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Purpose: To evaluate through a systematic review and meta-analysis whether the immediate and long-term bonding performance of universal adhesives would be improved by prior acid etching. Materials and methods: Two reviewers performed a literature search up to April 2018 in eight databases: PubMed, Web of Science, Cochrane Library, SciELO, Scopus, LILACS, IBECS, and BBO. Only studies that evaluated the dentin or enamel bond strength of universal adhesives using a self-etch or etch-and-rinse strategy were included. Analyses were carried out using RevMan 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). A global analysis comparing self-etch or etch-and-rinse strategies and the influence of aging on bonding performance was performed with random-effects models at a significance level of p < 0.05. Results: A total of 59 in vitro studies were included in the meta-analysis. The enamel bond strength of universal adhesives was improved by the etch-and-rinse approach (p < 0.05). In dentin, this effect was observed for ultra-mild and intermediately strong universal adhesives (p < 0.05). Irrespective of the strategy employed, intermediately strong adhesives showed a decrease in bond strength after all types of aging. This effect was also observed for ultra--mild universal adhesives used in the etch-and-rinse approach (p < 0.05). Mild universal adhesives showed bond strength stability in both strategies (p > 0.05). Conclusions: The in vitro evidence suggests that bonding performance of mild universal adhesives can be improved by using the selective enamel-etch strategy. Mild universal adhesives seem to be the more stable materials, in both etch-and-rinse or self-etch strategies.
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Vol 21, No 1, 2019 7
Bonding Performance of Universal Adhesives:
An Updated Systematic Review and Meta-Analysis
Carlos Enrique Cuevas-Suárez
a
/ Wellington Luiz de Oliveira da Rosa
b
/ Rafael Guerra Lund
c
/
Adriana Fernandes da Silva
d
/ Evandro Piva
e
Purpose: To evaluate through a systematic review and meta-analysis whether the immediate and long-term bonding
performance of universal adhesives would be improved by prior acid etching.
Materials and Methods: Two reviewers performed a literature search up to April 2018 in eight databases: PubMed,
Web of Science, Cochrane Library, SciELO, Scopus, LILACS, IBECS, and BBO. Only studies that evaluated the dentin or
enamel bond strength of universal adhesives using a self-etch or etch-and-rinse strategy were included. Analyses were
carried out using RevMan 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).
A global analysis comparing self-etch or etch-and-rinse strategies and the influence of aging on bonding perfor-
mance was performed with random-effects models at a significance level of p < 0.05.
Results: A total of 59 in vitro studies were included in the meta-analysis. The enamel bond strength of universal
adhesives was improved by the etch-and-rinse approach (p < 0.05). In dentin, this effect was observed for ultra-
mild and intermediately strong universal adhesives (p < 0.05). Irrespective of the strategy employed, intermediately
strong adhesives showed a decrease in bond strength after all types of aging. This effect was also observed for
ultra- mild universal adhesives used in the etch-and-rinse approach (p < 0.05). Mild universal adhesives showed
bond strength stability in both strategies (p > 0.05).
Conclusions: The in vitro evidence suggests that bonding performance of mild universal adhesives can be im-
proved by using the selective enamel-etch strategy. Mild universal adhesives seem to be the more stable mater-
ials, in both etch-and-rinse or self-etch strategies.
Keywords: adhesive, dental bonding, dental materials, universal adhesives, systematic review.
J Adhes Dent 2019; 21: 7–26. Submitted for publication: 15.05.18; accepted for publication: 26.10.18
doi: 10.3290/j.jad.a41975
a PhD Candidate, Postgraduate Program in Dentistry, School of Dentistry, Fed-
eral University of Pelota; Associate Professor, Academic Area of Dentistry,
Auto nomous University of Hidalgo State, San Agustín Tlaxiaca, Hidalgo, Mex-
ico. Performed the literature search, extracted the article data, conducted the
meta-analysis, wrote the manuscript.
b PhD Candidate, Postgraduate Program in Dentistry, School of Dentistry, Fed-
eral University of Pelotas, Pelotas, RS, Brazil. Study idea, systematic review
design, performed the literature search, wrote the manuscript.
c Associate Professor, Postgraduate Program in Dentistry, School of Dentistry,
Federal University of Pelotas, Pelotas, RS, Brazil. Full-text reading, data extrac-
tion, proofread the manuscript.
d Associate Professor, Postgraduate Program in Dentistry, School of Dentistry,
Federal University of Pelotas, Pelotas, RS, Brazil. Study idea, systematic re-
view design, meta-analysis design, proofread the manuscript.
e Associate Professor, Postgraduate Program in Dentistry, School of Dentistry,
Federal University of Pelotas, Pelotas, RS, Brazil. Idea, systematic review de-
sign, contributed substantially to the discussion, proofread the manuscript.
Correspondence: Dr. Evandro Piva, Postgraduate Program in Dentistry,
School of Dentistry, Federal University of Pelotas, Rua Gonçalves Chaves,
457, Pelotas, RS 96015-560, Brazil. Tel: +55-53-3225-6741 / 134;
e-mail: evpiva@gmail.com
T
he current adhesives can be classified according to their
adhesion strategy into etch-and-rinse or self-etch adhe-
sives.
122
Etch-and-rinse adhesives are applied after com-
plete phosphoric acid etching of the dental substrates (den-
tin and enamel).
75
On the other hand, the acid etching step
is eliminated in the self-etching adhesives, as they contain
monomers with acidic functional groups that simultaneously
etch and prime the dental substrate.65
Currently, clinicians may choose between these two
types of adhesives.120 According to Van Meerbeek,122 de-
spite the high-product dependency, both types of adhesives
have performed successfully in both laboratory and clinical
research. The current evidence has pointed out that ade-
quate bonding to dentin can be achieved with the self-etch
approach.10,107 However, this strategy has revealed some
limitations in bonding to enamel.
15,62
The bond strength to
enamel with self-etch adhesives has been reported to be
lower than that of etch-and-rinse adhesives.
122
Thus, selec-
8The Journal of Adhesive Dentistry
Cuevas-Suárez et al
tive enamel etching in a separate step with phosphoric acid
has been recommended prior to application of self-etching
adhesives.90
The “universal”, “multipurpose”, or “multimode” adhe-
sives have been introduced for use in any bonding strategy:
etch-and-rinse, self-etch, or selective enamel-etch.
67
They
are essentially one-step self-etch adhesives that may be
associated with phosphoric acid etching.
17
This multi-ap-
proach capability enables clinicians to apply the adhesive in
any of the bonding strategies described above, depending
on the specific clinical situation and the operators’ per-
sonal preferences.
2
Additionally, one of the major concerns
of the previous generation of one-step self-etch or “all-in-
one” adhesives was related to its increased nanoleakage
after any type of aging and limited bond durability.122 This
compromised long-term performance was related to the
presence of complex mixtures of hydrophilic and hydropho-
bic components within a single bottle.
118
As universal adhe-
sives represent one type of one-step self-etch adhesives,
the durability and stability of bonded interfaces created by
these new adhesives continue to be questionable.
A previous systematic review and meta-analysis by the
present group
20
showed that bond strength was improved
by the use of universal adhesives with prior acid etching of
enamel. In contrast, this effect was not evident on dentin
with the use of mild universal adhesives. Since the publica-
tion of our review,20 researchers have conducted new and
more sophisticated studies in this field. Also, there are also
some concerns about the effectiveness and long-term dura-
bility of these adhesives. Therefore, the aim of this study
was to evaluate whether the immediate and long-term bond-
ing performance of universal adhesives would be improved
by prior acid etching through a systematic review and meta-
analysis. The hypothesis tested was that there would be no
difference in immediate and long-term bond strength to den-
tal substrates when using universal adhesives with the
etch-and-rinse or self-etch strategy.
MATERIALS AND METHODS
This systematic review was reported in accordance with the
guidelines of the PRISMA statement.
63
The protocol was
registered in the PROSPERO international database for sys
-
tematic reviews (CRD42017079479). The research ques-
tion was: does the etch-and-rinse strategy improve the im-
mediate and long-term bond strength to dentin or enamel of
universal adhesives?
Literature Search
The literature search was systematically performed by two
independent reviewers up to April 11, 2018 (considering
unlimited publication years). Eight distinct electronic data-
bases were screened: PubMed (MedLine), ISI Web of Sci-
ence, Cochrane Library, SciELO, Scopus, LILACS, IBECS,
and BBO (Biblioteca Brasileira de Odontologia). The inter-
examiner agreement was quantified using the kappa coef-
ficient. The keywords and search strategy used in PubMed
and adapted for other databases are listed in Table 1. The
reviewers hand-searched the reference lists of included ar-
ticles for additional papers. After the screening of articles,
all studies were imported into Mendeley Desktop 1.17.11
software to remove duplicates.
Study Selection
Two reviewers independently assessed the titles and ab-
stracts of all studies. The eligibility criteria consisted of se-
lecting studies that evaluated dentin or enamel bond
strength of universal adhesives in sound permanent teeth
using self-etch or etch-and-rinse techniques. Only studies
that evaluated shear bond strength to enamel and micro-
tensile bond strength to dentin were considered.121 Case
reports, case series, pilot studies, clinical trials, and re-
views were also excluded. Only papers written in the English
language were considered for this updated review. Full cop-
ies of all of the potentially relevant studies were assessed.
Those that appeared to meet the inclusion criteria, or had
insufficient data in the title and abstract to make a clear
decision were selected for full analysis. The full-text papers
were independently assessed in duplicate by two review
authors. Any disagreement regarding the eligibility of the
included studies was resolved through discussion and con-
sensus by a third reviewer. Only papers that fulfilled all of
the eligibility criteria were included.
Data Extraction
The data were extracted using a standardized form in Excel
2016 (Microsoft; Redmond, WA, USA), with all of the trial
documents containing demographic data (year, country),
outcomes evaluated, number of teeth, universal adhesive
used, predominant failure mode and composite used. If any
information was missing, the authors of the included stud-
ies were contacted twice via e-mail to retrieve the missing
data. If authors had not given any answer by two weeks
after the first contact, the missing information was not in-
cluded. For the articles that presented the information in
graph formatting and for which the data could not be ob-
tained from the authors, mean and standard deviation was
calculated using WebPlotDigitizer 4.0 software (Austin; TX,
USA).
Quality Assessment
The methodological quality of each included in vitro study
was assessed by two reviewers according to the parame-
ters of the previous systematic review.
