d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121

available at www.sciencedirect.com

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

Review

Relationship between bond-strength tests and clinical

outcomes

B. Van Meerbeek ∗ , M. Peumans, A. Poitevin, A. Mine, A. Van Ende, A. Neves,

J. De Munck
Leuven BIOMAT Research Cluster, Department of Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Kapucijnenvoer 7, B-3000 Leuven, Belgium

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

Article history: One often alleges that laboratory bond-strength testing cannot predict clinical effectiveness
Received 19 November 2009 of adhesives. Major argument to sustain this claim is the wide variation in bond-strength
Accepted 19 November 2009 values recorded for one specific adhesive among different research institutes worldwide.
The main reason for these inconsistent bond-strength measurements is supposedly the
current lack of a standard bond-strength testing protocol. This paper (and presentation)
Keywords: aimed to report on an extensive literature review with regard to the different laboratory
Review bond-strength test methods and their data provided, along with a second extensive litera-
Bond strength ture review on clinical effectiveness data of adhesives in terms of retention rates of adhesive
Clinical effectiveness Class-V restorations. Combining both systematic reviews, we have subsequently searched
Clinical trial for a potential relationship between bond-strength data and clinical outcomes.
Retention © 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
Adhesive

Contents

1. Dental adhesive technology ANNO 2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e101

1.1. Etch&rinse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e101
1.2. Self-etch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e101
1.3. Self-adhesive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e103
2. Measuring bond strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e104
2.1. Macro-shear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e105
2.2. Macro-tensile/push-out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e105
2.3. Micro-tensile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e105
2.4. Micro-shear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e107
2.5. Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e107
2.6. Bond durability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e107
2.7. KULeuven systematic review on bond strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e108
2.8. Fracture mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e109

∗
Corresponding author. Tel.: +32 16 33 75 87; fax: +32 16 33 27 52.
E-mail address: bart.vanmeerbeek@med.kuleuven.be (B. Van Meerbeek).
0109-5641/$ – see front matter © 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2009.11.148
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121 e101

3. Assessment of sealing ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e109

3.1. Micro-leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e109
3.2. Marginal adaptation/gap formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e109
3.3. Bacterial leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
3.4. Permeability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
3.5. Nano-leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
3.6. 3D-leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
4. Clinical performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
4.1. Class-V clinical data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e110
4.2. KULeuven systematic review on Class-V clinical data, Part I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e113
4.3. KULeuven systematic review on Class-V clinical data, Part II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e114
5. Relationship between laboratory and clinical bonding effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e114
5.1. Relationship I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e115
5.2. Relationship II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e115
5.3. Relationship III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e115
5.4. Relationship IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e115
6. Conclusions and closing remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e116
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e116
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e116

step following a 3-step procedure. The final objective is to

1. Dental adhesive technology ANNO 2009 micro-mechanically interlock upon diffusion and in situ poly-
merization of monomers into the enamel etch-pits (Fig. 1a),
The fast progress in dental adhesive technology has exten-
the opened dentin tubules and the exposed collagen network,
sively influenced modern restorative dentistry. Although
the latter forming the well-documented hybrid layer (Fig. 2a).
decayed/fractured teeth can be reconstructed minimal-
Without doubt, the micro-mechanical interlocking of tiny
invasively and nearly invisibly using adhesive technology, the
resin tags within the acid-etched enamel surface is still today
clinical longevity of composite restorations is today still too
the best achievable bond to enamel [6–8]. It not only effec-
short [1,2]. Despite the enormous advances made in adhesive
tively seals the restoration margins on the long term, but also
technology during the last 50 years, the bonded interface itself
protects the more vulnerable bond to dentin against degrada-
remains the Achilles heel of an adhesive filling [3,4]. Mainly
tion [9]. On the contrary, etching dentin is a rather aggressive
water sorption is thought to destabilize the adhesive–tooth
procedure as it dissolves and removes (through rinsing) the
bond, though the actual interfacial degradation mechanisms
natural protection of collagen (Fig. 2a), thereby producing a
are far from understood. In this context, several aspects
resin–collagen complex that is vulnerable to degradation upon
should be considered with regard to the strength and dura-
water sorption, possibly enhanced by the documented enzy-
bility of the bond to the two dental hard tissues, enamel and
matic degradation process [10–12]. As the most intimate and
dentin. These include the heterogeneity of tooth structure and
stable intermolecular interaction possible, primary chemical
composition, the features of the dental surface exposed after
interaction between resin and the mainly organic substance
cavity preparation, and the characteristics of the adhesive
remaining at acid-etched dentin would definitely contribute to
itself, such as its strategy of interaction with both substrates
the bond durability, but is however lacking [13,14]. This defi-
and its basic physicochemical properties. Furthermore, all
cient chemical interaction should most likely be regarded as
sorts of chemical and mechanical challenges that are inher-
the major shortcoming of today’s etch&rinse approach. Never-
ent to the oral environment should be taken into account,
theless, traditional 3-step etch&rinse adhesives are still today
such as there are moisture, masticatory stresses, changes in
regarded as ‘gold-standard’.
temperature and pH, and dietary and chewing related habits
[5].
Modern adhesive approaches can be divided into (1) an 1.2. Self-etch
etch&rinse, (2) a self-etch (or etch&dry), and (3) nowadays also
a self-adhesive approach [6]. The self-etch approach can be further subdivided into a
‘strong’ (pH < 1), an ‘intermediately strong’ (pH ≈ 1.5), a ‘mild’
1.1. Etch&rinse (pH ≈ 2), and an ‘ultra-mild’ (pH ≥ 2.5) self-etch approach
depending on the self-etching or demineralization intensity
In brief, the multi-step etch&rinse approach involves a phos- [15]. Self-etching only dissolves the smear layer, but does not
phoric acid-etch step that at enamel produces deep etch-pits remove the dissolved calcium phosphates, as there is no rinse
in the hydroxyapatite (HAp)-rich substrate, and at dentin dem- phase. The more intense the self-etching, the more calcium
ineralizes up to a depth of a few micrometers to expose a phosphates are dissolved and embedded within the interfacial
HAp-deprived collagen mesh. The next step involves either transition zone [16]. Such resin-encapsulated calcium phos-
a separate priming step followed by the application/curing phates within the exposed collagen mesh are however rather
of a combined primer/adhesive resin following a simplified soluble (Fig. 3) and may explain the lower laboratory and clin-
2-step procedure, or a separate primer and adhesive resin ical bonding performance of strong self-etch adhesives, in
e102 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121

Fig. 1 – TEM photomicrographs illustrating the adhesive–enamel interface for an etch&rinse (a) versus a ‘mild’ self-etch
adhesive (b). Note the partially dissolved HAp-crystals and much deeper interaction at phosphoric-acid-etched enamel
(following the etch&rinse approach in (a)) versus the visibly hardly ‘touched’ HAp-structure and superficial but tight
interaction at self-etched enamel (following the mild self-etch approach in (b)). The white porosities in between the
HAp-crystals (b) should be regarded as an artifact due to the diamond knife-sectioning procedure through the brittle enamel
substrate.

