Immediate Dentin Sealing: A Literature Review: Clinical, Cosmetic and Investigational Dentistry Dove

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REVIEW
Immediate Dentin Sealing: A Literature Review

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Theodora- Purpose: The immediate application of a dentin-bonding agent after tooth preparation and
Kalliopi Samartzi 1 before impression-taking (immediate dentin sealing [IDS]) has been suggested to provide
2 several advantages concerning bacterial microleakage, hypersensitivity, and bonding quality.
Dimokritos Papalexopoulos
Aspasia Sarafianou2 We reviewed the literature and clarified certain aspects related to each step of IDS
application.
Stefanos Kourtis2
Materials and Methods: The search strategy comprised an electronic research in
1
Private Dentistry Practice, Athens, MEDLINE, Cochrane, Ovid and Scopus for studies published from January 1990 to
Greece; 2Department of Prosthodontics,
National and Kapodistrian University of December 2020 regarding the IDS technique and including both in vitro and clinical studies.
Athens, Athens, Greece Results: After exclusion of irrelevant or duplicate articles, 88 articles focusing on aspects of
For personal use only.
the IDS technique were assessed. IDS seems to be advantageous with regard to bond
strength, gap formation, bacterial microleakage, and dentin hypersensitivity. However, issues
arising from interaction with impression materials, the provisional phase, and conditioning
methods before cementation require further investigation.
Conclusion: There are no documented reasons preventing clinicians applying IDS in their
everyday practice. On the contrary, the presented technique seems to be beneficial in certain
aspects regarding indirect restorations.
Keywords: IDS, indirect restorations, restorative dentistry, review
Introduction
Indirect restorations (even if they are more expensive and time-consuming com
pared with direct restorations) provide reduced polymerization shrinkage;1 better
esthetic, physical, and mechanical properties by post-curing the restoration with
light/heat; ideal occlusal morphology; interproximal contacts and wear compatibil
ity with opposing teeth.1,2 Indirect restorations can also aid the restoration of deep
preparations with gingival margins located in dentin.3
Restorative dentistry is opposed to the wastage of tooth tissue. Hence, mini
mally invasive restorations such as inlays, onlays, and laminate veneers are
employed. However, regardless of the amount of tooth substance removed, expo
sure of dentin tubules is inevitable.4 Given the inadequate sealing provided by
interim cementation materials, exposed dentin is confronted with bacterial micro
leakage, as well as chemical and mechanical stimuli transmitted during impression-
taking, rinsing, drying, function, and removal of provisional materials.5
To counterbalance the above-mentioned issues and prevent potential pulp
damage, the immediate application of a dentin-bonding agent (DBA) after tooth
Correspondence: Dimokritos preparation and before impression-taking was introduced in the early-1990s by
Papalexopoulos
Department of Prosthodontics, National Pashley et al.6 This method, which is also referred to as “prehybridization”, “dual
and Kapodistrian University of Athens, bonding technique”, and “resin coating technique”, was established with the term
Athens, Greece
Email dimpapalex@hotmail.com “immediate dentin sealing” (IDS).7 In conventional procedures, sealing of the
Clinical, Cosmetic and Investigational Dentistry 2021:13 233–256 233

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Samartzi et al Dovepress
dentin tubules takes place at the bonding stage of the final appropriate adhesive systems; interaction with impression
restoration (delayed dentin sealing [DDS]).8 Thus, during materials; provisional restorations; surface conditioning;
provisionalization, exposed dentin leaves a potential path material selection for adhesive luting and film thickness;
way for bacterial infiltration. Conversely, in the IDS tech restorative materials; microleakage/marginal adaptation;
nique, dentin adhesives are applied before the provisional time of restoration placement; and hypersensitivity.
phase, which presents benefits with regard to bacterial

microleakage, dentin hypersensitivity, gap formation, and IDS Protocol
bond strength.9 The IDS technique rests upon four fundamental
Because articles elaborating all aspects regarding IDS principles.11 First, only fresh-cut, contaminant-free dentin
and providing a unanimous protocol are lacking,10 in this provides the optimum substrate for bonding. In any other
study we reviewed the literature and clarified certain clin case, the bond strength is inferior.12,13 Second, if the DBA
ical procedures related to each step of IDS application. and overlaying composite are light-cured together, the
hybrid layer may collapse due to the pressure from the
Materials and Methods composite or restoration placement.14–16 Thus, precuring
We searched for evidence-based research articles on IDS the DBA results in a better bond strength. Third, IDS and
published from January 1990 until December 2020 using delayed restoration placement permit maturation of the
MEDLINE, Cochrane, Ovid and Scopus databases. After dentin bond in an environment free of occlusal forces
initial screening of the literature, the terms “immediate and overlaying composite shrinkage.71,72 Fourth, IDS
dentin sealing”, “dual bonding technique”, “resin coating reduces fluid and bacterial penetration.
technique”, and “prehybridization” were used as key The clinical advantages emerging from the aforemen
words. Supplementary manual research was also tioned include11 (i) patient comfort during provisionaliza
conducted. tion, less need for anesthesia at the cementation
Peer-reviewed articles, articles written in English, and appointment, and reduced post-cementation sensitivity;
articles regarding the IDS technique in human, permanent (ii) increased bond strength and retention, especially for
teeth were the inclusion criteria. Articles not written in tapered teeth with short clinical crowns and minimum
English, duplicates, and articles not focusing on aspects of removal of tooth tissue;17 (iii) independent treatment and
the IDS technique or in vitro studies including primary or conditioning of dentin and enamel that maximizes the
bovine teeth were excluded from further evaluation. overall performance of both tissues according to their
The search identified 26.222 articles. After a gradual individual characteristics.
screening of titles, abstracts, and full texts, all articles were According to Magne,9,18 the first step of IDS is to
evaluated independently by two reviewers (T.S. and D.P.) distinguish dentin from enamel. For this purpose, a pre
for their appropriateness. Discrepancies between the two liminary etching of 2–3 s is undertaken at the whole tooth
reviewers were discussed until consensus was reached. surface. After thorough rinsing, enamel acquires a “frosty”
appearance, whereas dentin is more “glossy”. Then, using
Results a diamond bur (in etch-and-rinse systems) or a carbide
After exclusion of irrelevant or duplicated articles, 88 tungsten bur (in self-etch systems), a fresh layer of dentin
articles were included in this review. Information regard is exposed, over which a thick layer of a DBA is applied
ing the type of study, study design, and main findings are and light-polymerized according to manufacturer instruc
depicted in Table 1. For better understanding and segmen tions. In the case of unfilled adhesive, a supplementary
tation of the available literature, we divided the articles layer of flowable resin is recommended or alternatively, a
and presented the information in accordance with the regular composite to correct geometry, eliminate under
chronological steps of the technique and corresponding cuts, or elevate the preparation. After that, the DBA is
clinical appointments (Figure 1). polymerized additionally through glycerin gel (air-block
Each section of this manuscript answers a crucial ques ing) to reduce the oxygen-inhibition layer (OIL) and rinsed
tion regarding the treatment approach as well as the tech with air/water spray. To remove excess adhesive, enamel
nical details of IDS application. First, the rationale margins may need to be corrected with a diamond bur.
supporting selection of the technique is analyzed. Before the impression procedure with elastomeric
Moreover, we cite all available evidence for the most materials, the tooth preparation is pumiced softly with
234 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Table 1 Characteristics of Articles Included in the Present Review in Publication Order

Authors and Type of Tested Study Design Main Findings
Year of Study Parameters
Publication
Pashley et al 19926 In vitro Dentin permeability Tested the sealing ability of 6 DBAs (Prisma Application of a DBA seems a simple
Universal Bond 2, Scotchbond 2, Superbond procedure to protect the pulp from

