10.59987/ads/2024.1.27-38
BackgroundSaliva contamination during the try-in procedure is one of the leading causes of decreased bond strength of resin to zirconia. In this meta-analysis, we evaluated the effects of different cleaning methods on the bond strength of the zirconia restoration.MethodsA systematic search was performed through MEDLINE via PubMed, EMBASE, Scopus, ISI web of knowledge, and Cochrane databases. In vitro articles in which the cleaning methods were compared with contaminated and non-contaminated surfaces were selected for this study. The duration of storage was separated into two subgroups of &lt;1 and &gt;1 week.ResultsOut of 909 results of database searches, 15 studies were included in the systematic review. In the storage period of &lt;1 week, there were significant differences between the saliva-contaminated, decontamination with air abrasion (SDM: 2.478, P&lt;0.01), and Ivoclean (SDM: 3.055, P&lt;0.01) groups. Also, in the storage period of &gt;1 week, significant differences were observed between air abrasion (SDM: 2.714, P&lt;0.01), Ivoclean (SDM: 2.575, P&lt;0.01), and argon plasma (SDM: 1.998, P&lt;0.01) groups. There was a significant difference between non-contaminated and isopropanol (&lt;1 week storage period: SDM: -3.252, P=0.05; &gt;1 week storage period; SDM: -1.302, P&lt;0.01) and phosphoric acid (&lt;1 week storage period: SDM: -1.584, P&lt;0.01; storage period &gt;1 week; SDM: -2.021, P&lt;0.01) decontaminated groups.ConclusionSandblasting with airborne-particle abrasion (Al2O3), Ivoclean, and argon plasma has been effective in recovering the bond strength of resin to saliva-contaminated zirconia, while bond strength of decontaminated surface with alcohol and phosphoric acid is significantly weaker than in non-contaminated situations.
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Tahereh  Parhizkar
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Annali di stomatologia
zirconia
Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies
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Tahereh  Parhizkar
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Postgraduate student, Department of Operative Dentistry, Mashhad Dental School, Mashhad University of Medical Sciences, Mashhad, Iran
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zirconia
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38
Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies
https://www.annalidistomatologia.eu/ads/article/view/285/296
15
Effect of Different Cleaning Methods
on Bond Strength of Resin to Saliva-
Contaminated Zirconia: A Systematic
Review and Meta-analysis of in Vitro
Studies

                                                                                           Authors
Alireza Sarraf Shirazi1
                                                                                           Alireza Sarraf Shirazi - Professor,
Sara Majidinia2                                                                            Department of Pediatric
Tahereh Parhizkar3                                                                         Dentistry, Mashhad University of Medical
                                                                                           Sciences, Masshad, Iran ORCID:
1
  Professor, Department of Pediatric Dentistry, Mashhad University of Medical Sciences,    0000-0001-6539-5478
Masshad, Iran ORCID: 0000-0001-6539-5478
                                                                                           Sara Majidinia - Assistant Professor,
2
  Assistant Professor, Dental Research Center, Department of Operative Dentistry, Mash-    Dental Research Center, Department
had Dental School, Mashhad University of Medical Sciences, Mashhad, IranORCID:             of Operative Dentistry, Mashhad Dental
0000-0002-7601-114X                                                                        School, Mashhad University of Medical
3
  Postgraduate student, Department of Operative Dentistry, Mashhad Dental School,          Sciences, Mashhad, IranORCID:
Mashhad University of Medical Sciences, Mashhad, Iran                                      0000-0002-7601-114X
                                                                                           Tahereh Parhizkar - Postgraduate
                                                                                           student, Department of Operative
Corresponding author: Tahereh Parhizkar                                                    Dentistry, Mashhad Dental School,
E-mail: Tahereh_parhizkar@yahoo.com                                                        Mashhad University of Medical Sciences,
                                                                                           Mashhad, Iran

ABSTRACT
Background
Saliva contamination during the try-in procedure is one of the leading causes of           License
decreased bond strength of resin to zirconia. In this meta-analysis, we evaluated          This work is licensed under a Creative
the effects of different cleaning methods on the bond strength of the zirconia res-        Commons Attribution-NonCommercial-
toration.                                                                                  NoDerivatives 4.0 International License.

