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645
RESTORATIVE DENTISTRY
Which self-etch bonding systems are
suitable for which clinical indications?
Bernd Haller, Prof Dr med dent
1
Self-etch bonding systems are promoted as a time-saving and user-friendly alternative to
etch-and-rinse bonding systems. Self-etch adhesives are characterized by a relatively mild
etching effect, resulting in a relatively low incidence of postoperative hypersensitivity. On
the other hand, their mild etching effect causes a reduction in bond strength to enamel
compared to that achieved with phosphoric acid etching. All-in-one adhesives still suffer
from less-than-optimal initial bond strengths and from inadequate durability of the bond.
Future developments need to focus on the elimination of water deposits along the adhe-
sive interface of all-in-one adhesives. While self-etch adhesives may yield acceptable
results when applied in combination with light-cured composite resin, their acidic mono-
mers inhibit the polymerization of auto-cured and dual-cured composite resins.
Unfortunately, most self-cure or dual-cure activators do not overcome this problem.
This incompatibility has to be taken into consideration when using self-etch adhesives for
adhesive cementation and for core build-up restorations. When assessing self-etch bond-
ing systems, it should be noted that they do not represent a homogenous category of ma-
terials but rather comprise a great variety of different types of products, each with specic
strengths and weaknesses. (Quintessence Int 2013;44:645661; doi: 10.3290/j.qi.a30182;
originally published in Quintessenz 2012;63(7):711732 and 2012;63(7):857869)
Key words: adhesive cementation, core build-up restorations, direct composite
restorations, dentin sealing, ber-reinforced composite root canal
posts, ssure sealing, self-etch bonding systems
1
Department of Conservative Dentistry and Periodontology,
Center of Dentistry, University Hospital of Ulm University, Ulm,
Germany.
Correspondence: Prof Dr med dent Bernd Haller, Department
of Conservative Dentistry and Periodontology, Center of Den-
tistry, University Hospital of Ulm University, Albert-Einstein-
Allee 11, 89081 Ulm, Germany. Email: b.haller@uniklinik-ulm.de
CHARACTERIZATION
OF SELF-ETCH BONDING
SYSTEMS
Self-etch (or self-conditioning) bonding sys-
tems can be dened as bonding systems
which dissolve the smear layer and create
porosities in the underlying dental sub-
strates without needing an extra condition-
ing agent (eg, phosphoric acid) to be
applied in a separate step. The term self-
etching is used for a diverse group of
bonding systems designed for a great vari-
ety of clinical applications ranging from
direct restorations in permanent and pri-
mary teeth and core build-up restorations to
the adhesive cementation of indirect restor-
ations and ber-reinforced composite resin
root canal posts. It is clear that the some-
times confusing variety of different types of
self-etch bonding systems has to be con-
sidered when assessing their suitability for
clinical use.
Self-etch adhesives contain acidic
monomers for the non-selective condition-
ing of dentin and enamel (Fig 1) which are
contained in the primer of two-step systems
(Fig 2), or in the adhesive itself in the case
of single-step all-in-one adhesives (Fig 3).
Most self-etching primers and adhesives
also contain HEMA (hydroxyethylmethacry-
late), a non-functional strongly hydrophilic
methacrylate monomer. Water and/or etha-
nol and acetone are used as solvents.
Many adhesives contain microller, nano-
ller, or uoro-aluminum-silicate glass parti-
cles with ller contents between 10% and
50% w/w in the case of two-step systems,
and between 1% and 10% w/w in the case
of all-in-one adhesives.
1
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The bonding of self-etch adhesives to
enamel and dentin is based on the forma-
tion of a hybrid layer resulting from subsur-
face monomer inltration into the substrate
(Fig 4). Additionally, specic monomers
such as 10-MDP (10-methacryloyloxydecyl
dihydrogen phosphate; eg, Clearfil SE
Bond, Kuraray Dental) seem to establish
ionic bonds with the calcium of the hydroxy-
apatite (Fig 4).
2
The acidity of self-etching
primers and adhesives is usually classied
as weak (pH 2), mild/medium (pH 1.5),
Fig 1 Examples of acidic self-etching monomers that are produced by the esterication of methacrylate
based monomers with derivates of phosphoric acid, carboxylic acid, or (more recently) phosphonic acid.
GPDM, glycero-phosphate dimethacrylate; 10-MDP, 10-MDP 10-methacryloyloxydecyl dihydrogen phos-
phate; 4-MET, 4-methacryloxyethyl trimellitic acid.
Fig 2 Example of a self-etch two-step system
(Clearl Protect Bond, pH 2) in which the more
hydrophilic components are incorporated in the self-
etching primer while the adhesive contains the more
hydrophobic components. The primer of this specif-
ic product contains an antibacterial monomer
(12-methacryloyl oxy dodecyl pyridinium, MDPB).
Fig 3 Example of a ready-for-use all-in-one adhe-
sive (Xeno V+, pH 1.3) in which the hydrophilic and
the hydrophobic components are mixed together in
one bottle.
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or strong (pH 1). The pH of most commer-
cially available self-etching primers and
adhesives ranges from 1.3 to 2.7.
All-in-one adhesives have a rather com-
plex chemical composition due to their mul-
tiple functions (ie, etching, priming, and
bonding). The ratio of water and organic
solvents (ethanol, acetone) inuences the
balance of hydrophilic and hydrophobic
monomers in the all-in-one adhesives and is
thus crucial to their clinical performance.
2

