Review Article

Universal dental adhesives: Current status, laboratory testing,

and clinical performance

Sanket Nagarkar ,1 Nicole Theis-Mahon,2 Jorge Perdigão 3

1
Park Dental Group, Minneapolis, Minnesota, and Clinical Research Assistant Professor (affiliated), Department of Restorative
Sciences, University of Minnesota, Minneapolis, Minnesota
2
Bio-Medical Library, University of Minnesota, Minneapolis, Minnesota
3
Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota, Minneapolis, Minnesota

Received 29 August 2018; revised 11 December 2018; accepted 19 December 2018

Published online 00 Month 2019 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jbm.b.34305

Abstract: Increasing demand for simplified and user-friendly laboratory and clinical evidence does not support the claim that
adhesive systems has led to the development of a new class of UAs can be used with any adhesive strategy. Although, they can
adhesives termed as Universal Adhesives (UAs). The term chemically bond to various tooth and direct/indirect restorative
“Universal” reflects manufacturers’ claims that these adhesives substrates, the stability of this bond is material-dependent and
can be applied with any adhesion strategy and offer the versatil- subject to hydrolytic degradation. Hence, additional measures
ity of use with a variety of direct and indirect restorative mate- are still needed to ensure long-term durability. which under-
rials. The aim of this review was to synthesize the literature mines the versatility of UAs. The lack of long-term data regarding
regarding the current status of UAs, their adhesion potential to the clinical performance of UAs further complicates clinical
various substrates and their performance in different restorative decision-making. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res B
situations. In vitro studies, clinical trials and systematic reviews Part B: 00B: 000–000, 2019.
were identified utilizing controlled vocabulary and keyword
searches in Medline and EMBASE databases. About 282 studies Key Words: universal adhesives, multi-mode adhesives, clinical
(272 in vitro studies; 11 clinical studies) were included. Available performance, laboratory performance, review

How to cite this article: Nagarkar S, Theis-Mahon N, Perdigão J. 2019. Universal dental adhesives: Current status, laboratory test-
ing, and clinical performance. J Biomed Mater Res B Part B. 2019:9999B:9999B:1–11.

INTRODUCTION most adhesive joints involve two interfaces, dental adhesive

Scientific advances in cardiology and dental adhesive tech- joints are more complex such as the one encountered with a
nology have extensively influenced and revolutionized many bonded porcelain restoration that involves enamel/dentin–
aspects of restorative dentistry.1–5 The restorative principle adhesive–luting composite–adhesive–porcelain interfaces.11
of “Extension for Prevention” suggested by GV Black6 has Success of adhesive restorations thus depends on achieving
evolved into “Prevention of Extension” or more commonly a strong bond with these substrates. Fundamentally, the
bond with dental substrates is based on an exchange process
known as “Minimal Intervention Dentistry”.1,7,8 Minimally
in which minerals removed from the dental hard tissues
invasive interventions aim to minimize cavity preparation
after acid conditioning are replaced by resin monomers that
size by preventing unnecessary removal of sound tooth
become micromechanically interlocked in the porosities
structure. Preparations are limited to the removal of friable upon polymerization.1,12 Main challenge for current dental
enamel and soft dentin only while unnecessary extensions or adhesives is to provide an equally effective bond to dental
undercuts are minimized.7 Subsequent proper sealing of substrates of differing nature.2 The interlocking of resin tags
these preparations with an adhesive restorative material within the acid-etched enamel surface can be predictably
prolongs tooth survival.9,10 achieved12 and can effectively seal the restoration margins
Adhesive restorations bond to tooth structure by means in the long-term.13,14 On the other hand, bonding to dentin is
of dental adhesives which are solutions of resin monomers intricate and less predictable due to the presence of signifi-
in an organic solvent with polymerization initiators. While cant amount of water and organic material in the