C&B, Amalgam Bond, Gluma, Clearfil microleakage.
PhotoBond) in crown preparations.
12
Paul et al 1997 Case report Technique - -
presentation
Nikaido et al In vitro Bond strength Compared μTBS of a single-step DBA RZ-II proved to be a useful resin
2003136 (RZ-II) in direct and indirect use. coating material for crown
preparation.
Jayasooriya et al In vitro Βond strength Evaluated the effect of a DBA (Clearfil SE Addition of an LVR significantly
200331 Bond/Single Bond) with/without an LVR improved μTBS in indirect restorations
(Protect liner F) on μTBS of a resin but direct restorations performed
cement (Panavia F) to dentin in indirect better.
composite restorations and compared it
with direct restorations.
Magne et al 20059 In vitro Βond strength Compared IDS and DDS techniques IDS had a superior μTBS compared
using a three-step etch-and-rinse DBA with that of DDS, and reached that
(Optibond FL). obtained using a direct restoration.
Magne 200511 Review – Presented the technical details and IDS improved the bond strength,
clinical advantages of IDS. reduced bacterial infiltration and
hypersensitivity, and has a positive
impact on preservation of dental
tissues, patient comfort, and
restoration survival.
Stavridakis et al In vitro DBA thickness Investigated the thickness of two three- Film thickness was dependent on the
200556 step-total-etch DBAs (Optibond FL, material and location.
Syntac Classic) and the effect of two
conditioning methods (APA with
aluminum oxide, prophy paste with a
rotary brush) on it.
Islam et al 2006117 In vitro Bond strength Evaluated μTBS of a resin cement Hybrid Bond significantly improved
(Chemiace II) to resin-coated dentin μTBS of Chemiace II to dentin in
using a single-step coating material indirect composite crowns.
(Hybrid Bond) on teeth prepared for
indirect composite crowns.
Maruoka et al In vitro Microleakage Evaluated coronal leakage of Both coatings reduced dye penetration
200696 endodontically treated incisors sealed with but Clearfil SE Bond + Protect Liner F
Clearfil SE Bond + Protect Liner F or RZII. eliminated it completely.
Frankenberger In vitro Bond strength Evaluated μTBS of class-I composite Dentin contamination with interim
et al 200746 inlays luted with different adhesives (XP cement negatively influenced the bond
Bond/Syntac/Optibond FL), temporary quality. IDS increased the internal bond
cements, cleaning methods (scaler, air strength of all adhesives tested.
polishing with Prophypearls/ClinPro
powder) and curing modes.
(Continued)
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Table 1 (Continued).

Publication
De Andrade et al In vitro Marginal adaptation/ Evaluated marginal adaptation and bond Previous sealing of dentin with a DBA,
200798 bond strength strength of composite indirect followed by a second application just
restorations bonded with dual-cure resin before the cementation, is an effective
cement (RelyX ARC) after sealing dentin technique for maintaining marginal
with a DBA (Sigle Bond) associated or adaptation and bond strength.
not with an LVR (Protect Liner F)
Magne et al 200719 In vitro Βond strength Tested μTBS after IDS application No influence upon bond strength by
(Optibond FL/SE Bond) at 2, 7 and 12 ≤12 weeks of elapsed time before
weeks of delay until restoration definitive restoration placement.
placement.
Udo et al 200732 In vitro Βond strength Tested the μTBS of different combinations Use of materials with high ultimate
of sealing materials (Clearfil SE Bond + tensile strength in the resin coating and
Protect Liner F/Clearfil Flow FX) and resin cementation led to enhanced bond
cements (Panavia F2.0, Clearfil DC Core strength between them.
Automix).
Okuda et al In vitro Βond strength Evaluated the effect of a DBA (Clearfil Addition of an LVR improved the bond
200767 Protect Bond) with/without an LVR strength but direct restorations
(Protect Liner F) on μTBS in indirect continued to perform better.
composite restorations and compared it
with direct restorations.
Ariyoshi et al In vitro Bond strength Evaluated the effect of resin coating Resin coating enhanced the dentin bond
200868 (Clearfil SE Bond/Clearfil SE Bond+ strength of indirect composite cores to
Clearfil Flow FX) on μTBS of composite pulpal floor dentin and Clearfil SE Bond+
cores to pulpal floor dentin. Clearfil Flow FX group exhibited the
highest μTBS values.
Santoz-Daroz et al In vitro Bond strength Investigated μTBS of a resin cement The bond strength of the resin cement
200866 (Panavia F) to dentin after application of to dentin was enhanced if an LVR was
seven DBAs (AdheSE, Clearfil Protect applied over the DBA.
Bond, One-Up Bond F, Single Bond, Tyrian
SPE/One-step Plus, Xeno III, Unifil Bond)
with/without an LVR (Protect Liner F).
Schenke et al In vitro Marginal integrity Investigated the marginal integrity of Among IDS and DDS groups, the
200897 partial ceramic crowns bonded using IDS former yielded better marginal
(Excite + Tetric Flow/Clearfil Se Bond + integrity. However, RelyX Unicem had
Protect Liner F/Syntac Classic + Tetric the lowest microleakage.
Flow) or DDS and compared the results
with marginal sealing provided by self-
adhesive cement (RelyX Unicem).
Terry et al 2009137 Review - Technique presentation -

3
Duarte et al 2009 In vitro Microleakage, Βond Compared the effect of total-etch Both DBAs favored IDS with regard to
strength (Adper Single Bond) and self-etch (Adper bond strength but did not influence
Prompt L-Pop) DBAs on bond strength microleakage.
and microleakage of an inlay composite
restoration.
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Dillenburg et al In vitro Βond strength, Evaluated different conditioning methods IDS could improve the bond strength if
200948 Conditioning (APA with aluminum oxide, 37% its surface was conditioned with APA
method phosphoric acid, combination of both) aluminum oxide + 37% phosphoric acid
applied on two-step etch-and-rinse DBAs and a second layer of DBA was applied
(Adper Single Bond 2, Prime&Bond NT) afterwards.
contaminated by interim cement.
Magne and In vitro Interaction with Investigated the interactions between Polyether was contraindicated for
Nielsen 200927 impression impression materials (Impregum soft, impression-taking. Polyvinylsiloxane was
materials Extrude) and DBAs (Optibond FL, recommended only after air-blocking
Clearfil SE Bond) used for IDS. and pumicing of the IDS surface.
Lee and Park In vitro Bond strength Evaluated the effect of IDS (AdheSE), A combination of the three variables
2009138 thinning of the DBA by air-blowing tested improved the bond strength.
before cementation, and light-curing the
DBA before cementation on the bond
strength of resin inlays.
Hu and Zhu Split-mouth Hypersensitivity Assessed the sensitivity perceived by 25 Post-cementation hypersensitivity was
2010103 clinical study male patients 1 week as well as 1, 6, 12 reduced significantly after IDS
and 24 months after cementation of a application.
three-unit fixed restoration.
Choi and Cho In vitro Βond strength Evaluated the differences in shear bond IDS with Clearfil SE Bond yielded
2010116 strength to dentin using IDS (Clearfil SE superior shear bond strength
Bond, Adapter Single Bond 2) compared compared with that obtained with
with DDS. DDS.
Magne et al In vitro Fatigue strength Evaluated the fatigue strength of There was no benefit of using fiber
2011139 compromised molars restored with reinforcement under molars with a
CAD/CAM composite resin inlays/onlays compromised cusp. Cusp-protecting
(Paradigm MZ100) with/without fiber- onlay was the best solution.
reinforced IDS (Ribbond)
Helvey 20117 Review – Evaluated the development of bonding Combining different bonding
materials and techniques. techniques led to IDS creation.
Kitayama et al In vitro Microleakage Investigated the effect of a DBA (Clearfil Resin coating reduced microleakage.
201195 Protect Bond) + LVR (Clearfil Majesty
Flow) and occlusal loading on
microleakage of a CAD/CAM ceramic
restoration cemented with resin cement
(Clearfil Esthetic Cement).
70
Magne et al 2011 In vitro Bond strength Evaluated the effect of different opaque An opaque resin for masking
resin applications (IDS alone-Optibond discolored resin reduced the bond
FL)/IDS + opaque/IDS mixed with strength.
opaque) on bond strength.
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Medina et al In vitro Marginal adaptation Evaluated the effect of different material The most appropriate resin coating
201299 combinations used in the resin coating combinations were the groups that
technique (Single Bond 2/Sigle Bond 2 used a liner.
+Scotch Bond Multi-Purpose/Sigle Bond
2+Filtek Flow/Scotch Bond Multi-
Purpose/Clearfil S3/Clearfil S3+Bond
Clearfil SE Bond/Clearfil S3+Protect
Liner F/Clearfil SE Bond+ Protect Liner
F) on the marginal adaptation of indirect
restorations with gingival margins in
enamel and cement.
Rocca et al Clinical - - Reinforcement of an endodontically

