Silane Coupling Agents are Beneficial for

Resin Composite Repair: A Systematic Review and

Meta-Analysis of In Vitro Studies
Laura Teixeira Mendesa / Bas A. C. Loomansb / Niek J. M. Opdamc / Carolina Lopes da Silvad /
Luciano Casagrandee / Tathiane Larissa Lenzif

Purpose: To systematically review the literature to determine whether silane combined with adhesive application
improves the repair bond strength of direct methacrylate-based resin composites in comparison to the use of an
adhesive alone.
Materials and Methods: The literature up to December 2019 was searched through PubMed/MEDLINE, Scopus,
and Lilacs databases with no publication year or language limits. From 676 potentially eligible studies, 81 were se-
lected for full-text analysis, and 19 were included in the systematic review. Two reviewers independently selected
the studies, extracted data, and assessed the risk of bias. Meta-analyses were conducted using a random effects
model to calculate pooled mean differences between adhesive- vs silane-plus-adhesive surface treatments (global
meta-analysis) and considering subgroup analyses (immediate and aged repair bond strengths and type of silane –
hydrolyzed or nonhydrolyzed). Statistical analyses were performed using RevMan5.3 at a significance level of 5%.
Results: Global meta-analysis showed that the use of silane prior to adhesive application produced significantly
higher repair bond strengths (p=0.003). A higher mean difference (effect size: 7.30, 95% CI: 2.91-17.51) between
groups was found when nonhydrolyzed silanes were used. The heterogeneity was high. Studies scored between
medium and high risk of bias.
Conclusion: An additional silane application step could increase the repair bond strength of methacrylate-based
resin composites.
Keywords: methacrylate functional silane, bond strength, repair, resin-based composites.

J Adhes Dent 2020; 22: 443–453. Submitted for publication: 04.10.19; accepted for publication: 12.06.20
doi: 10.3290/j.jad.a45175

D ental restorations are usually placed due to caries or

fracture,35 and resin composite is often the material of
choice for restoring anterior and posterior teeth. In case of
resin composite restoration failure, clinicians can decide to
replace or repair the restoration. Repair is a minimally inva-
sive treatment that involves removal of the defective part of
the restoration, followed by restoration of the prepared de-
fect.20 Although repair has often been seen as “bad den-
tistry” in the past,19 nowadays it is considered state-of-the-
art, as it limits the size of the restorative intervention,
reducing the risk for pulp complications and treatment
costs.20,26

a MSc Student, Faculty of Dentistry, Postgraduate Program in Pediatric Den-
tistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. Per-
r Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
formed the literature search and evaluation, wrote the manuscript.
b Assistant Professor, Department of Preventive and Restorative Dentistry, Rad-
boud University Medical Center Nijmegen, Nijmegen, The Netherlands. Con-
tributed substantially to discussion, proofread the manuscript.
c
Associate Professor, Department of Preventive and Restorative Dentistry, Rad-
boud University Medical Center Nijmegen, Nijmegen, The Netherlands. Con-
tributed substantially to discussion, proofread the manuscript.
d Undergraduate Student, Faculty of Dentistry, Department of Surgery and Or- r
thopedics, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
Proofread the manuscript.
e Associate Professor, Faculty of Dentistry, Postgraduate Program in Pediatric
Performed the literature search and evaluation, proofread the manuscript.
f Assistant Professor, Faculty of Dentistry, Postgraduate Program in Pediatric
Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
Consulted on idea, performed the literature search and evaluation, proofread
the manuscript.
Correspondence: Tathiane Larissa Lenzi, Faculty of Dentistry, Postgraduate
Program in Pediatric Dentistry, Federal University of Rio Grande do Sul, Ramiro
Barcelos 2492, 90035-003, Santa Cecília, Porto Alegre, RS, Brazil. Tel: +55-51-
3308-5493; e-mail: tathilenzi@hotmail.com