The specific shortcomings of all-in-one
adhesives are listed in Table 1 and
depicted in Fig 5.
Acidic self-etching monomers inhibit the
polymerization of auto-cured composite
resins due to the elimination of tertiary
amines from the redox initiator system in
these composite resins. As a result, the
bond strength to dentin is dramatically
reduced (Fig 6). Therefore, all-in-one adhe-
sives are not suitable for the combination
with auto-cured or dual-cured composite
resin. This problem may also occur in self-
etch two-step systems, when the acidic
monomers are not exclusively contained in
the primer but are also in the adhesive
resin.
BOND STRENGTH TO
DENTIN
The highest initial bond strength to dentin is
generally achieved with three-step etch-
and-rinse systems, followed by two-step
etch-and-rinse and two-step self-etch sys-
tems.
3
At present, all-in-one adhesives usu-
ally display the lowest dentin bond
strengths, although some advances have
recently been achieved in this eld.
4
Active
application of self-etching primers and
Table 1 Problems associated with all-in-one adhesives
Low content of HEMA
Phase separation between hydrophilic and hydrophobic
components
Promotes accumulation of water in the adhesive layer
High content of HEMA
Increased water sorption from the dentin
Low mechanical strength of the adhesive, further aggra-
vated by the uptake of water
Water accumulation along the adhesive interface Progressive degradation processes
Incomplete adhesive lm formation
Permeability of the adhesive layer
Incomplete sealing of the dentin
Relatively low degree of polymerization
Increased uptake of water
Low mechanical resistance of the adhesive layer
Fig 4 Schematic illustration of the dentin bonding
mechanisms of self-etch bonding systems. The acid-
ic monomers consist of one or more methacrylate
groups (M) for copolymerization, an intermediate
spacer group, and one or more acidic groups. H+
from the acidic groups dissolves the smear layer and
the hydroxyapatite of the underlying dentin (A). The
created microporosities around the collagen bers
are inltrated by the monomers (B) resulting in the
formation of a several hundred micrometers thick
hybrid layer. Specic monomers such as 10-MDP can
also establish ionic bonds between the negatively
charged acid group (R-) and the positively charged
calcium ions in the hydroxyapatite (C).
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adhesives is effective in improving bond
strength to dentin.
5
When using self-etch
two-step systems, the effects of operator
variability are less pronounced compared
with two-step etch-and-rinse systems.
6
In
contrast, all-in-one adhesives are sensitive
to incomplete evaporation of the solvent.
7

The most durable dentin bond strength is
achieved when the hydrophilic primer and
the hydrophobic adhesive are applied sep-
arately, such as in three-step etch-and-
rinse systems and in self-etch two-step
systems.
8-10
It is probable that the hydro-
phobic resin protects the adhesive layer
against water sorption. In contrast, all-in-
one adhesives are characterized by the
uptake of water from different sources (sol-
vents, dentin uid, and saliva) promoting
hydrolytic and enzymatic degradation pro-
cesses in the adhesive layer.
8
In agreement
Fig 5 Schematic illustration of the shortcomings of
all-in-one adhesives. HEMA-poor all-in-one adhe-
sives suer from phase separation leading to water
accumulation into the adhesive layer and nanoleak-
age (A). All-in-one adhesives form permeable mem-
branes instead of continuous lms (B). HEMA-rich
all-in-one adhesives absorb water from the underly-
ing dentin (C), probably driven by osmotic eects
which are suggested to result from salt precipita-
tions as inuenced by the negatively charged func-
tional groups of the acidic monomers (R- in Fig 4)
(D). Water droplets permeate the adhesive layer, in
particular when the composite resin is applied to the
light-cured adhesive with delay (E). Due to its hydro-
philic character, the adhesive layer may take up u-
ids from the oral cavity through incompletely sealed
margins (F). Water accumulated along the adhesive
interface of all-in-one adhesives promotes enzymat-
ic and hydrolytic degradation processes.
Fig 6 Dentin bond strengths of dierent bonding systems used in combination with a light-cured (LC) com-
posite resin and auto-cured (SC) composite resin. The detrimental eects of the self-etch adhesives on the
auto-cured composite resin are clearly visible. The dual-cure activator tested in one of the adhesives (Opti-
Bond Solo plus SE) turned out to be completely ineective in improving the bond strength to dentin (data
from Moll et al
34
).
OptiBond
Solo plus SE
OptiBond
Solo plus SE +
Activator
AdheSE Clearl
SE Bond
Prompt
L-Pop
Xeno III
35
30
25
20
15
10
5
0
S
h
e
a
r