20
The risk of bias of
the article was evaluated according to the description it
gave of the following parameters: random sequence genera-
tion, selective reporting, coefficient of variation, incomplete
outcome data, blinding, and other bias. The coefficient of
variation (CV) of each article was calculated and classified
as low, medium, high and very high.
16,89
Articles with low or
medium CV were classified as low risk of bias, while arti-
cles with high or very high CV were classified as high risk of
bias.
Vol 21, No 1, 2019 9
Cuevas-Suárez et al
Statistical Analysis
The meta-analyses were performed using Review Manager
Software version 5.3.5 (The Nordic Cochrane Centre, The
Cochrane Collaboration; Copenhagen, Denmark). The analy-
ses were carried out using a random-effect model, and
pooled-effect estimates were obtained by comparing the
standardized mean difference between bond strengths ob-
tained using etch-and-rinse or self-etch approach. Bond
strengths were compared considering the type of universal
adhesive (ultra-mild, pH ≥ 2.5; mild pH ≈ 2; or intermediately
strong, pH ≈ 1.5),
61
substrate (enamel or dentin) and meth
-
odology used. The comparisons were made to evaluate the
immediate and long-term bond strength with each bonding
approach (etch-and-rinse or self-etch) separately. Immediate
bond strength was considered when the bond strength test
was performed after storing the specimens for 24 h in water
at 37°C, while long-term bond strength was considered when
the bond strength test was performed after storing the spec-
imens for periods longer than 24 h or after any thermocy-
cling process.
43
p < 0.05 was considered statistically sig-
nificant. Statistical heterogeneity of the treatment effect
among studies was assessed using the Cochran Q test and
the inconsistency I2 test, in which values above 50% were
considered as indicative of substantial heterogeneity.
RESULTS
Search Strategy
A total of 9284 publications were retrieved in all data-
bases. A flowchart outlining the study selection process
according to the PRISMA Statement
63
is shown in Fig 1.
The initial literature review identified 6366 records for initial
examination. Of these, 6285 studies were excluded after
reviewing the titles and abstracts, leaving a total of
81 studies to be examined by full-text reading. Of these, 22
were not included, because 29 evaluated bond strength
using a methodology different than enamel shear bond
strength and dentin microtensile bond strength,
18, 21, 24,30,
31,33,46,47,51, 53, 64,85,92,94,101,102,110,13,112,116,126
two
36,87
did not evaluate bond strength and one70 did not evaluate
bond strength to sound dentin. Thus, a total of 59 in vitro
studies were analyzed in this review. The inter-examiner
agreement was excellent (kappa coefficient = 0.84).
Descriptive Analysis
Ten different universal adhesives were evaluated in this re-
view. The adhesives G-aenial Bond (GC; Tokyo, Japan) and
Peak Universal Bond [Primer] (Ultradent; South Jordan, UT,
Table 1 Search strategy used in PubMed (MEDLINE)
Search terms
#1 (Universal adhesive) OR (adhesive, universal) OR (universal adhesives) OR (adhesives, universal) OR (Multimode adhesive) OR (multi-
mode adhesive) OR (multimode adhesives) OR (multi-mode adhesives) OR (G Bond Plus) OR (Adhese Universal) OR (All-Bond
Universal) OR (One-step Universal Dental adhesive) OR (One-step plus universal) OR (Peak Universal Bond) OR (Clearfil Universal
Bond) OR (iBond Self Etch) OR (FuturaBond U) OR (Optibond XTR) OR (Optibond Universal) OR (Prelude One) OR (Prime&Bond Elect)
OR (One Coat 7 Universal) OR (Universal bond) OR (Universal bonding agent) OR (multi-mode bond) OR (multimode bond) OR (multi-
mode bonding agent) OR (multimode bonding agent)
#2 (Dental Bonding) OR (Bonding, Dental) OR (Dental Bonding, Chemically-Cured) OR (Chemically-Cured Dental Bonding) OR (Dental
Bonding, Chemically Cured) OR (Dental Bonding, Self-Cured) OR (Dental Bonding, Self Cured) OR (Self-Cured Dental Bonding) OR
(Chemical-Curing of Dental Adhesives) OR (Chemical Curing of Dental Adhesives) OR (Dental Bonding, Dual-Cure) OR (Dentin-Bonding
Agents) OR (dental primer) OR (Dental Materials) OR (Materials, Dental) OR (Dental Material) OR (Material, Dental) OR (dental resin)
OR (Dental Resins) OR (Resin, Dental) OR (Resins, Dental) OR (bonding interface) OR (adhesive) OR (Dentin-Bonding Agents) OR
(Agents, Dentin-Bonding) OR (Bonding Agents, Dentin) OR (Agents, Dentin Bonding) OR (Dentin Bonding Agents)
#3 Search #1 AND #2
24 studies excluded:
y 21 studies evaluated bond
strength using different meth-
odologies than shear to
enamel or microtensile to
dentin
y 2 studies that performed
evaluations different from
bond strength
y 1 study that did not evalu-
ated bond strength in sound
dentin
81 full-text articles as-
sessed for elegibility
9284 potentially relevant
records identified from
databases searches
Studies identified by database:
y PubMed (Medline): 2967
y Web of Science: 2966
y Cochrane: 382
y Scielo: 189
y Scopus: 1621
y Lilacs: 601
y lbecs: 20
y BBO: 538
2918 records were re-
moved (duplicates)
57 studies included in
the qualitative synthesis
57 studies included in
the quantitative synthe-
sis (meta-analysis)
6285 records excluded on the
basis of the title and/or abstract
6366 screened records
IdentificationScreeningElegibilityIncluded
PRISMA 2009 Flow Diagram
Fig 1 Search flowchart according to the PRISMA Statement.
10 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
41,44,59,69,73,86,99,102-104,111,113-115
evaluated shear bond
strength to enamel, 3
13,53,79
evaluated microshear bond
strength to enamel, and 37
1,17,19,25,29,32,33,35,37,38,44,
45,48,50,56-58,61,66-68,71,74,79,80,93,96-98,105,109, 123,124,129–131
evaluated microtensile bond strength to dentin.
Meta-Analyses
The etch-and-rinse strategy improved the enamel shear
bond strength (Figs 2a, 2b, and 3a), and differed signifi-
cantly from the self-etch strategy for all universal adhesives
before aging (p < 0.05). After aging, comparisons could be
made for mild (Fig 2c) and intermediately strong (Fig 3b)
universal adhesives, resulting in a difference between the
USA) were considered intermediately strong (pH ≈ 1.5); the
adhesives Futurabond M+ (VOCO; Cuxhaven, Germany), Fu-
turabond U (VOCO), Adhese Universal (Ivoclar Vivadent;
Schaan, Liechtenstein), Clearfil Universal Bond (Kuraray
Noritake; Okayama, Japan), OptiBond XTR (Kerr; Orange,
CA, USA), Prime&Bond Elect (Dentsply Caulk; Milford, DE,
USA) and Single Bond Universal (3M Oral Care; St Paul, MN,
USA) were considered mild (pH ≈ 2); and finally, only the
adhesive All-Bond Universal (Bisco; Schaumburg, IL, USA)
was considered ultra-mild (pH ≥ 2.5). The main components
of these universal adhesives are described in Table 2.
Among the different methodologies used by the in vitro
studies included in this review (Table 3), 20
4,6–8,8,26,34,
Table 2 Main components and classification of universal adhesives included
Classification* pH Name Manufacturer Main components**
Ultra-mild 3.2 All-Bond Universal Bisco; Schaumburg,
IL, USA
Bisphenol A diglycidylmethacrylate, ethanol, MDP,
2-hydroxyethyl methacrylate
Mild 2.7 Single Bond
Universal
3M Oral Care; St Paul,
MN, USA
2-hydroxyethyl methacrylate, bisphenol A diglycidyl ether
dimethacrylate, decamethylene dimethacrylate, ethanol, silane
treated silica, water, 2-propenoic acid, 2-methyl-, reaction
products with 1,10-decanediol and phosphorous oxide,
copolymer of acrylic and itaconic acid, dimethylamino ethyl
methacrylate, camphorquinone, dimethylaminobenzoate, 2,6-di-
tert-butyl-P-cresol
2.5 Adhese Universal Ivoclar Vivadent;
Schaan, Liechtenstein
2-hydroxyethyl methacrylate, bisphenol A diglycidyl ether
dimethacrylate, ethanol, 1,10-decandiol dimethacrylate,
methacrylated phosphoric acid ester, campherquinone,
2-dimethylaminoethyl methacrylate
2.5 Prime&Bond Elect Dentsply Caulk;
Milford, DE, USA
Acetone, urethane dimethacrylate resin, dipentaerythritol
pentaacrylate phosphate, polymerizeable dimethacrylate resin,
polymerizeable trimethacrylate resin
2.4 OptiBond XTR Primer Kerr; Orange, CA, USA Acetone, 2-hydroxyethyl methacrylate, ethanol
OptiBond XTR
Adhesive
Kerr Ethanol, 2-hydroxyethyl methacrylate, 2-hydroxy-1,3-propanediyl
bismethacrylate, propylidynetrimethanol, ethoxylated, esters
with acrylic acid, alkali fluorosilicates
2.3 Futurabond M+ VOCO; Cuxhaven,
Germany
Bisphenol A diglycidylmethacrylate, ethanol, acidic adhesive
monomer, catalyst.
2.3 Clearfil Universal
Bond
Kuraray Noritake;
Okayama, Japan
Bisphenol A diglycidylmethacrylate, 2-hydroxyethyl
methacrylate, ethanol, 10-methacryloyloxydecyl dihydrogen
phosphate, hydrophilic aliphatic dimethacrylate, colloidal silica,
dl-camphorquinone, silane coupling agent, accelerators,
initiators, water
2.3 Futurabond U VOCO Bisphenol A diglycidylmethacrylate, 2-hydroxyethyl
methacrylate, 1,6-hexanediylbismethacrylate, acidic adhesive
monomer, urethanedimethacrylate, catalyst
Intermediately
strong
1.5 G-aenial Bond GC; Tokyo, Japan Acetone, dimethacrylate, phosphoric acid ester monomer,
dimethacrylate component, photoinitiator, butylated
hydroxytoluene.
1.2 Peak Universal Bond
Primer
Ultradent; South
Jordan, UT, USA
Ethyl alcohol, methacrylic acid, 2-hydroxyethyl methacrylate
Peak Universal Bond
Adhesive
Ultradent Ethyl alcohol, 2-hydroxyethyl methacrylate, methacrylic acid,
chlorhexidine di(acetate)
* Van Meerbeek, B, Peumans, M, Poitevin, A, Mine, A, Van Ende, A, Neves, A, et al. Relationship between bond-strength tests and clinical outcomes. Dent
Mater 2010;26:e100-e121. ** According to manufacturers’ MSDS.
