SYSTEMATIC REVIEW

Does the application of an adhesive layer improve the bond

strength of etched and silanized glass ceramics to resin-based
materials? A systematic review and meta-analysis
Iara de Oliveira Nogueira, DDS,a Paula Fernanda Gomes de Oliveira, DDS,b Marcela Baraúna Magno, DDS, MSc,c
Daniele Masterson Tavares Pereira Ferreira, MSc,d Lucianne Cople Maia, DDS, MSc, PhD,e and
Tiago Braga Rabello, DDS, PhDf

With the demand for indirect ABSTRACT

esthetic restorations, contem-
porary ceramic systems have
been developed with varying
proportions of glass and crys-
talline phases to ensure a
balance between improved me-
chanical properties, color sta-
bility, and radiopacity.1,2 Among
the several types of ceramics
available in dentistry, glass-
ceramics, including feldspathic-
reinforced, leucite-reinforced,
and lithium disilicateereinforced
materials, have been widely
used, mainly because they can
be adhesively bonded to tooth
structure.1
To optimize the bonding
procedures, pretreatment steps
for the tooth and ceramic surface
are necessary before applying
resin cements.3,4 The most com-
mon method of pretreating the
glass-ceramic surface is etching
Statement of problem. A consensus on whether to use an adhesive layer on glass ceramics after
etching with hydrofluoric acid and applying a silane-coupling agent is lacking.
Purpose. The purpose of this systematic review and meta-analysis was to determine whether
adhesive layer application after etching and silanization influences the bond strength values of
glass ceramics to resin-based materials.
Material and methods. PubMed, ISI Web of Science, and Scopus electronic databases were
searched to select in vitro studies comparing bond strength values of etched and silanized glass
ceramics bonded with or without an adhesive layer. No publication year or language restriction
was applied. Data sets were extracted, and the mean differences were applied by using the Rev
Man 5.3 program. The association between bond strength (shear/microshear or tensile/
microtensile) and an adhesive layer application on nonaged and aged specimens was analyzed.
Results. Of 4727 potentially eligible studies, 54 were selected for full-text analysis, and 15 were
included for qualitative synthesis; of these, 14 were used in the meta-analysis. A total of 2 meta-
analyses were performed with heterogeneity varying from high to moderate among study
specimens. For shear/microshear studies, both nonaged (MD, 1.36 [95% CI: -0.18, 2.90], P=.080,
I2=79%) and aged (MD, 0.89 [95% CI: -1.04, 2.82], P=.370, I2=80%) specimens presented no
statistically significant difference between groups bonded with or without an adhesive layer
application. For microtensile studies, both nonaged (MD, -1.49 [95% CI: -2.48, -0.50], P=.003,
I2=88%) and aged (MD, -3.87 [95% CI: -5.63, -2.11], P<.001, I2=97%) specimens exhibited higher
values without an adhesive application.
Conclusions. Regardless of the bond strength test used, an adhesive layer application did not
improve the bond strength of etched and silanized glass ceramics to resin-based materials. The
influence of this adhesive layer application should be evaluated under clinical conditions. (J Pros-
thet Dent 2020;-:---)

a
Postgraduate student in Operative Dentistry, Department of Dental Clinic, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
b
Masters student in Operative Dentistry, Department of Dental Clinic, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
c
Doctoral student, Department of Pediatric Dentistry and Orthodontics, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
d
Doctoral student, Health Information and Communication, Institute of Communication and Scientific Information and Technological in Health, Oswaldo Cruz Foundation
(FIOCRUZ), Rio de Janeiro, Brazil.
e
Full Professor, Department of Pediatric Dentistry and Orthodontics, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
f
Associate Professor, Department of Dental Clinic, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.

