RESEARCH AND EDUCATION

Influence of different surface treatments and universal

adhesives on the repair of CAD-CAM composite resins: An
in vitro study
Soner Sismanoglu, DDS, PhD,a Zuhal Yildirim-Bilmez, DDS,b Aysegul Erten-Taysi, DDS, PhD,c and
Pınar Ercal, DDS, PhDd

As fractures are considered ABSTRACT

the major cause of direct
Statement of problem. The repairability of computer-aided design and computer-aided
restoration failure, the use of manufacturing (CAD-CAM) composite resins might be adversely affected by the high degree of
indirect techniques has been matrix polymerization that occurs during their manufacturing process. However, information on
recommended for large cor- their repairability is lacking.
onal defects involving one or
Purpose. The purpose of this in vitro study was to evaluate the microtensile bond strength of CAD-
more cusps and proximal CAM composite resins subjected to simulated repair procedures by using varying surface treatments
surfaces.1 Indirect resin- and universal adhesives.
based restorative materials,
Material and methods. Four different CAD-CAM blocks (Brilliant Crios, Lava Ultimate, Shofu Block HC,
including computer-aided
and Vita Enamic) were thermocycled (5000 times, 5/55  C) and divided into 4 groups according to the
design and computer-aided surface treatment: control, 9% hydrofluoric acid etching, aluminum oxide airborne-particle abrasion,
manufacturing (CAD-CAM) and tribochemical silica airborne-particle abrasion. After surface treatments, the surface roughness
composite resin materials, was measured with a nanoindenter and further examined with scanning electron microscopy. After
have better mechanical and the application of 3 different universal adhesives (Clearfil Universal Bond, Prime&Bond Universal,
physical properties than and Single Bond Universal), the specimens were subjected to a simulated repair process with
direct placement composite composite resin. Bonded specimens were cut into 1 mm2 beams, and microtensile bond strength
values were determined until failure at a crosshead speed of 0.5 mm/min. The bond strength data
resin materials, including
were analyzed with 3-way analysis of variance, and surface roughness data were analyzed with 2-
better fracture resistance.2,3 way analysis of variance tests. Pairwise analyses were performed with the Tukey test (a=.05).
With CAD-CAM technol-
ogy, successful restorations Results. All surface treatments effectively improved repair microtensile bond strength values
compared with the control (P<.05). Aluminum oxide airborne-particle abrasion had similar mean
can be performed in a bond strength values compared with tribochemical silica airborne-particle abrasion (P>.05). Among
single-visit, without the the CAD-CAM blocks treated with hydrofluoric acid etching, Vita Enamic had the highest mean
need for conventional bond strength values. The highest mean microtensile bond strength repair values with the highest
impressions.3 cohesive failure rates were found with the silane-containing universal adhesive (Single Bond Universal).
Current polymer-based Conclusions. Surface treatment with aluminum oxide airborne-particle abrasion and tribochemical
CAD-CAM materials, in- silica airborne-particle abrasion produced successful repair results for aged resin nanoceramics,
cluding ceramic-based whereas hydrofluoric acid etching can be used for aged hybrid ceramic repair. Silane-containing
interpenetrating phase com- universal adhesive reported increased bond strength. Application of universal adhesive after surface
posite resins, double- treatment is recommended to increase repair strength. (J Prosthet Dent 2020;-:---)

a
Assistant Professor, Department of Restorative Dentistry, School of Dentistry, University of Altinbas, Istanbul, Turkey.
b
Assistant Professor, Department of Restorative Dentistry, School of Dentistry, University of Hatay Mustafa Kemal, Hatay, Turkey.
c
Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Altinbas, Istanbul, Turkey.
d
Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Altinbas, Istanbul, Turkey.