                                                                                           Authors contributing to Annali di
Methods                                                                                    Stomatologia agree to publish
A systematic search was performed through MEDLINE via PubMed, EMBASE, Sco-                 their articles under the Creative
pus, ISI web of knowledge, and Cochrane databases. In vitro articles in which the          Commons Attribution-NonCommercial-
                                                                                           NoDerivatives 4.0 International License,
cleaning methods were compared with contaminated and non-contaminated sur-                 which allows third parties to copy and
faces were selected for this study. The duration of storage was separated into two         redistribute the material providing
subgroups of <1 and >1 week.                                                               appropriate credit and a link to the
                                                                                           license but does not allow to use the
                                                                                           material for commercial purposes and to
Results                                                                                    use the material if it has been remixed,
Out of 909 results of database searches, 15 studies were included in the system-           transformed or built upon.
atic review. In the storage period of <1 week, there were significant differences
                                                                                           How to Cite
between the saliva-contaminated, decontamination with air abrasion (SDM: 2.478,            A Sarraf Shirazi, S Majidinia, T Parhizkar.
P<0.01), and Ivoclean (SDM: 3.055, P<0.01) groups. Also, in the storage period of          Effect of Different Cleaning Methods
>1 week, significant differences were observed between air abrasion (SDM: 2.714,           on Bond Strength of Resin to Saliva-
P<0.01), Ivoclean (SDM: 2.575, P<0.01), and argon plasma (SDM: 1.998, P<0.01)              Contaminated Zirconia: A Systematic
groups. There was a significant difference between non-contaminated and isopro-            Review and Meta-analysis of in Vitro
                                                                                           Studies
panol (<1 week storage period: SDM: -3.252, P=0.05; >1 week storage period; SDM:
                                                                                           Annali Di Stomatologia, 15(1), 27-38.
-1.302, P<0.01) and phosphoric acid (<1 week storage period: SDM: -1.584, P<0.01;          https://doi.org/10.59987/ads/2024.1.27-38
storage period >1 week; SDM: -2.021, P<0.01) decontaminated groups.

Conclusion
Sandblasting with airborne-particle abrasion (Al2O3), Ivoclean, and argon plasma has
been effective in recovering the bond strength of resin to saliva-contaminated zirconia,
while bond strength of decontaminated surface with alcohol and phosphoric acid is sig-
nificantly weaker than in non-contaminated situations.

Key words: Bond strength, cleaning, saliva contamination, zirconia.


10.59987/ads/2024.1.27-38                                                                                               27
     Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies

     Introduction                                                                      ramic, which was superior to isopropanol and phosphoric
                                                                                       acid in a previous study by Yang et al (9).
     Recently, the use of the high-strength ceramic mate-                              This meta-analysis evaluated the effects of different
     rial yttrium-oxide-partially-stabilized zirconia (YPSZ)                           cleaning methods on the shear bond strength of zirco-
     ceramic, as a restorative dental material, has gained                             nia restorations contaminated with saliva.
     tremendous interest in dentistry. Considering the ad-
     vantages of zirconia, such as esthetic, biocompatibil-
                                                                                       METHODS
     ity, mechanical characteristics, and excellent optical
     behavior, it is used in implants, implant abutments all-                          This study was conducted based on the Preferred Re-
     ceramic crowns and bridges, all-ceramic post and core                             porting Items for Systematic Reviews and Meta-Analy-
     systems, and for single and/or multi-unit fixed dental                            ses (PRISMA) statement (10). The PICOS was identified
     prostheses (1). In addition, the application of the ce-                           as Table 1.
     mentation process between the tooth and restoration
     plays an important role in the clinical success of zirco-                         Search strategy
     nia restorations.
     Although recently there have been advances in ad-                                 We electronically searched MEDLINE via PubMed, EM-
     hesive promotors, the use of resin-bonded minimal                                 BASE, Scopus, ISI Web of Science, and Cochrane da-
     invasive restorations in reconstructive dentistry has                             tabases using the search strategy of (Zirconia OR zirco-
     increased significantly. Adhesive resin cements have                              nium OR Ceramic OR Ceramics OR 3Y-TZP OR CAD/
     become popular because they increase retention and                                CAM OR CAD-CAM) AND (Contamination OR Clean-
     marginal adaptability (2). However, the bonding sur-                              ing OR Decontamination OR Cleansing) AND ((Bond
     face is prone to contamination and moisture, leading                              strength) OR Bonding OR Adhesion OR Adhesive OR
     to decreased bond strength; it is difficult to avoid the                          Adhesives OR μTBS) on 7 February 2021 without time
     contamination of the bonding interface (3).                                       and language limitation.
     Before adjusting the restoration, there is a need for a
     try-in procedure to achieve optimal fixation. During this                         Eligibility criteria
     procedure, the bonding surface might become contam-                               The inclusion criteria for this study were:
     inated by silicone indicators, blood, or saliva. Among                            1. A comparison of bond strengths between a cleaning
     them, saliva contamination is one of the main causes                                   method and a control group
     of decreased bond strength (4). Zirconium shows a                                 2. Zirconia-adjusted ceramics
     strong affinity for the phosphate groups found in saliva,                         3. Zirconia ceramics which were contaminated with
     which react with the zirconia surface (5). Hence, sever-                               saliva
     al cleaning methods have been studied to clean these                              4. The studies used appropriate statistical tests to an-
     contaminations and prepare an appropriate bonding
                                                                                            alyze the bond strength data and the sample size.
     surface for clinically successful restoration. Cleaning
                                                                                            P-values, means, and standard deviations were re-
     with water, alcohol (70% to 96% isopropanol), phos-
                                                                                            ported in the results.
     phoric acid, a newly introduced product Ivoclean, plas-
     ma, and additional airborne particle abrasion (Al2O3)
                                                                                       Study selection and data extraction
     are some of the well-known methods used to remove
     zirconia surface contamination (6).                                               The results of the searches were imported into the End-
     Both acid etching and alkaline-based agents can be used                           Note application, and after removing duplicated studies,
     as chemical cleaning methods. Previous studies have re-                           two authors (SM and TP) independently screened the
     ported that sandblasting with Al2O3 and chemical clean-                           articles based on titles and abstracts. Studies that did
     ing methods like Ivoclean are effective methods in recov-                         not meet the inclusion criteria in titles or abstracts were
     ering the bond strength (7). Studies have claimed that                            excluded from the study. In case of any disagreement, it
     acid-based methods can recover the bond strength, but                             was resolved after discussion or by an expert research-
     phosphoric acid leaves a phosphorous residue that can                             er’s (AS) comment. Afterward, possible related studies
     weaken the resin-cement bond (8). Also, airborne par-                             were investigated in the full-text stage. For complete
     ticle abrasion is recommended as an effective method                              coverage of published studies, the reference list of each
     in recovering the strength of resin bonds to zirconia ce-                         article was also checked. Finally, the data regarding the



     Table 1. Search strategy using PICOs analysis
                                                                                  Definition

      Participants                                                                Zirconia restorations

      Innervation                                                                 Different cleaning methods

      Comparison                                                                  Contaminated/non contaminated zirconia

      Outcomes                                                                    Bond strength

      Study design                                                                Invitro studies




28                                                                                                                                 10.59987/ads/2024.1.27-38
A.Sarraf Shirazi et al.

