d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

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journal homepage: www.intl.elsevierhealth.com/journals/dema

Review

Clinical effectiveness of contemporary adhesives

for the restoration of non-carious cervical lesions.
A systematic review

M. Peumans a,∗ , J. De Munck a , A. Mine b , B. Van Meerbeek a

a KU Leuven – BIOMAT, Department of Oral Health Sciences, KU Leuven & Dentistry, University Hospitals Leuven,
Leuven, Belgium
b Department of Fixed Prosthodontics, University Graduate School of Dentistry, Osaka, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. The aim of this systematic review was to evaluate the clinical effectiveness of
Received 21 March 2014 contemporary adhesives for the restoration of non-carious cervical lesions (NCCLs) in terms
Received in revised form 6 July 2014 of restoration retention as a function of time.
Accepted 11 July 2014 Methods. Medline Ovid and IADR abstracts were reviewed for NCCLs clinical trials from 1950
to 2013. The reference list of all eligible trials and relevant review articles was checked to
find additional studies. The review did not have any language restrictions. Only randomized
Keywords: controlled clinical trials that evaluated at least two adhesives for a follow-up period of at
Adhesives least 18 months were included. Materials with adhesive potential were categorized into 6
Clinical trial main classes: 3-step etch&rinse adhesives (3E&Ra’s), 2-step etch&rinse adhesives (2E&Ra’s),
Non-carious cervical lesion 2-step self-etch adhesives (2SEa’s), 1-step self-etch adhesives (1SEa’s), glass-ionomers (GI’s)
Clinical effectiveness and self-adhesive composites (SAC’s). The first four can bond restorative composite to tooth
Systematic review tissue. Both 2SEa and 1SEa were further sub-divided in ‘mild’ and ‘intermediately strong
(1/2SEa m), with a pH ≥ 1.5, and ‘strong’ (1/2SEa s), with a pH < 1.5. From the restoration
retention rates as a function of time the average annual failure rate (AFR) per adhesive and
adhesive class was calculated.
Results. The lowest AFR scores [mean (SD)] were recorded for GI [2.0 (1.4)] shortly followed by
2SEa m [2.5 (1.5)], 3E&Ra [3.1 (2)] and 1SEa m [3.6 (4.3)] (Tukey Contrasts: p > 0.05). Significantly
higher AFR scores were recorded for 1SEa s [5.4 (4.8)], 2E&R [5.8 (4.9)], and 2SEa s [8.4 (7.9)]
(p > 0.05). In addition, significant differences in AFR were noticed between adhesives of the
same class (Kruskal–Wallis sum test: p > 0.05), except for GI (p = 0.7) and 2SEa m (p = 0.1).
Finally, selective enamel etching did not significantly influence the retention rate of SEa
(AFR SEa etch = 0.43 (0.49), AFR SEa non-etch = 1.43 (1.77).

∗
Corresponding author at: KU Leuven – BIOMAT, Department of Oral Health Sciences, KU Leuven & Dentistry, University Hospitals Leuven,
Kapucijnenvoer 7, B-3000 – Leuven, Belgium. Tel.: +32 16 332744; fax: +32 16 332752.
E-mail address: [email protected] (M. Peumans).
http://dx.doi.org/10.1016/j.dental.2014.07.007
0109-5641/© 2014 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
1090 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

Significance. The adhesive approach significantly influences the clinical effectiveness of

adhesives in NCCLs. Within each class, except for GI, there was a wide variation in clinical
bonding effectiveness.
© 2014 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090
2.1. Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1102
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1102
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1102

easily accessible buccal surface, (3) do not require complicated

1. Introduction
restorative techniques, (4) can be restored with a large ‘free’
Non-carious cervical lesions (NCCLs) should be restored as versus ‘bonded’ surface, (low C-factor), (5) involve both enamel
minimally invasive as possible. Currently, adhesive materi- and dentin, and most of all (6) commonly do not provide any or
als indicated to restore NCCLs include glass-ionomers and only minimal macro-retention, by which ineffective bonding
their resin-modified version, poly-acid modified composites will result in de-bonding and thus restoration loss. Retention,
(most frequently referred to as ‘compomers’), compos- marginal integrity and clinical micro-leakage (discoloration)
ite [1] and recently also self-adhesive composites [2,3]. are usually the key parameters recorded to assess clinical
In contrast to GI, compomers and conventional compos- effectiveness of adhesives. Among these criteria, retention is
ites require the use of a separate adhesive. In NCCLs, definitely the most objective one worldwide, especially when
the major part of tooth surface to bond to consists of comparing clinical data from many different research groups
dentin, while at the incisal side the restoration margin is in as in the present meta-analysis [4,12].
enamel. Dental adhesive technology evolves quickly and continu-
Contemporary adhesives can be classified according to ously with a rapid turnover of commercial adhesives, a high
their mode of action into etch&rinse (E&Ra) and self-etch (SEa) number of laboratory studies on adhesive materials and a
adhesives [4]. Materials with adhesive potential to tooth tis- high demand for laboratory techniques and data in poten-
sue can be categorized into 6 main classes: 3-step etch&rinse tial prediction of clinical effectiveness. In this context, an
adhesives (3E&Ra’s), 2-step etch&rinse adhesives (2E&Ra’s), 2- up-to-date systematic review on the clinical effectiveness of
step self-etch adhesives (2SEa’s), 1-step self-etch adhesives contemporary adhesives for the restoration of NCCLs is use-
(1SEa’s), all four can bond restorative composite to tooth ful. Therefore, the aim of this literature meta-analysis was to
tissue, glass-ionomers (GI’s) and self-adhesive composites evaluate the clinical effectiveness of contemporary adhesives
(SAC’s; excluded in this study due to absence of clinical for the restoration of NCCLs in terms of restoration reten-
data). Both 2SEa and 1SEa can be sub-divided into ‘mild’ and tion as a function of time (annual failure rate, AFR). The null
‘intermediately strong’ 1/2SEa (1/2SEa m), having a pH ≥ 1.5 hypothesis stated was that there is no difference in clini-
and leaving hydroxyapatite available as receptor for chemi- cal effectiveness of contemporary resin-based adhesives (and
cal interaction with the functional monomer contained in the glass-ionomers) for the restoration of NCCLs against the alter-
adhesive, and ‘strong’ 1/2SEa (1/2SEa s), having a pH < 1.5 and native hypothesis of a difference between (1) adhesives of the
a functional monomer that etches (demineralizes) rather than different adhesive (sub)classes, (2) adhesives within the same
chemically bonds to hydroxyapatite (HAp) [5]. class, and (3) SEa’s with and without prior selective enamel
Bonding effectiveness of adhesives is frequently tested on etching.
sound tooth substrate under optimal laboratory conditions,
showing large variability among the different classes of adhe-
sives as well as among adhesives of the same class [6–8]. 2. Materials and methods
Although several contemporary adhesives have been docu-
mented to provide a favorable ‘immediate’ bond to enamel and Randomized and non-randomized controlled clinical trials
dentin, many studies noted a considerable drop in bonding (RCT’s) comparing the clinical effectiveness of two or more
effectiveness upon artificial aging [7,9–11]. To determine the adhesives (to bond a restorative composite or compomer), GI’s,
clinical effectiveness of adhesives [12], NCCLs are considered SAC’s, and/or combinations of these in NCCLs were included
most ideal because NCCLs in need of restoration (1) are rela- in this review. Since not only adhesives as such were eval-
tively highly prevalent, (2) are most frequently present at the uated, but also GI’s and SAC’s, the term ‘adhesive material’
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1091

Table 1 – Medline Ovid Search strategy (1950–2013) used to systematically review dental literature.
1 Tooth Cervix/and (lesion$ or cavit$).mp.
2 (“cementoenamel junction$” and (lesion$ or cavit$)).mp.
3 (((tooth or teeth) adj3 (cervix or cervical)) and (lesion$ or cavit$)).mp.
4 (“non-carious cervical lesion$” or “noncarious cervical lesion$” or “class v lesion$” or “non-carious lesion$” or
“noncarious lesion$” or “abfraction lesion$” or “class v restor$”).mp.
5 (flexure adj3 (tooth or teeth)).mp.
6 ((tooth or teeth) adj3 sclerosis).mp.
7 6 or 4 or 1 or 3 or 2 or 5
8 Dental Restoration, Permanent
9 exp Dental Bonding/
10 (adhesiv$ or bond$).mp.
11 Glass Ionomer Cements/
12 Composite Resins/
13 Resin Cements/
14 (“acid etch$” or acid-etch$ or compomer$ or composite$ or nanocomposite$ or resin$ or “polyacid-modified
composite resin$” or “polyacid modified composite resin$” or “glass ionomer$” or glass-ionomer$ or “self etch$”
or self-etch$).mp.
15 8 or 11 or 13 or 10 or 9 or 12 or 14
16 7 and 15

