Advertisement
Journal of Prosthetic Dentistry

Impact of in vitro findings on clinical protocols for the adhesion of CAD-CAM blocks: A systematic integrative review and meta-analysis

Open AccessPublished:December 19, 2022DOI:https://doi.org/10.1016/j.prosdent.2022.08.024

      Abstract

      Statement of problem

      Computer-aided design and computer-aided manufacturing (CAD-CAM) blocks have evolved rapidly, making it difficult to establish the best clinical protocol for bonding a given block and whether an established protocol is appropriate for a newly introduced product.

      Purpose

      This integrative systematic review and meta-analysis aimed to clarify whether the clinician can select the most efficient adhesion protocols for CAD-CAM blocks by reading published in vitro studies and implementing them in daily practice.

      Material and methods

      Based on the population, intervention, comparison, and outcome (PICO) strategy, 3 databases were searched for in vitro studies, randomized clinical trials, prospective or retrospective studies, and case reports from January 1, 2015, to July 31, 2021. A meta-analysis analyzed 28 studies to calculate the mean difference between best and worst protocols for each author and block with a random-effects model (α=.05).

      Results

      From 508 relevant studies, 37 in vitro studies, 2 clinical studies, and 1 clinical report were selected for data extraction and qualitative analysis. Vita Enamic, IPS e.max CAD, LAVA Ultimate, and Vita Mark II blocks were the most studied, and RelyX Ultimate was the most used luting cement. The meta-analysis confirmed the null hypothesis that the evidence-based efficacy of clinical protocols to bond CAD-CAM blocks is still controversial (P<.05).

      Conclusions

      There are objective standards for individual in vitro tests, but the studies lack standardization. Some tested protocols were more efficient than others. Randomized clinical trials and well-documented clinical situations were almost nonexistent, making direct application of in vitro findings in clinical practice impossible.
      Clinical Implications
      Clinicians must conscientiously update adhesive protocols and techniques for each new material based on the manufacturer’s instructions. Technical requirements may differ for similar products within the same brand and even for products with similar names from other brands.
      Computer-aided design and computer-aided manufacturing (CAD-CAM) is becoming common in restorative dentistry, facilitating the manufacturing and delivery of indirect esthetic restorations.
      • Hardan L.
      • Bourgi R.
      • Cuevas-Suárez C.E.
      • et al.
      The bond strength and antibacterial activity of the universal dentin bonding system: A systematic review and meta-Analysis.
      • Scaminaci Russo D.
      • Cinelli F.
      • Sarti C.
      • Giachetti L.
      Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      • Skorulska A.
      • Piszko P.
      • Rybak Z.
      • Szymonowicz M.
      • Dobrzyński M.
      Review on polymer, ceramic and composite materials for CAD/CAM indirect restorations in Dentistry - Application, mechanical characteristics and comparison.
      • Zarone F.
      • Ruggiero G.
      • Leone R.
      • Breschi L.
      • Leuci S.
      • Sorrentino R.
      Zirconia-reinforced lithium silicate (ZLS) mechanical and biological properties: A literature review.
      CAD-CAM allows 3D modeling, chairside milling of restorations,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      and predictable single visit
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      restorations with excellent fit and mechanical properties,
      • Skorulska A.
      • Piszko P.
      • Rybak Z.
      • Szymonowicz M.
      • Dobrzyński M.
      Review on polymer, ceramic and composite materials for CAD/CAM indirect restorations in Dentistry - Application, mechanical characteristics and comparison.
      ,
      • Ahmed W.M.
      • Troczynski T.
      • McCullagh A.P.
      • Wyatt C.C.L.
      • Carvalho R.M.
      The influence of altering sintering protocols on the optical and mechanical properties of zirconia: A review.
      contrasting with operator-dependent laboratory-made restorations with a high variation of mechanical and esthetic properties.
      • Bin-Shuwaish M.S.
      • AlFawaz Y.F.
      • AlGamaiah H.A.
      • et al.
      Technical Accuracy of Dental Laboratories in the Quality and Shade Matching of Porcelain Fused to Metal Crowns: An In Vitro Study.
      • Silva L.H.D.
      • Lima E.
      • Miranda R.B.P.
      • Favero S.S.
      • Lohbauer U.
      • Cesar P.F.
      Dental ceramics: a review of new materials and processing methods.
      • Spitznagel F.A.
      • Boldt J.
      • Gierthmuehlen P.C.
      CAD/CAM Ceramic Restorative Materials for Natural Teeth.
      The quality, bond strength, and clinical longevity of CAD-CAM restorations appear to have increased, with contemporary restorations having excellent performance.
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      CAD-CAM blocks for indirect esthetic restorations are typically made from ceramic or composite resin.
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      Composite resins have more straightforward fabrication and favorable properties, with lower hardness, lower elastic modulus, and straightforward cementation.
      • Ahmed W.M.
      • Troczynski T.
      • McCullagh A.P.
      • Wyatt C.C.L.
      • Carvalho R.M.
      The influence of altering sintering protocols on the optical and mechanical properties of zirconia: A review.
      High-strength monolithic zirconia materials are also available for CAD-CAM technology, with no need for esthetic porcelain veneering.
      • Silva L.H.D.
      • Lima E.
      • Miranda R.B.P.
      • Favero S.S.
      • Lohbauer U.
      • Cesar P.F.
      Dental ceramics: a review of new materials and processing methods.
      ,
      • Sola-Ruiz M.F.
      • Baima-Moscardo A.
      • Selva-Otaolaurruchi E.
      • et al.
      Wear in antagonist teeth produced by monolithic zirconia crowns: A systematic review and meta-analysis.
      This allows restorations with a thickness of 0.5 mm or less and minimal antagonist wear, less than with other ceramic or metal-ceramic restorations.
      • Sola-Ruiz M.F.
      • Baima-Moscardo A.
      • Selva-Otaolaurruchi E.
      • et al.
      Wear in antagonist teeth produced by monolithic zirconia crowns: A systematic review and meta-analysis.
      Bonding is essential for CAD-CAM indirect restorations, both ceramic and composite resin, as they rely on adhesion for retention and strength, both of which directly affect their longevity.
      • Scaminaci Russo D.
      • Cinelli F.
      • Sarti C.
      • Giachetti L.
      Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
      ,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      Catastrophic, partial, or chipping fractures are the most common failures reported.
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      High retention, microleakage prevention, and enhancement of marginal adaptation are characteristics of a resilient and durable adhesive bond.
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      Recent advances in chemical modification of the composite resin cement with, for example, the introduction of antibacterial agents and multifunctional monomers improved the adhesive bond strength to dentin, enhancing long-term performance and protecting the tooth-adhesive interface from microleakage.
      • Hardan L.
      • Bourgi R.
      • Cuevas-Suárez C.E.
      • et al.
      The bond strength and antibacterial activity of the universal dentin bonding system: A systematic review and meta-Analysis.
      The optimal surface treatment for interface substrates and the best luting cement, restoration material, and dentin bonding agent to produce the highest bond strength is unclear. A consensus regarding the optimal adhesive protocol is lacking.
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Malysa A.
      • Wezgowiec J.
      • Orzeszek S.
      • Florjanski W.
      • Zietek M.
      • Wieckiewicz M.
      Effect of different surface treatment methods on bond strength of dental ceramics to dental hard tissues: A Systematic Review.
      Composite resin cement has been used for its advantageous mechanical and adhesive properties to cement conventional metal crowns, fixed partial dentures, ceramic crowns, veneers, or to repair fractured metal-ceramic, ceramic, and composite resin restorative materials.
      The composition of CAD-CAM blocks influences the bond strength of the ceramic material, and the mechanical and chemical interactions between the substrate and the bonding agent.
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      Surface treatment and its selection depend on the chemical and physical properties of each material.
      • Quigley N.P.
      • Loo D.S.S.
      • Choy C.
      • Ha W.N.
      Clinical efficacy of methods for bonding to zirconia: A systematic review.
      A combination of mechanical and chemical strategies has been the most accepted procedure for enhancing the composite resin cement-to-glass–ceramic bonding.
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      Silane provides chemical adhesion to silica-containing ceramic substrates. In addition, acid etchants, such as hydrofluoric acid, can partially dissolve the glassy phase, improving mechanical interlock with the composite resin cement.
      • Quigley N.P.
      • Loo D.S.S.
      • Choy C.
      • Ha W.N.
      Clinical efficacy of methods for bonding to zirconia: A systematic review.
      A consensus regarding the optimal bonding of monolithic zirconia materials is lacking.
      • Quigley N.P.
      • Loo D.S.S.
      • Choy C.
      • Ha W.N.
      Clinical efficacy of methods for bonding to zirconia: A systematic review.
      ,
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      As various factors can influence the bond’s quality and the adhesion mechanism’s physical characteristics,
      • Quigley N.P.
      • Loo D.S.S.
      • Choy C.
      • Ha W.N.
      Clinical efficacy of methods for bonding to zirconia: A systematic review.
      ,
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      ,
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      several in vitro studies have evaluated the effect of different pretreatments on adhesion between restorative materials and dentin.
      • Scaminaci Russo D.
      • Cinelli F.
      • Sarti C.
      • Giachetti L.
      Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
      ,
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      Nevertheless, some have technical limitations for clinical use. Furthermore, many tested techniques are difficult to compare from the studies.
      • Scaminaci Russo D.
      • Cinelli F.
      • Sarti C.
      • Giachetti L.
      Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
      For clinicians, selecting the ideal surface treatment protocol or adequate luting agent for each material is a significant concern as they are aware of its influence on the long-term success of the restoration.
      This integrative systematic review and meta-analysis aimed to determine whether a clinician can select the most efficient adhesion protocol for each CAD-CAM block by reading published in vitro studies and implementing them in daily practice. In addition, the in vitro adhesion of CAD-CAM blocks reported in the literature was compared with the in vivo efficacy of the protocols. The research hypotheses were that the clinical protocols for CAD-CAD block adhesion would be well established and clinically reproducible or that the evidence-based efficacy of clinical protocols to adhere CAD-CAM blocks would remain controversial.