Correspondence to: Jorge Perdigão; e-mail: perdi001@umn.edu

© 2019 Wiley Periodicals, Inc. 1

substrate.1,15,16 Furthermore, mechanical instrumentation of TABLE I. Search Strategy for Medline via Ovid
tooth structure during cavity preparation leaves behind a
Universal Adhesives:
uniform layer of debris on the tooth surface. This layer (adhesive* adj3 universal).ti,ab. OR (all-bond adj3 universal).
called as the “Smear Layer” is composed primarily of ti,ab. OR (ambar adj3 universal).ti,ab. OR (clearfil adj3
hydroxyapatite and altered collagen that plugs the entrance universal).ab,ti. OR futurabond.ab,ti. OR gaenial.ab,ti. OR
of dentinal tubules reducing its permeability.11,17 (g-aenial adj3 bond).ti,ab. OR g-premio.ab,ti. OR ibond.
Current adhesion strategies depend on how dental adhe- ab,ti. OR optibond adj3 universal.ab,ti. OR (one coat
sives interact with the smear layer and are grouped into two adj3 universal).ab,ti. OR parkell.ab,ti. OR prime&bond.
ab,ti. OR scotchbond adj3 universal.ab,ti. OR (xeno adj3
basic categories: Etch-and-rinse (ER) strategy and self-etch
select).ab,ti. OR (multi-mode adj3 bond).ab,ti. OR single
(SE) strategy. ER strategy involves complete removal of the bond universal.ab,ti.
smear layer and superficial hydroxyapatite through etching AND
with a separate acid gel (commonly phosphoric acid)11,14 fol- Methods for testing or analyses (mechanical, morphological,
lowed by infiltration of adhesive monomers that permeate or chemical):
the micro-porosities forming hybrid tissue known as the Exp Dental Bonding/OR (bond adj3 strength*).ab,ti.
resin–dentin inter-diffusion zone or the “Hybrid Layer”.18,19 OR fatigue.ab,ti. OR fracture*.ab,ti. OR
push-out.ab,ti. OR SEM.ab,ti. OR FESEM.ab,ti. OR TEM.
In contrast, the SE strategy makes the smear layer perme- ab,ti. OR CLSM.ab,ti. OR
able without removing it completely. This does not require a CONFOCAL.ab,ti. OR micro-ct.ab,ti. OR microct.ab,ti. OR
separate phosphoric acid-etch step as acidic adhesive mono- nanoleakage.ab,ti. OR exp Dental
mers are utilized to partially dissolve the smear layer and Leakage/OR contact angle.ab,ti. OR exp X-Ray Diffraction/OR
demineralize the underlying dentin/enamel while infiltration XRD.ab,ti. OR EDS.ab,ti.
is achieved simultaneously.14 OR EDAX.ab,ti. OR NMR.ab,ti. OR exp Magnetic Resonance
Spectroscopy/OR MAS.ab,ti.
Although, clinical studies suggest that adhesives utilizing
OR magic angle spinning.ab,ti. OR qcm-d.ab,ti. OR raman.ab,ti.
the ER strategy have superior clinical performance for load
bearing restorations,20 many clinicians demand materials or
strategies that are simpler and less technique-sensitive.2 This
demand has urged manufacturers to develop more user- to Microsoft Excel (Version 2013). Details of the search strat-
friendly adhesive systems. The newest of these are “Universal” egy are listed in Table I.
or “Multi-mode” adhesives which provide dentists with the
choice of selecting the adhesion strategy – ER, SE, or an Inclusion and exclusion criteria
alternative “selective enamel etching” (SEE) strategy, which is Both clinical and laboratory studies comparing properties of
