Clinical Oral Investigations (2022) 26:3383–3393

https://doi.org/10.1007/s00784-022-04406-z

REVIEW

A systematic review and meta‑analysis on using preheated resin

composites as luting agents for indirect restorations
Fabíola Jardim Barbon1 · Cristina Pereira Isolan1 · Leonardo Dias Soares2 · Alvaro Della Bona3 ·
Wellington Luiz de Oliveira da Rosa1 · Noéli Boscato1

Received: 24 November 2021 / Accepted: 6 February 2022 / Published online: 12 February 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Objectives This systematic review investigated the hypothesis that preheated resin composites (RCs) used as luting agents
improve the mechanical properties, physicochemical performance, and color of indirect ceramic restorations.
Materials and methods Literature search was performed in three databases (Medline/PubMed, Scopus, and Web of Science)
and in the grey literature (OpenGrey, ProQuest, and Catalog of Theses & Dissertations from CAPES). Eligibility criteria
included only studies comparing at least one preheated RC used as a luting agent with resin cements.
Results Data regarding the mechanical properties, physicochemical characteristics, and color were analyzed qualitatively,
and the microtensile bond strength and film thickness were also evaluated by meta-analysis. The search strategy identified
3894 papers, and 28 were full-text screened. Seven studies were included in the review, and 5 were included in the meta-
analysis. No significant difference was found for microtensile bond strength (P = 0.14). Preheated RCs showed significantly
higher film thickness than resin cements (P = 0.001).
Conclusion Overall, the use of preheated RCs as luting agents offers similar to poorer performance than using resin cements
for bonding indirect restorations.
Clinical relevance.
Despite the claim that preheated RC could be used as a luting agent, further studies should investigate the effect of clinically
unacceptable film thickness.

Keywords Dental cements · Mechanical strength · Indirect restorations · Luting · Heating

* Noéli Boscato Introduction

noeliboscato@gmail.com
Fabíola Jardim Barbon Luting agents represent the weakest link of a restorative
fabi_barbon@hotmail.com bonded assembly such as restoration luting agent–substrate,
Cristina Pereira Isolan affecting its overall strength [1]. Studies have reported that
cristinaisolan1@hotmail.com the inorganic filler content of resin-based luting agents
Leonardo Dias Soares could improve the strength of thinner ceramic restorations
leonardodiassoares@hotmail.com [2, 3]. However, the resin cements used as luting agents [4,
Alvaro Della Bona 5] commonly have a lower concentration of inorganic fillers
dbona@upf.br than other resin-based materials such as conventional resin
Wellington Luiz de Oliveira da Rosa composites (RCs) [6]. Therefore, using RCs as luting agents
wellington_xy@hotmail.com has been suggested [4, 7] based on its potential advantages,
including the availability of a greater range of shades, and
1
Graduate Program in Dentistry, Federal University improved mechanical performance by its higher filler con-
of Pelotas, Pelotas, Brazil
tent [4, 8].
2
Technical Course in Mechanical Engineering, Luting agents strengthen indirect restorations by penetrat-
Sul-Rio-Grandense Federal Institute, Pelotas, Brazil
ing the ceramic intaglio surface porosities created by acid
3
Postgraduate Program in Dentistry, University of Passo etching [9] and sealing superficial cracks [10]. The high
Fundo, Passo Fundo, Brazil

