The Journal of Adhesive Dentistry, Volume 26/2024

Purpose: To investigate the microtensile bond strength (µTBS) to dentin in class-I cavities using different layering techniques, adhesive application modes, and aging.Materials and Methods: 150 caries-free human molars were randomly assigned to 8 experimental and 2 control groups (n=15 teeth/ group). For each tooth, a standardized class-I cavity was prepared (4x4x4 mm) and pretreated with a universal adhesive (self-etch or etch-and-rinse mode). Incrementally layered restorations served as the control. In the experimental groups, either lining with bulk-fill flowable composite and a layering technique, bulk filling, or the snowplow technique with one or two layers of viscous composite were applied. Four microsticks were obtained from each cavity. Half were tested initially and the other half after aging (thermocycling, 15,000 cycles, 5-55°C, n=30 sticks/group). Tobit regression was used for analyzing group differences, including analysis of interactions, Pearson’s chi-squared test or Fishers’s exact test for fracture analyses (significance level 0.05).Results: Regression analysis showed significant differences in µTBS between groups initially and after aging. In both etching modes, lining with a bulk-fill flowable composite and layering technique achieved the highest µTBS both initially and after aging. In contrast to the etching mode (self-etch < etch-and-rinse), aging did not influence µTBS significantly. The predominant failure types were adhesive and mixed, with a significantly lower number of pre-test failures in the etch-and-rinse groups.Conclusion: The etch-and-rinse mode achieves higher µTBS in class-I cavities compared to the self-etch mode. The lining technique with bulk-fill flowable composite as well as the snowplow technique yielded the highest µTBS after aging, whereas bulk filling and its combination with the snowplow technique resulted in lower µTBS. Keywords: class-I cavity, snowplow technique, bulk filling, µTBS, configuration factor

Purpose: To evaluate the effect of different lithium-disilicate (LiSi) glass-ceramic surface decontamination procedures on the shear bond strength (SBS) to resin cement. Materials and Methods: Seventy CAD/CAM LiSi ceramic specimens (IPS e.max CAD, Ivoclar) were cut and sintered. Fifty specimens were treated with 5% hydrofluoric acid (HF) for 20 s, while 20 were left untreated. All 70 specimens were then contaminated with human saliva and try-in silicone paste. The following surface cleaning methods were investigated (n = 10): C: water rinsing (control); PA: 37% H3PO4 etching for 20 s; E: 70% ethanol applied for 20 s; CP: cleaning paste (Ivoclean, Ivoclar) brushed for 20 s; HFSEP: self-etching ceramic primer (Monobond Etch&Prime, Ivoclar) rubbed for 20 s; HF: 5% HF applied for 20 s or no HF etching prior to contamination; SEP: self-etching ceramic primer rubbed for 20 s and no HF etching prior to contamination. Composite cylinders were created and luted with an adhesive resin cement to the decontaminated surfaces. After storage for 24 h at 37°C, the SBS test was conducted. Two fractured specimens per group were observed under SEM to perform fractographic analysis. The data were statistically analyzed with p set at <0.05. Results: The type of surface cleaning approach influenced bond strength (p < 0.001). HFSEP, SEP, and HF attained higher SBS (p < 0.001) compared to other groups. None of the approaches were able to completely remove contaminants from the ceramic surfaces. SEM images showed residual traces of contaminants on CP-treated surfaces. Conclusions: The self-etching ceramic primer enhanced bond strength to contaminated LiSi ceramic surfaces, irrespective of previous treatment with hydrofluoric acid. Keywords: lithium-disilicate glass-ceramic, surface cleaning, decontamination, hydrofluoric acid, ceramic primer, shear bond strength

Purpose: The study evaluated the clinical performance of partial indirect resin composite (PIRC) restorations with “proximal box elevation” (PBE) placed in molars.Materials and Methods: Sixty-three patients received 80 posterior PIRC (SR Nexco, Ivoclar Vivadent) restorations. Large posterior defects with cuspal loss and deep cervical margins were included in the study. PBE was performed prior to preparation and impression making. Two independent observers evaluated the restorations using the FDI criteria (scores 1-5) for esthetic, functional, and biological properties. Patients were recalled at 6 months and 1, 2, and 3 years. Overall success rates were calculated (Kaplan-Meier analysis) and compared (log-rank tests) according to baseline variables. The impact of the baseline variables on the failure of the restorations was analyzed (multiple proportional Cox regression).Results: Seventy-nine (98.7%), 69 (88.4%), 66 (92.9%), 44 (86.2%) and 45 (91.8%) PIRCs completed their follow up at baseline, 6 months, and 1, 2 and 3 years, respectively. In total, 10 failures were observed: 5 with partial loss, 4 with material chipping, and one with secondary caries, yielding an overall success rate of 87.5% and a survival rate of 93.8%, with a mean observation time of 26.5 ± 13.6 months.Conclusions: PIRCs with PBE demonstrated a high survival rate and satisfactory esthetic properties. Failure was less likely for PIRC restorations with partial cuspal coverage (onlay) compared to full cuspal coverage (overlay). Keywords: adhesive dentistry, clinical trial, dental materials, indirect resin composite, survival, proximal box elevation