Fig. 2 – TEM photomicrographs illustrating the adhesive–dentin interface for an etch&rinse (a) versus a ‘mild’ self-etch
adhesive (b), taken after heavy-metal staining and at the same magnification. While the etch&rinse approach (using 30–40%
phosphoric acid) exposes collagen deeply (a), all collagen remained protected by HAp following the mild self-etch approach (b).
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
Fig. 3 – TEM photomicrograph illustrating the
adhesive–dentin interface produced by a ‘strong’ self-etch
adhesive. Besides deep hybridization, typical of such an
adhesive are the intensely stained interfibrillar spaces in
between the exposed collagen fibrils of the hybrid layer,
most likely representing dissolved calcium phosphates.
particular to dentin [17]. At enamel, they however perform in
general much better due to this more aggressive self-etching
[18]. The less intense the self-etching, the more bur-smear
may interfere with the eventual bonding performance (Fig. 4)
[19,20]. In particular ‘mild’ (pH ≈ 2) self-etch adhesives appear
to deal reasonably well with bur-smear, producing a submi-
cron hybrid layer with substantial HAp-crystals still protecting
the collagen fibrils (Fig. 2b). Functional monomers, in par-
ticular like 10-MDP (10-methacryloyloxydecyl dihydrogen
phosphate), have been proven to interact with this resid-
ual HAp through primary ionic binding [21,22]. The resultant
twofold micro-mechanical and chemical bonding mechanism
closely resembles that of glass-ionomers (Fig. 5; see below)
[6,21,23–27]. However, chemical bonding potential on its own
is insufficient; the formed ionic bonds should also be stable in
an aqueous environment. Chemical bonding promoted by 10-
Fig. 4 – TEM photomicrographs showing the resin–smear complex at the interface of an ‘ultra-mild’ self-etch adhesive
bonded to enamel in (a) and to dentin in (b).
e103
MDP appeared not only more effective, but also more stable in
water than that provided by other functional monomers like
4-MET (4-methacryloyloxyethyl trimellitic acid) and phenyl-
P (2-methacryloyloxyethyl phenyl phosphoric acid), in this
order [22]. The dissolution rate of the respective calcium salts
of these three monomers, as measured by AAS (or atomic
absorption spectroscopy), was inversely related to their chem-
ical bonding potential revealed by XPS: the more intense the
chemical bonding potential, the less the resultant calcium salt
could be dissolved. This finding was further explained in the
‘AD-concept’ or the adhesion–decalcification concept that dic-
tates if molecules will either adhere to or decalcify mineralized
tissues [28,29].
Two-step self-etch adhesives involve the application of
a separate, more hydrophobic adhesive resin after the
hydrophilic self-etch primer. This makes the interface more
hydrophobic and thus better seals it to the direct benefit of
bond durability. Finally, the most simple- and fast-to-use 1-
step (self-etch) adhesives generally come with some sacrifice
in bonding performance. This lower bonding efficiency has
been thoroughly documented in laboratory research, and must
be ascribed to, among others, to a lower polymerization con-
version and thus inferior mechanical properties, enhanced
water sorption through osmosis from the host dentin, poten-
tial phase-separation effects when the adhesive solution is
low in or free of HEMA (2-hydroxyethyl methacrylate), filler de-
bonding within the adhesive resin through hydrolysis of the
silane coupling, potential smear interference for ultra-mild
self-etch adhesives, and reduced shelf life in particular with
regard to one-component formulations [30–35].
1.3. Self-adhesive
Glass-ionomers and resin-modified glass-ionomers are ‘self-
adhesive’ through submicron hybridization, combined with
well-proven primary ionic interaction of polyalkenoic acid
with calcium within HAp (Fig. 5). Polyalkenoic acid possesses
abundant functional carboxylic groups that ‘grab’ HAp simul-
taneously at different and remote sites. Other ‘self-adhesive’
materials are the so-called self-adhesive luting composites
e104 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
Fig. 5 – TEM photomicrograph illustrating the twofold
‘self-adhesive’ mechanism of (resin-modified)
glass-ionomers, consisting of micro-mechanical
interlocking through submicron hybridization, along with
primary electrostatic binding of the carboxyl groups of
polyalkenoic acid as the principal functional polymer with
the glass-ionomer formulation to HAp.
that have been introduced some years ago [36–38]. They are
often mistakenly termed as ‘self-etching’, while they inter-
act only very superficially with dentin without clear signs of
demineralization (Fig. 6). Finally, it is in the line of expecta-
tions that such self-adhesive luting composites will soon lead
to the development of self-adhesive flowable and later full-
restorative composites.
While adhesive–enamel/dentin interfacial characteriza-
tion using scanning and even more reliably using transmission
Fig. 6 – TEM photomicrographs illustrating the interface of a self-adhesive luting composite to either fractured (and thus
smear-free) dentin in (a) and to bur-cut dentin in (b).
electron microscopy (potentially supplemented with chemical
interfacial analysis) definitely reveals a deeper insight in the
underlying mechanisms of adhesion, the actual bonding effec-
tiveness of today’s adhesive approaches should be measured
using a mechanical bond-strength test.
2. Measuring bond strength
By definition, the ideal bond-strength test should be in the
first place easy (meaning low technique-sensitivity) and rel-
atively fast. In general, advantages of ‘laboratory testing’ are,
among others, (1) the quickness to gather data on a specific
parameter/property, (2) the relative ease of the test method-
ology commonly used, (3) the possibility (and necessity) to
measure one specific parameter, while keeping all other
variables constant, (4) to be able to directly compare the per-
formance of a new and/or experimental material/technique
with that of the current ‘gold-standard’, (5) to be able to test
simultaneously many (of course within certain limits) exper-
imental groups within one study set-up, and (6) to be able
to mostly use relatively unsophisticated and inexpensive test
protocols/instruments. The final objective of a laboratory test
should obviously be to gather data in prediction of the eventual
clinical outcome.
In order to measure the bonding effectiveness of adhesives
to enamel and dentin, diverse methodologies can today be
used [39]. The bond strength can be measured statically using
a MACRO- or MICRO-test set-up, basically depending upon the
size of the bond area. The MACRO-bond strength, with a bond
area larger than 3 mm2 , can be measured in ‘shear’, ‘tensile’,
or using a ‘push-out’ protocol.
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
2.1. Macro-shear
Definitely most commonly used is the shear bond-strength
technique [39]; it was found to have been used in 26% of
scientific papers reporting on bond strength. As no further
specimen processing is required after the bonding procedure,
the shear bond-strength test undoubtedly thanks its high pop-
ularity in companies and other research institutes as it is the
most easy and fastest method. In an attempt to standard-
ize the test protocol, specific jigs have been prepared, such
the Ultradent jig (Ultradent, Salt Lake City, UT, USA) and the
more recent SDI rig (SDI, Bayswater, Victoria, Australia) (Fig. 7).
Despite such standardization attempts, a meta-analysis of
factors involved in bond-strength testing revealed the signifi-
cant influence of various parameters, like those related to the
dentin substrate (i.e. nature of teeth), to the composite and
bonding area (i.e. composite stiffness), to the storage condi-
tions of the bond assemblies (i.e. thermo-cycling), and to the
test design (i.e. crosshead speed) [40]. In particular, a strong
correlation was found between the mean bond strength and
the failure mode: the higher the bond strength, the higher the
rate of cohesive failure. Also the type of composite is crucial.
A stiffer composite will result in different stress distributions
at the interface and lead to a higher apparent bond-strength
value. Our extensive literature review conducted on the occa-
sion of this presentation at the Portland Academy of Dental
Materials (ADM) meeting (see below) revealed a positive cor-
relation between bond strength and the E-modulus of the
composite used [41,42]. Somewhat surprisingly, adhesives are
quite often tested in bond-strength studies along with the
respective composite of the same company in the sense that
the composite was fine-tuned to the adhesive (or vice versa).
While this may be true to a certain extent, doing so, conclu-
sions can only be drawn at the level of the adhesive/composite
combination, and certainly not at the level of the adhesive
itself. Another source of variability are the different configura-
tions employed to apply the shear force, including wire loops,
points and knife edges [43]. In particular, the use of a wire loop
for shear bond-strength tests appeared to concentrate stress
more near the interface rather than a knife edge.
The most frequently ignored guideline in the test pro-
tocol following the ISO/TS 11405 specification (2003) is that
‘a limitation of the bonding area is important’ [44]. Many
times, the adhesive is applied to the entirely exposed
enamel/dentin substrate, by which the bonding area is not
only substantially larger, but also the shear load is applied
to the adhesive–composite interface rather than to the
adhesive–tooth interface (Fig. 7). Besides such major flaws in
the test protocol, there is a good consensus in current litera-
ture that the shear stress is not uniformly distributed across
and not necessarily focused at the true interface [43,45–48].
Nevertheless, the shear bond-strength test probably
remains a very popular test to screen new adhesive formu-
lations on their bonding effectiveness. The most noteworthy
example of shear bond-strength testing is the ‘Battle of
Bonds’ series by Degrange et al. [49,50]. A gigantic dataset
of more than 16,000 ‘immediate’ bond strengths to dentin
was collected, and revealed upon pooling of the data per
adhesive class a statistically significant higher bond strength
of etch&rinse adhesives than of self-etch adhesives. More-
e105
over, 3-step etch&rinse adhesives outperformed the 2-step
etch&rinse adhesives, and they on their turn the 2-step self-
etch adhesives that presented with a pooled bond strength
that was not statistically significant from that recorded for
the most simple-to-use 1-step adhesives. The significantly
highest bond strength was measured for OptiBond FL (Kerr,
Orange, CA, USA) that somewhat surprisingly performed only
not significantly better than the relatively new 1-step adhesive
Easy Bond (3M ESPE, Seefeld, Germany). Very striking is also
the operator effect, widely varying for each product. Indeed,
very pertinent information gathered in this mega-test is the
coefficient of variance that gives some idea on the technique-
sensitivity of individual products. Products that presented
with the highest bond strength, were not necessarily the least
technique-sensitive. Care should nevertheless be taken not to
over-interpret the data, this in the first place because of the
shear bond strength set-up (see above) and in particular also
because of the solely ‘immediate’ bond-strength data recorded
without any kind of bond aging involved (see below).
2.2. Macro-tensile/push-out
Less popular is a macro-tensile bond-strength approach that
nevertheless can be used to measure for instance the bond
strength of cements to hard materials such as ceramics and
metal alloys [51,52]. A push-out approach has also been
employed, in particular to dynamically test the fatigue resis-
tance of adhesive–dentin bonds [53–56]. It has however never
been adopted as a universal bond-strength test method, most
likely because of the more laborious specimen preparation
involved as well as the more time-consuming methodology.
This method appeared however very useful to test the reten-
tion of posts luted in root canals [55,56].
2.3. Micro-tensile
Common MICRO-bond strength is typically measured in
tensile, as micro-tensile bond-strength testing (␮TBS) was
developed in 1994 by Sano et al. [57]. The bond area tested
is much smaller compared to that of the ‘MACRO’ tests, being
about 1 mm2 or less. After the bonding procedure, some fur-
ther specimen processing or the actual preparation of the
micro-specimens is required, rendering the test more labo-
rious and technique-sensitive. Nevertheless, a long list of
advantages is typically ascribed to ␮TBS when compared to
macro-bond-strength testing, of which the most important
are the better economic use of teeth (with multiple micro-
specimens originating from one tooth), the better control of
regional differences (e.g. peripheral versus central dentin),
the better stress distribution at the true interface (avoid-
ing cohesive failure in tooth substrate or composite), etc.
[57,58]. This renders the ␮TBS test more versatile, as multiple
specimens obtained from a single tooth enable more inven-
tive study set-ups and better controlled substrate variables.
However, several micro-specimen preparation protocols are
being used worldwide, one being more technique-sensitive
than the other. Today, so-called ‘trimmed’ and ‘non-trimmed’
micro-specimens are prepared, both having advantages and
disadvantages [59,60]. Non-trimmed micro-specimens are
definitely most easy and fast to prepare. Trimming the micro-
e106 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121