b
o
n
d

s
t
r
e
n
g
t
h

t
o

d
e
n
t
i
n

(
M
P
a
)
Brilliant (LC)
Brilliant MH (SC)
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with this, increased bond strengths to den-
tin and reduced nanoleakage have been
observed when the all-in-one adhesive was
covered with a hydrophobic adhesive
layer.
11
Some manufacturers offer hydro-
phobic liners for use in combination with the
all-in-one adhesive (eg, All-Bond SE/All-
Bond SE Liner, Bisco) in clinical situations
with increased stress.
BOND STRENGTH TO
ENAMEL
The enamel etching pattern produced by
self-etch primers and adhesives is consid-
erably less intense than when etching the
enamel with phosphoric acid (Fig 7). As a
result, the enamel bond strength of self-
etch bonding systems is limited to between
30% and 65% of that achieved by phos-
phoric acid etching (Fig 8). Therefore, small
and supercial defects and discolorations
gradually occur along the enamel margins
of restorations placed by use of self-etch
bonding systems.
12
Although such marginal
defects may compromise the esthetic
appearance of a restoration, they usually do
not affect its longevity. Enamel bonds cre-
ated by self-etch two-step systems are usu-
ally more durable than those achieved with
all-in-one adhesives.
13
Recently, it has been
recommended to selectively etch the
enamel with phosphoric acid prior to the
application of self-etch systems in order to
optimize the marginal quality in enamel.
14,15

Some recently marketed self-etch bonding
systems (eg, Adper Easy Bond Self Etch,
3M Espe; G-nial Bond, GC) have explic-
itly included this option in the instructions
for use. Phosphoric acid application should
be restricted to the enamel, since most self-
etch bonding systems have proved to be
sensitive to phosphoric acid etching of the
dentin.
16
There seems to be no difference in
bond strength to enamel between perma-
nent and primary teeth, either in self-etch
two-step systems or in all-in-one adhesives.
Figs 7a to d Enamel after treatment with dierent conditioning agents. The SEM micrographs (magnica-
tion 10,000) reveal the mild etching potential of self-etch primers and adhesives compared with phosphoric
acid. (a) Phosphoric acid gel 36% (pH 0.5 to 0.7); (b) Xeno V+ (pH 1.3); (c) OptiBond XTR Primer (pH 1.6); (d)
AdheSE Primer (pH 1.7).
a
c
b
d
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ANTERIOR AND CERVICAL
COMPOSITE RESIN
RESTORATIONS (CLASS 3,
4, AND 5)
Self-etch bonding systems may be an alter-
native to etch-and-rinse systems in the res-
toration of cervical lesions (Fig 9).
17

Omitting the extra step of phosphoric acid
etching is a helpful simplication of the clin-
ical procedure, particularly in situations
where contamination control is difcult,
such as in Class V lesions with subgingival
cervical margins, especially in posterior
teeth. Meta-analyses comparing the longev-
ity of restorations in non-caries cervical
lesions showed that failure rates were
higher when using all-in-one adhesives
compared to all other types of bonding sys-
tems.
17,18
In addition, the considerable dif-
ferences between the results of different
studies indicate that the sensitivity of all-in-
one adhesives to incorrect manipulation
might be higher than suggested by the
manufacturers. Most in vitro studies have
reported larger gap formation along the
dentin margins of Class V restorations
placed by use of all-in-one adhesives com-
pared to self-etch two-step systems.
19
In
clinical studies, Class 5 and Class 3 com-
posite resin restorations placed with self-
etch bonding systems displayed small,
supercial defects and discolorations along
the enamel margins which, however, did
not affect clinical function of the restor-
ations, even after several years. In the
esthetic zone, such marginal defects and
discolorations can be avoided by etching
the enamel margins with phosphoric acid.
Phosphoric acid etching of the enamel is
essential in Class 4 restorations in order to
provide adequate micromechanical reten-
tion for the composite resin. Since acidic
monomers possess a relatively weak etch-
ing potential compared to phosphoric acid,
especially on unground enamel, self-etch
bonding systems are not recommended for
the esthetic correction of tooth malposition
and tooth malformation.
20
POSTERIOR COMPOSITE
RESIN RESTORATIONS
(CLASS 1 AND 2)
In posterior composite resin restorations,
marginal adaptation to enamel of self-etch
bonding systems is inferior to that of etch-
Fig 8 Enamel bond strength of self-etch bonding systems in comparison with phosphoric acid etching.
45