2012133 technique treated tooth by incorporating a fiber-
reinforced composite (FRC) layer into
the resin coating of the tooth
preparation, allows the use of FRCs in

combination with any kind of
restorative material for an adhesive
overlay/endocrown.
Sahin et al 20125 In vitro Dentin permeability Tested dentin permeability after IDS Only one-step self-etch G-Bond and
application with five DBAs (Single Bond two-step self-etch Clearfil Protect
2, Adper Prompt L-Pop, Clearfil Protect Bond provided more effective sealing
Bond, Clearfil S3 Bond, G-Bond) and a than the original smear layer.
dentin desensitizer (Gluma).
Schoenbaum et al Clinical Provisionalization - Provisionalization involving silicone and

201235 technique separating medium was efficacious for
≤6 weeks.
Sailer et al 201245 In vitro Βond strength Evaluated the effect of a dentin Resin sealing of dentin had a beneficial
desensitizer (Gluma) and three DBAs effect on the shear bond strength of
(Syntac, Clearfil SE Bond, ED Primer) on the self-adhesive resin cement tested.
the bond strength of dentin cemented
with a shelf-adhesive resin cement
(RelyX Unicem) and two conventional
resin cements (variolink II, Panavia 21).
Dalby et al 201273 In vitro Βond strength Investigated the effect of IDS with four IDS did not influence the shear bond
DBAs (Optibond FL, One Coat Bond, strength of the restoration luted with
Single Bond, Go!) on the shear bond RelyX Unicem.
strength of ceramic restorations luted
with a self-adhesive resin cement (RelyX
Unicem).
Bruzi et al 201330 In vitro Interaction with Investigated the interactions between Interactions were not observed if a
impression DBAs used for IDS (Optibond FL, liner was applied over the DBA.
materials Scotchbond Universal, Optibond XTR,
Filtek LS) and impression materials
(Express STD, Impregum F).
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Spohr et al 201357 In vitro Film thickness Evaluated the thickness of the material Film thickness was dependent upon
used for IDS (Clearfil SE Bond, Clearfil the position under the crown and may
SE Bond + Protect Liner F) on full-crown increase the fracture load of the
preparations and its influence on the restoration.
fracture load of the restorations.
Perugia et al Case report – Used IDS in indirect restorations of IDS protected the pulp from bacterial
2013140 dental fractures in children. infiltration and formed a hybrid layer
that had excellent adhesive properties.
Medina et al In vitro Nanoleakage Evaluated the nanoleakage patterns in The combination of a two-step self-
2014100 indirect composite restorations bonded etch DBA with an LVR presented a
to dentin using different combinations of superior behavior and revealed less
resin coating materials (Single Bond 2+ nanoleakage compared to the other
Scotch Bond Multi-Purpose/Single Bond groups.
2+ Filtek Flow/Clearfil S3/Clearfil S3
+Protect Liner/Clearfil SE Bond+ Protect

Liner), after thermal and load cycling.
18
Magne 2014 IAAD - - -
Working
Instructions
Ghiggi et al 201428 In vitro Interaction with Evaluated the interactions between the Application of glycerin jelly and alcohol
impression materials used for IDS (Clearfil SE Bond, prevented the interaction of Clearfil
materials Clearfil SE Bond + Protect Liner F) and CE Bond with Express XT and Protect
impression materials (Express XT, Liner F with Impregum; however, these
Impregum) as well as the effect of treatments could not completely
additional polymerization with glycerin prevent the interaction of Clearfil SE
jelly and treatment with alcohol. Bond with Impregum, or Protect Liner
F with Express XT.
Falkensammer In vitro Bond strength, Evaluated alterations in the bond Polishing and APA with aluminum
et al 201449 Conditioning strength after application of different oxide or glycine were efficient
method conditioning methods (polishing with conditioning methods. APA with
fluoride-free pumice paste, APA with aluminum oxide left significant surface
silicoated aluminum oxide, glycine or alterations. Calcium carbonate was
calcium carbonate). contraindicated.
Oliveira et al In vitro Cuspal deflection, Investigated the effect of IDS (Clearfil SE IDS did not affect fracture resistance.
2014119 Fracture resistance Bond/Clearfil SE Bond + Protect Liner F) IDS with Clearfil SE Bond alone
on the cuspal deflection and fracture provided cuspal deflection similar to that
resistance of teeth with composite resin in a sound tooth. LVR addition did not
inlays. reduce the cuspal deflection further.
Özcan 201555 In vitro Bond strength Investigated the effect of mechanical and Provisional cement remnants on the
air-particle cleansing protocols (APA with IDS surface could best be removed by
50μm at 2, 3.5 bar/30μm at 2, 3.5 bar/ cleansing methods using air-abrasion
prophylaxy paste/pumice-water slurry at for a short duration of 5 sec.
1500 rpm for 15 sec) of provisional
cement on IDS surface.
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Rocca et al Review - - IDS is a crucial step of the indirect

2015141 restoration fabrication procedure.
Giannini et al In vitro Bond strength, Evaluated the effect of IDS (Clearfil SE The increase in bond strength was
201574 Cement type Bond + Clearfil Majesty Flow) on the dependent upon the resin cement
dentin bond strength of five resin type. IDS improved the bond strength
cements (RelyX Unicem, RelyX Unicem of Panavia 2.0, RelyX Unicem, RelyX
2, Clearfil SA Cement, G-Cem, Panavia Unicem 2, but did not influence
F2.0). Clearfil SA Cement or G-Cem.
Leesungbok et al In vitro Bond strength Tested the effect of IDS (All Bond II) on Ceramic restorations should be
201589 bond strength of ceramic restorations bonded within 1 week after IDS.
under various thermocycling periods (1,
2, 7, and 14 days).
Nawarek et al Review – Described the sealing ability of DBAs Two-step self-etch and three-step
201520 used for IDS. total-etch adhesives sealed dentin very
well.
van der Breemer Systematic – Evaluated the available literature There were no clinical studies
et al 201582 review concerning the cementation of glass– regarding IDS. Possible benefits mainly
ceramic restorations with an additional concern favorable μTBS values.
focus on IDS.
De Rose et al In vitro Internal adaptation Evaluated the effect of immediate Immediate endodontic sealing
2015101 endodontic sealing (Clearfil SE Bond + significantly improved internal
Majesty Flow/Majesty Posterior) and the adaptation compared with that using
composite viscosity on internal delayed endodontic sealing, and
adaptation of the final restoration. composite viscosity did not affect
internal adaptation.
Nikaido et al Review - - The resin coating technique can

2015142 minimize pulp irritation, improve the
bond strength between a resin cement
and tooth, and enhance interfacial
adaptation of the restorations.
Goldeberg et al In vitro Fatigue resistance Evaluated the accelerated fatigue Light-polymerizing luting composites in
2016143 resistance of thick CAD/CAM composite combination with IDS are not
resin overlays luted with three different contraindicated with thick
bonding methods (IDS Optibond FL+ restorations.
luting cement Herculite XRV/IDS
Optibond FL luting cement Nexus 3/
direct luting with Optibond FL+Nexus 3)
Da Silva et al In Vitro Bond Strength Compared the effect of a resin-based Adhesion to dentin was negatively
201634 provisional material (Clip F) on μTBS to influenced in the IDS procedure when
human dentin developed using DDS and a resin-based provisional material was
IDS. applied. Isolation with a water-soluble
gel was recommended.
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Gresnigt et al In vitro Fracture strength Investigated the effect of DDS and IDS When laminate veneers were bonded
201686 (Optibond FL) on the fracture strength to a large dentin substrate, IDS
of lithium-disilicate laminate veneers. improved the adhesion and, therefore,
the fracture strength.
Santana et al In vitro Βond strength Investigated the effect of simulated pulpal Regardless of the simulated pulpal
201675 pressure and IDS (Clearfil SE Bond) on pressure, IDS increased the bond
μTBS of indirect composite restorations strength of Panavia F, Clearfil SA Luting
luted with four resin cements (RelyX and RelyX Unicem, but did not
Unicem, Clearfil SA Luting, RelyX ARC, influence RelyX ARC.
Panavia F).
Qanungo et al Review – Reviewed the available literature IDS was recommended for indirect
2016144 concerning IDS between 1990 and 2014. bonded restorations.
El-Damanhoury In vitro Fracture resistance Investigated the effect of IDS (Syntac) IDS did not improve the fracture
and and optical powder removal on the resistance of premolar endocrowns.
Gaintantzopoulou fracture resistance of premolar

