Daniel Edelhoff
Mutlu Özcan
Authors’ affiliations:
Daniel Edelhoff, Department of Prosthodontics,
Ludwig-Maximilians-University, Munich,
Germany
Mutlu Özcan, University Medical Center
Groningen, Department of Dentistry and Dental
Hygiene, Division of Clinical Dental Biomaterials,
University of Groningen, Groningen, The
Netherlands
Correspondence to:
Prof. Dr med. dent. Daniel Edelhoff
Department of Prosthodontics
Ludwig-Maximilians-University
Goethestr. 70
D-80336 Munich
Germany
Tel.: þ 49 89/5160 9510
Fax: þ 49 89/5160-9502
e-mail: daniel.edelhoff@med.uni-muenchen.de
To cite this article:
Edelhoff D, Özcan M. To what extent does the longevity
of fixed dental prostheses depend on the function of the
cement? Working Group 4 materials: cementation.
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007; 193–204
doi: 10.1111/j.1600-0501.2007.01442.x
c 2007 The Authors. Journal compilation


c 2007 Blackwell Munksgaard
To what extent does the longevity of
fixed dental prostheses depend on the
function of the cement?
Working Group 4 materials: cementation
Key words: adhesive techniques, all-ceramic restorations, cast-metal restorations, cement
types, cementation modes, implant-supported restorations, metal-ceramic restorations,
non-bonded fixed dental prostheses, resin-bonded fixed dental prostheses
Abstract
Aims/Background: The objective of this review was to define the impact of cementation
mode on the longevity of different types of single tooth restorations and fixed dental
prostheses (FDP).
Methods: Literature search by PubMed as the major database was used utilizing the terms
namely, adhesive techniques, all-ceramic crowns, cast-metal, cement, cementation, ceramic
inlays, gold inlays, metal-ceramic, non-bonded fixed-partial-dentures, porcelain veneers,
resin-bonded fixed-partial-dentures, porcelain-fused-to-metal, and implant-supported -
restorations together with manual search of non-indexed literature. Cementation of root
canal posts and cores were excluded. Due to lack of randomized prospective clinical studies
in some fields of cementation, recommendations had to be based on lower evidence level
(Centre of Evidence Based Medicine, Oxford) for special applications of current cements.
Results: One-hundred-and-twenty-five articles were selected for the review. The primary
function of the cementation is to establish reliable retention, a durable seal of the space
between the tooth and the restoration, and to provide adequate optical properties. The
various types of cements used in dentistry could be mainly divided into two groups: Water-
based cements and polymerizing cements. Water-based cements exhibited satisfying long-
term clinical performance associated with cast metal (inlays, onlays, partial crowns) as well
as single unit metal-ceramic FDPs and multiple unit FDPs with macroretentive preparation
designs and adequate marginal fit. Early short-term clinical results with high-strength all-
ceramic restorations luted with water-based cements are also promising. Current
polymerizing cements cover almost all fields of water-based cements and in addition to that
they are mainly indicated for non-retentive restorations. They are able to seal the tooth
completely creating hybrid layer formation. Furthermore, adhesive capabilities of
polymerizing cements allowed for bonded restorations, promoting at the same time the
preservation of dental tissues.
The longevity of indirect fixed dental pros- restoration, and to provide adequate optical
theses (FDPs) could be affected by multiple properties especially for tooth-colored cera-
factors including the cementation mode. mic or polymeric FDPs. Various types of
The primary function of the cementation cements with different properties are avail-
is to establish reliable retention, a durable able in dentistry that can primarily be
seal of the space between the tooth and the divided into two groups (Table 1): water-
193
Edelhoff & Özcan . Longevity of fixed dental prostheses

Table 1. Survey over the most common dental cements classified by application, benefits and drawbacks modified according to Powers,
J. M. & Sakaguchi R. J. (2006) Cements. In: Powers, J.M. & Sakaguchi R.J., eds. Craig’s Restorative Dental Materials, 12th edition, p. 481.
St Louis, Mosby Elsevier.
Cements
Water-based cements
Glass-ionomer
Zinc Phosphate
Polymerizing cements
Composites and adhesive cements Retention of conventional
Resin-modified glass ionomer
Application
Class 5 restorations
Retention of conventional
alloy based restorations
Retention of alumina- or
zirconia-based all-ceramic
restorations
Retention of long-term
provisional restorations
Retention of conventional
restorations
Retention of long-term
provisional restorations
alloy-based restorations
Bonded all-ceramic crowns,
bridges, veneers, inlays, and
onlays
Bonded laboratory composite
crowns, bridges, veneers,
inlays, and onlays
Bonded posts and cores
Class 5 restorations
Retention of conventional
alloy-based restorations
Retention of alumina- or
zirconia-based all-ceramic
restorations
Retention of long-term
provisional restorations
Benefits
Bond to tooth tissues
Fluoride release
Relatively great resistance of
disintegration
Relatively biocompatible
Long-term experiences
Universal cementation agent
Good handling characteristics
Proven longevity with well-
designed and well-fitting
restorations
Very low solubility
Excellent compressive strength
Superior long-term bond to
enamel
Under certain limitations
acceptable bond to dentin
High fracture toughness
Increased elastic modulus
Increased compressive strength
Low solubility
Drawbacks
Short working time
Slow maturing process
Crack development during dry
conditions
Low elastic modulus
High in vivo solubility
Pulp irritant
Lack of adhesive properties
No anticariogenic ingredients
Difficult handling characteristics
Pulp irritant
Lack of anticariogenic properties
Hydrophilic properties
Water uptake expansion

based cements and polymerizing cements.
As the use of water-based cements is
strongly dependent on the macroretentive
tooth preparation and excellent marginal fit
of the restoration, polymerizing cements
can confer adhesive properties to both the
tooth tissues and the restorative material.
They also present negligible solubility and
significantly improved optical properties.
The use of polymerizing adhesive cements
for translucent restorative materials such as
glass-ceramics or reinforced polymeric re-
storations enables an outstanding esthetic
outcome and simultaneously reduces the
need for macroretention. This could be
considered as a high impact on the preser-
vation of sound tooth tissues (Edelhoff &
Sorensen 2002a, 2002b). Not only for the
bonded indirect FDPs but also for all types
of restorations, polymerizing cements are
considered in general as better alternatives
as improved retention as well as a better
seal of the margins can be established.
Selection of appropriate cementation
mode is frequently affected by the restora-
tive material properties, marginal fit, type
of restoration, and the surface-conditioning
method (Özcan et al. 1998). Furthermore,
the properties of the cement (i.e., viscosity,
biocompatibility, adhesive potential, solubi-
lity, water uptake, color stability, wear re-
sistance, working and setting characteristics,
sealing ability, radio-opacity) as well as var-
ious clinical confounding factors (i.e., occlu-
sion, preparation design, moisture control,
type of build-up material, type of supporting
tooth structure, surface roughness, margin
location, tooth location, amount of tooth
destruction, and abutment mobility) deter-
mine the selection of the cement.