Purpose: To compare the adhesion of a self-curing (Tokuyama Universal Bond, TUB) and a light-curing (Scotchbond Universal, SBU) universal adhesive to CAD/CAM materials, enamel, and dentin. This study also assessed differences in enamel adhesion between self-etch vs selective etching modes, as well as immediate and long-term adhesion to dentin for both adhesives.Materials and Methods: Shear bond strength (SBS) testing was used to assess adhesion to enamel, dentin, Lava Ultimate (LU), Vita Enamic (VE), IPS e.max CAD (LD), IPS e.max ZirCAD (3Y-Zir), and Lava Esthetic (5Y-Zir) (n = 10). Moreover, bonding to enamel in self-etch and selective etching modes (n = 10) as well as immediate and aged resin-dentin bond strength (24 h after bonding, after 100,000 thermal cycles [TC] and long-term storage) was evaluated using the microtensile bond-strength test (n = 30). Failure mode was also determined for the bonding to dentin. Statistical analyses consisted of one-way and two-way ANOVA with appropriate post-hoc Tukey-Kramer or two-sample t-tests, as well as the chi-squared or Fisher’s exact test (α = 0.05).Results: TUB and SBU universal adhesives presented similar bonding to LU, VE, 3Y-Zir, and 5Y-Zir. However, SBS for TUB was superior to SBU when bonding to lithium-disilicate glass-ceramic (IPS e.max CAD). SBU showed better adhesion to dentin and enamel when used in the self-etch mode, while TUB promoted strong bond strength to enamel in the selective etching mode. TUB after TC was the only aging condition that yielded a significant reduction in resin-dentin bond strength.Conclusion: In-vitro adhesion performance of the self-curing and light-curing universal adhesives varies depending on the dental substrate or CAD/CAM restorative material used for bonding. Keywords: universal adhesives, bond strength, resin cement, enamel, dentin, self-curing adhesive, CAD/CAM

Purpose: This study aimed to investigate the bonding effectiveness of two HEMA/BPA-free universal adhesives (UAs) to flat dentin, to characterize their adhesive-dentin interfacial ultrastructure, and to measure their water sorption (Wsp), water solubility (Wsl), and hydrophobicity.Materials and Methods: The immediate and aged (50,000 thermocycles) microtensile bond strength (μTBS) to flat dentin of the HEMA/BPA-free UAs Healbond Max (HbMax; Elsodent) and Healbond MP (HbMP; Elsodent) as well as the reference adhesives OptiBond FL (Opti-FL; Kerr), Clearfil SE Bond 2 (C-SE2; Kuraray Noritake), and Scotchbond Universal (SBU; 3M Oral Care) was measured. The adhesive-dentin interfaces of HbMax and HbMP were characterized by TEM. Wsp and Wsl of all adhesive resins and of the primer/adhesive resin mixtures of HbMax, Opti-FL, and C-SE2 were measured. Hydrophobicity was determined by measuring the contact angle of water dropped on adhesive-treated dentin.Results: In terms of µTBS, HbMax and HbMP performed statistically similarly to Opti-FL and C-SE2, but outperformed SBU. Aging only significantly reduced the μTBS of SBU when applied in E&R bonding mode. TEM revealed typical E&R and SE hybrid-layer ultrastructures at dentin, while electron-lucent globules of unknown origin, differing in size and shape, were observed within the adhesive resin of HbMP and even more frequently in that of HbMax. Higher Wsp was measured for the primer/adhesive resin mixtures than for the adhesive resins. Opti-FL was more hydrophobic than all other adhesives tested.Conclusion: The HEMA/BPA-free UAs bonded durably to flat dentin with bond strengths comparable to those of the gold-standard E&R/SE adhesives and superior to that of the HEMA/BPA-containing 1-step UA. Keywords: dental bonding, bond durability, water sorption, interface, HEMA, BPA

Purpose: This study investigated and compared the bond strengths, microleakage, microgaps, and marginal adaptation of self-adhesive resin composites (SAC) to dentin with or without universal adhesives.Materials and Methods: Dentin surfaces of 75 molars were prepared for shear and microtensile bond strength testing (SBS and µTBS). Silicon molds were used to build up direct restorations using the following materials to form 5 groups: 1. Surefil One; 2. Prime&Bond active Universal Adhesive + Surefil One; 3. Vertise Flow; 4. OptiBond Universal + Vertise Flow; 5. Scotchbond Universal + Filtek Z500 (control group). Bonded specimens were thermocycled 10,000x before being tested either for SBS or µTBS using a universal testing machine at a crosshead speed of 0.5 mm/min. Direct mesial and distal class-II cavities were created on 100 sound premolars, with the gingival margin of distal cavities placed below CEJ and restored according to the five groups. After thermocycling, microleakage scores were assessed following immersion of restored premolars in 2% methylene blue dye for 24 h, while marginal gaps and adaptation percentages were investigated on epoxy resin replicas under SEM at magnifications of 2000X and 200X, respectively. Results were statistically analyzed with parametric and non-parametric tests as applicable, with a level of significance set at α = 0.05.Results: Bond strengths, microleakage scores, microgaps, and percent marginal adaptation of Surefil One and Vertise Flow were significantly (p < 0.001) inferior to the control group. Dentin preconditioning with universal adhesives significantly increased the study parameter outcomes of Surefil One and Vertise Flow, yet they were still significantly below the performance of the control group.Conclusion: Conventional resin composite outperformed the SAC whether applied solely or in conjunction with their corresponding universal adhesives. Keywords: self-adhesive resin composites, universal adhesives, shear bond strength, microtensile bond strength, microleakage, marginal adaptation

