,
Elena Vitocco
1,*,†,
Ali Jahjah
1,
Antonio Capogreco
1,
Stefania Mauro
2,
Camillo D’Arcangelo
3 and
Francesco De Angelis
3
1
Department of Life, Health and Environmental Sciences, Dental School, University of L’Aquila, 67100 L’Aquila, Italy
2
Private Practice, 67100 L’Aquila, Italy
3
Unit of Restorative Dentistry and Endodontics, Department of Medical, Oral and Biotechnological Sciences, University of Chieti, 66100 Chieti, Italy
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Appl. Sci. 2025, 15(23), 12445; https://doi.org/10.3390/app152312445
Submission received: 24 September 2025 / Revised: 8 November 2025 / Accepted: 15 November 2025 / Published: 24 November 2025
(This article belongs to the Special Issue Advanced Dental Materials and Its Applications)
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This study provides strong scientific evidence for improving conservative treatment in patients with MIH.

Abstract

This study aimed to investigate adhesive techniques applied to MIH-affected teeth by analyzing the one-year failure rate of restorations performed using total-etch and self-etch adhesive methods. This systematic review was conducted in accordance with the PRISMA 2020 statement. Eligibility criteria were defined using the PICO acronym. In vivo studies published from 2017 onward were evaluated. Two independent reviewers conducted the search on PubMed, Scopus, Cochrane, and Web of Science. The risk of bias was assessed with RoB2 and the Newcastle-Ottawa Scale. Statistical analysis was performed using the Open Meta [Analyst] software based on the absolute risk of failure. Results were presented as a pooled estimate with a 95% confidence interval (CI) and visualized in forest plots. Four RCTs and one retrospective cohort study were selected for the analysis. Data collected included information such as authors, study design, age, restorations, degree of hypomineralization, protocol, and follow-up. The meta-analysis showed no statistically significant differences between the techniques (p = 0.338) on MIH-affected teeth. This meta-analysis supports the use of both adhesive techniques for managing MIH teeth, emphasizing the need for further studies to examine the specific clinical and technical conditions under which each technique might be more advantageous.

1. Introduction

Molar incisor hypomineralization (MIH) is a qualitative developmental defect of the dental enamel that affects one or more permanent first molars and, occasionally, the incisors of the same dentition [1]. MIH depends on multifactorial etiology, with exposure to various combined factors: perinatal hypoxia, prematurity and other hypoxia related perinatal problems, including cesarean section, certain infant and childhood illnesses [1,2]. The global prevalence of MIH is estimated to be 13.5% and according to the EAPD criteria, the severity levels of MIH can be mild or severe [2,3]. The mild form is characterized by demarcated enamel opacities without enamel breakdown, induced sensitivity to external stimuli (e.g., air/water, but not brushing), and mild esthetic concerns regarding discoloration of the incisors. The severe form, on the other hand, involves demarcated enamel opacities with breakdown and caries, spontaneous and persistent hypersensitivity affecting function (e.g., brushing, mastication), and strong esthetic concerns that may have a socio-psychological impact [2,4].
Hypomineralized enamel is more porous and less mineralized compared to normal enamel, which makes it prone to fracture after masticatory contact, increasing MIH severity with age [5,6,7,8]. In vitro studies have shown that hypomineralized enamel contain higher organic content and more aprismatic enamel than normal enamel, with yellow-brownish opacities being more porous than white-creamy ones [5,9,10]. Given this information on the microscopic characteristics of teeth affected by MIH, and that explains why the most common consequences are dental caries, hypersensitivity, and post-eruptive fracture [11,12,13,14]. Various restorative treatments are proposed, primarily depending on the severity of hypomineralization, but the topic of adhesive restorations has not been extensively studied [15,16,17,18,19,20]. Micromorphological analyses revealed that conventional phosphoric acid etching produces a markedly less pronounced etching pattern in affected enamel and results in a porous structure that represents a weak point in the resin–enamel bond. Micro-shear data indicate a reduction in adhesion to MIH-affected teeth, with porosities observed at the resin–enamel interfaces. Furthermore, MIH enamel surfaces display irregular etching patterns, heterogeneous crystalline organization, and an elevated protein content. In cases of severe MIH, particularly in posterior teeth, prosthetic restoration such as dental crowns are often preferred [21,22,23,24]. However, the therapeutic approach should be individualized based on the patient’s needs and on the number of affected teeth, as dental crowns are not the best or option. This is particularly relevant because the modulus of elasticity of teeth affected by MIH is significantly reduced compared to non-hypomineralized teeth [25]. Consequently, more attention should be given to identifying adhesive techniques suitable for these teeth [26,27,28,29]. The challenge of adhesion to hypomineralized teeth originate from reduced enamel hardness and the irregularity of the apatite, leading to frequent breakdown of restoration margins or loss of retention [30,31,32,33,34]. As a result, restorations in MIH teeth tend to have lower clinical performance rates than those in non-hypomineralized teeth [35,36,37]. The clinical performance of a restoration is assessed by analyzing its behavior according to specific criteria, such as anatomical form, marginal integrity, surface texture, marginal discoloration, retention, and the presence of secondary caries (according to the modified USHPH criteria) [Figure 1]. A restoration not fulfilling one or more of these requirements is deemed clinically unsuccessful. Considering all this information, this systematic review aims to further investigate the topic of adhesion to MIH teeth, assisting future researchers in identifying the best strategy for creating adhesion to hypomineralized teeth. The null hypothesis of the study stated that there is no statistically significant differences in the one-year clinical performance between a total-etch and a self-etch adhesive system on MIH-affected teeth.