Fig. 7 – Figure showing the Ultradent jig (top) and the SDI rig (bottom), both specifically designed and fabricated for shear
bond-strength testing. An inappropriate, though commonly used specimen-preparation technique involves the application
of the adhesive to the entire tooth surface, on top of which a composite cylinder is bonded (top). As shown by the fractured
specimen (top right), the shear stress caused the specimen to de-bond at a much larger area than the area to which the
composite cylinder was bonded. The SDI rig much better enables both the adhesive and the composite be applied to a
confined area (bottom).

specimens at the interface to so-called hourglass-shaped
specimens better concentrates stress at the interface, but
involves a more invasive specimen procedure. When this
trimming is not carefully performed, interfacial defects may
easily be introduced and early set off crack-propagation dur-
ing the tensile loading of the micro-specimen, eventually
causing the interface to fail prematurely at a lower (bond)
strength [61]. Originally, interfaces were trimmed by free hand
using a dental handpiece [57,62]. Despite being very labori-
ous, such micro-specimen trimming largely depends on the
skills of the operator, thereby introducing a learning curve
and non-negligible factor of technique-sensitivity. Therefore,
semi-automatic trimming of micro-specimens using a so-
called MicroSpecimen Former (University of Iowa, Iowa City,
IA, USA) is highly advisable to trim rectangular specimens in
a well-controlled and standardized way into specimens with a
circular cross-section. Also other factors such as specimen–jig
attachment, specimen-loading speed and specimen align-
ment, do influence the final outcome, and therefore should
be standardized within the test set-up [58,63,64].
One major issue of dispute in current literature is the
required number of individual teeth from which many micro-
specimens can be prepared to be statistically sound [65]. An
elegant way to handle this problem is to use every tooth as its
own control. This means that the tooth surface for bonding is
divided into 2 or, for practical reasons, a maximum of 4 sectors,
each receiving a different treatment. Probably, the best way is
to know which micro-specimen comes from which tooth, and
then use linear mixed models (ANOVA with random effects)
to analyze the data. As also recommended by the ISO Tech-
nical specification on testing adhesion to tooth structure (ISO
No. 11405, 2003) [44], another way would be to apply survival
analysis like the Weibull model or Cox proportional hazard
using the force that is required for bond failure [66]. Although
not generally agreed upon, a minimum of 5 teeth seems rea-
sonable in order to keep the advantage of more economic use
of teeth using a ␮TBS approach.
A second issue involves the hard-to-neglect amount of
pre-testing failures often recorded with micro-tensile bond-
strength testing [65]. Several approaches have been applied to
deal with the pre-testing failures: (a) exclude all pre-testing
failures from further (statistical) analysis, which obviously
overestimates the actual bond strength; (b) assign a bond-
strength value of for instance 0 MPa to each pre-testing failure.
This actually penalizes the product too severely, as there was
a certain bond strength; and (c) a modification of the for-
mer approach by assigning a pre-determined value to each
pre-testing failure, as for example the lowest ␮TBS measured
within the respective group [66–68]. Apart from the obvious
effect on the mean ␮TBS value, these data transformations
may also affect the subsequent statistical analysis. Especially
in case of many pre-testing failures, methods (b) and (c) will
result in a data distribution that is inevitably skewed. As a
result, more powerful parametric statistical analyses cannot
be applied anymore and one has to rely on more basic non-
parametrical methods such as the Kruskall–Wallis test. Just
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
ignoring pre-testing failures, following method (a), should not
be done (perhaps except when the micro-specimen failed
remote from the interface in one of the adherents), as a high
proportion of pre-testing failures is typically associated with
low ␮TBSs measured for the other micro-specimens that did
not de-bond prior to testing [65]. Moreover, adhesives that con-
sistently present with relatively high ␮TBSs, do not suffer from
pre-testing failures. Eventually, micro-specimen processing
should be as a-traumatic as possible and the use of special
measures to avoid pre-testing failures, such as the use of
alginate or gypsum to fill up the space between the slabs,
thereby better supporting the slabs during the second 90-
degree-turned cut, is highly advisable.
Although hard to scientifically prove, a micro-tensile proto-
col appears to be able to discriminate adhesives better on their
bonding performance than a traditional shear bond-strength
approach (see above), most likely the reason why up to 60%
of current scientific papers reporting on bond strengths have
employed the ␮TBS approach [41,42].
2.4. Micro-shear
Also in order to generate as much specimens as possible
from a single tooth, a micro-shear bond-strength test (␮SBS)
was introduced in 2002 [69,70]. This test combines the ease
of manipulation with the ability to test several specimens
per tooth. The very fine composite build-up (cylinder) with
a typical diameter of 0.7 mm, in combination with a rela-
tive thick adhesive layer, may however result in considerable
bending and variable and non-uniform loading conditions.
This non-uniform stress distribution is probably even more
pronounced as compared to macro-shear bond testing. Fur-
thermore, it is impossible to confine the adhesive to the area
tested, as required by ISO-standard No. 11405 (2003) [44]. Basi-
cally due to these major shortcomings, this ␮SBS test has not
been adopted very well, since only 7% of recent bond-strength
studies have used this protocol [41,42]. In a recent study com-
paring both MICRO-bond methodologies, it was shown that
the micro-shear values were about 1/3 of the micro-tensile
values, while no difference in failure analysis was observed
[71].
2.5. Fatigue
Besides static bond-strength tests, theoretically clinically
more relevant is to test adhesive interfaces dynamically, as
in the clinical situation tooth-composite bonds are seldom
subjected to acute tensile/shear stresses. It is rather exposed
to cyclic sub-critical loadings produced during chewing [3].
However, since such fatigue tests are even more labor-
intensive and time-consuming than static bond-strength
tests, a steadily growing, but still only low number of fatigue
tests have been tried out throughout recent years on their
potential to predict clinical effectiveness. In literature, 6 dif-
ferent fatigue tests have been reported on, as there are,
chronologically, (1) a macro-push-out fatigue test [53,54,72],
(2) a macro-shear fatigue test [53,72–77], (3) a micro-rotary
fatigue test [78–80], (4) a micro-shear fatigue test [81], (5)
a micro-4-point-bend fatigue test [82,83] and most recent
(6) a micro-tensile fatigue test [84,85]. Despite the alleged
e107
need for more fatigue testing of adhesives and even though
several typical fatigue phenomena can be observed (Fig. 8)
[72,78], little new information on bonding effectiveness is
provided than that revealed by the easier and faster static
bond-strength tests. For example, micro-rotary [79] as well as
micro-tensile fatigue testing [84,85] revealed a similar superior
bonding effectiveness of the 3-step ‘gold-standard’ etch&rinse
adhesive OptiBond FL (Kerr) over the 2-step ‘gold-standard’
self-etch adhesive Clearfil SE Bond (Kuraray, Tokyo, Japan), that
on its turn bonds significantly better than the 1-step adhesive
G-Bond (GC, Tokyo, Japan). In addition, these fatigue tests have
largely been applied to dentin with bonding to enamel being
much more difficult to assess in fatigue.
2.6. Bond durability
While early or 24-h bond strength is mostly measured, there
is a definite need to test bonding effectiveness of adhesives
under more clinically relevant circumstances or upon aging
of the specimens. Indeed, many currently available dental
adhesives have presented with a relatively high short-term
bond strength, while not always equally favorable clinical
results have been obtained. Therefore, more laboratory effort
should definitely go to durability testing of adhesion, rather
than measuring the ‘immediate’ bond strength. In up to
35% of the bond-strength studies, some kind of ‘aging’ fac-
tor is added to the study design [41,42]. Water storage and
thermo-cycling are the most popular artificial aging meth-