The achieved enamel bond strengths are not correlated with the acidity of the respective self-etch agents, eg,
Clearl SE Bond (pH 2) versus Prompt L-Pop (pH 1). The high bond strengths achieved with Clearl SE Bond
may be the result of ionic bonds between the acidic monomer (10-MDP) and the calcium of the hydroxyapa-
tite (see Fig 4). TC, thermocycle.
35
30
25
20
15
10
5
0
Phosphoric
acid/
Polol Bond
OptiBond
Solo plus SE
AdheSE
S
h
e
a
r

b
o
n
d

s
t
r
e
n
g
t
h

t
o

e
n
a
m
e
l

(
M
P
a
)

Clearl SE
Bond
Adper
Promt L-Pop
iBond Xeno III
24 hours water storage (37 C)
180 days water storage (37 C) + 6 x TC (5 C/55 C)
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and-rinse systems. Such marginal imperfec-
tions can easily be avoided by selectively
etching the enamel margins with phosphoric
acid. In contrast, even the most effective
multiple-step bonding systems are not able
to completely prevent gap formation and
microleakage along dentin margins, with all-
in-one adhesives usually showing the high-
est incidence of marginal defects among all
types of bonding systems.
14,21
In clinical studies, self-etch two-step
systems have achieved acceptable to high
success rates despite their tendency to
marginal discoloration and small marginal
defects along enamel margins (Fig 10).
22

Self-etch two-step bonding systems in com-
bination with selective phosphoric acid
etching of the enamel margins (Fig 11) can
be recommended for posterior replacement
restorations without restriction.
The few clinical studies investigating the
potential of all-in-one adhesives in posterior
composite resin restorations have reported
conicting results.
23,24
With regard to the
inconsistent clinical data and the inade-
quate durability of the dentin bond in vitro, it
is concluded that, at present, all-in-one
adhesives cannot be considered as the
bonding agents of choice for posterior res-
torations.
In the minimally invasive restorative
treatment of primary caries lesions, etch-
Figs 9a to c Class 5 composite resin restoration by use of a self-etch two-step system. (a) Application of the
self-etching primer to enamel and dentin. (b) After careful evaporation of the primer solvent, the cavity is
coated with the hydrophobic adhesive. (c) Completed Class 5 restoration.
Fig 10 Class 2 composite resin restoration by use
of a self-etch two-step system (Resulcin AquaPrime +
MonoBond). Two years after baseline, the enamel
margins exhibit discolorations and marginal defects,
which are usually not detected when etch-and-rinse
systems are employed.
Fig 11 Marginal defects as shown in Fig 10 can be
prevented by selectively etching the enamel mar-
gins with phosphoric acid in a separate step.
a b c
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and-rinse bonding systems are superior to
self-etch adhesives. Small, defect-oriented
occlusal cavity preparations are usually
treated according to the preventive resin
restoration concept, which includes the
sealing of the ssures adjacent to the cavity
preparation. It has been shown that self-
etching primers or adhesives are not suit-
able for ssure sealing. The small size of
minimally invasive proximal cavity prepar-
ations makes visual and tactile examination
of the proximal margins very difcult if not
impossible, especially in alternative access
preparations such as the tunnel prepar-
ation. In the case of inaccessible restor-
ation margins, the goal of producing perfect
marginal adaptation is best achieved with
the etch-and-rinse technique.
RESTORATION OF
PRIMARY TEETH
Self-etch bonding systems are often recom-
mended as an alternative to etch-and-rinse
systems for the restoration of primary teeth.
However, their suitability depends on the
type of self-etch system applied. All-in-one
adhesives in combination with composite
resin have yielded very low survival rates
with a high degree of complete loss of
retention.
25
Therefore, in primary teeth all-in-
one adhesives should only be used in com-
bination with compomers (polyalkenoic-
acid modied composite resins) and only in
small- to medium-sized cavity preparations
with adequate macroretention.
26
Two-step
self-etch systems are considered to be a
better option.
FISSURE SEALING
The excellent caries-preventive effect of s-
sure sealants is based on etching of the
enamel with phosphoric acid, which pro-
duces an excellent retentive etching pattern
(see Fig 7). The less intense monomer inl-
tration and tag formation achieved with self-
etching monomers result in increased
microleakage and lower clinical retention
rates.
27,28
Self-etch adhesives are therefore
not recommended for ssure sealing.
SEALING OF
EXPOSED DENTIN
Treatment of cervical dentin
hypersensitivity
Self-etch bonding systems are considered
to be suitable for adhesive coating of
hypersensitive cervical dentin due to their
gentle mode of dentin conditioning. Coating
of exposed cervical dentin with an all-in-one
adhesive signicantly reduced the intensity
of hypersensitivity over a period of 4
weeks.
29
Two-step self-etch systems may
be even more effective, since the adhesive
lms they produce are less permeable and
more durable compared to those produced
by all-in-one adhesives.
Sealing of prepared dentin prior
to cementation
The retention of partial and full crowns
cemented with zinc phosphate or glass-ion-
omer cements is based on the micro-rough-
ness of the prepared dentin. Therefore, any
smooth adhesive layer covering the pre-
pared dentin surfaces, especially when
using a multiple-step bonding system, will
automatically level off the micro-roughness
of the dentin walls and thus interfere with
the retentive micro-interlocking of the
cement and the prepared tooth surfaces.
30