a combination of ER strategy on enamel and SE strategy on UAs used with different application strategies (ER vs. SE
dentin.21–24 Additionally, these adhesives offer the versatility vs. SEE), against other SE and ER adhesives and with different
of use for bonding various direct and indirect restorative mate- substrates (enamel, coronal and root dentin, composite resins,
rials such as composite resins, glass-matrix ceramics, zirconia, glass-matrix ceramics, zirconia, and other materials) in primary
and metals.21,25–27 Though there is no official definition for and permanent human or animal dentitions were included.
what qualifies as a Universal Adhesive (UA), literature Systematic reviews of clinical and in vitro studies were also
describes it as a single-bottle, no-mix adhesive system that included. The following studies were excluded: case reports,
performs equally well with any adhesion strategy and bonds case series, abstracts, thesis/dissertations, and editorials.
adequately to tooth structure as well as to different direct and
indirect restorative materials.28,29 The present review aims Study selection and data collection
to synthesize the literature regarding the current status of Two reviewers Sanket Nagarkar and Jorge Perdigão
UAs, their adhesion potential to different substrates and reviewed the title and abstracts of studies. Full-texts of these
performance in different restorative situations. screened studies were assessed for eligibility. Any disagree-
ments at the title, abstract or full-text screening stages were
METHODS resolved through mutual discussion. Extracted information
Information sources and search strategy included: first author and publication year; study design
A trained librarian (NT-M) developed the search algorithms (systematic review vs. clinical vs. in vitro); type of teeth
and conducted the literature searches. Search strategies uti- (human vs. animal; permanent vs. primary teeth); types of
lizing controlled vocabulary (Medical Subject Headings) and adhesives (UA vs. ER vs. SE); adhesion strategy (ER vs. SE
keywords were developed for the Medline database vs. SEE); type of substrates (enamel, coronal/root dentin,
(National Library of Medicine) via the Ovid interface (Epub glass-matrix ceramics such as lithium disilicate, zirconia,
Ahead of Print, In-Process & Other Non-Indexed Citations, other materials such as composite resins including pre-
Ovid MEDLINE(R) Daily, Ovid MEDLINE and Versions(R) polymerized resin composites for indirect restorations, and
1946 to June 27, 2018) and translated to EMBASE metals); type of outcome measures for clinical studies
(1947–2018 June 29) on July 2, 2018. No restrictions (survival/retention, restoration fracture, marginal adapta-
were placed on publication type or language. The search tion, secondary caries, and marginal discoloration); types of
results were exported to EndNote X8 (Clarivate Analytics, outcomes/tests for in vitro studies (bond strength testing,
Philadelphia, PA) for de-duplication and were then exported fracture toughness, fatigue testing, morphological analysis,