13
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3384
viscosity of RC [11] could not only increase film thickness
but also impair adaptation of the restoration [12]. Indeed,
the polymerization shrinkage of preheated RCs used as
luting agents could generate more significant stress on the
cement layer, which could favor the appearance of cracks
in thinner ceramic restorations [13]. However, studies have
suggested that preheating the material reduces its viscos-
ity and improves its ability to penetrate the etched ceramic
surface [3, 14]. Despite the lack of consensus on the clini-
cally acceptable film thickness [15], most authors suggest it
should be lower than 120 µm [16, 17]. The influence of resin
composite inorganic filler content on the color change of
resin composite restorations has also been investigated [18].
As the color change can be influenced by several factors [19]
and achieving a natural tooth-like restoration is still one of
the most significant challenges for restorative dentistry, color
stability remains a relevant topic for esthetic dentistry.
A previous systematic review proposed to evaluate the
physical properties of preheating materials, including RCs
[20]. Yet, the effect of using preheated RC as a luting agent
on the overall performance of indirect restorations is relevant
to clinical dentistry, and it is not comprehensively addressed
in the literature. Therefore, this systematic review investi-
gated the hypothesis that preheated RC used as a luting agent
improves the mechanical properties, physicochemical per-
formance, and color of indirect restorations.
Materials and methods
This systematic review was conducted according to the
Cochrane Handbook guidelines and followed the 4-phase
flow diagram included in the Preferred Reporting Items
statement for Systematic Reviews and Meta-Analyses
(PRISMA) [21]. The study protocol was registered on the
Open Science Framework (OSF) Registries (https://​doi.​
org/​10.​17605/​OSF.​IO/​6T8UG), and the research question
was adapted to the PICO framework, as follows: popula-
tion, teeth restored with indirect restorations; intervention
and comparison, use of preheated RCs vs. resin cements
as luting agents; and outcomes, mechanical properties (i.e.,
microtensile bond strength, shear test, flexural strength),
physicochemical performance (i.e., viscosity, film thickness,
volumetric shrinkage, microleakage, marginal sealing), and
color change. The research question was, “Would preheated
resin composites used as luting agents improve the mechani-
cal properties, physicochemical performance, and color of
indirect restorations?”.
Search strategy and selection process
The search strategy (Table 1) was applied to the Medline/
PubMed, Scopus, Web of Science databases, and grey
13
Clinical Oral Investigations (2022) 26:3383–3393
literature (OpenGrey, ProQuest, and Catalog of Theses &
Dissertations from CAPES), with the last search being car-
ried out in February 2021. There were no language or date
restrictions.
Studies that compared at least one preheated RC as a lut-
ing agent with resin cements were included. Studies that
examined preheated RCs but did not evaluate the mechanical
properties of the luted restoration were excluded. Moreover,
literature reviews, case series, and case studies that used
experimental materials or did not follow the manufacturer’s
guidelines were also excluded.
The eligible studies were initially identified through title
scanning by two independent reviewers. Then, the abstract
evaluation was carried out, and the full text was examined
whenever information relevant to the eligibility criteria was
not included in the abstract. Articles that met the eligibility
criteria were included in the study for data extraction. In
addition, the references of all eligible papers were manually
searched, and any disagreements regarding the eligibility of
identified studies for inclusion were resolved through discus-
sion with a third reviewer.
Data collection
Duplicates were identified and removed using EndNote X7
software (Thomson Reuters®, NY, USA), and data were
extracted using a standardized form where studies were
grouped according to material properties evaluated, as fol-
lows: microtensile bond strength, film thickness, flexural
strength, volumetric shrinkage, shear test, color change,
marginal sealing, and microleakage. In case of missing or
unpublished data, the authors of the relevant studies were
contacted via email up to three times, and the study was only
included if the missing information was provided.
Risk of bias assessment
The risk of bias for each study was independently assessed
by two reviewers using parameters adapted from a previous
systematic review of in vitro studies [22] as follows: sam-
ple randomization, sample size calculations, blinding of the
operator of the testing machine, sufficient detail to enable
replication, and other biases. Each parameter was judged
as having high (when the parameter was not fulfilled and
it was clearly reported), low (the parameter was fulfilled
and clearly reported), or unclear (where no information on
whether the parameter was fulfilled was provided) risk of
bias. This assessment was carried out using the RevMan
(Review Manager Software®, version 5.2, The Nordic
Cochrane Centre, The Cochrane Collaboration, Copenha-
gen, Denmark).
Clinical Oral Investigations (2022) 26:3383–3393 3385