Purpose: Multiple materials are found in the root canal after fiber-post cementation. The layer of a bioceramic-based (BC) sealer may affect the bond strength (σBS) of the fiber post in the root canal. The purpose of this study was to employ multilayer composite-disk models in diametral compression to investigate whether the bond strength between a fiber post and root dentin can be increased by the application of a primer on the BC sealer. Materials and Methods: The multilayers of materials in the root canal required 3D finite-element (FE) stress analyses (FEA) to provide precise σBS values. First, BC sealer was characterized using x-ray powder diffraction (XRD) to determine when the sealer completely set and the types of crystals formed to select which primer to apply to the sealer. We selected a 10-methacryloyloxydecyl dihydrogen phosphate (10-MDP)-based primer to treat the BC sealer before post cementation. Ultra-highspeed (UHS) imaging was utilized to analyze the crack initiation interface. The obtained failure force was used in FE analysis to calculate σBS. Results: UHS imaging validated the fracture interface at the post-dentin junction as FEA simulations predicted. σBS values of the fiber posts placed with various material combinations in the root canal were 21.1 ± 3.4 (only cement/ post), 22.2 ± 3.4 (BC sealer/cement/post) and 28.6 ± 4.3 MPa (10-MDP primer treated BC sealer/cement/post). The 10-MDP-treated BC sealer exhibited the highest σBS (p < 0.05).Conclusion: The multilayer composite disk model proved reliable with diametral compression testing. The presence of BC sealer in the root canal does not reduce σBS of the fiber post. Conditioning the BC sealer layer with 10-MDP primer before fiber-post cemen-tation increases σBS. Keywords: bioceramic-based sealer, bond strength testing, fiber post, finite element analysis, multilayer composite-disk model, ultra-highspeed imaging

Purpose: This investigation aimed to assess the impact of additive manufacturing-generated surface textures on zirconia bond strength.Materials and Methods: Zirconia samples (n = 144) fabricated using digital light-processing (DLP) technology were categorized into 6 groups according to the type of surface conditioning (group NN: no designs, no air abrasion; group NY: no designs, with air abrasion; group GN: groove designs, no air abrasion; group GY: groove designs with air abrasion; group HN: hexagon grid, no air abrasion; group HY: hexagon grid, with air abrasion). Composite resin cylinders were cemented to the treated zirconia surfaces with dual-curing, self-adhesive resin cement (Clearfil SA Luting). The shear bond strength (SBS) was tested after water storage for 3 days or 3 days with an additional 10,000 thermocycles.Results: The zirconia samples fabricated using DLP technology have high accuracy. The SBS of the NY, GY, and HY groups did not significantly differ after 3 days, and neither did the SBS of the NN, GN, and HN groups. The NN, NY, and HY groups exhibited reduced SBS compared to their initial values following artificial aging, while the SBS of the remaining three groups were not diminished. The GY group obtained the highest SBS value after aging.Conclusion: Printing grooves with air abrasion can improve the bond strength. Keywords: additive manufacturing, bonding, resin cements, zirconia

Purpose: This paper describes previously unknown details about the discovery of resin adhesion to acid-etched human enamel.Materials and Methods: A literature review was performed through manual assessments. Primary sources revealing the discovery of resin curing on etched enamel were analyzed considering the research objectives and methodological procedure during that era, including the type of teeth used, preparatory measures, acid-etching process, type of resin and its application, and follow-up observations. Additionally, the political and economic contexts were examined.Results: In 1949, acid etching was found to promote adhesion with acrylic resin, a finding described again in 1955. The 1949 studies utilized nitric acid for enamel etching and the acrylate resin Paladon from the Kulzer company (Germany). Conversely, the 1955 investigations employed phosphoric acid and an unnamed acrylate, likely a self-curing resin supported by Kulzer in the late 1930s. Disparities in the 1949 and 1955 findings can be ascribed to varying objectives and test conditions amidst a turbulent political backdrop, significantly impacting the Kulzer company.Conclusion: The discovery of resin adhesion to acid-etched enamel, approaching its 75th anniversary in 2024, is a landmark in 20th-century adhesive dentistry. Paladon represents a pioneering compound, exemplifying the influence of political, ideological, and economic factors on scientific advancements during that period. Keywords: adhesion of acrylics to acid-etched enamel, history of adhesive dentistry, history of dental acrylics

Purpose: To investigate the influence of contamination and different cleaning methods on resin bonding to cobalt-chro-mium (CoCr) alloy disks.Materials and Methods: A total of 160 CoCr disks were divided into 3 groups. The first group (N = 64) was air abraded with alumina particles; the second group (N=64) was air abraded and contaminated with silicone disclosing agent and saliva; the third group (N = 32) was neither air abraded nor contaminated. The first two groups were divided into 4 subgroups (N = 16) according to the cleaning method: ultrasonic bath in 99% isopropanol, use of a cleaning suspension of zirconium oxide particles, use of a cleaning suspension based on 10-MDP salt, and treatment with atmospheric plasma. The third group was divided into 2 subgroups (N = 16): treatment with atmospheric plasma and no treatment. All CoCr specimens were bonded to plexiglas tubes filled with a bonding resin that contained phosphate monomer. Tensile bond strength (TBS) was examined by tensile testing after 3 and 150 days of water storage plus 37,500 thermal cycles (N = 8).Results: After contamination, TBS was significantly reduced after 150 days of water storage. Groups without air abrasion showed initially low TBS and debonded spontaneously after 150 days of water storage.Conclusion: None of the cleaning methods was able to remove saliva and silicone disclosing agent on CoCr-alloy sur-faces. Surface activation by plasma treatment has no long-term effect on the bond strength. Keywords: alloy, contamination, cleaning, bonding, plasma treatment