was used throughout the manuscript. All adhesive materi- In this review, we focused on loss of retention as a function
als were classified into one of the 6 main classes (3E&Ra, of time and expressed as annual failure rate (AFR or percent-
2E&Ra, 2SEa, 1SEa, GI, SAC), with the 1/2SEa sub-divided in age loss divided by the number of years followed up). AFR
1/2SEa m and 1/2SEa s. To identify the studies to be considered was calculated for each adhesive and each adhesive (sub)class.
for inclusion in this review, a search strategy for MEDLINE (via This AFR calculation, although commonly used in dental lit-
OVID) (1950–2013) was developed (Table 1). The reference list erature [12,13], implies that restorations fail at a constant
of all eligible trials and relevant review articles was checked rate over time. This effect will be analyzed and addressed
to find additional studies. Abstracts presented at all meet- by categorizing the studies in ‘short-term’ (18 months to 3
ings of the International Association of Dental Research (IADR; years), ‘medium-term’ (3–5 years) and ‘long-term’ (more than
1965–2013) were searched as well. The review did not have any 5 years) studies. If a long-term study also included short- and
language restrictions. The list of exclusion criteria is reported medium-term results, these were also added to the short-
in Table 2. and medium-term studies. Other subgroup analyses were per-
Two reviewers (MP, AM), independently and in duplicate, formed to assess the influence of (1) the actual restorative
assessed the relevance of the articles identified. Any dis- material used, (2) the date the adhesive material was launched
agreement regarding relevance of an article was resolved by onto the market, as indicated by the date of the publication
discussion between the two reviewers, and if necessary by reporting on the adhesive material for the first time (‘young’
referral to a third reviewer (JDM). Full text versions of all arti- published between 2000 and 2013; ‘medium’ between 1994
cles that appeared to meet the inclusion criteria, regarding and 1999; ‘old’ between 1985 and 1993), and (3) the recall rate
study method, kind of participants, intervention and out- (‘high’ > 95%; ‘medium’ = 75–95%; ‘low’ < 75%).
come, were retrieved and subjected to data assessment. For To partly correct for factors that were not evaluated, such
each clinical trial, details of study, study method, partic- as differences in evaluation criteria, patient selection, etc., a
ipants, intervention and outcome were introduced into a ‘study correction factor’ was calculated for each study and
specially custom-designed relational database (FileMaker Pro, added to every observed AFR in the respective study. There-
FileMaker Inc., Santa Clara, CA, USA) (Table 3). Multiple reports fore, for each adhesive material that was tested several times
of the same clinical trial were linked together. in the database, a weighted average AFR was calculated using a

Table 2 – Exclusion criteria applied in the systematic literature review.

Studies were excluded if:
1. A combination of cervical carious and non-carious lesions were treated
2. A combination of cervical non-carious lesions and other classes of cavities were treated
3. The adhesive was not used according to the instructions of the manufacturer. An exception was made for the group of
self-etch adhesives in case the adhesive was applied according to the instructions of the manufacturer with prior
selective etching of the enamel cavity margins with phosphoric acid
4. The effectiveness of a single adhesive applied in different conditions was evaluated (e.g. variations in polymerization
time, differences in occlusal loading of the restored teeth, . . .)
5. The study follow-up was less than 18 months
6. Studies reported extremely low recall rates (<75% after 18 months, <60% after 3 years and <50% after 5 years or more)
7. The data were reported incorrectly or with insufficient information so that it could not be used in the review, unless the
authors supplied appropriate data
8. When the adhesive could not be classified into one of the 6 abovementioned classes
1092 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

Table 3 – Data introduced into the specially custom-designed relational database (FileMaker Pro; FileMaker Inc., Santa
Clara, CA, USA).
1. Details of the study, including year of publication and first author
2. Details of study methods, including study design and total study duration
3. Details of participants, including number, age, gender, setting, source of recruitment, and criteria for inclusion
4. Details on the intervention, including number of adhesive materials, class of the adhesive materials, product
name of adhesive materials, product name of restorative material, type of restorative material, cavity
preparation (dentin surface roughening), enamel bevel, method of isolation
5. Details of the outcome collected and reported, including loss of retention, caries occurrence, marginal defects,
marginal discoloration, recall percentage, reasons for drop out, statistical analysis

weight factor of 4 for a long-term study, of 2 for a medium-term Comparing the AFR’s (standard deviation, SD) of the 6 main
study, and of 1 for a short-term study. The study correction fac- classes, the best results were obtained by the GI’s [2 (1.4)],
tor was then calculated as the sum of differences between the followed by the 3E&Ra’s [3.1 (2)], 1SEa’s [4.4 (4.6)], 2SEa’s [4.7
observed AFR and each study’s weighted average AFR. (5.7)] and finally, the 2E&Ra’s [5.8 (4.9)]. The 2E&Ra’s showed a
significantly lower mean AFR score compared to the 3E&Ra’s
2.1. Statistics (p = 0.02) and GI’s (p < 0.001) (multiple comparisons of means
Tukey Contrasts). Taking also the 2 subclasses of 1/2SEa’s into
Differences in AFR between the 8 (sub)classes were sta- account, the 2SEa m adhesives presented with an AFR of 2.5
tistically analyzed for all three follow-up periods (short-, (1.5), thereby approaching the lowest AFR recorded for the GI’s
medium- and long-term) using general linear models and [2 (1.4)]. In increasing order, the AFR of the 1SEa m, 1SEa s
Tukey contrasts. To assess differences in AFR between adhe- and 2SEa s adhesives was 3.6 (4.3), 5.4 (4.8), and 8.4 (7.9),
sive materials of the same class, a subset of the data including respectively (Fig. 1). No statistically significant difference was
only the adhesive materials that had been evaluated at least found in AFR between GI’s, the 2SEa m, 3E&Ra’s and 1SEa m
3 times, was analyzed (non-parametric Kruskal–Wallis rank adhesives. Their AFR’s were significantly lower than those
sum test). In addition, the results of the statistical tests used in of 2E&R’s and 2SEa s adhesives (p < 0.05), while the 1SEa s
the published clinical trials – analyzing the difference in reten- adhesives only showed a significant difference with the GI
tion rate between two adhesive (sub)classes – were recorded. (p = 0.02).
A general linear model was applied to statistically analyze The statistical analysis used in the published clinical tri-
the influence of the restorative material and the recall rate als rarely reported a significant difference in retention rate
(high, medium, and low) on AFR. The influence of adhesive between adhesives of two different (sub)classes (Table 5). A
age (young, medium, and old) was evaluated with the help of significantly higher retention rate for GI than for 2E&Ra’s was
descriptive statistics. Finally, to assess the effect of selective reported 6 out of 11 times. Similarly, GI showed a significant
enamel etching prior to the use of 1/2 SEa’s on AFR, the odds higher retention rate than 1 SEa s in 3 out of 10 times. In gen-
ratios of the respective studies were calculated and the overall eral, better performing and less performing adhesives showed
effect was assessed with the Mantel–Haenszel odds ratio. a similar ranking. During the short, medium and long-term
All tests were performed at a significance level of ˛ = 0.05 observation periods, mean AFR scores were quite stable for GI,
using a software package (R3.01, R Foundation for Statistical 3E&Ra’s, 2SEa m, 2E&Ra’s. On the long term the AFR score of
Computing, Vienna, Austria). the 1SEa m, 1SEa s and 2SEa s adhesives obviously decreased
(Fig. 2). The adhesives most frequently tested in long-term
clinical trials were 3E&Ra’s (11 times), followed by 2E&Ra’s and
3. Results 1SEA m (5 times); GI (4 times); 2SEa s; 1SEa s and 2SEa m (3
times).
Following our search strategy, 915 study reports were AFR scores for the adhesives of each category are presented
introduced in the database, of which 679 did not involve a in Table 6. Significant differences between adhesives of the
clinical/Class-V study. In the 236 remaining reports, 178 dif- same category were noticed for 2E&Ra’s (p = 0.001), 3E&Ra’s
ferent clinical trials were identified. From these, 87 Class-V (p = 0.002) and 1SEa’s (1SEA s: p = 0.02; 1SEA m: p = 0.01) and
clinical trials met the inclusion criteria, for 15 of which only 2SEA’s (p = 0.009) (2SEA s: p = 0.03) (Kruskal–Wallis sum test). In
an abstract was found, and for 72 of which at least one peer- the category of 2SEa m’s (p = 0.1) and GI (p = 0.7), no significant
reviewed paper was published. Most studies were carried out differences were observed.
at university, 1 study in general practice and 1 study in a hospi- In most clinical trials, the restoration recall rate was regis-
tal. The follow-up period was short-term for 78, medium-term tered (83%) while less than half of the clinical trials provided
for 18 and long-term for 10 studies. In total, 78 adhesive mate- information about the recall rate of the patients (57%). Most
rials were tested. Table 4 shows a reference list of all eligible clinical trials had a medium recall rate (75–95%) (patient recall
clinical trials. The most frequently tested adhesive materials rate: 26 studies; restoration recall rate: 43 studies). Higher
were the 2E&Ra’s (65) and 1SEa’s (63), followed by the 3E&Ra’s recall rates were correlated with higher AFR scores, although
(37), 2SEa’s (34) and GI’s (32), No clinical trials investigating this correlation was not significant (patient recall rate: high:
SAC’s were available. Appendix A summarizes all the adhe- 5.3 (6.1); medium: 4.1 (4.8); low: 4.1 (4.5); p = 0.4/restoration
sive materials that were tested in the various clinical trials recall rate: high: 4.9 (6.3); medium: 4.1 (3.8); low: 3.4 (3.2);
along with the AFR’s calculated for each adhesive material. p = 0.3, general linear model).
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1093

Table 4 – List of included clinical trials (study identification – full reference).