Vol 21, No 1, 2019 11
Cuevas-Suárez et al
Table 3 Demographic and study design data of the included studies
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Ahn 2015 Korea 42 (2) Dentin μTBS Failure pattern Adhesive G-aenial Bond (GC; Tokyo, Japan) Filtek Z-250 (3M
Oral Care)
Microhybrid
Single Bond Universal (3M Oral
Care, St Paul, MN, USA)
All-Bond Universal (Bisco; Schaum-
burg, IL, USA)
Ayar 2017 Turkey 60 (10) Enamel SBS Failure pattern Adhesive Single Bond Universal (3M Oral
Care)
Valux Plus Microhybrid
Ballyram 2015 Southafrica 120 (20) Dentin SBS, cut
enamel SBS and
uncut enamel SBS
Failure pattern Adhesive Single Bond Universal (3M Oral
Care)
Filtek Supreme XTE
(3M Oral Care)
Nanocom-
posite
Belltrami 2016 Italy 160 (10) Enamel SBS Single Bond Universal (3M Oral
Care)
Grandio (VOCO) Nanohybrid
Futurabond M+ (VOCO; Cuxhaven,
Germany)
Adhese Universal (Ivoclar Vi-
vadent)
Clearfil Universal Bond (Kuraray
Noritake; Okayama, Japan)
GBU 500 (GC)
Peak Universal Bond (Ultradent;
South Jordan, UT, USA)
OptiBond XTR (Kerr; Orange, CA,
USA)
Bermudez 2015 United States 120 (20) Enamel SBS Failure pattern Mixed OptiBond XTR (Kerr) Filtek Supreme
Ultra (3M Oral
Care)
Nanocom-
posite
Cardenas 2016 Brazil 63 (24) Enamel μSBS Degree of conver-
sion, failure pattern,
enamel etching
pattern
Adhesive Clearfil Universal (Kuraray Nori-
take)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Futurabond U (VOCO)
Singlebond Universal Adhesive
(3M Oral Care)
Chen 2015 United States 200 (10) Dentin μTBS TEM resin-dentin
interfaces
Mixed Prime&Bond Elect (Dentsply Caulk;
Milford, DE, USA)
TPH Spectra, Dent-
sply Caulk
Hybrid
Singlebond Universal Adhesive
(3M Oral Care)
All-Bond Universal (Bisco)
Clearfil Universal (Kuraray Nori-
take)
Futurabond U (VOCO)
12 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Choi 2018 Korea 72 (12) Dentin μTBS Failure pattern Adhesive G-Premio Bond (GC)
Single Bond Universal (SBU; 3M
Oral Care)
All Bond Universal (Bisco)
Filtek Z250 (3M
Oral Care)
Microhybrid
Diniz 2016 Brazil 52 (13) Enamel μSBS Failure pattern Adhesive Singlebond Universal Adhesive
(3M Oral Care)
TPH (Dentsply;
Petrópolis, RJ,
Brazil)
Microhybrid
Futurabond U (VOCO)
Donmez 2015 Turkey 8 (1) Dentin μTBS Failure pattern Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
All-Bond Universal (Bisco) Aelite All Purpose
Body (Bisco)
Microhybrid
Elmourad 2014 Saudi Arabia 90 (10) Enamel SBS Failure pattern Cohesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z250, 3M
Oral Care
Microhybrid
Farias 2016 United States 88 (11) Dentin μTBS Failure pattern,
exent of resin infil-
tration into dentin
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
TPH3 (Dentsply
Caulk, Milford, DE,
USA)
Hybrid
All-Bond Universal (Bisco)
Frattes 2017 Brazil 88 (11) Enamel and Dentin
μTBS
Failure pattern AND
SEM observation
Adhesive/mixed Singlebond Universal Adhesive
(3M Oral Care)
Amelogen Plus
(Ultradent Prod-
ucts; South Jordan,
UT, USA)
Microhybrid
Gateva 2017 Bulgaria 60 (20) Dentin μSBS Singlebond Universal Adhesive
(3M Oral Care)
Filtek Ultimate (3M
Oral Care)
Nanocom-
posite
Goracci 2013 Italy 133 (20) Enamel and dentin
SBS
Microleakage and
SEM
Adhesive/Mixed G-aenial Bond (GC, Tokyo, Japan) G-aenial Universal
Flo (GC, Tokyo,
Japan)
Flowable
composite
Gré 2016 Brazil 15 (5) Dentin μTBS Failure pattern Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Guan 2016 Japan 45 (8) Dentin μTBS SEM and TEM ob-
servation
Adhesive/Mixed Singlebond Universal Adhesive
(3M Oral Care)
Clearfil AP-X (Ku-
raray, Tokyo, Japan)
Microhybrid
composite
OptiBond XTR (Kerr, Orange, CA,
USA).
Hanabusa 2012 Belgium 25 (5) Enamel and Dentin
μTBS
Ultra-structural
analysis (TEM)
Mixed G-Bond Plus (GC, Tokyo, Japan) Clearfil AP-X (Ku-
raray, Tokyo, Japan)
Microhybrid
composite
Imai 2017 Japan 160 (10) Enamel SBS Failure mode Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Clearfil AP-X (Ku-
raray Noritake)
Microhybrid
All-Bond Universal (Bisco)
AdheSE Universal (Ivoclar Vi-
vadent, Schaan, Liechtenstein)
G-Premio Bond (GC, Tokyo, Japan)
Table 3 (cont.) Demographic and study design data of the included studies
Vol 21, No 1, 2019 13
Cuevas-Suárez et al
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Isolan 2014 Brazil 50 (5) Enamel SBS and
Dentin μTBS
Failure pattern Adhesive - Adhe-
sive/Mixed
Singlebond Universal Adhesive
(3M Oral Care)
Opalis (FGM, Bra-
zil)
Microhybrid
composite
Jang 2016 Korea 24 (4) Dentin μTBS Ultra-structural
analysis (TEM)
Adhesive All-Bond Universal (Bisco) Filtek Z250, 3M
Oral Care
Microhybrid
Singlebond Universal Adhesive
(3M Oral Care)
Kusdemir 2016 Switzerland 18 (3) Dentin μTBS Failure pattern Adhesive/Mixed Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Loguercio 2015 United States 84 (4) Enamel μSBS Etching pattern and
in situ degree of
conversion
Adhesive/Mixed AdheSE Universal (Ivoclar Vi-
vadent, Schaan, Liechtenstein)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
All-Bond Universal (Bisco)
Clearfil Universal (Kuraray Noritake
Dental Inc., Tokyo, Japan)
Futurabond U (VOCO)
G-Bond Plus (GC Corporation
Tokyo, Japan)
Prime&Bond Elect (Dentsply Caulk,
Milford, DE, USA)
Singlebond Universal Adhesive
(3M Oral Care)
Luque-
Martinez
2014 Brazil 140 (5) Dentin μTBS Interfacial nanoleak-
age
Adhesive All-Bond Universal (Bisco) Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Prime&Bond Elect (Dentsply Caulk,
Milford, DE, USA)
Singlebond Universal Adhesive
(3M Oral Care)
Manfroi 2016 Brazil 24 (6) Dentin μTBS Failures and
adhesive interface
analysis (SEM)
Mixed Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z250, 3M
Oral Care
Microhybrid
Marchesi 2014 Italy 60 (15) Dentin μTBS Interfacial nanoleak-
age and MMP Ex-
presion
Adhesive (cohe-
sive in composite
only with etch-and-
rinse strategy)
Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z250, 3M
Oral Care
Microhybrid
McLean 2015 Canada 60 (5) Enamel SBS Failure pattern Adhesive/Mixed All-Bond Universal (Bisco) Filtek Z250, 3M
Oral Care
Microhybrid
Singlebond Universal Adhesive
(3M Oral Care)
Michaud 2017 Canada 60 (5) Dentin μTBS Singlebond Universal Adhesive
(3M Oral Care)
All-Bond Universal (Bisco)
OptiBond XTR (Kerr)
CompCore AF
White (Premier
Dental)
CoreFlo (Bisco)
Dual-poly-
merizing
foundation
composite
resin.