Purpose: To investigate the antibacterial effects of Terminalia catappa Linn (TCL) leaf extracts at different concentrations and the effects of these extracts used as primers on the long-term adhesive properties of two universal adhesives.Materials and Methods: After extract preparation, the antimicrobial and antibacterial activities of TCL against Streptococcus mutans (UA 159) were assessed in microdilution assays to provide the minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC). Additionally, to provide quantitative data on the ability of TCL extract to reduce cell viability, colony forming units (CFU) were counted. To examine adhesive properties, 288 human molars were randomly assigned to 32 experimental conditions (n = 9) according to the following variables: (1) treatment agent: negative control (untreated surface), and primers at concentrations of 1xMIC, 5xMIC, and 10xMIC; (2) adhesives: Scotchbond Universal (SBU) and Futurabond Universal (FBU); (3) adhesive strategy: etch-and-rinse (ER) or self-etch (SE); and (4) storage time: 24 h or after 2 years. Primers were applied for 60 s, upon which the teeth were incrementally restored and sectioned into adhesive-dentin bonded sticks. These were tested for microtensile bond strength (μTBS) and nanoleakage (NL) after 24-h and 2-year water storage, as well as in-situ degree of conversion (DC) at 24 h. The chemical profile of the hybrid layer was determined via micro-Raman spectroscopy. Biofilm assay data were analyzed using the Kruskal-Wallis test; the pH of culture media and the chemical profile were analyzed by one-way ANOVA. The adhesive properties (µTBS, NL, DC) were evaluated using a four-way ANOVA and Tukey’s test. Significance was set at 5%.Results: Similar values of MIC and MBC were observed (2 mg/ml), showing bactericidal potential. CFU analysis demonstrated that concentrations of 5xMIC and 10xMIC significantly inhibited biofilm formation (p < 0.001). The application of the TCL primer at all concentrations significantly increased the immediate μTBS and DC, and decreased the immediate NL values when compared to the control group (p < 0.05), regardless of the adhesive and adhesive strategies. Despite an increase in the NL values for all groups after 2 years (p > 0.05), in groups where the TCL primer was applied, the μTBS remained constant after 2 years for both adhesives, while a decrease in the μTBS was observed in the control groups (p < 0.05). Usually, 10xMIC showed better results than 1xMIC and 5xMIC (p < 0.05). The application of TCL promoted cross-linking; cross-linking rates increased proportionally to the concentration of TCL (p < 0.05).Conclusion: Primers containing TCL promoted bactericidal and bacteriostatic action, as well as cross-linking with dentin, while maintaining the adhesive properties of the adhesive-dentin interface after 2 years of water storage. Keywords: microbial degradation, dentin adhesives, scanning electron microscopy, flavonoids

Purpose: The aim of this retrospective study was to assess the short- to mid-term restorative and periodontal outcome of deep margin elevation (DME) performed using resin composite.Materials and Methods: Twenty-eight teeth treated with DME and indirect adhesive restorations were followed-up for a mean of 25.4 months (minimum: 12 months). Clinical and radiographic examination assessed the adaptation of the DME material and indirect restorations, presence of recurrent caries or discoloration, periodontal health at DME and non-DME sites, and periapical health.Results: The overall success rate was 96.6%. One tooth showed signs and symptoms of apical pathology after 34 months following DME. No caries, discoloration, or periodontal pockets were detected in any of the treated teeth. DME had no detrimental effect on the gingival/periodontal health or plaque accumulation. There was no correlation between the distance from the DME material to the marginal bone level and pocket depth, gingival inflammation, and plaque accumulation (p > 0.05).Conclusion: Deep margin elevation might be considered a safe procedure for teeth with deep subgingival proximal caries in the short- and mid-term. Keywords: subgingival margins, deep margin elevation, cervical margin relocation, restorative dentistry

Purpose: To investigate the effect of adhesive type and long-term aging on the shear bond strength (SBS) between silica-based ceramics and composite cement (CC).Materials and Methods: Lithium-silicate (LS), feldspathic (FD) and polymer-infiltrated ceramic (PIC) blocks were sectioned (10 x 12 x 2 mm) and divided into 24 groups considering the factors: “ceramics” (LS, FD, and PIC), “adhesive” (Ctrl: without adhesive; 2SC: 2-step conventional; 3SC: 3-step conventional; 1SU: 1-step universal), and “aging” (non-aged or aged [A]). After the surface treatments, CC cylinders (n = 15, Ø = 2 mm; height = 2 mm) were made and half of the samples were subjected to thermocycling (10,000) and stored in water at 37°C for 18 months. The samples were submitted to SBS testing (100 kgf, 1 mm/min) and failure analysis. Extra samples were prepared for microscopic analysis of the adhesive interface. SBS (MPa) data was analyzed by 3-way ANOVA and Tukey’s test (5%). Weibull analysis was performed on the SBS data.Results: All factors and interactions were significant for SBS (p<0.05). Before aging, there was no significant difference between the tested groups and the respective control groups. After aging, the LS_1SU (22.18 ± 7.74) and LS_2SC (17.32 ± 5.86) groups exhibited significantly lower SBS than did the LS_Ctrl (30.30 ± 6.11). Only the LS_1SU group showed a significant decrease in SBS after aging vs without aging. The LS_1SU (12.20) group showed the highest Weibull modulus, which was significantly higher than LS_2SC_A (2.82) and LS_1SU_A (3.15) groups.Conclusion: No type of adhesive applied after silane benefitted the long-term adhesion of silica-based ceramics to CC in comparison to the groups without adhesive. Keywords: adhesive, ceramics, dentin-bonding agents, dental materials, surface treatment