Vol 22, No 5, 2020 443

Mendes et al
Fig 1 Flowchart diagram of study selection according to PRISMA statement.
Although it has been shown that repair may increase the
survival time of posterior restorations,8,36 there is no gold
standard protocol for treating aged resin composite sur- r was no comparison of repair bond strengths between si-
faces before repair. Physical surface treatments such as
grinding with burs or air abrasion have the ultimate goal of
improving mechanical attachment between aged and new
(repair) resin composite, whereas chemical surface treat-
ments such as silane or adhesives are applied to improve
chemical coupling between resin-based materials at the ad-
hesive interface.40
A previous systematic review40 assessed the influence
of physical and/or chemical surface treatments on the re-
pair bond strength of methacrylate-based resin compos-
ites. It was shown that silane coupling agents seem to play
a minor role in improving repair potential compared to ad-
hesives. However, both chemical treatments were com-
444
Were not in vitro studies;
pared with physical treatment involving grinding of resin
composite surfaces with burs or abrasive papers, i.e. there
lane combined with adhesive vs the use of an adhesive
alone.
It has been shown that clinicians prefer to follow the same
procedure for both placing and repairing a restoration.39 The
use of burs, followed by acid etching and application of adhe-
sive, appeared to be used by over 80% of clinicians as a
pretreatment of the to-be-repaired old composite.39 Pooled in
vitro data might help elucidate whether silane treatment of
the resin composite surfaces before repair is indispensable.
Furthermore, several factors may play a role related to the
application of silane coupling agents, such as type of silane
(hydrolyzed or nonhydrolyzed) and the service life of the de-
fective resin composite restoration to be repaired.
The Journal of Adhesive Dentistry

Therefore, this systematic review and meta-analysis aimed
to evaluate the effect of the use of silane prior to adhesive ap-
plication on repair bond strength of direct methacrylate-based
resin composites in comparison to the use of adhesive alone.
MATERIALS AND METHODS
This study was carried out according to the Cochrane Hand-
book21 and reported according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement.25 The following research question was formu-
lated to address the literature and outline the search strat-
egy: Does silane plus adhesive application improve the re-
pair bond strength of direct methacrylate-based resin
composites in comparison to the use of adhesive alone?
Search Strategy
A comprehensive literature search was undertaken through
PubMed/MEDLINE, Scopus, and Lilacs databases. The last
search was carried out in December 2019 to identify stud-
ies relevant studies. The subject search used a combina-
tion of controlled vocabulary and text words based on the
search strategy for the PubMed/MEDLINE database as fol-
lows: ((((((Composite Resins[MeSH Terms]) OR Composite
Resin*) OR Resin* Composite) OR Composite*) AND Si-
lane)) AND (((((((((((((Repair bond strength) OR Bond
strength) OR Tensile strength[MeSH Terms]) OR Tensile
strength) OR Shear strength[MeSH Terms]) OR Shear
strength) OR Tensile) OR Shear) OR Microtensile) OR Micro-
tensile bond strength) OR Microshear) OR Microshear bond
strength) OR Repair*).
The keywords and search strategy used in PubMed/MED-
LINE were adapted for Scopus and Lilacs databases (see Ap-
pendix, last page). The results of searching the various data-
bases were cross checked to locate and eliminate duplicates.
No publication year or language limits were considered.
Selection, Inclusion and Exclusion Criteria
The titles and abstracts of all identified studies were care-
fully assessed by two independent reviewers (TLL and LTM)
and selected based on the inclusion criterion: in vitro stud-
ies that assessed the influence of the silane application on
the repair bond strength of resin composites. If consensus
was not reached, the abstract was set aside for further
evaluation by a third reviewer (LC). The references of all
selected studies were manually searched for further rele-
vant studies that could fulfill the inclusion criteria.
The full texts of all studies that met the inclusion criteria
for eligible papers were then reviewed independently by the
same reviewers considering the following exclusion criteria:
(1) did not compare silane plus adhesive application with
adhesive alone; (2) did not evaluate the repair bond
strength of direct methacrylate-based resin composite; (3)
did not use the same adhesive in both experimental
groups; and (4) did not store the resin composite for more
than 24 h before repair or perform mechanical loading or/
and thermocycling to age the resin composite.
Vol 22, No 5, 2020
Mendes et al
Additionally, the resin composite surface could have been
left untreated or ground with dental burs, SiC abrasive pa-
pers, or similar abrasives. Studies that used other types of
surface treatment, such as use of hydrofluoric acid and air
abrasion, were excluded. Grinding was considered, because
the resin composite surfaces are commonly prepared intra-
orally with burs before repair. Abrasive papers were consid-
ered an acceptable grinding treatment, since their granulom-
etry resembles the granulometry of diamond instruments.40
Any disagreements in terms of meeting the eligibility criteria
were solved with the help of a third reviewer (LC) by discus-
sion and consensus. Interexaminer agreement on the eligi-
bility of studies was excellent, with a kappa score of 0.91.
Data Extraction
Data were extracted by means a standardized sheet in Mi-
crosoft Office Excel (Microsoft; Redmond, WA, USA). For
each paper, the following data were systematically ex-
tracted: publication details (title, authors, country, and
year), study methodology (sample size, aging protocol of
resin composite, silane, adhesive and resin composite eval-
uated, bond strength test, time of storage before test), and
outcome information (bond strength mean ± SD in MPa).
For studies that did not report the exact bond strengths
and showed the results in graphs or figures, corresponding
authors were contacted 3 times by e-mail at 2-week inter-
vals to determine whether any information was missing. If
no information was provided, the study was excluded from
the meta-analysis.
Risk of Bias Assessment
Two authors (TLL and LTM) independently evaluated the risk
of bias of each included study using a scoring system de-
scribed in previous systematic reviews of in vitro stud-
ies.37,40 The following parameters were considered: random-
ization of specimens, materials used according to
manufacturer’s instructions, description of sample size cal-
culation, blinding of the testing machine operator, and use
of storage method able to age the resin composite before
repair. If the authors reported the given parameter, the
paper received a “yes” for that specific parameter; if it was
not possible to find the information, the paper received a
“no”. Papers that reported 1 or 2 items were classified as
having a high risk of bias, 3 or 4 as medium risk, and 5 as
low risk. Disagreements between the reviewers regarding the
classification of risk of bias were resolved by consensus.
Data Analyses
For the meta-analyses, pooled-effect estimates were ob-
tained by comparing bond strength means of silane-plus-
adhesive vs adhesive-alone groups, as well as by consider-r
ing the subgroups according to the storage duration before
testing (immediate or aged repair bond strength), type of
silane (hydrolyzed or nonhydrolyzed), and type of bond
strength test. For studies that evaluated several adhesives
or resin composites, the values were extracted and one
mean was calculated by a formula according to the Co-
chrane Statistical Guidelines,21 to obtain a single sample
445
Mendes et al