ods, but also other methodologies as mechanical loading and
degradation by enzymes and various chemical substances
have been employed in literature [3]. Actually, the probably
most widely used aging technique is simple thermo-cycling,
although not always sufficiently long. A short thermo-cycling
regimen of 500 cycles, as recommended by the ISO TR 11450
standard (2003) [44], is of little use, while sometimes only
very long thermo-cycling up to 100,000 cycles can discrimi-
nate differences in bond durability of different adhesives [86].
A well-validated method to assess bond durability is how-
ever the storage of micro-specimens in water [87]. Doing so,
it was reported that within about 3 months, all classes of
adhesives exhibited mechanical and morphological evidence
of degradation that resembles in vivo aging [88]. Today, the
current challenge in adhesive dentistry is indeed to make the
adhesive–tooth interface more resistant against aging, thereby
rendering the restorative treatment more predictable in terms
of clinical performance on the long term. The longevity of
bonded restorations is to a large extent related to the degrada-
tion of the adhesive interface, which may occur in a relatively
short term, depending on the way the adhesive has been
manipulated, on the actual adhesive approach and on the
adhesive composition. Hydrolysis of interface components,
such as dentinal collagen and resin, due to water sorption,
potentially enhanced by enzymatic degradation, and sub-
sequent elution of the break-down products are the major
factors lately identified as involved in this bond degradation
process [3,4,10,26,30,89–91]. In fact, none of the current adhe-
sives or techniques is today able to produce an interface that
is absolutely resistant to degradation, but fortunately many
research efforts are currently devoted to improving bond dura-
bility.
e108 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
Fig. 8 – Figure illustrating the micro-rotary fatigue approach developed by De Munck et al. [78–80], thereby showing some
typical fatigue phenomena such as ‘beach marks’ at the fracture plane.
2.7. KULeuven systematic review on bond strength
At Leuven, we have recently thoroughly reviewed the literature
using the search term ‘dentin bond strength’ in PubMed with a
limitation to PubMed-registered papers published in the last 5
years [41,42]. This search was done on 18/01/2009 and revealed
1019 studies, of which at the time of this paper 744 papers were
evaluated on the following inclusion criteria: (a) measuring
bond strength to dentin; (b) involving at least two commercial
adhesives; (c) only in combination with light-cure composites
(no glass-ionomers, nor resin cements for instance); (d) and
reporting at least the type of bond-strength test, the mean
bond strength in MPa, the standard deviation and the total
number of specimens tested. So far, 214 studies were included
in the dataset, leading to 1828 bond-strength data for spe-
cific adhesive/composite combinations. Most popular tests
conducted were the micro-tensile bond-strength tests (1012
individual test groups were inserted in the database), followed
by macro-shear (287), micro-shear (221), and macro-tensile
(113) bond-strength tests. Only 26 macro-push-out and 12
micro-push-out bond-strength tests were reported on. Clearly,
the most recent 1-step adhesives were tested most frequently
(531), followed closely by both the 2-step etch&rinse (510)
and 2-step self-etch adhesives (450), while somewhat surpris-
ingly the traditional 3-step etch&rinse adhesives have been
tested least frequently (173). This finding confirms that still too
often in many of today’s bond-strength studies so-called ‘gold-
standard’ controls, by preference a well-documented and
consistently good-performing 3-step etch&rinse or 2-step self-
etch adhesive, are lacking in the study set-ups. Perhaps should
journals be more strict in publishing bond-strength studies
solely when a proper ‘gold-standard’ control is included. Also
following the systematic review [41,42], the bond strength
of (resin-modified) glass-ionomers is scarcely tested, which
could be due to the well-known fact that they tend to fail
cohesively within the material itself, while the actual bond
strength to tooth tissue can hardly be determined. Among
the individual adhesives tested, the 2-step self-etch adhe-
sive Clearfil SE Bond (Kuraray) was tested most (250 times),
followed closely by the 2-step etch&rinse adhesive Scotch-
bond 1/Single Bond (3M ESPE) that was tested 211 times.
All other adhesives were substantially less frequently tested,
among which the 1-step adhesive Adper Prompt L-Pop (3M
ESPE) was tested 76 times, the 1-step adhesive Clearfil S3
Bond (Kuraray) 73 times, the 1-step adhesive One-up Bond
F (Tokuyama, Tokyo, Japan) 62 times, the 2-step etch&rinse
adhesive One-Step (Bisco, Schaumburg, IL, USA) 56 times, the
2-step etch&rinse adhesive Prime&Bond NT (Dentsply, Kon-
stanz, Germany) 52 times, the 3-step etch&rinse adhesive
OptiBond FL (Kerr) 50 times, etc. From this dataset, already
some preliminary conclusions can be drawn. At first, there
is an excessive number of bond-strength data published in
literature and the variability between the studies is huge.
Especially the difference between the different test set-ups is
remarkable; a simple general linear model revealed that the
weighted mean of all micro-tensile bond-strength values is
about twice as high as the weighted mean of the macro-shear
test (16 versus 30 MPa). As the fine details of the bond-strength
test in the first place determine the height of the absolute
bond strength, it therefore does make not much sense to state
that a certain absolute value in MPa is needed for a product to
be clinically effective. Likewise, striving for a standard bond-
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
Fig. 9 – Upon the systematic review recently conducted on
bond strength at Leuven [41,42], the weighted
bond-strength means were found to clearly differ per
adhesive class. The weighted mean and large confidence
interval for the (2-step) glass-ionomers is less trustworthy,
since only few products could be included at the moment
this paper was written.
strength test, enabling bond strength to be measured as a
true material property (thus independent from the test set-up,
and reproducible in different research institutes worldwide),
is most likely never achievable. Following the present sys-
tematic review [41,42], significant differences in the ‘pooled’
mean bond strength can be observed, as the weighted bond-
strength means of individual adhesives ranges from about
12 MPa (for Absolute, Dentsply-Sankin, Tokyo, Japan) to 49 MPa
(for OptiBond FL, Kerr) and the weighted bond-strength means
per adhesive class range from 31 MPa for 3-step etch&rinse
adhesives, to 29 MPa for 2-step self-etch adhesives, 26 MPa for
2-step etch&rinse adhesives, and 20 MPa for 1-step self-etch
adhesives (Fig. 9). The weighted mean and large confidence
interval for the 2-step glass-ionomers is less trustworthy since
only few products could be included at the moment this paper
was written.
2.8. Fracture mechanics
As concluded in the ADM review paper from Scherrer et al.
[92], the high scatter in dentin bond-strength data found in
the literature, regardless which current bond-strength test is
used, should be attributed primarily to non-uniform stress dis-
tributions due to a number of geometrical, loading, material
property and specimen-preparation variables, as this was also
confirmed by Finite Element Analysis [45,47,48,59,60,93,94].
It has been proposed that an interfacial fracture mechanics
approach that studies the failure of an interface by the initi-
ation and growth of a single, large, dominant crack, such as
the fracture toughness test, would be more appropriate for
testing the relatively brittle adhesive–tooth interface [92,95].
Nevertheless, this fracture mechanics approach has so far
not received much support despite several fracture toughness
measurements of adhesives have previously been reported on
[96–103]. Probably, the big hurdle to take is the more labori-
ous and time-consuming specimen preparation, by which this
methodology no longer meets with the basic requirements of
an easy and fast, and ‘first’ product-screening test. In addition,
e109
one should not underestimate the perhaps higher technique-
sensitivity involved in fracture mechanics, by which also using
this methodology large scattering of the data among the
diverse research centers worldwide can hardly be avoided.
3. Assessment of sealing ability
As the longevity of an adhesive composite restoration is
mainly affected by leakage of oral fluids along the interface