St 25 Reis A, Leite TM, Matte K, Michels R, Amaral RC, Geraldeli S, Loguercio AD. Improving clinical retention of one-step self-etching
adhesive systems with an additional hydrophobic adhesive layer. J Am Dent Assoc 2009;140:877–85
St 28 Ritter AV, Swift Jr EJ, Heymann HO, Sturdevant JR, Wilder Jr AD. An eight-year clinical evaluation of filled and unfilled one-bottle
dental adhesives. J Am Dent Assoc 2009;140:28–37
Swift EJ Jr, Perdigao J, Wilder Jr AD, Heymann HO, Sturdevant JR, Bayne SC. Clinical evaluation of two one-bottle dentin adhesives
at three years. J Am Dent Assoc 2001;132:1117–23
Swift Jr EJ, Perdigao J, Heymann HO, Wilder Jr AD, Bayne SC, May Jr KN, Sturdevant JR, Roberson TM. Eighteen-month clinical
evaluation of a filled and unfilled dentin adhesive. J Dent 2001;29:1–6
St 30 Van Landuyt KL, Peumans M, De Munck J, Cardoso MV, Ermis B, Van Meerbeek B. Three-year clinical performance of a HEMA-free
one-step self-etch adhesive in non-carious cervical lesions. Eur J Oral Sci 2011;119:511–6
Van Landuyt KL, De Munck J, Ermis RB, Peumans M, Van Meerbeek B. Five-year clinical performance of a HEMA-free one-step
self-etch adhesive in noncarious cervical lesions. Clin Oral Invest 2013;17:1061–9
St 33 Ritter AV, Heymann HO, Swift Jr EJ, Sturdevant JR, Wilder Jr AD. Clinical evaluation of an all-in-one adhesive in non-carious
cervical lesions with different degrees of dentin sclerosis. Oper Dent 2008;33:370–8
St 35 van Dijken JW, Pallesen U. Long-term dentin retention of etch-and-rinse and self-etch adhesives and a resin-modified glass
ionomer cement in non-carious cervical lesions. Dent Mater 2008;24:915–22
St 37 Loguercio AD, Reis A. Application of a dental adhesive using the self-etch and etch-and-rinse approaches: an 18-month clinical
evaluation. J Am Dent Assoc 2008;139:53–61
St 39 Celik C, Ozgunaltay G, Attar N. Clinical evaluation of flowable resins in non-carious cervical lesions: two-year results. Oper Dent
2007;32:313–21
St 40 van Dijken JW, Sunnegardh-Gronberg K, Lindberg A. Clinical long-term retention of etch-and-rinse and self-etch adhesive
systems in non-carious cervical lesions. A 13 years evaluation. Dent Mater 2007;23:1101–7
St 44 Peumans M, De Munck J, Van Landuyt KL, Kanumilli P, Yoshida Y, Inoue S, Lambrechts P, Van Meerbeek B. Restoring cervical
lesions with flexible composites. Dent Mater 2007;23:749–54
Van Meerbeek B, Kanumilli PV, De Munck J, Van Landuyt K, Lambrechts P, Peumans M. A randomized, controlled trial evaluating
the three-year clinical effectiveness of two etch & rinse adhesives in cervical lesions. Oper Dent 2004;29:376–85
Peumans M, De Munck J, Van Landuyt KL, Poitevin A, Lambrechts P, Van Meerbeek B. A 13-year clinical evaluation of two
three-step etch-and-rinse adhesives in non-carious class-V lesions. Clin Oral Investig 2012;16:129–37
St 45 Peumans M, De Munck J, Van Landuyt K, Lambrechts P, Van Meerbeek B. Five-year clinical effectiveness of a two-step self-etching
adhesive. J Adhes Dent 2007;9:7–10
Peumans M, Munck J, Van Landuyt K, Lambrechts P, Van Meerbeek B. Three-year clinical effectiveness of a two-step self-etch
adhesive in cervical lesions. Eur J Oral Sci 2005;113:512–8
Van Meerbeek B, Kanumilli P, De Munck J, Van Landuyt K, Lambrechts P, Peumans M. A randomized controlled study evaluating
the effectiveness of a two-step self-etch adhesive with and without selective phosphoric-acid etching of enamel. Dent Mater
2005;21:375–83
St 47 Loguercio AD, Bittencourt DD, Baratieri LN, Reis A. A 36-month evaluation of self-etch and etch-and-rinse adhesives in noncarious
cervical lesions. J Am Dent Assoc 2007;138:507–14; quiz 535–537
St 48 Burrow MF, Tyas MJ. Clinical evaluation of three adhesive systems for the restoration of non-carious cervical lesions. Oper Dent
2007;32:11–5
St 50 Abdalla AI, Garcia-Godoy F. Clinical evaluation of self-etch adhesives in Class V non-carious lesions. Am J Dent 2006;19:289–92
St 51 Saboia Vde P, Almeida PC, Ritter AV, Swift Jr EJ, Pimenta LA. 2-Year clinical evaluation of sodium hypochlorite treatment in the
restoration of non-carious cervical lesions: a pilot study. Oper Dent 2006;31:530–5
St 52 Reis A, Loguercio AD. A 24-month follow-up of flowable resin composite as an intermediate layer in non-carious cervical lesions.
Oper Dent 2006;31:523–9
Reis A, Loguercio AD. A 36-month clinical evaluation of ethanol/water and acetone-based etch-and-rinse adhesives in
non-carious cervical lesions. Oper Dent 2009;34:384–91
St 54 Franco EB, Benetti AR, Ishikiriama SK, Santiago SL, Lauris JR, Jorge MF, Navarro MF. 5-Year clinical performance of resin composite
versus resin modified glass ionomer restorative system in non-carious cervical lesions. Oper Dent 2006;31:403–8
St 55 Kubo S, Kawasaki K, Yokota H, Hayashi Y. Five-year clinical evaluation of two adhesive systems in non-carious cervical lesions. J
Dent 2006;34:97–105
Kubo S, Yokota H, Takada H, Hayashi Y. Eight-year clinical evaluation of two adhesives in non-carious cervical lesions. J Dent Res
2008;87B [Abstr. No. 1786]
Kubo S, Kubo H, Yokota H, Yokota Y, Hayashi Y. Twelve-year clinical evaluation of two adhesives in non-carious cervical Lesions. J
Dent Res 2013;92A [Abstr. No. 3101]
St 57 Onal B, Pamir T. The two-year clinical performance of esthetic restorative materials in noncarious cervical lesions. J Am Dent
Assoc 2005;136:1547–55
St 62 Gladys S, Van Meerbeek B, Lambrechts P, Vanherle G. Marginal adaptation and retention of a glass-ionomer, resin-modified
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St 63 Van Meerbeek B, Peumans M, Gladys S, Braem M, Lambrechts P, Vanherle G. Three-year clinical effectiveness of four total-etch
dentinal adhesive systems in cervical lesions. Quintessence Int 1996;27:775–84
St 69 Ozgunaltay G, Onen A. Three-year clinical evaluation of a resin modified glass-ionomer cement and a composite resin in
non-carious class V lesions. J Oral Rehabil 2002;29:1037–41
St 72 Ermis RB. Two-year clinical evaluation of four polyacid-modified resin composites and a resin-modified glass-ionomer cement in
Class V lesions. Quintessence Int 2002;33:542–8
1094 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