Purpose: To measure zirconia-to-zirconia microtensile bond strength (µTBS) using composite cements with and without primer.Materials and Methods: Two Initial Zirconia UHT (GC) sticks (1.8x1.8x5.0 mm) were bonded using four cements with and without their respective manufacturer’s primer/adhesive (G-CEM ONE [GOne] and G-Multi Primer, GC; Panavia V5 [Pv5]), and Panavia SA Cement Universal [PSAu], and Clearfil Ceramic Plus, Kuraray Noritake; RelyX Universal (RXu) and Scotchbond Universal Plus [SBUp], 3M Oral Care). Specimens were trimmed to an hour-glass shaped specimen whose isthmus is circular in cross-section. After 1-week water storage, the specimens were either tested immediately (1-week μTBS) or first subjected to 50,000 thermocycles (50kTC-aged μTBS). The fracture mode was categorized as either adhesive interfacial failure, cohesive failure in composite cement, or mixed failure, followed by SEM fracture analysis of selected specimens. Data were analyzed using linear mixed-effects statistics (α = 0.05; variables: composite cement, primer/adhesive application, aging).Results: The statistical analysis revealed no significant differences with aging (p = 0.3662). No significant difference in µTBS with/without primer and aging was recorded for GOne and PSAu. A significantly higher µTBS was recorded for Pv5 and RXu when applied with their respective primer/adhesive. Comparing the four composite cements when they were applied in the manner that resulted in their best performance, a significant difference in 50kTC-aged μTBS was found for PSAu compared to Pv5 and RXu. A significant decrease in µTBS upon 50kTC aging was only recorded for RXu in combination with SBUp.Conclusion: Adequate bonding to zirconia requires the functional monomer 10-MDP either contained in the composite cement, in which case a separate 10-MDP primer is no longer needed, or in the separately applied primer/adhesive. Keywords: zirconia, bond strength, sandblasting, tribochemical silica coating, functional monomer, silane, aging.

Purpose: To systematically review in-vitro studies that evaluated the influence of erbium laser pretreatment on dentin shear bond strength (SBS) and bond failure modes.Materials and Methods: Electronic databases (PubMed, Cochrane Central, Embase, and Web of Science) were searched. Only in-vitro studies involving erbium laser irradiation of the dentin surface and SBS testing of the bonded resin block were included. The three common modes of bond failure (1. adhesive, 2. cohesive, and 3. mixed) were observed and analyzed. The network meta-analysis (NMA) was performed by Stata 15.0 software, the risk of bias was evaluated, and the certainty of the evidence was assessed by the Confidence in Network Meta-analysis (CINeMA).Results: Forty studies with nine pretreatments (1. blank group: BL; 2. phosphoric acid etch-and-rinse: ER; 3. self-etch adhesive: SE; 4. Er:YAG laser: EL; 5. Er,Cr:YSGG laser: ECL; 6. ER+EL; 7. ER+ECL; 8. SE+EL; 9. SE+ECL) were included in this analysis. The NMA of SBS showed that ER+EL [SMD = 0.32, 95% CI (0.11, 0.98)] had the highest SBS next to ER, especially when using one of the 3M ESPE adhesives, followed by EL, ECL, SE and SE+EL. The Ivoclar Vivadent adhesives significantly increased the SBS of the ECL [SMD = 0.37, 95% CI (0.16,0.90)] and was higher than ER+EL [SMD = 0.25,95% CI (0.07,0.85)]. Finally, the surface under the cumulative ranking curve (SUCRA) value indicated that ER+EL (SUCRA = 71.0%) and EL (SUCRA = 62.9%) were the best treatments for enhancing dentin SBS besides ER. ER+EL (SUCRA = 85.3%), ER (SUCRA = 83.7%) and ER (SUCRA = 84.3%) had the highest probability of occurring in adhesive, cohesive and mixed failure modes, respectively.Conclusion: Er:YAG and Er,Cr:YSGG lasers improved dentin SBS compared to the blank group, especially when the acid etch-and-rinse pretreatment was combined with Er:YAG laser. Shear bond strength and failure mode do not appear to be directly related. Keywords: dentin, shear bond strength, bond failure mode, erbium laser