Table 1  Search strategy used in each database

Search terms

PubMed (MedLine)
#4 Search #1 AND #2 AND #3
#3 Composite resins [Mesh] OR Composite resins OR Resin composite OR Adhesive resin composites OR Dental composites OR Resins,
composites OR Dental resin OR Dental resins OR Resin OR Resins OR Composite OR Composites
#2 Heating [Mesh] OR Heating OR Preheating OR Hot temperature [Mesh] OR Hot temperature OR Hot temperatures OR Heat OR Transi-
tion temperature [Mesh] OR Transition temperature OR Transition temperatures OR Preheating OR Preheated OR Preheated OR Pre-
heating OR Preheating composites OR Pre-warming OR Composite pre-heating OR Temperature
#1 Porcelain veneering materials OR Dental veneers [Mesh] OR Dental veneers OR Dental laminates OR Dental laminate OR Dental onlay
OR Dental onlays OR Inlays [Mesh] OR Inlays OR Inlay OR Dental inlays OR Onlays OR Onlay OR Ceramic OR Ceramics OR Dental
porcelain OR Porcelain OR Porcelain, dentals OR Dental, porcelain OR Dental veneer OR Veneer, dental OR Veneers, dental OR
Veneers OR Veneer
Scopus and Web of Science
#4 Search #1 AND #2 AND #3
#3 (Composite resins) OR (Composite resins) OR (Resin composite) OR (Adhesive resin composites) OR (Dental composites) OR (Resins,
composites) OR (Dental resin) OR (Dental resins) OR (Resin) OR (Resins) OR (Composite) OR (Composites)
#2 (Heating) OR (Heating) OR (Preheating) OR (Hot temperature) OR (Hot temperature) OR (Hot temperatures) OR (Heat) OR (Transition
temperature) OR (Transition temperature) OR (Transition temperatures) OR (Preheating) OR (Preheated) OR (Preheated) OR (Preheat-
ing) OR (Preheating composites) OR (Pre-warming) OR (Composite pre-heating) OR (Temperature)
#1 (Porcelain veneering materials) OR (Dental veneers) OR (Dental veneers) OR (Dental laminates) OR (Dental laminate) OR (Dental onlay)
OR (Dental onlays) OR (Inlays) OR (Inlays) OR (Inlay) OR (Dental inlays) OR (Onlays OR Onlay) OR (Ceramic) OR (Ceramics) OR
(Dental porcelain) OR (Porcelain) OR (Porcelain, dentals) OR (Dental, porcelain) OR (Dental veneer) OR (Veneer, dental) OR (Veneers,
dental) OR (Veneers) OR (Veneer)
OpenGrey
((Composite resins) OR (Composite resins) OR (Resin composite) OR (Adhesive resin composites) OR (Dental composites) OR (Resins,
composites) OR (Dental resin) OR (Dental resins) OR (Resin) OR (Resins) OR (Composite) OR (Composites)) AND ((Heating) OR
(Heating) OR (Preheating) OR (Hot temperature) OR (Hot temperature) OR (Hot temperatures) OR (Heat) OR (Transition tempera-
ture) OR (Transition temperature) OR (Transition temperatures) OR (Preheating) OR (Preheated) OR (Preheated) OR (Preheating) OR
(Preheating composites) OR (Pre-warming) OR (Composite pre-heating) OR (Temperature)) AND ((Porcelain veneering materials) OR
(Dental veneers) OR (Dental veneers) OR (Dental laminates) OR (Dental laminate) OR (Dental onlay) OR (Dental onlays) OR (Inlays)
OR (Inlays) OR (Inlay) OR (Dental inlays) OR (Onlays OR Onlay) OR (Ceramic) OR (Ceramics) OR (Dental porcelain) OR (Porce-
lain) OR (Porcelain, dentals) OR (Dental, porcelain) OR (Dental veneer) OR (Veneer, dental) OR (Veneers, dental) OR (Veneers) OR
(Veneer))
ProQuest (Filter: Dissertations and Thesis)
((Composite resins) OR (Composite resins) OR (Resin composite) OR (Adhesive resin composites) OR (Dental composites) OR (Resins,
composites) OR (Dental resin) OR (Dental resins) OR (Resin) OR (Resins) OR (Composite) OR (Composites)) AND ((Heating) OR
(Heating) OR (Preheating) OR (Hot temperature) OR (Hot temperature) OR (Hot temperatures) OR (Heat) OR (Transition tempera-
ture) OR (Transition temperature) OR (Transition temperatures) OR (Preheating) OR (Preheated) OR (Preheated) OR (Preheating) OR
(Preheating composites) OR (Pre-warming) OR (Composite pre-heating) OR (Temperature)) AND ((Porcelain veneering materials) OR
(Dental veneers) OR (Dental veneers) OR (Dental laminates) OR (Dental laminate) OR (Dental onlay) OR (Dental onlays) OR (Inlays)
OR (Inlays) OR (Inlay) OR (Dental inlays) OR (Onlays OR Onlay) OR (Ceramic) OR (Ceramics) OR (Dental porcelain) OR (Porce-
lain) OR (Porcelain, dentals) OR (Dental, porcelain) OR (Dental veneer) OR (Veneer, dental) OR (Veneers, dental) OR (Veneers) OR
(Veneer)) AND ((Dental) OR (Dentistry) OR (Odontology))
Catalog of Theses & Dissertations of CAPES
((Composite resins) OR (Composite resins) OR (Resin composite) OR (Adhesive resin composites) OR (Dental composites) OR (Resins,
composites) OR (Dental resin) OR (Dental resins) OR (Resin) OR (Resins) OR (Composite) OR (Composites)) AND ((Heating) OR
(Heating) OR (Preheating) OR (Hot temperature) OR (Hot temperature) OR (Hot temperatures) OR (Heat) OR (Transition temperature)
OR (Transition temperature) OR (Transition temperatures) OR (Preheating) OR (Preheated) OR (Preheated) OR (Preheating) OR (Pre-
heating composites) OR (Pre-warming) OR (Composite pre-heating) OR (Temperature))