THE JOURNAL OF PROSTHETIC DENTISTRY 1.e1

1.e2
Clinical Implications
Micromechanical retention with airborne-particle
abrasion or tribochemical silica airborne-particle
abrasion is essential for repairing aged resin
nanoceramics. HF etching can be beneficial for aged
hybrid ceramic. The use of a universal adhesive
alone reported promising results. However,
universal adhesive application after surface
treatments is recommended for the repair of aged
CAD-CAM blocks.
network materials, hybrid ceramics, resin nanoceramics,
resin-matrix ceramics, and polymer-infiltrated ceramic
networks have been categorized as ceramic-like or com-
posite resin.4-6 Composite resin blocks are gaining atten-
tion over ceramics because their cost is lower and their
physical properties closer to tooth structure.6-8 CAD-CAM
composite resin blocks have a conversion rate of up to
95%,7 an improvement over direct composite resin mate-
rials with a conversion rate of 50% to 60%.8 The high
conversion rate is associated with increased biocompati-
bility and enhanced mechanical properties. However,
disadvantages include the reduction in chemical bonding
for luting to tooth structure because of the decrease in the
free carbon-carbon double bonds,6,9-11 meaning pretreat-
ment is required to achieve reliable bond strength.11-14
Restoration fracture or chipping is usually a result of
trauma or fatigue from masticatory function. Repairing
such defects with composite resins can be a less expen-
sive and more straightforward alternative to replace-
ment.15 Surface pretreatment by chemical and physical
methods, such as with silane or adhesive resins,13,16,17
abrasion with a diamond rotary instrument or silicon
carbide disk, acid etching,18,19 airborne-particle abra-
sion,20-23 and tribochemical silica airborne-particle abra-
sion 16,20,23-25 have been evaluated in laboratory studies
that simulated intraoral repair.12-14,26-28 Alternatively, a
chemical bond can be developed through ionic interac-
tion between filler particles of the substrate and acidic
groups of the functional monomers of the adherent,29,30
which are found in universal adhesives.11 Because there
is no standard adhesive resin material for repairing
restorative materials, adhesive resins in combination with
different surface treatments are typically advocated, with
silane coupling agents and adhesive resins applied in
chemical pretreatments.12,14,26,31
The bonding potential of CAD-CAM composite resin
blocks decreases because of the high degree of conver-
sion. Therefore, a pretreatment procedure is required for
repair. However, a consensus on the ideal pretreatment
for repair of the CAD-CAM composite resins is lacking,
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume - Issue -
and the variations in the characteristics of these materials
do not facilitate the determination of the ideal pretreat-
ment.32 Accordingly, the purpose of this in vitro study
was to evaluate the efficiency of CAD-CAM composite
resin block materials repaired with different pre-
treatments and universal adhesives after artificial aging.
The null hypotheses were that the CAD-CAM block type
would not affect the tensile bond strength or surface
roughness that the pretreatment protocol would not
affect the tensile bond strength or surface roughness of
the tested CAD-CAM materials and that universal ad-
hesives would not affect the tensile bond strength of the
tested CAD-CAM materials.
MATERIAL AND METHODS
The chemical compositions of the tested materials are
presented in Table 1. Prefabricated CAD-CAM blocks
were cut into 6×6×5.5-mm specimens with a high pre-
cision cutting machine (IsoMet High Speed Pro; Buehler
Ltd). The specimens were then submitted to a thermo-
cycling protocol (×5000, dwell time of 30 seconds, be-
tween 5  C and 55  C) to mimic the oral environment
through artificial aging.33-35 After the aging protocol, the
bonding surface of each specimen was abraded with a
320-grit SiC disk to obtain a standardized substrate
surface,36 followed by ultrasonic cleaning for 10 minutes
in distilled water. The aged specimens then received one
of the following surface treatment protocols (n=10): no
treatment; 9% hydrofluoric acid (Porcelain Etch; Ultra-
dent Products, Inc) etching for 1 minute (HF etching);
airborne-particle abrasion with 30-mm aluminum oxide
particles (Cobra; Renfert GmbH) at a 10-mm distance for
15 seconds (AL); and tribochemical silica airborne-
particle abrasion (TSC) with 30-mm particles (CoJet; 3M
ESPE Dental Products) at a 10-mm distance for 15 sec-
onds. The AL and TSC treatments were performed by
using an airborne-particle abrasion device (Airsonic mini;
Hager & Werken GmbH & Co) at 0.25 MPa. After the
surface treatment protocols, the specimens were ultra-
sonically cleaned for 10 minutes.
After surface treatment, each specimen was analyzed
for surface roughness (n=10). A diamond Berkovich tip
was used as a scanning probe on a triboindenter (Ti-950;
Hysitron Inc) to raster scan an area (10×10 mm) with a
contact force maintained at 0.5 mN. Image analysis from
the topography scan was used to calculate surface
roughness. All measurements were performed by the
same operator at the Nanomechanical Research Labo-
ratory, Hatay Mustafa Kemal University. Seven mea-
surements were made for each specimen. The root mean
square roughness values were recorded in nanometers.
After surface roughness measurements, the aged and
surface-treated blocks were further divided into 3 sub-
groups according to the universal adhesive applied:
Sismanoglu et al
- 2020 1.e3