      Material and methods

      The review followed the preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 recommendations.
      • Page M.J.
      • Moher D.
      • Bossuyt P.M.
      • et al.
      PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews.
      The population, intervention, comparison, and outcome (PICO) question was as follows: “Do in vitro findings influence the clinical protocols for the adhesion of CAD-CAM blocks?” The CAD-CAM blocks constituted the population. The intervention was defined as the adhesion protocol performed on the block or teeth for cementation; specifically, teeth or block surface treatment, type of block, coupling agent, and luting cement. The comparison was made between protocols for each CAD-CAM block to find intrastudy and interstudy differences in the mechanical performance. Clinical protocols were the outcome.
      A bibliographic search was carried out in the databases Medline/PubMed, ScienceDirect, and EBSCOhost, with keywords combined in the Boolean expression: [(CAD-CAM) AND (adhesive OR adhesion OR bonding OR cement) AND (ceramics OR blocks) AND protocol], filtered by the English language. Inclusion criteria were research papers, randomized clinical trials (RCTs), and clinical cases that addressed the theme, published from January 1, 2015 to July 31, 2021, with accessible full text. Duplicates and papers published before 2015 were excluded.
      Retrieved pertinent systematic reviews and reviews were not included in the qualitative analysis, but were still included in the study. Also included were those found by manual search, done by pairing each key word with the word CAD or by searching the reference lists of the included articles to allow comparisons, and broadening of the introduction and discussion sections. Duplicate articles were preliminarily withdrawn with a citation manager (EndNote X8 Windows; Clarivate). Articles were then filtered by title, abstract, and complete reading, agreeing with the PRISMA Statement, as shown in Figure 1. Two investigators (M.J.C.L., R.C.) independently selected each pertinent article for detailed reading. A third investigator (T.P.) resolved disagreements.
      Figure thumbnail gr1
      Figure 1Flow diagram of study selection according to preferred reporting items for systematic reviews and meta-analysis statement.
      Qualitative analysis for risk of bias assessment was done by individually scoring the 10 elected parameters within the following criteria: (0) clearly mentioned, (1) present but not accurately mentioned, and (2) not mentioned. Global scoring was categorized as Low Risk (0-4), Medium Risk (5-12), High Risk (13-17), and Very High Risk (18-20) of bias. The SJR score (Q1-Q4) was assigned by publication date for each study. The quality assessment of the observational studies was done by an adapted grading of recommendations, assessment, development, and evaluations (GRADE) method.
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Data extraction was summarized in tables. Pertinent information was examined in comprehensive graphics after applying the following filters: type of CAD-CAM block tested, luting material used in the laboratory and in vivo tests, mechanical test used for bonding strength evaluation, light source intensity, type of surface treatment, and coupling agent.
      A meta-analysis focused on adhesive strategies for each type of CAD-CAM block was conducted using a software program (Stata v17.0; StataCorp). Subgroup analyses were performed to assess the different kinds of surface treatment methods, adhesive joint substrates, and types of mechanical tests, and, for all studies that evaluated more than 1 type of CAD-CAM block or more than 1 surface treatment method, each type of material or treatment method was considered independently.
      The statistical heterogeneity was detected using the I2 statistic test (α=.05). A subgroup was formed with the 28 articles that studied the 9 most tested blocks in at least 2 in vitro studies. A meta-analysis was conducted by the authors and CAD-CAM block to find intrastudy heterogeneity and protocol splitting by efficiency after calculating the difference between means and the effect size (α=.05; 95% CI; Z-value=1.96). Funnel and Galbraith plots assessed the publication bias and heterogeneity (random-effects model; α=.01; 99.9% CI; Z-value=2.58).

      Results

      The search retrieved 508 articles (Medline/PubMed [108], ScienceDirect [176], EBSCOhost [224]). After applying inclusion and exclusion criteria, 37 in vitro studies,
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      ,
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      ,
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      • Dos Santos R.A.
      • de Lima E.A.
      • Mendonca L.S.
      • et al.
      Can universal adhesive systems bond to zirconia?.
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      • Lumkemann N.
      • Schonhoff L.M.
      • Buser R.
      • Stawarczyk B.
      Effect of cleaning protocol on bond strength between resin composite cement and three different CAD/CAM materials.
      • Monteiro R.V.
      • Dos Santos D.M.
      • Bernardon J.K.
      • De Souza G.M.
      Effect of surface treatment on the retention of zirconia crowns to tooth structure after aging.
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      • Nejat A.H.
      • Lee J.
      • Shah S.
      • et al.
      Retention of CAD/CAM resin composite crowns following different bonding protocols.
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      • Rigos A.E.
      • Dandoulaki C.
      • Kontonasaki E.
      • Kokoti M.
      • Papadopoulou L.
      • Koidis P.
      Effect of immediate dentin sealing on the bond strength of monolithic zirconia to human dentin.
      • Roperto R.
      • Akkus A.
      • Akkus O.
      • et al.
      Effect of different adhesive strategies on microtensile bond strength of computer aided design/computer aided manufacturing blocks bonded to dentin.
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      • Shinohara A.
      • Taira Y.
      • Sawase T.
      Effects of tributylborane-activated adhesive and two silane agents on bonding computer-aided design and manufacturing (CAD/CAM) resin composite.
      • Silthampitag P.
      • Chaijareenont P.
      • Tattakorn K.
      • Banjongprasert C.
      • Takahashi H.
      • Arksornnukit M.
      Effect of surface pretreatments on resin composite bonding to PEEK.
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      2 non-RCTs,
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      ,
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      and 1 clinical report
      • Claus-Peter E.
      Innovative adhesive luting protocol. Case Study.
      were selected. The manual search retrieved 3 systematic reviews with meta-analysis,
      • Hardan L.
      • Bourgi R.
      • Cuevas-Suárez C.E.
      • et al.
      The bond strength and antibacterial activity of the universal dentin bonding system: A systematic review and meta-Analysis.
      ,
      • Silva L.H.D.
      • Lima E.
      • Miranda R.B.P.
      • Favero S.S.
      • Lohbauer U.
      • Cesar P.F.
      Dental ceramics: a review of new materials and processing methods.
      ,
      • Sola-Ruiz M.F.
      • Baima-Moscardo A.
      • Selva-Otaolaurruchi E.
      • et al.
      Wear in antagonist teeth produced by monolithic zirconia crowns: A systematic review and meta-analysis.
      4 systematic reviews,
      • Scaminaci Russo D.
      • Cinelli F.
      • Sarti C.
      • Giachetti L.
      Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
      ,
      • Ahmed W.M.
      • Troczynski T.
      • McCullagh A.P.
      • Wyatt C.C.L.
      • Carvalho R.M.
      The influence of altering sintering protocols on the optical and mechanical properties of zirconia: A review.
      ,
      • Malysa A.
      • Wezgowiec J.
      • Orzeszek S.
      • Florjanski W.
      • Zietek M.
      • Wieckiewicz M.
      Effect of different surface treatment methods on bond strength of dental ceramics to dental hard tissues: A Systematic Review.
      ,
      • Quigley N.P.
      • Loo D.S.S.
      • Choy C.
      • Ha W.N.
      Clinical efficacy of methods for bonding to zirconia: A systematic review.
      3 reviews,
      • Skorulska A.
      • Piszko P.
      • Rybak Z.
      • Szymonowicz M.
      • Dobrzyński M.
      Review on polymer, ceramic and composite materials for CAD/CAM indirect restorations in Dentistry - Application, mechanical characteristics and comparison.
      ,
      • Zarone F.
      • Ruggiero G.
      • Leone R.
      • Breschi L.
      • Leuci S.
      • Sorrentino R.
      Zirconia-reinforced lithium silicate (ZLS) mechanical and biological properties: A literature review.
      ,
      • Spitznagel F.A.
      • Boldt J.
      • Gierthmuehlen P.C.
      CAD/CAM Ceramic Restorative Materials for Natural Teeth.
      and 1 survey.
      • Klosa K.
      • Meyer G.
      • Kern M.
      Clinically used adhesive ceramic bonding methods: a survey in 2007, 2011, and in 2015.
      The qualitative analysis for risk of bias assessment (Table 1) revealed 1 low-risk
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      (2.7%) and 36 medium-risk of bias (97.3%) articles. Transversal factors for lower score were the absence of operator blindness (referred to in 1 article
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      [2.7%]), no sample size calculation (referred to in 3 studies
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      ,
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      [8.1%]), and no reference to a single operator (referred to in 5 studies
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Rigos A.E.
      • Dandoulaki C.
      • Kontonasaki E.
      • Kokoti M.
      • Papadopoulou L.
      • Koidis P.
      Effect of immediate dentin sealing on the bond strength of monolithic zirconia to human dentin.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      ,
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      [13.5%]). Specimen randomization and the control group were frequently inadequately described or lacking. The level of evidence of the 2 observational studies is shown in Table 2. Given the parameters, the non-RCTs were scored as very good
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      and good
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      (mainly because of the dropout percentage, a known cause of bias). The clinical report
      • Claus-Peter E.
      Innovative adhesive luting protocol. Case Study.
      achieved good quality (within the scientific knowledge and manufacturer’s instructions despite not using a dental dam, and given the periodontal health, supragingival margins, and a cooperative patient).
      Table 1Synthesis of qualitative analysis for risk of bias assessment
      StudyAbdou et al, 2021
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      Cardenas et al, 2017
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      Ceci et al, 2015
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      Demirel et al, 2019
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      De Oliveira et al, 2018
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      Dos Santos et al, 2019
      • Dos Santos R.A.
      • de Lima E.A.
      • Mendonca L.S.
      • et al.
      Can universal adhesive systems bond to zirconia?.
      El-Damanhoury et al, 2017
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      Elsaka et al, 2020
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      Elsayed et al, 2017
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      Emsermann et al, 2019
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      Frankenberger et al, 2015
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      Ilie et al, 2019
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      Ishii et al, 2017
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      Kalavacharla et al, 2015
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      Kassem et al, 2020
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      Komoto et al, 2021
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      Liebermann et al, 2019
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      Lümkemann, 2020
      • Lumkemann N.
      • Schonhoff L.M.
      • Buser R.
      • Stawarczyk B.
      Effect of cleaning protocol on bond strength between resin composite cement and three different CAD/CAM materials.
      Monteiro et al, 2020
      • Monteiro R.V.
      • Dos Santos D.M.
      • Bernardon J.K.
      • De Souza G.M.
      Effect of surface treatment on the retention of zirconia crowns to tooth structure after aging.
      Murata et al, 2018
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      Murillo Gómez et al, 2017
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      Nejat et al, 2018
      • Nejat A.H.
      • Lee J.
      • Shah S.
      • et al.
      Retention of CAD/CAM resin composite crowns following different bonding protocols.
      Фilo et al, 2015
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      Passia et al, 2015
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      Peumans et al, 2016
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      Rigos et al, 2018
      • Rigos A.E.
      • Dandoulaki C.
      • Kontonasaki E.
      • Kokoti M.
      • Papadopoulou L.
      • Koidis P.
      Effect of immediate dentin sealing on the bond strength of monolithic zirconia to human dentin.
      Roperto et al, 2016
      • Roperto R.
      • Akkus A.
      • Akkus O.
      • et al.
      Effect of different adhesive strategies on microtensile bond strength of computer aided design/computer aided manufacturing blocks bonded to dentin.
      Sakrana, 2017
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      Shinohara et al, 2017
      • Shinohara A.
      • Taira Y.
      • Sawase T.
      Effects of tributylborane-activated adhesive and two silane agents on bonding computer-aided design and manufacturing (CAD/CAM) resin composite.
      Şişmanoğlu et al, 2020
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      Siqueira et al, 2019
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      Silthampitag et al, 2016
      • Silthampitag P.
      • Chaijareenont P.
      • Tattakorn K.
      • Banjongprasert C.
      • Takahashi H.
      • Arksornnukit M.
      Effect of surface pretreatments on resin composite bonding to PEEK.
      Tekçe et al, 2017
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      Trindade et al, 2016
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      Ustun, 2020
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      Wu et al, 2018
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      Yazigi et al, 2017
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      Specimen Randomization0000010000011101111100010010100020100
      Single Operator2002222222222222222222222022220222220
      Operator Blinded2222222222222222222222222222222222222
      Standardized Specimens0000001000000000000000100000010010001
      Control Group0220020000020000210000020220000000001
      Fractographic analysis0000010000200220000000000020120000101
      Manufacturer's Instructions0000000100000000000001000000200200000
      Sample Size Calculation2222222222222202220222222222220222222
      International Standards1111011011001111101011111011101111111
      Proper statistical analysis0000000000000000000000000000000000000
      TOTAL77776118777898107810867788107612711939107978
      Risk of BiasMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMLMMMMMM
      Journal SJR score by the date of publication(Q2)Q2Q2NSQ1Q1Q1Q1Q2Q1Q2Q1Q2Q1NS(Q1)Q1Q1Q1Q2Q1Q2Q1Q1Q1Q1Q3Q3Q2Q2Q2Q1Q1Q1Q1Q1Q1
      NS, Not scored; Q1, First quartile; Q2, Second quartile; Q3, Thrid quartile; ( ) - Quartile in the previous year. Green- good score/low risk, orange- average score/medium risk, red- bad score/high risk.
      Table 2Methodological evaluation of studies according to grading of recommendations, assessment, development, and evaluations method (adapted scale of 0-20)
      ItemsCriteriaApplication
      Risk of biasRandomized or observational[-1] J-risk of serious bias [-2] • very serious
      Inconsistency of results (heterogeneity)Assessment of similarities and estimates[-1] important inconsistency
      Indirect evidenceEvaluation of the presence of differences in the population, intervention and outcomes between the Included studies and the review question[-1] - serious indirect evidence [-2] - very serious
      ImprecisionSample dimension[•1] ifn<50, [-2] ifn<30
      Publication/methodology biasLack of methodological information[-1] suspicion of publication bias or lack of information
      Weighting for observational studies
      Impact of the JournalEvaluation of the impact of the journalMaximum impact (Q1) - [+2]
      Variation in relation to the average of studies in the held workEvaluation of variation of the Identical studiesOn average of identical studies •1+2]
      Effectiveness of the treatmentEvaluation of effectivenessGood clinical performance [+2]
      Sample sizeEvaluation of the sampled size of the studyIf >50 - [+2J]: if >30 - [+1]
      Well-founded studyAssessment of the rationale of the articleWell-founded [+2]
      Archibald et al, 2017Spitznagel et al, 2018
      Bias risk (randomized or observational)33
      Inconsistency of results (heterogeneity)--
      Indirect evidence--
      Imprecision--
      Methodology22
      Weighting for observational studies
      Journal Impact (+2ifQ1)22
      Effect with % within the range of other studies in the field (42)22
      Effectiveness of the CAD-CAM block (+2)22
      Sample size (+2 >50) (+1 >30)22
      Rationale for the study (+2)22
      Percentage of dropouts (+2 <20%) (-2 >40%)-22
      TOTAL1317
      Data extraction from in vitro and in vivo studies is shown in Table 3, Table 4, Table 5, Table 6. The authors identified 686 protocols to adhere 37 different CAD-CAM blocks (Supplementary Table 1 available online). Filtered data are displayed in Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7. The meta-analysis with the initial 37 selected in vitro studies, combining various agents of the adhesive strategy, revealed very high heterogeneity (I2>99%) in all attempts, even with a random-effects model (α=.05), and gave illegible graphics because of the large number of entries; therefore, results are not displayed. The meta-analysis based on the difference between means and effect size (P=.05; 95% CI; Z-value=1.9599) (Supplementary Table 2 available online) conducted by data filtering is shown in the forest plots (Fig. 8 and 9). Overall, tested protocols performed better than control protocols, but differences were evident. The IPS e.max ZirCAD bonding to substrates was not consistent in various studies with the need for simultaneous physico-chemical treatment of the block surface, and immediate dentin sealing (IDS) with a universal self-adhesive followed by a low-viscosity resin-matrix restorative favored adhesion to the tooth. As a second joint substrate, only composite resin bonded to IPS e.max ZirCAD raised concerns.
      Table 3Resumed data extraction from the selected in vitro studies
      Author, y