Data analysis change, marginal sealing, and microleakage were quali-

Quantitative analyses of microtensile bond strength and
film thickness data were carried out using Review Man-
ager software. Additionally, data on flexural strength,
volumetric shrinkage, shear bond strength test, color
tatively analyzed. The global analysis was carried out
using a random-effect model. Pooled-effect estimates
for preheated RC and resin cement (conventional treat-
ment) mean differences and standard error from each
study were calculated. A P value < 0.05 was considered

13
3386
statistically significant. The following subgroup analyses
were performed to decrease heterogeneity: (a) compar-
ing microtensile bond strength between preheated RC and
self-etch or conventional resin cements and (b) comparing
film thickness between the following, preheated RCs and
dual resin cement, preheated RCs and photopolymeriz-
able resin cement, preheated nanohybrid RCs and resin
cement, preheated microhybrid RCs and resin cement,
preheated RCs and self-etch resin cement, and preheated
RCs and conventional resin cements. The statistical het-
erogeneity of the treatment effects between studies was
assessed using Cochrane’s Q test and the inconsistency
I2 statistic.
Results
Description of studies
The search strategy yielded 3,894 papers (Fig. 1), and 3,366
publications were screened after excluding the duplicates.
No documents were identified through manual searching,
and 3,292 studies were excluded because they did not meet
the eligibility criteria. Therefore, 28 papers were full-text
screened. Nineteen studies were excluded for the reasons
presented in Fig. 1, resulting in 7 studies included in this
review. No clinical studies were identified. Five studies were
included in the meta-analysis, and 2 studies were only ana-
lyzed qualitatively as they evaluated material properties not
investigated in other included study. The materials and the
main outcomes from each included study are described in
Tables 2 and 3.
Qualitative and descriptive analyses
Properties such as flexural strength [3], shear bond strength
[23], volumetric shrinkage [24], color change [18], marginal
sealing [25], and microleakage [25] were evaluated using
qualitative analysis (Tables 2 and 3), while microtensile
bond strength [25–27] and film thickness [3, 24, 26] were
assessed using both qualitative and quantitative analyses.
The included studies evaluated the materials’ properties of
the luting agent in association with the overall performance
of the restorations.
Three studies evaluated the microtensile bond strength.
A study [26] compared a RC (Filtek Z250®, 3 M ESPE,
MN, USA) with three resin cements (a dual self-adhesive,
RelyX Unicem®, 3 M ESPE, MN, USA; a conventional
dual, RelyC ARC®, 3 M ESPE, MN, USA; and a dual self-
etching, Clearfill Esthetic®, Kuraray, Tokyo, Japan), while
another study [27] compared two RCs (Filtek Z250®, 3 M
ESPE, MN, USA; and Venus®, Hareaus Kulzer, Weihrheim,
Germany), with and without preheating, with conventional
13
Clinical Oral Investigations (2022) 26:3383–3393
dual resin cement (RelyX ARC®, 3 M ESPE, MN, USA).
The third study [25] compared the resin cement RelyX
U200® (3 M ESPE, MN, USA) with the nanohybrid ENA
HRi® (Synca, Le Gardeur, CA, USA). In two studies [26,
27] the preheated RC revealed increased microtensile bond
strength. In contrast, in another study [25], the use of resin
cement yielded higher microtensile bond strength.
Regarding shear bond strength [23], the Panavia V5®
(Kuraray, Tokyo, Japan) luting agent, with and without
immediate dentin sealing, showed higher shear bond strength
values than the preheated RC (Protect Liner F®, Kuraray,
Tokyo, Japan). A study compared different resin cements
with two RCs (Empress Direct®, Ivoclar Vivadent Schaan,
Liechtenstein; and Filtek Supreme Ultra Universal®, 3 M
ESPE, MN, USA) used with and without preheating. Pre-
heating had no significant effect on volumetric shrinkage.
However, the RCs, whether preheated or not, produced
significantly higher volumetric shrinkage than the tested
resin cements [24]. Besides, all included studies examining
film thickness [3, 24, 26] observed increased film thickness
when using preheated RCs as luting agents compared with
the resin cements.
Only one study evaluated color change [18]. The study
used three RCs (Filtek Z100®, 3 M ESPE, MN, USA; Her-
culite Classic®, CA, USA; and Durafill®, Heraeus Kulzer,
Weihrheim, Germany), with and without preheating, com-
paring them to a conventional light-cured resin cement
(Allcem Veneer®, FGM, São Paulo, Brazil). Overall, color
changes were within the acceptability threshold ΔE (both
ΔEab = 2.66 and ΔE00 = 1.77) for all tested groups after
1 year of storage in distilled water.
Microleakage and marginal sealing were evaluated in
another study [25]. A preheated RC (ENA HRi®, Synca,
Le Gardeur, CA, USA) was compared to a self-etching resin
cement (U200®, 3 M ESPE, MN, USA), and no signifi-
cant difference was found for the degree of microleakage
using either preheating RC or resin cement. Under scanning
electron microscopy, a descriptive analysis of a longitudinal
cut of the indirect composite restorations luted with cement
resin revealed gaps in the tooth–restoration interface. In
addition, a narrower interface thickness was observed along
the walls and cavity floor for the restorations luted with pre-
heating RC.
Meta‑analysis
The meta-analysis examined the microtensile bond strength
and film thickness (Table 3). In the global analysis, pre-
heated RCs did not yield significantly higher microtensile
bond strength than resin cements (P = 0.14; I2 = 92%). Fur-
thermore, there was no statistically significant difference in
the subgroup analysis comparing preheated RCs with self-
etching cements (P = 0.65). In contrast, conventional resin
Clinical Oral Investigations (2022) 26:3383–3393 3387