Table 1. Chemical composition of materials used

Batch
Material Number Type Composition
Clearfil Universal Bond 3V0037 Universal adhesive Bis-GMA, HEMA, ethanol, 10-MDP, hydrophilic aliphatic dimethacrylate, colloidal silica, DL-
(Kuraray Noritake Dental Inc) camphorquinone, silane coupling agent, accelerators, initiators, water. pH: 2.3
Prime&Bond Universal 1806000800 Universal adhesive Mono-, di- and trimethacrylate resins, PENTA, diketone, stabilizers, organic phosphine
(Dentsply Sirona) oxide, cetylamine hydrofluoride, acetone, water, self-cure activator. pH: 2.5
Single Bond Universal (3M 665259 Universal adhesive HEMA, 10-MDP, dimethacrylate resins, VitrebondTM copolymer, silane, filler, ethanol, water,
ESPE Dental Products) initiators. pH: 2.7
Brilliant Crios (Coltène) I17557 Resin Nanoceramic Bis-GMA, Bis-EMA, TEGDMA.
Filler: Barium glass, and silica particles, 71% by weight.
Lava Ultimate (LU; 3M ESPE N619802 Resin Nanoceramic Bis-GMA, UDMA, Bis-EMA, TEGDMA.
Dental Products) Filler: SiO2, ZrO2, Si/ZrO2 cluster, 80% by weight.
Shofu Block HC (HC; Shofu 111501 Resin Nanoceramic UDMA, TEGDMA.
Dental GmbH) Filler: Silica powder, micro fumed silica, zirconium silicate, 61% by weight.
Vita Enamic (VE; Vita 66701 Hybrid ceramic UDMA, TEGDMA.
Zahnfabrik Filler: Feldspar ceramic enriched with aluminum oxide, 86% by weight.
H. Rauter GmbH & Co)

10-MDP, 10-methacryloyloxydecyl dihydrogen phosphate; Bis-EMA, bisphenol A polyethethylene glycol diether dimethacrylate; Bis-GMA, bisphenol A diglycidylmethacrylate; Bis-MEPP, 2,2-
Bis (4-methacryloxypolyethoxyphenyl) propane; HEMA, 2-hydroxyethyl methacrylate; PENTA, dipentaerythritol penta-acrylate phosphate; TEGDMA, triethylene glycol dimethacrylate; UDMA,
urethane dimethacrylate.