      MaterialSurface TreatmentCoupling AgentAdhesive SystemLuting CementSample PairingType of Test and Procedures
      Abdou et al, 2021
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      Estelite Block EsteliteP Block Katana Avancia Katana AvanciaP

      KZR-CAD HR2 KZR-CAD HR3 Lava Ultimate Tetric CAD Vita Enamic
      9.6% HF -60s

      Al2O3

      50 μm/??s/10 mm

      /0.2 MPa
      Clearfil Ceramic Primer PlusClearfil Tri-S Bond ND Quick

      Clearfil Tri-S Bond ND Quick + Porcelain Bond Activator
      PanaviaV5Block to Block (n=6)μTBS MPa Light polymerization

      1400 mW/cm2

      24 h Water
      Cardenas et al, 2017
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      IPSe. max CAD5% HF -20sNo silane

      Monobond Plus

      MonobondS

      Prime & Bond Elect
      No adhesive system

      Scotchbond UA
      RelyX Ultimate

      Enforce
      Block to Luting cement (n=10)μSBS MPa Light polymerization

      1200 mW/cm2 24 h or 1 y (37 °C) - Water
      Ceci et al, 2015
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      Lava UltimateSiC paper –600 grit

      No acid

      35%H3PO4 –15s

      Glycine powder -30 s

      No glicyne powder
      Scotchbond UA

      No treatment
      Scotchbond UARelyX Ultimate

      RelyX Unicem2
      Block to Bovine dentin (n=10)μSBS MPa Light polymerization

      1000 mW/cm2 24 h -Saline solution
      Demirel et al, 2019
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      Cera Smart Lava Ultimate Shofu Block Vita EnamicSiO2-coated Al2O3

      30 μm/10s/10 mm/

      0.28 MPa
      N/APorcelain Primer+Adapter Single Bond Universal Single Bond-2 All Bond Universal Clearfil Universal BondN/ABlock to Resin composite (n=11)μSBS MPa Light polymerization

      >1000 mW/cm2 5 °C-55 °C –5000c
      De Oliveira et al, 2018
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      TriniaAl2O3

      45 μm/10s/10 mm/0.2 MPa

      37%H3PO4 -30s
      Cera-Resin BondAll Bond3C&B Resin CementBlock to Human dentin (n=15)SBS MPa + μTBS MPa

      24 h - Water

      Light polymerization

      >380 mW/cm237 °C -500 000c

      5 °C-55 °C -500c
      Dos Santos et al, 2019
      • Dos Santos R.A.
      • de Lima E.A.
      • Mendonca L.S.
      • et al.
      Can universal adhesive systems bond to zirconia?.
      IPSe.max ZirCAD LTAl2O3

      50 μm/15s/?? mm/

      ?? MPa

      SiC -180/220/440

      /600 grit
      Z Prime PlusScotchbond UA

      All Bond Universal

      Z-Prime Plus + All Bond Universal
      Z350 XT composite resinBlock to Resin composite (n=10)μSBS MPa24 h - Water

      Light polymerization

      1200 mW/cm2
      El-Damanhoury et al, 2017
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      IPSe.max CAD Vita Enamic Vita Mark IINo treatment

      4.8% HF

      20s (e.max) or

      60s (Enamic/Mark II)

      Monobond Plus
      No treatment

      Monobond Plus
      Monobond Plus

      Monobond Etch & prime
      MultilinkN automix dual-cure resin cementBlock to Luting cement (n=10)SBS MPa24-h Water

      Light polymerization

      1200 mW/cm2 -20s 5 °C-55 °C -5000c
      Elsaka et al, 2020
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      GRANDIO Block Lava Ultimate Vita EnamicNo treatment

      Al2O3

      45 μm/5s/10 mm/0.2 Mpa

      Silane -60s

      9% HF -60s

      Titanium tetrafluoride
      Silane

      (Ceramic Bond)
      N/ABifix QMBlock to Block (n=20)μTBS MPa24h (37 °C) - Water

      5 °C-55 °C -0 and5000c
      Elsayed et al, 2017
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      IPSe. max CAD ZenostarSiC -600 grit