type of intervention, duration of the storage period, the        Risk of bias assessments
comparison, and the bond strengths from each study
were extracted using a data extraction table.                    The risk of bias was assessed in terms of randomization,
The authors of articles with insufficient data were con-         use of the material according to instructions, sample size
tacted via e-mail to receive the missing data and infor-         calculation, identical interventions other than the inter-
mation. If no response was received within two weeks             vention of interest, same operator outcome measure-
of the initial e-mail contact, a second e-mail was sent.         ments, and blinding of outcome assessors. Papers that
One month after the first contact, the article was ex-           reported one or two items were classified as high risk of
cluded if no reply or an incomplete reply was received           bias, with three or four as medium risk and five to six as
from the authors.                                                low risk.
All the eligible articles were compared with contami-
nated and non-contaminated surfaces according to the             Statistics
cleaning methods (including air abrasion, isopropanol,           The statistical analyses were conducted using the com-
Ivoclean, phosphoric acid, argon plasma, and sodium              prehensive meta-analysis 2 (CMA2) software with 95
hypochlorite). The duration of storage was categorized           confidence intervals and an 0.05 level of significance
into two subgroups of <1 and >1 week. A summary of               for P-value. The outcomes were reported as standard-
the included studies is presented in Table 2                     ized differences in means (SDM) between the interven-



Table 2. The summary of eligible studies in this meta analysis
                                                                                       Type of bond       Duration
 First author, year         Country       Cleaning method         Cement type
                                                                                       strength           of storage
                                          Air abrasion
 Farahnaz                                                                                                 < 1 week
                            Iran          Isopropanol             3M ESPE              Shear
 Nejatidanesh 2018                                                                                        >1 week
                                          Ivoclean
                                          Air abrasion                                                    < 1 week
 Da-Hye Kim, 2015           Korea                                 Panavia F2           Shear
                                          Ivoclean                                                        >1 week
                                          Isopropanol                                                     < 1 week
 Christoph Piest, 2018      Germany                               Panavia 21           Tensile
                                          Argon plasma                                                    >1 week
 Philip Guers, 2019         Germany       Isopropanol             Panavia 21           Tensile            < 1 week
                                          Isopropanol
 Mayara Noronha,                                                                                          < 1 week
                            Brazil        Ivoclean                Variolink LC         Shear
 2020                                                                                                     >1 week
                                          Argon plasma
 Francisco Martinez,                      Ivoclean
                            Spain                                 Panavia SA           Shear              >1 week
 2021                                     Argon plasma
 Asuka Kawaguchi,                         Air abrasion                                                    < 1 week
                            Japan                                 Panavia V5           μ Tensile
 2017                                     Phosphoric acid                                                 >1 week
                                          Air abrasion
                                                                                                          < 1 week
 Ryo Ishi, 2014             Japan         Ivoclean                Not mentioned        Shear
                                                                                                          >1 week
                                          Phosphoric acid
                                          Isopropanol
                                                                                                          < 1 week
 Sa Feitosa 2014            USA           Ivoclean                Multilink            Shear
                                                                                                          >1 week
                                          Phosphoric acid
                                                                  PanaviaSA/ Rely
 Akifumi Takahashi,
                            Japan         Ivoclean                X unicem2/Speed      Tensile            <1 week
 2018
                                                                  Cem
                                                                  Rely X unicem2/
 Stephanie Krifka,
                            Germany       Sodium hypochlorite     Multilink/ Rely X    Shear              <1 week
 2017
                                                                  ultimate
                                          Ivoclean
 Akin Aldag, 2014           Turkey                                Variolink II         μ Shear            <1 week
                                          Sodium hypochlorite
                                          Air abrasion
 Pattarika Angkasith,
                            USA           Ivoclean                Not mentioned        Shear              >1 week
 2016
                                          Phosphoric acid
                                                                                                          < 1 week
 Zhang S, 2010              Slovenia      Phosphoric acid         Panavia 21           Tensile
                                                                                                          >1 week
 Elisabetta Mangione,                     Air abrasion            Panavia 21/                             < 1 week
                            Switzerland                                                μ Shear
 2019                                     Phosphoric acid         Variolink II                            >1 week