Table 4 – (Continued)
St 78 Folwaczny M, Mehl A, Kunzelmann KH, Hickel R. Clinical performance of a resin-modified glass-ionomer and a compomer in
restoring non-carious cervical lesions. 5-Year results. Am J Dent 2001;14:153–6
St 81 Brackett WW, Browning WD, Ross JA, Brackett MG. Two-year clinical performance of a polyacid-modified resin composite and a
resin-modified glass-ionomer restorative material. Oper Dent 2001;26:12–6
St 83 Matis BA, Cochran M, Carlson T. Longevity of glass-ionomer restorative materials: results of a 10-year evaluation. Quintessence
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St 85 Perdigao J, Carmo AR, Geraldeli S. Eighteen-month clinical evaluation of two dentin adhesives applied on dry vs moist dentin. J
Adhes Dent 2005;7:253–8
St 86 Dalton Bittencourt D, Ezecelevski IG, Reis A, Van Dijken JW, Loguercio AD. An 18-months’ evaluation of self-etch and etch & rinse
adhesive in non-carious cervical lesions. Acta Odontol Scand 2005;63:173–8
St 87 Brackett WW, Brackett MG, Dib A, Franco G, Estudillo H. Eighteen-month clinical performance of a self-etching primer in
unprepared class V resin restorations. Oper Dent 2005;30:424–9
St 89 Gallo JR, Burgess JO, Ripps AH, Walker RS, Ireland EJ, Mercante DE, Davidson JM. Three-year clinical evaluation of a compomer and
a resin composite as Class V filling materials. Oper Dent 2005;30:275–81
St 90 Perdigao J, Carmo AR, Anauate-Netto C, Amore R, Lewgoy HR, Cordeiro HJ, Dutra-Correa M, Castilhos N. Clinical performance of a
self-etching adhesive at 18 months. Am J Dent 2005;18:135–40
St 91 Turkun LS. Five-year clinical performance of an antibacterial adhesive system. J Dent Res 2009;87C [Abstr. No. 623]
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St 93 Aw TC, Lepe X, Johnson GH, Mancl LA. A three-year clinical evaluation of two-bottle versus one-bottle dentin adhesives. J Am
Dent Assoc 2005;136:311–22
St 96 Matis BA, Cochran MJ, Carlson TJ, Guba C, Eckert GJ. A three-year clinical evaluation of two dentin bonding agents. J Am Dent
Assoc 2004;135:451–7
St 106 van Dijken JW. Clinical evaluation of three adhesive systems in class V non-carious lesions. Dent Mater 2000;16:285–91
St 110 Brackett WW, Gilpatrick RO, Browning WD, Gregory PN. Two-year clinical performance of a resin-modified glass-ionomer
restorative material. Oper Dent 1999;24:9–13
St 116 McCoy RB, Anderson MH, Lepe X, Johnson GH. Clinical success of class V composite resin restorations without mechanical
retention. J Am Dent Assoc 1998;129:593–9
St 117 Abdalla AI, Alhadainy HA. Clinical evaluation of hybrid ionomer restoratives in Class V abrasion lesions: two-year results.
Quintessence Int 1997;28:255–8
St 120 Neo J, Chew CL, Yap A, Sidhu S. Clinical evaluation of tooth-colored materials in cervical lesions. Am J Dent 1996;9:15–8
St 121 Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada BE. Two-year clinical performance of Class V resin-modified glass-lonomer
and resin composite restorations. Oper Dent 2003;28:477–81
St 123 Kim SY, Lee KW, Seong SR, Lee MA, Lee IB, Son HH, Kim HY, Oh MH, Cho BH. Two-year clinical effectiveness of adhesives and
retention form on resin composite restorations of non-carious cervical lesions. Oper Dent 2009;34:507–15
St 127 Brackett MG, Dib A, Franco G, Estrada BE, Brackett WW. Two-year clinical performance of Clearfil SE and Clearfil S3 in restoration
of unabraded non-carious class V lesions. Oper Dent 2010;35:273–8
St 130 van Dijken JW. A prospective 8-year evaluation of a mild two-step self-etching adhesive and a heavily filled two-step
etch-and-rinse system in non-carious cervical lesions. Dent Mater 2010;26:940–6
St 138 Burgess JO, Gallo JR, Ripps AH, Walker RS, Ireland EJ. Clinical evaluation of four Class 5 restorative materials: 3-year recall. Am J
Dent 2004;17:147–50
St 139 van Dijken JW. Durability of three simplified adhesive systems in Class V non-carious cervical dentin lesions. Am J Dent
2004;17:27–32
St 141 Loguercio AD, Reis A, Barbosa AN, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin-modified glass
ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent 2003;5:323–532
St 142 Turkun SL. Clinical evaluation of a self-etching and a one-bottle adhesive system at two years. J Dent 2003;31:527–34
St 148 Gurgan S, Kiremitci A, Firat E. Clinical evaluation of self-etch adhesive in cervical lesions: 36-month results. J Dent Res 2011;90A
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St 149 Kubo S, Yokota H, Yokota H, Hayashi Y. Two-year clinical evaluation of one-step self-etch systems in non-carious cervical lesions. J
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Kubo S, Kawasaki A, Kawakubo A, Hayashi Y. Five-year clinical evaluation of two all-in-one systems. J Dent Res 2011;90A [Abstr.
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St 150 Barabanti N, Cerutti F, Acquaviva PA, Cerutti A. 24-Month clinical evaluation of class-V restorations with two different composites.
J Dent Res 2011;90A [Abstr. No. 146]
St 152 Moretto SG, Russo EMA, Carvalho RCR, Van Landuyt K, Peumans M, Van Meerbeek B, Cardoso MV. 2-year clinical effectiveness of
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Moretto SG, Russo EM, Carvalho RC, De Munck J, Van Landuyt K, Peumans M, Cardoso MV. 3-Year clinical effectiveness of one-step
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St 153 Ottenga M, Nimmo S, Soderholm KJ. Two-year clinical evaluation of two self-etching dentin adhesives. J Dent Res 2010;89B [Abstr.
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Ottenga M, Nimmo S and Soderholm KJ. Four-year clinical evaluation of two self-etching dentin adhesives. J Dent Res 2012;91A
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St 154 Dondi Dall’orologio G, Fazzi F, Lorenzi R. Restoration of cervical lesions: 7-year results of a RCT. J Dent Res, 2010;89B [Abstr. No. 688]
Dondi dall’orologio G, Lodi D, Fazzi F, Lorenzi R. Restoration of NCCls: 6-year results of a RCT. J Dent Res 2009;88B [Abstr. No. 105]
Dondi Dall’orologio G, Lorenzi R. Restoration of cervical lesions: 3-year results of a RCT. J Dent Res 2006;85B [Abstr. No. 1152]
Dondi Dall’orologio G, Lorenzi R. Restoration of cervical lesions: 18-month result of a RCT. J Dent Res 2004;83A [Abstr. No. 1375]
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1095