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Clinical Implications
This study showed that the use of an adhesive layer
on glass ceramics after etching with hydrofluoric
acid and the application of a silane-coupling agent
is unnecessary because it did not improve the bond
strength between glass-ceramics and resin-based
luting agents.
with hydrofluoric acid (HF) followed by application of a
silane-coupling agent.5,6 This pretreatment has been re-
ported to provide the highest bond strength values.3,4,7-11
Resin cements need sufficient wettability to
completely infiltrate the irregularities of a ceramic sur-
face; however, whether the viscosity of the cement pre-
vents interaction with the conditioned and silanized glass
ceramic surface is unclear.1 Therefore, the use of an in-
termediate adhesive layer has been recommended before
applying the resin cements.1,3,12,13 This hydrophobic
layer over a silanized surface could increase wettability,
especially of bis-GMAebased resin materials because its
viscosity is lower than that of resin cement.9
Bond strength studies on glass ceramics are conflict-
ing regarding the use of an adhesive layer in association
with HF etching and a silane-coupling agent.1,3,8,10-12,14
This lack of consensus has created confusion among
dentists seeking to choose the ideal technique. Although
no mechanical test is adequate to precisely simulate all
existing clinical variables, in vitro studies allow the
evaluation and comparison of the performance of
different materials in a condensed period. Furthermore,
they are useful for creating guidelines for clinical practice,
considering the difficulty in conducting clinical studies to
assess the durability of a bonded restoration. Therefore,
the purpose of this systematic review and meta-analysis
was to assess in vitro studies on the influence of an ad-
hesive layer application on the bond strength of etched
and silanized glass ceramics to resin-based materials.
MATERIAL AND METHODS
This systematic review was conducted according to the
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) statement and the Patient or
Population, Intervention, Control or Comparison,
Outcome, and Study types (PICOS) approach.15,16 The
following research question was formulated to address
the literature search strategy: Does an adhesive layer
application improve the bond strength of etched and
silanized glass ceramics to resin-based materials?
An electronic search was conducted in the PubMed,
Scopus, and ISI Web of Science databases till October 22,
2018, to identify potential studies to be evaluated. A
combination of MeSH and free terms with the Boolean
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operators OR and AND following the syntax rules of
each database was used. Publication year and language
were not limited. The search strategy is outlined in
Table 1.
After removing duplicates, all titles and abstracts were
independently analyzed and selected by 2 authors
(I.O.N., P.F.G.O.) according to their first consensus for
further assessment by considering the following inclusion
criterion: studies comparing the bond strength values of
etched and silanized glass ceramics to resin-based ma-
terials, with or without adhesive layer application. No
restriction regarding bond strength methodology was
applied.
The reference lists of the full text of all included
studies were manually searched to identify any further
studies. In the case of the absence of the full text, the
main and corresponding authors were contacted.
The full texts of all studies that fulfilled the inclusion
criteria for eligible articles were then again reviewed
independently by 2 authors (I.O.N., P.F.G.O.), and the
studies matching the following criteria were included:
in vitro studies evaluating bond strength to feldspathic-
reinforced, leucite-reinforced, and/or lithium
disilicateereinforced ceramics and studies that presented,
among the experimental groups, specimens comparing
the use of the same silane product, followed or not by an
adhesive layer application. Any disagreement in terms of
eligibility criteria was solved by discussion and a third
reviewer (T.B.R.).
Exclusion criteria for the studies were literature review
studies; the absence of the main material comparison
(silane versus silane+adhesive layer); other materials
studied instead of the main glass ceramic groups (feld-
spathic ceramics, leucite-reinforced and lithium
disilicateereinforced glass ceramics); pretreatment of
surfaces other than HF etching; use of other bonding
material instead of resin-based ones; and in vitro testing
that did not evaluate bond strength values.
From the included articles, the following data were
extracted: publication year, origin country, type of glass
ceramic, type of adhesive system used, number of spec-
imens, type of resin-based material, type of test, and any
potential aging procedure (water storage time, thermo-
cycling, and number of thermocycles) imposed. The bond
strength mean values in megapascal (MPa) and standard
deviations (±SD) for each interest group were also
extracted. If information was missing or if the bond
strength values were not reported in mean values, the
authors were contacted 3 times by e-mail at 1-week in-
tervals until any missing data were retrieved.
The methodological quality of each included study was
independently assessed by 2 reviewers (I.O.N., T.B.R.), by
using an adapted scoring system, which has been described
in previous systematic reviews of in vitro studies.17,18 The
description of the following parameters were evaluated in
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Table 1. Search strategy in PubMed, Scopus, and ISI Web of Science

Databases Literature Search Strategy
PubMed ((adhesives [MeSH] OR adhesi*[tiab] OR tissue adhesives [MeSH] OR tissue adhesi*[tiab] OR dentin-bonding agents [MeSH] OR dentin bonding agent*
[tiab] OR dentin bonding[tiab] OR bonding agent*[tiab] OR dental cements [MeSH] OR dental cement*[tiab] OR cement* [tiab] OR luting agent*[tiab] OR
dental adhesi* [tiab] OR dental adhesive system* [tiab]) AND (silanes [MeSH] OR silan*[tiab] OR silane coupling [tiab] OR silane coupling agent*[tiab] OR
surface treatment*[tiab]) AND (dental porcelain [MeSH] OR dental porcelain*[tiab] OR porcelain* [tiab] OR lithiadisilicate [tiab] OR lithium disilicate[tiab]
OR lithium disilicate glass ceramic*[tiab] OR ceramics [MeSH] OR ceramic*[tiab] OR dental ceramic*[tiab] OR feldspathic[tiab] OR feldspathic ceramic*
[tiab] OR feldspathic porcelain[tiab] OR glass ceramic*[tiab]))
Scopus (TITLE-ABS-KEY (adhesi* OR “tissue adhesives” OR “dentin bonding agents” OR “dentin bonding” OR “bonding agents” OR “dental cements” OR cement*
OR “luting agents” OR “dental adhesives” OR “dental adhesive systems”) AND TITLE-ABS-KEY (silan* OR “silane coupling” OR “silane coupling agents” OR
“surface treatment”) AND TITLE-ABS-KEY (“dental porcelain” OR porcelain OR “lithiadisilicate” OR “lithium disilicate” OR “lithium disilicate glass ceramic”
OR ceramic* OR “dental ceramics” OR feldspathic OR “feldspathic ceramics” OR “feldspathic porcelain” OR “glass ceramic"))
ISI Web of TS=(adhesi* OR tissue adhesi* OR dentin bonding agent OR “dentin bonding” OR bonding agent* OR dental cement* OR cement* OR luting agent* OR
Science dental adhesi* OR dental adhesive system*) AND TS=(silan* OR “silane coupling” OR silane coupling agent* OR surface treatment*) AND TS=(dental
porcelain* OR porcelain* OR “lithiadisilicate” OR “lithium disilicate” OR lithium disilicate glass ceramic* OR ceramic* OR dental ceramic* OR feldspathic OR
feldspathic ceramic* OR feldspathic porcelain* OR glass ceramic*)