Dual-poly-
merizing
foundation
composite
resin
14 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Muñoz 2015 Brazil 40 (5) Dentin μTBS Nanoleakage Adhesive/Mixed Singlebond Universal Adhesive
(3M Oral Care)
Opallis, FGM Produ-
tos Odontológicos,
Joinville, SC, Brazil
Microhybrid
All-Bond Universal (Bisco)
Peak Universal Bond (Ultradent)
Muñoz 2014 United States 60 (5) Dentin μTBS Nanoleakage and
in-situ degree of
conversion
Adhesive/Mixed All-Bond Universal (Bisco) Filtek Z350 (3M
Oral Care)
Nanocom-
posite
G-Bond Plus (GC)
Singlebond Universal Adhesive
(3M Oral Care)
Muñoz 2013 Brazil 40 (5) Dentin μTBS Nanoleakage and
in-situ degree of
conversion
Adhesive/Mixed Singlebond Universal Adhesive
(3M Oral Care)
Opallis, FGM Produ-
tos Odontológicos,
Joinville, SC, Brazil)
Microhybrid
All-Bond Universal (Bisco)
Peak Universal Bond (Ultradent)
Nagura 2018 Japan 450 (15) Enamel SBS Shear fatigue
strength
Surface free energy
Failure mode
Adhesive Adhese Universal (Ivoclar Vi-
vadent)
All-Bond Universal (Bisco)
Clearfil Universal Bond Quick
(Kuraray Noritake)
Gpremio Bond (GC)
Scotchbond Universal Adhesive
(3M Oral Care)
Z100 (3M Oral
Care)
Microhybrid
Nicoloso 2017 Brazil 48 (6) Dentin μTBS Failure mode Adhesive/mixed Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
Ouchi 2017
Japan
90 (7)
Enamel SBS Failure mode
Adhesive
Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
AdheSE Universal (Ivoclar Vi-
vadent)
G-Premio Bond (GC)
Pashaev 2017 Turkey 216 (30) Dentin μTBS SEM obser vation Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Ultimate
Universal Restora-
tive (3M Oral Care)
Nanocom-
posite
All-Bond Universal (Bisco)
Perdigao 2014 United States 60 (5) Enamel μSBS and
Dentin μTBS
Degree of conver-
sion
Adhesive/Mixed G-Bond Plus (GC) Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Perdigao 2012 United States 36 (6) Dentin μTBS Ultra-morphologic
evaluation
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z250, 3M
Oral Care
Microhybrid
Poggio 2014 Italy 100 (10) Enamel SBS Failure patter and
ARI
Adhesive G-aenial Bond (GC) Grandio (VOCO) Nanohybrid
Sezinando 2015 United States 60 (5) Dentin μTBS Nanoleakage Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
All-Bond Universal (Bisco)
G-Bond Plus (GC)
Sezinando 2017 USA 84 (12) Dentin μTBS Failure mode and
nanoleakage challenge
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z250, 3M
Oral Care
Microhybrid
Table 3 (cont.) Demographic and study design data of the included studies
Vol 21, No 1, 2019 15
Cuevas-Suárez et al
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Sinhoreti 2015 Brazil 20 (5) Dentin μTBS Confocal microscopy Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
Silva Leite 2018 Brazil 30 (5) Dentin μTBS Failure mode Cohesive/mixed Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
Siso 2018 Turkey 20 (5) Dentin μTBS Failure mode Adhesive/mixed Clearfil Universal Bond Quick
(Kuraray Noritake)
Clearfil AP-X (Ku-
raray Noritake)
Microhybrid
Sutil 2017 Brazil 96 (8) Dentin μTBS Failure mode Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
Suzuki 2016 Japan 45 (15) Enamel SBS Shear fatigue
strength and SEM
Adhesive. Mixed/
cohesive in
enamel in etch-
and-rinse groups
Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
Prime&Bond Elect (Dentsply Caulk)
All-Bond Universal (Bisco)
Takami-
sawa
2015
(A)
Japan 90 (15) Enamel and Dentin
SBS
Shear fatigue
strength and SEM
For enamel: adhesive G-aenial Bond (GC) Filtek Z100 (3M
Oral Care)
Microhybrid
For dentin: adhe-
sive/mixed
OptiBond XTR (Kerr)
Singlebond Universal Adhesive
(3M Oral Care)
Takami-
sawa
2015
(B)
Japan 270 (15) Enamel and Dentin
SBS
Shear fatigue
strength and SEM
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
G-aenial Bond (GC)
Takami-
sawa
2016
(B)
Japan 120 (15) Enamel SBS Shear fatigue
strength and SEM
Adhesive Prime&Bond Elect (Dentsply Caulk) Filtek Z100 (3M
Oral Care)
Microhybrid
Singlebond Universal Adhesive
(3M Oral Care)
G-aenial Bond (GC)
OptiBond XTR (Kerr)
Tekce 2016 Turkey 50 (5) Dentin μTBS Failure mode and
SEM observations
of the interface
Adhesive/Mixed Singlebond Universal Adhesive
(3M Oral Care)
Filtek Ultimate
Universal (3M Oral
Care)
Nanocom-
posite
All-Bond Universal (Bisco)
Torres 2017 Brazil 112 (14) Enamel μTBS Failure mode Adhesive Futurabond U (VOCO) Grandio (VOCO) Nanohybrid
Dentin μTBS Singlebond Universal Adhesive
(3M Oral Care)
Tsujimoto 2016
(A)
Japan 90 (15) Enamel SBS Failure mode, sur-
face free energy and
SEM observations
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Clearfil AP-X, (Ku-
raray Noritake)
Microhybrid
G-aenial Bond (GC)
Tsujimoto 2016
(C)
Japan 135 (7) Enamel SBS Failure mode, sur-
face free-energy
and SEM observa-
tions
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z100 (3M
Oral Care)
Microhybrid
AdheSE Universal (Ivoclar Vivadent)
G-aenial Bond (GC)
16 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
Study Year Country Number
of teeth
(per
group)
Primary outcome Secondary out-
comes
Predominant
failure mode
Universal adhesive used Composite Type of
composite
Tsujimoto 2017
(A)
Japan 555 (18) Enamel SBS Failure mode and
surface charateris-
tics
Adhesive Clearfil Universal (Kuraray Noritake
Dental)
Filtek Z100 (3M
Oral Care)
Microhybrid
G-aenial Bond (GC)
Singlebond Universal Adhesive
(3M Oral Care)
Tsujimoto 2017
(B)
Japan 100 (25) Enamel SBS Surface free energy
measurements
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Clearfil AP-X (Ku-
raray Noritake
Dental)
Microhybrid
Failure mode G-Premio Bond (GC)
Vermelho 2017 Brazil 56 (8) Enamel μTBS Ultramorphological
dentin-resin inter-
face TEM
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Filtek Z350 (3M
Oral Care)
Nanocom-
posite
48 (8) Dentin μTBS All-Bond Universal (Bisco)
Wagner 2014 Germany 20 (12) Dentin μTBS Resin penetration Adhesive Futurabond M+ (Voco) Grandio (Voco) Nanohybrid
Singlebond Universal Adhesive
(3M Oral Care)
All-Bond Universal (Bisco)
Zeidan 2017 Brazil 36 (6) Dentin μTBS Failure mode - SEM
observation
Cohesive in resin/
adhesive
Singlebond Universal Adhesive
(3M Oral Care)
TPH3 (Dentsply
Caulk)
Microhybrid
Zenobi 2017 Brazil 24 (6) Dentin μTBS Failure mode - SEM
observation
Adhesive Singlebond Universal Adhesive
(3M Oral Care)
Spectrum TPH
(Dentsply)
Microhybrid
Zhang 2016 United States 200 (20) Dentin μTBS Failure mode - TEM
observation
Mixed All-Bond Universal (Bisco) TPH3 (Dentsply
Caulk)
Microhybrid
Clearfil Universal (Kuraray Noritake)
Futurabond U (Voco)
Prime&Bond Elect (Dentsply Caulk)
Singlebond Universal Adhesive
(3M Oral Care)
Table 3 (cont.) Demographic and study design data of the included studies
Vol 21, No 1, 2019 17
Cuevas-Suárez et al
Fig 2 Summary of meta-analysis findings comparing the shear bond strength of ultra-mild and mild universal adhesives to enamel.
18 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
Fig 3 Summary of meta-analysis findings comparing the shear bond strength of intermediately strong universal adhesives to enamel.
Vol 21, No 1, 2019 19
Cuevas-Suárez et al
Fig 4 Summary of meta-analysis findings comparing the microtensile bond strength of ultra-mild universal adhesives to dentin using random-
effects models.
20 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
Fig 5 Summary of meta-
analysis findings comparing
the microtensile bond
strength of mild universal
adhesives to dentin using
random-effects models.
Vol 21, No 1, 2019 21
Cuevas-Suárez et al
Fig 6 Summary of meta-analysis findings comparing the microtensile bond strength of intermediately strong universal adhesives to dentin
using random-effects models.
Random sequence generation
Selective reporting
Coefficient of variation
Incomplete outcome data
Blinding
Other bias
0% 25% 50% 75% 100%
Low risk of bias Unclear risk of bias High risk of bias
Fig 7 Review authors’ judgments about
each risk of bias item for each included in
vitro study.
22 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
bonding approaches, favoring the etch-and-rinse strategy
(p < 0.05). In terms of stability within the etch-and-rinse
(Figs 2d and 3c) or self-etch approach (Figs 2e and 3d), the
meta-analysis showed that the bond strength remained
stable after any type of aging for mild and intermediately
strong adhesives.
The etch-and-rinse approach improved the dentin micro-
tensile bond strength for ultra-mild universal adhesives be-
fore aging (p < 0.05; Fig 4a). The meta-analysis of bond
strength after aging also showed this tendency (Fig 4b).
When used in the etch-and-rinse approach, the bond
strength of ultra-mild adhesives was impaired after aging pro-
cesses (p < 0.05; Fig 4c), whereas when the self-etch strat-
egy was used, the bond strength remained stable (Fig 4d).
For mild adhesives, the etch-and-rinse approach was sta-
tistically similar to the self-etch approach before aging in
dentin (Fig 5a), and this behavior was observed after aging
(p > 0.05; Fig 5b). The bond strength stability analysis re-
vealed that both strategies remained stable after the aging
processes (Figs 5c and 5d).
For intermediately strong adhesives, the etch-and-rinse
strategy favored both the immediate (Fig 6a) and aged
(Fig 6b) bond strength to dentin (p < 0.05). In terms of sta-
bility, bond strength was impaired after the aging processes
in all of the bonding strategies analyzed (Figs 6c and 6d).
Quality Assessment
According to the parameters considered in the analysis of
in vitro studies, the majority of studies scored particularly
poorly for the items selective reporting and blinding of the
examiner (Fig 7). A low risk of bias was observed regarding
the items random sequence generation, coefficient of varia-
tion, incomplete outcome data, and other bias.
DISCUSSION
An updated a systematic review and meta-analysis was con-
ducted regarding the bond strength of universal adhesives
depending on the approach to their use: self-etch and etch-
and-rinse based on literature published after 2015. Since
that date, a considerable number of new articles evaluating
the performance of universal adhesives have been pub-
lished; our previous review
20
included 10 studies and most
of them reported only immediate bond strength, while this
updated review included 59 studies involving universal ad-
hesives with different pH and bond strength evaluation after
different aging protocols.
In accordance with our previous systematic review,
20
the
performance of universal adhesives was shown to be de-
pendent on their pH, the substrate to which it was bonded
(dentin or enamel), and adhesive strategy used: self-etch or
etch-and-rinse. However, the new meta-analyses performed
in this update demonstrated that the stability of multimode
adhesives’ bond strength to dentin depends largely on their
pH. On enamel, irrespective of the pH of the adhesive,
bond strength was improved by the use of prior phosphoric
acid etching. On the other hand, dentin bond strength of
mild universal adhesives was not dependent on the adhe-
sive strategy used, and these adhesives seemed to be the
materials with better stability. Considering these factors,
the hypothesis of this updated review was partially ac-
cepted.
The present findings regarding bonding to enamel con-
firm that to date, the use of phosphoric acid is still the best
achievable strategy to improve bond strength of universal
adhesives.
120
The etching step with phosphoric acid pro-
duces macro- and microporosities on the enamel surface
resulting from the dissolution of hydroxyapatite.
128
This pro-
cess leads to an increase in surface area of the substrate,
allowing the resin monomers to infiltrate into the enamel,
resulting in the formation “prism-like” resin tags after the
polymerization process.