between restorative material and tooth substrate [104,105],
probably more clinically relevant than bond-strength stud-
ies is to evaluate the capacity of an adhesive to maintain
the tooth-restoration transition sealed. It is especially thought
to predict better the clinical performance of adhesives with
regard to the occurrence of postoperative sensitivity and/or
secondary caries [105].
3.1. Micro-leakage
Leakage on the micrometer scale (micro-leakage) is often
assessed in vitro microscopically on cross-sections using a
wide variety of tracers or dyes that are able to infiltrate
the composite–tooth interface, such as silver nitrate, methy-
lene blue, basic fuchsin, and erythrosine [104], and even
some radioactive markers [105]. Although such micro-leakage
assessment is in principle even easier than bond-strength
measurements (and therefore done very frequently), the
reliability of conventional micro-leakage protocols remains
controversial [104,106,107]. Like for bond-strength studies,
a systematic review of dye penetration studies for restora-
tive materials concluded that a comparison of study results
is impossible due to the great variability of methodol-
ogy parameters employed worldwide [104]. In addition, the
cross-section-based procedure is destructive and part of the
specimen is lost through slicing. More importantly, the pro-
cedure allows only a limited 2D-view on the distribution of
the marker fluid, by which it is for instance not possible to
determine the point of deepest leakage with certainty. Newer
so-called micro-permeability tests make use of fluorescent
dyes like rhodamine, that are ‘loaded’ to the pulp chamber
in order to investigate at higher resolution using confocal
microscopy the sealing ability of adhesives at the interface
itself [108–110].
3.2. Marginal adaptation/gap formation
Another technique to assess marginal sealing ability involves
a semi-quantitative marginal analysis of replicas of restored
teeth using SEM, combined with custom-made software
to measure the length of the margin part that exhibits a
(gap-free) ‘continuous margin’ versus any kind of marginal
defect following a pre-determined set of margin qualities
[106,111,112]. Besides being laborious and time-consuming
(most likely being the main reasons why this methodology
is solely consistently used in a few research centers), another
major drawback of this technique is that it only enables to
assess marginal sealing in 2D at the outer surface. The advan-
tage of using replica’s however is that the same margins can
be assessed multiple times after having exposed the spec-
e110 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
imens to some kind of aging procedure [112]. A simplified
marginal sealing screening test evaluates the gap formation
around standardized cylindrical cavities, a test introduced
a long time ago [106,113]. Based on this simple approach,
an automated system has recently been developed that can
detect marginal gaps automatically using an optical sensor
[114]. Using this automated methodology, 21 adhesives were
for instance screened on their ability to produce gap-free
margins [115]. This study revealed that the etch&rinse adhe-
sives demonstrated the best marginal adaptation, followed
by the 2-step self-etch adhesives. The 1-step self-etch adhe-
sives yielded the poorest marginal adaptation and the highest
scatter in test results between materials and within the same
material.
3.3. Bacterial leakage
A bacterial micro-leakage model has mainly been applied in
endodontic research [116–119].
3.4. Permeability
A full-quantitative test to measure sealing ability has been
developed on basis of the early dentin permeability studies
by Reeder and Pashley et al. [120–123], but is perhaps too
technique-sensitive to become a standard test to screen adhe-
sives on their sealing ability [124,56].
3.5. Nano-leakage
Just like ‘classical’ micro-leakage assessment, also qual-
itative imaging and certainly quantification of so-called
nano-leakage (as per definition being ‘the diffusion of small
ions or molecules within the hybrid layer in the absence
of gap formation’ [125,126]), using SEM, TEM or confocal
microscopy [127–130] should also be interpreted with care
[131]. The high regional variability makes it very difficult to
obtain representative information with regard to the resis-
tance of adhesives against nano-leakage. Moreover, at least
5 independent studies agree on the absence of any correla-
tion between nano-leakage and bond strength of adhesives
[132–135].
3.6. 3D-leakage
For leakage, either micro- or nano-leakage, to be a valuable
criterion for evaluating adhesive performance, a fully quan-
titative methodology that measures leakage in three rather
than two dimensions is most likely required [131]. In search
for a full-quantitative 3D leakage test, microfocus-CT with a
potential resolution of the order of 1 ␮m (depending on the
hardware capabilities and X-ray source characteristics) has
recently been tried out [132–140].
4. Clinical performance
Despite the importance of laboratory studies attempting to
predict clinical performance of biomaterials, clinical trials
remain the ultimate way to collect scientific evidence on the
clinical effectiveness of a restorative treatment [2,6,141,142].
The popularity of in vitro studies in the field of adhesive den-
tistry may in part be ascribed to the rapid evolution of dental
adhesive technology and the resultant high turnover of adhe-
sive systems, which often tempts manufacturers to release a
successor product on the market even before its precursor has
been clinically evaluated, at least on the long term. By carrying
out in vivo studies, all possible aging factors play at the same
time, thereby disclosing whether an adhesive is truly reliable
for routine clinical practice.
4.1. Class-V clinical data
Clinical effectiveness of adhesives should best be determined
using Class-V clinical trials, because (1) such lesions do not
provide any macro-mechanical retention, so that ineffective
bonding will result in early restoration loss, (2) Class-V restora-
tion margins are located in enamel as well as in dentin,
(3) lesions are commonly located on vestibular surfaces of
anterior teeth and premolars, thus providing good access
for the restorative procedure as well as evaluation (visually
using an explorer and magnifying glasses, and even by SEM
if epoxy replicas are made), (4) preparation and restoration
of Class-V lesions is minimal and relatively easy, thereby
somewhat reducing practitioner variability, (5) lesions are rel-
atively wide spread and prevail on multiple teeth, facilitating
patient selection and enabling split-mouth study designs, and
(6) Class-V lesions have a relatively small C-factor, by which
the mechanical properties of the composite used are more
or less unimportant and the actual adhesive performance
determines the eventual clinical outcome to a great extent
[2,6,142–145]. Retention, marginal integrity and clinical micro-
leakage are usually the key parameters recorded to judge
upon clinical effectiveness of adhesives. Definitely the most
objective criterion is retention, by which Class-V clinical data
recorded worldwide can be mutually compared [2].
At KULeuven (Belgium), there is a long track record in con-
ducting Class-V clinical trials [2,6,141,142,145–158], as part of
our overall translational research line within BIOMAT on the
development of new adhesive dental restorative materials.
This research line involves basic research investigating molec-
ular interactions of functional monomers with inorganic tooth
tissue components, applied research up to mechanical testing
of adhesive interfaces, and eventually clinical research into
the ultimate clinical performance of new adhesive materi-
als/procedures in the mouth of patients (KULeuven University
Hospital). From the start in the mid-1980s, almost the same
standard study design has been employed. The data collec-
tion was done by well-trained and calibrated examiners in an
attempt to maintain the study quality equally high, basically
enabling the Class-V data that have been collected throughout
the past 25 years be compared mutually. The major outcome
strived for was always the basic clinical effectiveness of exper-
imental and/or commercial adhesives, while sufficient care
was taken to include an appropriate control(s) within each
individual study. The major modifications of the initial clinical
trial protocol to the current one entail a gradually increas-
ing number of restorations/patients (a), as well as a shift of a
‘split-mouth’ design to a ‘pair-tooth’ study design (b). We cur-
rently place at least 50 Class-V restorations per experimental
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121 e111