each study: specimen randomization; single operator pro-
tocol implementation; blinding of the testing machine
operator; the presence of a control group; standardization of
sample preparation; failure mode evaluation; use of all
materials according to the manufacturer’s instructions;
description of sample size calculation; and discarded sample
if there was any evidence (irregularities, bonding defects, or
flaws) that could influence the results. If the authors re-
ported the parameter, the study received a “YES” for that
specific parameter; otherwise, if it was not possible to find
the information, it received a “NO.” The risk of bias was
classified according to the sum of “YES” answers received as
follows: 1 to 3=high, 4 to 6=medium, and 7 to 9=low risk of
bias.
The extracted data were analyzed by using a software
program (Review Manager v5.3; the Cochrane Collabo-
ration) to assess the relationship between an adhesive
layer application on the bond strength of resin-based
materials to etched- and silanized-glass ceramics.
Following previous literature,19-21 only studies judged as
low or medium risk of bias were included in a meta-
analysis. Two meta-analyses were carried out to eval-
uate the association between shear/microshear bond
strength and adhesive layer application in nonaged and
aged specimens and the association between tensile or
microtensile bond strength and adhesive layer applica-
tion in nonaged and aged specimens.
The mean and standard deviation of bond strength
values and the number of specimens per group (with
adhesive application versus without adhesive applica-
tion) were used to calculate the mean difference with a
95% confidence interval (95% CI). As the studies re-
ported the outcome with the same method, the mean
difference (MD) was applied.22 A level of significance
lower than 0.05 for MD was adopted to consider statis-
tical significance for all analyses for inverse variance
statistical methods.22
A random-effect model was used when the studies
were not functionally equivalent to generalize the results
from the meta-analysis. A fixed-effect model was used
when a small number of studies (5 or fewer) were
included.23 Heterogeneity was tested using the I2 index,
and the following scale was considered: an I2 value close
to 0% indicated nonheterogeneity between studies, close
to 25% indicated low heterogeneity, close to 50% indi-
cated moderate heterogeneity, and close to 75% indi-
cated high heterogeneity between studies.24
RESULTS
Figure 1 summarizes the selection process of the studies.
In total, 5250 studies were identified through search
strategies based on the 3 databases (PubMed, Scopus,
and ISI Web of Science). After the first review process
and removal of duplicates, 4727 titles and abstracts were
analyzed. Subsequently, 4673 records were excluded
because they did not meet the primary inclusion criteria,
leaving 54 records. These full texts were assessed for
eligibility, and 39 articles were excluded based on the
inclusion and exclusion criteria. Fifteen1-4,8-10,12-14,25-29
studies were included for the qualitative synthesis (sys-
tematic review). However, one of them was not included
in the meta-analysis because of a high risk of bias.4
Therefore, 14 studies were part of the quantitative
synthesis.
Table 2 presents the descriptive data extraction from
the included studies in the systematic review. All the
15 included studies were published between 1987
and 2018, with only 1 published before 2000.25
Most studies were conducted in Brazil,1,2,9,10,12,13,26,27
followed by the Netherlands.3,14 In this collection, 14
different brands of adhesive system were evaluated,
including hydrophobic1,8,9,13,14,27,28 and hydrophilic
adhesives.2-4,10,12,14,25,26,29 In general, shear or micro-
shear bond strength tests were the most prevalent test
evaluated among the studies,1,2,4,10,12,13,25-27,29 followed
by the microtensile bond strength tests3,8,9,14,28 (the
mean and confidence interval for shear or microshear
bond strength tests and the microtensile bond strength of
each study included in the present systematic review are
presented in Supplemental Tables 1 and 2, available
online). No studies presenting tensile bond strength test

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Records identified through database searching

IDENTIFICATION
(n=5250)
PubMed search n=1224
Scopus search n=1850
Web of Science search n=2176

Records after duplicates removed +

SCREENING

title and abstract analysis

(n=4727)

Titles and abstracts excluded

(n=4673)

Full text articles assessed for

eligibility
ELIGIBILITY

(n=54)

Excluded articles based on specific criteria

(n=39)
Absence of the main comparison (silane X silane + adhesive) n=26
Other materials instead of the main glass ceramics group n=5
Pre-treatment surface ≠ HF etching n=3
In vitro tests did not evaluate bond strength n=2
Review study n=1
Not full text available in library and failure contact with authors n=1
Overlapping record n=1

Included for qualitative synthesis

(Systematic review)
INCLUDED

(n=15)

Excluded to present a high risk of bias

(n=1)

Included for quantitative synthesis

(Meta-analysis)
(n=14)

Figure 1. Flowchart of study selection.

were included in this systematic review. In addition, few
studies performed aging procedures, such as water
storage for more than 2 months2,12,26 or
thermocycling.4,9,28
All included studies in the systematic review scored
between high and low risk of bias (Table 3). From the 15
studies included in the systematic review, after fitting the
inclusion criteria, only one4 presented a high risk of bias,
so this study was excluded from the quantitative syn-
thesis. In this way, 14 studies were included in the meta-
analyses (Supplemental Tables 1 and 2, available online),
of which the data sets were used in both meta-analyses.
Most of the included studies showed more than 1
type of resin-based material, resulting in more than 1
comparison (with versus without adhesive application) in
the same study. These comparisons in each study
included in the meta-analyses were identified by
different letters (A, B, C, D, E, F). The various types of
resin-based materials were included in the meta-analyses
with different amounts of *. In the meta-analysis, the
amount of * next to the author’s name and year identifies
the type of resin-based materials used by the study in the
related analysis: * conventional resin cement, ** self-
adhesive resin cement, *** medium viscosity composite
resin, **** low-viscosity composite resin. Moreover, if a
study presented 2 types of adhesive system and only 1
control group, the etch-and-rinse systems (3- or 2-step)
were adopted as an intervention group as there was no

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Table 2. Data extraction of included studies