201683 endocrowns.
Belleflamme et al Retrospective - Evaluated documented cases of The study supported the use of IDS
201784 clinical study endocrowns performed using IDS. which contributed to the high success
rate in terms of debonding (2%).
Lima et al 2017145 In vitro Bond strength Assessed the bond strength of a resin Provitemp temporary cement sealing
cement (RelyX ARC) when IDS (Adper increased microshear bond strength of
Scotchbond Multi-Purpose) was the resin cement on dentin treated
contaminated by different temporary with IDS. Residues of Provy and
cements (Provy/RelyX Temp NE/ Provitemp were observed on the
Provitemp). sealed dentin.
Leite et al 201710 Case Report - - The incorporation of IDS in indirect

restorations provided better marginal
fit, reduced marginal infiltration and
postoperative Sensitivity.
Brigagao et al In vitro Bond strength, Evaluated the effect of IDS (Scotchbond Immediate application of a DBA before
201744 Interim cement Universal) and interim cement on the interim cement promoted the highest
bond strength of a conventional (RelyX bond strength for both resin cements
ARC) and a self-adhesive (RelyX U200) tested.
resin cement.
Ishii et al 201778 In vitro Βond strength Investigated the bonding state of metal- IDS improved the bond reliability of
free CAD/CAM onlay restorations metal-free CAD/CAM onlay
fabricated by two resin blocks (Lava restorations.
Ultimate, VITA ENAMIC) and one glass–
ceramic block (VITABLOCS Mark II)
after loading, with/without IDS
(Scotchbond Universal + Filtek Supreme
Ultra Flowable Restorative).
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van der Breemer In vitro Fracture strength Investigated the effect of IDS (Clearfil SE IDS significantly improved the fracture
et al 201779 Bond + Tetric Evoflow) on the fracture resistance of lithium disilicate but not
strength of two indirect restorative that of a multi-phase resin composite.
materials (Lithium disilicate: IPS e.max,
multi-phase resin composite: Lava
Ultimate).
Yazigi et al 201777 In vitro Fracture strength Investigated the effect of IDS (total-etch/ Selective etching of enamel was as
selective-etch) on the fracture strength efficacious as total-etching. IDS was
of CAD/CAM occlusal veneers. recommended if dentin was exposed.
Nikaido et al Review - - Coating materials have the potential to

201817 reinforce sound tooth,leading to the
maximum preservation of tooth
structures.
Augusti et al In vitro Bond strength Investigated the influence of different IDS protected freshly-cut dentin from
201847 cleaning techniques (Hand-scaler/ the adverse effects of temporary

Alumina air-abrasion/Glycine powder air- materials. Glycine air-abrasion was
abrasion/D-Limonene chemical solvent) suggested when a temporary resin
upon microshear bond strength of a cement is adopted.
composite resin cement (Nexus
Universal adhesive luting cement) to a
pre-hybridized dentinal substrate
(Optibond FL) exposed to two different
temporary materials (TempBond NE/
TempBond Clear)
Ferreira-Filho et al In vitro Bond strength Evaluated the immediate and 3-month After 7 days, IDS groups yielded higher
201821 water-storage behavior of four DBAs μTBS than that of the control group
(Xeno V, Clearfil SE Bond, XP Bond, (without IDS), except for XP Bond and
Optibond FL) used for IDS. Clearfil SE Bond. After 3 months, IDS
groups did not differ significantly from
control group.
Hironaka et al In vitro Bond strength, Investigated the effect of IDS (Clearfil SE IDS provided higher μTBS values,
201839 Interim cement Bond+ Protect Liner F) and interim whereas the interim cement did not
cement (Temp Bond NE) on the bond interfere with bond quality if IDS was
strength of indirect restorations luted with applied.
a dual-cure resin cement (Panavia F 2.0).
Murata et al In vitro Bond strength Evaluated the effect of different IDS IDS improved μTBS as well as the
201860 applications (thin layer/slope-shaped/base- bonding reliability and durability of the
shaped) on the bond strength of CAD/ restorations tested. The slope-shaped
CAM ceramic inlays subjected to loading. group yielded the highest performance.
Redoul et al In vitro Bond strength Evaluated the bond strength of glass– Panavia V5 + IDS yielded the best
201881 ceramic overlays luted using different resistance to shear forces. IDS
bonding techniques (Panavia V5 + IDS- increased the bond strength.
Optibond FL/Panavia V5 without IDS/
Heated composite + IDS).
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Publication
Fouda 2019146 Randomized Hypersensitivity Compared IDS and DDS effect on Inter-operative and post-cementation
Control Hypersensitivity of teeth prepared for hypersensitivity reduced by using the
Clinical Trial indirect composite restorations using IDS protocol with a self-etch adhesive.
Visual Analog Scale.
Anzlovar et al In vitro Bond strength Evaluated the influence of chemical and Concentration of free radicals at the
201954 physical processes at the resin-composite surface of the resin composite is only
and composite-cement interface on the relevant immediately after the
bond strength between these two polymerisation to the bond strength
components. between the resin composite and the
composite cement.
Khakiani et al Ex vivo Interaction with Evaluated the interactions between IDS Air-blocking and pumicing should be
201929 impression (Adper Single Bond 2/Clearfil SE Bond) applied with silicone impressions.
materials and two impression materials (Aquasil/ Polyether was not recommended with
Impregum Soft) after air-blocking alone IDS.
or combined with pumicing.
Sinjari et al 201933 In vitro Interaction with Evaluated the interactions between two Regardless of the impression material
impression impression materials (Extrude medium/ used, complete elimination of any
materials Impregum Penta) and IDS (Optibond FL). interaction was observed in the prophy
Specimens subjected to two cleaning paste + Marseille-soap group.
protocols before impression-taking
(prophy paste/prophy paste + Marseille
soap).
Hayashi et al In vitro Βond strength Investigated the effect of IDS (Clearfil IDS increased the bond strength,
2019147 Universal Bond + Clearfil Majesty ES whereas temporary restoration did
Flow) and temporary restoration not affect it at all. IDS without a
materials (Protemp4 Temporization temporary restoration yielded the
material, TempBond NE) on the bond maximum bond reliability.
strength of CAD/CAM ceramic crowns
after loading.
van der Breemer In vitro Βond strength Evaluated the effect of different IDS Dentin exposure during clinical
et al 201950 combinations (one layer-Optibond FL, procedures for indirect restorations
two layers-Optibond FL, one layer- benefited from IDS application, which
Optibond FL + LVR- Grand IO Flow) and was shown to result in higher bond
conditioning methods (pumice rubbing/ strength. Significant differences were
pumice rubbing + tribochemical-silica not found between cleaning with
coating) at two water-storage times (1 pumice alone or pumice followed by
week/6 months). tribochemical-silica coating.
van der Breemer In vitro Βond strength Evaluated the effect of two DBAs Regardless of the combination, IDS
et al 201951 (Clearfil SE Bond/Optibond FL) used for improved the bond strength compared
three IDS combinations (one layer/two with DDS. Significant differences
layers/one layer + LVR) and two surface- among the conditioning methods
conditioning methods (pumice/pumice + tested were not observed.
silica coating) on the bond strength of a
resin cement (Variolink II) to dentin.
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van der Breemer Randomized Survival, success Investigated the survival, success rate, and Ceramic restorations with IDS did not
et al 2019148 clinical trial rate, and quality of quality of survival of partial ceramic yield differences in the success rate or
survival of partial restorations (IPS e.max) in vital molars survival rate after 3 years of function.
ceramic bonded using IDS (Clearfil SE Bond +
restorations Clearfil Majesty Flow) after 3 years of
function.
Rigos et al 201980 In vitro Βond strength Evaluated the bond strength of Bonding strategies for monolithic
pretreated monolithic zirconia bonded zirconia restorations could potentially
to dentin using IDS (Optibond FL) and benefit from IDS regardless of the
two self-adhesive resin cements adhesive luting agent system used.
(Panavia F2.0/Permacem Dual
Smartmix).
Gresnigt et al Prospective Survival, success Evaluated the survival, success rate, IDS significantly benefited teeth with
201987 clinical trial rate, patient and satisfaction regarding laminate >50% of dentin exposure.
satisfaction veneers received by 104 patients, in