Fig. 11 – Graph representing the retention rate of Class-V

Fig. 10 – Graph representing the retention rate of Class-V
restorations up to 13 years of clinical service for three
3-step etch&rinse adhesives [156,161]. This study is
conducted at the Catholic University of Leuven in Belgium
(KULeuven). Be aware that the retention rate (in the Y-axis)
starts at 75%.
restorations up to 8 years of clinical service for a 2-step
self-etch adhesive with and without selective phosphoric
acid etching of enamel [157,165]. This study is conducted at
the Catholic University of Leuven in Belgium (KULeuven).
Be aware that the retention rate (in the Y-axis) starts at 50%.

effectiveness of two 3-step etch&rinse adhesives in combi-

nation with a hybrid, stiffer composite versus a micro-filled,
group in at least 50 patients, by which we comply with the
more flexible composite (Fig. 10) [156,161]. After 13 years of
current recommendations for conducting randomized con-
clinical service, 94% of the restorations in the control group
trolled clinical trials (RCT) of dental restorative materials [159].
(OptiBond FL in combination with Prodigy, Kerr) were still in
(a) Although in the latter recommendations it is stated that
function. After this long clinical service, obviously marginal
the clinical investigator performs only two restorations per
defects and discolorations were observed at a steadily grow-
patient (one restoration per experimental group), we believe
ing incidence, but most are only minor defects that do not
that it is of primary importance to include a sufficiently
require urgent restoration repair and certainly not restoration
high number of restorations in the clinical trial. We therefore
replacement. As flexure at the tooth cervix has been advanced
nowadays employ a ‘multi-restoration approach’, by which we
as one of the three principal factors causing non-carious cer-
restore ALL Class-V lesions that need to be restored within one
vical lesions [162,163], it was reasonable to hypothesize that
patient, equally dividing ad random the lesions per experimen-
tal group. It is of course correct that treating more than one
lesion per condition within one mouth introduces a potential
‘patient factor’ (dependent data), but this does not necessar-
ily mean that the power of the study cannot be increased by
this multi-restoration approach. Provided that a suitable (but
unfortunately more complex) statistical analysis is applied,
the supplementary restorations may still add new informa-
tion. The eventual increase in power of the study will depend
on the strength of correlation between the repeated measure-
ments (within one patient). Only in the worst case, when the
clinical outcome is completely determined by patient factors,
one can return to a one-restoration-per-condition-per-patient
analysis by ad random (and multiple times) selecting pairs of
restorations within each mouth. Most often, the patient factor
will have some influence, but will never completely determine
the outcome so that treating more lesions per patient with the
same material (as patients often present with multiple Class-
V lesions) is an easy and valid option to prevent conducting Fig. 12 – Graph representing the retention rate of Class-V
clinical trials with low sample size and thus power [160]. (b) restorations up to 3 years of clinical service for two 1-step
The second ‘pair-tooth’ design indicates that restorations will self-etch adhesives as compared to that of a 3-step
always be placed in pairs of two restorations (each experimen- etch&rinse control adhesive [158,166,167]. This study is
tal group) in nearly equal teeth (first and second premolar at conducted at three university institutes, namely the
the same side, left and corresponding right incisor, canine or University of Sao Paulo in Brazil (USP), the Suleyman
premolar, respectively). Demirel University at Turkey (SDU), and the Catholic
At the moment, we run three Class-V studies at Leuven University of Leuven in Belgium (KUL). Be aware that the
(Figs. 10–12). (KUL-1) A long-term study evaluates the clinical retention rate (in the Y-axis) starts at 50%.
e112 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121

similar stress is imposed to restored Class-V lesions, thereby
promoting marginal degradation or even dislodgement of the
restoration [150,164]. This study however failed to prove that
the composite stiffness affects the clinical longevity of cervical
composite restorations. (KUL-2) In a second long-term study,
the clinical effectiveness of a ‘mild’ 2-step self-etch adhesive
(Clearfil SE Bond) was evaluated (Fig. 11) [157,165]. At 8 years,
the clinical effectiveness appeared excellent, with selective
acid-etching of the enamel margins only having some minor
effect on secondary clinical parameters (higher incidence of
small marginal defects/discolorations at enamel that were of
clinical negligible relevance, since they did not require any
restorative intervention at the 8-year recall). (KUL-3) The most
recent clinical Class-V study is multi-center based and evalu-
ates the clinical performance of two 1-step self-etch adhesives
(G-Bond, GC; Clearfil S3 Bond, Kuraray) in comparison to
the ‘gold-standard’ 3-step etch&rinse adhesive (OptiBond FL,
Kerr) (Fig. 12) [158,166,167]. Each of the studies did exam-
ine two adhesives following the same multi-restoration and
paired-tooth design explained above. Up to 2 years of clinical
service, no major differences in clinical performance between
the 1-step adhesives and the 3-step etch&rinse control were
observed. Obviously, longer-term clinical evaluation is needed
in respect to bond durability. In a recent Class-V clinical trial by
Burrow and Tyas [168], a 3-year retention rate of, respectively,
100% and 97% was recorded for the 1-step adhesives G-Bond
(GC, in combination with the composite Gradia, GC) and for
Clearfil S3 Bond (Kuraray, in combination with the composite
Clearfil ST, Kuraray).
At UNC (USA), a wide spectrum of adhesives, among
which 3-step etch&rinse adhesives (OptiBond Dual cure, Kerr;
ProBond, Dentsply; Scotchbond MP, 3M-ESPE; Gluma Solid
Bond, Hereaus-Kulzer, Hanua, Germany), 2-step etch&rinse
adhesives (Excite, Ivoclar-Vivadent, Schaan, Liechtenstein;
OptiBond Solo, Kerr; Prime&Bond NT, Dentsply; Single Bond,
3M ESPE), 1-step (self-etch) adhesives (Adper Prompt LP-2, 3M
ESPE; iBond, Hereaus-Kulzer; One-up Bond, Tokuyama; Vari-
glass, Dentsply), and (resin-modified) glass-ionomers (Fuji II
LC, GC; Variglass, Dentsply), have been evaluated in non-
carious Class-V lesions in a consistent way (Fig. 13) [169–176].
For the 3-step etch&rinse adhesive, OptiBond Dual Cure (Kerr),
12-year data are available, reporting a very high retention rate
of 93% [175]. While almost all other retention curves show
a clear downward trend, that of OptiBond Dual Cure (Kerr)
remains high and rather stable on a long-term perspective.
Especially the difference with its 2-step etch&rinse successor
(OptiBond Solo, Kerr) is striking, as for this adhesive after 8
years the retention rate dropped to 69% [176]. Likewise, the
8-year retention rate of the acetone-based 2-step etch&rinse
adhesive, Prime&Bond 2.1 (Dentsply), dropped to even 59%
[176]. Also the water-based 3-step and 2-step etch&rinse adhe-
sives Scotchbond MP and Single bond (both from 3M ESPE)
performed rather equally with retention rates of, respectively,
78% and 75% at 3 years [172]. They both however cannot
compete with the ethanol-based 3-step etch&rinse adhesive
OptiBond Dual Cure (Kerr), being the precursor of the still cur-
rently commercially available successor OptiBond FL (Kerr).
Regarding the clinical performance of 1-step adhesives, it is
worth to mention the steep drop in retention rate of Adper
Prompt LP-2 (3M ESPE) to 81% at 1.5 years of clinical service
[172], while for the more recently marketed ‘mild’ 1-step self-
etch adhesives, iBond (Hereaus-Kulzer), so far no losses were
recorded (100% retention rate at 1.5 years) [174], and for One-
up Bond (Tokuyama) a less favorable retention rate of 90% was
recorded [173].
Two other long-term Class-V studies worth mentioning
were performed at Umeå University (Sweden) by Van Dijken
et al. (Fig. 14) [177,178]. At Umeå, the retention rates of Class-V