2 NAGARKAR, THEIS-MAHON AND PERDIGÃO UNIVERSAL ADHESIVES

 REVIEW ARTICLE

TABLE II. Common Universal Adhesives (references listed

below)

Classification Functional
Universal Adhesive by pH Monomer(s)
All-Bond Universal (ABU) Ultra-mild 10-MDP
(BISCO Inc.) 3.1–3.2
AdheSE Universal (AU) Ultra-mild 10-MDP, MCAP
(Ivoclar Vivadent) 2.5–3.0
Optibond Universal (OBU) Ultra-mild GPDM
(Kerr) 2.5–3.0
One Coat 7 Universal (OC7U) Ultra-mild 10-MDP
(Coltene) 2.8
Scotchbond Universal (SBU) Ultra-mild 10-MDP, PAC
(3M Oral Care) 2.7
Prime&Bond Elect (PBE) Ultra-mild PENTA
(Dentsply Sirona) 2.5
Clearfil Universal Mild 10-MDP
Bond (CFU) 2.3
(Kuraray Noritake
Dental Inc.)
Futurabond U (FBU) Mild 10-MDP
(VOCO GmbH) 2.3
iBOND Universal (IBU) Intermediate 10-MDP, 4-MET
(Kulzer GmbH) strong
FIGURE 1. Study flow diagram. 1.6–1.8
G-Premio Bond (GPB) Intermediate 10-MDP, 4-MET
(GC Corp) strong
1.5
chemical analysis, micro/nanoleakage, and artificial-aging);
10-MDP, 10-methacryloyloxydecyl dihydrogen phosphate; MCAP,
and common UAs tested. One review author (Sanket methacrylated carboxylic acid polymer; GPDM, glycero-phosphate
Nagarkar) extracted the data, which was double-checked by dimethacrylate; PAC, Polyalkenoic acid copolymer; PENTA, dipentaery-
a second reviewer (Jorge Perdigão). If discrepancies were thritol penta acrylate monophosphate; 4MET, 4-methacryloxyethyl tri-
mellitic acid.
identified, they were resolved through mutual discussion.
References
Aggregate data was used for qualitative synthesis. Findings 1. Rosa WL, Piva E, Silva AF. Bond strength of universal adhesives: A
from laboratory tests and clinical performance were summa- systematic review and meta-analysis. J Dent 2015;43(7):765–776.
rized separately. Quantitative synthesis (meta-analysis) was 2. Perdigão J, Swift EJ, Jr. Universal Adhesives. J Esthet Restor Dent
2015;27(6):331–334.
not undertaken due to wide variations in study design, 3. Kaczor K, Gerula-Szymanska A, Smektala T, Safranow K,
substrates, adhesives, and testing methods. Lewusz K, Nowicka A. Effects of different etching modes on the nano-
leakage of universal adhesives: A systematic review and meta-analysis.
J Esthet Restor Dent 2018;30:287-298.
RESULTS 4. de Albuquerque EG, Santana FW, Calazans FS, Poubel LA, Marins
The initial database searches identified 1250 articles. Eight SS, de Paris Matos T, Hanzen TA, de Oliveira Barceleiro M, Loguercio
additional records were identified by manual searches of AD. A new universal simplified adhesive: 6-month randomized multi-
center clinical trial. Rev Bras Odontol 2017;74(4):251–260.
reference lists and other sources. A total of 285 studies were 5. Gutiérrez MF, Sutil E, Malaquias P, de Paris Matos T, de Souza LM,
included for the final data syntheses. Majority of the Reis A, Perdigão J, Loguercio AD. Effect of self-curing activators and
included studies (273 studies) were in vitro or systematic curing protocols on adhesive properties of universal adhesives bonded
to dual-cured composites. Dent Mater 2017;33(7):775–787.
reviews of in vitro studies. Only 12 clinical studies (11 ran-
6. Saikaew P, Chowdhury AF, Fukuyama M, Kakuda S, Carvalho RM,
domized trials; 1 systematic review of randomized trials) Sano H. The effect of dentine surface preparation and reduced applica-
were identified and included. Figure 1 describes the study tion time of adhesive on bonding strength. J Dent 2016;47:63–70.
flow in detail. 7. iBOND Universal Dental Science: Scientific Compendium. Kulzer
GmbH, Hanau, Germany 2017: 12. Available at: https://www.kulzer.com/
media/webmedia_local/downloads_new/ibond_8/ibond_universal_2/
Mechanism of adhesion of UAs iBOND_Universal_Compendium_GB.pdf [accessed August 26, 2018].
When UAs are applied with the SE strategy, they basically work
as traditional one-step SE adhesives30 and differ in their aggres-
siveness (pH of acidic monomers). Most UAs fall under the bonds ionically to dentin forming hydrolytically stable
ultra-mild (pH ≥ 2.5), mild (pH ≈ 2) and intermediately strong calcium salts on hydroxyapatite in the form of “nanolayer-
(pH between 1 and 2) categories.22,30,31 Despite similar compo- ing”.32,33 Chemical bonding promoted by 10-MDP is more effec-
sition to older SE adhesives, UAs contain specific carboxylate tive and stable in water than that provided by other functional
and/or phosphate functional monomers (Table II). The most monomers.2,34 Additionally, 10-MDP has been shown to chemi-
notable of these monomers is 10-methacryloyloxydecyl dihydro- cally bond with the oxides in zirconia while copolymerizing with
gen phosphate (10-MDP or MDP), a phosphate monomer that resin monomers of the luting cement.35–37 Glycero-phosphate