      Al2O3

      50 μm/??s/10 mm/

      0.1M Pa

      5% HF -20s
      Monobond Plus

      Calibra Silane
      Scotchbond UA

      All Bond Universal

      OptiBond XTR Kerr

      Prime and Bond NT
      Variolink Esthetic DC

      RelyX Ultimate

      NX3

      Duo-Link Universal

      Calibra Esthetic
      Block to Luting cement (n=24)μTBS MPa Light polymerized

      650 mW/cm2 -2 ×20s +90s3d (37 °C)/Water +0c30d (37 °C)/Water +7500c

      150d (37 °C)/Water

      +37 500c
      Emsermann et al, 2019
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      Brilliant Crios Cerasmart Gradia Block Lava Ultimate Vita EnamicSiC -180-grit

      SiO2-coated Al2O3 -30 μm/5s/10 mm/

      0.2M Pa

      Al2O350 μm/5s/10 mm/

      0.15 MPa

      5% HF -60s
      Ultradent Silane

      G-Multi Primer

      GC-Primer

      Vitasil Silane
      Scotchbond UA

      One Coat7 Universal
      RelyX Unicem2

      Duo Cem

      G-Cem LinkForce

      RelyX Ultimate
      Block to Luting cement (n=24)μSBS MPa Light polymerized

      1200 mW/cm2 -3 ×20s6m (37 °C)

      -Demineralized water
      Frankenberger et al, 2015
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      Celtra Duo IPSe. max CAD Lava Ultimate Vita EnamicNo treatment

      Al2O3

      50 μm/10s/5 mm/?? MPa

      5% HF -20/30 or60s
      Monobond PlusPrime & Bond XP + SCA

      (self-cure activator)
      Calibra

      RelyX Unicem2
      Block to Luting cement (n=24)μTBS MPa Light polymerized

      1200 mW/cm2 -60s +80s24h (37 °C) -Water

      5 °C-55 °C -10 000c
      Ilie et al, 2019
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      Tetric CAD HTSiC papers

      60,320, and600 grit
      N/AAdhese UniversalVariolink Esthetic LCBlock to Luting cement (n=24)μSBS MPa Light polymerized

      1313.60 (±11.41) mW/cm2 24 h (37 °C) -Water

      5 °C-55 °C -10 000c
      Ishii et al, 2017
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      Lava Ultimate Vita Enamic Vita Mark II32%H3PO4 -15s

      Al2O3

      40 μm/10s/10 mm/0.15 MPa

      Scotchbond Universal Etchant
      Scotchbond UAScotchbond UA

      Filtek Supreme Ultra - Flowable Restorative
      RelyX UltimateBlock to human molars (n=12)μTBS MPa Light polymerized

      700 mW/cm2 -5 ×20s24 h (37 °C) -Water

      37 °C -30 000c
      Kalavacharla et al, 2015
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      IPSe. max CADSiC papers –180/320 grit

      Al2O3 -0.5 μm/4x30s

      No treatment

      5% HF -20s9.5% HF -60s
      RelyX ceramic primerScotchbond UAZ100

      Composite resin
      Block to Composite resin

      (n=10)
      μSBS Light polymerized

      1200 mW/cm2 -4 ×20s24 h (37 °C) -Water
      Al2O3, aluminum oxide; c, cycle; d, day; h, hour; HF, hydrofluoric acid; H3PO4, phosphoric acid; H2SO4, sulfuric acid; m, month.
      N/A, not applied; Scotchbond UA, scotchbond universal adhesive; SiC, silica paper abrasive; s, second; w, week; y, year; ??, not displayed.
      Table 4Resumed data extraction from the selected in vitro studies
      Author, yMaterialSurface TreatmentCoupling AgentAdhesive SystemLuting CementSample PairingType of Test and Procedures
      Kassem et al,

      2020
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      Ceramill COMP

      CeraSmart
      5% HF -60 s Al2O3

      25 μm/?? s/?? MPa

      35% H3PO4 -None or 15 s
      Silane coupling agent Ceramic Primer IIScotchbond UA

      None on blocks (manufacturer’s recommendation)
      RelyX UltimateBlock to Human dentin (n=8)μ-TBS MPa

      Light polymerization

      Power not displayed – 20 s 5 °C-55 °C – 150 000 c
      Komoto et al,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.


      2021
      Vita Mark IIIDS

      Non-additional treatment Silane dry heating -20 s UV Light -20 s Visible Light -20 s
      Rely X Ceramic PrimerIDS

      (Scotchbond UA

      + Filtek Supreme Ultra Restorative)
      Rely X Unicem 2Block to human molars (n=12)μTBS MPa

      Light polymerized

      1560 mW/cm2 -2 ×20 s 24 h/30 d/90 d (37 °C) -Water
      Liebermann et al, 2018
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      Celtra Duo

      Initial LRF

      IPS e. max CAD Vita Mark II
      SiC papers – 500/1200

      9% HF 20, 30, or 60 s

      None (Monobond Etch&Prime)
      Monobond Etch & Prime

      G-Multi Primer

      One coat 7

      Scotchbond UA

      Prime & Bond Active
      All-Bond Universal

      Clearfil Universal G-Multi Primer

      iBond Universal One Coat 7 Universal
      Variolink Esthetic DCBlock to Luting cement (n=18)TBS MPa

      Light polymerized

      1200 mW/cm2 -20 s 24 h (37 °C) - Distilled water
      Lümkemann, 2020
      • Lumkemann N.
      • Schonhoff L.M.
      • Buser R.
      • Stawarczyk B.
      Effect of cleaning protocol on bond strength between resin composite cement and three different CAD/CAM materials.
      IPS e. max CAD

      IPS e.max ZirCAD LT Tetric CAD
      Al2O3 50 μm/10 s/0.1 MPa < 5% HF - 20s 37% H3PO4 -15sMonobond Plus

      Adhese Universal
      Adhese UniversalVariolink Esthetic DCBlock to Luting cement (n=90)TBS MPa

      Light polymerized

      1200 mW/cm2 – 20 s 24 h (37 °C) - Distilled water 5 °C-55 °C -20 000 c
      Monteiro et al, 2020
      • Monteiro R.V.
      • Dos Santos D.M.
      • Bernardon J.K.
      • De Souza G.M.
      Effect of surface treatment on the retention of zirconia crowns to tooth structure after aging.
      Lava Esthetic

      Fluorescent Full-Contour Zirconia
      Al2O3

      50 μm/10 s/10 mm/0.2 MPa SiO2-coated Al2O3 -30 μm/10 s/10 mm

      /0.2 MPa
      Scotchbond UAScotchbond UARelyX UltimateBlock to human molars

      (n=11)
      μTBS MPa

      Light polymerized

      1102 mW/cm2 – 80 s 24 h (37 °C) -Distilled water

      35 °C -240 000 c

      Thermal and pH cycling

      -10 000 c
      Murata et al, 2018
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      Vita Mark IIIDS

      40% H3PO4 -5 s
      PANAVIA V5 Tooth Primer

      Clearfil Ceramic Primer Plus Scotchbond UA
      IDS

      (Scotchbond UA

      + Filtek Supreme Ultra Restorative)
      Panavia V5Block to human molars

      (n=16)
      μTBS

      Light polymerized

      700 mW/cm2 – 5 ×20 s 30 min - (37 °C) - Water

      37 °C -30 000 c
      Murilo Gómez

      et al, 2017
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      IPS e.max ZirCAD LTAl2O3 50 μm/5 s/5 mm

      /0.2 MPa

      10% HF– 20 s
      None

      RelyX Ceramic Primer

      Clearfil Ceramic Primer

      Scotchbond UA
      Scotchbond UA

      Adper Single Bond Plus
      RelyX UltimateBlock to Luting cement (n=18)μSBS MPa

      Light polymerized

      600 mW/cm2 -40 s 24 h/6 m (37 °C) - Water
      Nejat et al,

      2018
      • Nejat A.H.
      • Lee J.
      • Shah S.
      • et al.
      Retention of CAD/CAM resin composite crowns following different bonding protocols.
      Experimental blockAl2O3

      50 μm/10 s/10 mm

      /0.28 MPa 5% HF – 20 s
      No primer

      Kerr Silane Primer

      Gluma

      (teeth)
      OptiBond XTR AdhesiveMaxcem EliteBlock to human molars

      (n=10)
      μSBS MPa

      Light polymerized

      1100 mW/cm2 – 10 s 1 h (37 °C) – Water

      24 °C/water -100 000 c
      Фilo et al,

      2015
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      Prettau Anterior (5Y-Z)

      Prettau Zirkon (3Y-Z)
      Diamond disc -20 μm grain (Control)

      Al2O3 50 μm/10 s/10 mm

      /0.25 MPa KHF2/10 min/280 °C
      Monobond Plus

      All-bond Universal

      Scotchbond UA

      OptiBond XTR
      Scotchbond UA

      Monobond Plus
      RelyX UnicemBlock to SDR Flow+ (n=10)μTBS MPa

      Auto (2 minutes) +

      light-cured - 5 ×20 s. Room temp. -15 minutes + 37 °C distilled water

      (24 ±2 h)
      Passia et al, 2015
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      IPS e.max CADSiC papers –600 grit

      5% HF – 20 s
      Monobond Plus

      All-bond Universal

      Scotchbond UA

      OptiBond XTR
      Monobond Plus

      All-bond Universal

      Scotchbond UA

      OptiBond XTR
      Multilink Automix

      Duo-Link

      RelyX Ultimate NX3
      Block to MultiCore Flow DC (n=8)μTBS MPa

      Light polymerized

      650 mW/cm2 – 40 s

      + (80 s lab curing unit) 3/30/150 d (37 °C) - Water

      5 °C-55 °C -7500 c

      37 500 times
      Peumans et al,

      2016
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      Celtra Duo IPS e.max CAD IPS Empress CAD Lava Ultimate Vita Enamic

      Vita Mark II
      SiC papers –320/600 grit

      Al2O3

      27 μm/20 s/10 mm

      /0.28 MPa

      SiO2-coated Al2O3

      -30 μm//20 s/10 mm

      /0.28 MPa

      < 5% HF
      Monobond Plus

      Heliobond
      N/AClearfil Esthetic Cement Panavia SA CementBlock to Block (n=5)μTBS MPa