Fig. 1  Flowchart of the system-

atic review Identification of studies via databases and registers

Records removed before

screening:

Identification
Duplicate records removed (n
Records identified from*:
= 528)
Databases (n = 3,894)
Records marked as ineligible
Registers (n = 0)
by automation tools (n = 0)
Records removed for other
reasons (n = 0)

Records screened Records excluded

(n = 3,366) (n = 3,292)

Reports sought for retrieval Reports not retrieved

Screening

(n = 28) (n = 0)

Reports assessed for eligibility Full-text articles excluded, with

(n = 28) reasons (n = 21)
• No control group (n=11)
• No heated resin composite
(n=1)
• No used resin composite
with luting agent (n=7)
• Not in accordance with the
manufacturer's standards
(n=2)
Included

Studies included in review

(n = 7) and in meta-analysis
(n=5)

Table 2  Relevant information from each included study

Study Substrate Restoration Evaluated Properties

Alvarado et al., 2020 Third molars human Prefabricated resin composite restorations Marginal sealing
Microleakage
Microtensile bond strength
Coelho et al., 2019 Resin composite Overlapping blocks of resin composite and Film thickness
lithium disilicate ceramic Biaxial flexural strength
Goulart et al., 2018 Third molars human Indirect resin composite restorations, made on Microtensile bond strength
cylindrical molds
Gugelmin et al., 2020 Forty pigmentation-free bovine incisors Ceramic veneers of lithium disilicate Color change
Reboul et al., 2018 Third molars human Overlay made of lithium disilicate block Shear bond
Sampaio et al., 2016 Artificial plastic maxillary central incisors Laminate veneers with the manufacturer’s Film thickness
plastic veneers Volumetric shrinkage
Sartori et al., 2016 Third molars human Leucite-reinforced glass–ceramic slabs Microtensile bond strength
Film thickness

13
 Table 3  Description of luting agents evaluated and main qualitative and quantitative results from each included study
3388

Outcomes Luting agents Type of resin Preheated type Number of Main results Mean (SD)
samples