Clearfil Universal Bond (Kuraray Noritake Dental Inc); Table 2. Influence of material type, surface treatment, and additional
Prime&Bond Universal (Dentsply Sirona); and Single silane application on mTBS results according to 3-way ANOVA
Bond Universal (SBU) (3M ESPE Dental Products). After Type III Sum Mean
Source of Squares df Square F P
universal adhesive application (Table 1), a composite
Corrected Model 160885.314* 47 3423.092 32.715 <.001
resin (Filtek Ultimate Universal A3.5; 3M ESPE Dental
Intercept 2624089.451 1 2624089.451 25078.968 <.001
Products) was applied to the substrates as a repair ma- Material 6351.411 3 2117.137 20.234 <.001
terial. The composite resin was condensed onto treated Treatment 90856.662 3 30285.554 289.445 <.001
CAD-CAM surfaces in 2-mm-thick increments by using Adhesive 36434.205 2 18217.103 174.105 <.001
a split 6×6×11-mm Teflon mold to fill up the mold. Each Material×treatment 15557.518 9 1728.613 16.521 <.001
increment was light polymerized with a light-emitting Material×adhesive 6960.293 6 1160.049 11.087 <.001
diode device (Elipar Deep Cure; 3M ESPE Dental Prod- Treatment×adhesive 2925.140 6 487.523 4.659 <.001
ucts) for 20 seconds with an output of 1250 mW/cm2. Material×treatment× 1800.086 18 100.005 0.956 .510
adhesive
After polymerization, the CAD-CAM composite resin
Error 115514.909 1104 104.633
was removed from the mold, and the adhesive interface
Total 2900489.674 1152
was further irradiated for 40 seconds to ensure adequate
Corrected Total 276400.224 1151
polymerization.
mTBS, microtensile bond strength. *R Squared=.582 (Adjusted R Squared=.564).
The repaired specimens were longitudinally sectioned
across the adhesive interface in both the x- and
y-directions by using the precision cutter to obtain microscope (SEM) observations. Two specimens were
specimens with a cross-section of 1 mm2. Peripheral prepared for each surface treatment group as described in
sticks of each block were discarded, and remaining sticks the previous section. The specimens were sputter-coated
were immersed in distilled water for 24 hours at 37  C. with gold (Polaron SC7620; Quorum Technologies) and
Each stick was measured with digital calipers (ABS Dig- were examined under a SEM (JEOL 5500 LV.; JEOL Ltd)
imatic; Mitutoyo Corp) and recorded in mm2 before at 10 kV accelerating voltage. Observations were per-
microtensile bond strength (mTBS) testing. For the mTBS formed under ×1000 magnification.
testing, the specimens were attached to the mTBS testing For the mTBS data, 3-way analysis of variance
device (MOD Tester; Esetron Smart Robotechnologies) (ANOVA) and the Tukey post hoc tests were performed.
with cyanoacrylate adhesive (Pattex; Henkel GmbH & For surface roughness data, 2-way ANOVA and the
Co) and subjected to tensile force (N) until failure at a Tukey post hoc tests were performed. A statistical soft-
crosshead speed of 0.5 mm/min. The mTBS values were ware program (IBM SPSS Statistics, v20.0; IBM Corp)
recorded in MPa. The failure mode was determined by was used for the analysis (a=.05 for all tests).
using a stereomicroscope at ×30 magnification and
categorized as adhesive; cohesive (failure within CAD-
RESULTS
CAM block or composite resin); or mixed.
Thirty-two specimens (6×6×3 mm) were prepared by The mean mTBS values for the repaired CAD-CAM ma-
using the precision cutter for scanning electron terials after surface treatments, and universal adhesive

Sismanoglu et al THE JOURNAL OF PROSTHETIC DENTISTRY

1.e4 Volume - Issue -

Table 3. Means ±standard deviations of mTBS data and post hoc analysis for pairwise comparison
CAD-CAM Indirect Restoratives
Adhesive Application Surface Treatment BC LU HC VE
Clearfil Universal Bond Control 36.30 ±12.76A 26.30 ±8.85A 27.07 ±7.71A 31.05 ±7.66A
HF 51.39 ±6.91B 38.80 ±6.81B 39.86 ±7.67B 54.81 ±7.19B
B C C
AL 59.37 ±9.86 57.80 ±9.32 57.20 ±9.71 43.75 ±7.63B
TSC 56.98 ±9.70B 52.11 ±9.00C 53.10 ±8.18C 47.29 ±8.90B
Prime&Bond Universal Control 32.87 ±9.94A 19.94 ±8.06A 27.34 ±6.14A 25.42 ±8.15A
B B AC
HF 45.96 ±6.46 38.17 ±9.72 37.53 ±9.17 49.33 ±7.57B
B C B
AL 55.35 ±7.67 49.99 ±8.62 51.53 ±7.28 42.70 ±9.12B
B C BC
TSC 52.68 ±8.98 51.94 ±11.59 47.35 ±10.31 41.67 ±10.24B
Single Bond Universal Control 46.18 ±14.49A 44.25 ±13.10A 37.45 ±14.26A 48.19 ±12.60A
HF 48.31 ±9.18A 51.28 ±9.34AC 38.69 ±6.66A 65.90 ±7.34B
B B C
AL 66.19 ±12.24 68.22 ±13.02 62.47 ±14.47 65.52 ±13.19B
B CB C
TSC 62.28 ±11.27 61.50 ±16.85 56.50 ±14.83 62.93 ±14.98B

mTBS, microtensile bond strength; AL, aluminum oxide airborne-particle abrasion; BC, Brilliant Crios; HC, Shofu Block HC; HF, hydrofluoric acid; LU, Lava Ultimate; TSC, tribochemical silica
airborne-particle abrasion; VE, Vita Enamic. Means followed by similar uppercase superscript letters indicate no significant different (surface treatment comparison).