2. Materials and Methods

2.1. Registration and Protocol

This systematic review was conducted in accordance with the PRISMA 2020 statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [36]. It has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) with the following ID: [CRD420250628573].

2.2. Eligibility Criteria

Eligibility criteria were defined using the PICO acronym: (P) Population: pediatric patients with erupted permanent first molars diagnosed with MIH; (I) Intervention: dental restorations performed using a total-etch adhesive system; (C) Comparison: dental restorations performed using a self-etch adhesive system; (O) Outcome: restoration clinical performance one-year post-treatment. Clinical performance is comprehensively defined by the following parameters: anatomic form, marginal integrity, superficial texture, margin coloring, retention, and the presence of secondary caries. The non-compliance of any single parameter will signify the clinical failure of the adhesive restoration. For this systematic review, the null hypothesis (H0) was defined as the intervention group having the same clinical performance of MIH teeth compared to the control group. To obtain the most recent information, it was established before the database search that only studies published within the last 7 years of research (from 2017 onward) would be included. Additional inclusion criteria were to include only studies that had a control group; to include only studies that had been conducted in vivo.

2.3. Information Sources and Search Strategy

The search was performed in March 2024 and updated in January 2025 by two independent reviewers. The following electronic databases were searched: PubMed, Scopus, Cochrane, Web of Science. Specific key words were used for each dataset, summarized in Table 1. The MeSH terms used in the PubMed search were derived from a review read during a previous literature review conducted by one of the authors [37]. Subsequently, the same reviewers thoroughly assessed the selected studies by reading their full texts. Any discrepancies in the selection process were resolved through discussion and consensus between the reviewers.

2.4. Selection Process

Study selection was conducted by two independent reviewers. The process involved an initial phase of identifying articles in various databases based on keywords. Before screening, duplicates appearing in at least two databases were removed. Subsequently, the screening phase commenced. First, where possible, a publication year filter was applied to exclude articles published outside the period of 2017 to 2024. When this filter could not be applied, articles were manually excluded by examining their publication year. The next step involved reading the abstract of the remaining articles to assess eligibility based on the inclusion criteria and evaluate journal relevance. The final step of the screening phase consisted of a full-text review of the remaining articles. Web applications were not used at any stage. Any discrepancies in the selection process were resolved through discussion and consensus between the reviewers.

2.5. Data Collection Process

Data extraction was performed by the two reviewers after independently reading all articles selected for the systematic review. Data was collected in Excel and included the following: authors, journal, study design, number of patients and their age, number of teeth restored, degree of hypomineralization, number of teeth treated with self-etch and total-etch adhesives along with their respective protocols, presence of pre-treatments, final cavity margins, materials used, follow-up period, evaluation method for restoration clinical performance, results, and authors’ conclusions.

2.6. Quality Assessment

Different scales were employed to assess the risk of bias, depending on the study design. For randomized controlled trials (RCTs), the RoB 2 tool, currently recommended by the Cochrane Collaboration, was used [38]. This tool evaluates bias in five domains: randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. For retrospective cohort studies, the risk of bias was assessed using the Newcastle-Ottawa Scale (NOS), specifically the appendix for cohort studies, which evaluates selection, comparability, and outcomes [39]. To create a unified risk of bias graph, the NOS was adapted to align with the RoB 2. Each domain in the Traffic Light plot corresponds to specific sections of the NOS: D1 (representativeness of the intervention cohort, selection of the non-intervention cohort, and ascertainment of intervention), D2 (demonstration that the outcome of interest was not present at baseline), D3 (comparability), D4 (assessment of outcome and median follow-up duration), and D5 (adequacy of follow-up cohorts).

2.7. Data Analysis and Synthesis

Statistical analysis was performed using the open-source software OpenMeta [Analyst] (https://openmetaanalysis.github.io/, accessed on 14 November 2025) and only studies with sufficient data to compute relative risk were included in the meta-analysis. Meta-analysis was performed using a random-effects model and absolute failure was used to calculate the relative risk, as it is considered a direct indicator of clinical performance. Clinical performance is assessed based on parameters such as anatomical form, marginal integrity, surface texture, marginal discoloration, retention, and the occurrence of secondary caries. A deviation in any of these parameters is regarded as indicative of restoration failure. Statistical heterogeneity of the intervention effects across the included studies was evaluated using the I2 test. According to this, values exceeding 50% indicate substantial heterogeneity. When such heterogeneity was observed, a random-effects model was employed for data analysis [40]. The meta-analysis results were presented as a pooled estimate with a 95% confidence interval (CI) and visualized in forest plots. Sensitivity analysis was performed using the leave-one-out module to assess the influence of each omitted study. Publication bias was evaluated using forest plots. A p-value of <0.05 was considered statistically significant.