88
Conversely, self-etch adhesives
contain acidic monomers that simultaneously condition and
prime the dental substrates.122 Nevertheless, self-etch ad-
hesives are unable to etch enamel to the same depth as
phosphoric acid,
27
resulting in lower enamel bond
strengths,76 which was also observed in the present analy-
sis. After aging, no decreases were observed for either
etch-and-rinse or self-etch approaches, suggesting that both
techniques can achieve sufficiently strong bonds which
could effectively seal off the water diffusion pathway
through the restoration-tooth interface, limiting degradation
of its components by hydrolysis.
22
From a clinical point of
view, it seems that long-term bonding stability of an adhe-
sive is more desirable than achieving higher initial bond
strengths. This explains why several randomized clinical tri-
als have concluded that additional etching of the enamel
margins is not critical for the overall clinical performance of
two-step self-etch adhesives. 12,28,82,83
Bonding to dentin is considered a more challenging sce-
nario, due to the composition on this substrate.
120
The
present results showed that the bond strength to dentin was
affected by the bonding strategy and the pH of the adhesive
used. The etch-and-rinse approach improved the bond
strength to dentin of intermediately strong universal adhe-
sives. When an etch-and-rinse approach is used, the acid-
etching step solubilizes the mineral content of dentin (in-
cluding the smear layer) to some extent.
75
Subsequent
application of the adhesive lets monomers infiltrate into the
collagen network and replace the water between the colla-
gen fibrils.
78
After this, in situ polymerization leads to the
formation of the hybrid layer, which in combination with the
presence of resin tags within the dentinal tubules, provides
the composite restoration with micromechanical reten-
tion.
119
Irrespective of the bonding strategy used – etch-and-
rinse or self-etch – the dentin bond strength of intermedi-
ately strong universal adhesives was significantly impaired
after all aging processes examined here. These lower values
are explained by the presence of unpolymerized monomers
remaining after light activation, which continue to demineral-
ize the dentin due to their high level of acidity, thus promot-
ing dentin-adhesive interfaces with low hydrolytic stability
and low-stability chemical interactions with the collagen.122
In addition, the dissolved calcium phosphates embedded
within the interface are soluble and very unstable, which
Vol 21, No 1, 2019 23
Cuevas-Suárez et al
may weaken the interfacial integrity.
122
Laboratory and clini-
cal data have previously demonstrated the reduced bond
durability and restoration longevity when strong self-etch ad-
hesives were used on dentin,
9,23,95,117
this being one of the
reasons why the literature has recommended that it is bet-
ter to avoid their use.122 Regards the intermediately strong
self-etch adhesives analyzed in this review, their inconsis-
tent bonding performance to dentin could be correlated with
higher rates of clinical failure; however, the lack of evidence
on the clinical performance of these types of adhesives pre-
vented us from confirming this correlation, so this type of
adhesive should be further studied.
Dentin bond strength of ultra-mild self-etch adhesives
was also improved when using the etch-and-rinse strategy in
both immediate and long-term analysis. Although the role of
resin tags in bonding performance is still debatable,55,100 a
recent study demonstrated that ultra-mild self-etch adhe-
sives did not form resin tags when used in self-etch mode,
but they did when used in etch-and-rinse mode.
124
Based
on this, micromechanical interlocking achieved through
good dentin hybridization, considering the presence of resin
tags and hybrid layer, could be proposed to improve the
bond strength of ultra-mild self-etch adhesives. Despite the
beneficial effect of the etch-and-rinse approach on the im-
mediate bond strength of ultra-mild universal adhesives, it
should be noted that the application of phosphoric acid led
to a decrease in the bond strength after aging. A previous
study demonstrated that the phosphoric acid treatment
prior to application of the single-step adhesive may impact
adversely on long-term dentin bond durability.
39
The basis
of this behavior lies in the fact that phosphoric acid etching
of dentin removes hydroxyapatite, which is essential to
achieve chemical bonding.40 Moreover, excessive drying of
etched surfaces may lead to collapse of the collagen net-
work, which prevents monomer penetration into the decalci-
fied dentin.81 Another explanation could be that impregna-
tion of the collagen fibrils exposed after acid etching could
increase the activity of different endogenous gelatinolytic/
collagenolytic enzymes, such as matrix metalloproteinases
(MMPs) and cysteine cathepsins,108 that promote degrada-
tion of the hybrid layer.106 In clinical terms, applying a uni-
versal adhesive using an etch-and-rinse approach trans-
forms it into a two-step etch-and-rinse adhesive, leading to
the limitations inherent to this type of bonding strategy.
Actually, with regard to the etch-and-rinse approach, the
two-step etch-and-rinse adhesives did not clinically perform
as well as conventional three-step etch-and-rinse adhesives;
therefore, their use is questionable.84
Bonding performance of mild universal adhesives to den-
tin was not dependent on the bonding strategy used, which
suggests that these types of adhesives could be used in a
multimode approach. Studies with mild self-etch adhesives
have demonstrated that when adhesive is applied, dentin is
partially demineralized, leaving a substantial amount of hy-
droxyapatite crystals around the collagen fibrils.122 Thus,
self-etch adhesives could interact with dentin in two ways:
micromechanically and chemically.
122
The micromechanical
interaction occurs due to in situ polymerization of the mono-
mers that infiltrated into the dentin tissue, in a manner
similar to that occurring with conventional etch-and-rinse
adhesives. In contrast, the chemical interactions occur due
to ionic bonding between functional monomers of adhesives
and calcium in the residual dentin hydroxyapatite.
14
In addi-
tion, after aging processes, no differences were observed
when using either the etch-and-rinse or self-etch approach.
Furthermore, the majority of studies included in the meta-
analysis demonstrated that bond strength of mild universal
adhesives remained stable, irrespective of the technique
used. The stability of universal adhesives has been related
to the presence of 10-MDP monomer
42,125
that forms a low-
solubility, stable nanolayer together with deposition of MDP-
Ca salts at the bond interface,127 thereby increasing its
mechanical strength and preventing its degradation over
time. Clinically, using the etch-and-rinse approach for bond-
ing to dentin has several disadvantages; it should be con-
sidered that the best option for bonding to dentin using
mild universal adhesives may be the self-etch strategy.
The present systematic review demonstrated the influ-
ence of pH on the immediate and long-term bonding perfor-
mance of universal adhesives. These results should be in-
terpreted with caution, due to the high heterogeneity
observed in the different comparisons made, and the inher-
ent limitations of laboratory studies, which may not reflect
the clinical performance of materials evaluated. Although
there is a high number of in vitro studies, only a few clinical
trials are currently available in the literature evaluating the
bonding performance of universal adhesives, and the evi-
dence available at present was gathered in short follow-up
periods.
11,49,52,54,60,77,91
The published data from these
clinical trials suggested that the clinical performance of
these adhesives did not depend on the bonding strategy in
up to 36 months of follow-up. Nevertheless, a less satisfy-
ing performance was reported relative to marginal discolor-
ation over time, and further clinical studies with longer fol-
low-up periods are still needed.
Finally, although it is difficult to stablish a relationship
between the bonding effectiveness measured in the labora-
tory with the clinical effectiveness determined by random-
ized clinical trials,121 it must be mentioned that the gener-
ally superior laboratory data of the adhesives currently
considered the “gold standard” confirms their excellent
clinical performance.14,72 Since the main causes of failure
of composite restorations are related to the occurrence of
fracture and secondary caries, achieving a stable bonding
interface, especially in the long-term, renders the restor-
ative treatment more predictable in terms of clinical perfor-
mance. Considering the results obtained in this review, the
following recommendations to clinicians are made: a) when
applied to dentin, prior acid etching before the use of inter-
mediately strong and ultra-mild universal adhesives it is not
recommendable, and b) selective etching of enamel fol-
lowed by the application of a mild universal adhesive cur-
rently appears to be the best choice to effectively achieve a
durable bond to tooth tissues.
24 The Journal of Adhesive Dentistry
Cuevas-Suárez et al
CONCLUSION
The in vitro evidence suggests that bond strength to dentin
of universal adhesives was dependent on their pH. Bonding
performance of mild universal adhesives could be improved
by using the selective enamel-etch strategy. When applied
in dentin, mild universal adhesives seem to provide better
stability in both etch-and-rinse and self-etch strategies. Fur-
thermore, a significant decrease in the bond strength after
any type of aging was observed with the use of intermedi-
ately strong adhesives, irrespective of the substrate or ad-
hesion strategy used.
ACKNOWLEDGMENTS
This study was financed in part by the Coordenação de Aperfeiçoa-
mento de Pessoal de Nível Superior – Brasil (CAPES) and the Na-
tional Council for Scientific and Technological Development (CNPq
#310879/2015-9 and #432127/2018-6). Author Carlos Enrique
Cuevas-Suárez would like to thank PRODEP, México for PhD scholar-
ship (DSA/103.5/15/6615).
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Clinical relevance: General practitioners should be
aware of the category to which their universal adhesive
belongs in order to determine the best application
method.
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... Universal adhesives are single-step, self-etch (SE) adhesive systems due to their composition and bonding process 1,2) . They are widely used due to their multi-functional properties, versatility in clinical performance, and the reduced number of bonding steps involved 1,2) . ...
... Universal adhesives are single-step, self-etch (SE) adhesive systems due to their composition and bonding process 1,2) . They are widely used due to their multi-functional properties, versatility in clinical performance, and the reduced number of bonding steps involved 1,2) . However, similar to the early single-step SE adhesive systems, universal adhesives' enamel bonding effectiveness in SE mode was lower than that in the etch-and-rinse (ER) mode due to their lower etching capability [3][4][5] . ...
... GU's excellent bond durability might be related to the primer, the bonding agent's components, and the adhesive layer's properties. Although universal adhesives' bond effectiveness is not as high as those of two-step SE adhesive systems, many previous studies have indicated their superior versatility and bond reliability 1,2,12,27,37) . GU was designed to expand the range of clinical use by utilizing the benefits of universal adhesives as a primer and employing a hydrophobic bonding agent 24) . ...
Article
This study investigated the enamel and dentin bond durability of a two-step adhesive system, using a universal adhesive-derived primer (G2-Bond Universal [GU]), and compared it with the two conventional, two-step, self-etch adhesive systems (Clearfil SE Bond 2 [CS] and OptiBond XTR [OX]) under thermal cycling (TC) and long-term water storage (WS). The shear bond strengths to bovine enamel and dentin were determined using the etch-and-rinse and self-etch modes. Twelve specimens per test group were prepared and further divided into the following subgroups: 1) subjected to TC, 2) long-term WS, and 3) WS for 24 h (baseline). The enamel and dentin bond durability of GU was superior to those of CS and OX in different etching modes and under different degradation conditions. The latest two-step adhesive system, which utilizes universal adhesives’ benefits in its primer, might offer durable clinical bonding performances and can be widely used in a clinical setting.