      Light polymerized

      1100 mW/cm2 – 4 ×40 s

      +4 ×60 s 24 h (37 °C) -Distilled water

      1 w - micro specimens - Distilled water at 37 °C
      Rigos et al,

      2018
      • Rigos A.E.
      • Dandoulaki C.
      • Kontonasaki E.
      • Kokoti M.
      • Papadopoulou L.
      • Koidis P.
      Effect of immediate dentin sealing on the bond strength of monolithic zirconia to human dentin.
      BruxZirIDS

      SiC papers -800/1000/1200 grit

      Al2O3 50 μm/10 s/10 mm/

      0.3 MPa

      SiO2-coated Al2O3- 30 μm/10 s/10 mm/0.28 MPa

      37% H3PO4 -15 s
      Monobond SIDS

      (Optibond FL)
      Panavia F2.0 Perma Cem Dual SmartmixBlock to human molars

      (n=15)
      SBS MPa

      Light polymerized

      1250 mW/cm2 24 h (37 °C) -Distilled water
      Al2O3, aluminum oxide; c, cycle; d, day; h, hour; HF, hydrofluoric acid; H3PO4, phosphoric acid; H2SO4, sulfuric acid; IDS, immediate dentin sealing; KHF2 - potassium hydrogen difluoride; m, month.
      NaCl, sodium chloride; N/A, not applied; Scotchbond UA, scotchbond universal adhesive; SiC, silica paper abrasive; s, second; w, week; y, year; ??, not displayed.
      Table 5Resumed data extraction from the selected in vitro studies
      Author, yMaterialSurface TreatmentCoupling AgentAdhesive SystemLuting CementSample PairingType of Test and Procedures
      Roperto et al, 2016
      • Roperto R.
      • Akkus A.
      • Akkus O.
      • et al.
      Effect of different adhesive strategies on microtensile bond strength of computer aided design/computer aided manufacturing blocks bonded to dentin.
      Vita Mark II Paradigm34% H3PO4 -30 s (enamel) + 15 s (dentin)

      No treatment

      5% HF – 30 s Al2O3

      50 μm/5 s/5 mm/?? MPa
      Monobond Plus (2x 30 s)Primer and Bond NT + Bond Activator Clearfil SE Bond

      None
      Calibra Panavia F2.0 Smart Cem 2Block to freshly extracted human molars - γ radiation 24 h (37 °C) - Water (n=30)μTBS MPa

      Light polymerized

      Power not displayed

      2 ×20 s 24 h (37 °C) -Distilled water
      Sakrana and Özcan

      2017
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      Filtek Z250

      IPS e.max ZirCAD LT
      SiC paper -400 grit

      No treatment

      Al2O3

      50 μm/?? s/10 mm/0.2 Mpa Methylene chloride

      Experimental solution
      Monobond PlusN/ARelyX Ultimate AplicapBlock to Filtek Z250 (n=20)μTBS

      Light polymerization

      Power not displayed -20 s 24h (37 °C) -Distilled water

      Half of the sticks - no aging 5 °C-55 °C – 6000 c
      Shinohara et al, 2017
      • Shinohara A.
      • Taira Y.
      • Sawase T.
      Effects of tributylborane-activated adhesive and two silane agents on bonding computer-aided design and manufacturing (CAD/CAM) resin composite.
      Gradia BlockSiC paper – 600 grit 40% H3PO4 – 5 sMethyl methacrylate

      GC Ceramic Primer
      Scotchbond UAN/ABlock to Gradia Direct (n=8)μSBS MPa

      Light polymerized

      Power not displayed – 40 s 24 h (37 °C) - Water Thermocycling 60 °C -zero/10 000 c
      Siqueira et al, 2019
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      IPS e. max CAD5% HF

      None
      Monobond Plus

      Monobond Etch & prime
      Excite F DSDVariolink IIBlock to Luting cement μSBS - (n=20) Others - (n=12)μSBS MPa

      Light polymerized

      1200 mW/cm2 – 20 s 24 h/1 y (37 °C) -Water
      Silthampitag et al, 2016
      • Silthampitag P.
      • Chaijareenont P.
      • Tattakorn K.
      • Banjongprasert C.
      • Takahashi H.
      • Arksornnukit M.
      Effect of surface pretreatments on resin composite bonding to PEEK.
      PEEKSiC paper -400/2000 grit

      No treatment

      98% H2SO4 -60 s

      Piranha solution -30 s

      Al2O3 50 μm/10 s/10 mm

      /0.2 MPa
      HeliobondHelioBondFiltek Z350 XTBlock to Flowable composite resin (n=10)SBS MPa

      Light polymerized

      1000mW/cm2- 40s

      24h (37 °C) - Water
      Şişmanoğlu et al, 2020
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      Cera Smart Lava Ultimate Shofu Block HC Vita Enamic Vita Mark IINo treatment

      9% HF acid -60 s

      Al2O3 50 μm/?? s/10 mm

      /0.25 MPa

      SiO2-coated Al2O3

      30μ m/?? s/10 mm

      /0.25 MPa
      Clearfil Ceramic Primer PlusSingle Bond UniversalPanavia SA RelyX U200 TheraCemBlock to Luting cement (n=8)μSBS MPa

      Light polymerization

      1200 mW/cm2 -20 s

      5 °C-55 °C -zero and 5000 c
      Tekçe et al,

      2017
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      CeraSmart Lava Ultimate Vita EnamicSiC paper -600 grit

      No treatment Al2O3 27 μm/15 s/10 mm

      /0.25 MPa Al2O3 50 μm/15 s/10 mm

      /0.25 MPa SiO2-coated Al2O3

      30 μm/15 s/10 mm

      /0.25 MPa
      G - Multi PrimerN/AG-Cem LinkForceBlock to Block (n=30)μTBS MPa

      Light polymerized

      1200 mW/cm2 - 4 ×80 s 24 h (37 °C) -Distilled water
      Trindade et al, 2016
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      IPS e. max CAD IPS e.max Press Vita Mark II Vita PM9 Vita VM710% HF

      20 s (IPS e. max)

      or 60 s (Vita Mark II)

      35% H3PO4 – 15 s

      (enamel and dentin)
      Rely X Ceramic PrimerAdapter Single Bond -2 x

      Single Bond Universal
      Rely X ARCBlock to human maxillary premolars (n=10)μTBS MPa

      Light polymerized

      Power not displayed – 40 s 24 h (37 °C) -Distilled water

      37 °C - zero and 1 200 000 c
      Ustun and Ayaz,

      2020
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      Cerasmart Vita Enamic Vita SuprinityNo treatment

      37% H3PO4 – 15 s or 30 s

      5% HF

      60 s or 20 s (Suprinity)
      Ultradent Porcelain SilaneSingle Bond Universal AdhesiveRelyX Ultimate

      RelyX U200
      Block to human molars

      (n=7)
      μSBS MPa

      Light polymerized

      1000 mW/cm2 - 4x40 s Thermocycling

      (half samples)

      5 °C-55 °C – 5000 c
      Wu et al,

      2018
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      Lava UltimateSiC paper -600/1000 grit

      No treatment

      SiO2-coated Al2O3

      30 μm/20 s/10 mm

      /0.25 MPa

      Al2O3

      50 μm/20 s/10 mm

      /0.25 MPa
      None

      Porcelain Primer
      Single Bond Universal AdhesiveRely X Veneer Rely X Unicem 2Block to Pre-polymerized resin composite

      (Valux Plus) (n=15)
      μSBS

      Light polymerized

      Power not displayed

      6× 40 s

      5 °C-55 °C – zero/10 000 c + Aging – 90 d water
      Yazigi et al,

      2017
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      IPS e. max CADDiamond rotary instruments

      IDS

      37% H3PO4 – 30 s (enamel) + 15 s (dentin) or 0s (dentin)

      5% HF acid – 20 s

      Al2O3

      50μm/??s/10 mm

      /0.20 MPa
      Adhese Universal

      Monobond Plus
      Adhese UniversalVariolink Esthetic DCBlock to human premolars

      (n=8)
      μSBS Mpa

      Auto- and light polymerized

      Power not displayed – 20 s

      Aging -2 w (37 °C) -Water

      5 °C-55 °C – 1 200 000 c
      Al2O3, aluminum oxide; c, cycle; d, day; h, hour; HF, hydrofluoric acid; H3PO4, phosphoric acid; H2SO4, sulfuric acid; m, month; NaCl, sodium chloride.
      N/A, not applied; Scotchbond UA, scotchbond universal adhesive; SiC, silica paper abrasive; s, second; w, week; y, year; ??, not displayed.
      Table 6Resumed data extraction from the selected in vivo studies
      Author, yMaterialSurface TreatmentCoupling AgentAdhesive SystemLuting CementSample PairingType of Test
      Archibald et al, 2017
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      IPS e.max CAD

      IPS e.max Press
      10% HF -20 s

      35% H3PO4

      Rubber dam
      Monobond S 60 sMultilink Primer

      Excite DSC

      Scotchbond UA
      Variolink IIBlock to human molars

      30 patients

      37 restorations
      Restoration assessment - modified United States Public Health Service (USPHS) criteria

      Two independent investigators Dropouts - 42% Participants not coming into the clinic – via telephone or email
      Spitznagel et al,

      2018
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      Vita Enamic37% H3PO4

      40 s (enamel) + 15 s (dentin)

      Al2O3

      50 μm/?? s/?? mm/?? MPa

      4.9% HF -60 s

      Rubber dam
      Syntac Primer

      Monobond S 60 s
      Syntac Adhesive

      Heliobond
      Variolink IIBlock to human molars

      Prospective clinical

      5-y study

      48 patients

      103 restorations
      Block to human molars

      Prospective clinical

      5-y study

      48 patients

      103 restorations
      Claus-Peter,

      2015
      • Claus-Peter E.
      Innovative adhesive luting protocol. Case Study.
      IPS e.max Press5% HF -20 s