10.59987/ads/2024.1.27-38                                                                                                     29
     Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies

     tion and control groups. The results were presented in                            analysis, there was no significant difference between the
     forest plots, too. The control group could only be con-                           non-contaminated and air abrasion cleaning groups in the
     taminated with saliva or non-contaminated, considered                             storage period of >1 week (6 studies; 10 comparisons;
     negative and positive control groups, respectively. The                           SDM: -0.441, P=0.27); however, there was a significant
     duration of storage was categorized into two groups                               difference between the non-contaminated and air abra-
     of <1 and >1 week. Due to diversities in the cement                               sion cleaning groups in the storage period of <1 week (3
     types applied, duration of storage, different operators                           studies; 4 comparisons; SDM: -0.795, P<0.01). In addi-
     and conditions a random-effect model was used for the                             tion, there was a significant difference between the air
     meta-analysis.                                                                    abrasion and surface-contaminated groups in both stor-
                                                                                       age periods of <1 week (3 studies; 4 comparisons; SDM:
                                                                                       2.478, P<0.01) and >1 week (6 studies; 10 comparisons;
     RESULTS
                                                                                       SDM: 2.714, P<0.01) (Supplementary Figures 1-4).
     After two steps of assessing the eligibility of the studies,
     of 909 results of database searches, 15 studies were                              Isopropanol
     included in this systematic review (6, 12-25) (Figure 1).
     Table 3 summarizes the results of meta-analyses.                                  Five included studies assessed the cleaning effects of
                                                                                       isopropanol. In terms of isopropanol, although there
     Air abrasion                                                                      was a significant difference between the saliva-con-
                                                                                       taminated group and the group decontaminated with
     Six included studies assessed the cleaning effects of                             isopropanol with storage periods of >1 week (3 stud-
     the air abrasion method. According to the present meta-                           ies; 4 comparisons; SDM: 0.048, P=0.87), there was




                                    Records idenfied through                                 Addional records idenfied
                                       database searching                                        through other sources
          Idenficaon




                                            (n = 1273)                                                   (n = 0)
                                                '



                                                         Records aer duplicates were removed
                                                                       (n = 909)
          Screening




                                                                       Records screened                                       Records excluded
                                                                           (n = 909)                                              (n = 861)


                                                                                                                        Full-text arcles excluded,
                                                                                                                                with reasons
                                                                  Full-text arcles assessed                                       (n = 33)
                                                                    for eligibility (n = 48)
                                                                                                                        - not met eligibility criteria (n=28)
                                                                                                                           - conference abstracts (n=3)
          Eligibility




                                                                                                                                - duplicaon (n=2)

                                                                       Studies included
                                                                    in qualitave synthesis
                                                                            (n = 15)




                                                                      Studies included
                                                                       in quantave
          Included




                                                                  synthesis (meta-analysis)
                                                                           (n = 15)


     Figure 1. PRISMA Flow Diagram.



30                                                                                                                                 10.59987/ads/2024.1.27-38
A.Sarraf Shirazi et al.

Table 3. Summary of the results of meta-analyses
 Intervention                                                             95% confidence interval
                                                           Standard
 (Forest plot in
                            Comparison         Storage     difference                                 P-value
 supplementary                                                                           Upper
                                                           in means       Lower limit
 material)                                                                               limit
 Air abrasion (SF1)         Non-contaminated   <1 week     -0.795         -1.360         -0.230       <0.01*

 Air abrasion (SF2)         Non-contaminated   >1 week     -0.441         -1.235         0.353        0.27

 Air abrasion (SF3)         Contaminated       <1 week     2.478          0.646          4.310        <0.01*

 Air abrasion (SF4)         Contaminated       >1 week     2.714          1.782          3.647        <0.01*

 Isopropanol (SF1)          Non-contaminated   <1 week     -3.252         -6.498         -0.005       0.05*

 Isopropanol (SF2)          Non-contaminated   >1 week     -1.302         -2.146         -0.458       <0.01*

 Isopropanol (SF4)          Contaminated       >1 week     0.048          -0.556         0.653        0.87