Table 4 – (Continued)
St 155 Burrow MF, Tyas MJ. Comparison of two all-in-one adhesives bonded to non-carious cervical lesions-results at 3 years. Clin Oral
Investig 2012;16:1089–94
St 156 Dondi Dall’orologio G, Fazzi F, Lorenzi R. Restoration of NCCls: 60-month results of a QRCT. J Dent Res 2009;88A [Abstr. No. 547]
St 157 Peschke A, Watzke R, Roulet JF. One-step vs. Two-step self-etch-adhesive for cervical restorations after 2 years. J Dent Res
2009;88A [Abstr. No. 552]
St 159 Ermis RB, Van Landuyt K, Cardoso MV, Peumans M, Van Meerbeek B. Eighteen-month clinical effectiveness of a one-step self-etch
adhesive. J Dent Res 2008;87C [Abstr. No. 573]
Ermis RB, Van Landuyt KL, Cardoso MV, De Munck J, Van Meerbeek B, Peumans M. Clinical effectiveness of a one-step self-etch
adhesive in non-carious cervical lesions at 2 years. Clin Oral Investig 2012;16:889–97
St 161 Rodrigues LKA, Fernandes CAO, Macedo GV, Carvalho RM. Clinical trial of acid-etching prior to a self-etching adhesive system. J
Dent Res 2008;87B [Abstr. No. 1784]
St 165 Ernst CP, Brandenbusch M, Meyer GR, Canbek K, Werling U, Willershausen B. Hybrid bond and Xeno III in cervical lesions: two year
results. J Dent Res 2007;86A [Abstr. No. 895]
St 168 Helbig EB, Klimm HW, Schreger IE, Rietschel J, Richter G, Haufe E. One-bottle and a self-etching adhesive in class V restorations. J
Dent Res 2004;83A [Abstr. No. 537]
St 170 Friedl KH, Hiller KA, Jung H, Schlittenbauer T, Lichtblau J, Schmalz G. Clinical evaluation of composite restorations using different
adhesive systems. J Dent Res 2004;83A [Abstr. No. 535]
St 174 Elderton RJ, Vowles RW, Bell CJ, Marshall KJ. Three-year retention of cervical compomer restorations in non-undercut cavities. J
Dent Res 1997;76:162 [Abstr. No. 1185]
St 176 Brackett WW, Gilpatrick RO, Browning WD, Gregory PN. Clinical performance of a light-cured glass ionomer restorative material. J
Dent Res 1997;76:185 [Abstr. No. 373]
St 177 Platt JA, Winkler MM, Matis BA, Moore BK. Correlation of dentin adhesive laboratory & clinical performance at 3-years. J Dent Res
1998;77:236 [Abstr. No. 1044]
St 180 Ngo H, Fraser M, Burgess V, Smales R. Clinical performance of a RMGI adhesive system: 24 months results. J Dent Res 2001;80:709
[Abstr. No. 1460]
St 182 Santiago SL, Passos VF, Vieira AH, Navarro MF, Lauris JR, Franco EB. Two-year clinical evaluation of resinous restorative systems in
non-carious cervical lesions. Braz Dent J 2010;21:229–34
St 184 Fron H, Vergnes JN, Moussally C, Cazier S, Simon AL, Chieze JB, Savard G, Tirlet G, Attal JP. Effectiveness of a new one-step
self-etch adhesive in the restoration of non-carious cervical lesions: 2-year results of a randomized controlled practice-based
study. Dent Mater 2010;27:304–12
St 189 Zander-Grande C, Ferreira SQ, da Costa TR, Loguercio AD, Reis A. Application of etch-and-rinse adhesives on dry and rewet dentin
under rubbing action: a 24-month clinical evaluation. J Am Dent Assoc 2011;142:828–35
St 211 Can Say E, Ozel E, Yurdaguven H, Soyman M. Three-year clinical evaluation of a two-step self-etch adhesive with or without
selective enamel etching in non-carious cervical sclerotic lesions. Clin Oral Investig 2013 [published online]
St 214 van Dijken JW. A randomized controlled 5-year prospective study of two HEMA-free adhesives, a 1-step self etching and a 3-step
etch-and-rinse, in non-carious cervical lesions. Dent Mater 2013;29:e271–80
St 217 Yaman BC, Dogruer I, Gumustas B, Efes BG. Three-year randomized clinical evaluation of a low-shrinkage silorane-based resin
composite in non-carious cervical lesions. Clin Oral Investig 2013 [published online]
St 220 Tuncer D, Yazici AR, Ozgunaltay G, Dayangac B. Clinical evaluation of different adhesives used in the restoration of non-carious
cervical lesions: 24-month results. Aust Dent J 2013;58:94–100
St 221 Qin W, Song Z, Ye YY, Lin ZM. Two-year clinical evaluation of composite resins in non-carious cervical lesions. Clin Oral Investig
2013;17:799–804
St 222 Eliguzeloglu Dalkilic E, Omurlu H. Two-year clinical evaluation of three adhesive systems in non-carious cervical lesions. J Appl
Oral Sci 2012;20:192–9
St 228 Zander-Grande C, Amaral RC, Loguercio A, Barroso L, Reis A. Clinical performance of one-step self-etch adhesives applied actively
in cervical lesions: 24-month clinical trial. Oper Dent 2014 [in press]
St 229 Perdigao J, Kose C, Mena-Serrano A, De Paula E, Tay L, Reis A, Loguercio A. A new universal simplified adhesive: 18-month clinical
evaluation. Oper Dent 2013 [in press]
St 230 Dutra-Correa M, Saraceni CH, Ciaramicoli MT, Kiyan VH, Queiroz CS. Effect of chlorhexidine on the 18-month clinical performance
of two adhesives. J Adhes Dent 2013;15:287–92
St 232 Burgess JO, Sadid-Zadeh R, Cakir D, Ramp LC. Clinical evaluation of self-etch and total-etch adhesive systems in noncarious
cervical lesions: a two-year report. Oper Dent 2013;38:477–87
St 234 Moosavi H, Kimyai S, Forghani M, Khodadadi R. The clinical effectiveness of various adhesive systems: an 18-month evaluation.
Oper Dent 2013;38:134–41
St 235 Stojanac IL, Premovic MT, Ramic BD, Drobac MR, Stojsin IM, Petrovic LM. Noncarious cervical lesions restored with three different
tooth-colored materials: two-year results. Oper Dent 2013;38:12–20
St 237 Perdigao J, Dutra-Correa M, Saraceni CH, Ciaramicoli MT, Kiyan VH, Queiroz CS. Randomized clinical trial of four adhesion
strategies: 18-month results. Oper Dent 2012;37:3–11
St 244 Loguercio AD, Ferri L, Costa TR, Reis A. 18-Month clinical evaluation of new etch-and-rinse adhesive in cervical lesions. J Dent Res
2013;92A [Abstr. No. 596]
St 245 Blunck U, Steidten J, Sandberg N, Zaslansky P. Two-year clinical performance of one-step self-etch adhesives in cervical
restorations. J Dent Res 2013;92A [Abstr. No. 3109]
St 247 Walter R, Swift Jr EJ, Boushell LW, Heymann H, Wilder Jr AD, Sturdevant J, Ritter AV, Chung Y. Clinical evaluation of dental
adhesives of different bonding strategies. J Dent Res 2013;92A [Abstr. No. 605]
1096 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

Table 4 – (Continued)
St 253 Kurokawa H, Takamizawa T, Rikuta A, Tsubota K, Miyazaki M. Long-term clinical evaluation of one-step self-etch adhesive
systems. J Dent Res 2012;91A [Abstr. No. 803]
St 257 Robles A, Sadid-Zadeh R, Anabtawi M, Givan D, Waldo B, Ramp L, Cakir D, Burgess J. Two-year clinical evaluation of three
adhesives in Class V restorations. J Dent Res, 2012;91A [Abstr. No. 805]
St 259 Ciampalini G, Barabanti N, Don D, Madini L, Cerutti A. 48-Month clinical evaluation of Class-V restorations with two different
composites. J Dent Res 2012;91C [Abstr. No. 546]
St 268 Dondi dall’orologio G, Fazzi F, Lorenzi R. Restoration of cervical lesions: 60-month results of a RCT. J Dent Res 2008;87B [Abstr. No.
1785]

Regarding the influence of the restorative material, the 1.43 (1.77) to 0.43 (0.49) by acid etching. Once more, none of
general linear model showed a significant influence on AFR the studies showed a significant difference.
(p < 0.001) (Table 7). The lowest AFR for restorative materials
that were tested at least 3 times was calculated for Gradia
Direct Anterior (GC, Tokyo Japan) (7 times) [1.9 (1.3)]. The 4. Discussion
restorative materials that were tested most frequently were:
Clearfil AP-X (Kuraray Noritake, Tokyo, Japan) (15 times) ([AFR: This review is partially based on an earlier review assessing
2.5 (0.9)]; Filtek Z250 (3M ESPE, St. Paul, MN, USA)(13 times) the clinical effectiveness of adhesives for the restoration of
([AFR: 4.9 (3.9)] and Filtek A110 (3M ESPE) (10 times) ([AFR: 3.6 NCCLs in trials published from 1998 to 2004 [12]. Compared to
(2.3)]. this previous review, the search strategy of the present review
The age of the adhesive, as assessed by its first appear- was described more precisely. More exhaustive exclusion and
ance in PubMED, did not influence AFR of the different inclusion criteria were selected. Only randomized controlled
(sub)categories (young: 4 (4.7); medium: 5.3 (4.8); old: 3 (1.9)). clinical trials and controlled clinical trials evaluating at least 2
However, this observation is biased by the fact that for some adhesives for at least 18 months were used. By choosing strict
approaches there were almost no “young” products (e.g. glass- selection criteria data quality was improved, bias reduced
ionomers), while for others, there were no “old” products (e.g. and consequently more studies were available in article form
mild self-etch adhesives) (Table 8). Remarkable is the signifi- (72) than in abstract form (15). In addition to retention, other
cant correlation between AFR and adhesive age in the group of variables such as marginal adaptation, marginal discoloration
1SEa’s (r = 0.3, p = 0.01) and 2E&R’s (r = 0.3, p = 0.006) (descriptive and caries recurrence were recorded in the database as well.
statistics). None of the other groups showed such a correlation. Moreover, information was collected regarding operative pro-
Finally, the influence of selective enamel etching with cedures such as tooth preparation (dentin surface roughening,
phosphoric acid prior to application of a SEa was evaluated enamel bevel) and method of isolation. The results of these
in 7 clinical trials (St 45, 55, 90, 161, 184, 211, 229). All tested variables on clinical bonding effectiveness of adhesives in
adhesives belong to the 1/2 SEa m. The adjusted odds ratio NCCLs will be analyzed in future.
(Mantel–Haenszel odds ratio: 0.439 [0.133–1.45]) favored acid Classifying the adhesives into 6 main classes, we recorded
etching, but not significantly (p = 0.167). AFR decreased from the lowest AFR scores for GI [2.0 (1.4)], followed by 3E&Ra’s

Fig. 1 – Mean AFR scores and standard errors for the 8 different (sub)classes. Different letters indicate a significant
difference between the different classes.
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1097