which IDS was done, after 11 years of
function.
van der Breemer Prospective Tooth sensitivity, Investigated tooth sensitivity and patient IDS was not superior with regard to
et al 2019102 randomized patient satisfaction satisfaction regarding partial ceramic tooth sensitivity or patient satisfaction
clinical trial restorations in 30 patients, bonded using after 1 year of function.
IDS (Clearfil SE Bond + Clearfil Majesty
Flow).
Akehashi et al In vitro Βond strength Investigated the bond strength provided μTBS values of the combination
201969 by different combinations of resin Clearfil SE Bond2 + Panavia V5 and
materials used for IDS (Clearfil SE Bond cementation with Panavia F2.0 were
2 + Protect Liner F/Clearfil Majesty LV/ identical with those of a direct
Panavia V5) in indirect composite composite restoration.
restorations luted with a dual-cure resin
cement (Panavia V5/Panavia F2.0).
Rozan et al In vitro Bond strength and Assessed the effect of the resin- Resin coating did not influence the
2020149 Internal adaptation coating technique (G-Premio Bond/ bond strength of RelyX Ultimate,
Clearfil SE Bond 2+Clearfil Majesty ES whereas resin coating increased the
Flow) on bond strength and internal bond strength of G-CEM LinkForce
adaptation of CAD/CAM inlays luted and Panavia V5.
with different resin cements
(PelyX Ultimate/G-CEM LinkForce/
Panavia V5).
Cesca et al In vitro Tensile load Compared direct/indirect resin IDS group yielded significantly higher
2020150 composite copings for perio- tensile load.
overdentures, luted using DDS or IDS
(Syntac+ Variolink II/Tetric Ceram).
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Sag and Bektas In vitro Bond strength Compared bond strength of different IDS improved bond strength of
2020118 resin cements (RelyX Unicem/RelyX indirect restorations.
Ultimate Clicker) on an indirect
composite (Solidex) and a resin
nanoceramic CAD/CAM block (Lava
Ultimate) with or without IDS (Clearfil
SE Bond+ Filtek Ultimate).
Ashy et al 20208 In vitro Marginal adaptation Investigated marginal adaptation and Luted ceramic inlays had a superior
and internal internal adaptation of ceramic inlay marginal adaptation immediately after
adaptation restorations bonded using IDS (All-Bond cementation and a superior internal
Universal) or DDS. adaptation after thermocycling if using
IDS compared with using DDS.
However, marginal adaptation after
thermocycling was not significantly
different between the two techniques.
Shafiei et al In vitro Fracture resistance Investigated the effect of dentin IDS with/without PA increased the
2020120 pretreatment with polyanthocyanidin fracture strength of premolars. The
(PA) combined with IDS (Futurabond) or combination of both reached the level
DDS on the fracture resistance of of a sound tooth.
premolar ceramic inlays luted with a self-
adhesive resin cement (BiFix SE)
Hofsteenge et al In vitro Aging and Fracture Evaluated the effect of aging, fracture IDS application and the preparation
202088 strength strength, failure mode, and repairability design influenced the fracture strength,
on lithium-disilicate inlays and onlays in respectively. IDS application did not
relation with IDS (Optibond FL) or DDS. interact with the effect of the
preparation design on fracture
strength.
van der Breemer Prospective Clinical Assessed the clinical performance of 765 Partial glass–ceramic posterior
et al 202176 clinical trial performance partial glass–ceramic posterior restorations treated with IDS had an
restorations (IPS e.max) luted with a excellent medium-term prognosis.
conventional photo-activated resin
composite in conjunction with IDS
(Clearfil SE Bond).
Abbreviations: DBA, dentin-bonding agent; LVR, low-viscosity resin; μTBS, microtensile bond strength; IDS, immediate dentin sealing; DDS, delayed dentin sealing; APA,
airborne particle abrasion.
a rubber cup for OIL reduction and, after that it is integrate the new materials simultaneously following
isolated with a separating medium (eg, petroleum manufacturer instructions.
jelly) to avoid locking of the interim restoration. With
regard to placement of the final restoration, the Type of Adhesive System
sealed surface must be air-abraded and the enamel In adhesive dentistry, there are always attempts to simplify
etched with phosphoric acid (H3PO4). Finally, the bonding steps to reduce “chair time” and make clinical
restoration is luted with a resin-based cement. procedures less technique-sensitive. However, a conven
However, materials and protocols are evolving con tional three-step total-etch DBA claimed to be the most
stantly, so the above-mentioned guidelines may devi reliable long-term option is recommended by Magne9 for
ate. The key element is to follow the basic steps and IDS. Scholars have reported19,20 that older three-step etch-

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Figure 1 Questions regarding each clinical step of the restorative protocol containing the IDS technique and determination of the sections discussed in this review.
Abbreviations: IDS, immediate dentin sealing; DDS, delayed dentin sealing.
and-rinse systems and two-step self-etch systems are materials (two-step self-etch Clearfil Protect Bond; all-in-
superior to single-step systems with regard to durability, one self-etch adhesive Adper Prompt L-Pop; one-compo
aging, and bond strength. Furthermore, older adhesives nent self-etch adhesives Clearfil S3 Bond and G-Bond;
form a more hydrophobic resin coating, which is desirable etch-and-rinse adhesive Single Bond 2; one dentin desen
for IDS efficacy.19 Single-step self-etching adhesives have sitizer Gluma). They reported that none of the adhesives
been accused of being susceptible to degradation if water examined achieved hermetic dentin sealing. However,
stored because of the increased hydrophilicity of their G-Bond and Clearfil Protect Bond managed more effica
interface.21 It has also been suggested that, for vital teeth cious sealing than the original smear layer. The results of
with positive pulpal pressure, the penetration of dentinal that study are in agreement with data from another study23
fluid through polymerized adhesive layers may deteriorate demonstrating that Clearfil Protect Bond had the lowest
hermetic dentin sealing if simplified adhesive systems are fluid permeability, followed by G-Bond (which manifested
employed.5 lower but statistically similar permeability with that using
Duarte et al3 revealed that both total-etch adhesives Clearfil S3 Bond).
and self-etch adhesives favored IDS achieving a signifi Although a few studies have compared the efficacy of
cantly higher bond strength than that using the conven different DBAs used for IDS, conventional systems (three-
tional approach (without IDS). Conversely, Ferreira-Filho step-total-etch, two-step-self-etch) are recommended
et al,21 in an attempt to investigate the behavior of four because their clinical efficacy has been substantiated by
adhesive systems (one-step self-etch Xeno V; two-step many studies in recent decades. Adherence to manufac
self-etch Clearfil SE Bond; two-step etch-and-rinse XP turer instructions is of the utmost importance.
Bond; three-step etch-and-rinse Optibond FL), found no
differences in microtensile bond strength among the adhe Interaction with Impression Materials
sives tested and the control group (without IDS) after 3 Several issues arise regarding the contamination of a resin
months of water storage. coating surface by elastomeric impression materials. If
It is clear that the adhesive system applied influences light-cured, DBAs present a superficial OIL.25 The thick
the permeability of sealed dentin, not to mention that there ness of the OIL is ~40 μm and can inhibit the polymeriza
are adhesives reported to be less effective than the original tion of elastomeric impression materials.25,26 Magne and
smear layer.22–24 Sahin et al5 attempted to identify the Nielsen27 demonstrated a substantial layer of unpolymer
hydraulic conductance of dentin after application of five ized resin in specimens in which IDS had been applied