In conclusion, the adhesive coating of
exposed dentin in crown preparations
reduces the sensitivity of the prepared tooth
and is not recommended.
Prevention of root surface
caries
The adhesive coating of exposed root sur-
faces for the prevention of root surface car-
ies is still experimental. It has been shown
that coating of the exposed root dentin with
a self-etch adhesive has the potential of
reducing the demineralization of the root
dentin, while the effects of adhesive coating
of root dentin on biolm formation are still
controversial.
31-33
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CORE BUILD-UP
RESTORATIONS
Core build-up with
light-cured composite resin
If an intermediate core build-up restoration is
intended to stay in the mouth for several
months, a light-cured composite resin
placed with an incremental technique is
probably the material of choice since such
restorations must have an adequate ana-
tomic form, including proper proximal con-
tacts and a well-adjusted occlusal surface.
Consequently, the required standards of
quality are comparable to those applying for
denitive composite resin restorations. Cavi-
ties needing restoration with full or partial
crowns are usually large and may extend
close to the pulp. From a biologic point of
view, self-etch bonding systems are consid-
ered to have advantages over etch-and-rinse
systems. As a result of their gentle mode of
dentin conditioning, the increase in dentin
permeability evoked by self-conditioning
systems is only limited compared to phos-
phoric acid etching. When using self-etch
two-step systems for core build-up restor-
ations, an additional phosphoric acid etching
of the enamel (as recommended for deni-
tive composite resin restorations) is not nec-
essary (Fig 12), since all marginal defects or
discolorations will be removed during crown
preparation. Self-etch two-step systems can
also be recommended for the selective
build-up and the blocking-out of undercuts
with owable composite resins (Fig 13).
Core build-up with auto-cured
and dual-cured composite resin
Teeth designed for restoration with partial
or full crowns often receive core build-up
and crown preparation in the same appoint-
Figs 12a to d Core build-up restoration with light-cured composite resin by use of a two-step self-etch
bonding system. (a) Baseline situation after removal of defective amalgam restorations. (b) Active application
of the self-etching primer. (c) Coating of cavity walls with the adhesive. (d) Completed core build-up restor-
ations in the rst and second molar, denitive Class 2 composite resin restoration in the premolar.
Figs 13a to c Selective core
build-up with owable com-
posite resin. (a) Cavity after
removal of an overextended,
fractured amalgam restoration.
Note hairline cracks at the prox-
imal margins. (b) Application of
a white-opaque owable com-
posite resin following applica-
tion and light-curing of a
two-step self-etch bonding sys-
tem. (c) Completed cavity prep-
aration for a full-ceramic partial
crown.
a
a
b
b
c
c
d
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ment. In this case, a core build-up restor-
ation does not require proximal contacts or
a properly adjusted occlusal surface. Auto-
cured or dual-cured composite resins have
the advantage of being applied in bulk,
which is less time-consuming than any lay-
ering technique. The combination of self-
etch adhesives with auto-cured or
dual-cured composite resins is fraught with
problems, since the acidic monomers from
self-etch adhesives inhibit the auto-curing
polymerization mechanism of composite
resin (see Fig 6). This phenomenon has not
only been observed with all-in-one adhe-
sives, but also with self-etch two-step sys-
tems in which the acidic monomers are not
only contained in the self-etch primer but
also in the adhesive resin (Fig 6).
With regard to the potential incompatibil-
ity of self-etch bonding systems with auto-
curing and dual-curing composite resins,
dentists are confronted with a rather inho-
mogenous and confusing market situation.
It is therefore mandatory to carefully check
the instructions of each individual product
for the relevant passages. A classication
of current products is given in Table 2
(Figs 14 to 16). Some all-in-one adhesives
are especially designated for use in combi-
nation with their proprietary dual-curing
core build-up composite resin with separate
light-curing of the adhesive as a mandatory
step (eg, Clearl S3 Bond Plus/Clearl DC
Core Plus, Kuraray Dental). Other self-etch
bonding systems claim that the incompati-
bility with auto-cured or dual-cured com-