A high variety of cements is available
today in dentistry with a continuously ex-
panding range of new products and applica-
tions (Rosenstiel et al. 1998; Diaz-Arnold
et al. 1999; Powers & Sakaguchi 2006). The
purpose of this review therefore was to define
the impact of cement type and cementation
mode on the longevity of different types of
single- and multiple-unit FDPs. Owing to
lack of randomized prospective clinical stu-
dies in some application fields, recommen-
dations must be based on lower evidence
level (Centre of Evidence Based Medicine,
Oxford) for applications of current cements.
Water-based cements
The most commonly used water-based
permanent luting agents are zinc phosphate
and glass-ionomer cements. Zinc phos-
phate cement has served for decades as
the universal cement for different applica-
tions in restorative dentistry relying on the
retention and resistance form of the tooth
preparation and an adequate marginal fit.
Because of its long history of successful
clinical use, associated with cast and me-
tal-ceramic restorations, zinc phosphate
cement is considered as the ‘reference’ or
‘gold standard’ (Kerschbaum et al. 1991,
1997; Creugers et al. 1994). In an in vitro
study, Utz et al. (1989) categorized the
sealing capacity of zinc phosphate cement
as the most favorable when compared with
glass-ionomer cement. These findings are
in compliance with the results of an in vivo
study where a higher solubility of glass-

194 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204 c 2007 The Authors. Journal compilation


c 2007 Blackwell Munksgaard

ionomer cement was detected compared
with zinc phosphate cement (Phillips
et al. 1987). In contrast, in an in vivo
evaluation of marginal fit of restorations
before and after cementation, Kern et al.
(1993) could show that cast copings luted
with glass-ionomer cement exhibited a bet-
ter fit than those luted with zinc phosphate
cement. In an in vitro study, glass-ionomer
cement used for crown cementation was
more resistant to dynamic load than zinc
phosphate cement (Wiskott et al. 1997).
Clinical data on the longevity of ceramic
inlays placed with water-based cements are
limited in the literature. Long-term data are
almost only available on cast-gold inlays
luted with zinc phosphate cement. In a retro-
spective clinical study, 2717 gold restorations
were observed and after 10 years, 231 (8.1%)
had to be removed (Fritz et al. 1992). For one-
surface inlays, a success rate of 65%, for two-
surface inlays 60%, and for three-surface
inlays 68% was calculated. The success
rate for cast-gold onlays and partial crowns
was 70%. The reasons for failures were
recurrent caries (29.2%), endodontical com-
plications (17.8%), insufficient fit (13.5%),
lack of retention (13.1%), and caries in un-
treated areas (12.7%). Erpenstein et al. (2001)
subsequently, in a retrospective clinical
study, investigated 2071 cast-gold inlays ce-
mented with zinc phosphate cement. The
20-year Kaplan–Meier survival rate for
restoration-bearing teeth was 98.9%. This
result, however, decreased to 73.4% at the
25-year follow-up. Gold inlays inserted into
maxillary teeth had significantly better sur-
vival probabilities after this period than those
inserted into the mandible. Based on the
number of surfaces involved, 52% of one-
surface inlays, 64.3% of two-surface inlays,
75.8% of three-surface inlays, and 84.8% of
inlays with more than three surfaces were
still in situ after 25 years. In a further retro-
spective clinical evaluation of 1314 cast-gold
restorations conducted by Donovan et al.
(2004), almost 90% of the restorations had
been in service for over 9 years, 72% for over
20 years, and 45% from 25 to 52 years.
Restorations were evaluated in terms of mar-
ginal integrity, anatomic form, and surface
texture. Ninety-six percent of the evaluated
restorations were rated excellent. Sixty re-
storations required removal and replacement,
yielding an overall survival rate of 95.4%.
The survival rates at various time periods
were 97% at 9 years, 90.3% at 20 years,
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c 2007 Blackwell Munksgaard
Edelhoff & Özcan . Longevity of fixed dental prostheses
94.9% at 25 years, 98% at 29 years, 96.9%
at 39 years, and 94.1% of the restorations
were in place after more than 40 years.
According to the cited clinical studies, accu-
rately fabricated cast-gold inlays, onlays, and
partial crowns cemented with zinc phosphate
cement can provide very predictable, long-
term clinical service.
The influence of cementation mode on
the clinical performance of 115 fired ceramic
inlays in a 6-year clinical follow-up was
investigated by Van Dijken et al. (1998).
The inlays were either placed adhesively
(n ¼ 58) or conventionally with glass-iono-
mer cement (n ¼ 57) in a split-mouth de-
sign. After 6 years of clinical service, a 12%
failure rate with adhesively placed inlays and
26% with glass-ionomer cement were de-
tected. Based on these results, it was con-
cluded that the longevity of ceramic inlays is
largely related to adhesive cementation.
In a further study by Gemalmaz et al.
(2001), 45 fired ceramic inlays were bonded
with three different luting agents. Fifteen of
the inlays were inserted with one of the three
different luting agents, namely two resin-
based cements and one polyacrylic acid-
modified glass-ionomer cement. The restora-
tions were evaluated using modified USPHS
criteria for a period between 3 and 46
months, with a mean of 26.3 months after
insertion. The Kaplan–Meier statistical ana-
lysis was used to calculate the survival rate of
the inlays. The fracture rates observed for
resin-based cements were 13%, and 33% for
polyacrylic acid-modified glass-ionomer ce-
ment. It was concluded that the use of a
polyacrylic acid-modified glass-ionomer ce-
ment resulted in a higher fracture rate and
loss of marginal adaptation in fired ceramic
inlays. Although the study was not long
term, during the observation period the mar-
ginal adaptation of the luting agent was more
durable at the enamel–cement interface than
that at ceramic–cement interface. These
clinical findings were confirmed by the
results of an in vitro study, in which
resin-modified glass-ionomer cement was
not recommended as a luting material for
feldspathic partial ceramic crowns due to
a significantly higher incidence of microleak-
age (Federlin et al. 2005).
As placement of fired ceramic inlays
with water-based cement increased the
fracture rate more than twice, this cemen-
tation mode cannot be recommended for
predictable long-term restorations.
195 |
Owing to their reliability and durability,
conventionally cemented cast-metal and
metal-ceramic restorations with a com-
plete crown preparation design were ac-
cepted as the treatment of choice for
single- or multiple-unit FDPs for decades
(Kerschbaum et al. 1991, 1997; Creugers
et al. 1994). When conventional cementa-
tion is used, macroretentive preparation is
considered to be an important parameter for
success (Shillingburgh et al. 1997). In a
literature review, Goodacre et al. (2001)
suggested the following guidelines for tooth
preparation when conventional cementa-
tion is to be applied: teeth should be pre-
pared with 10–201 of total occlusal
convergence and a minimal occlusocervical
height of 4 mm for molars and 3 mm for
other teeth. In another in vitro study, 121
of taper was detected as the transition point
where the slope of the graph of cycles to
dislodgement as a function of taper
abruptly changed (Cameron et al. 2006).