Table 5 – Within study comparisons – number of studies showing some difference (number of studies showing a
statistical significant difference).
Comparison A versus B A better B better Number of studies (identification of study)
1SEa versus 2E&Ra 7(0) 15(1) 17 (St 139, St 214, St 220, St 222, St 229, St 230, St 232, St 234, St 235, St 237,
St 247, St 257, St 47, St 50, St 72, St 86, St 89)
1SEa versus 2SEa 4(0) 8(1) 13 (St 127, St 139, St 153, St 157, St 221, St 222, St 232, St 235, St 237, St 257,
St 50, St 57, St 91)
1SEa versus 3E&Ra 7(1) 12(1) 13 (St 123, St 154, St 159, St 170, St 214, St 234, St 237, St 245, St 268, St 30,
St 33, St 35, St 57)
1SEa versus GI 1(0) 9(3) 8 (St 117, St 141, St 174, St 35, St 57, St 62, St 72, St 78)
1SEa s versus 2E&Ra 5(0) 6(0) 8 (St 139, St 222, St 235, St 247, St 47, St 72, St 86, St 89)
1SEa s versus 3E&Ra 4(0) 4(0) 4 (St 123, St 170, St 35, St 57)
1SEa s versus GI 1(0) 9(3) 8 (St 117, St 141, St 174, St 35, St 57, St 62, St 72, St 78)
1SEa m versus 1SEa s 2(0) 0(0) 4 (St 165, St 247, St 253)
1SEa m versus 2E&Ra 2(0) 8(1) 10 (St 214, St 220, St 229, St 230, St 232, St 234, St 237, St 247, St 257, St 50)
1SEa m versus 2SEa s 3(0) 0(0) 3 (St 232, St 237, St 257)
1SEa m versus 2SEa m 0(0) 2(0) 4 (St 127, St 153, St 157, St 50)
1SEa m versus 3E&Ra 3(1) 8(1) 9 (St 154, St 159, St 214, St 234, St 237, St 245, St 268, St 30, St 33)
1SEa m versus GI 0(0) 0(0) 0
2E&Ra versus 3E&Ra 5(0) 4(1) 7 (St 106, St 138, St 214, St 234, St 237, St 40, St 93)
2E&Ra versus GI 0(0) 11(6) 8 (St 106, St 121, St 138, St 182, St 48, St 54, St 72, St 81)
2SEa versus 2E&Ra 12(0) 6(1) 17 (St 130, St 139, St 142, St 148, St 168, St 217, St 222, St 232, St 235, St 237,
St 257, St 37, St 40, St 48, St 50, St 55, St 87)
2SEa versus 3E&Ra 4(0) 8(0) 4 (St 116, St 237, St 40, St 57)
2SEa versus GI 1(0) 2(1) 3 (St 120, St 48, St 57)
2SEa s versus 2E&Ra 4(0) 5(1) 7 (St 148, St 232, St 237, St 257, St 37, St 40, St 87)
2SEa s versus 3E&Ra 3(0) 8(0) 4 (St 116, St 40, St 57, St 237)
2SEa s versus GI 1(0) 1(1) 2 (St 120, St 57)
2SEa m versus 2E&Ra 9(0) 1(0) 10 (St 130, St 139, St 142, St 168, St 217, St 222, St 235, St 48, St 50, St 55)
2SEa m versus 2SEa s 0(0) 0(0) 0
2SEa m versus 3E&Ra 0(0) 0(0) 0
2SEa m versus GI 0(0) 1(0) 1 (St 48)
3E&Ra versus GI 2(0) 10(1) 7 (St 106, St 138, St 177, St 180, St 35, St 57, St 69)

[3.1 (2)], 1SEa’s [4.4 (4.6)], 2SEa’s [4.7 (5.7)] and 2E&Ra’s [5.8 criteria as the present review, was limited to the qualitative
(4.9)]. A significant difference was noticed between 3E&Ra’s description of NCCLs clinical trials. There was not enough
- 2E&Ra’s (p = 0.02) and GI-2E&Ra’s (p < 0.001). Different conclu- evidence to support one adhesive strategy over another, as
sions were drawn in 3 other systematic reviews investigating most studies were not of sufficient quality to fully address
the clinical performance of adhesives in NCCLs [14–16]. In a the review’s objective. Finally, they emphasized the need for
systematic review of clinical trials from 1994 to 2008 Heintze better standardization and reporting of randomized clinical
et al. [14] recorded a superior performance of 2SEa’s. The 1SEA trials investigating adhesive performance. This conclusion
performed worst while 3E&Ra’s, GI, 2E&Ra’s and polyacid- can also be drawn from the present systematic review. There-
modified resin composites were ranked in between. These fore, CONSORT guidelines [17] should be strictly followed
conclusions were based on observation periods of up to 3 when submitting manuscripts of RCT’s to journals. Only this
years. A clinical index, based on the combination of 3 clin- would make it possible to analyze the data in a meta-analysis
ical outcomes (retention, marginal adaptation and marginal providing a highly reliable measure of restoration longevity. In
discoloration) was used to rank adhesives according to their the present study a wide variation in AFR-scores was noticed
clinical effectiveness. The polyacid-modified resin compos- in both groups of SEa’s (Table 6). Therefore, two subcate-
ites were taken as a separate category. This was not the gories were created: SEa’s with a pH ≥ 1.5 and containing a
case in the present study as this restorative material can be functional monomer (SEa m), and the older precursors of self-
used with an adhesive of different classes. Krithikadatta [15] etch adhesives and strong SEa’s (pH < 1) (SEa s). It was shown
published a systematic review addressing the same research in vitro that a higher bonding efficiency was obtained for
question including studies from 2004 to 2010. They con- intermediate (pH ≈ 1.5), mild (pH ≈ 2), and ultra-mild self-etch
cluded that the clinical performance of different categories of (pH ≥ 2.5) adhesives, especially in the long term. This was the
bonding systems (E&Ra’s, SEa’s and self-etch primers) were case mainly because no thick hydrolysis-prone hybrid layer is
comparable. The alpha scores for different USPHS criteria formed and because some residual hydroxyapatite is present
(retention, marginal adaptation, marginal discoloration, sec- to chemically bond the restoration to the tooth tissue [5]. If
ondary caries and postoperative sensitivity) were used to rank the 2 subclasses of 1/2 SEa’s are included, 2 groups can be
adhesives according to their clinical effectiveness. In addi- distinguished (Fig. 1). Group 1 contains the better performing
tion, in both systematic reviews the selection criteria and the adhesives, consisting of GI [2.0 (1.4)] with the lowest AFR score,
review/assessment process were different from the present shortly followed by 2SEa m [2.5 (1.5)], 3E&Ra’s [3.1 (2)] and
review. This accounts for the different conclusions. A sys- 1SEa m [3.6 (4.3)]. Group 2 contains adhesive approaches with
tematic review by Chee et al. [16], using the same selection significantly higher AFR scores: SEa s (1SEa: 5.4 (4.8); 2SEa: 8.4
1098 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

Fig. 2 – Mean AFR scores and standard errors for the 8 different (sub)classes in the short (18 months to 3 years), medium
(3–5 years) and long-term (>5 years) studies. The number below each box plot represents the number of tests available.

(7.9) and 2E&Ra’s [5.8 (4.9)]. For GI, 2SEa m and 3E&Ra, mean [18], 6 different 1SEa’s showed a 100% retention rate. Similarly,
AFR scores were relatively stable with time (short, medium in the group of 2SEa s, 3 (old) adhesives showed moderate AFR
and long-term) confirming that this score is a reliable param- scores after 13 years [19].
eter to measure retention loss with time (Fig. 2). Only for the 1 From this we can conclude that the first hypothesis of
SEa’s and 2SEa s a decrease in mean AFR-score was reported this review is rejected as differences between adhesives of
on the long term, due to quite high retention rates in two long- the 8 different (sub)classes were present. Glass-ionomers
term clinical trials. In the 8-year clinical trial of Kurokawa et al. and 2SEa m showed the most favorable and durable clinical
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1099