posite resins is eliminated by mixing the
adhesive with a dual-cure (DC) or self-cure
(SC) activator. In combination with etch-
and-rinse two-step systems, such SC or DC
activators were shown to be ineffective, with
only a few exceptions (eg, ExciTE DSC, Ivo-
clar Vivadent).
34
It is uncertain how reliably
SC or DC activators work in combination
with self-etch bonding systems. In one
study, the DC activator investigated was not
only ineffective when light activation of the
dual-cured core build-up composite resin
was completely omitted; its application also
caused a severe drop in the bond strength
to dentin when the dual-cured core build-up
composite resin has been light-cured, irre-
spective of which light curing protocol was
applied.
35
The adverse effects of DC and
SC activators have been attributed to the
dilution of the photoinitiator of the adhesive
Table 2 Classifcation of self-etch bonding systems according to their suitability
for combination with auto-cure and dual-cure core build-up composite
resins (according to manufacturers instructions)
Description Product examples
Self-etch, two-step bonding systems approved by the manufacturer for
use in combination with all composite resins (light-cured, auto-cured,
dual-cured) without self-cure (SC) or dual-cure (DC) activator.
All-Bond SE, OptiBond XTR
Self-etch, single-step adhesives mixed from two components, exclu-
sively designed for use in combination with auto-cured or dual-cured
composite resins.
Clearl DC Bond, Futurabond DC
Self-etch two-step bonding systems or single-step all-in-one adhesives
originally designed for the combination with light-cured composite res-
ins. Their use in combination with auto-cured or dual-cured composite
resins requires mixing of the adhesive with a SC or DC activator.
AdheSE/AdheSE DC Activator, One
Coat 7.0/One Coat 7.0 Activator
Self-etch two-step bonding systems or single-step all-in-one adhesives
basically designed for the combination with light-cured composite res-
ins. Their use in combination with auto-cured or dual-cured composite
resins makes separate light-curing of the adhesive mandatory.
Clearl Protect Bond, Clearl S3
Bond Plus (for exclusive use with
Clearl DC Core Plus), GC G-Bond,
G-nial Bond
Self-etch two-step bonding systems or single-step all-in-one adhesives
for which the combination with dual-cured composite resin is either not
mentioned as an indication (*), or explicitly listed as a contraindication
(**) in the instructions for use.
AdheSE One F**, Adper Easy Bond
Self Etch**, Clearl SE Bond*,
Futurabond M*, iBond Self Etch**,
Xeno V+**
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when mixed with the activator. The potential
of some recently introduced self-etch sys-
tems (eg, OptiBond XTR, Kerr) that claim to
be compatible with all composite resins,
including auto-cured and dual-cured prod-
ucts, remains to be conrmed by indepen-
dent study. While any incompatibility
between self-etch bonding systems and
dual-cure core build-up composite resins
cannot be denitely ruled out, it is recom-
mended to coat the light-cured adhesive
with a layer of light-cured owable compos-
ite resin prior to the bulk application of the
dual-cured core build-up composite resin.
36
ADHESIVE CEMENTATION
OF INDIRECT
RESTORATIONS
Self-etch bonding systems are usually not
recommended for the adhesive luting of
veneers since their bond strength to enamel
is less than optimal. Bonded tooth-colored
inlays/onlays made of silicate ceramics (eg,
feldspathic ceramic, leucite reinforced
glass ceramic, and lithium disilicate glass
ceramic) or composite resins have demon-
strated very high clinical success rates
when all margins were located in enamel.
Etch-and-rinse bonding systems usually
produce better marginal adaptation than
Fig 14 Example of a self-etch bonding
system (OptiBond XTR) approved by the
manufacturer for use in combination with
all composite resins (light-cured, auto-
cured, dual-cured) without self-cure (SC)
or dual-cure (DC) activator.
Figs 15 a and b Example of a self-etch, single-step adhesive, mixed from two compo-
nents (Futura Bond DC) which is exclusively designed for use in combination with auto-
cured or dual-cured composite resin. (a) Two-compartment blister package. (b) The
active self-etch adhesive is produced by pressing the content of the rst (small) blister
into the second (big) blister.
Fig 16 Example of a self-etch all-in-one adhesive
which has originally been designed for the combina-
tion with light-cured composite resin (One Coat 7.0).
The use of products like this in combination with