      No rubber dam
      Monobond Etch & PrimeAdhese UniversalVariolink Esthetic DCCase ReportEsthetic evaluation of anterior crowns after cementation
      Al2O3, aluminum oxide; HF, hydrofluoric acid; H3PO4, phosphoric acid; Scotchbond UA, scotchbond universal adhesive; s, second; m, month.
      Figure thumbnail gr2
      Figure 2CAD-CAM blocks in selected studies. CAD-CAM, computer-aided design and computer-aided manufacturing.
      Figure thumbnail gr4
      Figure 4Number of studies using each type of test. μSBS, microshear bond strength; μTBS, microtensile bond strength; SBS, shear bond strength; TBS, tensile bond strength.
      Figure thumbnail gr5
      Figure 5Light source intensity used for polymerization.
      Figure thumbnail gr6
      Figure 6Surface treatments in selected studies.
      Figure thumbnail gr7
      Figure 7Coupling agents in selected studies.
      Figure thumbnail gr8
      Figure 8Forest plot summarizing effect size between control protocols and all other tested protocols by CAD-CAM block, luting cement, and tooth surface treatment. CAD-CAM, computer-aided design and computer-aided manufacturing.
      Figure thumbnail gr9
      Figure 9Forest plot summarizing effect size by joint substrate.
      The meta-analysis combining the selected 28 articles,
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      ,
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      ,
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      ,
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      ,
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      ,
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      ,
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      • Lumkemann N.
      • Schonhoff L.M.
      • Buser R.
      • Stawarczyk B.
      Effect of cleaning protocol on bond strength between resin composite cement and three different CAD/CAM materials.
      ,
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      ,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      ,
      • Roperto R.
      • Akkus A.
      • Akkus O.
      • et al.
      Effect of different adhesive strategies on microtensile bond strength of computer aided design/computer aided manufacturing blocks bonded to dentin.
      ,
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      based on the difference between means and the effect size (P=.05; 95% CI; Z-value=1.9599) is represented in Figure 10. For the most tested blocks, best and worst adhesion protocols were identified (Table 7). Supplementary Tables 3 and 4 (available online) show more and less favorable protocols. Figure 11 shows the highest and lowest mean results obtained according to the test and joint substrate. Assessment of publication bias and heterogeneity is shown in Figures 12 and 13. The funnel plot asymmetry suggests an overestimation of the intervention effect, probably induced by the disparity between samples, with some possible bias. Studies that tested composite resin or luting cement as the second joint substrate and those that used microshear bond strength (μSBS) or microtensile bond strength (μTBS) tests had more publication bias. The Galbraith plot suggests an absence of substantial heterogeneity among the effect size (only 2 studies outside the 99.9% CI region). All studies had high precision (toward the right on the X-axis). Globally the studies were above the green line with the red line sloping upward, suggesting favorable tested protocols compared with the control protocol.
      Figure thumbnail gr10
      Figure 10Forest plot summarizing effect size by joint substrate, mechanical test, and bonding protocol by study and most tested blocks.
      Table 7Best and worst performance protocols for most tested CAD-CAM blocks
      Author, yCAD-CAM BlockSurface PretreatmentBlock Surface TreatmentCoupling AgentAdhesive SystemLuting CementMeanSDIlUlMechanical Test
      More favorable protocol
       Liebermann, 2018
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      Celtra DuoSiC -1200 gritNOMonobond Etch & PrimeNOVariolink Esthetic DC35.203.5031.7038.70TBS MPa
       Tekçe, 2017
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      CeraSmartSiC -600 gritAl2O3 50 μmG-Multi PrimerNOG-Cem LinkForce58.909.3547.0068.25μTBS MPa
       Elsayed, 2017
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      IPS e.max CADNO5% HFMonobond PlusNOVariolink Esthetic DC43.106.1037.0049.20SBS MPa
       Trindade, 2016
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      IPS e.max PressNO10% HFRelyX Ceramic PrimerNORelyX ARC5.401.304.106.70SBS MPa
       Sakrana and Özcan, 2017
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      IPS e.max ZirCADSiC -400 gritExperimental solutionMonobond PlusNORelyX Ultimate51.201.1050.1052.30SBS MPa
       Tekçe, 2017
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      Lava UltimateSiC -600 gritAl2O3 50 μmG-Multi PrimerNOG-Cem LinkForce73.904.0563.3377.95SBS MPa
       Abdou, 2021
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      Tetric CADNO9.6% HFClearfil Tri-S Bond ND Quick + Porcelain Bond ActivatorNOPanavia V577.909.7068.2087.60SBS MPa
       Tekçe, 2017
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      Vita EnamicSiC -600 gritAl2O3 50 μmG-Multi PrimerNOG-Cem LinkForce55.207.5348.2062.73SBS MPa
       Liebermann, 2018
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      Vita Mark IISiC -1200 grit9% HFG-Multi PrimerNOVariolink Esthetic DC36.406.7029.7043.10TBS MPa
      Less favorable protocol
       Frankenberger, 2015
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      Celtra DuoSiC -600 gritNONOPrime & Bond NT + ActivatorCalibra2.407.20-4.809.60SBS MPa
       Emsermann, 2019
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      CeraSmartSiC -180 grit5% HFUltradent SilaneNORelyX Unicem 21.630.501.132.13μSBS MPa
       Elsayed, 2017
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      IPS e.max CADNO5% HFNOAll-Bond UniversalDuo-Link Universal0.000.000.000.00SBS MPa
       Trindade, 2016
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      IPS e.max PressNO10% HFRelyX Ceramic PrimerAdper Single BondRelyX ARC3.601.302.304.90SBS MPa
       Sakrana and Özcan, 2017
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      IPS e.max ZirCADSiC -400 gritNOMonobond PlusNORelyX Ultimate5.100.504.605.60SBS MPa
       Emsermann, 2019
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      Lava UltimateSiC -180 gritNONONORelyX Unicem 21.760.261.502.02μSBS MPa
       Ilie, 2019
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      Tetric CADSiC -320 gritNONOAdhese UniversalVariolink Esthetic LC7.713.993.7211.70μTBS MPa
       Frankenberger, 2015
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      Vita EnamicSiC -600 gritNONOPrime & Bond NT + ActivatorCalibra0.000.000.000.00SBS MPa
       El-Damanhoury, 2017
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      Vita Mark IISiC -600 gritNONONOMultilink-N1.823.18-1.365.00μTBS MPa
      Al2O3, aluminum oxide; HF, hydrofluoric acid; il, inferior limit; ul - upper limit; NO, not used; SD, standard deviation; SiC, silica paper abrasive; μSBS, micro-shear bond strength; SBS, shear bond strength; μTBS, micro-tensile bond strength; TBS, tensile bond strength.
      Figure thumbnail gr11
      Figure 11Means by kind of test and substrate for mainly used blocks. μSBS, microshear bond strength; μTBS, microtensile bond strength; SBS, shear bond strength; TBS, tensile bond strength.
      Figure thumbnail gr12
      Figure 12Funnel plots of publication bias of all selected publications and filtered by joint substrate and mechanical test.
      Figure thumbnail gr13
      Figure 13Heterogeneity assessment among effect sizes.