... Universal adeziv sistemlerin uygulanmasında, minenin selektif olarak asitlenmesi önerilen bir teknik olsa da Adhese Universal (Adhese Universal, Ivoclar-Vivadent, Schaan, Lihtenştayn) gibi hafif asidik universal adeziv sistemlerde dentinin asitlenmesi bağlanma gücünü artırmamıştır. 8,9 Ancak söz konusu metaanalizler in vitro çalışmalara dayanmaktadır. 8,9 Bu çalışma, 3 farklı adeziv teknik kullanılarak yapılan posterior kompozit restorasyonların klinik performansını değerlendirmeyi amaçlamıştır. ...
... 8,9 Ancak söz konusu metaanalizler in vitro çalışmalara dayanmaktadır. 8,9 Bu çalışma, 3 farklı adeziv teknik kullanılarak yapılan posterior kompozit restorasyonların klinik performansını değerlendirmeyi amaçlamıştır. Birinci grup restorasyonlar selektif mine pürüzlendirme işleminden sonra universal adeziv sistem uygulanarak yapılırken, 2. grup restorasyonlar aynı universal adeziv sistemin "self-etch" modunda kullanılmasıyla yapılmıştır. ...
Article
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Objective: This study aimed to evaluate the clinical per- formance of posterior composite restorations performed using 3 differ- ent adhesive techniques. Material and Methods: A total of 29 patients with at least 3 carious teeth that need restorations in their posterior teeth were included to the study. Composite restorations were performed to each of the decayed teeth using a different method randomly. Each of the different methods represented a group as follow: Group 1: Selec- tively etching the enamel margins with 37% phosphoric acid+applying a universal adhesive system (Adhese Universal, Ivoclar, Schaan, Liechtenstein). Group 2: Applying a universal adhesive system (Ad- hese Universal, Ivoclar, Schaan, Liechtenstein), Group 3: Applying a self-etch adhesive system (Clearfil SE Bond, Kuraray, Okayama, Japan). Although the adhesive procedure was different, each group was restored with a posterior composite resin (Clearfil Majesty Posterior, Kuraray, Okayama, Japan). The restorations were evaluated by 2 cali- brated clinicians according to FDI World Dental Federation criteria after 6 months and 1 year. Data were analyzed using the Kruskal-Wal- lis and Wilcoxon tests at 95% confidence intervals. Results: At the end of 1 year, 26 patients attended the control examination. No significant difference was found between the groups at the end of 1 year in terms of the examined criteria (p>0.05). The baseline scores of all 3 groups and the scores after 1 year were found to be statistically similar (p>0.05). Conclusion: Within the limitations of this study, the 1-year clinical performances of the groups were found to be similar. Clinical studies with longer follow-up periods are needed on this subject.
... The development of universal adhesives can be counted as the latest novelties in adhesive dentistry and it has already been clinically utilized since 2011. The new universal adhesives are also commonly known as "multi-mode′′ or ′′multi-purpose′′ adhesives because they may be used as self-etch adhesives, etch-and-rinse adhesives, or selective enamel etching [8]. Most of it contains 10-methacryloyloxydecyl dihydrogen phosphate (10-MDP) monomers, composed of a hydrophobic methacrylate group on one end (capable of chemical bonding to methacrylatebased restoratives and cements) and a hydrophilic polar phosphate group on the other (capable of chemical bonding to tooth tissues, metals, porcelain and zirconia) [9]. ...
Article
A systematic review was performed to compare the human dentin microtensile bond strength of universal adhesives with 10-MDP when used as total-etch and self-etch strategies. Literature search was done on October 2019 without limitations on the language of publication, in four databases: PubMed, Web of Science, Scopus, and EBSCO. Additional manual search was done for the grey literature articles: OpenGrey and OpenThesis. Studies that evaluated the dentin bond strength of universal adhesives with 10-MDP using total-etch and self-etch strategy from the year 2000 up till October 2019 were included. The initial search resulted in 5121 references: 2234 from PubMed, 1814 from Scopus, 516 from Web of Science, 553 from EBSCO and 4 from OpenThesis. After full text analysis, 30 references were included in this systematic review. Seven different universal adhesives with 10-MDP were evaluated for dentin microtensile bond strength comparing total-etch and self-etch strategies: Single Bond Universal/Scotchbond Universal (3M ESPE), All Bond Universal (Bisco), Clearfil Universal Bond (Kuraray), G-Premio Bond (GC Corp), Tetric Bond Universal (Ivoclar Vivadent), Ambar Universal (FGM) and One Coat 7 Universal (Coltene). The total-etch strategy improved the dentine microtensile bond strength compared to self-etch strategy for all universal adhesives when stored in all three conditions: 24h, thermocycling and long-term immersion according to ISO (TS 11405:2015(E)). The evidence suggests that microtensile bond strength of universal adhesives containing 10-MDP may be improved utilizing total-etch strategy compared to self-etch strategy. This study provides valuable information on the importance of appropriate dentin adhesives strategy that affect success rate of restorations, which helps clinicians to make informed decisions on the strategy to be used during restorations in practice.
... These results agree with those of previous studies. 7,8,21,30 When bonding to contaminated dentin, using a universal adhesive in SE mode demonstrated inferior bonding performance. Similar results were found in previous studies using self-etching adhesives 4,9,10,16,19,26 and universal adhesives in SE mode. ...
Article
Purpose: To evaluate the microtensile bond strength (µTBS) of three universal adhesives to dentin contaminated with a hemostatic agent. Materials and methods: Ninety-six human premolars were cut to expose mid-coronal dentin. The teeth were randomly divided into a control group (uncontaminated dentin) and an experimental group in which a hemostatic agent was applied (contaminated dentin). Each group was further divided into 6 subgroups according to universal adhesives - SBU (Single Bond Universal), OPU (OptiBond Universal), CBQ (Clearfil Universal Bond Quick) - and etching mode, either etch-and-rinse (ER) or self-etch (SE). Following adhesive application, composite was placed in two increments and light cured. The specimens were stored in distilled water at 37°C for 24 h. The µTBS test was performed using a universal testing machine. Failure mode was assessed using a light microscope. The data were statistically analyzed using three-way ANOVA followed by Scheffe's test (p < 0.05). The resin-dentin interface was observed using scanning electron microscopy. Results: Significantly lower bond strength was observed when the universal adhesives were bonded to contaminated dentin in SE mode (p < 0.05). In contrast, the µTBS of the universal adhesives in ER mode was not affected by contamination (p > 0.05). The µTBS of CBQ to contaminated dentin was significantly lower than that of the other adhesives. Observation of the resin-dentin interface revealed limited resin penetration when the universal adhesive was applied in SE mode on contaminated dentin. Conclusion: Contaminating the dentin with a hemostatic agent significantly reduced the µTBS of the universal adhesives in SE mode. However, this adverse effect was not found when the universal adhesives were used in ER mode.
... The risk of bias of the studies included in the present review was assessed by two reviewers (MF and FI) and was evaluated according to previous reviews of in vitro studies [18,19], and the description given of the following parameters: random sequence generation, blinding of outcome assessment, incomplete outcome data, selective reporting, coe cient of variation and other bias. For determining the coe cient of variation (CV), the coe cient of each article was calculated and classi ed as low, medium, high and very high [20,21], in which articles with low or medium CV were classi ed as low risk of bias, while articles with high or very high CV were classi ed as high risk of bias. ...
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Objective: to evaluate the different bonding strategies for repairing aged resin composite restorations. Materials and Methods: The review was reported according to PRISMA Statement and registered in the Open Science Framework (DOI:10.17605/OSF.IO/WZTGS). Two reviewers performed a literature search across Embase (758), Pubmed (1244), Scopus (4300), The Cochrane library (128), and Web of Science (2538) databases. The risk of bias was assessed according to random sequence generation, blinding of outcome assessment, incomplete outcome data, selective reporting, coefficient of variation, and other bias. Results: Forty-four in vitro studies with different repair strategies on aged resin composite substrates were included from 1990 up to July 2022 which evaluated superficial treatment using shear, flexural, tensile, and bond strength tests. The most frequent treatments were diamond bur and air abrasion. Meta-analysis showed an overall effect significant to diamond bur (shear test; p = 0.02), air abrasion (shear; p = 0.009; flexural, p = 0.003; tensile; p = 0.004 tests), and to phosphoric acid (tensile test, p < 0.00001). Conclusions: Within the limitations of this study, strategies for improving bond to aged composites may consider better bond using air abrasion or diamond burs, and surface etching with phosphoric followed by the application of an adhesive system. Clinical Significance: This review presents the best treatments for performing the repair on aged resin composite, as guidance for clinical studies to improve emphasis on these findings, with the aim of creating a protocol that will enable dentists to promote minimally invasive treatments. Clinical Significance: This review presents the best treatments for performing repair with resin composite, as guidance for clinical studies to improve emphasis on these findings, with the aim of creating a protocol that will enable dentists to promote minimally invasive treatments.
... However, systematic errors, or bias, during laboratory study conduction or during their reporting, are common. Examples include selection bias due to poor randomization of samples, questionable reproducibility of specimen treatment and methods or insufficient statistical detail, among others [9][10][11][12]. Yet no clear bias reduction checklists exist for such data collection. ...
Article
Full-text available
Objectives: To develop a risk of bias tool for pre-clinical dental materials research studies that aims to support reporting of future investigations and improve assessment in systematic reviews. Methods: A four-stage process following EQUATOR network recommendations was followed, which included project launch, literature review, Delphi process and the tool finalization. With the support of the European Federation of Conservative Dentistry (EFCD) and the Dental Materials Group of the International Association for Dental Research (DMG-IADR), a total of 26 expert stakeholders were included in the development and Delphi vote of the initial proposal. The proposal was built using data gathered from the literature review stage. During this stage, recent systematic reviews featuring dental materials research, and risk of bias tools found in the literature were comprehensively scanned for bias sources. The experts thus reached a consensus for the items, domains and judgement related to the tool, allowing a detailed guide for each item and corresponding signalling questions. Results: The tool features nine items in total, spread between 4 domains, pertaining to the following types of bias: bias related to planning and allocation (D1), specimen preparation (D2), outcome assessment (D3) and data treatment and outcome reporting (D4). RoBDEMAT, as presented, features signalling questions and a guide that can be used for RoB judgement. Its use as a checklist is preferred over a final summary score. Conclusion: RoBDEMAT is the first risk of bias tool for pre-clinical dental materials research, supported and developed by a broad group of expert stakeholders in the field, validating its future use. Clinical significance: This new tool will contribute the study field by improving the scientific quality and rigour of dental materials research studies and their systematic reviews. Such studies are the foundation and support of future clinical research and evidence-based decisions.