13
Microtensile bond strength
Sartori et al., 2016 Filtek Z250 Microhybrid 68°C Calset 3 Filtek Z250 showed a statistically 35.58 (10.3) MPa*
RelyX Unicem - - 3 higher microtensile bond strength 19.52 (8.1) MPa
than resin cements
Clearfil Esthetic - - 3 19.23 (7.9) MPa
RelyX ARC​ - - 3 18.13 (7.0) MPa
Goulart et al., 2018 Filtek Z250 Microhybrid 22°C Digital wax pot 5 When luting 2 mm restorations, only 36.90 (6.38) MPa*
Venus Submicron 22°C Digital wax pot 5 Filtek Z250XT preheated or at room 29.11(10.3) MPa*
temperature, achieved significantly
Filtek Z250 Microhybrid 64°C Digital wax pot 5 higher microtensile bond strength 32.43 (5.54) MPa*
Venus Submicron 64°C Digital wax pot 5 than RelyX Arc 27.78 (10.3) MPa*
RelyX ARC​ - - 5 25.48 (7.92) MPa
ENA HRi Nanohybrid 55ºC 15 A higher microtensile bond strength 14.42 (4.86) MPa*
Alvrado et al., 2020 RelyX U200 - 15 was obtained with resin cement when 27.82 (5.81) MPa
compared with preheated RCs
Film thickness
Sartori et al., 2016 Filtek Z250 Microhybrid 68°C Calset 3 Preheated RCs showed the higher film 443.41 (3.0) µm*
RelyX Unicem - - 3 thickness 16.38 (1.0) µm
Clearfil Esthetic - - 3 48.13 (1.0) µm
RelyX ARC​ - - 3 97.13 (1.0) µm
Sampaio et al., 2016 Filtek Supreme Ultra Universal Nanocomposite - 6 The film thickness of direct RCs, 320 (30) µm*
Filtek Supreme Ultra Nanocomposite 68°C Water bath 6 preheated or not, was significantly 300 (60) µm*
higher than the film thickness of
IPS Empress Direct Nanohybrid - 6 veneer luting agents and flowable 310 (30) µm*
IPS Empress Direct Nanohybrid 68°C Water bath 6 resin composites 310 (40) µm*
RelyX Veneer - - 6 170 (30) µm
Variolink Esthetic LC - - 6 210 (40) µm
Coelho et al., 2019 Estelite Omega Suprananometric 69°C Hotset 30 All preheated RCs showed a higher 196 (68.0) µm*
Empress Direct Nanohybrid 69°C Hotset 30 film thickness than the resin cement 165 (58.0) µm*
Filtek Z100 Microhybrid 69°C Hotset 30 106 (35.0) µm*
RelyX Veneer - - 30 59 (27.0) µm
Shear bond strength
Reboul et al., 2018 Protect Liner F Microfiller 60 °C Ena Heat 10 Preheated RC provided higher shear 8.33 (2.85) MPa*
Panavia V5 with immediate dentin - - 10 strength than resin cement 15.74 (2.13) MPa
sealing
Panavia V5 without immediate dentin - - 10 12.08 (1.41) MPa
sealing
Biaxial flexural strength Z=0 Z =  − t2
Coelho et al., 2019 Estelite Omega Suprananometric 69°C Hotset 30 Pheheated RCs yielded higher biaxial 155 (17.4) MPa 54.9 (12.2) MPa*
Empress Direct Nanohybrid 69°C Hotset 30 flexural strength than RelyX Veneer 152 (17.4) MPa 48.8 (8.47) MPa*
in the groups where the resin-based
Filtek Z100 Microhybrid 69°C Hotset 30 agent surface above the ring was 145 (13.6) MPa 49.2 (6.81) MPa*
RelyX Veneer - - 30 located (position z =  − t2) 144 (17.3) MPa 24.6 (3.29) MPa
Clinical Oral Investigations (2022) 26:3383–3393
 Table 3  (continued)
Outcomes
Volumetric shrinkage
Sampaio et al., 2016
Color change
Gugelmin et al., 2020
Microleakage
Alvarado et al., 2020
Marginal sealing
Alvarado et al., 2020
NF, not found
*
Preheated RCs were significantly different than resin cements
13
Luting agents Type of resin Preheated type Number of Main results Mean (SD)
samples
Filtek Supreme Ultra Universal Nanocomposite - 6 Preheated RCs showed a statistically 2.44 (0.26) %
Filtek Supreme Ultra Nanocomposite 68°C Water bath 6 similar volumetric polymerization 2.09 (0.40) %
shrinkage to RelyX Veneer, but
IPS Empress Direct Nanohybrid - 6 higher than flowable RCs and the 2.13 (0.25) %
IPS Empress Direct Nanohybrid 68°C Water bath 6 resin cement Variolink Esthetic LC 1.95 (0.33) %
RelyX Veneer - - 6 1.74 (0.57) %
Variolink Esthetic LC - - 6 1.03 (0.46) %
Allcem Veneer - - 10 Preheated RCs and resin cements ΔE00 = 2.0 (0.5)
Allcem showed a similar color change at the
Clinical Oral Investigations (2022) 26:3383–3393
- - 10 ΔE00 = 2.3 (0.8)
Filtek Z100 end of 1 year of storage in distilled
Filtek Z100 Microhybrid - 10 water, and all groups maintained ΔE00 = 2.4 (0.2)
Herculite Classic Microhybrid 60ºC 10 their ΔE00 lower than the acceptabil- ΔE00 = 2.1 (0.6)
Herculite Classic Microhybrid - 10 ity threshold ΔE00 = 2.7 (1.4)
Durafill
Microhybrid 60ºC 10 ΔE00 = 2.0 (0.7)
Durafill
Microfilled - 10 ΔE00 = 3.6 (1.0)
Microfilled 60ºC 10 ΔE00 = 3.6 (1.6)
ENA HRi Nanohybrid 55ºC 15 Preheated RCs was statistically similar 47.7 (NF) µm