Table 1 Descriptive data from studies included in the systematic review

Time and aging

method before
Bond strength
Type of silane
Aging method
before repair
Author, year,

composite

Adhesive

Adhesive
adhesive
country

Type of
MDP in
Silane
Resin

test

test
N
Eren et al, Filtek Z550 Water at 37°C for 24h Bis-Silane (Bisco) Two components, Clearfil SE Bond Yes Two-step Shear 8 Water at 37°C
2019,15 (3M Oral Care) + thermocycling nonhydrolyzed (Kuraray Noritake) self-etch for 24h
Turkey (5000 cycles)
Alqarni et Filtek Supreme Water at 37°C for Clearfil Porcelain One component, Clearfil One (Kuraray Yes One-step Microshear 2 Water at 37°C
al, 2019,3 Ultra (3M Oral 1 week or 1 month Bond Activator nonhydrolyzed Noritake) self-etch for 24h
Japan Care) (Kuraray Noritake) (Universal)
Estelite Sigma
Quick
(Tokuyama
Dental)
Beautifil II
(Shofu)
Clearfil AP-X
(Kuraray
Noritake)
Altinci et al, Venus Pearl Water at 37°C for Signum Ceramic Two components, iBond Universal Yes One-step Microtensile 24 Water at 37°C
2018,4 (Heraeus 48 h, boiled water for Bond (Heraeus nonhydrolyzed (Heraeus Kulzer) self-etch for 24h or
Finland Kulzer) 8 h and water at 37°C Kulzer) (Universal) thermocycling
Filtek Z100 (3M for 48 h for 3 weeks (6000 cycles)
Oral Care)
Filtek Supreme
Ultra (3M Oral
Care)
Al-Asmar et Filtek Z350 XT Water at 37°C for RelyX Ceramic One component, Adper Single Bond No Two-step Shear 22 Water at 37°C
al, 2017,2 (3M Oral Care) 6 weeks Primer (3M Oral hydrolyzed Plus (3M Oral Care) etch-and- for 2 weeks
Jordan Care) rinse
Andrade et Filtek Z250 (3M Water at 37°C for Monobond S 1 component Adper Single Bond No Two-step Microshear 10 Water at 37°C
al, 2017,5 Oral Care) 6 months (Ivoclar Vivadent) hydrolyzed Plus (3M Oral Care) etch-and- for 24h
Brazil rinse
Clearfil tri-S Bond Yes One-step
(Kuraray Noritake) self-etch
Clearfil SE Bond Yes Two-step
(Kuraray Noritake) self-etch