 Ivoclean (SF1)             Non-contaminated   <1 week     -0.144         -0.494         0.205        0.41

 Ivoclean (SF2)             Non-contaminated   >1 week     -0.317         -0.646         0.013        0.06

 Ivoclean (SF3)             Contaminated       <1 week     3.055          1.318          4.791        <0.01*

 Ivoclean (SF4)             Contaminated       >1 week     2.575          1.455          3.695        <0.01*
 Phosphoric acid
                            Non-contaminated   <1 week     -1.584         -2.129         -1.039       <0.01*
 (SF1)
 Phosphoric acid
                            Non-contaminated   >1 week     -2.021         -2.677         -1.365       <0.01*
 (SF2)
 Phosphoric acid
                            Contaminated       <1 week     0.980          -0.530         2.490        0.20
 (SF3)
 Phosphoric acid
                            Contaminated       >1 week     0.789          -0.298         1.876        0.15
 (SF4)
 Argon plasma (SF2)         Non-contaminated   >1 week     -1.143         -3.352         1.067        0.31

 Argon plasma (SF4)         Contaminated       >1 week     1.998          1.278          2.717        0.00*
 Sodium
                            Contaminated       <1 week     0.217          -0.214         0.647        0.32
 hypochlorite (SF3)

SF: Supplementary figure



a significant difference between the non-contaminated     Phosphoric acid
group and the group with isopropanol cleaning method
in both storage periods of <1 week (3 studies; 3 com-     Six included studies assessed the cleaning effects of
parisons; SDM: -3.252, P=0.05) and >1 week (4 stud-       phosphoric acid. In assessing the effects of phosphoric
ies; 5 comparisons; SDM: -1.302, P<0.01) (Supplemen-      acid as a cleaning method, there was no significant dif-
tary Figures 1,2 and 4).                                  ference between decontaminated and contaminated
                                                          groups in <1-week storage (5 studies; 6 comparisons;
                                                          SDM: 0.980, P=0.20) and >1-week storage (6 studies;
Ivoclean
                                                          10 comparisons; SDM: 0.789, P=0.15). However, a sig-
Nine included studies assessed the cleaning effects of    nificant difference was observed between the surfaces
Ivoclean. There was a significant difference between      cleaned with phosphoric acid and non-contaminated sur-
the Ivoclean-decontaminated group and the contami-
                                                          faces in storage periods of <1 week (5 studies; 6 com-
nated groups in both storage periods of <1 week (4
                                                          parisons; SDM: -1.584, P<0.01) and >1 week (6 studies;
studies; 6 comparisons; SDM: 3.055, P<0.01) and >1
                                                          10 comparisons; SDM: -2.021, P<0.01) (Supplementary
week (7 studies; 9 comparisons; SDM: 2.575, P<0.01).
                                                          Figures 1-4).
However, there was no significant difference between
non-contaminated groups and the Ivoclean group in
the storage durations of <1 week (4 studies; 6 compari-   Argon plasma
sons; SDM: -0.144, P=0.41) and >1 week (7 studies;        Three included studies assessed the cleaning effects
9 comparisons; SDM: -0.317, P=0.06) (Supplementary        of argon plasma. Although there was a significant dif-
Figures 1-4).                                             ference between decontaminated and contaminated


10.59987/ads/2024.1.27-38                                                                                            31
     Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies




     Supplementary figure 1. The meta-analysis of the comparison of bond strength between cleaned surface with different
     cleaning methods and non-contaminated surface. Duration of storage was <1 week in these studies.



32                                                                                                                                 10.59987/ads/2024.1.27-38
A.Sarraf Shirazi et al.




Supplementary figure 2. The meta-analysis of the comparison of bond strength between cleaned surface with different
cleaning methods and non-contaminated surface. Duration of storage was >1 week in these studies.



10.59987/ads/2024.1.27-38                                                                                             33
     Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies




     Supplementary figure 3. The meta-analysis of the comparison of bond strength between cleaned surface with different
     cleaning methods and contaminated surface. Duration of storage was <1 week in these studies.