RelyX U200 - 15 to resin cement in the degree of 84.4 (NF) µm
microfiltration
ENA HRi Nanohybrid 55ºC 15 In the preheated RC group, a narrower -
RelyX U200 - 15 interface was observed along the -
walls and the floor of the cavity
compared to the resin cement group,
that revealed the presence of gaps
in the tooth restoration junction
interface in the descriptive analysis
of the Scanning electron microscope
micrograph
3389
3390
cements showed higher microtensile bond strength values
than preheated RCs (P = 0.002), as shown in Fig. 2. Moreo-
ver, preheated RCs exhibited significantly higher film thick-
ness than resin cements in the global and subgroup analyses
(P < 0.001), as shown in Fig. 3.
Study quality assessment
Considerable heterogeneities in research design, methods,
outcome variables, and data variability were observed in the
selected studies (Fig. 4). Only one study reported operator
blinding for testing, and few studies randomly allocated their
specimens to minimize the risk of bias. None of the studies
reported on sample size calculation. In contrast, all studies
reported sufficient information to enable replication. The
reviewers identified no other potential sources of bias.
Discussion
This systematic review was the first to summarize in vitro
evidence on mechanical properties, physicochemical perfor-
mance, and color change of indirect restorations luted with
preheated conventional RCs showing that the type of luting
agents affected the evaluated outcomes.
The global analysis of the bond strength performance
found no significant difference. Indeed, the subgroup analy-
sis comparing preheated RCs with different resin cements
revealed that preheated RCs presented mechanical properties
similar to self-etch resin cement and worse than conven-
tional luting agents. The similar bond strength performance
Fig. 2  Microtensile bond strength analysis: a subgroup analysis com-
paring self-etch resin cement versus preheated resin composite with
no statistically significant differences between groups (P = 0.65); b
subgroup analysis comparing conventional resin cement versus pre-
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Clinical Oral Investigations (2022) 26:3383–3393
observed between preheated RCs and self-etch resin cements
may be explained by the acidic monomers (i.e., 10 MDP)
present in the formulation of the self-etch, which could
act as diluents, reducing the viscosity of the material and
increasing its wettability and the ability to interact with the
dental tissues [28]. It is known that the main differences
in the composition of resin cements and RCs are linked to
the concentration of inorganic filler particles and organic
matrix, which improve the mechanical properties of RCs.
Compared to RCs, the resin cements typically comprise a
more organic matrix and a lower concentration of inorganic
filler particles [29].
Considering film thickness, the global and subgroup
meta-analysis showed that preheated RC exhibited clinically
unacceptable film thickness (> 120 µm). Higher organic
matrix content of resin cements provides a more efficient
flow, resulting in lower film thickness than preheated RCs
[3]. A previous study showed that films created by preheated
RCs were 4.5 times thicker than those produced by dual-
cure resin cements when using the same adhesive system
and applied load [26], agreeing with the findings of the pre-
sent meta-analysis. It has been suggested that luting agents
should ideally create a film thickness with values equal to or
lower than 120 µm [16, 17]. However, only one recent s­ tudy3
showed that Filtek Z100® resin preheated using Hotset® at
69 ºC produced clinically acceptable film thickness, with
an approximate value of 100 µm. A film thickness above
the recommended values may result in higher exposure of
the luting agent to the oral environment [30], yielding poor
marginal adaptation [31] and higher microleakage in long-
term follow-up of indirect restorations [24]. A recent study
heated resin composite, with a higher and statistically significant
microtensile bond strength in the preheated resin composite group
(P = 0.002). Global analysis shows no statistically significant differ-
ences between groups (P = 0.14)
Clinical Oral Investigations (2022) 26:3383–3393
Fig. 3  Film thickness analysis shows a higher and statistically sig-