When the above features are missing, the
teeth should be modified with auxiliary
resistance features such as axial grooves or
boxes, preferably on proximal surfaces
(Goodacre et al. 2001). In a 10-year clinical
trial conducted by Jokstad & Mjör (1996)
on 81 fixed protheses placed on 135 abut-
ment teeth, no differences were found
between glass-ionomer and a zinc phos-
phate luting agent in the prognosis. Non-
parametric survival estimates indicated
that 80–85% of the abutment teeth re-
mained intact after 5 years and 71–81%
after 10 years. The prevailing reason for
abutment tooth failure was secondary
caries (n ¼ 21) and pulp necrosis (n ¼ 5).
Hypersensitivity occurred in five teeth
restored with glass-ionomer cement.
Unlike metal-based restorations, all-
ceramic restorations should not involve
any primary retention, as this would pro-
duce crack-inducing tensile stresses from
the inner surface of the restoration (Anu-
savice & Hojjatie 1992). The overall fit of
all-ceramic restorations exhibit inferior
adaptation compared with their cast-metal
or metal-ceramic counterparts (Molin &
Karlsson 1993; Albert & El-Mowafy
2004; Sailer et al. 2006). The large mar-
ginal discrepancy and the lack of primary
retention have to be compensated by an
appropriate cement selection. Bonding
glass-ceramic restorations using a resin
composite cement significantly increased
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
Edelhoff & Özcan . Longevity of fixed dental prostheses
the fracture strength compared with ce-
mentation with zinc phosphate cement
(Scherrer et al. 1996).
Commonly, the high flexural strength
and fracture toughness as well as the better
fit of new all-ceramic systems including
high-strength core materials allow for the
use of water-based cements that are pri-
marily based on macromechanical reten-
tion. Naert et al. (2005) reported on the
crown adaptation, marginal fit, and clinical
behavior of all-ceramic full-coverage alu-
mina FDPs (Procera, Gothenburg, Sweden)
luted with glass-ionomer cement in one
clinical center and followed up to 5 years.
The marginal fit and coping adaptation
before and after luting were determined by
direct measurement as well as after sec-
tioning in an in vitro study. Three-hundred
all-ceramic restorations were cemented in
165 patients between 1994 and 1998. Pa-
tients were recalled for the assessment of
their restorations using the California Den-
tal Association quality evaluation index,
their own appreciation, and the reaction
of the periodontal tissues. The in vitro data
revealed a mean marginal gap of 30 mm,
before and after luting of the alumina cop-
ing onto the tooth. However, at the deepest
part of the chamfer, the gap increased to
135 mm. In the clinical part of the study,
only one restoration fractured, while in 6%
of the restorations, small chippings of the
veneering ceramic were observed. After
polishing the chipped areas, no persistent
patient complaints remained. At the last
recall, 1.8% of the evaluated margins were
rated as unacceptable. Dentists rated 72%
and 78% of the restorations as excellent for
surface, color, and anatomic form, respec-
tively. Eighty-seven percent of the patients
rated their restorations more than seven on
an ordered analog scale, with a maximum
of 10 for esthetics and for function. In
another clinical follow-up, 107 anterior
and posterior all-ceramic alumina crowns
(Procera Alumina AllCeram) placed with
glass-ionomer cement were evaluated for 6
years. Six crowns had to be removed be-
cause of non-repairable fracture. At 6 years,
the cumulative survival rate was 94.3% for
all crowns, 96.7% for anterior crowns, and
91.3% for posterior crowns (Walter et al.
2006).
According to the results of the cited
studies, the use of water-based cements
can be recommended for cast metal (inlays,
196 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
onlays, partial crowns) as well as metal–
ceramic and high-strength all-ceramic full-
coverage single- or multiple-unit FDPs
with a macroretentive preparation design
and adequate marginal fit. However, as the
ceramic inlay failure rate was twice as high
with water-based or polyacrylic acid-mod-
ified glass-ionomer cements compared
with polymerizing cements, adhesive ce-
mentation should be compulsory for the
cementation of silica-based ceramic inlay
restorations (Van Dijken et al. 1998; Ge-
malmaz et al. 2001).
Polymerizing cements
With advances in the field of polymerizing
cements with added advantages of bonding
to dental tissues and to indirect restora-
tions, conservative preparation designs
could be achieved with reduced need for
macroretention. The reliable adhesion to
enamel achieved with the adhesive techni-
ques has had a major impact on saving the
remaining tooth structure and has led to a
crucial change in the existing paradigms in
tooth preparation. Even adhesive cementa-
tion of gold inlays and onlays would allow
for conservative tooth preparation (Ohsawa
et al. 2004). However, clinical data proving
the longevity of adhesively bonded gold
inlays are limited in the dental literature
(Miya 1997; Fabianelli et al. 2005).
The marginal adaptation and microleak-
age of densely sintered alumina all-ceramic
and metal-ceramic FDPs using four differ-
ent cements were evaluated by Albert &
El-Mowafy (2004). Alumina all-ceramic
copings had a significantly larger mean
marginal gap (54 mm) compared with metal
ceramic (29 mm). Marginal gap extension
influenced the degree of microleakage.
With both types of crowns, resin cement
exhibited the lowest percentage of micro-
leakage, whereas the zinc phosphate ce-
ment resulted in the most extensive
microleakage. In a split-mouth randomized
clinical trial, 39 metal-ceramic, and 39
alumina all-ceramic single-unit FDPs re-
tained with resin-modified glass-ionomer
and zinc phosphate luting cements were
evaluated (Jokstad 2004). The results
showed that a resin-modified glass-ionomer
luting cement performed at least as good as
zinc phosphate cement to retain single
FDPs over a 102-month observation period.
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c 2007 Blackwell Munksgaard
Osman et al. (2006) compared the film
thickness and rheological properties of zinc
phosphate cement with different polymer-
izing cements, including Panavia 21, Su-
perbond, All Bond C&B Cement, and
Variolink. An initial film thickness of
25 mm was observed and was not signifi-
cantly different between the cements.
Veneers
The combination of highly translucent
ceramics and polymerizing cements has
facilitated the clinical use of the adhesive
technique and launched innovative restora-
tive treatment options. The increased pre-
servation of enamel promotes a superior
adhesion to dentin, less post-cementation
sensitivity, improved support to the cera-
mic restoration, and reduced endodontic
intervention (Marinello & Schärer 1987;
Scherrer & De Rijk 1993; Scherrer et al.
1996). Therefore, the preservation of en-
amel has become an important pre-requi-
site for preparation design (Belser et al.