Fig. 13 – Graph representing the retention rate of Class-V restorations up to 12 years of clinical service for 13 different
commercial adhesives (Single Bond (3M ESPE) was tested twice). These studies are (have been) conducted at the University
of North Carolina at Chapel Hill (UNC) [168–175]. Be aware that the retention rate (in the Y-axis) starts at 50%.
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
Fig. 14 – Graph representing the retention rate of Class-V
restorations up to 13 years of clinical service for 13 different
commercial adhesives. These studies have been conducted
at Umeå University (Sweden) [176,177]. Some recent clinical
retention rates [178] are depicted by letters in the graph. For
the 3-step etch&rinse adhesive cmf (‘a’: Saremco; in
combination with the composite els, Saremco), a 1.5-year
retention rate of 96% was recorded versus a 1.5-year
retention rate of 91.8% for the 2-step etch&rinse adhesive
XP-Bond (‘b’: Dentsply; also in combination with the
composite els, Saremco). For the 2-step self-etch adhesive
Clearfil Protect Bond (Kuraray), a 1.5-year retention rate of
98.2% was recorded when used in combination with both
the composite Tetric Ceram (‘c’: Ivoclar-Vivadent) and els
(‘d’: Saremco). A 3-year retention rate of, respectively,
96.7%, 96.5% and 93.7% have been recorded at Umeå
University for G-Bond (GC), AdheSE (Ivoclar-Vivadent) and
Clearfil SE Bond (Kuraray).
restorations placed using 13 different adhesives were sys-
tematically recalled up to 13 years of clinical service. For
correct interpretation of the Umeå data, it is important to
mention that all restorations were placed in dentin lesions
without any intentional enamel involvement. In this respect,
only the clinical bonding performance to dentin was evalu-
ated, in contrary to most other (also the above-mentioned)
Class-V studies, in which the adhesive was applied to both
enamel and dentin in a so-called mixed enamel/dentin lesion.
After 13 years, only 5 adhesives presented with a retention
rate higher than 50%: the 3-step etch&rinse adhesive Clearfil
Liner Bond (Kuraray) with 74%; the 3-step etch&rinse adhe-
sive OptiBond Dual Cure (Kerr) with 59%; the resin-modified
glass-ionomer Vitremer (3M ESPE) with 64%; the 2-step self-
etch adhesive ART Bond (Coltène, Altstätten, Switzerland)
with 59% and the 3-step etch&rinse adhesive Syntac Classic
(Ivoclar-Vivadent) with 64%. The four worst-performing adhe-
sives (retention rates below 30% at 13 years) were all obsolete
adhesives that fortunately are no longer commercially avail-
able. The clinical bonding performance of the more recently
marketed adhesives is clearly better, corresponding to the bet-
ter laboratory data reported on in literature and thus with the
great progress dental adhesive technology has undergone in
e113
the last decade. As at Umeå recalls have systematically been
done on a year basis, the data clearly show the continuous
degradation in bonding effectiveness of all adhesives tested,
though at a significantly varying speed for each individual
adhesive. Again, if enamel would have been bonded to as well,
the retention data would obviously have been much higher.
This once again confirms that bonding to dentin remains very
challenging, in the laboratory as well as clinically. Some more
recent Class-V retention rates of studies conducted at Umeå
University are mentioned in Fig. 14 [179]. They again confirm
the improved clinical effectiveness of recent-generation adhe-
sives, even when applied in less application steps.
Considering only the really long-term clinical data, not
much information on long-term clinical effectiveness of adhe-
sives is today available, especially when abstracting the Umeå
data because of the dentin-only study design. The most favor-
able long-term (retention) data have been recorded for the
3-step etch&rinse adhesives Optibond FL (Kerr) and its precur-
sor Optibond Dual-Cure (Kerr). At Leuven, Optibond FL (Kerr)
presented with a 94% retention rate at 13 years [161], while
even a 97% retention rate was recorded at Chicago [180]. At
Chapel Hill, an almost equally high retention rate of 93% was
recorded for OptiBond Dual Cure (Kerr) at 12 years [175]. The
only other favorable retention rate (97%) was recorded for the
2-step self-etch adhesive Clearfil SE Bond (Kuraray) at 8 years
[157,165].
4.2. KULeuven systematic review on Class-V clinical
data, Part I
In an attempt to get a better insight in the current over-
all clinical performance of adhesives, we refer to a relatively
recently conducted systematic review, in which the annual
failure rates were determined per adhesive class (Fig. 15)
[2]. According to that review, the best clinical performance
with regard to retention has so far been achieved by glass-
ionomers. Their low annual failure rates can be ascribed to
their unique self-adhesiveness, based on the twofold micro-
mechanical and chemical bonding mechanism (see above).
Despite their excellent clinical performance in terms of reten-
Fig. 15 – Graph representing the mean annual failure rates
per adhesive class, determined according to a systematic
review of Class-V clinical trials of adhesives during the
period 1998–2004 [2].
e114 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
tion, glass-ionomers commonly present with lower aesthetic
features when compared to resin-based restorative materi-
als. The poorer mechanical properties of glass-ionomers also
explain the lower scores achieved in bond-strength tests when
compared to those of resin-based adhesives, by which a glass-
ionomer typically fails cohesively rather than it de-bonds
from the tooth surface (see above). Besides glass-ionomers,
in particular 3-step etch&rinse adhesives have exhibited a
reasonably good clinical effectiveness (Fig. 15) [2]. The clin-
ical durability of 3-step etch&rinse adhesives confirms their
generally superior laboratory results, in which they are con-
sidered as ‘gold-standard’ and often employed as control
to compare the performance of new-generation adhesives
with. According to the same standard, 2-step self-etch adhe-
sives tend to approach the clinical performance of 3-step
etch&rinse adhesives in terms of low annual failure rates
(Fig. 15) [2]. Their ability to provide a shallow but uniform
hybrid layer, along with their capability to chemically bond
to the dentin substrate seems to play an important role to
resist long-term hydrolytic degradation (see above). Com-
monly, the clinical performance of such self-etch adhesives
does not vary substantially from one study to another, which
is indicative of their rather low technique-sensitivity. Further-
more, another clinically important benefit is, as mentioned
before, that these self-etch adhesives are repeatedly associ-
ated with very low levels of postoperative sensitivity [181].
In general, 2-step etch&rinse adhesives have performed less
favorably than the conventional 3-step version (Fig. 15) [2].
Laboratory studies have corroborated these results, ascribing
their poorer performance to their higher hydrophilicity and
reduced hybridization potential (see above). It is noteworthy
that irrespective of the number of application steps, acetone-
based etch&rinse adhesives have generally performed less
satisfactorily than their water/ethanol-based alternatives. The
above-mentioned high technique-sensitivity of acetone-based
adhesives must be the reason for their compromised long-
term clinical data. According to this review [2], a so far
rather inefficient clinical performance has been noted for
the newest generation of 1-step adhesives. Widely varying
retention scores have been recorded, indicating their high
technique-sensitivity despite their user-friendliness (Fig. 15).
Such lower bonding performance must be ascribed to the
many concerns advanced earlier.
4.3. KULeuven systematic review on Class-V clinical
data, Part II
On the occasion of this manuscript and the ADM 2009 meet-
ing at Portland, the systematic review of the literature that
appeared in the period 1998 until 2004 [2], was continued in
the same way for the literature that appeared in the period
2004–2009 and has provided new data with regard to annual
failure rates per adhesive class [182,183] (Fig. 16). Besides the
calculation of the annual failure rates per adhesive class for
the new period 2004–2009, also both datasets were combined,
revealing annual failure rates for the 10-year period 1998–2009.
Still the lowest annual failure rates have been recorded for the
glass-ionomers, irrespective of the time period during which
the literature was reviewed. Equally favorably performed the
so-called ‘mild’ and ‘intermediately strong’ 2-step self-etch
Fig. 16 – Graph representing the mean annual failure rates
per adhesive class, determined according to a systematic
review of Class-V clinical trials of adhesives during the
period 2004–2009 [182], in continuation of the earlier con-
ducted review during the period 1998–2004 [2]. The overall
mean annual failure rates per adhesive class for the total
10-year review period (1998–2009) are mentioned as well.
adhesives. This is not that surprising taking into account
that these self-etch adhesives make use of a bonding mech-
anism that most closely approaches that of glass-ionomers
(see above). Including all 2-step self-etch adhesives (also the
so-called ‘strong’ self-etch adhesives) substantially increases
the annual failure rates. This can also be explained as these
‘strong’ self-etch adhesives significantly performed worse in
laboratory, especially regarding their bonding efficiency to
dentin. As mentioned above, the aggressive self-etch proce-
dure of these ‘strong’ self-etch adhesives relatively deeply
dissolves HAp (exposing collagen). As these adhesive do not
involve a rinse step, the dissolved calcium phosphates are
embedded within the hybrid layer. These calcium phosphates
are however not very hydrolytically stable, thereby seriously
jeopardizing the bond longevity. Somewhat higher annual fail-
ure rates were recorded for the 3-step etch&rinse adhesives,
but they decreased in the more recent literature review, also
having resulted in a decreased annual failure rate for the
whole 10-year review period (1998–2009). The annual failure
rate of the 2-step etch&rinse adhesives remained nearly sta-
ble, while that of the most simple-to-use 1-step adhesives
substantially improved in the most recent literature, even to
an annual failure rate in line with that recorded for the 3-
step etch&rinse adhesives in the same period. For the whole
10-year review period, the annual failure rate of the 3-step
etch&rinse adhesives is still significantly lower. Nevertheless,
it is noteworthy that the most recent generation of 1-step
adhesives have substantially improved and evolve definitely
in the good direction (Fig. 16).
5. Relationship between laboratory and
clinical bonding effectiveness
The ultimate question is if there is a relationship between
the bonding effectiveness measured in the laboratory with
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121 e115