3. Results

3.1. Study Selection

Figure 2 illustrates the study selection process. With the specified keywords and MeSH terms in the Section 2, 251 articles were identified from PubMed, 61 from Scopus, 105 from Cochrane, and 50 from Web of Science, totaling 467. Before starting the screening, duplicate articles, which amounted to 213, were manually removed, leaving 254 articles for the screening phase. By automation tool, all studies not published between 2017 and 2024 were excluded, resulting in 177 articles. During the screening, the title and abstract of all 77 remaining articles were reviewed and 71 of these did not meet the inclusion criteria After this phase, 6 articles were assessed for eligibility and their full text were reviewed. After a full reading, only 1 article was excluded. A total of 5 studies were included in the review [41,42,43,44,45].

3.2. Study Characteristics

Each study’s characteristics are presented in Table 2. Summarizing the characteristics of the studies included in the systematic review, we can observe that 4 out of 5 are Randomized Clinical Trials (Hakmi et al., Özgür et al., de Souza et al., Rolim et al.) and 1 is a retrospective cohort study (Linner et al.) [41,42,43,44,45]. All RCT studies have a defined study group called GROUP 1, compared to a control group, called GROUP 2. In the retrospective cohort study, there were four study groups compared to each other (Glass ionomer cement, Composite with self-etching adhesive, Composite with total-etching adhesive, CAD/CAM ceramics). However, for the outcome of this systematic review, it was necessary to include only the groups Composite with self-etching adhesive and Composite with total-etching adhesive. In total, 164 pediatric patients with an average age of 10 years were included in the systematic review. The total number of restorations included in the systematic review was 408, of which 252 were self-etch and 156 were total-etch. The degree of MIH varies across studies: Hakmi et al. and de Souza et al. performed adhesive restorations on MIH teeth with severe grade, Özgür et al. with moderate grade, while Rolim et al. and Linner et al. specified that restorations were performed on teeth with various grades of MIH [41,42,43,44,45].
Only Linner et al. performed different restorations based on the degree of MIH present in the tooth: self-etch adhesive restorations were performed on teeth with disintegration of hard tissue with small- to medium-sized defects, while total-etch adhesive restorations were performed on teeth with disintegration of hard tissue with small- to large-sized defects [45]. Almost all authors performed a pretreatment before the restoration, except for Linner et al. who did not specify whether this was done [41,42,43,44,45]. Hakmi et al. and Rolim et al. performed restorations on sound enamel, Linner et al. only for the total-etch group; Özgür et al. did not remove hypomineralized tissue before performing the restoration, while de Souza et al. did not specify [41,42,43,44,45]. For each study, restorations were evaluated during follow-up periods of at least 12 months according to Modified USHPH criteria (anatomic form, marginal integrity, superficial texture, margin coloring, retention and minor decay), except for Linner et al., where only the statistical method for survival analysis (Kaplan-Meier estimators and the Cox regression model) were specified [41,42,43,44,45]. It is noteworthy that each author performed survival analysis using Kaplan-Meier survival analysis, some accompanied by the Long Rank test (Özgür et al.; de Souza et al.; Rolim et al.) [41,42,43,44,45]. The results obtained by the authors were heterogeneous: Hakmi et al., de Souza et al., and Rolim et al. obtained no difference in the clinical survival of restorations in FPMs affected by MIH using TEA or SEA adhesives; while Özgür et al. and Linner et al. argued that there is a significant difference in survival between total-etch and self-etch adhesive restorations on MIH teeth. Özgür et al. suggested that the lower survival in self-etch restorations is due to the type of adhesive technique used [41,42,43,44,45].

3.3. Study Risk of Bias Assessment

As specified in Section 2, both the domains analyzed with ROB2 tool (Hakmi et al.; Özgür et al.; de Souza et al.; Rolim et al.) and those analyzed with NOS (Linner et al.) were reported in the same traffic light plot to obtain a unique Overall Bias graph (Figure 3) [41,42,43,44,45]. The RCTs all have a low risk of bias in domains 2, 3, 4, and 5, with only Özgür et al. shows some concerns for the randomization process, as the randomization method was not specified [41,42,43,44,45]. Regarding the retrospective cohort study, there were some concerns of risk of bias since it received 3 out of 4 stars for Selection of intervention (D1 and D2), 1 out of 2 stars for Comparability (D3), and 2 out of 3 stars for Outcome (D4 and D5) [45]. The overall bias for the systematic review was “Some concerns” for 78.8%, “low risk” for 45%, and “high risk” for 0%.