Eliasson Filtek Supreme Water at 37°C for Silane Porcelain Two components, Adper Scotchbond No Three-step Microtensile 16 Water for
and Dahl, Ultra (3M Oral 2 weeks + Primer (Bisco) nonhydrolyzed Multi-Purpose (3M etch-and- 6 months +
2017,14 Care) thermocycling (5000 Oral Care) rinse thermocycling
Iceland cycles) (5000 cycles)
Clearfil SE Bond Yes Two-step
(Kuraray Noritake) self-etch
One-step Plus No Two-step
(Bisco) etch-and-
rinse
Scotchbond Yes One-step
Universal Adhesive self-etch
(3M Oral Care) (Universal)
Fornazari et Filtek Supreme Water at 37°C for RelyX Ceramic One component, Heliobond (Ivoclar No Two-step Microshear 12 Water at 37°C
al, 2017,18 Ultra (3M Oral 14 days Primer (3M Oral hydrolyzed Vivadent) etch-and- for 48 h
Brazil Care) Care) rinse
Monobond Plus One component, Scotchbond Yes One-step
(Ivoclar Vivadent) hydrolyzed Universal Adhesive self-etch
(3M Oral Care) (Universal)
Staxrud and Filtek Supreme Water at room Bis-Silane (Bisco) Two components, Clearfil SE Bond Yes Two-step Shear 10 Thermocycling
Dahl, Ultra (3M Oral temperature for nonhydrolyzed (Kuraray Noritake) self-etch (5000 cycles)
2015,38 Care) 60 days or 1 year
Norway
22
Eliasson et Tetric Evo Water for 2 weeks + Bis-Silane (Bisco) Two components, AdheSE One (Ivoclar No Two-step Microtensile 4 Water +
al, 2014,13 Ceram (Ivoclar thermocycling (5000 nonhydrolyzed Vivadent) self-etch thermocycling
Iceland Vivadent) cycles) (5000 cycles)
for 1 and
12 months
Clearfil SE Bond Yes Two-step
(Kuraray Noritake) self-etch
Adper Scotchbond No Three-step
Multi-Purpose (3M etch-and-
Oral Care) rinse
Cho et al, Point 4 (Kerr) Thermocycling (5000 Silane (Ultradent) One component, OptiBond Solo Plus No One-step Shear 10 Water at 37°C
2013,10 cycles) hydrolyzed (Kerr) etch-and- for 24h
USA rinse

446 The Journal of Adhesive Dentistry

 Mendes et al

Time and aging

method before
Bond strength
Type of silane
Aging method
before repair
Author, year,

composite

Adhesive

Adhesive
adhesive
country

Type of
MDP in
Silane
Resin

test

test
N
Acharya and Esthet X HD Water at 37°C for RelyX Ceramic One component, Adper Single Bond No Two-step Microtensile 5 Water at 37°C
Manjunath, (Dentsply) 14 days Primer (3M Oral hydrolyzed Plus (3M Oral Care) etch-and- for 24h
2012,1 Care) rinse
India
El-Askary et Grandio Caps Water at room Monobond S One component, Solobond Plus No Three-step Tensile 10 Water at 37°C
al, 2012,12 Shade (Voco) temperature for (Ivoclar Vivadent) hydrolyzed (Voco) etch-and- for 24h and
Egypt 1 month rinse 1 month