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B: APPLIED BIOMATERIALS | MONTH 2019 VOL 000B, ISSUE 0 3
dimethacrylate (GPDM) is another functional monomer that and analyze interfacial chemical reactions include Energy
forms a calcium salt with hydroxyapatite though the bond is not dispersive X-ray spectroscopy,33,73 X-ray diffraction,33,66
stable.38 A polyalkenoic acid copolymer (PAC; also known as Nuclear magnetic resonance spectroscopy,40,71,74 X-ray photo-
Vitrebond copolymer) is a component of some adhesives electron spectroscopy,71,75 Fourier-transform infrared
(Scotchbond Universal; 3M Oral Care) that chemically binds to spectroscopy,40,71,75,76 and Raman spectroscopy.61,77
calcium ions in hydroxyapatite39,40 and may contribute to long-
term bond stability.39 Laboratory performance of UAs
Adhesion to enamel. It is well known that phosphoric acid
Overview of methods for testing performance of UAs etching produces most durable resin–enamel bonds.78
Randomized controlled trials (RCTs) with long-term follow- Hence, when UAs are used with the SE strategy, their lower
ups are the best study designs to evaluate clinical effectiveness aggressiveness reduces their potential to fully demineralize
of restorative materials including dental adhesive systems. enamel thereby resulting in inadequate retentive micro-
RCTs evaluating performance of UAs have compared clinical porosities. A meta-analysis of in vitro studies by Rosa et al.22
outcomes such as restoration retention/survival, restoration confirmed that UAs utilizing the SE strategy (vs. ER) resulted
fracture, marginal discoloration, post-operative sensitivity, in significantly lower enamel micro-shear and μTBS values.
marginal adaptation, and secondary caries.41–52 Several other in vitro studies not included in the above
Laboratory studies are predominantly used during the meta-analysis have reported improved enamel bond
development phase of restorative materials to define guide- strength values when ER strategy was utilized.79–82 Simi-
lines for application procedures and predict clinical behavior larly, studies utilizing artificial-aging for testing enamel bond
to some extent.22 The micro-tensile bond strength (μTBS) test durability of SE adhesives (including UAs) concluded that
developed by Sano et al.53 is the current standard for bond the ER strategy resulted in significantly better long-term
strength testing54,55 and has a larger discriminative power bond characteristics.57,58,83,84
than the traditional macro-shear test.56 Although μTBS tests In vitro studies have suggested several methods to improve
provide useful information regarding the bonding ability of the resin–enamel bond characteristics with UAs. Some studies
adhesives, the stresses applied to the adhesive interfaces are have suggested use of an active85,86 and prolonged applica-
different from those that occur in the oral cavity where resto- tion86 of the adhesive with the SE strategy as a practical alter-
rations are subjected to cyclic loading over time, including native to enamel etching. One study indicated that double
compressive, flexural, or tensile stresses. For this reason, application of UAs may be effective in enhancing enamel bond
mechanical fatigue testing has been used to dynamically chal- strengths with the SE strategy possibly due to the increased
lenge the bonding effectiveness of adhesive-tooth inter- thickness and improved mechanical properties of the adhesive
faces.57,58 Interfacial fracture toughness testing has also been layer.87 Another in vitro study reported improved enamel
suggested for evaluating the bonding effectiveness59 but it is bonding with the use of an additional hydrophobic resin coat-
more laborious and requires specific equipment.56 Though ing (Heliobond, Ivoclar Vivadent) after SEE.88
the fracture toughness test is more valid than the μTBS test,
the latter is more versatile and universal.54 Adhesion to dentin. While acid etching benefits resin–
While laboratory studies mostly evaluate immediate enamel bonds, removal of smear layer and exposed dentinal
bond characteristics, durability of adhesion under aged con- collagen with the ER strategy or with aggressive SE adhe-
ditions is considered more clinically relevant.54 Thermal sives results in an increase fluid flow onto the exposed den-
fatigue (thermocycling) and storage in water or artificial tin surface.89 Furthermore, it makes the bonding interface
saliva are the most popular artificial-aging methods.55 A cor- highly vulnerable to hydrolytic and possibly enzymatic
relation has also been shown between in vitro dentin bond degradation processes2,90,91 resulting in decreased short-
strengths of 6-month, water-aged specimens, and marginal and long-term dentin bond strengths. However, for UAs,
discoloration of restorations in the oral cavity.60 results from in vitro studies indicate that the adhesive strat-
The ultra-morphology of the interface between UAs egy does not affect immediate dentin bonding. Meta-analysis
(or respective functional monomers) and tooth structure or of in vitro studies by Elkaffas et al.92 reported statistically
restorative materials has been characterized using several similar average dentin μTBS values of about 37 MPa for ER
imaging methods. Due to its ease of use, the most predomi- versus 35 MPa for SE strategies. Rosa, et al. meta-analysis
nant technique is Scanning electron microscopy (SEM), either also did not find any statistically significant difference in the
in secondary mode,39,61,62 or backscattered mode.63–66 The μTBS of UAs (SBU, GPB, PBE, and FBU) with the ER versus
secondary mode is more common in the literature and is used SE strategies. For ABU, however, the ER strategy resulted in
to analyze the ultra-morphology of the dentin hybrid layer. higher bond strengths although considerable heterogeneity
SEM has also been used to measure the surface roughness of was noted among the included studies.22 Contrastingly, stud-
zirconia specimens prior to several bonding procedures67 as ies utilizing artificial-aging for testing dentin bond durability
well as to evaluate the ultra-morphology of lithium disilicate of UAs concluded that the SE strategy resulted in more sta-
after bonding.68 Other tools for ultra-morphological evalua- ble long-term bond characteristics.39,64,93,94 Studies have
tion of adhesive interfaces include Transmission electron attributed this to the stable chemical bonding produced by
microscopy,33,38,69–71 Confocal laser scanning microscopy,61,72 10-MDP.39,66,95 Another meta-analysis of in vitro studies
and Atomic force microscopy.61,72 Methods used to identify assessing nanoleakage with UAs found inconsistent results