3.4. Synthesis Methods

The studies included in the quantitative analysis were the RCTs, as it was not possible to calculate the absolute failure (RR) in the retrospective cohort study: this is because the authors incorporate retreated teeth into the follow-up periods, not exclusively those with primary restorations [41,42,43,44,45]. The included studies showed high heterogeneity (I2 = 86.243), so a meta-analysis was performed using the random-effects model with a 95% confidence interval (C.I.) [41,42,43,44]. As visible in the forest plot in Figure 4, according to this statistical analysis, there was no statistically significant difference between the results (p-value greater than 0.05, p-value = 0.338). To verify the robustness of the results, a leave-one-out summary meta-analysis was performed with a 95% confidence interval (C.I.). In each leave-one-out analysis, the p-value was always greater than 0.05, indicating no statistically significant difference (Figure 5). This result supports the validity of the findings, demonstrating that no single study influenced the result in a predominant way. From this meta-analysis, it appears that, for MIH teeth, there is no difference in the clinical performance of adhesive restorations with total-etch technique (intervention group) compared to self-etch (control group), nor vice versa. Therefore, H0 was not rejected

4. Discussion

This meta-analysis aimed to evaluate the clinical performance of adhesive restorations on molars affected by Molar-Incisor Hypoplasia (MIH), comparing two widely used adhesive techniques in dentistry: the total-etch technique (TEA) and the self-etch technique (SEA). This comparison holds significant clinical relevance, given the potential impact that the choice between these techniques may have on the treatment of teeth affected by MIH, a condition increasingly prevalent in the pediatric population [2]. However, our analysis showed no statistically significant difference between the two techniques regarding the clinical performance of adhesive restorations. The statistical analysis was conducted using a random-effects model due to the high heterogeneity between the included studies (I2 = 86.243). This high heterogeneity justified the use of this model, which is particularly appropriated for managing variability across studies. The forest plot indicated a p-value of 0.338, higher than the significance threshold of 0.05, suggesting that there was no difference between the intervention group (TEA) and the control group (SEA). However, to ensure the robustness of the results, a leave-one-out analysis was performed by progressively removing each study from the data set. This analysis confirmed that the p-value remained above 0.05, excluding the possibility that a single study disproportionately influenced the outcome. These results are consistent with those obtained in other systematic reviews on the subject, which reported that there are no significant differences between self-etch and total-etch techniques, at least in terms of adhesive strength and restoration clinical performance. In particular, in the systematic review by Lagarde et al., whose results are similar to ours, no significant differences were found in the composite bond strength when comparing self-etch adhesives to etch-and-rinse adhesives, although attention was also given to laboratory studies [37]. Our meta-analysis, on the other hand, focused exclusively on in vivo studies, which may explain some differences in the results obtained. However, both reviews agree in stating that neither technique demonstrates a clear advantage over the other, at least in terms of long-term clinical performance [37]. Other reviews, such as that by Weber et al., also support the conclusion that there are no performance differences between self-etch and total-etch adhesive systems, although it is important to note that their review was based on a limited number of articles [46]. There appear to be no recent meta-analyses specifically focused on the clinical performance of restorations with an explicit focus on self-etch or total-etch adhesive techniques. This makes our meta-analysis one of the first to fill this gap in the scientific literature. Among the studies included in our analysis, most reported similar results, indicating that both adhesive techniques are effective in managing MIH-affected teeth [41,43,44]. However, some studies presented results that were not fully consistent with this conclusion. Two studies seemed to suggest a potential advantage of the total-etch technique over the self-etch technique [42,45]. It is important to note, however, that these studies had a higher risk of bias compared to the other studies included in our analysis. Ozgur B et al. did not specify the randomization methods used to assign teeth to the two adhesive techniques, a methodological gap that could reduce the reliability of their results [42]. Additionally, Linner et al., which suggested a longer lifespan of restorations using the total-etch technique, divided the groups based on cavity preparation type, another factor that could influence the results [45]. In this study, the self-etch technique was applied to teeth with smaller MIH defects, with no cavity preparation, while the total-etch technique was used on teeth with larger defects, with removal of hypomineralized tissue [45]. This procedural difference could have influenced the longevity of the restorations, as removing the damaged tissue allows restorations on healthy enamel, improving the stability of the adhesive bond. Furthermore, the high heterogeneity among the studies may indicate that other factors may have influenced the results, as shown in studies where hypomineralized tissue was removed before restoration. In fact, the data from individual studies revealed that adhesive restorations demonstrated greater longevity on MIH-affected teeth when the hypomineralized tissue was removed, providing a healthy base for the restoration [41,43,44,45]. Indeed, studies where the hypomineralized tissue was not removed (Ozgur et al. and Group 1 of Linner et al.), showed limited durability for self-etch techniques [42,45]. A key point for discussion is the high heterogeneity resulting from this meta-analysis, which led to the use of a random-effects statistical model. The I2 statistic remained high, despite the risk of bias in the systematic review being moderate, because the studies analyzed had differing data. For instance, the number of teeth and patients included varied markedly across studies: Hamki et al. evaluated 40 teeth in 20 patients, whereas Linner et al. evaluated 440 teeth in 52 patients [42,45]. These two studies represent the extremes of the minimum and maximum number of teeth analyzed, with other studies falling within this range [41,45]. All studies focused on adolescents population, yet. The degree of severity of MIH teeth varied as well, as previously mentioned, which obviously increased the level of heterogeneity. Another key factor influencing the results was the protocol: although each study performed adhesive restorations on MIH teeth using either the self-etch or total-etch technique, no one study followed the exact same steps. Each study employed a different pretreatment method, with Linner et al. being the only study not specifying this step, and naturally, each protocol differed [41,42,43,44,45]. In fact, within the same study, the protocols for self-etch and total-etch groups varied. This lack of standardization not only explains the high heterogeneity in the meta-analysis but also highlights that clinicians may need standardization in procedures for treating MIH teeth, which can obviously vary depending on the degree of MIH, patient sensitivity, esthetic needs, or cost considerations. One thing all studies agree on is the follow-up methodology: all used the Kaplan-Meier method [41,42,43,44,45]. Of course, heterogeneity, variability in study designs, and incomplete methodological description likely contributed to some variability in the results. These factors suggest that, although the results are useful, further research with greater homogeneity between studies is needed to reach more robust conclusions. It would be helpful to conduct studies with larger sample sizes, longer follow-up periods, and more standardized treatment protocols to enhance the comparability and reliability of outcomes.
From a clinical perspective, this meta-analysis is relevant for clinical practice. Therefore, dental professionals can consider both techniques as valid options, making the decision based on other factors, such as material availability and individual preference, rather than the longevity or long-term clinical performance of the restorations.