1997; Federlin et al. 2005). Owing to their
excellent clinical performance, outstanding
esthetics, and minimal invasiveness, resin-
bonded veneers offer reliable treatment op-
tions with an escalating range of indica-
tions (Nattress et al. 1995; Peumans et al.
1998; Magne & Douglas 1999). In a 15-year
clinical evaluation of adhesively luted cera-
mic veneers, approximately 3500 restora-
tions were observed and 93% of them were
classified as successful (Friedman 1998).
Sixty-seven percent of the 245 failed veneer
restorations presented fractures, 22% mi-
croleakage, and 11% debonding. Increased
microleakage was particularly detected
when the veneers were bonded to dentin.
In a prospective 10-year clinical trial of
87 ceramic veneers on maxillary anterior
teeth (Peumans et al. 2004), 93% of the
restorations could be evaluated. Clinical
performance was assessed in terms of es-
thetics, marginal integrity, retention, clin-
ical microleakage, secondary caries,
fracture, vitality, and patient satisfaction.
Failures were recorded either as ‘clinically
unacceptable but repairable’ or as ‘clinically
unacceptable with replacement needed.’
The authors reported that ceramic veneers
maintained their esthetic appearance after
10 years of clinical service. Only 4% of the
restorations needed to be replaced at the

10-year recall. The percentage of restora-
tions that remained ‘clinically acceptable’
(without need for intervention) signifi-
cantly decreased from an average of 92%
at 5 years to 64% at 10 years. Fractures of
ceramic (11%) and large marginal defects
(20%) were the main reasons for failure.
Marginal defects were especially noted at
locations where the veneers ended in exist-
ing composite fillings. At such vulnerable
locations, severe marginal discoloration
(19%) and caries (10%) were frequently
observed. Most of the restorations that
present one or more ‘clinically unaccepta-
ble’ problems (28%) were repairable. The
authors concluded that labial ceramic ve-
neers luted adhesively represent a reliable,
effective procedure for conservative treat-
ment of unesthetic anterior teeth. In a
further retrospective clinical study on 328
veneers, prepared with a lingual mini-
chamfer, a 10-year Kaplan–Meier survival
rate of 97% was found (Laubach 2005).
Murphy et al. (2005) investigated in a
retrospective study over a time period of 5
years the performance of 62 ceramic lami-
nate veneers delivered by undergraduate
dental students. On the date of recall, while
89% of veneers were never debonded or
fractured, 6% had to be rebonded since the
date of insertion and 5% presented fracture.
From this study, it appears that ceramic
laminate veneers are successful in the treat-
ment of discolored and irregular-configured
anterior teeth. It was shown that under-
graduate students were also capable of
achieving satisfactory veneer restorations.
In all these clinical studies, polymerizing
cements were employed.
According to the results of numerous
clinical trials for silica-based ceramics,
polymerizing resin cements should be the
material of choice for cementation. Static
and dynamic occlusion, preparation design,
presence of composite fillings, dentin ex-
posure, and the adhesive used to bond
veneers to tooth substrate were reported
to be covariables that could contribute to
the clinical outcome of these restorations
in the long term (Karlsson et al. 1992;
Peumans et al. 2004).
Inlays
A review of the clinical survival of direct
and indirect restorations in posterior per-
manent dentition evaluated the longevity
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c 2007 Blackwell Munksgaard
Edelhoff & Özcan . Longevity of fixed dental prostheses
and annual failure rates of amalgam, direct
composite restorations, compomers,
glass-ionomers, and derivative products,
composite and ceramic inlays, and cast-
gold restorations for Class I and II cavities
(Manhart et al. 2004). The mean annual
failure rates for indirect restorations in
posterior stress-bearing cavities were
2.9% for composite inlays, 1.9% for cera-
mic restorations, 1.7% for CAD/CAM
ceramic restorations, and 1.4% for cast-
gold inlays and onlays. Indirect restorations
exhibited a significantly lower mean an-
nual failure rate than direct techniques.
The principal reasons for failure were sec-
ondary caries, fracture, marginal deficien-
cies, wear and post-operative sensitivity.
Unfortunately, this review article did not
concentrate on the effect of cement type.
Fuzzi & Rappelli (1999) evaluated 182
ceramic inlays with 2–11.7 years of clinical
service. A success rate of 95% could be
predicted at 11.5 years. The excellent long-
evity proved that adhesively luted ceramic
inlays represent a valuable tool for the
restoration of posterior teeth. These data
agree with the clinical performance of 96
bonded leucite-reinforced hot-pressed
glass-ceramic inlays and onlays evaluated
in a prospective controlled clinical study
(Krämer & Frankenberger 2005) after 8
years of clinical service. The restorations
were bonded with an enamel/dentin bond-
ing system and four different resin compo-
site systems. The restorations were
assessed after placement by two calibrated
investigators using modified USPHS scores
and criteria. Eight of the 96 restorations
investigated had to be replaced, resulting in
an 8% failure rate according to Kaplan–
Meier analysis. Six inlays suffered from
cohesive bulk fractures and two teeth re-
quired endodontic treatment. Ninety-eight
percent of the surviving restorations exhib-
ited marginal deficiencies, independent of
the luting composite. Heat-pressed ceramic
inlays and onlays demonstrated to be suc-
cessful even in large defects.
In a clinical trial conducted in private
practice, 1010 ceramic inlays and onlays
manufactured by the Cerec CAD/CAM-
technique were adhesively placed and ob-
served (Reiss & Walther 2000). According
to the Kaplan–Meier analysis, the probabil-
ity of survival decreased to 90% after 10
years and 84.9% after 11.8 years, with no
further loss at the final observation at 12
197 |
years. The size and outline form did not
affect the success rate. Premolars rated
better than molars. Vital teeth provided
better results than non-vital teeth. The
application of dentin adhesive increased
the probability of success. Even when ad-
hesively luted, the most frequent reason for
failures was fracture of ceramic and tooth.
In a further prospective evaluation of CAD/
CAM-manufactured (Cerec) ceramic inlays
cemented with a chemically cured or dual-
cured resin composite, 61 Class II Cerec
inlays were evaluated after 10 years of
clinical service using a slight modification
of the USPHS criteria (Sjögren et al. 2004).
Fifty-four of the re-evaluated 61 inlays still
functioned well at the 10-year recall. Dur-
ing the follow-up period, seven (11%) of the
inlays required replacement due to four
inlay fractures, one cusp fracture, endodon-
tic problems in one case, and postoperative
symptoms in another case. The fractured
inlays were all in molars. The estimated
cumulative survival rate after 10 years was
89% where 77% was for the dual-cured
resin composite-luted inlays and 100% for
the chemically cured resin composite-luted
ones. The difference was statistically sig-
nificant. The properties of the luting agents
seem to affect the longevity of the type of
ceramic inlays evaluated.