34                                                                                                                                 10.59987/ads/2024.1.27-38
A.Sarraf Shirazi et al.




Supplementary figure 4. The meta-analysis of the comparison of bond strength between cleaned surface with different
cleaning methods and contaminated surface. Duration of storage was >1 week in these studies.



10.59987/ads/2024.1.27-38                                                                                             35
     Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies

     Supplementary Table 1. Details of Risk of Bias assessments.
                                                Use of
                                                                                                         Same op-
                                               material           Sample              Identical                             Blinding of
                             Random-                                                                    erator out-                            Overall risk
           Study                              according             size              interven-                              outcome
                              ization                                                                   come mea-                                of bias
                                              to instruc-        calculation            tions*                              assessors
                                                                                                        surements
                                                 tions
      Nejatidanesh
                                 UC                Yes                Yes                Yes                 UC                  UC               Medium
          2018
         Kim 2015                UC                Yes                 No                Yes                 UC                  UC                 High
        Piest 2018               UC                Yes                 No                Yes                 UC                  UC                 High
       Güers 2019                UC                Yes                 No                Yes                 UC                  UC                 High
         Noronha
                                 UC                Yes                 No                Yes                 UC                  UC                 High
          2020
         Martínez
                                 Yes               Yes                Yes                Yes                 UC                  UC               Medium
          2021
       Kawaguchi
                                 UC                Yes                 No                Yes                 UC                  UC                 High
         2017
        ISHII 2015               UC                Yes                 No                Yes                 UC                  UC                 High
      Feitosa 2015               UC                Yes                 No                Yes                 Yes                 UC               Medium
        Takahashi
                                 UC                Yes                 No                Yes                 UC                  UC                 High
          2017
       Krifka 2017               No                Yes                 No                Yes                 UC                  UC                 High
      Aladağ 2015                No                Yes                 No                Yes                 UC                  UC                 High
      Angkasith
                                 UC                Yes                 No                Yes                 UC                  UC                 High
         2015
       Zhang 2010                No                Yes                 No                Yes                 UC                  UC                 High
        Mangione
                                 UC                Yes                Yes                Yes                 UC                  UC               Medium
          2019




     groups with a storage period of >1 week (3 studies; 3                             overall risk of bias in four studies was medium and high
     comparisons; SDM: 1.998, P<0.01), there were no sig-                              in eleven studies.
     nificant differences between the argon plasma group
     and non-contaminated group with storage of >1 week (3
                                                                                       Discussion
     studies; 3 comparisons; SDM: -1.143, P: 0.31) (Supple-
                                                                                       This study was performed to evaluate the effects of dif-
     mentary Figures 2 and 4).
                                                                                       ferent decontamination methods on the bond strength
                                                                                       of resin to zirconia ceramic after contamination with
     Sodium hypochlorite                                                               saliva. The meta-analysis results showed that air abra-
     Two included studies assessed the cleaning effects of                             sion, Ivoclean, and argon plasma were effective clean-
     sodium hypochlorite. Finally, a meta-analysis of the ef-                          ing methods compared with other methods, including
     fects of sodium hypochlorite did not show a significant                           isopropanol, phosphoric acid, and sodium hypochlorite.
     difference between the decontaminated and contaminat-                             In addition, Ivoclean could completely recover the bond
     ed groups with a storage period of <1 week (2 studies;                            strength to the same level as the non-contaminated sur-
     4 comparisons; SDM: 0.217, P=0.32) (Supplementary                                 face in both <1 and >1 week storage periods. In the <1
     Figure 3).                                                                        week storage period, there was a significant difference
                                                                                       between air abrasion decontaminated and non-contam-
                                                                                       inated groups.
     Risk of bias
                                                                                       Over the past years, YTZP, as a core material for manu-
     Supplementary Table 1 presents the results of risk of                             facturing dental restorations, has gained widespread
     bias assessments. The randomization procedure was                                 popularity in dentistry. It is being used in various types
     unclear in most of the studies. Appropriate sample size                           of restorations, including full-coverage crowns, fixed par-
     calculation was carried out only in three studies. The                            tial prostheses, veneers, endodontic posts, and implant
     same operator for outcome measurements was men-                                   abutments, mainly due to high biocompatibility, excellent
     tioned only in one study, and blinding of outcome asses-                          mechanical properties, aesthetics, and suitable optical
     sors was reported in none of the included studies. The                            behavior (15). Selecting an appropriate cementation pro-