nificant film thickness in the preheated resin composite group com-
pared to a dual resin cement (P < 0.001) or b photopolymerizable
resin cement (P < 0.001). Comparison between different types of
resin composite shows a higher and statistically significant film thick-
ness in the c preheated nanohybrid (P < 0.001) and d microhybrid
resin composite (P < 0.001) compared to resin cements. Comparison
reported that variability in film thickness could be explained
by distinct preheating behavior from different RC compo-
sitions [15]. Nevertheless, there is moderate evidence that
3391
between different types of resin cement also shows a higher and sta-
tistically significant film thickness in the preheated resin composite
group compared to e self-etch resin cement (P < .001) or f conven-
tional resin cement (P = 0.03). Global results indicate a higher and
statistically significant film thickness for preheated resin composite
than resin cements (P < 0.001)
microleakage tests with dye penetration do not correlate with
any of the clinical parameters (post-operative hypersensitiv-
ity, retention, marginal staining) [32].
13
3392
Fig. 4  Risk of bias summary: review authors’ judgments about each
risk of bias item for each included study. ( +) low risk of bias; (?)
unclear risk of bias; *studies not included in the meta-analysis
It is important to consider some limitations for the
present review. Blinding of the testing machine operator
was performed by only one study included in this review.
In vitro studies rarely assess dental materials, as sug-
gested by other reviews [22, 33]. Yet, this is an impor-
tant limitation since an experienced operator could easily
identify the different types of samples assessed, which
may lead to bias in the observation of the results. In addi-
tion, none of the included studies calculated the sample
size. The researchers have used a sample size similar to
previous studies or suggested by standards [23]. Studies
that did not use materials in accordance with the manu-
facturer’s instructions were not included in this system-
atic review to minimize any bias; therefore, a low risk
of bias was observed in the majority of the parameters
investigated.
Although the different types of preheated RC may
influence the outcomes [3, 15], based on qualitative and
quantitative analysis of the included studies, our findings
suggested that preheated RCs exhibited similar to poor
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Clinical Oral Investigations (2022) 26:3383–3393
physicochemical performance and color change, with a
minor improvement in the mechanical properties of indi-
rect restorations when compared to resin cements. Indeed,
a clinically unacceptable film thickness and volumetric
shrinkage were observed in indirect restorations luted
with preheated RCs. Therefore, the study hypothesis was
rejected, because preheated RC did not show significant
advantages compared to resin cements to justify its unre-
stricted use. From seven included studies assessing indi-
rect restoration properties using preheated RCs as luting
agents, only one study reported findings on shear bond
strength [23], flexural strength [3], volumetric shrinkage
[24], color stability [18], microleakage [25], and marginal
sealing [25] (Table 3), which precluded the assessment of
heterogeneity by using meta-funnel and subgroup analyses.
Therefore, the results found in the meta-analysis should
be cautiously interpreted, and further studies assessing
different preheated RCs as luting agents and preheating
techniques are needed to evaluate their influence on the
mechanical properties, physicochemical performance, and
color change on indirect ceramic restorations.
Conclusion
Within the abovementioned limitations of this study, this
systematic review showed that using preheated RCs as
luting agents offers minor improvements in the mechani-
cal properties of indirect restorations and similar to poorer
physicochemical properties than resin cements, including a
clinically unacceptable film thickness.
Funding This study was partly funded by the Coordenação de Aper-
feiçoamento de Pessoal de Nível Superior — Brasil (CAPES) —
Finance Code 001.
Declarations
Ethics approval Not applicable.
Consent to participate Not applicable.
Conflict of interest The authors declare no competing interests.
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