Posselt & Kerschbaum (2003), on the
other hand, evaluated 2328 ceramic inlays
that were manufactured chair-side using
Cerec technology. The inlays were adhe-
sively inserted at the same appointment.
Thirty-five Cerec restorations were judged
as having failed and the probability of
survival was 95.5% after 9 years. The
clinical success was not significantly influ-
enced by restoration size, tooth vitality,
treatment of caries, type of tooth treated,
or whether the restoration was located in
the maxilla or mandible. The most com-
mon type of failure was the extraction of a
tooth. In this clinical follow-up, 44 ran-
domly selected restorations were examined
under a light microscope where an average
composite joint width of 236.3 mm was
found. Forty-five percent of the restora-
tions exhibited perfect margins, and
47.4% of the investigated cement joint
sections showed underfilled margins.
According to this part of the literature
review, gold inlays and onlays cemented
with zinc phosphate exhibited higher
clinical success rates than adhesively luted
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
Edelhoff & Özcan . Longevity of fixed dental prostheses
ceramic inlays of different fabrications (heat
pressed, fired on a refractory die or CAD/
CAM) (Molin & Karlsson 2000). As the
ceramic inlay failure rate was two times
higher when luted with conventional glass-
ionomer cement, adhesive placement
should be considered as the treatment of
choice (Van Dijken et al. 1998; Gemalmaz
et al. 2001). The application of dentin
adhesive and the use of chemically poly-
merized resin composite seemed to be ad-
vantageous for the longevity of ceramic
inlays (Reiss & Walther 2000; Sjögren
et al. 2004). Under certain restrictions, the
absence of enamel margins, or cuspal repla-
cement as well as a solely light-polymer-
ized resin composite significantly affected
the quality of the restorations (Federlin
et al. 2004; Federlin et al. 2005; Krämer
& Frankenberger 2005; Schulte et al. 2005).
FDPs
Unlike metal-based restorations, all-cera-
mic restorations should not involve any
primary retention, as this would produce
crack-inducing tensile stresses from the in-
ner surface of the restoration. Certain pre-
paration guidelines that differ from
recommendations for metal-supported sys-
tems have to be taken into consideration for
all-ceramic FDPs (Doyle et al. 1990a,
1990b; Friedlander et al. 1990). These stu-
dies were published on cementation and
preparation design for all-ceramic full
crowns. The details of these studies have
been contradictory with regard to cementa-
tion mode, preparation geometry of the
margin, angle of convergence, and extent
of tooth removal (Doyle et al. 1990b; Meier
et al. 1995; Edelhoff et al. 2000). In vitro
investigations have shown that substruc-
tures with a high elastic modulus increase
the strength of all-ceramic crowns, espe-
cially of those fully fabricated out of silica-
based ceramic; the residual dentin thickness
after preparation therefore may influence
the life expectancy of the restoration (Scher-
rer & De Rijk 1993). A preparation design
that requires the removal of large amounts
of hard tooth tissues must be rejected for a
number of reasons: exposure of dentin near
the pulp with a high density of dentin
tubules, increased secretion of dentinal
fluid, adverse influence on the ratio of
residual dentin to cavities (pulp cavity, den-
tin tubules), increased risk of postoperative
198 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
sensitivity, and contraindication for young
patients with large pulps.
All-ceramic restorations exhibit an infer-
ior overall fit compared with cast metal or
metal-ceramic restorations (Molin & Karls-
son 1993; Albert & El-Mowafy 2004; Sailer
et al. 2006). The high marginal discrepancy
and the lack of primary retention have to be
compensated by an appropriate cementation
technique. Adhesive bonding represents a
fundamental stage in the clinical application
of all-ceramic restorations, as this approach
has extensive advantages in the preparation
design, esthetic appearance, and longevity of
the restorations. Several in vitro studies
provided information proving that adhesive
cementation is capable of sealing inner sur-
faces and thereby reinforcing silica-based
ceramic restorations (Anusavice & Hojjatie
1992; Ludwig & Joseph 1994; Pospiech
et al. 1996; Mörmann et al. 1998). Polymer-
izing cements show further negligible
solubility, providing excellent properties to
compensate for the insufficient marginal fit
of the early all-ceramic systems. However,
adhesive cementation procedures require
meticulous and skilled work and they are
relatively more time consuming. In case of
full crown preparation, large areas of dentin
are exposed, and adhesive bonding may not
always provide a reliable and durable bond.
Furthermore, absolute isolation with a rub-
ber dam is not possible in most of the cases
and subgingival preparation margins are of-
ten unavoidably associated with full-crown
preparations. This raises the question as to
which cementation technique would be ap-
propriate for the insertion of all-ceramic
FDPs. Generally, the high flexural strength
and the better fit of new all-ceramic systems
including high-strength core materials allow
for the use of conventional cements, which
are primarily based on macromechanical
retention. In the literature, only a few clin-
ical studies are available comparing different
cementation modes for all-ceramic FDPs.
Glass-ceramic single-unit FDPs
Edelhoff et al. (2000) investigated leucite-
reinforced heat-pressed glass-ceramic
crowns (Empress 1) luted with adhesive
dual polymerizing composite and zinc
phosphate cement. No differences in survi-
val rate (98%) were detected between both
groups of glass-ceramic crowns after a
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c 2007 Blackwell Munksgaard
4-year period of clinical service. Cremer &
Pfeiffer (2000) placed and evaluated 46 glass-
ceramic (Empress 1) crowns and 46 infil-
trated alumina ceramic crowns (In-Ceram
Alumina) in the posterior area, which were
placed either with dual-polymerizing compo-
site or zinc phosphate cement. Within the
observation period of 26 months, 59 of
88 all-ceramic crowns were rated to be clini-
cally excellent. Zinc phosphate cement was
considered in this clinical study as an accep-
table alternative to resin composite luting
cement. In two long-term clinical trials
over 14 years on different types of Dicor
restorations (Malament & Socransky
1999a, 1999b), complete-coverage full-
crown FDPs survival improved when restora-
tions were acid-etched with hydrofluoric acid
before luting. The survival of restorations
with either chamfer or shoulder preparations
did not differ when the restoration was
etched. The thickness of the restoration
also did not relate to the survival. Acid-
etched Dicor restorations luted to gold core
structures exhibited a significantly better
survival rate than restorations luted to den-
tin. A further evaluation of this study after 16
years of clinical service confirmed that acid-
etched Dicor restorations survived better
than non-acid-etched restorations when lu-
ted to dentin preparations and that the glass-
ionomer exhibited a lower relative risk for
failures than zinc phosphate cement (Mala-
ment & Socransky 2001). Kinnen et al.
(2006) investigated heat-pressed lithium-
disilicate glass-ceramic crowns (Empress 2)
luted with either adhesive polymerizing
cements or glass-ionomer cement. Sufficient
tooth preparation height (3 mm) and a
taper of a 6–101 were used as pre-requisites
for cementation with glass-ionomer cement.