36                                                                                                                                 10.59987/ads/2024.1.27-38
A.Sarraf Shirazi et al.

cess between the tooth and zirconia restoration plays a          and Ivoclean cleaning methods, used to eliminate saliva,
crucial role in the clinical success of the restoration. It is   could not achieve a durable resin bonding to zirconia af-
important to have an optimal bond strength at two dif-           ter application (29). Our meta-analysis showed that air
ferent interfaces (dentin-resin cement and ceramic-resin         abrasion, Ivoclean, and argon plasma effectively cleaned
cement interfaces) in bonding the ceramic to the tooth           saliva-contaminated zirconia ceramic interfaces, with the
substrate. Although zirconia restorations can be luted           least effects on the bond strength.
with both traditional and resin adhesive cements, using          The present study had some limitations, including the
resin can be beneficial in many cases due to its better          limited number of clinical trials for our purpose. Also, the
retention and marginal seal (26).                                bond strength of resin cement to zirconia has been mea-
The restorative surface is at risk of becoming contami-          sured with different methods in the included articles, and
nated during a try-in session. The ceramics might be-            the meta-analyses of the data were carried out by ignor-
come contaminated by saliva, blood, or silicone disclos-         ing the differences in applied methods, types of cement,
ing agents in the try-in procedure, negatively affecting         and duration of storage. Therefore, the mentioned limita-
the composite-ceramic bond strength clinically (14). Un-         tions should be addressed in future studies.
fortunately, it is impossible to avoid ceramic surface con-
tamination; therefore, there are several cleaning meth-
ods to remove the contamination, obtain a clean bonding          Conclusion
surface, and provide a strong bond. Rinsing with water,          In different decontamination methods, sandblasting with
immersing in isopropanol, cleaning with ethanol, phos-           airborne-particle abrasion (Al2O3), an alkaline-based sur-
phoric acid, sodium hypochlorite, and airborne-particle          face cleansing agent called Ivoclean, and argon plasma
abrasion with Al2O3 are some techniques that decontami-          are effective in recovering the bond strength of resin
nate the zirconia surface (17). The present meta-analy-          to saliva-contaminated zirconia. Ivoclean can recover
sis showed that air abrasion, Ivoclean, and argon plasma         the bond strength to the same level as a non-contam-
are effective cleaning methods for the decontamination           inated surface. Alcohol (70% to 96% isopropanol) and
of saliva-contaminated surfaces.                                 phosphoric acid cannot significantly improve the bond
Air abrasion is not a new technique, but it has recently         strength of saliva-contaminated surfaces, which was
regained attention in dentistry. This method removes the         significantly weaker than the non-contaminated surface.
contaminated layers from the surface, allowing the resin         Future well-designed studies, especially clinical investi-
cement to create a stronger micromechanical interlock-           gations, can make the available evidence in this regard
ing (27). Based on our assessment, air abrasion can sig-         more conclusive.
nificantly improve the strength of contaminated surfaces.
Ivoclean is an alkaline surface cleansing agent whose            Acknowledgement
main composition is sodium hydroxide (NaOH) solution,
which can enhance the phosphate adsorption proper-               This study was supported by a grant from Mashhad Uni-
ties. By absorbing the phosphate contaminants found in           versiy Research Council, which is gratefully acknowl-
the saliva, Ivoclean can recover the strength of bonds           edged.
in 20 seconds based on the manufacturer’s claims (27).
Based on our meta-analysis, Ivoclean decontamination             References
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