Type of Glass Sample Number Resin-Based Bond Strength
Article Year Country Ceramic per Group Storage/Aging Adhesive System Material Testing
Sebben et al27 2018 Brazil Feldspathic 20 24 h Clearfil SE Bond Rely X Veneer mSBS
Z350 Flow
Romanini-Junior 2018 Brazil Lithium disilicate 5 24 h Scotchbond SureFil SDR Flow mSBS
et al26 1y Universal
XP Bond
Cardenas et al2 2017 Brazil Lithium disilicate 8 24 h Prime & Bond Elect Enforce mSBS
1y Scotchbond RelyX Ultimate
Universal
Murillo-Gómez 2017 Brazil Lithium disilicate 18 24 h Adper Single Bond 2 RelyX Ultimate mSBS
et al12 6 mo
Al-Thagafi et al28 2016 Egypt Lithium disilicate 15 5000 thermocycles Heliobond Tetric EvoCeram mTBS
Lise et al10 2015 Brazil Lithium disilicate 12 24 h ExciTE F DSC Variolink II mSBS
Multilink Automix
RelyX Unicem 2
Sundfeld Neto 2015 Brazil Lithium disilicate/ 6 24 h Scotchbond Variolink II mSBS
et al1 leucite MultiPurpose
Naves et al13 2010 Brazil Leucite 6 24 h Scotchbond Variolink II mSBS
MultiPurpose
Passos et al9 2008 Brazil Feldspathic 50 Immediate Scotchbond Variolink II mTBS
12 000 MultiPurpose
thermocycles+50 d
Peumans et al8 2007 Belgium Leucite 12 24 h Heliobond Variolink II mTBS
*Reich et al4 2005 Germany Feldspathic 10 24 h Heliobond Calibra SBS
5000 thermocycles Variolink II
10 000 thermocycles RelyX Unicem
El Zohairy et al14 2004 The Feldspathic 10 24 h Syntac single- Tetric Flow mTBS
Netherlands 7d component Nexus 2
28 d OptiBond Solo Plus
Vision Bond
El Zohairy et al3 2003 The Feldspathic 10 24 h Syntac Single- Tetric Flow mTBS
Netherlands Component Nexus 2
OptiBond Solo Plus RelyX ARC
Scotchbond 1
Estafan et al29 2000 USA Leucite 6 24 h Bond-1 Lute-It SBS
Stangel et al25 1987 Canada Leucite 7 7d Creation Bond Ultra-Bond SBS

mSBS, microshear bond strength; mTBS, microtensile bond strength; SBS, shear bond strength. *Not included in meta-analysis.

difference in the results when 1 type of adhesive system
was compared with the other. Furthermore, for the aged
data set, studies were considered when the specimens
were either stored in water for longer than 2 months or
subjected to thermocycling for more than 1000 cycles.30
Nine studies1,2,10,12,13,25-27,29 were included in the first
meta-analysis (Fig. 2), and, as the Cochrane handbook22
suggests, it was analyzed with the random-effect model.
In the separate analysis of the subgroups, nonaged
specimens bonded with an adhesive layer (n=258) pre-
sented a statistically similar shear or microshear bond
strength to those without an adhesive layer (n=258) (MD,
1.36 [95% CI: -0.18, 2.90], P=.080, with I2=79%). In
addition, in the aged specimens, no statistically signifi-
cant difference was observed between bonding with
(n=55) and without an adhesive layer (n=55) (MD, 0.89
[95% CI: -1.04, 2.82], P=.370, with I2=80%).
Five studies3,8,9,14,28 were included in the second
meta-analysis (Fig. 3), and, as the Cochrane handbook22
suggests, the fixed-effect model was used. In the separate
analysis of the subgroups, nonaged specimens without
an adhesive layer (n=152) presented statistically signifi-
cant higher microtensile bond strength than the nonaged
specimens with an adhesive layer (n=152) (MD, -1.49
[95% CI: -2.48, -0.50], P=.003, with I2=88%). The sta-
tistically significant superiority of the group without an
adhesive layer (n=65) in relation to the group with an
adhesive layer (n=65) remained with the aged specimens
(MD, -3.87 [95% CI: -5.63, -2.11], P<.001, with I2=97%).
DISCUSSION
To achieve the durable adhesion of resin-based materials
to glass-ceramics, the sequence of surface treatment
before resin adhesion is important. The need for HF
etching and silanization in bonding procedures involving
ceramics has been well established.5,6 However, the use of
an adhesive layer on etched and silanized glass ceramic
surfaces has been reported to be questionable,3,4,9,14 spe-
cifically in terms of whether the viscosity of a resin-based
material is sufficient to completely infiltrate the irregular-
ities of the ceramic surface.1 However, this systematic
review and meta-analysis did not provide evidence justi-
fying the use of an adhesive system once an adhesive layer
application had not improved the bond strength of etched
and silanized glass-ceramics to a resin-based materials.

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Table 3. Qualitative synthesis (risk of bias assessment)

(8)
(1) Specimens (2) Single (3) Operator (4) Control (5) Standardized (6) Failure (7) Manufacturer’s Sample (9) Discarded Risk of
Study Randomization Operator Blinded Group Specimens Mode Instructions Size Samples Bias
Sebben YES YES NO YES YES YES NO NO YES Medium
et al27
Romanini- YES NO NO YES YES YES NO NO NO Medium
Junior et al26
Cardenas YES YES NO YES YES YES YES YES YES Low
et al2
Murillo- YES NO NO YES YES YES YES NO YES Medium
Gómez et al12
Al-Thagafi NO NO NO YES YES YES NO NO YES Medium
et al28
Lise et al10 YES YES NO YES YES YES NO NO YES Medium
Sundfeld YES YES NO YES YES YES NO YES YES Low
Neto et al1
Naves et al13 NO NO NO YES YES YES NO NO YES Medium
Passos et al9 YES NO NO YES YES YES YES NO YES Medium
Peumans YES NO NO YES YES YES NO NO YES Medium
et al8
Reich et al4 NO NO NO YES YES YES NO NO NO High
El Zohairy YES NO NO YES YES YES NO NO YES Medium
et al14
El Zohairy YES NO NO YES YES YES NO NO YES Medium
et al3
Estafan et al29 YES NO NO YES YES YES NO NO NO Medium
Stangel et al25 YES NO NO YES YES YES NO NO NO Medium