Joulaei et TPH Spectrum Water at 37°C for Silane (Ultradent) One component, Margin Bond No Two-step Microshear 3 Thermocycling
al, 2012,23 (Dentsply) 24 h + thermocycling hydrolyzed (Coltène Whaledent) etch-and- (1000 cycles)
Iran (5000 cycles) rinse

Filtek Z250 (3M Clearfil SE Bond Yes Two-step

Oral Care) (Kuraray Noritake) self-etch
Adper Single Bond No Two-step
Plus (3M Oral Care) etch-and-
rinse
Çelik et al, Filtek Z250 (3M Water at 37 °C for Composite primer One component, AdheSe (Ivoclar No Two-step Tensile 10 Water at 37°C
2011,9 Oral Care) 6 months (GC) hydrolyzed Vivadent) No self-etch, for 24 h
Turkey XP Bond (Dentisply) two-step
etch-and-
rinse
Melo et al, Charisma ASTM-G-53 machine, Silane (Dentsply) Two components, Excite (Ivoclar No Two-step Shear 16 Water at 37°C
2011,31 (Heraeus 4 h of exposure to nonhydrolyzed Vivadent) etch-and- for 24 h
Brazil Kulzer) UV-B at 60°C and 4 h rinse
of condensation at
60°C, 192 h

Kashi et al, Clearfil AP-X Water at 37°C for Clearfil Porcelain One component, Clearfil SE Bond Yes Two-step Shear 15 Water at 37°C
2011,24 (Kuraray 3 weeks Bond Activator nonhydrolyzed (Kuraray Noritake) self-etch for 1 week and
Iran Noritake) (Kuraray Noritake) 6 months
Fawzy et al, Gradia anterior Water at 37°C for Monobond S One component Excite (Ivoclar No Two-step Tensile 8 Water at 37°C
2008,16 (GC) 30 days (Ivoclar Vivadent) hydrolyzed Vivadent) etch-and- for 24 h
Egypt rinse

Bonstein et Vit-L-escence Water at 37°C for Monobond S One component, Excite (Ivoclar No Two-step Shear 20 Water for 10
al, 2005,6 (Ultradent) 24 h or 20 days (Ivoclar Vivadent) hydrolyzed Vivadent) etch-and- min
Canada rinse

Brosh et al, Pertac-hybrid Water at 37°C for Scotch Prime One component, Enamel Bond Not Not Shear 20 Water at 37°C
1997,7 (3M Oral Care) 14 days Ceramic Primer hydrolyzed (Ultradent) reported reported + thermocycling
Israel (3M Oral Care) (300 cycles)

size and means ± SD for both groups. In the selected stud-
ies, only the data of interest were extracted to be analyzed
in the meta-analyses.
When the specimens were stored up to 30 days before
testing, the repair bond strengths were considered as as
immediate, while aged repair bond strength was as speci-
mens having been submitted to thermocycling or water stor- r
age at least 6 months. The between-group differences were
tested for statistical significance in Review Manager (Rev-
Man version 5.3 software, Cochrane Collaboration; Copen-
hagen, Denmark, 2014) using a random effect method.
Statistical significance was defined as p ≤ 0.05 (Z test).
The number of specimens was considered as the number of
experimental units. Statistical heterogeneity among studies
was assessed via the Cochran Q test with a threshold p-
value of 0.1 and by applying the inconsistency index (I2).
RESULTS
Search and Selection
Figure 1 depicts a flowchart summarizing the selection pro-
cess for studies according to the PRISMA statement.25 The
search strategy identified 676 potentially relevant records
excluding duplicates. The first screening resulted in 81
studies for full-text reading. Finally, 19 papers were in-
cluded in the systematic review and meta-analysis.
Descriptive Analysis
Table 1 shows descriptive extracted data from the studies
included in the review. The papers were published between
1997 and 2019. In this collection, 18 methacrylate-based
resin composites were used; Filtek Supreme Ultra (3M Oral
Care; St Paul, MN, USA), Filtek Z250 (3M Oral Care) and

Vol 22, No 5, 2020 447

Mendes et al

Table 2 Assessment of the risk of bias of included studies in the systematic review