Table 6 – List of AFR scores and SD per adhesive and – Table 6 (Continued)
adhesive category.
Adhesive (manufacturer) Times AFR SD
Adhesive (manufacturer) Times AFR SD tested
tested
One-step Plus (Bisco Inc) 1 19.9 –
1SEa PQ1 (Ultradent, South Jordan, UT, USA) 1 4.6 –
1SEa m SCA (Dentsply DeTrey) 1 10.2 –
Clearfil S3 Bond (Kuraray Noritake, Tokyo, 7 2.6 1.3 Syntac Single Component (Ivoclar 1 5.5 –
Japan) Vivadent)
G-Bond (GC, Tokyo, Japan) 7 1.3 0.6 Total 2E&Ra 65 5.8 4.9
iBond (Hereaus Kulzer, Hanau,Germany) 6 5 5.7
Hybrid Bond (Sun Medical Co., Shiga, 2 1.2 0.7 2SEa
Japan) 2SEa m
Adhese One (Ivoclar Vivadent, Schaan, 1 4.4 – Adhese (Ivoclar Vivadent) 3 3.6 1.7
Liechtenstein) Futurabond (Voco) 1 6 –
AQ Bond Plus (Sun Medical Co) 1 0.3 – Clearfil SE Bond (Kuraray Noritake) 12 2.2 1.2
Bond Force (Tokyama Dental Corporation, 1 2.5 – Clearfil Liner Bond 2 (Kuraray Noritake) 2 2.3 0.07
Tokyo, Japan) Clearfil Protect Bond (Kuraray Noritake) 1 2.6 –
iBond NG plus (Hereaus Kulzer) 1 2.8 – Clearfil Liner Bond 2V (Kuraray Noritake) 1 0 –
Futurabond NR (Voco, Cuxhaven, 1 23.5 – Silorane System Adhesive (3M ESPE) 1 1.8 –
Germany) Total 2SEa m 21 2.5 1.5
Xeno V (Dentsply DeTrey, Konstanz, 1 7.6 –
2SEa s
Germany)
Prisma Universal Bond 3 (Dentsply Caulk, 3 3.7 1.4
Adper Easy Bond (3M ESPE, St. Paul, MN, 3 3.2 0.7
Milford, DE, USA)
USA)
ART Bond (Coltène Whaledent) 2 4.9 2.4
AQ Bond (Sun Medical Co.) 2 5.3 0.4
Denthesive 2 (Hereaus Kulzer) 1 5.7 –
Fluoro Bond Shake One (Shofu Inc., Kyoto, 1 0.3 –
Tyrian SPE/one-step plus (Bisco Inc) 2 25.3 6
Japan)
Adper Scotchbond SE (3M ESPE) 4 5.3 0.2
Optibond All-in One (Kerr, Orange, CA, 1 4.5 –
NRC&Prime&Bond NT (Dentsply DeTrey) 1 11.1 –
USA)
Total 2SEa s 13 8.4 7.9
Scotchbond Universal SE (3M ESPE) 1 4 –
Total 2SEa 34 4.7 5.7
Xeno IV (Dentsply DeTrey) 1 3.7 –
Total 1SEa m 37 3.6 4.3
3E&Ra
1-SEa s Adper Scotcbond Multi-Purpose (3M ESPE) 13 3.9 2
PSA (Dentsply DeTrey) 6 8.7 7.9 Optibond FL (Kerr) 6 1.8 0.8
Compomer Primer Adhesive (3MESPE) 3 7.6 3.5 Clearfil Liner Bond (Kuraray Noritake) 3 2.2 0.37
Adper Prompt L-Pop (3M ESPE) 7 2.3 1.5 ESPE Bonding System (3M, St Paul, MN, 3 5 1.3
Prompt L-Pop (3M ESPE) 2 8.8 0.4 USA, now 3M ESPE)
Xeno III (Dentsply DeTrey) 7 4.8 2.3 All-Bond 2 (Bisco Inc.) 2 2.9 1.9
One-up Bond F Plus (Tokuyama Dental 1 0.3 – Permaquick (Ultradent) 2 1.6 0.3
Corporation) Adper Scotchbond Multi-Purpose Plus (3M 1 1.7 –
Total 1SEa s 26 5.4 4.8 ESPE)
Total 1SEa 63 4.4 4.6 Cmf (Saremco, Rebstein, Switzerland) 1 0.7 –
Denthesive (Hereaus Kulzer) 1 7.3 –
2E&Ra FL Bond (Shofu Inc.) 1 1 –
Scotchbond 1 (3M ESPE) 17 3.8 3.3 Gluma Solid Bond (Hereaus Kulzer) 1 2.3 –
Prime&Bond NT (Dentsply DeTrey) 10 6.3 1 Permagen (Ultradent) 1 6.4 –
Adper Scotchbond 1 XT (3M ESPE) 5 1.4 1 ProBond (Dentsply Caulk) 1 1.7 –
XPBond (Dentsply DeTrey) 5 3.5 1.4 Syntac (Ivoclar Vivadent AG) 1 2.5 –
One-Step (Bisco Inc., Schaumburg, IL, 4 17.1 6 Total 3E&Ra 37 3.1 2
USA)
One Coat Bond (Coltène Whaledent, 3 3.8 0.9 GI
Altstätten, Switzerland) Fuji II LC (GC) 10 1.8 1.6
Admira Bond (Voco) 2 0.9 1.2 Vitremer (3M) 9 1.6 1.1
Excite (Ivoclar Vivadent) 2 10.6 0.6 Ketac-Fil (3M ESPE) 4 2.5 0.9
Gluma Comfort Bond (Hereaus Kulzer) 2 4.6 0.6 Photac Fil (3M ESPE) 3 2.9 2
Optibond Solo (Kerr) 2 6.8 1.7 Fuji Cap II (GC) 2 3.7 2.4
Prime&Bond 2.1 (Denstply DeTrey) 2 9.7 4 Chelon-Fil (3M ESPE) 1 1.3 –
Scotchbond Universal E&R (3M ESPE) 2 0.5 0.7 Chemfil (Dentsply DeTrey) 1 0 –
Solobond M (Voco) 2 11.6 2.8 Fuji Bond LL (GC) 1 1.1 –
Ambar (FGM Dental Products, Joinville, 1 2.6 – HIFI Master Palette (Shofu Inc.) 1 2.7 –
Brazil) Total GI 32 2 1.4
Gluma 2000 (Hereaus Kulzer) 1 6.5 –
Optibond Solo Plus (Kerr) 1 4.6 –
1100 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

bonding performance. In fact, the bonding mechanism of both

Table 7 – mean AFR scores and SD for each restorative
material tested in the selected NCCL clinical trials. classes is quite similar [20,21]. They only superficially interact
with dentin, and hardly dissolve HAp crystals, but rather keep
Restorative material Times AFR SD
them in place (within a thin submicrometre hybrid layer) [5].
(manufacturer) tested
Resin-based self-etch adhesives have functional monomers
Admira Flow (Voco, Cuxhaven, 1 0 –
(such as 10-MDP, 4-MET (or 4-methacryloxyethyl trimellitic
Germany)
acid) and phenyl-P), while glass-ionomers contain the func-
Amelogen Microfill (Ultradent, South 1 1.7 –
Jordan, UT, USA) tional polymer polyalkenoic acid. Both have the potential to
Amelogen Hybrid (Ultradent) 1 1.3 – chemically interact with HAp in the hybrid layer [22,23]. This
Arabesk Top (Voco) 2 7.7 2.5 chemical bonding, combined with micro-mechanical inter-
Beautifil (Shofu Inc., Kyoto, Japan) 1 1 – locking through shallow hybridization, is responsible for the
Brillant (Coltène Whaledent, Altstätten, 2 4.8 2.3 favorable bonding performance [24,25].
Switzerland)
Despite their excellent clinical performance in terms
CeramX Duo (Dentsply DeTrey, 6 4.1 2.5
of retention, glass-ionomers commonly present with lower
Konstanz, Germany)
CeramX Mono (Dentsply DeTrey) 3 3.5 1.7 esthetic features (higher surface roughness, lower color sta-
Charisma (Hereaus Kulzer, Hanau, 2 6.5 1.1 bility, and lower wear resistance) and inferior mechanical
Germany) properties when compared to resin-based restorative mate-
Clearfil AP-X (Kuraray Noritake, Tokyo, 15 2.5 0.9 rials [26,27]. These shortcomings can negatively influence
Japan) clinical performance of GI restorations in NCCLs particularly
Clearfil Lustre (Kuraray Noritake) 1 2 –
in the mid to long term. Nevertheless, one must keep in
Clearfil Photo Anterior (Kuraray 2 2.3 0.4
Noritake)
mind their low technique sensitivity as indicated by the low
Clearfil ST (Kuraray Noritake) 2 2.3 0.5 standard deviations for all tested GI (Table 6).
Compoglass F (Ivoclar Vivadent, Schaan, 2 7.8 3.3 In comparison with the previous review [12] the 2SEa m
Liechtenstein) surpassed the 3E&Ra’s or the so-called golden standard. How-
Denfil (Vericom Co, Gyeonggi, Korea) 4 2.8 1.4 ever, the difference in AFR between both adhesive categories
Durafill (Hereaus Kulzer) 3 2.2 0.0
was small and not significant. Consequently, it can be con-
Dyract (Dentply DeTrey) 6 8.5 7.9
cluded that the bonding efficiency of 3E&Ra’s is favorable in
Dyract AP (Dentsply DeTrey) 3 7.3 3.3
Dyract Flow (Dentsply DeTrey) 1 11.8 – NCCLs. A similar conclusion was drawn in a review of bond
Elan (Kerr, Orange, CA, USA) 1 8 – strength tests [7], where the highest and most aging-resistant
ELS (Saremco, Rebstein, Switzerland) 1 0.7 – bond strengths were found for 2SEa’s and 3E&Ra’s.
Esthet-X (Dentsply DeTrey) 7 4.9 2.2 The bonding performance of 1SEa’s substantially improved
F2000 (3M ESPE) 4 7 3.1 compared with those reported in the previous review thanks to
Filtek A110 (3M ESPE) 10 3.6 2.3
the introduction of 1SEA m in the last few decades [4,12]. A less
Filtek Flow (3M ESPE) 1 0 –
favorable bonding performance was noted for 2E&Ra’s. Labo-
Filtek Supreme (3M ESPE) 4 5.7 7.6
Filtek Supreme XT (3M ESPE) 9 3.4 2 ratory studies have corroborated these results, ascribing their
Filtek Z100 (3M ESPE) 6 2.6 1.6 poorer performance to their higher hydrophilicity and reduced
Filtek Z250 (3M ESPE) 13 4.9 3.9 hybridization potential [28]. Similarly as for the 1SEa’s, a better
Gradia Direct Anterior (GC, Tokyo, Japan) 7 1.9 1.3 clinical performance was observed with more recent formula-
Grandio (Voco) 2 18.5 7 tions (Table 8). In the other adhesive categories no correlation
Herculite XRV (Kerr) 4 3.5 1.2
was noticed between AFR and adhesive age (r = 0.15, p = 0.32).
Micronew (Bisco Inc., Schaumburg, IL, 3 21.8 6.9
USA)
This review showed that next to the adhesive strategy,
Pekafill (Bayer, Leverkusen, Germany, 2 6.4 0 clinical performance was highly product-dependent. Signif-
now Hereaus Kulzer) icant differences in AFR scores between adhesives of the
Pertac Hybrid (ESPE, Seefeld Germany, 2 6 3.4 same (sub)category were noticed for 3E&Ra’s, 2E&Ra’s, 2SEa’s,
now 3M ESPE) 2SEA s, 1 SEa’s, 1 SEa m, 1SEa m and 1SEa s. We therefore con-
Pertac II (ESPE) 2 7 2.8
clude that our study’s second hypothesis is also rejected. In
Pertac III (ESPE) 1 6.2 –
other systematic reviews on NCCLs the studies included also
Point 4 (Kerr) 2 3.3 0.5
Prisma (ESPE) 3 7.7 7.8 found a wide variation between the clinical performances of
Prodigy (Kerr) 2 3.3 3.2 adhesives with the same bonding strategy [14,16].
Renew (Bisco Inc.) 2 23 2.8 Variation in AFR between the different glass-ionomers
Silux Plus (3M, St Paul, MN, USA) 6 4.1 2.5 (0–3.7) and 2SEA m (0–6) was smaller compared to that of
Spectrum TPH (ESPE) 6 4.3 2 other categories (Table 6). Indeed, only these two categories
Synergy Duo Shade (Coltène Whaledent) 3 3.8 0.8
did not show a significant difference in AFR between the indi-
Tetric (Ivoclar Vivadent) 1 2.5 –
vidual materials (p > 0.05; Kruskal–Wallis). Clearfil SE (Kuraray
Tetric Ceram (Ivoclar Vivadent) 3 8.5 3.4
Tetric Evo Ceram (Ivoclar Vivadent) 3 3.8 1.7 Noritake) was the most frequently tested 2SEa m adhesive (12
Valux Plus (3M) 1 10.1 – times) with an AFR of 2.2 (1.2) (Table 6). Although 2SEa m
Variglass VLC (Ivoclar Vivadent) 1 4.5 – are known for their rather low technique sensitivity, some
Venus (Hereaus Kulzer) 2 2.8 0 variability in retention rates was noticed between different
Venus Diamond (Hereaus Kulzer) 2 4.5 0.6 studies. The operator factor [29], bonding to non-roughened
sclerotic dentin [30], bonding only to dentin without enamel
 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103 1101