Adhesives are available in either hydrophobic or hy-
drophilic forms.9 Most of the current bonding agents
include hydrophilic monomers and solvents to promote
adhesion to dentin.14 The difference in the stability of
composite resins bonded to ceramic surfaces when hy-
drophilic adhesives or hydrophobic adhesives are used is
unclear. Greater stability for hydrophobic adhesives is
expected, as water would not be able to penetrate the
adhesive interface.14 Such an investigation could not be
made in the present meta-analysis because only 1
study14 submitted specimens to this comparison (hy-
drophilic versus hydrophobic). Thus, as adhesive
composition may be a possible confounding variable,
future investigations should evaluate the ceramic-resin
bonding strength produced by different adhesive
compositions.
HF etching and silane application to improve bond
strength between luting agents and glass ceramics has
been well documented. However, if one of the steps is
not correctly performed, the long-term success of the
restoration can be compromised.31 The reduction of
steps without compromising the quality of restorations
is desirable.26 Therefore, silane-containing universal
adhesive systems were developed, making the silane
application step unnecessary according to the manu-
facturer.26 However, the effectiveness of this bond
procedure is still unclear. Silane-containing universal
adhesives have been reported to require a prior silane
application to improve adhesion between glass-ceramic
and composite resin.2,26,31 Thus, one of the inclusion
criteria of this systematic review was studies comparing
bond strength values of etched and silanized glass-
ceramics to resin-based materials, excluding specimens
that received only a silane-containing universal adhe-
sive layer.
Less attention has been given to the role of the resin
cement in ceramic-resin bond durability. However, var-
iations in chemical composition, wetting ability, viscosity,
and mechanical properties of each resin-based luting
agent might also be responsible for variations in the bond
strength.10,27 The ceramic-resin bond durability has been
reported to depend on the resin cement.14 Conversely, El
Zohairy et al3 reported that HF etching and silanization
surface treatment had the main effect of establishing the
ceramic-resin bond, regardless of the type of cement
used. As clinical trials comparing resin cements are
sparse,10 future studies should evaluate the bond
strength between different resin-based luting agents and
glass-ceramics.
In this systematic review, 15 in vitro
studies1-4 ,8-10,12-14,25-29 were selected, and 14 were
also meta-analyzed. A high risk of bias was the reason
for the exclusion of 1 study from the meta-analysis. 4
In the first meta-analysis (Fig. 2), which evaluated
the association between shear or microshear bond
strength and an adhesive layer application, both
nonaged (P=.080, without statistical significance)
and aged (P=.370, without statistical significance) data
sets did not present significant differences between
bonding with and without an adhesive layer.

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With Adhesive System Without Adhesive System Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

1.1.1 Non-aged
Cardenas et al., 2017 A* 30 0.9 8 29.9 2.8 8 3.6% 0.10 [–1.94, 2.14]
Cardenas et al., 2017 B* 30.7 2.1 8 29.3 3 8 3.4% 1.40 [–1.14, 3.94]
Cardenas et al., 2017 C* 23.9 1.8 8 26.7 2.7 8 3.5% –2.80 [–5.05, –0.55]
Cardenas et al., 2017 D* 24.9 1.6 8 23.6 2.5 8 3.6% 1.30 [–0.76, 3.36]
Estafan et al., 2000 A* 27.22 5 6 37.24 5.05 6 2.1% –10.02 [–15.71, –4.33]
Estafan et al., 2000 B* 28.69 8.75 6 30.22 10.7 6 0.9% –1.53 [–12.59, 9.53]
Lise et al., 2015 A* 42.46 5.08 12 40.7 8.4 12 2.2% 1.76 [–3.79, 7.31]
Lise et al., 2015 B* 39.87 9.16 12 45.68 9.65 12 1.6% –5.81 [–13.34, 1.72]
Lise et al., 2015 C** 35.86 8.05 12 41.78 6.45 12 2.1% –5.92 [–11.76, –0.08]
Murillo–Gómez et al., 2017* 23.4 4.4 18 27.2 3.1 18 3.5% –3.80 [–6.29, –1.31]
Naves et al., 2010 A* 17.4 4.8 6 19.4 3.5 6 2.5% –2.00 [–6.75, 2.75]
Naves et al., 2010 B* 21.3 2.1 6 22.3 5.1 6 2.6% –1.00 [–5.41, 3.41]
Naves et al., 2010 C* 21.1 2.3 6 22.2 3.2 6 3.2% –1.10 [–4.25, 2.05]
Naves et al., 2010 D* 24.7 5.8 6 17.8 2.1 6 2.4% 6.90 [1.96, 11.84]
Naves et al., 2010 E* 20.4 2.2 6 15.3 3 6 3.3% 5.10 [2.12, 8.08]
Naves et al., 2010 F* 18.5 4.6 6 14.3 1.8 6 2.8% 4.20 [0.25, 8.15]
RomaniniJr et al., 2018**** 42.7 3.8 5 33.9 3.7 5 2.5% 8.80 [4.15, 13.45]
Sebben et al., 2018 A* 26.3 4.5 20 24.2 5.1 20 3.2% 2.10 [–0.88, 5.08]
Sebben et al., 2018 B**** 22.8 5.1 20 30.5 3.8 20 3.3% –7.70 [–10.49, –4.91]
Stangel et al., 1987*** 19.37 1.29 7 18.68 1.83 7 3.8% 0.69 [–0.97, 2.35]
Sundfeld Neto et al., 2015 A* (LD–RGC) 29.2 5.4 6 23.6 5.6 6 2.0% 5.60 [–0.62, 11.82]
Sundfeld Neto et al., 2015 A* (Le–RGC) 27.6 6.3 6 20.7 5.3 6 1.8% 6.90 [0.31, 13.49]
Sundfeld Neto et al., 2015 B* (LD–RGC) 29.4 9.8 6 28.3 5.7 6 1.2% 1.10 [–7.97, 10.17]
Sundfeld Neto et al., 2015 B* (Le–RGC) 27.3 7.9 6 23.8 5.7 6 1.5% 3.50 [–4.29, 11.29]
Sundfeld Neto et al., 2015 C* (LD–RGC) 28.5 3.9 6 28.1 6.1 6 2.1% 0.40 [–5.39, 6.19]
Sundfeld Neto et al., 2015 C* (Le–RGC) 32.5 9.1 6 31.1 5.9 6 1.3% 1.40 [–7.28, 10.08]
Sundfeld Neto et al., 2015 D* (LD–RGC) 34.4 3.3 6 27.3 5.4 6 2.4% 7.10 [2.04, 12.16]
Sundfeld Neto et al., 2015 D* (Le–RGC) 32.1 3.1 6 31.8 6.1 6 2.2% 0.30 [–5.18, 5.78]
Sundfeld Neto et al., 2015 E* (LD–RGC) 36.1 4.17 6 26.6 5.7 6 2.2% 9.50 [3.85, 15.15]
Sundfeld Neto et al., 2015 E* (Le–RGC) 39.2 6.7 6 31.3 5.5 6 1.7% 7.90 [0.96, 14.84]
Sundfeld Neto et al., 2015 F* (LD–RGC) 38.5 6.1 6 28.9 3.1 6 2.2% 9.60 [4.12, 15.08]
Sundfeld Neto et al., 2015 F* (Le–RGC) 32.3 3.2 6 27.6 6.2 6 2.2% 4.70 [–0.88, 10.28]
Subtotal (95% CI) 258 258 79.2% 1.36 [–0.18, 2.90]
Heterogeneity: Tau2=13.37; Chi2=150.21, df=31 (P<.00001); I2=79%
Test for overall effect: Z=1.73 (P=.08)