No fracture of the framework occurred in
both groups of glass-ceramic crowns after a
5-year period of clinical service. However,
this study was not a randomized clinical trial.
Even if it is stated that adhesive cemen-
tation reduces the need for macroretentive
preparation for crowns, some restrictions in
application of less retentive preparation de-
signs were detected in clinical long-term
studies (Bindl et al. 2005).
Oxide-ceramic single-unit FDPs
Oxide ceramics such as densely sintered
pure alumina or partially stabilized zirconia
exhibit significantly higher flexural

strengths than those of glass-ceramics.
Therefore, the influence of cementation
mode on the strength of the restoration
seems to be diminished (Bindl et al.
2006). In addition, one in vitro study stated
that the use of a composite resin cement
(Panavia F 2.0) with a bonding agent (ED
Primer A&B) did not yield higher retention
of zirconium oxide ceramic crowns com-
pared with a resin-modified glass-ionomer
cement (Rely  Luting) or a self-etch poly-
merizing resin cement (Rely  Unicem)
(Palacios et al. 2006). Similar long-term
clinical results were reported by Galindo
et al. (2006) for 135 single crowns with the
same system. Owing to one crown fracture,
the cumulative survival was rated as 99%
after 5 and 7 years. This clinical success
was achieved irrespective of the tooth posi-
tion, tooth vitality, the preparation margin,
and the cement medium used, either being
a resin composite or glass-ionomer cement.
Based on these findings, it can be con-
cluded that all-ceramic crowns made of
densely sintered pure alumina represent a
predictable esthetic type of restoration in
the anterior and posterior region. The ce-
mentation mode, either adhesive or con-
ventional, could be selected depending on
the individual clinical situation considering
the preparation design, tooth position, and
geometry (Hagmann et al. 2006).
All-ceramic multiple-unit FDPs
Glass-ceramic three-unit FDPs
Kinnen et al. (2006) investigated heat-pressed
lithium-disilicate glass-ceramic three-unit
FDPs (Empress 2) luted with either an adhe-
sive composite or glass-ionomer cement. As
guidelines for the use of glass-ionomer ce-
ment, a minimum tooth preparation height
of 3 mm and a taper of a 6–101 were used (no
randomization). Despite the high fracture rate
in the experimental group (molar region), no
influence of cementation mode on the survi-
val rate was detected after a 5-year period of
clinical service. In another clinical trial con-
ducted by Marquardt & Strub (2006), 31
three-unit glass-ceramic FDPs (Empress 2)
were placed exclusively with adhesive com-
posite in the anterior and premolar regions.
Six failures occurred as framework fractures
(3), non-repairable partial veneer fracture (1),
and biologic failures (2), resulting in a 70%
survival rate in the 50-month analysis.
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c 2007 Blackwell Munksgaard
Edelhoff & Özcan . Longevity of fixed dental prostheses
Oxide-ceramic multiple-unit FDPs
Tinschert et al. (2005) investigated the
longevity of FDPs made of partially stabi-
lized zirconia ceramic (DC-Zirkon) that
were cemented in part with zinc phosphate
cement. No fracture and retention loss
occurred after an observation period of 36
months. In a prospective clinical study on
the survival of zirconia posterior FDPs
(Sailer et al. 2006), 46 posterior FDPs luted
with two types of resin cements (Variolink,
Panavia TC) were evaluated. After 36
months, seven FDPs had to be replaced
because of biologic and technical problems,
resulting in a survival rate of 84.8%. Chip-
ping of the veneering material was found in
13%. Secondary caries was found in 10.9%
of the FDPs, representing the major cause
for replacement. This result was explained
by marginal discrepancies that occurred in
50% of the investigated FDPs and was
related to the prototype stage of the man-
ufacturing technique used in the study.
Obviously, the use of composite cement
could not prevent microleakage and the
related consequences.
As a result of the cited studies, the
strength of glass-ceramics and thus the
longevity could significantly be improved
utilizing adhesive procedures and using
supporting abutments or build-up materi-
als with a high modulus of elasticity
(Scherrer & De Rijk 1993). When water-
based cements are required, glass-ionomer
cements seem to exhibit certain advantages
compared with zinc phosphate cements
due to the improved fit of the restorations
after setting, better optical properties, and a
slight adhesion to tooth tissues as well as to
restorative materials (Wiskott et al. 1997;
Malament & Socransky 2001). Nonethe-
less, they also present a high solubility and
have a low elasticity modulus. Associated
with oxide ceramics, the positive influ-
ences on strength by bonding procedures
and the physical properties of the abutment
decrease significantly (Scherrer et al. 1996;
Bindl et al. 2006). The main indication for
adhesive measures with regard to oxide
ceramic FDPs should be to avoid loss of
retention.
Wing-retained resin-bonded FDPs
The fundamental principle in replacing
missing tooth tissues should be to restore
the function and esthetics at minimal bio-
logic cost (Marinello et al. 1997). Wing- or
199 |
inlay-retained FDPs are considered advan-
tageous to maintain both the tooth vitality
and biological structures of hard dental
tissues (Paszyna et al. 1990; Edelhoff
2002a, 2002b). In a 7.5-year survival study
on resin-bonded FDPs (Creugers et al.
1992), survival rates were reported to be
75% for anterior and 44% for posterior
restorations. In this study, electrolytically
etched metal FDPs were found to be more
retentive (78%) than perforated ones
(63%). In another study by Rammelsberg
et al. 1993, 141 wing-retained resin-
bonded FDPs were placed under controlled
conditions in a 6-year longitudinal study.
The influence of location (anterior/poster-
ior, maxilla/mandible), tooth preparation
techniques (retentive/less invasive), and
four different methods of metal condition-
ing (airblasting/electrolytic etching and/or
pyrolytic/tribochemical silica coating) on
the survival rate was investigated. In this
study, dual-cured resin cement was used.
Failures (23 of 24) were caused by loss of
adhesion at the metal–cement interface.
The retentive tooth preparation reduced
the risk of failure to almost one-twentieth,
whereas the intraoral location did not in-
fluence the survival time. The effect of
silane coating on longevity was extremely
positive and was not reflected by successful
retainers.
Enamel-preserving preparations and the
establishment of a reliable bond to both the
tooth structure as well as restorative mate-
rial were the most important pre-requisites
for predictable long-term results. However,
macroretentive preparation design can sig-
nificantly improve bond strength (Burgess
& McCartney 1989). One-thousand three-
hundred and ten three-unit resin-bonded
FDPs were examined in a clinical study by
Haastert et al. (1992). After 5 years, 86%
were still in situ. 64% did not need rebond-
ing. The significant prognostic factors in
this study were preparation, surface treat-
ment of restoration, type of luting agent as
well as the mobility of the abutments.