4 NAGARKAR, THEIS-MAHON AND PERDIGÃO UNIVERSAL ADHESIVES

 REVIEW ARTICLE

depending on the UA used.31 SBU showed comparable effi- presence of a Bis-GMA monomer in the silane solution signifi-
cacy with both strategies whereas ABU showed significantly cantly reduces the contact angle of the solution decreasing its
less nanoleakage with the SE strategy. The reviewers specu- surface wettability.133 In addition, silanols are more stable and
lated that the lower nanoleakage with these adhesives may reactive when used separately and not when combined with
be due to their lower aggressiveness and incorporation of resin monomers.129 Furthermore, the acidic pH of UAs reduces
10-MDP.31 the bonding effectiveness of the incorporated silane.134
Several methods have been proposed to preserve the Kalavacharla et al.135 recommended the use of 9.5% HF for 60 s
resin–dentin bonds. In vitro studies have demonstrated (vs. 5% for 20 s) if an additional silane step were to be avoided
improved immediate and long-term resin–dentin bond charac- prior to UA application. The higher concentration and pro-
teristics of UAs with the SE strategy by applying an additional longed application perhaps increase the micromechanical reten-
hydrophobic resin coat possibly due to improvement in the tion and thus the bond strength due to the enhanced etch
degree of monomer conversion at the resin–dentin inter- pattern. The authors further recommended that a separate
faces.63,88,96 Active application (scrubbing) of the adhesive on silane should always be applied to lithium disilicate since the
the dentin surface has also been shown to increase its imme- silane and 10-MDP in the composition of UAs were not effective
diate bonding effectiveness97 as well as long-term bond stabil- in optimizing the ceramic-resin bond.135 Studies utilizing
ity irrespective of the adhesion strategy.98 Other studies have artificial-aging also advocate a separate silane application step,
demonstrated improved long-term bond stability by applica- especially utilizing silane solutions with 10-MDP77,136 speculat-
tion of matrix metalloproteinases (MMPs) inhibitors such as ing that this additional step may enhance the hydrolytic stabil-
Chlorhexidine, Benzalkonium chloride, polymerizable benzalk- ity and the capability of UAs to form strong bonds with
onium methacrylate, and ethylenediaminetetraacetic acid different substrates at the same time.136 Thus, additional silane
(EDTA).99,100 Preconditioning with EDTA using a sonic device pretreatment can effectively improve the bond strength and
has also been shown to improve bonding performance of UAs marginal sealing of UAs to glass-matrix ceramics and is still
with the SE strategy on sclerotic dentin.101 Since residual recommended even if the UA contains a silane in its
water and/or solvent may compromise the performance of composition,68,134,135,137,138 as silane incorporated in the com-
UAs, studies have demonstrated prolonged air-blowing after position of universal adhesives is not expected to bond chemi-
adhesive application for 15–30 s versus manufacturer recom- cally to glass ceramics.137
mended 5–10 s to enhance immediate adhesive properties of
UAs.102,103 Caries-affected dentin is a more challenging sub- Adhesion to zirconia. Several mechanical and chemical pre-
strate for bonding than sound dentin where ER adhesives treatment methods have been suggested for bonding zirconia
work better than SE adhesives.104,105 However, with UAs, the restorations.139–141 Mechanical methods such as aluminum
adhesive strategy did not make a significant difference in oxide air-abrasion, tribochemical silica coating, laser irradia-
bond strengths of caries-affected dentin.106–109 Similarly, tion, chemical etching and ceramic coating can increase the
eroded dentin-UA bonding properties did not depend on the bond strengths by increasing the surface roughness and
adhesive strategy.110–112 micromechanical interlocking.140,142 Chemical pretreatments
For primary teeth, the ER strategy resulted in better with silane solutions/zirconia primers containing functional
dentinal bond strengths with UAs.113–115 Studies evaluating monomers such as 10-MDP, phosphonic acid acrylate, or
UA-root dentin bond strengths have presented conflicting anhydride containing primers promote chemical bonding
evidence with some advocating the use of SE strategy116,117 to zirconia.140,143 Recommended strategies for durable
while others recommending the ER strategy118,119 for luting resin–zirconia bonding are tribochemical silica coating
fiber-reinforced composite posts. followed by silanization; aluminum oxide air-abrasion fol-
Contamination of bonding surfaces with saliva, blood or lowed by preconditioning with a MDP-containing primer; or
hemostatic agents impairs bonding of adhesives.120–122 Several silica/ceramic coating followed by a MDP-primer.139,140,144
decontamination methods have been proposed to regain den- Many MDP-based UAs have also been recommended for
tin adhesion with UAs. These include drying the contaminants effectively bonding zirconia.26,30,75 Adequate bonding with
and adhesive re-application;123 rinsing and drying followed by UAs still requires prior abrasive surface treatment26,37,145,146
re-application;123–125 and re-etching and re-bonding.126 and although acceptable bond strengths were achieved in
the short-term, their durability after artificial-aging was
Adhesion to glass-matrix ceramics. Successful bonding of found to be questionable.67,73 One study suggested silica
resin cements to glass-matrix ceramics such as lithium disilicate coating followed by heat treated ceramic primer or a
can be achieved by hydrofluoric acid (HF) etching followed by MDP-based UA to improve the bond durability.147 Xie et al.75
application of a silane solution, γ-methacryloxypropyl tri- tested the effect of preconditioning with a MDP-primer
methoxysilane (MPTMS).127–129 Silane application increases the (Z-Prime Plus; BISCO Inc.) prior to UA application on resin-
ceramic wettability130 while promoting chemical interaction zirconia bonding. Although, this repeated application of MDP
between the silica in the ceramic and the methacrylate groups did not increase the chemical bonding, one group (Z-Prime
of the adhesive or luting resin.131,132 Therefore, some manufac- Plus and CFU) exhibited better bond stability after aging.75
turers have incorporated a silane in their UAs (e.g., CFU and Overall, laboratory studies suggest that achieving reliable
SBU) with an intention to simplify the glass–ceramic bonding long-term bonds to zirconia is challenging with most bond-
protocol.30 However, studies have demonstrated that the ing strategies. Hence, Bömicke et al.67 recommended that