... Another factor that may also interfere and influence the bond strength values is the adhesive's pH value. The use of the ER adhesion strategy can improve the bond strength results of UAs with mild (pH ≈ 2; granting an interaction depth of 1µm) and ultra-mild (pH > 2.5; allowing a true nano interaction zone, contrary to the conventional thicker hybrid layer) pH values [37][38][39]. Mild and ultra-mild adhesives demineralize dentin superficially, hence the smear plug is not completely removed from the dentine tubule. As a result, a shallow hybrid layer is formed [40]. ...
Article
Full-text available
Adhesive resins with guided application protocols have been developed with the main goal of reducing the number of clinical steps. Universal Adhesives (UA) can be applied with both Self-Etch (SE) or Etch-and-Rinse (ER) adhesion strategies. This review aims to evaluate the bond strength of UA, applied to dental tissues, by a systematic bibliometric review of in vitro studies. The research question, through the PICO model, aimed to assess the current knowledge of the immediate and long-term bond strength of UA, applied with a direct restorative technique. PubMed and ScienceDirect database searches focused on the bond resistance of UA applied with the ER and SE strategies. Studies assessing shear bond strength and microtensile bond strength, in both enamel and dentin, were included. From 1109 screened articles, 12 fulfilled the inclusion criteria. The bond strength of UA to enamel showed better results with the ER approach, while the adhesion strategy did not significantly affect the bond strength of UA to dentin. Evidence from in vitro studies has tended to suggest that the use of the SE adhesion approach seems to be a better choice to improve the bond strength to the dentin. The selective enamel etching is advisable when applied with the SE adhesion approach to optimize the UA bond strength to the enamel.
... The weakened hybrid layer causes collagen fibers nano-space leakage, subsequently restoration failure (5). The demineralized dentin zone is generated by inconsistency between demineralization and the resin infiltration dep-th, consisting of exposed collagen fibrils encircled by nanometer-sized and water-filled zones (6). Thus, these zones permit the uptake of silver nitrate, a phenomenon termed nanoleakage (7). ...
Article
Full-text available
Background: Adhesive monomers are not able to fully encapsulate collagen fibrils in hybrid layer leaving them vulnerable to time-dependent hydrolytic degradation. The current in vitro study was designed for investigation of the remineralization of the resin-dentin hybrid layer using biomimetic analogs by nanoleakage investigation. Material and methods: Firstly, occlusal enamel of thirty human molars was removed exposing flat surface of dentin, then randomly divided into three main groups according to the different remineralizing protocols (n=10) (R): control group (R0), STMP group (R1), and biomimetic remineralizing group (R2). The dentin surface of the STMP and biomimetic remineralizing groups (R1 and R2) was treated with STMP solution, followed by self-etch adhesive application on dentin surface of all groups, and restored with double 2-mm thick layers of resin composite. Each tooth was sectioned perpendicularly to the resin-dentin interface for producing 1-mm thick slaps. Each group was subdivided into four subgroups according to the incubation time to 24 hours, one month, three months, and 4 months. Retrieved slabs were prepared for nanoleakage for evaluation of metallic silver particles distribution percentage at the resin-dentin interface using digital image analysis software. Results: There was a statistically significant increase in nanoleakage over time in all three groups. However, the third group showed the least increase in metallic silver uptake over time. Conclusions: Hybrid layer could be remineralized by using dual-biomimetic analogs (PAA and STMP). Key words:Hybrid layer, remineralization, nanoleakage, polyacrylic acid, sodium trimetaphosphate.
Article
Objective To investigate the effects of a sodium carboxymethyl cellulose (SCMC)-based extrafibrillar demineralization conditioner on dentin bonding durability and explore the possible mechanisms. Methods The SCMC-based extrafibrillar demineralization conditioner was facilely developed by dissolving SCMC into deionized water at an appropriate concentration. A single layer collagen mineralization/demineralization model was designed to visualize extrafibrillar demineralization in detail. Dentin surfaces of human third molars were conditioned with 3 % SCMC or 37 % phosphoric acid (PA). The morphology, composition, and mechanical properties of conditioned dentin from each group were characterized. To evaluate dentin bonding performance, SCMC- and PA- conditioned dentin were applied with adhesive restoration using the dry-bonding technique. The microtensile bond strength (MTBS), interface nanoleakage, and in situ zymography were measured after 24 h of water storage, 10,000 thermocycles, or one month of collagenase aging. The inhibitory effect of SCMC on recombinant human matrix metalloproteinase-2 (rhMMP-2) and cell toxicity were also investigated. Results After SCMC conditioning, both demineralization of extrafibrillar minerals and retention of intrafibrillar minerals were observed in the single layer collagen model and the dentin ultrastructure. The mechanical properties of SCMC-conditioned dentin were largely preserved. Compared with PA, SCMC conditioning produced greater MTBS values and less nanoleakage expression after aging. Endogenous gelatinolytic activity was suppressed in SCMC-conditioned dentin. In addition to being nontoxic, the inhibition of rhMMP-2 by SCMC was confirmed to be dose-dependent. Significance From the perspective of minimal intervention, the SCMC-based extrafibrillar demineralization conditioner could improve dentin bonding durability, suggesting a promising strategy to extend the service life of adhesive restorations.
Article
In underwater and hyperbaric oxygen therapy chambers, hyperbaric environments may cause dislodgement or crack on dental restorations. This study aimed to investigate microleakage in different bonding techniques under hyperbaric conditions. Class II cavities were prepared on sixty human molar teeth. According to the manufacturer's instructions, a universal adhesive was applied to half of the samples with the self-etch technique, and the selective-etch technique to the other half, then light-cured. The cavities were restored with a conventional resin composite. The two main groups were divided into subgroups for hyperbaric conditions as control (1-bar), 2.8-bar, and 4-bar air pressure. The samples were immersed in a 1% methylene blue dye solution and then sectioned. Microleakage was evaluated under a stereomicroscope. Data were analyzed with the Chi-square test and Fisher's Exact Chi-square test with a p < 0.05 significance level. The 4-bar groups showed significantly higher microleakage scores than the control and 2.8-bar groups among each selective-etch and self-etch subgroups (0.009, 0.000 respectively). In the 4-bar groups, The self-etch subgroup score was significantly higher than the selective-etch subgroup under 4-bar pressure (p < 0.05). The selective-etch technique for universal adhesive showed better results against microleakage under hyperbaric conditions.
Article
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Objectives: Universal adhesives have been recently introduced for use as self-etch or etch-and-rinse adhesives depending on the dental substrate and clinical condition. However, their bonding effectiveness to laser-irradiated dentin is still not well known. Therefore, the aim of this study was to compare the shear bond strength (SBS) of two universal adhesives (Single Bond Universal, Nova Compo-B Plus) applied following laser-etching with SBS of the same adhesives applied in self-etch and acid-etch modes, respectively. Materials and methods: Sixty bovine incisors were used to obtain the flattened dentin surfaces. Specimens were divided into two groups according to universal adhesives. Each universal adhesive was applied with one of the following modes, self-etch, acid-etch, or laser-etch (n = 10). Er,Cr:YSGG laser was used for laser-etching with 1.5 W-20 Hz parameters. After adhesive applications and composite buildups, SBS was determined after storage in water for 24 h using a universal testing machine with a crosshead speed of 0.5 mm/min. Failure modes were evaluated using a stereomicroscope. Data were analyzed using two-way of analyses of variances (ANOVA) (P = 0.05). Results: Two-way ANOVA revealed that adhesive had no effect on SBS (P > 0.05), but application mode significantly influenced SBS (P < 0.001). Laser-etch significantly increased SBS for NCP when compared to self-etch mode, whereas laser-etch provided similar SBS with self-etch mode for SBU. Conclusions: The influence of different application modes on dentin bond strength of universal adhesives was dependent on the adhesive material. Clinical significance: For universal adhesives, laser etching may provide some benefits on bonds strength but this would depend on product.
Article
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This study evaluated application protocol (etch-and-rinse/ER and self-etching/SE) and dentin wettability (wet and dry) on microtensile bond strength (μTBS) and transdentinal cytotoxicity of ScotchbondTM Universal (SU) adhesive system. The μTBS values and fracture mode were registered 24 h after adhesive system application and resin composite block build-up (n=5). For analysis of transdentinal cytotoxicity, odontoblast-like MDPC-23 cells were seeded on pulpal surface of dentin discs (0.4 mm thick) adapted to artificial pulp chambers (n=8). The adhesive system was applied to occlusal surface, followed by 24-h incubation time. Cell viability (Alamar Blue) and morphology (SEM) were assessed. Adper Single Bond 2 and Clearfil SE Bond were used as positive controls of the ER and SE application protocols, respectively. No treatment was performed on negative control (NC) group. Data were analyzed by ANOVA and Tukey's tests (α=5%). Higher μTBS values were found for ER mode in comparison with SE protocol (p<0.05). Dentin wettability had no effect on bond strength of SU in both the ER and SE techniques (p>0.05). Most fractures involved hybrid layer and/or adhesive layer. Neither variable prevented the intense toxic effects of adhesive systems on MDPC-23 cultured cells, since intense reduction in cell viability (±88%) and severe alterations in cell morphology were observed for all groups compared to NC, with no differences among them (p>0.05). Therefore, it was concluded that application of SU following the ER protocol had better adhesive performance. However, this adhesive system featured intense transdentinal cytotoxicity to pulp cells, regardless of application protocol and dentin wettability.