1.1.2 Aged
Cardenas et al., 2017 A*
Cardenas et al., 2017 B* 20.1 1.3 8 19.3 1.5 8 3.8% 0.80 [–0.58, 2.18]
Cardenas et al., 2017 C* 24 2.3 8 20.1 1.3 8 3.7% 3.90 [2.07, 5.73]
Cardenas et al., 2017 D* 19.2 1.5 8 19.5 1.8 8 3.8% –0.30 [–1.92, 1.32]
Murillo–Gómez et al., 2017* 20.5 2.5 8 19.9 1.8 8 3.6% 0.60 [–1.53, 2.73]
RomaniniJr et al., 2018**** 22.2 5.4 18 18 4.9 18 3.1% 4.20 [0.83, 7.57]
Subtotal (95% CI) 38.5 4 5 43.8 2.2 5 2.8% –5.30 [–9.30, –1.30]
55 55 20.8% 0.89 [–1.04, 2.82]
Heterogeneity: Tau2=4.35; Chi2=25.30, df=5 (P=.0001); I2=80%
Test for overall effect: Z=0.90 (P=.37)

Total (95% CI) 313 313 100.0% 1.19 [–0.02, 2.41]

Heterogeneity: Tau2=9.51; Chi2=176.59, df=37 (P<.00001); I2=79%
Test for overall effect: Z=1.93 (P=.05) –10 –5 0 5 10
Test for subgroup differences: Chi2=0.14, df=1 (P=.71); I2=0% Without With
Adhesive System Adhesive System

Figure 2. Evaluation of association between shear or microshear bond strength and adhesive layer application in nonaged and aged specimens.

Although no significant difference was observed in
either subgroup, most studies presented their results
favoring an adhesive application. In the second
meta-analysis (Fig. 3), which evaluated the associa-
tion between microtensile bond strength and an
adhesive application, both nonaged (P=.003, with
statistical significance) and aged (P<.001, with statis-
tical significance) data sets favored a nonadhesive
application. Therefore, this difference between the
results of both meta-analyses could indicate a certain
bias from the type of mechanical test.
Meta-analyses featured heterogeneity varying from
high to moderate among study specimens, which prob-
ably refers to the degree of differences between the re-
sults of individual studies.22 The high heterogeneity
could be explained by the differences among methodol-
ogies, such as material composition, specimen prepara-
tion, different types of aging procedures, and the type of
mechanical testing.32 These factors might have affected
the results of this review despite eligibility criteria being
applied, although they cannot be completely avoided
because random and systematic heterogeneities exist
among the studies.33
Although initial bond strength values are important,
the main concern is bond durability. However, little
attention has been paid to investigating the role of
an adhesive layer application on the bond durability of
HF-etched and silanized glass ceramics. Only 5 studies
included in the meta-analyses subjected the specimens to
long-term aging conditions.2,9,12,26,28

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8 Volume - Issue -

With Adhesive System Without Adhesive System Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI

2.1.1 Non-aged
EI Zohairy et al., 2003 A**** 24.7 7.1 10 28.7 5.9 10 2.3% –4.00 [–9.72, 1.72]
EI Zohairy et al., 2003 B* 36.6 6.5 10 24.3 3.1 10 3.7% 12.30 [7.84, 16.76]
EI Zohairy et al., 2003 C* 26.5 10.9 10 27.6 8 10 1.1% –1.10 [–9.48, 7.28]
EI Zohairy et al., 2004 A (24 hours)**** 18.2 3.9 10 28.7 5.9 10 3.9% –10.50 [–14.88, –6.12]
EI Zohairy et al., 2004 A (28 days)**** 21.5 2.4 10 19.4 2.7 10 14.9% 2.10 [–0.14, 4.34]
EI Zohairy et al., 2004 A (7 days)**** 21 3.2 10 20.2 4.3 10 6.7% 0.80 [–2.52, 4.12]
EI Zohairy et al., 2004 B (24 hours)* 17 5.4 10 24.3 3.1 10 5.0% –7.30 [–11.16, –3.44]
EI Zohairy et al., 2004 B (28 days)* 20.2 3.9 10 22.8 3.3 10 7.4% –2.60 [–5.77, 0.57]
EI Zohairy et al., 2004 B (7 days)* 18.9 2.4 10 24.7 4.2 10 8.3% –5.80 [–8.80, –2.80]
Passos et al., 2008* 18 4.4 50 20 5.3 50 20.4% –2.00 [–3.91, –0.09]
Peumans et al., 2007* 34.5 5.1 12 34.6 8.9 12 2.2% –0.10 [–5.90, 5.70]
Subtotal (95% CI) 152 152 75.9% –1.49 [–2.48, –0.50]
Heterogeneity: Chi2=82.96, df=10 (P<.00001); I2=88%
Test for overall effect: Z=2.95 (P=.003)