5. Conclusions

This meta-analysis demonstrated that the clinical performance of adhesive restorations in teeth affected by molar incisor hypomineralization (MIH) is not significantly influenced by the choice of adhesive technique. No statistically significant differences were found between the self-etch (SEA) and total-etch (TEA) methods. The results suggest that both techniques are equally effective for treating MIH-affected teeth, offering comparable performance in terms of restoration durability and adhesive strength. However, the substantial heterogeneity, small sample size, and brief follow-up period suggest that definitive equivalence cannot be established. Hence, the results should be interpreted as suggestive rather than conclusive of clinical equivalence. The results also provide a foundation for future research, which could explore the identification of the optimal adhesive technique for hypomineralized teeth. This research could consider additional factors such as cavity preparation, severity of hypomineralization, and the type of restorative material used. Investigating these variables could further enhance our understanding of the best clinical practices for treating MIH, with the goal of improving the longevity and performance of adhesive restorations while reducing the need for more invasive procedures. Therefore, the decision between the two techniques can be based on practical factors such as ease of use, material availability, or clinician preference, rather than on significant differences in long-term restoration longevity. These findings are particularly relevant to clinical practice, as they allow for a more flexible approach to managing MIH teeth, with practitioners able to select the technique that best meets their needs and those of the patient, without compromising treatment quality.