Table 4. Mean and standard deviation of surface roughness (Rq ±standard deviation) values of CAD-CAM indirect restoratives with different surface
treatments
CAD-CAM Indirect Restoratives
Surface Treatment BC LU HC VE
Control 46.23 ±2.29a,A 46.28 ±2.64a,A 47.89 ±3.54a,A 35.94 ±3.38a,A
HF 98.61 ±19.53b,A 96.78 ±13.75b,A 110.10 ±24.31b,A 161.83 ±21.03b,B
AL 227.05 ±28.70c,A 249.45 ±32.93c,A 238.32 ±14.74c,A 209.97 ±38.03c,A
TSC 222.16 ±31.09c,A 210.04 ±25.29d,AB 202.60 ±35.88c,AB 180.52 ±43.14c,B
AL, aluminum oxide airborne-particle abrasion; BC, Brilliant Crios; HC, Shofu Block HC; HF, hydrofluoric acid; LU, Lava Ultimate; TSC, tribochemical silica airborne-particle abrasion; VE, Vita
Enamic. Mean values represented with similar uppercase letters (row) or lowercase letters (column) not significantly different (P>.05).

Figure 1. Scanning electron micrographs of Brilliant Crios. Original magnification ×1000. A, Control. B, HF etching. C, AL. D, TSC. AL, aluminum oxide
airborne-particle abrasion; HF, hydrofluoric acid; TSC, tribochemical silica airborne-particle abrasion.