auto-cured or dual-cured composite resin requires
mixing of the adhesive with a SC or DC activator.
a b
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self-etch systems.
37
The incomplete trans-
mission of light through ceramic or compos-
ite inlay/onlay restorations results in a
reduction in ceramic bond strength to den-
tin, even when using dual-cured luting com-
posites.
38
Combination of adhesives with
DC or SC activators usually does not solve
the problem. A compromised dentin bond
of the luting composite resin will impair the
quality of cervical dentin margins and
reduce the cusp reinforcing potential of the
adhesive restoration as well as the fracture
resistance of inlay/onlay restorations made
of low-strength ceramics, such as feld-
spathic ceramic and leucite reinforced
glass ceramic. It has been shown that the
marginal adaptation of bonded tooth-col-
ored inlays/onlays to dentin is incomplete
even when using a multi-step bonding sys-
tem.
37
The situation can be improved by
applying the so-called selective double-
bonding technique (Fig 17), which is prefer-
ably carried out by use of a multi-step
bonding system including a self-condition-
ing dentin primer with maleic acid (eg,
A.R.T. Bond, Coltene; Syntac, Ivoclar Viva-
dent).
Self-etch two-step bonding systems
(including those with a maleic acid contain-
ing dentin primer) are also the material of
choice for the immediate dentin sealing
(IDS) technique. The IDS technique is char-
acterized by the sealing of the exposed den-
tin immediately after cavity preparation and
before taking the impression.
39
Immediate
dentin sealing lowers the risk of postopera-
tive hypersensitivity and blocks the penetra-
tion of bacteria and their toxins into and
through the dentinal tubules.
40
For this pro-
cedure, self-etch two-step systems are
again preferred to etch-and-rinse systems
due to their less aggressive mode of dentin
conditioning. In comparison, all-in-one adhe-
sives have proved to be less effective.
41
Figs 17a to d Selective double-bonding technique for the adhesive cementation of bonded indirect restor-
ation with cervical margins in dentin. (a) Selective etching of enamel with phosphoric acid. (b) Application of
a self-etch primer to all exposed dentin surfaces. (c) Conditioning of enamel and dentin is followed by the
application of a rst layer of adhesive, selectively to margins located in dentin. After light-curing of this adhe-
sive layer, the complete cavity preparation is coated with the adhesive, followed by application of the luting
composite resin and seating of the restoration. (d) Completed full-ceramic partial crown after nishing and
polishing.
a
c
b
d
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ADHESIVE CEMENTATION
OF FIBER-REINFORCED
COMPOSITE (FRC) ROOT
CANAL POSTS
Adhesive cementation of FRC root canal
posts is only promising if an effective bond-
ing system is used in combination with a
chemically compatible resin cement
(Fig 18). Apart from the self-adhesive, dual-
cured adhesive cements without any condi-
tioning agent or primer (eg, RelyX Unicem,
3M Espe), there are basically two different
types of self-etch systems available for
adhesive post cementation (Table 3). Adhe-
sive cementation systems in group A
(Fig 19) are designed for cementation of the
post only while the core build-up is made
from a different composite resin. An
increasing number of dual-cured composite
resins employed for post cementation are
also used as core build-up materials (eg,
Clearfil DC Core Plus, Kuraray Dental;
Core-X Flow, Dentsply; MultiCore Flow, Ivo-
clar Vivadent). Bonding systems designed
for the combined post-and-core tech-
nique (group B; Fig 20) can be self-etching
(Fig 21) or based on phosphoric acid etch-
ing. When using self-etch adhesives, resin
tag formation is less intense and less
homogenous compared with etch-and-rinse
adhesives.
42
FRC posts cemented by use of
all-in-one adhesives have shown relatively
low retentive strengths.
43
In addition, the
Table 3 Modes of adhesive cementation for FRC root canal posts using the
principle of self-etching in different variations
Group Description Product examples
A
Self-etch, auto-cured adhesives (mixed
from liquids 1 and 2) for the exclusive
use in combination with the proprietary
dual-cure resin cement
Futurabond DC/Bix QM, Multilink Primer/Multilink, ED
Primer II/Panavia F 2.0
B
Self-etch bonding systems (* including a
SC or DC activator) for use in combina-
tion with (any) dual-cured resin cement
(and core build-up composite resin)
AdheSE/AdheSE DC Activator*, All-Bond SE, DentinBond
Evo*, OptiBond XTR