Author Contributions

Conceptualization: M.D., E.V. and C.D.; Data curation: M.D., E.V., A.J., A.C., S.M., F.D.A. and C.D.; Formal analysis: M.D., E.V., F.D.A. and C.D.; Methodology: M.D. and E.V.; Validation: S.M., F.D.A. and C.D.; Writing—original draft preparation: E.V., A.J., A.C. and S.M.; Writing—review and editing: M.D., F.D.A. and C.D. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Sequential phases (pre-treatment, intraoperative, and post-treatment) of restorative management of teeth affected by Molar Incisor Hypomineralization (MIH).
Figure 1. Sequential phases (pre-treatment, intraoperative, and post-treatment) of restorative management of teeth affected by Molar Incisor Hypomineralization (MIH).
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Figure 2. Flowchart of the selection of studies according to PRISMA 2020 statement.
Figure 2. Flowchart of the selection of studies according to PRISMA 2020 statement.
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Figure 3. Traffic Light Forrest plot for the quality assessment [41,42,43,44,45].
Figure 3. Traffic Light Forrest plot for the quality assessment [41,42,43,44,45].
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Figure 4. Forest plot generated using a random-effects model, showing the calculation of relative risk (RR) with 95% confidence intervals [41,42,43,44].
Figure 4. Forest plot generated using a random-effects model, showing the calculation of relative risk (RR) with 95% confidence intervals [41,42,43,44].
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Figure 5. Leave-one-out Forest Plot generated showing the calculation of the relative risk (RR) with 95% confidence intervals [41,42,43,44].
Figure 5. Leave-one-out Forest Plot generated showing the calculation of the relative risk (RR) with 95% confidence intervals [41,42,43,44].
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Table 1. Summary of the electronic databases and keywords used for the search.
Table 1. Summary of the electronic databases and keywords used for the search.
PubMedScopusCochraneWeb of Science
(mottled enamel OR nonendemic mottling of enamel OR internal enamel hypoplasia OR cheese molars OR non-fluoride enamel opacities OR idiopathic enamel opacities OR enamel hypomineralization OR enamel hypomineralisation OR hypomineralized molars OR hypomineralised molars OR molar incisor hypomineralization OR molar incisor hypomineralisation OR MIH [MeSH Terms]) AND (bond strength OR bonding OR retention OR survival OR longevity OR infiltration [MeSH Terms])molar AND incisor AND hypomineralization AND therapy [title abstract keyword]molar incisor hypomineralization [title abstract keyword]molar incisor hypomineralization (All Fields) AND therapy (All Fields)
Table 2. Data extraction of included studied.
Table 2. Data extraction of included studied.
Authors, YearJournalStudy DesignNumber of
Patients (Age Range)		Number of TeethSeverity of HypomineralizationGroup 1Group 2PretratmentFinal MarginsProtocol G1Protocol G2Materials UsedFollow Up PeriodSurvival RateResultsAuthors’ Conclusions
Hakmi, A. & Dashash, M.—2023 [41].BDJ OpenRandomized clinical controlled trial20 children, aged 7–11 years40 (20 G1 and 20 G2)SEVERE MIH according to EAPD classification (demarcated enamel opacities with breakdown and caries, spontaneous and persistent hypersensitivity affecting function e.g., brushing, mastication) that could be restored.Self-EtchTotal-EtchAll prepared walls were wiped with cotton moistened in sodium hypochlorite 5.25% before applying the acid etch and bond [41]. The final margins of the preparation were placed on a sound enamel.Teeth were cleaned after completing the preparation, and then the impressions were taken for both jaws using an additional silicone rubber impression material. The impression was cast using yellow gypsum to obtain gypsum samples. Resin composite resin was applied to the gypsum samples in layering technique after they were isolated using silica, as the thickness of one layer does not exceed 2 mm, then each layer was light cured separately for 20 s. The finishing and polishing process was performed. using Fine and extra fine diamond burs, and then rubber points were applied until a smooth and polished surface was obtained. The inner surfaces of the restoration were sandblasted using air abrasion with 50 μm aluminum oxide, then silane was applied to the inner surface of the restoration with gentle air. A self-adhesive dual-cure resin cement was applied using light-cured for 40 s from all sides to ensure that the light reached the full thickness of the resin cement [41].The phosphoric acid 37% was applied to the enamel for 15 s, then to the enamel and dentin for 15 s, followed by thoroughly rinsing under running water for 10 s and dried with a gentle air. The single bond was placed on the enamel and was light cured for 20 s with a diode light. The resin composite was applied in a layering technique, as the thickness of one layer does not exceed 2 mm, then each layer was light cured separately for 20 s. The finishing and polishing process was done using Fine and extra fine diamond burs, and then rubber points were applied until a smooth and polished surface was obtained [41].Light-emitting diode lightcuring unit (Elipar Freelight II, 3M ESPE)
G1: additional silicone rubber impression material (Neosilk, Calmed Invest Kft, Busan, Korea), silane (Ceramic Bond Silane, Voco), selfadhesive dual-cure resin cement (Breeze-Pentron Clinical).
G2: phosphoric acid 37% (3 M Universal Etchant, 3 M/Oral Care, USA), single bond (3 M/ESPE), resin composite (Filtek 350, 3M ESPE, St Paul, MN, USA) [41].		 3, 6, and 12 months Kaplan–Meier survival analysis;
Modified USHPH criteria.		The clinical success rate was 90% in the group 1 versus 85% in the group 2 after 12 months of follow-up without statistically significant differences (p = 0.218).Both groups can be considered effective restorations with acceptable clinical performance in the restoration of hypomineralised first permanent molars [41].
Özgür, B.; et al.—2022 [42].BMC Oral HealthRandomized clinical trial39 children, aged 6–12 years 100 (50 G1 and 50 G2)MILD MIH with occlusal defects (demarcated white, yellow or brown lesions), sound surfaces and no incipient enamel caries.Total-etchSelf-etch Non-fuoridated paste [42].Enamel affected by MIH was not removed.A dental isolation device was used throughout the procedures. the occlusal surfaces were etched with 37% phosphoric acid for 30 s, rinsed with air–water spray for 30 s and dried with oil-free air for 15 s. Proper etching was confirmed by a dull frosty-white appearance of the enamel. The resin sealant applied into the occlusal fissures was light-cured with 460–500 nm wavelength halogen light unit for 20 s. The surfaces were checked with an explorer to ensure that no voids were present. The occlusion was checked and, if necessary, adjusted [42]. A dental isolation device was used throughout the procedures. The self-etch primer was applied to the occlusal fissures with a fine microbrush. After waiting for 5 s, and homogenizing the bond layer with gentle air stream for 5 s, the giomer sealant was placed and light-cured for 20 s. The surfaces were checked with an explorer to ensure that no voids were present. The occlusion was checked and, if necessary, adjusted [42].Dental isolation device (Mr. Tisty One Step, Zirc Dental, Bufalo, MN, USA), light-cured with 460–500 nm wavelength halogen light unit (Hilux Dental Curing Light Unit 250, Benlioğlu Dental Inc, Turkey).
G1: 37% phosphoric acid for 30 s (i-GEL N, i-dental, Lithuania), resin sealant (Conceal F, SDI, Australia).
G2: self-etch primer (BeautiSealant Primer, Shofu, Japan), giomer sealant (BeautiSealant Paste, Shofu, Japan) [42].		1, 3, 6 and 12 months Long-rank test and Kaplan–Meier survival analysis;
Modified USHPH criteria.		At 12 months, the retention rates in Group 1 and Group 2 were 68% and 8%, respectively (p = 0.000). The cumulative survival rates of G1 were significantly higher than G2 for all follow-up visits (p < 0.05). The average survival time was found as 10.46 ± 3.21 months in Group 1 and 4.02 ± 4.43 months in Group 2.The conventional resin-based sealants yielded a better clinical performance over the 12-month evaluation period than the giomer sealants which were applied with self-etch primer. The high failure rate observed in giomer sealants could be explained by the possible deficiency in the etching capacity of self-etch primer on MIH affected teeth [42].