Aging method
Study Randomized Materials Sample size Blinding before repair Bias risk
Acharya and Manjunath, 20121 No No No No No High
Al-Asmar et al, 20172 Yes Yes No Yes No Medium
Alqarni et al, 20193 No Yes No No No High
Altinci et al, 20184 Yes Yes No No No High
Andrade et al, 20175 Yes Yes No No Yes Medium
Bonstein et al, 20056 Yes Yes No No No High
Brosh et al, 19977 Yes Yes No No No High
Çelik et al, 20119 Yes Yes No No Yes Medium
Cho et al, 201310 Yes Yes No No Yes Medium
El-Askary et al, 201212 No Yes No No No High
Eliasson and Dahl, 201714 Yes No No No Yes High
Eliasson et al, 201413 Yes No No No Yes High
Eren et al, 201915 Yes Yes No No Yes Medium
Fawzy et al, 200816 No Yes No No No High
Fornazari et al, 201718 Yes Yes No No No High
Staxrud and Dahl, 201538 No Yes No No Yes High
Joulaei et al, 201223 Yes No No No Yes High
Kashi et al, 201124 Yes Yes No No No High
Melo et al, 201131 Yes No No No Yes High

Randomized: randomization of specimens; materials: materials used according to manufacturers’ instructions; sample size: description of sample size
calculation; blinding: blinding of the operator of the testing machine; aging method before repair: use of storage method able to age the resin composite
before repair.

Clearfil AP-X (Kuraray Noritake; Osaka, Japan) were the
most frequently used. Eleven commercially available silanes
were evaluated, most of which were hydrolyzed. Monobond
S (Ivoclar Vivadent; Schaan, Liechtenstein) was the silane
most frequently tested in the included studies.
Furthermore, 14 adhesives were evaluated, with the two-
step self-etch adhesive Clearfil SE Bond (Kuraray Noritake)
being the most commonly tested adhesive. Two silane-con-
taining universal adhesives were tested. Two studies14,18
evaluated Scotchbond Universal Adhesive (3M Oral Care),
and one study3 tested Clearfil SE One (Kuraray Noritake).
The majority of the studies used a static storage method
in water for aging composites prior to repair procedures,
while only four studies13-15,23 combined water storage with
thermocycling, and two studies10,31 used thermocycling
only. Additionally, six studies4,7,13,14,23,38 performed aging
of the repaired interfaces before bond strength test through
thermocycling. The shear bond strength test was the most
common method used (42.1%).
Risk of Bias
Of the 19 studies included in this review, 14 had a high and
5 a medium risk of bias (Table 2). The item that most fre-
quently received “No” in the analysis was description of
sample size calculation, and only one study2 reported the
presence of an operator blinded to experimental conditions
during the bond strength test. Ten studies1-4,6,7,12,16,18,24
did not use an appropriate storage method to age the resin
composite before repair, and the randomization of speci-
mens was not performed in 5 studies.1,3,12,16,38
Meta-Analyses
The meta-analyses were performed considering the global
analysis and also subgroup analyses according to the stor- r
age time before testing (immediate and aged repair bond
strength), type of silane (hydrolyzed and nonhydrolyzed),
and type of bond strength test.
The results of the global meta-analysis of repair bond
strength are presented in Fig 2. There was no difference
between groups in terms of immediate and aged repair
bond strength (p = 0.12 and p = 0.06, respectively). High
heterogeneity was observed for both subgroups. However,
in the global analysis, there was a significant difference be-
tween groups, showing evidence that use of silane prior to
adhesive application produced higher repair bond strengths
(p = 0.003). The heterogeneity was also high (I2 = 98%).
Use of nonhydrolyzed silanes combined with adhesive ap-
plication promoted higher mean differences (effect size:
7.30, 95% CI: -2.91-17.51) in comparison with the use of
adhesive alone (Fig 3). The heterogeneity was high (I2=97%).