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without further surface treatment, regardless of the type of concluded that both methods were equally efficient in
DBA or impression material used. This, in turn, led to preventing interaction with impression materials.
defective impressions. Those findings are in agreement Sinjari et al,33 in an attempt to identify a safe protocol
with data from Ghiggi et al,28 who observed diverse inter for clinical surfaces, evaluated the application of prophy
action types among resin materials and impression materi paste treatment (surface carefully cleaned with a hand
als: silicone showed incomplete polymerization and piece, coping brush, and prophy paste at 500 rpm under
polyether, although polymerized, attempted to adhere to a water spray for 15 s) and of a surfactant agent (Marseille
the resin present on the surface. It is speculated that the soap) on the IDS surface before impression-taking with
chemical composition of vinylpolysiloxane and polyethers silicone and polyether. The researchers demonstrated a
accounts for their different interactions with resin reduction of residues in prophy groups and their total
materials.28 Specifically, for vinyl polysiloxane, the mono disappearance in prophy + Marseille-soap groups for the
mers present in the OIL may react with the platinum salt two impression materials tested.
(the catalyst in the polymerization reaction). As a result, a Given that OIL elimination is the key factor for a
small portion of the light impression material remains defect-free impression, researchers have focused attention
unpolymerized over the resin materials. For polyethers, on double polymerization of the DBA with glycerin gel
and the several cleaning protocols suggested in literature.
the initiator agent is cation that can react with the free
Even if polyether as an impression material is disapproved
radicals of monomers from the surface of resin materials
by most authors, the protocol of Sinjari et al (prophy paste
(ionic polymerization). Furthermore, the hydrophilicity of
+ Marseille soap) offers cautious optimism regarding the

polyethers, their higher stiffness, and their lower resistance
choice of impression material.
to tear in comparison with those of vinyl polysiloxane
favors superficial adhesion to the resin surface, and so
Interaction with Provisional Materials
defective impressions emerge. The hydrophilic monomer
With regard to the choice of interim material and cement,
hydroxyethylmethacrylate, which is present in the adhe
resin-based ones should be avoided.9,34 Direct acrylic-
sive resin of some DBAs, has been also accused of causing
based provisional materials cannot seal preparations her
residual inhibition.27
metically, which results in contamination of the IDS sur
Based on the knowledge that reducing/eliminating the
face and loss of retention.35 Conversely, regardless of OIL
OIL would lead to the abovementioned issues being
removal, direct bis-acryl-based provisional materials and
resolved, several cleaning protocols after IDS application
resin-based interim cements bond strongly to the IDS
and before impression-taking have been suggested. Magne substrate.35 Hence, removal of the provisional material
and Nielsen27 advocated that the residues of impression proves to be demanding and sometimes it must be cut-
materials could be reduced with additional polymerization off the tooth, which jeopardizes the integrity of tooth
of the DBA with glycerin jelly (air-blocking) and pumicing preparation.35 Even after persistent mechanical cleaning
(gentle application of a pumice water mix with a soft and conditioning with 37% phosphoric acid, the presence
rubber prophy cup and slow-speed handpiece at 500 of interim-material residue on dentin has been identified in
rpm), but only with silicone impression materials. A poly studies using scanning electron microscopy36,37 and
ether was not recommended with IDS because of the high atomic force microscopy.38 This is the reason why
incidence of faulty impressions (unpolymerized impres Magne9 strongly recommends isolation of the tooth pre
sion material, adhesion, tearing). Those findings are in paration with a thick layer of a separating medium (petro
agreement with an in vitro study by Khakiani et al.29 leum jelly) during fabrication of the provisional material.
Bruzi et al30 suggested that covering the IDS layer with The presence of interim-material residues after clean
a liner (flowable/composite) resolves the issue of interac ing has been documented. The question is whether the
tion with impression materials. Coating the DBA with remaining residues affect the bond strength to such an
flowable resin enhances subsequent polymerization of the extent that makes bonding insufficient.39 Some
OIL in uncured adhesives thanks to the diffusion of free authors have reported a reduction in the bond strength
radicals from the flowable resin.31,32 of resin materials only after use of eugenol-containing
Ghiggi et al28 compared the air-blocking technique cements,40,41 whereas other scholars have not discrimi
with the use of a cotton pellet soaked in alcohol. They nated the type of interim cement.42 To counteract the

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drawbacks of eugenol (interaction with initiators, loss of conditioned with silica coating. Silica coating expands
retention, microleakage43), one could propose its repla the adhesive surface area via deposition of silica particles.
cement by carboxylic acids. Nevertheless, a considerable This action permits superior mechanical retention52 and
reduction in bond strength after adhesive cementation cleans the surface, thereby enabling chemical co-polymer
has also been observed with non-eugenol formulations.13 ization of the resin-based cement with IDS.50 With regard
It has been demonstrated that if IDS is applied, regard to sandblasting with alumina, loss of filling particles is
less of the use of eugenol-containing or eugenol-free likely49 as is a reduction of the resin-to-resin bond
provisional luting agents,43 interim materials do not strength.51,53 Although as outlined above there are con
influence the adhesion quality of resin cements.39,43–46 flicting results, contrary to pumicing with a rotary brush,
Schoenbaum et al35 suggested the “reverse spot bond access to difficult parts of the preparation achieved by
ing technique” for provisional cementation. This technique sandblasting is desirable.
relies on the bonding of the provisional material in only a There is an array of conditioning methods/materials,
small area of the IDS-prepared tooth, away from the and further investigation on their potential influence on the
margins. This serves efficient cleaning of the surface at IDS surface is required. However, it seems that methods
the cementation appointment. A small portion of fast-set ensuring physical removal of a few micrometers (such as
ting condensation silicone is placed in the middle of the APA) from the resin surface which is in contact with oral
preparation, covering 2–3 mm of the sealed surface. Then, fluids should be implemented54 at limited application dura
a separating medium is applied on the entire surface of the tion since it enhances diffusion of resin cements.55 After
preparation. The silicone increment is removed to leave a cleansing, dentin surface needs to be reactivated by adhe
small active bonding area while the remaining portion of sive resin.55
the sealed surface does not bond to the bis-acryl material
thanks to the presence of the separating film.
Interim restoration should protect the underlying tooth Film Thickness
surface and not endanger the integrity of the preparation The risk of re-exposure of dentin after conditioning is
after its removal. Application of a separating medium substantive, and is dependent not only on the conditioning
combined with spot bonding seems to serve the above- method but also on the thickness of the IDS film.56 Film
mentioned requirements. Moreover, resin-based temporary thickness is dependent on the product and its location on
cements should be avoided,47 unless isolation using a the tooth (greater in concave areas than in convex areas).56
water-soluble gel has been applied beforehand.34 The higher film thickness in concave areas is attributed to
the tendency of the adhesive to “pool” at the inner angles
Conditioning Methods of the preparation. Low thickness in the border of the
A contaminant-free substrate is a necessity for optimum preparation is desirable because a high one would expose
bonding. Therefore, selection of the appropriate condition the adhesive to the oral cavity, with subsequent
ing method is of utmost importance. Magne et al9 degradation.57
employed air-borne particle abrasion (APA) with alumi Stavridakis et al56 suggested the use of a filled DBA to
num oxide, whereas Dillenburg et al48 demonstrated that prevent dentin re-exposure after conditioning. Hashimoto
additional etching with phosphoric acid had a positive et al58 observed an increase in the bond strength after
impact on conditioning sealed dentin. In another study,49 application of multiple layers of adhesive (≤4 layers),
polishing with fluoride-free pumice paste and APA with whereas Ito et al59 concluded that the separate polymer
silicoated aluminum oxide or glycin proved to be equally ization of each layer improved the quality of dentin adhe
efficient methods, whereas APA with calcium carbonate sion. The IDS layer has been found to affect cement
was contraindicated due to its higher roughness along with thickness.60 A thicker IDS film contributes to better dis
the lower bond strength following its application. van den tribution of stress, yields a superior bond strength, and
Breemer et al50,51 observed that neither cleaning with provides more stable bonding,50,60,61 whereas elimination
pumice nor pumicing with an additional tribochemical of undercuts becomes easier.51 However, if applying a
silica coating affected the bond strength. Although they multi-layering technique, one should pay attention to the
could not identify the optimum combination of IDS/con “ideal” thickness of the adhesive system used and follow
ditioning method, they suggested a thick IDS layer manufacturer instructions closely.62