Besimo et al. (1996) found an estimated
success rate of 94% after 5 years with
macroretentive preparations in the form of
boxes and grooves. Behr et al. (1998) found
in a clinical long-term study on 120 resin-
bonded FDPs that the survival time was
determined mainly by the preparation tech-
nique. Also in this study dual-polymerized
resin cement was used. Strict preparation
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
Edelhoff & Özcan . Longevity of fixed dental prostheses
of seating grooves and pin holes resulted in
a 95% survival rate after 10 years (Kaplan–
Meier estimation). Without retention, the
risk of failure increased by a factor of 3.7. In
a 10-year follow-up, Audenino et al. (2006)
estimated a survival probability until the
first debonding or failure as 85% after 5
years and 71% after 10 years. In this study,
the use of rubber dam during cementation
reduced the risk of debonding. Preparation
design (axial grooves or boxes, preferably on
proximal surfaces), type of metallic alloy,
conditioning the cementation surfaces (see
the review by Özcan et al. 1998), insula-
tion during cementation, type of cement,
number of abutments, and finally the
number of missing teeth included all play
roles in clinical success (Kerschbaum et al.
1988).
Inlay-retained resin-bonded FDPs
Inlay-retained FDPs fabricated by metal
alloy and placed with water-based cements
are considered as an intermediate stage
before starting complete crown-retained
FDPs at a later stage (Eichner 1982). This
aspect must be taken into account in view
of the higher rate of failure compared with
FDPs retained by complete crowns. Inlay-
retained FDPs made of gold alloys, which
were placed using water-based cements,
demonstrated a failure rate between
28.1% after an average period of 9 years
of service (Sobkowiak 1981) and 46.4%
after a period of 2.5–9 years of service
(Bauer 1967). Secondary marginal caries
and loss of retention were recorded as the
main causes of failure (Sobkowiak 1981).
After 10 years in situ, the secondary caries
rate under single inlay restorations was 7%
higher than under single full-crown restora-
tions (Kerschbaum & Vo 1981). This rate
does not include the development of new
carious lesions. Erpenstein & Diedrich
(1977) found new carious lesions, which
did not develop as a consequence of sec-
ondary caries, on the remaining tooth sur-
face in 6.1% of teeth restored with partial
crowns. The increased susceptibility to
caries, therefore, is a clear contraindication
for this type of restoration. The following
factors are considered to be responsible for
the loss of retention: mobility of the abut-
ment teeth because of elastic jaw deforma-
tion (Marx 1967), loosening of teeth
because of periodontal factors, and inade-
quate tooth preparation (Eichner 1982).
200 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
Additional adhesive support provided by
mechanical retention will help to prevent
the early loss of retention (Gardner 1991).
Specific adhesion systems used on alloy
surfaces (Marx 1987) and the tooth struc-
ture (Barkmeier et al. 1986) have led to
successful results for wing-retained resin-
bonded FDPs for a number of years (Besimo
et al. 1996; Marinello et al. 1997). In a
clinical study, where adhesive cementation
was used, inlay-retained FDPs fabricated
from high gold alloys demonstrated a fail-
ure rate of 3.9% after 5 years (Stokholm &
Isidor 1996). As reliable adhesive bond can
be generated to ceramic materials (Edelhoff
& Marx 1995; Kern & Strub 1998), a
similar positive influence of adhesion
could be expected in bonded ceramic in-
lay-retained FDPs.
Sorensen et al. (1999) claimed that ad-
hesive techniques could only be used suc-
cessfully in conjunction with resin-bonded
inlay-retained FDPs, when retentive ele-
ments are provided. This clinical study on
resin-bonded FDPs on teeth without reten-
tive features or slight preparations resulted
in 10.5% loss of retention after only 4
months (Sorensen et al. 1999).
Implant-supported FDPs
Implants as abutments offer the additional
option of screw-retained FDPs. Besides
numerous advantages with regard to an
additional retentive function and the op-
tion of removal, the main drawback is
caused by screw access holes. Placed
at the occlusal surface, the esthetics and
function (occlusion) can be compromised
(Hebel & Gajjar 1997). A higher potential
of screw loosening and stress introduction
associated with screw-retained implant-
supported FDPs was reported (Brägger
et al. 2005; Heckmann et al. 2006). Cemen-
ted implant-supported FDPs, offer better
handling characteristics, the reduction of
microleakage, increased esthetics and func-
tion as well as the reduction of stress
concentration by passive fit (Heinemann
et al. 2006; Karl et al. 2006). Specific
guidelines, comparable with those for abut-
ment tooth preparation, were given for the
abutment design to create durable retention
of the implant-supported FDP (Bernal et al.
2003). For splinted multi- and single-unit
implant-supported FDPs water-based as
well as polymerizing cements could be
used (Heinemann et al. 2006; Karl et al.
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c 2007 Blackwell Munksgaard
2006). The position of the crown margin
should simplify excess removal of the ce-
ment (Hebel & Gajjar 1997; Wolfart et al.
2006). Zarone et al. (2007) found in an in
vitro study a stronger implant–prosthetic
connection in cemented restorations than
in screw-retained single crowns. In an
experimental study in Beagle dogs compar-
ing screw- vs. cement-implant-retained re-
storations Assenza et al. (2005) reported,
after 12 months, that eight (27%) loosened
screws were present in screw-retained
FDPs, whereas no abutment loosening
was observed in cemented restorations.
However, zinc oxide-based temporary ce-
ments can increase the risk of retention
loss (Akashi et al. 2002; Naert et al. 2001;
Palmer et al. 2005; Heinemann et al.
2006). In another retrospective study by
Preiskel & Tsolka (2004), cement- and
screw-retained implant-supported pros-
theses were observed up to 10 years of
follow-up. Screw- and cement-retained
prostheses were found to be valuable op-
tions in implant prosthodontics. In this
study, no accidental dislodgment of any
prosthesis occurred.
In a clinical study, 86 anterior all-cera-
mic alumina single-unit FDPs were placed
either on natural teeth or implants using
a resin-modified glass ionomer cement
(Zarone et al. 2005). The evaluation was
conducted after a 48-month period of clin-
ical service. For crowns supported by nat-
ural tooth, a success rate of 100% and for
implant-supported abutments a success
rate of 98.3% was calculated. Within the
limitations of this study, it was concluded
that all-ceramic crowns fabricated by den-
sely sintered alumina ceramic proved to be
a reliable therapeutic choice for the restora-
tion of anterior teeth on both natural and
implant-supported abutments. The resin-
modified glass ionomer cement appeared
to be a reliable luting agent. In a rando-
mized, prospective clinical trial, the clin-
ical performance of two- to five-unit
implant-supported all-ceramic reconstruc-
tions cemented with zinc phosphate ce-
ment was evaluated (Larsson et al. 2006).
Early 12-month results suggested that all-
ceramic implant-supported FDPs of two to
five units could be considered as a treat-
ment alternative. In a 4-year prospective
clinical study on single-tooth implant re-
storation, Vigolo et al. (2004) found a
cumulative implant success rate of 100%.