448 The Journal of Adhesive Dentistry


aged repair bond strength
Fig 2 Summary findings of the meta-analyses comparing the repair bond strength of silane plus adhesive vs adhesive before repair.
Meta-analysis according to the type of bond strength test
(Fig 4) showed a significant difference between groups, fa-
voring silane plus adhesive (p = 0.02). Considering the sub-
group analysis, this difference was found only for studies
that used the microtensile bond strength test (p < 0.01).
However, data on type of bond strength showed high het- t (MPS) is frequently used.28,29 On one end, MPS silanes
erogeneity (I2 = 97%).
DISCUSSION
This systematic review was designed to determine whether
the application of a silane coupling agent is a necessary
clinical step in repair protocols. It is often maintained that
laboratory bond-strength testing cannot predict the clinical
effectiveness of dental materials.30 In fact, an excellent
performance of restorative materials in laboratory tests
does not necessarily imply optimum clinical results. How-
ever, catastrophic failure of a material or technique in a la-
boratory test definitely contraindicates its clinical use.
Thus, even if in vitro studies do not faithfully predict clinical
performance, laboratory testing is essential to determine
the potential for clinical applicability. Global meta-analysis
showed that silane application prior to adhesive application
resulted in higher repair bond strengths of resin composites
Vol 22, No 5, 2020
Mendes et al
compared to the use of adhesive alone (effect size: 5.06;
95% CI: 1.81-6.30).
Silanes are organofunctional molecules that promote the
union between two materials. In dentistry, a bifunctional
compound called 3-methacryloxypropyl-trimethoxysilane
consist of a methacrylate group that can react with the in-
termediate adhesive and resin composites, and, on the
other end, a reactive silanol group that can form siloxane
bonds with alumina and/or silica present on the air-abraded
or acid-etched substrate surfaces.28,29 In repair proced-
ures, this molecule promotes the union of the inorganic
phase of the substrate with the organic phase of the resin
composite to be repaired.22 Furthermore, silanes have a
higher surface wettability, facilitating the penetration of the
adhesive into surface defects,28 and thus facilitate in-
creased repair bond strength.
It has been shown that the application of physical plus
chemical surface treatments on aged resin composite im-
proves the repair bond strength.40 Removing the superficial
layer from an old resin composite and roughening with at
least a diamond instrument are necessary to obtain micro-
mechanical retention. Also, the effect of the silane on the
repair protocol depends upon availability of silica (eg, glass
particles) on the surface of the resin composite. Since
449
Mendes et al
Fig 3 Subgroup analyses according to the type of silane.
grinding with burs or SiC abrasive papers was performed
before repair in most of the studies included, it was ex-
pected that the silica content on the surface of the aged
resin composite was sufficient to promote chemical bond-
ing of silane with resin composite. Aging of resin compos-
ites during storage can also break filler-polymer bonds,17
allowing surface loss of glass particles.
It should be mentioned that the number of studies in-
cluded in this analysis was relatively low, and mainly con-
cerned those that evaluated aged repair bond strength of
resin composites. No single aging protocol is considered
the gold standard for simulating the aging of resin compos-
ites that occurs in the oral environment. However, it seems
unlikely that many of the aging protocols used in the in-
cluded studies actually aged the composites properly, be-
cause resin composites were stored in water for under
6 months.1-4,6,7,12,16,18,24 Recently cured resin composites
are more reactive than aged ones, due to the availability of
free radicals and monomers to improve bonding to compos-
ite upon repair.17 Thus, the storage protocols defined as
short in this review may have resulted in little or no effect
of the silanes in the repair protocol.
Failures leading to repair are expected to happen in the
medium- or long-term clinical service of restorations,11 when
the resin composite is old. Therefore, the “immediate” re-
pair bond strengths found in this review are probably less
450
representative of clinical situations. To increase clinical rel-
evance, future studies on the repair bond strength of resin
composites should be performed on resin composite sam-
ples that have been subjected to prolonged aging protocols.
A wide variety of materials were tested in the included
studies, but predominantly a two-step self-etch system
(Clearfil SE Bond, Kuraray Noritake) and a silane coupling
agent (Monobond S, Ivoclar Vivadent). It is important to con-
sider that repair bond strengths may be influenced by the
type of adhesive and silane coupling agent used. Although
the two-step self-etch adhesive dispenses with the previous
acid conditioning step, three studies13,14,23 used phos-
phoric acid prior to application of Clearfil SE Bond in the
repair protocol employed. Etching with phosphoric acid pro-
motes the removal of grinding debris from resin composite
surfaces,27 and might also enhance the reactivity between
the silica or zirconia surface and the silane coupling
agent.27 Moreover, this adhesive relies on the presence of
10-MDP, which may also improve the repair bond strength
of resin composites. This functional monomer is also
known for its ability to bond chemically to calcium in dental
tissues and oxide groups (such as SiO2, Al2O3, ZrO2) of the
resin composites to be repaired, making the adhesive inter- r
face more resistant to biodegradation.41
Silane coupling agents are available in two types, either
hydrolyzed or nonhydrolyzed. The hydrolyzed silanes are
The Journal of Adhesive Dentistry