Purpose: To evaluate the effect of urethane methacrylate precursor (UMP) on the enzymatic resistance of demineralized dentin (DD) matrices.Materials and Methods: Experimental treatments containing 0 (control), 1, and 5 mmol/L UMP dissolved in an acetone (Ace) solution were formulated. Dentin matrix specimens were demineralized in vitro and immersed in the experimental treatments for 1 h. The treated specimens were then stored in 0.1 mg/mL collagenase solution for 24 h, after which their dry mass loss and hydroxyproline (HYP) release were assessed. The swelling ratios of specimens in each group were also evaluated. The interaction between UMP and the dentin matrix was observed using field-emission scanning electron microscopy (FE-SEM). Endogenous enzyme activity in dentin was evaluated using confocal laser scanning microscopy (CLSM).Results: Compared with the other treatment groups, treatment with 1 mM and 5 mM UMP-Ace significantly decreased the dry mass loss, HYP release and swelling ratio of the DD matrix (p < 0.05). FE-SEM and CLSM observations showed that treatment with UMP-Ace protected the structure of the dentin matrix and decreased porosity within the dentin-collagen network.Conclusion: Treatment with 1 mM and 5 mM UMP-Ace protects DD matrix against collagenase degradation and may be clinically useful for improving the durability of the hybrid layer. Keywords: isocyanate, dentin, collagen, proteolysis, hydroxyproline

Purpose: Numerous studies report on the outcome performance of posterior composite restorations. However, there are fewer studies providing data for anterior restorations. The aim of this study was to evaluate the clinical outcome performance of anterior permanent restorations by analyzing a large dataset from a German national health insurance company. Materials and Methods: Routine claims data from a major German national health insurance company were assessed. Fee codes were used for tracing restoration careers on a day-count basis. The treatment was defined as a placed restoration (Class III and IV) on a mesial or distal tooth surface, irrespective of the extension. The restorations were placed between January 1, 2010 and December 31, 2013. Statistical analyses were conducted using Kaplan–Meier survival analysis to determine cumulative 4-year survival rates. The primary outcome was re-intervention on the same surface. Secondary outcomes were crowning and extraction which were analyzed separately. Results: A total of 2,417,791 restorations involving mesial surfaces and a number of 2,409,031 restorations involving distal surfaces were observed. At 4 years, the cumulative survival rates concerning the primary outcome “re-intervention” were 79.9% for mesial and 80.9% for distal restorations. The respective annual failure rates (AFR) were 5.5% and 5.2%. Four-year survival rates for the secondary outcome “crown” were 93.8% for mesial and 94.1% for distal anterior restorations. The respective AFRs were 1.6% and 1.5%. For the secondary outcome “extraction,” the respective rates were 94.6% for mesial and 93.9% for distal restorations. The respective AFRs were 1.4% and 1.6%. Conclusion: The performance of permanent anterior restorations which were placed in general dental practices in Germany can be rated as acceptable. Keywords: anterior restoration, outcome, public health, dental general practice, survival analysis

Purpose: This German S3 clinical practice guideline offers evidence-based recommendations for the use of composite materials in direct restorations of permanent teeth. Outcomes considered were the survival rates and restoration quality and process quality of the manufacturing process. Part 1 of this two-part presentation deals with the indication classes. Materials and Methods: A systematic literature search was conducted by two methodologists using MEDLINE and the Cochrane Library via the OVID platform, including studies up to December 2021. Six PICO questions were developed to guide the search. Recommendations were formulated by a panel of dental professionals from 20 national societies and organizations based on the collected evidence. Results: Composite materials are a viable option for the direct restoration of cavity Classes I–V and may also be used for restorations with cusp replacement, and tooth shape corrections. In the posterior region, direct composite restorations should be preferred over indirect composite inlays. For Class V restorations, composite materials can be used if adequate contamination control and adhesive technique are ensured. Conclusion: The guideline is the first to provide comprehensive evidence on the use of direct composite materials. However, further long-term clinical studies with comparators such as (modified) glass-ionomer cements are necessary. Regular updates will detail the future scope and limitations of direct composite restorations. Keywords: adhesive restorations, composite resin, composite restorations, evidence-based medicine

Purpose: Part 2 of this German S3 clinical practice guideline provides recommendations for the process of manufacturing composite restorations. It covers key aspects like caries removal, field isolation, matrix and adhesive techniques, as well as light curing and polishing. The outcomes of interest include survival rates and restoration quality. Materials and Methods: A systematic literature search was conducted by two methodologists using MEDLINE and the Cochrane Library via the OVID platform, including studies up to December 2021. Additionally, the reference lists of relevant manuscripts were manually reviewed. Six PICO questions were developed to guide the search. Consensus-based recommendations were for- mulated by a panel of dental professionals from 20 national societies and organizations based on the collected evidence and ex- pert opinion. Results: The guideline advocates for one-stage selective caries removal near the pulp and underscores the effectiveness of various isolation techniques, adhesive systems, and the crucial role of light polymerization. The use of anatomically pre- formed sectional matrices and phosphoric acid etching is recommended to enhance restoration quality. Additionally, polish- ing composite restorations is advised to improve surface finish. Conclusion: This guideline provides comprehensive recommendations that inform clinicians on optimizing the composite restor- ation manufacturing processes. The adoption of these best practices can improve the quality and longevity of dental restorations.