Etch-and-rinse analogs: Adper Scotchbond Multi-Purpose
plus*, All-Bond 3*, Adper Scotchbond 1 XT, ExciTE F
DSC*, OptiBond Solo Plus*, XP Bond/Self Cure Activator*
Fig 18 Inadequate adhesion between the resin
cement and the root canal dentin and between the
build-up composite resin and the remaining coronal
dentin has resulted in complete separation of the
FRC post together with the core build-up from the
tooth.
Fig 19 Example of a self-etch, auto-cured adhesive
(Multilink Primer) mixed from two components for
the exclusive use in combination with the proprie-
tary dual-cure resin cement (Multilink).
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degradation of all-in-one adhesives is fur-
ther accelerated by their high permeability
to water.
44
It can be assumed that the polymeriza-
tion inhibiting effect of self-etch adhesives
on auto-cure and dual-cure composite res-
ins will adversely affect the adhesion of
FRC posts to root canal dentin. Available
data suggest that etch-and-rinse bonding
systems may be a better option for the
adhesive cementation of FRC posts than
self-etch systems. Irrespective of which
type of bonding system is employed, a
translucent FRC post should be selected
which transmits some light through the post
into the root canal.
The indication-related recommendations
for the clinical use of bonding systems are
summarized in Table 4.
ACKNOWLEDGMENT
The author would like to thank Dr Florian Janke for his
valuable technical assistance.
CONFLICT OF INTEREST
The author declares that he has no conict of interest.
With regard to the large variety of products on the mar-
ket, it is impossible to mention all of them in this article.
If certain products have not been mentioned in the arti-
cle, it cannot be concluded that these products are not
suitable for clinical use. Vice versa, the mentioning of
specic products in this article is only exemplary and
should not be mistaken for an explicit recommendation
by the author.
Figs 20a to c In the combined post-and-core technique, the same dual-cured composite resin is used for adhesive post cementation
and as core build-up material. (a) Try-in of FRC post. (b) Self-etch primer-adhesive applied into the root canal by use of an endo micro-
brush. (c) Adhesively cemented FRC post with composite resin core build-up. The core build-up was made from the same dual-cured
composite resin that had been used for adhesive post cementation.
Fig 21 Example of a self-etch two-step bonding
system including a self-cure activator (AdheSE/AdheSE
DC Activator) for combination with dual-cured resin
cements and core build-up composite resins.
a b c
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Table 4 Indication-related recommendations for the clinical use of bonding sys-
tems:
-
well suited,
.
with restrictions/not frst choice,
/
unsuitable/not
recommended. In the case of self-etch bonding systems, additional phos-
phoric acid (PA) etching of enamel: mandatory, PA!; recommended, PA;
optional, (PA).
Self-etch Etch-and-rinse
2 steps 1 step 3 steps 2 steps
Cervical composite resin restorations (Class 5)
Caries lesions - (PA) . (PA) - -
Non-caries lesions - (PA) / - .
Direct anterior composite resin restorations
Class 3 all margins in enamel - (PA) . (PA) - -
Class 3 - gingival margins in dentin - (PA) / - .
Class 4 all margins in enamel - PA! . PA! - -
Class 4 - gingival margins in dentin - PA! / - .
Esthetic correction of tooth malformation and tooth malposition / / - -
Direct posterior composite resin restorations
Replacement restorations
Class 1 - PA . PA - .
Class 2 all margins in enamel - PA / - .
Class 2 - gingival margins in dentin - PA / - .
Minimally invasive restoration of primary caries lesions (occlusal,
proximal)
/ / - .
Fissure sealing / / - -
Core build-up restorations
Made with light-cured composite resin:
Complete intermediate restoration (incremental technique) - / - /
Selective build-up/blocking out of undercuts - . - .
Made with dual-cured composite resin:
Complete build-up for immediate preparation (bulk technique)
.* / - /
Adhesive luting of porcelain veneers / / - -
Adhesive luting of inlay and onlay restorations
All margins in enamel - PA / - .
Gingival margins in dentin . PA** / .** /
Adhesive cementation of endodontic FRC posts with dual-cured composite resin
Translucent FRC posts .*** / -*** -***
Non-translucent FRC posts / / .*** .***
*Coating of the light-cured adhesive with a owable composite resin; **selective double-bond technique at gingival mar-
gins; ***combination with dual-cure activator if applicable.
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