the clinical effectiveness determined in patients. In other 5.3. Relationship III

words, can we predict clinical effectiveness in the laboratory?
Although it is hard to give a straightforward answer to this
question, there are some trends that certainly point to cer-
tain associations between laboratory and clinical data on the
bonding effectiveness of adhesives.
5.1. Relationship I
A good correlation coefficient of 0.81 was found between
the annual failure rates reported in the systematic review of
Peumans et al. [2] and the ‘Battle-of-the-Bonds’ shear bond-
strength data from Degrange et al. [49,50].
5.2. Relationship II
In a more recent study by Heintze et al. [185], a correlation
analysis was performed between micro-tensile bond-strength
data and the same clinical index. Again, no significant correla-
tion could be found between the micro-tensile bond-strength
data and the clinical index, nor with the clinical retention
rate and marginal integrity. The only significant correlation
found existed between micro-tensile bond strength, espe-
cially measured after 6-month water storage, and the marginal
discoloration of Class-V restorations. The authors therefore
suggested that early marginal staining could be predictive for
future retention loss of non-carious cervical restorations. One
should however keep in mind that the clinical evaluation of
marginal staining is rather subjective, and may lead to sub-
stantially more variance in data when considered worldwide.

In a study by Heintze et al. [184], searching for a correlation 5.4. Relationship IV

between semi-quantitative margin analysis data (see above),
as performed in two research centers, and a somewhat arti-
ficial clinical index, consisting of retention loss, marginal
discoloration, and marginal integrity (weighted), only a weak
correlation was found. The in vitro measured ‘marginal adap-
tation’ appeared to only have a mediocre value in terms of
its ability to predict the clinical performance of adhesives (in
cervical cavities). Unfortunately, the analysis was hampered
by the great variability in clinical results, but also by the fact
that no correlation was found between the in vitro methods
employed at both research institutes involved.
On the occasion of this manuscript and the ADM 2009
meeting at Portland, we have searched for a potential rela-
tionship of the laboratory bond-strength data obtained in
the recently performed systematic review [41,42], with the
clinical retention rates collected in the systematic review
on the clinical effectiveness of adhesives in Class-V lesions
(Fig. 17) [2,182,183]. For this analysis, the complete database
(bond strength – all) was used, but also a database filtered
for bond-strength data measured after the specimens had
been subjected to some kind of in vitro aging procedure (bond

Fig. 17 – Correlation analysis between bond-strength data [41,42] and clinical Class-V retention rates [2,182]. Bond-strength
data were extracted and a weighted mean was calculated, considering all data in the database (bond strength – all), or only
for those data that were recorded after the specimens were subjected to some kind of durability factor (as for example water
storage, thermo-cycling, etc.) (bond strength – durability). For the clinical data, retention rates after 2 years (Class-V
retention rate at 2 years) as well as after 5 years of clinical service (Class-V retention rate at 5 years) were gathered.
Correlation analysis revealed that the bond strength seems not to predict the 2-year clinical outcome (no significant
correlation). The bond-strength data gathered after in vitro aging appear more clinically relevant and do predict the clinical
performance on the longer term (5 years) to some extent (r = 0.5811, p = 0.0475).
e116 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) e100–e121
strength – durability). Regarding the clinical data, the reten-
tion rate at 2 years was first chosen (Class-V retention rate
at 2 years), as this was the point in time when most reten-
tion rates were available. In a second phase, also the retention
rate at 5 years was used (Class-V retention rate at 5 years),
which is the longest recall time that still revealed sufficient
data. Using these criteria, the preliminary correlation anal-
ysis did not reveal any significant correlation between both
parameters for the 2-year clinical data and the 5-year clini-
cal data, the latter correlated to the complete bond-strength
dataset (Fig. 17). A significant, quite reasonable correlation was
nevertheless found between the aged bond-strength data and
the 5-year clinical data. The fact that no one-to-one relation-
ship between the in vitro and in vivo 2-year data exists, should
be attributed to the fact that many adhesives then still show
a very high retention rate (about half of the studies revealed
retention rates higher than 95% at 2 years). Another plausible
reason is that regarding the aged bond-strength data no cor-
rection was for instance performed for the kind of aging. So, a
regime of 500 thermo-cycles was for example pooled with 1-
year water-storage data, although the latter aging procedure
should have resulted for sure in more bond degradation than
the former. On the other hand, as could be expected from
the longer-term 5-year clinical data, a trend for association
between in vitro bond strength and the clinical data becomes
apparent for the complete dataset, and even significant when
all non-aged bond-strength data were excluded.
6. Conclusions and closing remarks
Adhesive technology has undergone great progress in the last
decade. In light of the major drawbacks attributed to all-in-
one adhesives, conventional 3-step etch&rinse adhesives and
(mild) 2-step self-etch adhesives are still the benchmarks for
dental adhesion in routine clinical practice. When bonding
to enamel, an etch&rinse approach is definitely preferred,
indicating that simple micro-mechanical interaction appears
sufficient to achieve a durable bond to enamel. When bonding
to dentin, a mild self-etch approach is superior, as it involves
(like with glass-ionomers) additional ionic bonding with resid-
ual HAp. This additional primary chemical bonding definitely
contributes to bond durability. Altogether, when bonding to
both enamel and dentin, selective etching of enamel followed
by the application of the 2-step self-etch adhesive to both
enamel and dentin currently appears the best choice to effec-
tively and durably bond to tooth tissue.
Along with the fast evolution of multi-step adhesives
toward 1-step adhesives, luting composites to adhesively lute
indirect ceramic restorations underwent a similar evolution
toward simple-to-use and less technique-sensitive 1-step lut-
ing agents. Hence, these self-adhesive luting composites do
not need any kind of pre-treatment of the tooth substrate,
thereby bringing the development of self-adhesive composites
closer to reality.
Design and synthesis of functional monomers with strong
and stable chemical affinity to HAp is definitely a worthwhile
pathway toward new and improved adhesive technology.
Actually, many studies on dental adhesive technology are
nowadays empirical, basically testing the bond strength of dif-
ferent cocktails of adhesive solutions to enamel and dentin in
the laboratory. The adhesive formulation that scores best com-
monly makes it rapidly to the market, after which the superior
laboratory performance of the product is hopefully confirmed
in independent randomized controlled clinical trials. Much
knowledge on the underlying mechanisms of adhesion to
enamel and dentin has been gathered by numerously imag-
ing adhesive–tooth interfaces with all sorts of microscopes.
On the contrary, the actual molecular interactions at the inter-
face have hardly been explored. Also many basic questions
still remain unanswered, like for instance why certain func-
tional monomers have better bonding potential than others,
and why mild self-etch adhesives with additional chemical
bonding do not perform better at enamel. Thus, fundamen-
tal for future design and development of dental adhesives
is the further unravelling of the interfacial molecular
interactions.
Finally, the ultimate objective of this paper (and presen-
tation) was to search for a potential relationship between
laboratory bond-strength data and clinical outcomes. After an
extensive discussion of the different laboratory test method-
ologies to measure bond strength (and sealing ability), and
the presentation of the most recent clinical effectiveness
data (with regard to retention rates of adhesive Class-V
restorations), some clear indications for correlation of labo-
ratory bond strength with clinical retention rates of Class-V
restorations have been advanced, in particular of ‘aged’
bond-strength data with medium-term retention rates. Con-
sequently, besides measuring the ‘immediate’ bond strength
of adhesives to enamel and dentin, measuring the ‘aged’ bond
strength should be encouraged in order to predict the clinical
effectiveness of adhesives.
Acknowledgments
The authors would like to thank Michael Burrow et al. (Univer-
sity of Melbourne), Ed Swift et al. (University of North-Carolina
at Chapel Hill), and Jan Van Dijken et al. (Umeå University) for
disclosing their most recent Class-V clinical data, and Sieg-
ward Heintze et al. (Ivoclar-Vivadent) for sharing their most
recent laboratory and clinical correlation data.
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