Table 8 – Adhesive age – average AFR (number of groups) of different age groups, based on first appearance in PubMed
(old: 1985–1993, medium: 1994–1999, young: 2000–2013).
1SEa s 1SEa m 2E&Ra 2SEa s 2SEa m 3E&Ra GI
Young 3.3 (15) 3.6 (37) 4.6 (26) 11.9 (6) 2.6 (18) 1.3 (3) 1.1 (1)
Medium 8.3 (11) – 6.6 (38) 6.6 (4) 1.5 (3) 2.8 (13) 1.6 (11)
Old – – 6.5 (1) 3.7 (3) – 3.6 (21) 2.3 (20)

involvement [31] can explain these differences. In the system- bond strengths were also shown for this adhesive after aging
atic review of Heintze et al. [14] Clearfil SE showed the best [39,40].
bonding performance in NCCLs. This high-quality bonding The most frequently tested (17 times) adhesive in this
performance can be explained by the presence of the func- review was Scotchbond 1 (3M ESPE), a 2E&Ra. The AFR score
tional monomer 10-MDP, which bonds through its phosphate of this water based adhesive was lower [3.8 (3.3)] compared
groups to HAp and peculiarly forms a regularly nano-layered to that of the two acetone-based 2E&Ra’s, Prime&Bond NT
structure at the HAp surface [32]. This chemical bonding pro- (Dentsply DeTrey, Konstanz, Germany) [6.3 (1)] and One-Step
moted by 10-MDP is more effective and also more stable in (Bisco Inc., Schaumburg, IL, USA) [17.4 (6)]. Acetone-based
water than that provided by other functional monomers like adhesives require the use of the wet bonding technique with
4-MET and phenyl-P [23]. 10-MDP is also present in other tested a relatively small window of opportunity to achieve optimal
2SEa m of the same manufacturer (Clearfil Liner Bond 2V (AFR: hybridization resulting in a higher technique sensitivity [21].
0) and Clearfil Protect Bond (AFR: 2.6). More recently 10-MDP One-step, with the highest AFR in this category, also had the
has also been used in some 1SEa m adhesives, with favorable, worst clinical performance in the systematic review of Heintze
though mainly short-term, results: Clearfil S3 Bond (Kuraray et al. [14]. As was mentioned above an improved clinical per-
Noritake) (AFR: 2.6), G-Bond (GC) (AFR: 1.3) and Scotchbond formance on the short term was measured for 2 recently
Universal (3M ESPE) in self-etch mode (AFR: 4). introduced 2E&Ra’s Adper Scotchbond 1 XT (3M ESPE) (AFR:
In the group of 3E&Ra’s the lowest AFR scores were noticed 1.4 (1)) (St 148,232,237,244,257) and for the multi-mode Scotch-
for Optibond FL (Kerr, Orange, CA, USA) (ethanol based E&R bond Universal (3M ESPE) (AFR: 0.5 (0.7)) (St 229). From this we
adhesive), which was tested in 4 studies [1.8 (0.8)] and Per- conclude that it is important for the dentist to select a prod-
maquick (Ultradent, South Jordan, UT, USA) (2 studies) [AFR: uct with a proven medium to long-term clinical performance
1.6 (0.3)] (Table 6). The AFR of both adhesives have a low in NCCLs.
standard deviation indicating their low technique sensitivity. A third factor that significantly influenced the clinical
The lower 13-year retention rate (59%) for Optibond FL in the performance of the adhesives in NCCLs was the restorative
study of van Dijken et al. [33] is probably also due to fact that material. This should be interpreted with caution as in most
the restorations were only bonded to dentin and not to the clinical trials the restorative material and the adhesive of
incisal enamel (no enamel involvement). High retention rates the same manufacturer were combined. NCCLs have a rela-
(93–97%) were noticed for Optibond FL in 3 other long-term tively small C-factor, meaning the mechanical properties of
clinical trials [34–36]. Two of these studies were excluded from the composite are less important to the outcome than the
this review because the recall rate was too low [36] or because actual performance of the adhesive [43]. Indeed, several clin-
only 1 adhesive was tested [34]. ical studies showed that the type of composite used (hybrid,
The AFR of the most frequently tested 3E&Ra Adper Scotch- microfilled or flowable) did not have an influence on the bond-
bond Multi-Purpose (3M ESPE) (13 times) was higher [3.9 ing performance of adhesives in NCCLs [35,41–43].
(2)] compared to that of the above-mentioned 3E&Ra’s, also Finally, the last hypothesis put forward in this review is
showing a higher standard deviation. It has been hypothe- also rejected as selective enamel etching had no significant
sized that this reduced durability is related to the solvent influence on the AFR of the SEa m tested in 7 clinical trials.
used (water versus ethanol) and the incorporation of a high In addition, although not significant (p = 0.167), the adjusted
molecular-weight polyalkenoic-acid copolymer, resulting in a odds ratio (Mantel–Haenszel odds ratio: 0.439 [0.133–1.45])
rather poorly infiltrated and polymerized hybrid layer, which favored acid etching. This corresponds with in vitro findings
is more susceptible to degradation [28]. showing that the bond of SEA m to enamel (and certainly
In the group of 1SEa m the lowest AFR score was recorded unground, aprismatic enamel) remains inferior compared
for the HEMA-free G-Bond (GC), which was tested 7 times with the bond of an E&Ra [21,44–49]. Indeed, the degree of sur-
[1.3 (0.6)] (Table 6). Another frequently tested 1SEA m, Clearfil face roughness produced by phosphoric acid is greater than
S3 Bond (Kuraray Noritake), showed a somewhat higher AFR that obtained with a self-etch primer because of its lower pH
score [2.6 (1.3)]. The slight tendency towards poorer bonding [50,51]. This increased surface roughness may provide higher
durability observed for Clearfil S3 Bond can be related to the bond strengths because the bonding of a resin composite to
presence of HEMA in its formulation, which decreases tech- enamel is mainly based on micromechanical retention. On the
nique sensitivity, but negatively influences hydrolytic stability one hand, loss of retention of a restoration in a NCCL did not
and durability of the adhesive interface complex [37,38]. occur easily as SEa m show adequate bonding effectiveness to
The acetone-based HEMA-free 1SEA m iBond (Hereaus dentin as described above. On the other hand, clinical research
Kulzer, Hanau, Germany), with 4-META as a functional has clearly revealed that marginal defects and marginal dis-
monomer, showed the highest AFR score [5 (5.7)]. Low in vitro coloration at the enamel margins of a composite restoration
1102 d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 1089–1103

develop rather rapidly [52–55]. Most of the marginal defects [7] De Munck J, Mine A, Poitevin A, Van Ende A, Cardoso MV,
were small and clinically acceptable. Van Landuyt KL, et al. Meta-analytical review of parameters
No clinical studies using SAC’s in NCCLs were identified. involved in dentin bonding. J Dent Res 2012;91:
351–7.
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