THE JOURNAL OF PROSTHETIC DENTISTRY Sismanoglu et al

- 2020
Figure 2. Scanning electron micrographs of Lava Ultimate. Original magnification ×1000. A, Control. B, HF etching. C, AL. D, TSC. AL, aluminum oxide
airborne-particle abrasion; HF, hydrofluoric acid; TSC, tribochemical silica airborne-particle abrasion.
applications are presented in Table 2. The 3-way AN-
OVA indicated that the CAD-CAM material (F=20.23,
P<.001), surface treatment (F=289.45, P<.001), and uni-
versal adhesive (F=174.11, P<.001) had a significant
impact on mTBS values (Table 3). In addition, significant
interactions between those factors were observed
(Table 3, P<.001). According to pairwise analysis, all
surface treatment protocols effectively improved repair
mTBS values compared with the control group, irre-
spective of the CAD-CAM material type (P<.05).
However, the improvement obtained for the HF+SBU
combination was not statistically significant, except for
the Vita Enamic (VE). The bond strength values of the AL
and TSC treatments were not significantly different
(P>.05). Among the CAD-CAM restorative materials
treated with HF etching, VE specimens exhibited the
highest bond strength values. The difference between HF
etching, AL, and TSC was not statistically significant for
VE (P>.05).
Failure mode distribution and pretest failure scores for
CAD-CAM materials after mTBS testing are listed in
Supplementary Table 1 (available online). The predomi-
nant mode of failure was adhesive failure at the interface.
An increase in the rate of mixed failure was observed
Sismanoglu et al
1.e5
among specimens that received surface treatment. AL
and TSC pretreatments tended to result in mixed failure
more often than HF etching in composite resin blocks
(Brilliant Crios, Lava Ultimate [LU], and Shofu Block
HC). The predominant mode of failure for hybrid ceramic
block (VE) was also adhesive failure, but, unlike com-
posite resin blocks, HF etching increased the rate of
mixed failure.
The mean roughness values and standard deviations
of the CAD-CAM materials after surface treatments are
presented in Table 4. Surface treatment protocols
(P<.001) affected the surface roughness values rather
than the CAD-CAM material type (P=.93) according to
the 2-way ANOVA results. Furthermore, a significant
interaction was observed between the material type and
the surface treatment factors (P<.001). All surface treat-
ment protocols generated rougher surfaces than the
control group (P<.001). AL pretreatment reported the
highest roughness followed by TSC (Table 3). However,
no significant difference was found between AL and TSC
pretreatments among the CAD-CAM materials (P>.05)
regarding the surface roughness, except for LU (P=.044).
In addition, HF-etched specimens exhibited significantly
lower surface roughness than airborne-particle abraded
THE JOURNAL OF PROSTHETIC DENTISTRY
1.e6
Figure 3. Scanning electron micrographs of Shofu Block HC. Original magnification ×1000. A, Control. B, HF etching. C, AL. D, TSC. AL, aluminum oxide
airborne-particle abrasion; HF, hydrofluoric acid; TSC, tribochemical silica airborne-particle abrasion.
specimens, including AL and TSC (P<.05). The greatest
amount of surface roughness with HF etching was in the
VE group (161.83 ±21.03 MPa, P<.05).
The SEM images of the CAD-CAM materials
treated with different surface treatments are presented
in Figures 1-4. Different surface topographies were
observed depending on the CAD-CAM material and
the surface treatment. After AL and TSC pre-
treatments, surface alterations and irregular particles
were detected. Furthermore, AL produced a rougher
surface than TSC. HF etching of the VE surfaces
created prominent ridges and deep pores. In addition,
HF etching has a similar effect on the VE surface to that
on etchable ceramics.
DISCUSSION
The purpose of the present in vitro study was to inves-
tigate the effects of various surface treatment protocols
and universal adhesive applications on the repair mTBS
and surface characteristics of aged CAD-CAM block
materials. Adhesive bonding to indirect restorative ma-
terials is dependent on micromechanical interlocking and
chemical bonding on the restoration surface.37 Because
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume - Issue -
the polymerization of these materials is better than direct
composite resins, the unreacted monomer content is
lower; thus, there is a need to increase the surface energy
with surface treatments, including cleaning and rough-
ening. However, the data on the efficiency of surface
treatments in combination with universal adhesive
application on resin nanoceramic and hybrid ceramic
CAD-CAM block materials are limited.12,26
HF chemically reacts with silica in feldspathic ce-
ramics to form hexafluorosilicate35 and creates a
honeycomb-like surface topography suitable for micro-
mechanical interlocking.20,37 For this reason, HF etching
is recommended for etchable ceramics; it enhances sur-
face roughness, wettability, and microretention and re-
veals hydroxyl groups, which favors the chemical
bonding with monomers.18,30 Bello et al13 reported that
HF etching of VE promotes more favorable results than
AL pretreatment. However, the augmentative effect of
HF etching on the repair bond strength values for resin
nanoceramics was not as pronounced as that of AL and
TSC in the present study. Furthermore, no significant
difference was found among HF etching, AL, and TSC
when applied on VE. This can be attributed to the
Sismanoglu et al
- 2020
Figure 4. Scanning electron micrographs of Vita Enamic. Original magnification ×1000. A, Control. B, HF etching. C, AL. D, TSC. AL, aluminum oxide
airborne-particle abrasion; HF, hydrofluoric acid; TSC, tribochemical silica airborne-particle abrasion.
feldspathic ceramics in the composition of VE, making
this material etchable. Moreover, HF etching of resin
nanoceramic materials resulted in significantly lower
surface roughness and repair bond strength values