Fig 4 Subgroup analyses according to the type of bond strength test.
already activated. They are applied before the adhesive, or
alternatively, are included in universal adhesives such as
Scotchbond Universal Adhesive (3M Oral Care) and Clearfil
One (Kuraray Noritake). The nonhydrolyzed silane must
first be activated with an acid, usually an acidic monomer
such as MDP, requiring either mixing of 2 components
(Bis-Silane, Bisco; Schaumburg, IL, USA) before the silane
is applied or by mixing the silane into the self-etching
primer (Clearfil SE Bond) or adhesive resin (Clearfil Photo-
Bond).26
Subgroup analysis according to the type of silane found
a higher mean difference (effect size: 7.30; 95% CI: -2.91-
17.51) between silane-plus-adhesive and adhesive-only
groups when nonhydrolyzed silanes were used. Hydrolyzed
silane solutions may have a relatively short shelf life and
gradually become less reactive after opening of the bottle,
preventing optimal adhesion.29 Further studies are neces-
sary to determine whether the use of a silane-containing
universal adhesive could eliminate silane application for
direct resin composite repair.
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Mendes et al
High heterogeneity was found in all statistical analyses.
Considering the methodological variability among studies,
heterogeneity is unavoidable. All included studies had a me-
dium or high risk of bias. This is a common finding in system-
atic reviews of laboratorial studies.33,37 Lack of information
about sample size calculation, randomization, and blinding of
the operator of the test machine are the main reasons for
this, and should be carefully considered in further in vitro
studies. Another important issue, not included in bias risk
assessment, is related to the experimental unit used for
statistical purposes, especially when multiple measurements
are done in the same tooth as in micro-bond strength tests.
Even though micro-bond strength tests are currently prefera-
ble,32 only some of the included studies1,3-5,13,14,18,23 per-r
formed microtensile or microshear tests.
Although the meta-analysis considering the type of bond
strength test showed better results when using silane, a
significant difference between groups was observed only for
studies that used the microtensile bond strength test
(p < 0.01). Although a great diversity in laboratory testing of
451
Mendes et al
adhesive materials exists, the validity of these tests can be
improved by application of standardized protocols in test
methodology.
Finally, for the dental practitioner, the results of this re-
view suggest the use of a separate, preferably nonhydro-
lized silane, which would lead to better results in the intra-
oral repairing of resin composites. However, clinical proof of
this supposed benefit is still lacking. Clinical studies on
resin composite repair8,34 only used routine bonding tech-
niques (acid etching plus adhesive) for the repaired restor- r ment, silane, and universal adhesive on microshear bond strength of
ation surfaces, which might be sufficient for low-risk repair
sites, eg, when an occluso-proximal cavity receives a new
box due to recurrent caries. Therefore, a clinical trial on
routine repair protocols including variables such as silane
and adhesives types is essential for establishing their clin-
ical relevance.
CONCLUSION
Despite high heterogeneity of the studies, the results of
this review suggest that the implementation of an addi-
tional, preferably nonhydrolyzed silane application step
could improve the repair bond strength of direct methacry-
y 131–137.
late-based resin composites.
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APPENDIX
LILACS Database
resin composite OR composite resin AND silane AND repair
bond strength OR bond strength OR tensile OR microtensile
OR shear OR microshear AND (db:("LILACS"))

Scopus Database
TITLE-ABS-KEY (composite AND resin OR resin AND compos-
ite AND silane AND repair AND bond ND strength)

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