No differences between screw- or cement-
retained implants in terms of peri-implant
marginal bone or peri-implant soft tissue
situation could be detected.
Discussion
Based on the literature review and the
authors’ own expertise, expectations from
the performance of the cement in terms of
retention should be confined mainly
within the preparation type and the mate-
rial from which the restoration is made of.
Although many factors come into play
when choosing the cement, the mechan-
ical properties of the prepared tooth still
dominate for the retention especially when
water based cements would be used. Dis-
lodgement of single-unit or multiple-unit
FDPs luted with water-based cements can
be employed when the coronal height of
the preparation is more than 3 mm, the
angle of convergence is established be-
tween 41 and 101, as well as when the
final preparation is performed using coarse
diamond burs. When the coronal height is
not sufficient or the preparation is over-
tapered (4101 angle of convergence), the
core geometry could be idealized with the
adhesive resin-based core materials and
additional macroretentions on the existing
dental tissues for contour corrections. In
this case, water-based cements can be used.
Owing to easy handling of the water-based
cements and more favorable properties as
opposed to the polymerizing ones, it can be
chosen especially in situations where the
preparation finish lines are subgingival,
crevicular fluid cannot be perfectly con-
trolled, or when a complete dry environ-
ment cannot be established. The use of
polymerizing cements in such situations
may then led to an impairment in the
hybrid layer.
One of the determinants of the choice
between water-based or polymerizing ce-
ments is the concern of microleakage and
eventually secondary caries on the dental
tissues underneath the FDP. Water-based
cements are more prone to solubility than
resin-based cements. An ideal fit of the
restoration should be one of the major tasks
of the clinicians and the dental technicians,
especially for restorations that are conven-
tionally cemented. Nonetheless, in that
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c 2007 Blackwell Munksgaard
Edelhoff & Özcan . Longevity of fixed dental prostheses
respect polymerizing cements offer more
forgiving properties.
Adhesive cementation is appropriate if
the location of the preparation margin per-
mits absolute isolation with a rubber dam
or when it is located supragingivally. The
adhesive cementation technique should be,
however, preferred in the presence of a
short clinical crown (o3 mm tooth height)
and an angle of convergence of more than
101, where the restorations may be more
prone to loss of retention due to the re-
duced size of the contact surfaces and the
lack of retentive walls (Wiskott et al. 1996,
1997; Cameron et al. 2006).
Esthetic considerations also play an im-
portant role associated with supragingival
margins and thereby the choice of cements.
In exceptional cases, partial isolation and a
retraction cord without impregnation could
be used instead of complete isolation.
Water-based cements, using for instance,
glass-ionomer cement could be preferred if
the patient is known to be allergic to any of
the ingredients present in adhesive bonding
agents, if suboptimal periodontal condi-
tions are present, or when visibility of the
working field is poor. The basic require-
ments for water-based cements are an ade-
quate marginal fit (o100 mm), tooth
preparations that exhibit only a slight taper
of 4–101 as well as rather long clinical
crowns (43 mm) that provide a large rough
contact surface to prevent the loss of reten-
tion (Phillips et al. 1987; Kern et al. 1993;
Goodacre et al. 2001). The best retention
method for full-coverage FDPs could be
achieved with tooth preparations ground
with coarse diamonds and cemented with
Panavia 21 cement (Tuntiprawon 1999).
Polymerizing cements offer a wide
plethora of colors with which the end result
of the restorations can even be manipulated
(Paul et al. 1996). This is particularly im-
portant for anterior ceramic veneers where
high esthetic is demanded.
The choice of polymerizing cements is
obligatory for ceramic veneers, inlays, and
onlays. The influence of adhesive cemen-
tation on increasing fracture strength of the
silica-based ceramic restorations had been
proven in in vitro and in vivo studies
(Scherrer et al. 1996; Malament & So-
cransky 1999a, 1999b). However, to avoid
a higher incidence of microleakage it is
advantageous to confine the preparation
margins within the enamel shell (Friedman
201 |
1998; Federlin et al. 2005). Marginal de-
fects of ceramic laminate veneers were
especially noted at locations where the
restoration ended in existing composite
fillings (Karlsson et al. 1992; Peumans
et al. 2004).
With the introduction of high-strength
oxide ceramics, the compulsory application
of adhesive cementation is diminished.
Reinforced ceramics do not seem to require
adhesive cementation for ceramic strength-
ening purposes unless of course, the fit of
the restorations is ideal. The main indica-
tion for adhesive measures should be the
avoidance of loss of retention and the im-
provement of esthetics. In situations where
collarless cores are fabricated, adhesive ce-
mentation seems to be advantageous for
oxide ceramics due to the tooth-like color
and improved light transmission of the
adhesive cements (Hagmann et al. 2006).
Furthermore, early reports on more user-
friendly self-etching cements are promising
(Piwowarczyk et al. 2005), but clinical
long-term data are not available to date.
For wing-retained FDPs, the choice of
dual-polymerizing resin-cements increased
the survival of such restorations. However,
the results from the literature all favor
additional support of adhesive measures
by the preparation of grooves and pin holes
for the metal wings. These additional
macroretentions decreased the risk of fail-
ure by a factor from 3.7 to 20 (Rammels-
berg et al. 1993; Behr et al. 1998).
In all aspects of adhesive cementation,
the right surface conditioning both for the
dental tissues and the cementation surface
of the restorations should be performed
accordingly. In adhesive applications,
tooth–cement–material unity could
be achieved with the most suitable condi-
tioning method for each group of dental
materials, namely metals, ceramics, or
polymers (Edelhoff & Marx 1995; Kern &
Strub 1998; Kern & Wegener 1998; Özcan
et al. 1998). This issue is particularly
important in minimally invasive applica-
tions where retention of the restoration
does not rely on mechanical retention.
Type of tooth substrate, enamel or dentin,
seems to have an impact on the type of
failure. Failures associated with wing-
retained resin-bonded FDPs bonded to
the enamel were caused mainly by
loss of adhesion at the metal–cement inter-
face (Rammelsberg et al. 1993). In clinical
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 193–204
Edelhoff & Özcan . Longevity of fixed dental prostheses
long-term studies with adhesively luted
glass-ceramic crowns, loss of retention
was caused mainly by loss of adhesion at
the dentin–resin interface (Kinnen et al.
2006). These in vivo observations were
confirmed by an in vitro study on the
marginal integrity of feldspathic partial
ceramic crowns, in which the dentin–
luting material interface, in general,
showed higher percentages of compromised
adhesion than enamel– and ceramic–luting
material interfaces (Federlin et al. 2005). If
this unity is not achieved, the bonded
interface would result in detachment of
one layer from the other and eventually
dislodgment of the restoration. A growing
number of efforts are being made to opti-
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