2.1.2 Aged
AI–Thagafi et al., 2016*** 28.3 4 15 22.4 5.7 15 6.0% 5.90 [2.38, 9.42]
Passos et al., 2008* 14.4 4.7 50 21.5 5.6 50 18.1% –7.10 [–9.13, –5.07]
Subtotal (95% CI) 65 65 24.1% –3.87 [–5.63, –2.11]
Heterogeneity: Chi2=39.29, df=1 (P<.00001); I2=97%
Test for overall effect: Z=4.32 (P<.0001)

Total (95% CI) 217 217 100.0% –2.07 [–2.93, –1.20]

Heterogeneity: Chi2=127.58, df=12 (P<.00001); I2=91%
Test for overall effect: Z=4.69 (P<.00001) –10 –5 0 5 10
Test for subgroup differences: Chi2=5.33, df=1 (P=.02); I2=81.3% Without With
Adhesive System Adhesive System

Figure 3. Evaluation of association between microtensile bond strength and adhesive layer application in nonaged and aged specimens.

In the aged data set, the use of an adhesive layer after
HF etching and silanization did not influence the shear or
microshear bond strength values (P=.370, without sta-
tistical significance). Conversely, the use of an adhesive
layer decreased microtensile bond strength values
(P<.001, with statistical significance). These results
should be carefully analyzed as different aging conditions
were used for each type of bond strength test. For shear
or microshear bond strength testing, while Murillo-
Gómez et al12 stored the specimens in water for 6
months, Cardenas et al2 and Romanini-Junior et al26
used 1-year water storage. For microtensile bond
strength testing, Al-Thagafi et al28 used 5000 thermo-
cycles. However, Passos et al9 submitted the specimens
to 12 000 thermocycles and stored them in distilled water
for 50 days subsequent to microtensile testing. This lack
of standardization regarding aging procedures could
directly impact the results of those studies.
Quantitative analysis of the studies included in the
aged meta-analyses subgroup of shear or microshear
bond strength (first meta-analysis) and microtensile
bond strength (second meta-analysis) indicated that
most studies presented their results favoring the use of
adhesive system except those of Passos et al9 and
Romanini-Junior et al.26 Although risk of bias was
assessed in this review, Passos et al9 included 50 speci-
mens per group. However, when the fixed-effect model
was used because of the low number of included
studies23 (5 studies3,8,9,14,28 were included in the second
meta-analysis that presented high heterogeneity,
I2=91%), it was responsible for displacing the diamond
overall results of the second meta-analysis in favor of the
absence of an adhesive system (P<.001, with statistical
significance). These details should also be considered as
they suggest that further studies with aging are needed.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. An adhesive layer application did not improve the
bond strength of etched and silanized glass ceramics
to resin-based materials.
2. The results may have been influenced by the type of
in vitro test applied and the medium and high het-
erogeneity of the meta-analysis, further reinforcing
the difficulty of standardizing in vitro studies.
3. Further studies with standard methodologies,
mainly the aged ones, need to be conducted.
4. The influence of an adhesive layer application
should be evaluated under clinical conditions.
REFERENCES
1. Sundfeld Neto D, Naves LZ, Costa AR, Correr AB, Consani S, Borges GA,
et al. The effect of hydrofluoric acid concentration on the bond strength and
morphology of the surface and interface of glass ceramics to a resin cement.
Oper Dent 2015;40:470-9.
2. Cardenas AM, Siqueira F, Hass V, Malaquias P, Gutierrez MF, Reis A, et al.
Effect of MDP-containing silane and adhesive used alone or in combination
on the long-term bond strength and chemical interaction with lithium dis-
ilicate ceramics. J Adhes Dent 2017;19:203-12.
3. El Zohairy AA, De Gee AJ, Mohsen MM, Feilzer AJ. Microtensile bond
strength testing of luting cements to prefabricated CAD/CAM ceramic and
composite blocks. Dent Mater 2003;19:575-83.