compared with AL and TSC pretreatments.
As alternatives to HF etching, AL consists of airborne-
particle abrasion with aluminum oxide, which roughens
the surface and increases the surface area, whereas TSC
provides additional silica on the material’s surface. Pre-
vious studies have suggested that AL and TSC pre-
treatments are efficient in improving the bond strength of
resin nanoceramic materials.12,16 Moreover, consistent
with the present study, they concluded that TSC is not
better than AL for CAD-CAM resin-based materials.12,16
Elsaka24 compared the efficiency of various surface
treatments, including HF etching and TSC, on VE and
reported that HF etching was better than TSC regarding
repair bond strength. However, Barutcigil et al14 inves-
tigated the effect of various surface treatments on the
bond strength of VE and reported no significant differ-
ence among surface treatments. This is consistent with
the present study, in which no significant difference was
found among the 3 surface treatments in terms of bond
strength for VE. However, AL and TSC pretreatments
Sismanoglu et al
1.e7
were significantly better than HF etching for resin
nanoceramic materials. Inconsistent results among
studies may be attributed to differences in study design.
Therefore, the first and second null hypotheses that the
CAD-CAM block type would not affect the tensile bond
strength or surface roughness and that the pretreatment
protocol would not affect the tensile bond strength or
surface roughness of the tested CAD-CAM materials
were rejected.
Elsaka24 suggested an acceptable bond strength range
of 15 to 25 MPa. The application of a universal adhesive
alone provided bond strength values above this range,
although lower than those of the surface treatment
groups. Arpa et al12 likewise obtained clinically sufficient
mTBS values in LU specimens (54 MPa), where they
applied only SBU. The results of the present study indi-
cated that the universal adhesive affected the repair bond
strength values. Therefore, the third null hypothesis that
universal adhesives would not affect the tensile bond
strength of the tested CAD-CAM materials was also
rejected. In the present study, higher bond strength
values and cohesive failure rates were obtained for SBU
applied groups than for other universal adhesives. Pre-
vious studies have concluded that the increase in bond
THE JOURNAL OF PROSTHETIC DENTISTRY
1.e8
strength with SBU application is because of the 10-
methacryloxydecyl dihydrogen phosphate (MDP)
monomer. MDP is a bifunctional monomer capable of
bonding to both oxides and methacrylate monomers on
the surface of the CAD-CAM material. Demirel et al26
investigated the effectiveness of different universal ad-
hesives on the repair mSBS of various hybrid CAD-CAM
specimens (CeraSmart, LU, Shofu Block HC, and VE)
and reported that the repair mSBS values obtained for
SBU were higher than the values obtained for Clearfil
Universal Bond. In addition, SBU also contains silane and
Vitrebond copolymer. Wu et al16 reported that SBU
improved the bond strength of CAD-CAM resin-based
material, consistent with the findings of the present
study. Yoshihara et al38 reported that separate silane
application was more effective than incorporating silane
into SBU. Therefore, the efficiency of incorporating a
silane coupling agent into universal adhesives remains
doubtful. Furthermore, Prime&Bond Universal contains
dipentaerythritol penta-acrylate phosphate, which is a
phosphate monomer alternative to the MDP monomer.
According to the present study, this monomer was not as
effective as the MDP monomer regarding the bond
strength. In this case, the chemical composition of a
universal adhesive plays a crucial role in the bond
strength.
The effects of different surface treatments on the
surface topography of CAD-CAM blocks were also
examined through surface roughness measurements and
SEM analysis. The HF etching and AL and TSC pre-
treatments reported a significant increase in roughness
compared with the control as confirmed by the SEM
images. For resin nanoceramic materials, the roughening
caused by AL and TSC pretreatments is seen in the SEM
images. However, HF etching caused prominent ridges
and undercuts only in the hybrid ceramics. These find-
ings coincide with the results of the bond strength test.
Limitations of the present in vitro study included the
lack of an aging protocol after the simulated repair pro-
cedures. Further studies should also test the repaired
specimens after an aging protocol. It would also be
prudent not to directly extrapolate the results of the
present in vitro study, as large clinical studies with long
follow-up times are needed.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn
1. HF acid etching is not recommended for materials
composed of an increased composite resin content.
2. Surface treatment with AL and TSC revealed suc-
cessful repair results for aged resin nanoceramics,
whereas HF etching can be used for aged hybrid
ceramic repair.
THE JOURNAL OF PROSTHETIC DENTISTRY
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3. Silane-containing universal adhesive demonstrated
increased bond strength.
4. Application of universal adhesive after surface
treatment is recommended to increase the strength
of repairs.
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Corresponding author:
Dr Soner Sismanoglu
Department of Restorative Dentistry
University of Altinbas
Zuhuratbaba Mah. Incirli Cad. No: 11/A 34147
Bakirkoy, Istanbul
TURKEY
Email: soner.s@hotmail.com
CRediT authorship contribution statement
Soner Sismanoglu: Conceptualization, Methodology, Investigation, Resources,
Formal analysis. Zuhal Yildirim-Bilmez: Investigation, Resources. Aysegul
Erten-Taysi: Writing - review & editing, Validation. Pınar Ercal: Writing -
original draft, Resources.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.02.029

Sismanoglu et al THE JOURNAL OF PROSTHETIC DENTISTRY