Purpose: To evaluate the long-term microtensile bond strength (µTBS) to dentin, water sorption (WSP) and solubility (WSL), and degree of conversion (DC) of self-adhesive resin composites (SACs). Materials and Methods: The mid-coronal dentin of human molars was exposed, and teeth were randomly assigned to five groups according to the SACs (n = 10): 1. FIT SA F03 (FIT); 2. Experimental (EXP); 3. Fusio Liquid Dentin (FLD); 4. Vertise Flow (VER); 5. Constic (CON). The µTBS was evaluated after 24 hours (24 h) and 6 months (6 m) storage. A scanning electron microscope examined failure modes and resin–dentin interfaces. The WSP and WSL (n = 5) were evaluated following ISO 4049:2019 specifications, and DC (n = 3) was measured using Raman spectroscopy. The statistical analyses were performed accepting a significance level of p = 0.05. Results: FIT, EXP, and FLD produced significantly higher µTBS median values than VER and CON after 24 h and 6 m (p 0.05). After 6m, the µTBS median of FIT and EXP significantly decreased (p 0.05), while FLD, VER, and CON showed no significant difference (p > 0.05). FLD and CON exhibited lower WSP than FIT, EXP, and VER (p 0.05). FLD presented the lowest (p 0.05), and VER revealed the highest WSL (p 0.05). FIT and EXP showed the highest (p 0.05), and VER demonstrated the lowest DC (p 0.05). Conclusions: Following the present study’s design, SACs’ bonding performance and physical properties remained restricted. Therefore, the application should be considered cautiously, and further clinical trials are necessary to evaluate their long-term performance. Keywords: self-adhesive resin composite, adhesion to dentin, physical properties, bond strength

Purpose: To evaluate interfacial three-dimensional adaptation and internal voids of different flowable materials before and after cyclic fatigue in a simulated deep-margin elevation scenario. Methods: Eighty (n = 80) extracted premolars were selected and two Class II cavities were prepared. The mesial one with cervical margin 1 mm above the cementum-enamel junction (CEJ) and the distal one with cervical margin 1 mm below the CEJ. After performing adhesive procedures, specimens were divided into four groups according to the employed materials for 2 mm horizontal deep-margin relocation: nanohybrid composite (Clearfil ES2, Kuraray); conventional viscosity flowable composite (Tetric Flow, Ivoclar); medium viscosity flowable composite (Majesty ES2 Low Flow, Kuraray); high viscosity flowable composite (Majesty ES2 Super Low Flow, Kuraray). All restorations were finalized by oblique layering with nanohybrid composite (Clearfil ES2, Kuraray). To reveal interfacial and internal gap progression, specimens were scanned with a micro-CT (SkyScan 1172), before and after 500,000 cycles of mechanical chewing simulation (50 N, 1 Hz). Data were imported into Mimics software after smoothing and region growing. Only the 2 mm margin relocation volumes were considered. Obtained masks were analyzed for noise removal and volume calculation. At baseline, interfacial gap progression and internal voids, expressed in mm3, were collected and statistically analyzed with two-way ANOVA (α 0.05) for the variables substrate and restorative materials followed by Tukey post-hoc test. An additional two-way ANOVA test, followed by Tukey post-hoc test, was performed to evaluate variation in interfacial gap progression after mechanical aging. Results: At baseline, the ANOVA test showed a significant difference for the variable restorative materials (p = 0.01). More specifically, the Tukey post-hoc test revealed that the highly filled medium viscosity composite performed better than the conventional viscosity composite at baseline for the interfacial gap. The internal voids ANOVA test at baseline reported no significant differences for the variable tested. Analysis of variance for internal gap progression after thermocycling showed no differences for both substrate and restorative material employed. Conclusions: Highly filled medium viscosity composite performed significantly better than the conventional viscosity flowable composite for what concern baseline interfacial gaps. Artificial aging with a chewing simulator and thermocycling did not affect interfacial gap progression on enamel and dentin. The tested restorative materials performed equally after aging. Keywords: 3D interfacial gap, adhesive interface, chewing simulator, highly filled flowable composites, internal voids, mechanical aging, micro-CT

Purpose: To assess the bond strength and the hybrid layer (HL) micro-morphological characteristics at the cement-dentin interface (CD-i) between root canal walls and two adhesive resin cements [self-etch (SERc) and self-adhesive (SARc)] in root-canal-treated (RCT) and naturally aged retreated teeth (RCR-T). Materials and Methods: Vital (n = 16) and RCT (n = 16) teeth were, respectively, endodontically treated or retreated. Fiber posts were luted either with SERc (Clearfil Universal Bond Quick + DC Core Plus) or SARc (iCEM). Samples were then sectioned into 1 mm thick slices perpendicular to the fiber post and submitted to push-out bond strength test. Vital (n = 4) and RCT (n = 4) first maxillary molars were also selected and prepared to evaluate CD-i morphology through confocal laser scanning microscopy (CLSM). Three-way analysis of variance (ANOVA) and Tukey post-hoc tests were assessed to statistically analyze the obtained data (p 0.05). Results: Bond strength was significantly jeopardized in retreated teeth and in the root apical half, while the cements had no significant influence. Most failures occurred between dentin and resin cement. HL thickness was also hindered in retreated teeth. iCEM produced a thinner HL compared to SERc. Resin tag formation was significantly hampered in the root apical half. Conclusions: SARc performed as well as SERc on aged RCT radicular dentin. Clinicians can rely on simplified one-step luting systems when adhesion is required in unfavorable substrates such as the root canal post space of aged RCT teeth. Keywords: bond strength, confocal laser scanning microscopy, radicular dentin, self-etch resin cement, self-adhesive resin cement