de Souza, J.F.; et al.—2017 [43].Clin Oral InvestigRandomized clinical trial18 children, aged 6–8 years41 (19 G1 and 22 G2)SEVERE MIH classified as enamel posteruptive breakdown (PEB) or unsatisfactory atypical restoration (UATR), with or without carious lesions.Self-etchTotal-etch1 month of fluoride varnish application with cotton roll isolation. After it, infiltrative anaesthesia, rubber dam, caries removal with low speed, 1% chlorhexidine application, protection of the dentin-pulp complex with calcium hydroxide if necessary, temporary restoration with Ketac. After 2 months, the teeth were randomly divided into two groups that received the definitive restoration [43].Not specificated. The SEA teeth were restored according to the following operative sequence: prophylaxis, infiltrative anesthesia, rubber dam, partial removal of GIC, primer application using an applicator (20 s), air jet (5 s) from 10-cm distance with 45° angle of the tip, adhesive application (5 s) using an applicator. After application of the dentin adhesive using an applicator, Filtek Z350 XT was inserted in increments of 1.0–1.5 mm, and each increment was polymerized for 40 s, followed by removal of rubber dam, examination of occlusal contact, and final polishing [43].The TEA teeth underwent the following clinical steps: prophylaxis, infiltrative anesthesia, rubber dam, partial removal of GIC, application of 37.5% phosphoric acid to enamel (30 s) and dentine (15 s), extensive washing, drying with cotton and air jet (5 s) from 10-cm distance with 45° angle of the tip, priming (5 s) using a applicator, air jet (5 s) from 10-cm distance with 45° angle of the tip, adhesive application (5 s) using an applicator, light curing (20 s), restoration with Filtek Z350 XT inserted in increments of 1.0–1.5 mm, where each increment was polymerized for 40 s, removal of rubber dam, examination of occlusal contact, and final polishing [43].Filtek XT350 restoration (3M ESPE, St. Paul, MN, USA), SEA (Clearfil SE Bond, Kuraray Medical, Tokyo, Japan), TEA (Adper Scotchbond Multi-Purpose, 3M ESPE, St. Paul, MN, USA), a light-curing unit (Elipar FreeLight 2, 3M ESPE) with 500 mW/cm2 intensisty. Fluoride varnish application (Duraphat, Colgate, New York, NY, USA). Ketac Molar Easymix (3M ESPE, St. Paul, MN, USA) [43].1, 6, 12, and 18 monthsLong-rank MantelCox test; Modified USHPH criteria.The cumulative survival rates were 100% at 1 month, 89% at 6 months, 73% at 12 months, and 68% at 18 months in SEA, and 95% at 1 month, 72% at 6 months, 59% at 12 months, and 54% at 18 months in TEA.There was no difference in clinical survival of restorations in FPMs affected by MIH using TEA or SEA adhesives [43].
Rolim, T.Z.C.; et al.—2021 [44].Clin Oral InvestigRandomized clinical trial35 children, aged 7–16 years 64 (37 G1 and 37 G2)Different manifestations of MIH.Total-etchSelf-etchProphylaxis was performed using pumice stone and water prior to the restorative treatment [44].Hypomineralized enamel removal was selective—removal of the hypomineralized enamel with an opaque appearance, which crumbles on contact with the instruments until more resistant enamel is obtained.Local anesthesia with 5% Emla topical cream and then local infiltration anesthesia with 2% mepivacaine. Absolute isolation was performed using clamps and rubber dam. The carious tissue was removed with a dental excavator. Thus, the soft decayed dentin was completely removed using a sharp excavator following the principles of minimum intervention dentistry. In the TE group, ultra-etch 35% phosphoric acid was used for etching the enamel (30 s) and dentin (15 s) and the cavity was washed thoroughly with water and dried with a sterile cotton ball. The adhesive was actively applied with a microbrush for 10 s and air blasting was used for 10 s at a distance of 15 cm from the cavity. The same steps were repeated, adding curing light for 20 s with low power. Restorations in both groups were made with Tetric N-Ceram bulk-fill composite resin in a single increment (up to 5 mm) with light curing for 20 s at a high power at a distance of 9 mm from the material. Occlusal adjustments, finishing, and polishing of the restorations were performed after removing the absolute insulation [44].Local anesthesia with 5% Emla topical cream and then local infiltration anesthesia with 2% mepivacaine. Absolute isolation was performed using clamps and rubber dam. The carious tissue was removed with a dental excavator. Thus, the soft decayed dentin was completely removed using a sharp excavator following the principles of minimum intervention dentistry. The adhesive was actively applied with a microbrush for 10 s and air blasting was used for 10 s at a distance of 15 cm from the cavity. The same steps were repeated, adding curing light for 20 s with low power. Restorations in both groups were made with Tetric N-Ceram bulk-fill composite resin in a single increment (up to 5 mm) with light curing for 20 s at a high power at a distance of 9 mm from the material.
Occlusal adjustments, finishing, and polishing of the restorations were performed after removing the absolute insulation [44].		Ultra-etch 35% phosphoric acid (Ultradent, USA), Universal Ambar adhesive (FGM Brazil), Tetric N-Ceram Bulk Fill composite resin (Ivoclar Vivadent, Liechtenstein). Light Bluephase N (Bluephase N, IvoclarVivadent, Austria) [44].1, 6, and 12 monthsLong-rank test and Kaplan–Meier survival analysis;
Modified USHPH criteria.		A total of 64 FPMs were restored (TE = 33; SE = 31). Survival rates were 96.9% (TE) and 96.7% (SE) after 1 month, 90.5% (TE) and 80.6% (SE) after 6 months, and 80.8% (TE) and 62.3% (SE) after 12 months (p > 0.05).Both restorative protocols presented similar longevity [44].
Linner, T.; et al.—2020 [45].Int J Paediatr DentA retrospective cohort study52 children, mean age 11.2 years153 (126 G1 and 27 G2)MILD and SEVERE MIH: Disintegration of hard tissue with small- to mediumsized defect (G1) and disintegration of hard tissue with small- to large-sized defects (G2).Self-etch Total-etch Not indicated [45].Removal of MIH tissue for G2 and no-removal of MIH tissue for G1.No local or general anaesthesia; Tooth cleaning, no cavity preparation, cotton roll isolation, self-etching adhesive, application and light polymerization of flowable composite and occlusion control [45].No, local or general anaesthesia in relation to patients’ cooperation and treatment needs; Tooth cleaning, removal of MIH tissue, preparation of cavity margins, cotton roll isolation, total etch and total bond, composite application, light polymerization, and occlusion control [45].G1: adhesive bonding agent (Adper Prompt L-Pop or Scotchbond Universal L-Pop, 3M Deutschland GmbH) and composite material (Tetric EvoFlow, Ivoclar Vivadent AG, Schaan, Liechtenstein).
G2: adhesive bonding agent (Syntac Classic, Ivoclar Vivadent AG, Schaan, Liechtenstein) and composite restorations (Tetric EvoCeram, Ivoclar Vivadent AG, Schaan, Liechtenstein) [45].		For a mean of 42.9 monthKaplan-Meier estimators and the Cox regression model.The cumulative survival probabilities after 12 months were 68% in G1 and 95% in G2 in Kaplan-Meier survival curves. They differed significantly in the regression analysis.Conventional restorations (G2) were associated with moderate-to-high survival rates in MIH teeth. In contrast, non-invasive composite restorations (G1), which were predominately used in younger or less cooperative children, were linked to lower survival rates [45].
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D’Amario, M.; Vitocco, E.; Jahjah, A.; Capogreco, A.; Mauro, S.; D’Arcangelo, C.; De Angelis, F. Comparative Survival of Restorations in MIH-Affected Pediatric Teeth Using Total-Etch Versus Self-Etch Adhesive Systems: A Systematic Review and Meta-Analysis. Appl. Sci. 2025, 15, 12445. https://doi.org/10.3390/app152312445