THE JOURNAL OF PROSTHETIC DENTISTRY Nogueira et al

- 2020
4. Reich SM, Wichmann M, Frankenberger R, Zajc D. Effect of surface
treatment on the shear bond strength of three resin cements to a
machinable feldspatic ceramic. J Biomed Mater Res B Appl Biomater
2005;74:740-6.
5. Lührs AK, De Munck J, Geurtsen W, Van Meerbeek B. Composite cements
benefit from light-curing. Dent Mater 2014;30:292-301.
6. El-Damanhoury HM, Gaintantzopoulou MD. Self-etching ceramic primer
versus hydrofluoric acid etching: etching efficacy and bonding performance.
J Prosthodont Res 2018;62:75-83.
7. Stewart GP, Jain P, Hodges J. Shear bond strength of resin cements to both
ceramic and dentin. J Prosthet Dent 2002;88:277-84.
8. Peumans M, Hikita K, De Munck J, Van Landuyt K, Poitevin A,
Lambrechts P. Effects of ceramic surface treatments on the bond strength of
an adhesive luting agent to CAD-CAM ceramic. J Dent 2007;35:282-8.
9. Passos SP, Valandro LF, Amaral R, Özcan M, Bottino MA, Kimpara ET. Does
adhesive resin application contribute to resin bond durability on etched and
silanized feldspathic ceramic? J Adhes Dent 2008;10:455-60.
10. Lise DP, Perdigão J, Van Ende A, Zidan O, Lopes GC. Microshear bond
strength of resin cements to lithium disilicate substrates as a function of
surface preparation. Oper Dent 2015;40:524-32.
11. Elsayed A, Younes F, Lehmann F, Kern M. Tensile bond strength of so-called
universal primers and universal multimode adhesives to zirconia and lithium
disilicate ceramics. J Adhes Dent 2017;19:221-8.
12. Murillo-Gómez F, Rueggeberg FA, De Goes MF. Short- and long-term bond
strength between resin cement and glass-ceramic using a silane containing
universal adhesive. Oper Dent 2017;42:514-25.
13. Naves LZ, Soares CJ, Moraes RR, Gonçalves LS, Sinhoreti MAC, Correr-
Sobrinho L. Surface/interface morphology and bond strength to glass ceramic
etched for different periods. Oper Dent 2010;35:420-7.
14. El Zohairy AA, De Gee AJ, Hassan FM, Feilzer AJ. The effect of adhesives
with various degrees of hydrophilicity on resin ceramic bond durability. Dent
Mater 2004;20:778-87.
15. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Int J Surg
2010;8:336-41.
16. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al.
The PRISMA statement for reporting systematic reviews and meta-analyses
of studies that evaluate health care interventions: explanation and elabora-
tion. J Clin Epidemiol 2009;62:e1-34.
17. Rosa WL, Piva E, Silva AF. Bond strength of universal adhesives: a systematic
review and meta-analysis. J Dent 2015;43:765-76.
18. Sarkis-Onofre R, Skupien JA, Cenci MS, Moraes RR, Pereira-Cenci T. The
role of resin cement on bond strength of glass-fiber posts luted into root
canals: a systematic review and meta-analysis of in vitro studies. Oper Dent
2013;39:31-44.
19. Magno MB, Neves AB, Ferreira DM, Pithon MM, Maia LC. The relationship
of previous dental trauma with new cases of dental trauma. A systematic
review and meta-analysis. Dent Traumatol 2019;35:3-14.
20. Fernandes LM, Neto JCL, Lima TFR, Magno MB, Santiago BM,
Cavalcanti YW, et al. The use of mouthguards and prevalence of dento-
alveolar trauma among athletes: a systematic review and meta-analysis. Dent
Traumatol 2019;35:54-72.
Nogueira et al
View publication stats
9
21. Ferreira RO, Corrêa MG, Magno MB, Almeida APCPSC, Fagundes NCF,
Rosing CK, et al. Physical activity reduces the prevalence of periodontal
disease: systematic review and meta-analysis. Front Physiol 2019;10:234.
22. Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of
interventions version 5.1.0 [updated March 2011]. The Cochrane Collabo-
ration; 2011. Available at: http://handbook.cochrane.org. Accessed October 1,
2018.
23. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-
analysis. Chichester: John Wiley & Sons, Ltd; 2009. p. 311-9.
24. Higgins JPT, Thompson SG. Quantifying heterogeneity in a metaanalysis.
Stat Med 2002;21:1539-58.
25. Stangel I, Nathanson D, Hsu CS. Shear strength of the composite bond to
etched porcelain. J Dent Res 1987;66:1460-5.
26. Romanini-Junior JC, Kumagai RY, Ortega LF, Rodrigues JA, Cassoni A,
Hirata R, et al. Adhesive/silane application effects on bond strength
durability to a lithium disilicate ceramic. J Esthet Restor Dent 2018;30:
346-51.
27. Sebben J, Canevese VA, Alessandretti, Pereira GKR, Sarkis-Onofre R,
Bacchi A, et al. Effect of surface coating on bond strength between etched
feldspar ceramic and resin-based luting agents. Biomed Res Int 2018;2018:
3039251.
28. Al-Thagafi R, Al-Zordk W, Saker S. Influence of surface conditioning pro-
tocols on reparability of CAD/CAM zirconia-reinforced lithium silicate
ceramic. J Adhes Dent 2016;18:135-41.
29. Estafan D, Dussetschleger F, Estafan A, Jia W. Effect of prebonding pro-
cedures on shear bond strength of resin composite to pressable ceramic. Gen
Dent 2000;48:412-6.
30. Inokoshi M, De Munck J, Minakuchi S, Van Meerbeek B. Meta-analysis
of bonding effectiveness to zirconia ceramics. J Dent Res 2014;93:
329-34.
31. Kalavacharla VK, Lawson NC, Ramp LC, Burgess JO. Influence of etching
protocol and silane treatment with a universal adhesive on lithium disilicate
bond strength. Oper Dent 2015;40:372-8.
32. Walker E, Hernandez AV, Kattan MW. Meta-analysis: its strengths and
limitations. Cleve Clin J Med 2008;75:431-9.
33. Melsen WG, Bootsma MCJ, Rovers MM, Bonten MJM. The effects of clinical
and statistical heterogeneity on the predictive values of results from meta-
analyses. Clin Microbiol Infect 2014;20:123-9.
Corresponding author:
Dr Tiago Braga Rabello
Department of Dental Clinic
School of Dentistry
Federal University of Rio de Janeiro
325 Prof. Rodolpho Paulo Rocco Street, 2nd floor
Rio de Janeiro, RJ 21841-913
BRAZIL
Email: tiagobragarabello@gmail.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.12.005
THE JOURNAL OF PROSTHETIC DENTISTRY