Purpose: This study aims to assess whether orthodontic bonding systems prevent orthodontic-induced white spot lesions (OIWSLs), exploring efficacy and identifying associated factors through a comprehensive systematic review of existing evidence. Materials and Methods: The study complied to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two evaluators screened records, and data were extracted on orthodontic bonding systems, outcomes, and participant characteristics from PubMed/MEDLINE, Cochrane Library, and EM Premium. The search equation focused on white spot lesions and orthodontic bonding. Only in-vivo studies and clinical trials on humans were included, while in-vitro studies were excluded. The risk of bias was assessed using Cochrane’s RoB2 tool for RCTs and ROBINS-I tool for non-randomized studies, evaluating key domains related to bias. Results: The systematic review, including 12 articles with 550 participants and 2,000 teeth, revealed that bonding with nanoparticles of nCaF2-primer and amorphous calcium phosphate-containing adhesives effectively reduced WSLs. In contrast, one-step adhesive without primer (GC Ortho Connect™) was associated with higher and more severe WSLs. Fluoride-releasing primers (Opal Seal™ and Clearfil™) did not exhibit an advantage in demineralization reduction. The inclusion of TiO2 nanoparticles in two studies yielded conflicting results on antibacterial effects. Discussion: Various nanoparticles incorporated into adhesives or primers exhibit promise in preventing white spot lesions in fixed orthodontic treatment. However, the used evaluation methods, such as clinical examinations or advanced imaging, significantly impact result interpretation. The effectiveness of orthodontic adhesives in preventing WSLs should balance between biocompatibility, bond strength and demineralization control tailored to patient-specific needs. Keywords: enamel demineralization, fixed orthodontics, orthodontic adhesive, prevention, white spot lesion

Purpose: This study aimed to develop a novel orthodontic primer that incorporated graphite fluoride (GF) and Bioactive glass (BAG) and to investigate its cell viability, bonding strength, and enamel damage, as well as its antibacterial and remineralization properties. Materials and Methods: Nine groups were prepared by adding different concentrations of GF (1, 2, and 4 wt.%) and BAG (1, 3, and 5 wt.%) to Transbond™ XT orthodontic primer. The prepared primers were compared to the control primer in terms of cell viability, shear bond strength (SBS), adhesive remnant index (ARI), enamel damage index (EDI), and antibacterial test. Then, the groups with better antibacterial properties (GFBAG 1-1, GFBAG 4-1, GFBAG 4-3, GFBAG 4-5) were evaluated for the remineralization properties. Results: All the prepared orthodontic primers with different concentrations of GF/BAG revealed acceptable cell viability levels, with comparable SBS and ARI values to the control primer (p>0.05). Simultaneously, the EDI was reduced, while the antibacterial properties were significantly enhanced when compared to the control group (p0.05). The result of remineralization properties revealed that the selected groups had significantly higher remineralization ability than the control group; this was most pronounced in the GFBAG 4-3 group. Conclusions: All the prepared GF/BAG orthodontic primers are biologically safe with adequate SBS, ARI, and EDI values for clinical application with enhanced antibacterial properties. The GFBAG 4-3 experimental primer reveals the best antibacterial and remineralization properties which require further in-vitro and in-vivo investigations as a preventive measure of white spot lesions. Keywords: antibacterial, bioactive glass, graphite fluoride, orthodontic primer, remineralization, white spot lesion

Purpose: To evaluate the survival and clinical quality of individually layered indirect composite restorations (ICRs) in the mixed and permanent dentition at two study centers. Materials and Methods: A total of 155 adhesively cemented ICRs in 34 participants (aged 6 to 50 years and treated between 2008 and 2018) were evaluated for survival and clinical quality. All were individually layered restorations fabricated from laboratory sculptable composites by a specialized dental technician. Two calibrated independent investigators examined and graded each restoration as success, survival with repair, or failure based on the FDI criteria. The marginal quality and gap width of the restorations were analyzed by scanning electron microscopy. The periodontal health of treated teeth (TT) was evaluated in comparison with that of unrestored control teeth (CT) by measuring the pocket depth (PD), clinical attachment level (CAL), sulcus bleeding index (SBI), and the modified Turesky Plaque Index (TPI). A serial t-test (p 0.05) was used for statistical analysis of periodontal parameters. Success and functional survival rates were calculated using the Kaplan–Meier method. Results: Molar incisor hypomineralization (MIH) was the most common indication for treatment (41%). The median age at treatment was 14.9 years (68%-CI: 7.7–29.5). The median service time of the restorations was 5.7 ± 3.4 years. 132 restorations were classified as a success, 21 as survival with repair, and 1 as a failure. The success rates at 1, 5, and 10 years were 95.4%, 87.4%, and 78.8%, respectively, and the corresponding functional survival rates were 100.0%, 98.9%, and 98.9%. The clinical quality, encompassing esthetic, functional, and biological criteria, was rated as excellent or good in over 90%. Periodontal response, however, was the only criterion showing worse results since restored teeth (TPI = 1.9) had significantly more plaque than CT (TPI = 1.7; p = 0.0001). No significant differences were observed in PD, CAL, or SBI. The mean marginal gap width was 135.7 µm and 63.8% of the restorations had perfect margins. Conclusion: ICRs are suitable for minimally invasive restoration of large tooth structure defects in the developing dentition of children and adolescents and for long-term temporary restoration of the adult dentition. Keywords: adolescent dentition, adult dentition, clinical quality parameters, indirect composite restorations, qualitative margin analysis, survival