AMA Style

D’Amario M, Vitocco E, Jahjah A, Capogreco A, Mauro S, D’Arcangelo C, De Angelis F. Comparative Survival of Restorations in MIH-Affected Pediatric Teeth Using Total-Etch Versus Self-Etch Adhesive Systems: A Systematic Review and Meta-Analysis. Applied Sciences. 2025; 15(23):12445. https://doi.org/10.3390/app152312445

Chicago/Turabian Style

D’Amario, Maurizio, Elena Vitocco, Ali Jahjah, Antonio Capogreco, Stefania Mauro, Camillo D’Arcangelo, and Francesco De Angelis. 2025. "Comparative Survival of Restorations in MIH-Affected Pediatric Teeth Using Total-Etch Versus Self-Etch Adhesive Systems: A Systematic Review and Meta-Analysis" Applied Sciences 15, no. 23: 12445. https://doi.org/10.3390/app152312445

APA Style

D’Amario, M., Vitocco, E., Jahjah, A., Capogreco, A., Mauro, S., D’Arcangelo, C., & De Angelis, F. (2025). Comparative Survival of Restorations in MIH-Affected Pediatric Teeth Using Total-Etch Versus Self-Etch Adhesive Systems: A Systematic Review and Meta-Analysis. Applied Sciences, 15(23), 12445. https://doi.org/10.3390/app152312445

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