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A supplementary layer of a low-viscosity resin (LVR) with conventional light-cured composites, as indicated by
over the DBA is recommended,57 especially if unfilled the excellent medium-term prognosis of partial ceramic
DBAs are used.11 Free radicals from the LVR interact restorations in a recent clinical study.76
with the uncured resin or the acidic monomers from the IDS has been demonstrated to improve the bond
OIL63 to improve the polymerization of the adhesive strength of resin cements (conventional or self-adhesive).
system.31 Moreover, an LVR reduces the permeability of Conventional resin cements are recommended in the lit
adhesives and improves coupling with the resin cement.64 erature for their superior properties with regard to bond
Even if resin–dentin interfaces degrade over time, an LVR strength, bond-degradation behavior, susceptibility to aqu
protects the underlying hybrid layer and preserves the eous aging, and water absorption.
integrity of the dentin seal.65 An LVR can act as an
“absorbing cushion” of the contraction stress generated
Interaction with Preparation Design
during resin cement polymerization and, thus, modify the
The survival rate of minimally invasive restorations is
failure pattern63,66 (the formation of a resistant hybridiza
influenced by the preparation design, restoration thickness
tion process contributes to the preservation of the bonded
and geometry, restorative material, occlusal loading, and
interface area if a fracture occurs). Hence, an improved
bonding procedures.77 Several studies77–82 investigating
bond strength has been recorded when adding an
different types of restorations and restorative materials
LVR31,67,68 although it seems that selection of the LVR
have shown that IDS enhances the bond strength, fracture
type can affect the performance of the restoration.69 In
resistance, and bond reliability of the restorations tested.
general, the use of materials with high ultimate strength

With regard to endocrowns, El-Damanhoury and
for cementation and coating is recommended.32 In the case
Gaintantzopoulou83 showed that IDS does not improve
of discolored dentin, application of an opaque resin over
their fracture resistance. However, a clinical study demon
the DBA reduces the bond strength likely due to the
strated the high success rate of endocrowns in terms of
limited mechanical properties of the liner.70 If masking is
debonding when IDS is applied.84 The survival rate of
needed, use of a separate layer of opaque resin is preferred
laminate veneers decreases if bonded to dentin.85 In the
to mixing with the DBA.70
case of limited dentin exposure (less than one-quarter of
A thick IDS layer is crucial to prevent dentin re-expo
the bonding surface), IDS has no influence on them.86
sure after conditioning. Addition of an LVR provides an
However, with >50% of dentin exposure, laminate veneers
array of advantages and so its application is imperative in
benefit significantly from IDS.87 In a recent study,
the case of unfilled DBAs.
Hofsteenge et al88 investigated the influence of IDS on
the fracture strength of different preparation designs
Interaction with Luting Cements
(inlays–overlays). Even though IDS in conjunction with
IDS manifests the highest retentive stress if combined with
an overlay preparation resulted in the highest fracture
resin cements. Thus, IDS is indicated in cases of a short
strength, the authors concluded that the IDS application
clinical crown height and high angle of convergence. IDS
did not interact with the effect of the preparation design on
provides efficient retention with glass ionomer cements as
fracture strength.
well, but under no circumstances should it be used with
zinc phosphate.71,72 Dalby et al73 found that IDS did not
affect the bond strength of the self-adhesive resin cement Time of Restoration Placement
RelyX Unicem. In a similar study74 that tested several With IDS, there is leeway in the dentin bond to develop in
self-adhesive resin cements, IDS was found to influence a stress-free environment and, thus, to be optimal.11
the bond strength of the resin cement depending on its type Magne19 advocates that IDS favors delayed restoration
(bond-strength values of Panavia F2.0, RelyX Unicem and placement for ≤12 weeks. Leesungbok et al89 investigated
RelyX Unicem2 were improved, but no effects were the influence of IDS on the dentin bond strength of a
reported for Clearfil SA Cement and G-Cem). It has been lithium-disilicate ceramic under various thermocycling
also demonstrated that even if simulated pulpal pressure periods (1, 2, 7 and 14 days). They identified a reduction
negatively affects the quality of resin–dentin interfaces, in bond strength after 1 week and a greater one (character
IDS increases the bond strength of self-adhesive and con ized by a larger area of detached cement and exposed
ventional resin cements.75 IDS also interacts well if luted dentin) after 2 weeks. Thus, the authors strongly

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recommend the final bonding to be within 1 week after movement through dentin tubules.21 Although dentin
IDS application. hypersensitivity usually resolves within 24 months,102 its
The IDS concept counts on the success of the bond persistence can overwhelm the patient and put the clini
between the resin coating and luting agent, which is simi cian’s reputation at risk. Hu and Zhu103 undertook a sen
lar to the one for resin-to-resin repair.19 Placement of a sitivity assessment 1 week as well as 1, 6, 12 and 24
provisional restoration for ≤2 weeks does not endanger the months after cementation of a three-unit full-coverage
resin-to-resin bond, and van den Waals interactions, and restoration on vital abutment teeth. They identified a sig
micro-mechanical interlocking can account for it.9,90,91 nificant improvement in patients to whom IDS was applied
However, to achieve this, the existing adhesive layer at 1 week and 1 month after cementation, whereas no
must be conditioned.9 Even if it is claimed that a delayed differences between IDS and DDS groups were found at
restoration placement is attainable when IDS is applied, the end of 6, 12 and 24 months. Conversely, van der
the final restoration should be delivered as soon as Breemer102 detected no difference among IDS and DDS,
possible. an anticipated result given the minimally invasive design
used for partial ceramic restorations in their study. Hence,
the amount of tooth tissue removed plays an important part
Microleakage/Adaptation of the Final
in the degree of postoperative sensitivity.104 A distance of
Restoration 0.5 mm from the pulp can cause a pulpal reaction in 60%
The adhesive layer–dentin interface constitutes the most
of cases, whereas a similar situation occurs in 5% of teeth
vulnerable part of the bonded restoration, so micro-leakage

in which >1 mm of dentin has been preserved.105
remains a major concern if a restoration is thermally and
Early sealing of dentin tubules provided by the IDS
occlusally stressed.3 There is a wide variation concerning
technique seems to reduce sensitivity during the provi
acceptable values for marginal discrepancy: they range from
sional phase and after cementation. This is a promising
20–40 μm to 160 μm.92–94 Duarte et al3 demonstrated that
strategy for enhancing comfort and treatment satisfaction.
even if IDS favored bond strength, micro-leakage was not
improved. Conversely, several studies have shown that if
Discussion
the DBA is combined with an LVR, a smaller gap formation
Systematic reviews showing a significant difference in
in the dentin–restoration interface is observed,31,95–99 even
terms of longevity between direct and indirect composite
if subjected to loading.95,100 A variant of IDS undertaken in
restorations are lacking.106,107 Nevertheless, indirect com
the access cavity of teeth subjected to endodontic treatment
posite restorations are recommended in the case of endo
(immediate endodontic sealing) has been shown to reduce
dontically treated teeth.108 Such restorations also
coronal leakage, which is the major cause of failure.101 In a
overcome the problems related to polymerization shrink
recent study, Ashy et al8 identified a better marginal adapta
age or inadequate curing, thereby providing better
tion immediately after cementation and a better internal
mechanical properties, occlusal morphology, and proximal
adaptation after thermocycling, when IDS was applied,
contacts.2,109 Although these restorations constitute a large
compared with that using the conventional method (DDS).
workload in everyday practice, clear protocols regarding
However, there was no significant difference in marginal
the handling of prepared tissues and materials used to
adaptation after thermocycling among the two techniques
obtain optimum results are lacking. We reviewed the lit
examined. Therefore, IDS seems to reduce microleakage,
erature to provide clinically oriented answers to questions
whereas a DBA combined with an LVR provides more
regarding crucial procedures related to each step of indir
predictable outcomes.
ect restorations, from the preparation appointment until
restoration delivery and maintenance.
Hypersensitivity Some types of indirect restorations interact entirely
During the provisional phase and after cementation of the with enamel,110 whereas others demand more aggressive
final restoration, it is common for the patient to experience preparation that inevitably leads to dentin exposure.111
an unpleasant symptom characterized by a short, sharp Knowledge of the anatomic and morphologic differences
pain upon thermal and chemical stimuli.102 Several factors between these two tissues is fundamental to handle them
can account for this effect: over-heating and dehydration appropriately. Enamel is mainly made of the mineral
during preparation, bacterial micro-leakage, or fluid hydroxyapatite (which is crystalline calcium phosphate)