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B: APPLIED BIOMATERIALS | MONTH 2019 VOL 000B, ISSUE 0 5
clinicians should not solely rely on adhesion for retention of roughening has earlier been recommended to increase resto-
zirconia restorations. ration retention rates in NCCLs irrespective of the type of
adhesive used.156 However, a recent RCT of UAs in NCCLs
Adhesion to other materials. Few laboratory studies evalu- with ER and SE strategies found no difference between the
ated bonding of UAs with other materials such as pre- retention rates in roughened vs. unprepared dentin.45
polymerized resin composites for indirect restorations, aged Table III summarizes the findings from laboratory and
direct resin composites, and metals. Studies evaluating use clinical studies.
of UAs for repairing aged pre-polymerized resin composites
for indirect restorations recommend prior air-abrasion for
effective bonding.136,148–150 For aged direct composites, DISCUSSION
either airborne-particle abrasion or grinding with a diamond Overall, for durable bonding with UAs, laboratory studies
bur were recommended for improving the repair bond recommend the use of SEE strategy for permanent teeth
strengths.151,152 For bonding composite resins to stainless and ER strategy for primary teeth. For glass-matrix ceramic
steel crowns, Hattan et al.153 reported superior shear bond restorations, such as lithium disilicate, an additional silane
strengths and lesser adhesive failures with a UA versus tra- application step is necessary even if the UA contains a
ditional one-bottle ER adhesive. Ghadimi et al.154 advocated silane in its composition. In addition, the use of an MDP-
use of air-abrasion or diamond bur roughening along with a based silane solution may increase the bond durability.
UA for improving the shear bond strengths. For zirconia restorations, relying solely on bonding for
retention should be avoided even though laboratory studies
Clinical performance of UAs suggest the use of air-abrasion with aluminum oxide or
Very few RCTs have evaluated the clinical performance of silica-coated aluminum oxide particles (tribochemical silica
UAs in restoring non-carious cervical lesions (NCCLs), Class II coating) or ceramic coating for acceptable bonding using an
cavity preparations and for luting partial ceramic crowns.41–52 MDP-based UA. For repair of direct composite resins and
Vogl et al.41 compared the clinical performance of partial pre-polymerized composite resins for indirect restorations,
ceramic crowns (feldspathic ceramic; CEREC blocks) cemen- the use of air-abrasion with aluminum oxide and UA appli-
ted using a self-adhesive resin cement (no separate etch or cation is recommended.
adhesive used) versus UA plus resin cement with a SEE or a Clinical studies recommend ER or SEE strategy for
SE strategy. Although, the cumulative survival at 18 months improving survival rates of composite restorations in NCCLs;
for restorations in the UA-resin cement-SEE group was and SEE strategy for Class II composite restorations. For
slightly higher (about 98% vs. 96% for SE group), this differ- glass-matrix ceramics, the adhesive strategy was not rele-
ence was not statistically significant. Interestingly, since the vant. Except for NCCLs, clinical studies were sparse and
UA (SBU) already had silane in its composition, no separate results should be interpreted with caution. There were no
silane application step was utilized for the UA-resin cement clinical studies evaluating the bonding performance of UAs
groups with either adhesion strategy.41 to zirconia or other restorative materials.
van Dijken et al.42 compared clinical performance of Strategies to improve adhesion of UAs to tooth structure
Class II composite resin restorations placed with an UA advocated by laboratory studies include preventing contami-
(ABU) using the SEE strategy versus those placed with a nation while bonding, utilizing decontamination procedures,
two-step SE adhesive (Optibond XTR; Kerr) and demon- use of MMP inhibitors, additional hydrophobic resin coating,
strated good short-term efficacy (annual failure rate of 1.8% active and prolonged adhesive application, double adhesive
for UA vs. 2.9% for SE adhesive) after 36 months of clinical application, and prolonged air blowing of the adhesive.
use. Oz et al.43 demonstrated excellent retention rates The review has several limitations. Majority of the
(97–100%) of composite restorations in NCCLs placed using included studies were in vitro studies, which have major
three different UAs with the SEE strategy after 18 months. A drawbacks. Accurate replication of clinical factors in the lab-
systematic review/meta-analysis of eight RCTs evaluating oratory is not possible. In addition, factors such as type of
composite restorations in NCCLs155 found no difference in test used, degree of dentin sclerosis, dentin depth, tooth age,
marginal adaptation, marginal discoloration, post-operative artificial-aging of the interface, and dentin roughness are fre-
sensitivity and secondary caries when UAs were used with quently not controllable.157,158 Hence, validity of laboratory
the ER or SE strategy. However, ER or SEE strategy resulted tests to predict clinical behavior is questionable. Although,
in higher retention rate and lesser incidence of restoration RCTs with long-term follow-ups are the best study designs
fractures. There was no significant difference between any of to evaluate clinical performance of adhesives, their validity
the clinical parameters when ER strategy was used with dry relies heavily on rigorous study design and completeness of
versus moist dentin.155 A recently published RCT not patient follow-up. This makes them difficult, time-consuming
included in the previous systematic review, showed no dif- and thus expensive. Additionally, rapid development and fre-
ference between the ER and SE strategies after 18 months of quent introduction of new dental adhesive materials makes
clinical use but reported a fairly high incidence of marginal existing materials obsolete within a few years of their intro-
discoloration when the UA (SBU) was used with the SE strat- duction. This often tempts manufacturers to release succes-
egy.44 However, this RCT was at high risk of bias due to its sor products even before its precursor has been clinically
high loss to follow-up (22% loss to follow-up). Dentin evaluated.54