      Discussion

      This review accessed whether in vitro findings concerning the strength of the bonding between CAD-CAM blocks and different substrates could be easily perceived by clinicians and incorporated into the daily clinical protocols, and was developed to integrate laboratory and clinical studies. Limiting the search to publications from the last 7 years restricted the review to materials used in contemporary clinical practice. Bias should not have occurred since, in the last 20 years, 70% of the articles were from that period. Based on the existing data (P<.05), the hypothesis that evidence-based efficacy for clinical protocols to adhere the different CAD-CAD blocks is still controversial, was accepted.
      Given the descriptive results (Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7), meta-analyses for each material subgroup were conducted. Still, as the technical protocol (specific sequence of technical steps) was the focus of this review, that methodology was abandoned, as the study would lose interest. Furthermore, as what should be chosen to be combined in a meta-analysis can be subjective and does not always fit into statistical solutions, after discussion, clinical judgment, and judicious consensus, a new meta-analysis focused on the best and worst adhesion protocols for each CAD-CAM block was carried out.
      The tested protocols identified (N=686), reflected the search for solutions to deliver long-lasting functional and esthetic restorative treatments dependent on a stable union between the restorative material and the dentin,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      ,
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      ,
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      ,
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      in a practical and rapid way, as proposed in the 2 clinical trials.
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      ,
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      However, the lack of systematization and standardization makes it difficult for clinicians to identify an evidence-based process that is easily reproducible in daily practice, as stated during the data extraction process (Table 3, Table 4, Table 5). Despite that, there was agreement among authors on the importance of using appropriate luting cement, surface conditioners, and bonding agents to obtain durable restorations.
      • Malysa A.
      • Wezgowiec J.
      • Orzeszek S.
      • Florjanski W.
      • Zietek M.
      • Wieckiewicz M.
      Effect of different surface treatment methods on bond strength of dental ceramics to dental hard tissues: A Systematic Review.
      ,
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      ,
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      ,
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      However, a survey
      • Klosa K.
      • Meyer G.
      • Kern M.
      Clinically used adhesive ceramic bonding methods: a survey in 2007, 2011, and in 2015.
      of German dentists showed the frequent use of inappropriate bonding methods, drawing attention to the benefit of establishing straightforward bonding protocols with clear evidence-based criteria.
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      A medium score of risk of bias in most articles is the probable cause of some bias confirmed by the funnel plots (Fig. 12). Globally, the articles were well structured. The 2 articles
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      ,
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      with no SJR score failed the 2021 criteria [Portal] (http://www.scimagojr.com)
      SCImago nd
      SJR. SCImago Journal & Country Rank.
      but were still published in open access journals and included in the directory of open access journals (DOAJ) [Portal](https://doaj.org/),
      DOAJ (Directory of Open Access Journals).
      a secure quality warranty for the clinician. Two studies
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      were excluded from the meta-analyses since the reported results did not allow a rigorous reading or statistical treatment.
      Matching in vitro with in vivo studies had evident limitations. Of the 2 in vivo observational studies, 1 used pressed ceramic IPS e.max and IPS e.max CAD,
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      and the other
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      used the Vita Enamic block. Also, these studies were not randomized and had a significant number of patient dropouts (42%
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      and 21.3%
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      at 3.5 and 3 years, respectively). The materials in these studies matched the most tested blocks of the 37 in vitro studies. RelyX Ultimate, Variolink Esthetic, and Variolink II were the luting materials used, corroborating the trend of choice either for in vitro or in vivo studies.
      Among the most in vitro tested blocks, IPS e.max CAD (lithium disilicate) >Vita Enamic (hybrid ceramic with a dual ceramic-polymer network structure) =LAVA Ultimate (80% nanoceramic resin) >Vita Mark II (reinforced nanoleucite crystals feldspathic porcelain), none require high-temperature crystallization, with no need for laboratory processing and facilitating in-office handling. Some tested in vitro protocols exposed dental laboratory technicians, clinicians, or patients to risk (high temperature, acids, or both), despite inducing the best mechanical performance for a specific material.
      • Öilo M.
      • Haugli K.
      • Ronold H.J.
      • Ulsund A.H.
      • Ruud A.
      • Kvam K.
      Pre-cementation procedures' effect on dental zirconias with different yttria content.
      ,
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      This entails pertinent guidelines for research with humans,
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      ,
      • Archibald J.J.
      • Santos Jr., G.C.
      • Moraes M.J.
      Retrospective clinical evaluation of ceramic onlays placed by dental students.
      possibly discouraging RCTs, a possible reason for finding only 2 observational studies.
      Tests assessing strength varied, consistent with the literature,
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      as did the protocols simulating aging or bonding failure. The choice of the best CAD-CAM block-adhesive system pair for clinical use was complex, as referred to in 1 article.
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      TBS and SBS tests, popular for 7-to 28-mm2 bonded areas, are larger than intraoral dimensions.
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      μSBS and μTBS tests, which improve factors related to cohesive failures in areas larger than 2 square millimeters
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      and lower failure coefficients,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      were found at most. One study used SBS and μTBS sequentially,
      • de Oliveira Lino L.F.
      • Machado C.M.
      • de Paula V.G.
      • et al.
      Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
      while the others used SBS,
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      ,
      • Ilie N.
      • Ruse N.D.
      Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
      ,
      • Rigos A.E.
      • Dandoulaki C.
      • Kontonasaki E.
      • Kokoti M.
      • Papadopoulou L.
      • Koidis P.
      Effect of immediate dentin sealing on the bond strength of monolithic zirconia to human dentin.
      ,
      • Silthampitag P.
      • Chaijareenont P.
      • Tattakorn K.
      • Banjongprasert C.
      • Takahashi H.
      • Arksornnukit M.
      Effect of surface pretreatments on resin composite bonding to PEEK.
      TBS,
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      ,
      • Lumkemann N.
      • Schonhoff L.M.
      • Buser R.
      • Stawarczyk B.
      Effect of cleaning protocol on bond strength between resin composite cement and three different CAD/CAM materials.
      μSBS,
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      ,
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      ,
      • Dos Santos R.A.
      • de Lima E.A.
      • Mendonca L.S.
      • et al.
      Can universal adhesive systems bond to zirconia?.
      ,
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      ,
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      ,
      • Nejat A.H.
      • Lee J.
      • Shah S.
      • et al.
      Retention of CAD/CAM resin composite crowns following different bonding protocols.
      ,
      • Shinohara A.
      • Taira Y.
      • Sawase T.
      Effects of tributylborane-activated adhesive and two silane agents on bonding computer-aided design and manufacturing (CAD/CAM) resin composite.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      ,
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      or μTBS
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      ,
      • Abdou A.
      • Takagaki T.
      • Alghamdi A.
      • Tichy A.
      • Nikaido T.
      • Tagami J.
      Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
      ,
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      ,
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      ,
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      ,
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      ,
      • Monteiro R.V.
      • Dos Santos D.M.
      • Bernardon J.K.
      • De Souza G.M.
      Effect of surface treatment on the retention of zirconia crowns to tooth structure after aging.
      ,
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      ,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      ,
      • Roperto R.
      • Akkus A.
      • Akkus O.
      • et al.
      Effect of different adhesive strategies on microtensile bond strength of computer aided design/computer aided manufacturing blocks bonded to dentin.
      ,
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      ,
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      ,
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      tests. The option for a specific test was more likely a researcher’s preference rather than a universal analysis standard.
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      No temporal association was found between the type of test and year of publication, neither with the material tested nor the paired adhered materials. Tests with human teeth showed a lower difference between the means (Fig. 11) with the worst adhesive performances. The highest absolute values were more dependent on the paired joint substrates and tested protocols than on the test performed.
      Protocols simulating aging or material fatigue differed among studies concerning thermocycling, ranging from 5000
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      ,
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      to 1 200 000
      • Trindade F.Z.
      • Kleverlaan C.J.
      • da Silva L.H.
      • et al.
      Ceramic Inlays: Effect of mechanical cycling and ceramic type on restoration-dentin bond strength.
      cycles, with different moisture and temperature conditions for the same test. Specimens were kept in water, not reproducing the dynamic oral environment (temperature, saliva baths, occlusal loads, or eventual parafunctional habits).
      • Kassem I.A.
      • Farrag I.E.
      • Zidan S.M.
      • ElGuindy J.F.
      • Elbasty R.S.
      Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
      ,
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      ,
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      ,
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      Storage in nonspecified water, deionized water, distilled water, or saline solution was identified. Initial storage was usually 24 hours, except in 4 studies (30 minutes,
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      1 hour,
      • Nejat A.H.
      • Lee J.
      • Shah S.
      • et al.
      Retention of CAD/CAM resin composite crowns following different bonding protocols.
      3 days,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      and 2 weeks
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      ). If the effect of aging was a research purpose, subsequent storage varied from 30 days
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      ,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      to 1 year,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      with intermediate intervals of 3,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      5,
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      ,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      and 6 months
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      ,
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      ,
      • Wu X.
      • Xie H.
      • Meng H.
      • et al.
      Effect of tribochemical silica coating or multipurpose products on bonding performance of a CAD/CAM resin-based material.
      A convergence for the objective temperature (37 oC) was found. Wavelengths in light-polymerizing protocols were 650 to 1560 mW/cm2 (1200 mW/cm2 in approx. 67.5% of the studies), and polymerization times were 20 seconds
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      to 400 seconds,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      variations that confuse clinicians are clinically questionable in terms of time expenditure (7 minutes per tooth) and potential pulp injury.
      • Lynch C.D.
      • Roberts J.L.
      • Al-Shehri A.
      • Milward P.J.
      • Sloan A.J.
      An ex-vivo model to determine dental pulp responses to heat and light-curing of dental restorative materials.
      The number of available materials makes it impossible to test all of them at the same time, forcing researchers to restrict testing, a limitation because, even though a dual-polymerizing composite resin cement is the standard for adhesive cementation, different brands have different properties and components.
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      ,
      • Liebermann A.
      • Detzer J.
      • Stawarczyk B.
      Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
      ,
      • Siqueira F.S.F.
      • Campos V.S.
      • Wendlinger M.
      • et al.
      Effect of self-etching primer associated to hydrofluoric acid or silane on bonding to lithium disilicate.
      These differences were the main reason for subgrouping the cements and CAD-CAM blocks by the authors. Researchers select some materials over others, reflecting the choice for more user-friendly materials. The most tested luting cement was Rely X Ultimate,
      • Sismanoglu S.
      • Gurcan A.T.
      • Yildirim-Bilmez Z.
      • Turunc-Oguzman R.
      • Gumustas B.
      Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
      ,
      • Peumans M.
      • Valjakova E.B.
      • De Munck J.
      • Mishevska C.B.
      • Van Meerbeek B.
      Bonding effectiveness of luting composites to different CAD/CAM materials.
      ,
      • Ceci M.
      • Pigozzo M.
      • Scribante A.
      • et al.
      Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
      ,
      • Cardenas A.M.
      • Siqueira F.
      • Hass V.
      • et al.
      Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
      ,
      • Murillo-Gomez F.
      • Rueggeberg F.A.
      • De Goes M.F.
      Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
      ,
      • Elsaka S.E.
      • Elnaghy A.M.
      Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
      ,
      • Demirel G.
      • Baltacioglu I.H.
      Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
      ,
      • El-Damanhoury H.M.
      • Gaintantzopoulou M.D.
      Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
      • Elsayed A.
      • Younes F.
      • Lehmann F.
      • Kern M.
      Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
      • Emsermann I.
      • Eggmann F.
      • Krastl G.
      • Weiger R.
      • Amato J.
      Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
      • Frankenberger R.
      • Hartmann V.E.
      • Krech M.
      • et al.
      Adhesive luting of new CAD/CAM materials.
      ,
      • Ishii N.
      • Maseki T.
      • Nara Y.
      Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
      ,
      • Kalavacharla V.K.
      • Lawson N.C.
      • Ramp L.C.
      • Burgess J.O.
      Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
      ,
      • Komoto M.
      • Maseki T.
      • Nara Y.
      The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
      ,
      • Monteiro R.V.
      • Dos Santos D.M.
      • Bernardon J.K.
      • De Souza G.M.
      Effect of surface treatment on the retention of zirconia crowns to tooth structure after aging.
      ,
      • Murata T.
      • Maseki T.
      • Nara Y.
      Effect of immediate dentin sealing applications on bonding of CAD/CAM ceramic onlay restoration.
      ,
      • Passia N.
      • Lehmann F.
      • Freitag-Wolf S.
      • Kern M.
      Tensile bond strength of different universal adhesive systems to lithium disilicate ceramic.
      ,
      • Sakrana A.A.
      • Özcan M.
      Effect of chemical etching solutions versus air abrasion on the adhesion of self-adhesive resin cement to IPS e.max ZirCAD with and without aging.
      ,
      • Tekce N.
      • Tuncer S.
      • Demirci M.
      • Kara D.
      • Baydemir C.
      Microtensile bond strength of CAD/CAM resin blocks to dual-cure adhesive cement: The effect of different sandblasting procedures.
      ,
      • Ustun S.
      • Ayaz E.A.
      Effect of different cement systems and aging on the bond strength of chairside CAD-CAM ceramics.
      ,
      • Yazigi C.
      • Kern M.
      • Chaar M.S.
      Influence of various bonding techniques on the fracture strength of thin CAD/CAM-fabricated occlusal glass-ceramic veneers.
      ,
      • Spitznagel F.A.
      • Scholz K.J.
      • Strub J.R.
      • Vach K.
      • Gierthmuehlen P.C.
      Polymer-infiltrated ceramic CAD/CAM inlays and partial coverage restorations: 3-year results of a prospective clinical study over 5 years.
      ,
      • Claus-Peter E.
      Innovative adhesive luting protocol. Case Study.
      probably because it combines dual polymerization with the possibility of total-etch, selective-etch, or self-etch adhesive strategies. However, the chosen materials may have been conditioned by research support from the manufacturer or by the clinical preference of the researcher.