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and it contains virtually no water.112 Dentin has a higher The literature recommends multiple coatings of a DBA
percentage of organic matter and is perforated by dentinal and additional application of an LVR in the case of an
tubules that contain odontoblasts and transmit thermal unfilled adhesive system.57–59 Hence, another issue that
stimuli, pressure, and pain.113 Pulp and dentin are embry requires further clarification is the impact of the thickness
ologically, histologically, and functionally identical tissue; of the DBA film on appropriate seating and marginal
this leads to the belief that they should not be studied as adaptation of the restoration. The above-mentioned thick
separate tissues but must be viewed as a pulp–dentin ness varies depending on the topography of the tooth
complex.114 Consequently, leaving dentin exposed is akin preparation,56,57 but it is captured with impression-taking
to an “open pathway” towards the pulp, which endangers and, therefore, the fit of the final restoration is not
tooth vitality because microorganisms can reach the pulp influenced.11 Addition of these coatings might raise con
tissue if it is not sealed adequately.102 This assumption is cerns regarding different material interfaces. However,
supported by the findings of Sailer et al,115 who found that composite resins have a modulus of elasticity that is
loss of vitality of an abutment tooth was the most frequent close to that of dental tissues,126 thereby eliminating the
biologic complication for metal–ceramic crowns. This risk of nonuniform stress distribution if there is a vast
finding supports the use of a technique that seals dentin difference between restorative materials.127 If a composite
hermetically. restoration instead of a ceramic restoration is chosen, this
One could claim that application of an adhesive at the risk is reduced further.
preparation appointment would diminish its bonding capa Another concern regarding IDS pertains to interaction
city at the final cementation appointment. However, stu with impression materials. However, this matter will prob
dies have shown that teeth on which DDS is carried out ably not concern future generations because intraoral scan
demonstrate inferior bond strength,31,67,68,82,86,116–118 ning technologies have yielded results that are equal (or
whereas IDS favors delayed restoration placement19 and even superior) to those of conventional impression
provides bond strength and cuspal deflection similar to that techniques.128 Currently, this technology is indicated in
observed in direct composite-restored teeth.9,69,119,120 short-span restorations and represents a challenge regard
Direct restorations yield higher bond strength in compar ing edentulous arches.129
ison with that using indirect restorations,121 so techniques Complete elimination of the provisional material is
such as IDS that enhance the bonding capacity of indirect difficult. Hence, penetration of the adhesive monomers
procedures should be adopted. Moreover, IDS does not into dentin could prove to be inadequate.44 Occlusion of
increase the number of clinical appointments but is incor dentin tubules with interim materials has been identified,
porated in the necessary steps of an indirect restoration. as has a subsequent reaction of zinc-oxide remnants with
An aspect that should be clarified is the mechanism the acidic primer of some adhesive systems.130 Therefore,
that defines composite-to-composite bond. Although one the early sealing of dentin tubules with a DBA could
might assume that chemical bonding of free radicals is the prevent their obstruction by interim residues, as well as
main factor that determines the subsequent bond,122 other the inhibition of adhesion-system polymerization due to
mechanisms play a more crucial role. Concentration of eugenol diffusion from interim material into dentin.43
free radicals declines as the material ages and according Removal of the provisional restoration endangers the
to Anzlovar et al54 they play a minor role within 24 hours integrity of tooth preparation, so it should be done with
and they are completely eliminated after 2.5 days. caution.35 Techniques that pursue spot bonding of the
Mechanisms such as micromechanical interlocking and provisional material must evolve and be carried out for
interpretating network matrices (IPN) seem to play a an optimum result. Nevertheless, novel digital technology/
major role.91,123,124 For the latter to be formed, monomers protocols tend to eliminate the need for provisional
of the resin cement are diffused into the composite resin restorations. Silva et al131 proposed a technique in which
and polymerized, and it is the depth of this penetration that digital design and three-dimensional-printed guides pro
determines bond strength.91,124,125 Factors such as the vide the opportunity for cementing restorations immedi
increased polarity of the surface due to contact with ately after preparation completion.
water reduces the diffusion potential and this is why IDS is a substantiated technique mainly according to
implementation of methods that remove a few microns of many in vitro studies. Among the 88 studies included in
the composite layer should be applied.54 this review, 64 are vitro studies and only 12 are clinical

251
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sealing improves bond strength of indirect restorations. J Prosthet
(which are considered the “gold standard” for evaluation
Dent. 2005;94(6):511–519. doi:10.1016/j.prosdent.2005.10.010
of interventions132) are needed to further support the effi 10. Leite M, Lopes LG, de Souza D, Carvalho M. Immediate dentin
cacy of this technique and clarify certain aspects regarding sealing with self-etch dentin bonding agent for indirect restora
tion. World J Dent. 2017;8(6):490–495. doi:10.5005/jp-journals-
it. Moreover, implementation of novel materials and tech 10015-1492
niques should be tested. A technique has been described 11. Magne P. Immediate dentin sealing: a fundamental procedure for
where a fiber network has been incorporated in the indirect bonded restorations. J Esthet Restor Dent. 2005;17
(3):144–154; discussion 155. doi:10.1111/j.1708-8240.2005.
IDS.70,133 The rationale behind this choice is that in case tb00103.x
of a vertical crack, its propagation may be stopped by the 12. Paul SJ, Scharer P. The dual bonding technique: a modified
method to improve adhesive luting procedures. Int J
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Periodontics Restorative Dent. 1997;17(6):536–545.
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Disclosure a33324
19. Magne P, So WS, Cascione D. Immediate dentin sealing supports
The authors report no conflicts of interest in this work. delayed restoration placement. J Prosthet Dent. 2007;98(3):166–
174. doi:10.1016/S0022-3913(07)60052-3
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Immediate Dentin Sealing: A Literature Review

Clinical, Cosmetic and Investigational Dentistry 2021:13 233–256 233

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phase, which presents benefits with regard to bacterial

234 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Table 1 Characteristics of Articles Included in the Present Review in Publication Order

Universal Bond 2, Scotchbond 2, Superbond procedure to protect the pulp from

with direct restorations.

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Authors and Type of Tested Study Design Main Findings

Terry et al 2009137 Review - Technique presentation -

236 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Authors and Type of Tested Study Design Main Findings

strength of resin inlays.

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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Authors and Type of Tested Study Design Main Findings

Rocca et al Clinical - - Reinforcement of an endodontically

preparation, allows the use of FRCs in

Schoenbaum et al Clinical Provisionalization - Provisionalization involving silicone and

238 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Authors and Type of Tested Study Design Main Findings

+Protect Liner/Clearfil SE Bond+ Protect

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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Authors and Type of Tested Study Design Main Findings

Rocca et al Review - - IDS is a crucial step of the indirect

Nikaido et al Review - - The resin coating technique can

240 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Authors and Type of Tested Study Design Main Findings

Gaintantzopoulou fracture resistance of premolar

Leite et al 201710 Case Report - - The incorporation of IDS in indirect

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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Authors and Type of Tested Study Design Main Findings

Nikaido et al Review - - Coating materials have the potential to

201847 cleaning techniques (Hand-scaler/ the adverse effects of temporary

242 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Authors and Type of Tested Study Design Main Findings

or combined with pumicing.

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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Authors and Type of Tested Study Design Main Findings

satisfaction veneers received by 104 patients, in

244 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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Authors and Type of Tested Study Design Main Findings

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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246 https://doi.org/10.2147/CCIDE.S307939 Clinical, Cosmetic and Investigational Dentistry 2021:13

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+ Marseille soap) offers cautious optimism regarding the

Clinical, Cosmetic and Investigational Dentistry 2021:13 https://doi.org/10.2147/CCIDE.S307939

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