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TABLE III. Summary of Recommendations for Bonding Different Substrates with Universal Adhesives

Recommendations

Substrate Laboratory Findings Clinical Findings Limitations

Enamel/dentin
Permanent teeth SEE strategy NCCLs: ER or SEE strategy Long-term clinical studies
Class II: SEE strategy are lacking
Only one clinical study
evaluated Class II
restorations
Primary teeth ER strategy No studies identified No clinical data available

Root dentin Findings inconclusive No studies identified No clinical data available

Conflicting findings regarding
adhesive strategy
Glass-matrix Separate silane application Tooth: SEE or SE strategy Clinical findings based
ceramics necessary Ceramic: UA with silane; no separate on only one study
silane application
Zirconia Reliance on adhesion should No studies identified No clinical data available
be avoided
Aluminum oxide air-abrasion
methods,
or ceramic coating
and a 10-MDP-based
UA recommended
Direct/indirect Prior aluminum No studies identified No clinical data available
composite resins oxide air-abrasion
ER, Etch-and-rinse; SE, Self-etch; SEE, Selective enamel etching (ER strategy on enamel and SE strategy on dentin); NCCL, Non-carious cervical
lesion; UA, Universal adhesive; MDP, methacryloyloxydecyl dihydrogen phosphate.

CONCLUSIONS 7. FDI policy statement on Minimal Intervention Dentistry (MID) for

managing dental caries. Adopted by the general assembly:
Within limitations of the review, available laboratory and
September 2016, Poznan, Poland. Int Dent J 2017;67(1):6–7.
clinical evidence does not support the claim that UAs can be 8. Mount GJ, Tyas JM, Duke ES, Hume WR, Lasfargues JJ, Kaleka R.
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cally bond to various tooth and direct/indirect restorative faces. Int Dent J 2006;56(2):82–91.
9. Schwendicke F, Frencken JE, Bjørndal L, Maltz M, Manton DJ,
substrates, the stability of this bond is material-dependent Ricketts D, Van Landuyt K, Banerjee A, Campus G, Doméjean S,
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JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B: APPLIED BIOMATERIALS | MONTH 2019 VOL 000B, ISSUE 0 11