Article
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The effects of dentin wetness on the bond strength and adhesive interface morphology of universal adhesives have been investigated using micro-tensile bond strength (μTBS) testing and confocal laser scanning microscopy (CLSM). Seventy-two human third molars were wet ground to expose flat dentin surfaces. They were divided into three groups according to the air-drying time of the dentin surfaces: 0 (without air drying), 5, and 10 s. The dentin surfaces were then treated with three universal adhesives: G-Premio Bond, Single Bond Universal, and All-Bond Universal in self-etch or etch-and-rinse mode. After composite build up, a μTBS test was performed. One additional tooth was prepared for each group by staining the adhesives with 0.01 wt % of Rhodamine B fluorescent dye for CLSM analysis. The data were analyzed statistically using ANOVA and Tukey's post hoc tests (α = 0.05). Two-way ANOVA showed significant differences among the adhesive systems and dentin moisture conditions. An interaction effect was also observed (p < 0.05). One-way ANOVA showed that All-Bond Universal was the only material influenced by the wetness of the dentin surfaces. Wetness of the dentin surface is a factor influencing the micro-tensile bond strength of universal adhesives.
Article
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Objectives: To evaluate the effects of dentin pretreatment and temperature on the bond strength of a universal adhesive system to dentin. Material and Methods: Ninety-six extracted non-carious human third molars were randomly divided into 12 groups (n=8) according to Scotchbond Universal Adhesive (SbU) applied in self-etch (SE) and etch-and-rinse (ER) mode, adhesive temperature (20°C or 37°C) and sodium bicarbonate or aluminum oxide air abrasion. After composite build up, bonded sticks with cross-sectional area of 1 mm² were obtained to evaluate the microtensile bond strength (μTBS). The specimens were tested at a crosshead speed of 0.5 mm/min on a testing machine until failure. Fractured specimens were analyzed under stereomicroscope to determine the failure patterns in adhesive, cohesive (dentin or resin) and mixed fractures. The microtensile bond strength data was analyzed using two-way ANOVA and Tukey's test (α=5%). Results: Interaction between treatment and temperature was statistically significant for SbU applied in self-etch technique. Both dentin treatments showed higher bond strength for ER mode, regardless of adhesive temperature. When compared to control group, sodium bicarbonate increased bond strength of SbU in SE technique. Adhesive temperature did not significantly affect the μTBS of tested groups. Predominantly, adhesive failure was observed for all groups. Conclusions: Dentin surface treatment with sodium bicarbonate air abrasion improves bond strength of SbU, irrespective of adhesive application mode, which makes this approach an alternative to increase adhesive performance of Scotchbond Universal Adhesive to dentin.
Article
BACKGROUND AND AIM: According to the effect of the adhesive and substrate type on the bond strength, examination of the adhesive is required in all aspects. The aim of this study was to evaluate the shear bond strength of different adhesive systems to normal dentin (ND) and caries affected dentin (CAD) in permanent teeth. METHODS: Thirty extracted molars with small occlusal caries were selected. After preparation and determination of ND and CAD by caries detector, teeth were divided into three groups and treated with one of the two tested adhesives: Single Bond 2 (SB2), Scotchbond Universal with etch (SBU-ER), and Scotchbond Universal without etch (SBU-SE). Then composite (Filtek Z-250 XT) were attached to the surfaces and cured. After water storage (24 hours) and thermocycling (500 cycles 5-55 °C), bond strength was calculated and failure modes were determined by stereomicroscope. The data were analyzed by one-way ANOVA and post-hoc test [Tukey HSD (honest significant difference)] and with P ˂ 0.050 as the level of significance. RESULTS: Only SBU-ER had significantly higher shear bond strength than SBU-SE in ND (P = 0.027) and CAD (P = 0.046). Bond strength in SBU-ER the highest and in SBU-SE had the lowest amounts in CAD and ND. There was no significant difference in each group between ND and CAD. CONCLUSION: The 2-step etch-and-rinse adhesive (SBU-ER) had higher bond strength to ND and CAD than the self-etch adhesive (SBU-SE).
Article
Objective: To evaluate the clinical performance of Scotchbond Universal (3M Oral Care) and Prime & Bond Elect (Dentsply Sirona) in the restoration of noncarious cervical lesions (NCCLs). Methods and materials: This was a randomized controlled clinical trial involving 63 subjects. Two hundred and three NCCLs were restored using Scotchbond Universal and Prime & Bond Elect using both an etch-and-rinse and a self-etch technique. Lesions were notch-shaped NCCLs, and the restorations were placed without any mechanical retention. Restorations were finished immediately after placement and scored with regard to retention, marginal discoloration, marginal adaptation, and secondary caries. Similar assessment of the restorations was performed 18 months after placement. Logistic regression was performed for each outcome separately with a compound symmetric variance-covariance structure assumed to consider a correlation of restorations within subjects. All analyses were conducted using SAS version 9.4 (SAS Inc). Results: One hundred and fifty-eight teeth (77.8% of the restorations placed) in 46 subjects (73% of subjects enrolled) were available for the 18-month follow-up. A statistically significant difference was reached only for the comparison Scotchbond Universal/self-etch (SU_SE) and Prime & Bond Elect/etch-and-rinse (PBE_E&R) groups ( p=0.01), where a restoration with SU_SE was 66% less likely to maintain a score of Alpha for marginal discoloration than a restoration performed with PBE_E&R. Conclusions: Scotchbond Universal and Prime & Bond Elect presented acceptable clinical performance after 18 months of clinical service. However, Scotchbond Universal, when applied with a self-etch approach, did demonstrate a relatively high level of marginal discoloration when compared to the other groups.
Article
The objective of this study was to evaluate the effect of acid pretreatment on the bond strength of composite resin bonded to enamel and dentin with 2 different universal self-etching adhesives. The null hypothesis was that the acid treatment performed prior to adhesive application would not significantly change the bond strength to enamel or dentin for either universal adhesive tested. A sample of 112 bovine incisors were selected and embedded in acrylic resin. Half were ground until a flat enamel surface was obtained, and the other half were polished until a 6 × 6-mm area of dentin was exposed, resulting into 2 groups (n = 56). The enamel and dentin groups were divided into 2 subgroups according to the adhesive system applied: Futurabond U or Scotchbond Universal. Each of these subgroups was divided into 2 additional subgroups (n = 14); 1 subgroup received phosphoric acid pretreatment, and 1 subgroup did not. The bond strength was assessed with a microtensile test. Data from enamel and dentin specimens were analyzed separately using 1-way analysis of variance. The acid pretreatment did not significantly change the bond strength of the adhesives tested, either to enamel (P = 0.4161) or to dentin (P = 0.4857). The acid etching pretreatment did not affect the bond strength to dentin and enamel when the tested universal multipurpose adhesive systems were used.
Article
The relationship between enamel bond fatigue durability and surface free-energy characteristics with universal adhesives was investigated. The initial shear bond strengths and shear fatigue strengths of five universal adhesives to enamel were determined with and without phosphoric acid pre-etching. The surface free-energy characteristics of adhesive-treated enamel with and without pre-etching were also determined. The initial shear bond strength and shear fatigue strength of universal adhesive to pre-etched enamel were higher than those to ground enamel. The initial shear bond strength and shear fatigue strength of universal adhesive to pre-etched enamel were material dependent, unlike those to ground enamel. The surface free-energy of the solid (γS) and the hydrogen-bonding force (γSh) of universal adhesive-treated enamel were different depending on the adhesive, regardless of the presence or absence of pre-etching. The bond fatigue durability of universal adhesives was higher to pre-etched enamel than to ground enamel. In addition, the bond fatigue durability to pre-etched enamel was material dependent, unlike that to ground enamel. The surface free-energy characteristics of universal adhesive-treated enamel were influenced by the adhesive type, regardless of the presence or absence of pre-etching. The surface free-energy characteristics of universal adhesive-treated enamel were related to the results of the bond fatigue durability.
Article
Objective: The purpose of this study was to evaluate the effect of the oxygen inhibition layer of universal adhesive on enamel bond fatigue durability and interfacial characteristics with different etching modes. Methods: The three universal adhesives used were Scotchbond Universal Adhesive (3M ESPE, St Paul, MN, USA), Adhese Universal (Ivoclar Vivadent, Schaan, Lichtenstein), and G-Premio Bond (GC, Tokyo, Japan). The initial shear bond strength and shear fatigue strength to enamel was determined in the presence and absence of the oxygen inhibition layer, with and without phosphoric acid pre-etching. The water contact angle was also measured in all groups using the sessile drop method. Results: The enamel bonding specimens with an oxygen inhibition layer showed significantly higher (p<0.05) initial shear bond strengths and shear fatigue strengths than those without, regardless of the adhesive type and etching mode. Moreover, the water contact angles on the specimens with an oxygen inhibition layer were significantly lower (p<0.05) than on those without, regardless of etching mode. Conclusion: The results of this study suggest that the oxygen inhibition layer of universal adhesives significantly increases the enamel bond fatigue durability and greatly changes interfacial characteristics, suggesting that the bond fatigue durability and interfacial characteristics of these adhesives strongly rely on its presence.
Article
Statement of problem: Information is lacking as to the effect on bond strength of the etching modes of universal adhesives when they are used to bond dual-polymerizing composite resins to dentin. Purpose: The purpose of this in vitro study was to investigate the bonding of dual-polymerizing foundation composite resins to dentin when universal bonding agents are used in self-etch or etch-and-rinse modes. Material and methods: Sixty caries-free, extracted third molar teeth were sectioned transversely in the apical third of the crown and allocated to 12 groups (n=5). Three different bonding agents (Scotchbond Universal, OptiBond XTR, All-Bond Universal) were used to bond 2 different dual-polymerizing composite resins (CompCore AF or CoreFlo DC) to dentin, using 2 different etching approaches (etch-and-rinse or self-etch). The specimens were sectioned into sticks (1×1×8 mm) with a precision saw. The bond strength of the specimens was tested under microtensile force at a crosshead speed of 0.5 mm/min. The data were analyzed using a 3-way ANOVA, a Games-Howell post hoc comparisons model, and Student t tests with Bonferroni corrections (α=.05). Results: In the overall model, the composite resin used had no effect on bond strength (P=.830). The etching protocol by itself also did not have a significant effect (P=.059), although a trend was present. The bonding agent, however, did have an effect (P<.001) on bond strength. Also, a significant interaction effect was found for the bonding agent and etching protocol on bond strength (P<.001). The etching protocol influenced the bond strength when Scotchbond Universal (P<.008) and All-Bond Universal (P<.004) were used but not when OptiBond XTR was used (P=1.00). A self-etch protocol provided significantly higher bond strength when Scotchbond Universal was used, whereas with All-Bond Universal, an etch-and-rinse protocol, provided higher bond strength. Conclusions: When universal bonding agents were used to secure dual-polymerizing composite resins to dentin, no single etching protocol is better than another. Depending on which bonding agent is being used, one etching mode may perform better.