      Conclusions

      Based on the findings of this systematic integrative review and meta-analysis, the following conclusions were drawn:
      • 1.
        Despite the objective standards for the individual in vitro tests, a lack of standardization for each technical step was evident.
      • 2.
        Some tested protocols were more efficient than others for each CAD-CAM block.
      • 3.
        The number of protocols found makes selecting the most suitable protocol for each block or clinical situation difficult for the clinician.
      • 4.
        Randomized clinical trials were nonexistent, and well-documented clinical situations were scarce, making the inference of direct application of in vitro findings into clinical practice impossible.
      • 5.
        Based on the data collected, a rapid and efficient translation from in vitro scientific evidence to clinical practice is a complex and time-consuming task.

      CRediT authorship contribution statement

      Maria João Calheiros-Lobo: Conceptualization, Methodology, Investigation, Software, Formal analysis, Writing – original draft. Ricardo Carbas: Formal analysis, Investigation, Visualization, Writing – review & editing. Lucas F.M. da Silva: Supervision, Validation, Writing – review & editing. Teresa Pinho: Investigation, Formal analysis, Writing – review & editing, Supervision, Project administration.

      Acknowledgments

      The authors thank, Dr Denis Lopes, from the Dental Medicine Department, University Institute of Health Sciences, IUCS - CESPU, Gandra, Portugal, as a participating investigator for his contribution to collecting and organizing the data.

      Supplementary data

      References

        • Hardan L.
        • Bourgi R.
        • Cuevas-Suárez C.E.
        • et al.
        The bond strength and antibacterial activity of the universal dentin bonding system: A systematic review and meta-Analysis.
        Microorganisms. 2021; 9: 1231-1245
        • Scaminaci Russo D.
        • Cinelli F.
        • Sarti C.
        • Giachetti L.
        Adhesion to zirconia: A systematic review of current conditioning methods and bonding materials.
        Dent J. 2019; 7: 1-19
        • Sismanoglu S.
        • Gurcan A.T.
        • Yildirim-Bilmez Z.
        • Turunc-Oguzman R.
        • Gumustas B.
        Effect of surface treatments and universal adhesive application on the microshear bond strength of CAD/CAM materials.
        J Adv Prosthodont. 2020; 12: 22-32
        • Skorulska A.
        • Piszko P.
        • Rybak Z.
        • Szymonowicz M.
        • Dobrzyński M.
        Review on polymer, ceramic and composite materials for CAD/CAM indirect restorations in Dentistry - Application, mechanical characteristics and comparison.
        Materials. 2021; 14: 1592
        • Zarone F.
        • Ruggiero G.
        • Leone R.
        • Breschi L.
        • Leuci S.
        • Sorrentino R.
        Zirconia-reinforced lithium silicate (ZLS) mechanical and biological properties: A literature review.
        J Dent. 2021; 109: 103661
        • Peumans M.
        • Valjakova E.B.
        • De Munck J.
        • Mishevska C.B.
        • Van Meerbeek B.
        Bonding effectiveness of luting composites to different CAD/CAM materials.
        J Adhes Dent. 2016; 18: 289-302
        • Ahmed W.M.
        • Troczynski T.
        • McCullagh A.P.
        • Wyatt C.C.L.
        • Carvalho R.M.
        The influence of altering sintering protocols on the optical and mechanical properties of zirconia: A review.
        J Esthet Restor Dent. 2019; 31: 423-430
        • Bin-Shuwaish M.S.
        • AlFawaz Y.F.
        • AlGamaiah H.A.
        • et al.
        Technical Accuracy of Dental Laboratories in the Quality and Shade Matching of Porcelain Fused to Metal Crowns: An In Vitro Study.
        Int J Env Res Public Health. 2021; 18: 2722
        • Silva L.H.D.
        • Lima E.
        • Miranda R.B.P.
        • Favero S.S.
        • Lohbauer U.
        • Cesar P.F.
        Dental ceramics: a review of new materials and processing methods.
        Braz Oral Res. 2017; 31: e58
        • Spitznagel F.A.
        • Boldt J.
        • Gierthmuehlen P.C.
        CAD/CAM Ceramic Restorative Materials for Natural Teeth.
        J Dent Res. 2018; 97: 1082-1091
        • Ceci M.
        • Pigozzo M.
        • Scribante A.
        • et al.
        Effect of glycine pretreatment on the shear bond strength of a CAD/CAM resin nano ceramic material to dentin.
        J Clin Exp Dent. 2016; 8: e146-e152
        • Sola-Ruiz M.F.
        • Baima-Moscardo A.
        • Selva-Otaolaurruchi E.
        • et al.
        Wear in antagonist teeth produced by monolithic zirconia crowns: A systematic review and meta-analysis.
        J Clin Med. 2020; 9: 997
        • Cardenas A.M.
        • Siqueira F.
        • Hass V.
        • et al.
        Effect of MDP-containing silane and adhesive used alone or in combination on the long-term bond strength and chemical interaction with lithium disilicate ceramics.
        J Adhes Dent. 2017; 19: 203-212
        • Malysa A.
        • Wezgowiec J.
        • Orzeszek S.
        • Florjanski W.
        • Zietek M.
        • Wieckiewicz M.
        Effect of different surface treatment methods on bond strength of dental ceramics to dental hard tissues: A Systematic Review.
        Molecules. 2021; 26: 1223
        • Quigley N.P.
        • Loo D.S.S.
        • Choy C.
        • Ha W.N.
        Clinical efficacy of methods for bonding to zirconia: A systematic review.
        J Prosthet Dent. 2021; 125: 231-240
        • Murillo-Gomez F.
        • Rueggeberg F.A.
        • De Goes M.F.
        Short- and long-Term bond strength between resin cement and glass-ceramic using a silane-containing universal adhesive.
        Oper Dent. 2017; 42: 514-525
        • Öilo M.
        • Haugli K.
        • Ronold H.J.
        • Ulsund A.H.
        • Ruud A.
        • Kvam K.
        Pre-cementation procedures' effect on dental zirconias with different yttria content.
        Dent Mater. 2021; 37: 1425-1436
        • Elsaka S.E.
        • Elnaghy A.M.
        Effect of Surface Treatment and aging on bond strength of composite cement to novel CAD/CAM nanohybrid composite.
        J Adhes Dent. 2020 2020; 22: 195-204
        • Page M.J.
        • Moher D.
        • Bossuyt P.M.
        • et al.
        PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews.
        BMJ. 2021; 372: n160
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Abdou A.
        • Takagaki T.
        • Alghamdi A.
        • Tichy A.
        • Nikaido T.
        • Tagami J.
        Bonding performance of dispersed filler resin composite CAD/CAM blocks with different surface treatment protocols.
        Dent Mater J. 2021; 40: 209-219
        • de Oliveira Lino L.F.
        • Machado C.M.
        • de Paula V.G.
        • et al.
        Effect of aging and testing method on bond strength of CAD/CAM fiber-reinforced composite to dentin.
        Dent Mater. 2018; 34: 1690-1701
        • Demirel G.
        • Baltacioglu I.H.
        Influence of different universal adhesives on the repair performance of hybrid CAD-CAM materials.
        Restor Dent Endod. 2019; 44: e23
        • Dos Santos R.A.
        • de Lima E.A.
        • Mendonca L.S.
        • et al.
        Can universal adhesive systems bond to zirconia?.
        J Esthet Restor Dent. 2019; 31: 589-594
        • El-Damanhoury H.M.
        • Gaintantzopoulou M.D.
        Self-etching ceramic primer versus hydrofluoric acid etching: Etching efficacy and bonding performance.
        J Prosthodont Res. 2017; 62: 75-83
        • Elsayed A.
        • Younes F.
        • Lehmann F.
        • Kern M.
        Tensile bond strength of so-called universal primers and universal multimode adhesives to zirconia and lithium disilicate ceramics.
        J Adhes Dent. 2017; 19: 221-228
        • Emsermann I.
        • Eggmann F.
        • Krastl G.
        • Weiger R.
        • Amato J.
        Influence of pretreatment methods on the adhesion of composite and polymer infiltrated ceramic CAD-CAM blocks.
        J Adhes Dent. 2019; 21: 433-443
        • Frankenberger R.
        • Hartmann V.E.
        • Krech M.
        • et al.
        Adhesive luting of new CAD/CAM materials.
        Int J Comput Dent. 2015; 18: 9-20
        • Ilie N.
        • Ruse N.D.
        Shear bond strength vs interfacial fracture toughness - Adherence to CAD/CAM blocks.
        Dent Mater. 2019; 35: 1769-1775
        • Ishii N.
        • Maseki T.
        • Nara Y.
        Bonding state of metal-free CAD/CAM onlay restoration after cyclic loading with and without immediate dentin sealing.
        Dent Mater J. 2017; 36: 357-367
        • Kalavacharla V.K.
        • Lawson N.C.
        • Ramp L.C.
        • Burgess J.O.
        Influence of etching protocol and silane treatment with a universal adhesive on lithium disilicate bond strength.
        Oper Dent. 2015; 40: 372-378
        • Kassem I.A.
        • Farrag I.E.
        • Zidan S.M.
        • ElGuindy J.F.
        • Elbasty R.S.
        Marginal gap and fracture resistance of CAD/CAM ceramill COMP and cerasmart endocrowns for restoring endodontically treated molars bonded with two adhesive protocols: an in vitro study.
        Biomater Investig Dent. 2020; 7: 50-60
        • Komoto M.
        • Maseki T.
        • Nara Y.
        The effect of additional photochemical treatments on the bonding of silanized CAD/CAM ceramic restorations after water-storage.
        Odontology. 2021; 109: 58-95
        • Liebermann A.
        • Detzer J.
        • Stawarczyk B.
        Impact of recently developed universal adhesives on tensile bond strength to computer-aided design/manufacturing ceramics.
        Oper Dent. 2019; 44: 386-395