CONTEMPORARY ISSUES

Contemporary Ceramics and Cements

Author
SABIHA S. BUNEK, DDS*
Associate Editor
EDWARD J. SWIFT, JR., DMD, MS

The demand for improved esthetics and concerns about

the biocompatibility of metals have caused a revolution
in the area of all-ceramic restorations. Ceramic
materials are evolving with higher strength and
increased translucency to provide improved esthetic
restorations. Additionally, monolithic ceramic
restorations are rapidly growing in popularity, rapidly
replacing ceramometal and layered restorations. As
dental materials continue to evolve, confusion regarding
material choice and cementation, bonding, and surface
treatment is prevalent. Clinicians are seeking ways to
navigate both material choice and cementation
protocols. Unfortunately, there is not an ideal
combination of materials that are suitable for every
clinical situation. The goal of this Contemporary Issues
article is to provide a brief understanding of available
materials on the market and discuss how the properties
of both the ceramic and cement perform together.

CERAMIC OPTIONS
Modern all-ceramic systems can be categorized based
on their glass and crystalline content. A ceramic with
high glass content will exhibit excellent esthetics
whereas a ceramic with high crystalline content will
provide superior strength. Ceramics can be classied
into three categories based on composition: porcelains
(feldspathic), glass ceramics (leucite-reinforced, lithium
silicate, and lithium disilicate), and polycrystalline
ceramics (zirconia and alumina).
Feldspathic porcelains (containing mostly glass) are
composed of potassium feldspar, quartz, and kaolin.
Because of their high glass content, they have superior

translucency and esthetics. They have the lowest

exural strength among ceramics, ranging from 70 to
110 MPa, making them highly brittle. They are most
commonly used as a veneering material on a stronger
ceramic or metal core.
Leucite-reinforced ceramics (IPS Empress Esthetic,
Ivoclar Vivadent, Amherst, NY, USA; Cerpress SL,
American Dental Supply, Allentown, PA, USA) oer
excellent esthetics and translucency. The addition of
leucite crystals to the glass matrix slightly improves
mechanical properties, making these ceramics ideal for
veneers, inlays/onlays, and anterior crowns.
Lithium disilicate ceramics (IPS e.max, Ivoclar
Vivadent) consists of approximately 70% lithium
disilicate crystals that are embedded in a glassy matrix,
resulting in a relatively translucent material that is 2 to
3 times stronger than leucite-reinforced ceramics
(360400 MPa). The combination of strength and
esthetics makes them one of the most versatile
materials on the market, allowing them to be used for
veneers, inlays/onlays, anterior/posterior crowns,
three-unit anterior xed partial dentures, and implant
restorations.
Zirconia-based ceramics (mostly crystals) are the
highest strength ceramics because of their crystalline
structure. The lack of a glass component within the
matrix results in an opaque restoration, compromising
esthetics in some cases. Traditional zirconia-based
ceramics utilize zirconia as a base framework. Similar to
the fabrication of a Porcelain-fused-to-metal (PFM)
crown, the framework is veneered with ceramic,
providing esthetics to the inherently opaque restoration.

*Editor-in-Chief, The Dental Advisor, Ann Arbor, MI, USA; Private Practice, Enspire Dental, Ann Arbor, MI, USA

2014 Wiley Periodicals, Inc.

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CONTEMPORARY ISSUES

The success of zirconia-based ceramics as a strong

framework led to the development of full-contour
monolithic restorations.
New zirconia-based ceramics have been developed that
are preshaded with improved translucency and are
designed for use as monolithic restorations (Lava Plus,
3M ESPE, St. Paul, MN, USA; NexxZr T, Sagemax,
Federal Way, WA, USA; Zenostar, Ivoclar
Vivadent/Wieland Dental, Amherst, NY, USA; Bruxzir,
Glidewell Dental Laboratories, Newport Beach, CA,
USA). Zirconia-based ceramics continue to gain
popularity because of high strength, fracture toughness,
biocompatibility, longevity, and versatility. They are
increasing in popularity because of minimal tooth
preparation (similar to cast gold), low cost, and use in
multiple connected units. The current clinical challenge
with zirconia ceramics is that they lack the esthetics of
other more translucent materials. These full-contour
restorations oer the strength of zirconia and when
stained and glazed properly, better esthetics than
previous full-contour zirconia material. Figure 1
illustrates properties of ceramics as a whole for
consideration in case selection.
Newer materials on the market include lithium silicate
(Obsidian, Glidewell Dental Laboratories) and resin
nano ceramics (Lava Ultimate, 3M ESPE; Enamic,

Vident, Brea, CA, USA). The latter are available as a

computer-aided design and computer-aided
manufacturing(CAD/CAM) block, both for chairside
milling and laboratory use. The block is fabricated by
combining resin nanoparticles with zirconia particles.
With a exural strength of 200 MPa, the material is
best used for inlay/onlays, anterior/posterior crowns,
and implant-supported crowns. The material is not as
brittle as a conventional ceramic; therefore, it mills
easily and does not require an additional ring step.
Lithium silicate is a glass ceramic material indicated for
the fabrication of full-contour crowns, three-unit
anterior xed partial dentures, veneers, inlays, and
onlays. The reported exural strength falls between
leucite reinforced and lithium disilicate. Obsidian can
be pressed or milled, or as a veneering ceramic to
metal.

CEMENTATION PROTOCOLS
FOR ALL-CERAMICS
The adhesive systems that allow newer ceramics to
bond to tooth structure have rapidly evolved as new
ceramics are introduced. There are a number of new
resin cements on the market, some of which combine
existing materials for convenience and simplied

FIGURE 1. As a general rule: As flexural

strength increases, esthetics decreases.
Reprinted by permission of Dental
Consultants Inc.

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CONTEMPORARY ISSUES

procedures, and some that have entirely new chemistry;

however, we have yet to see a true universal cement for
all indications.

RESIN CEMENTS
The introduction, improvement, and growing
popularity of all-ceramic restorations has, in turn,
spurred a surge in popularity of resin cements that
address the many of the shortcomings of traditional
luting cements. They exhibit high bond strength to
tooth structure, superior esthetics, and the lowest
solubility of the available cements. Currently, resin
cements can be classied into three categories:
self-adhesive, adhesive, and esthetic resin. Self-adhesive
cements (RelyX Unicem, 3M ESPE; Panavia SA,
Kuraray America, Inc., New York, NY, USA) require no
separate etching or priming of tooth structure.
Adhesive cements (Multilink Automix, Ivoclar
Vivadent; Duo-Link Universal, Bisco, Inc., Schaumburg,
IL, USA) bond to the tooth through the use of
self-etching primers. Esthetic resin cements (NX3, Kerr
Corporation, Orange, CA, USA; Calibra, Dentsply
Caulk, Milford, DE, USA) bond based on an
etch-and-rinse adhesive. Characteristics of each are
outlined in Table 1.

SELECTING THE BEST CEMENT

There are many types of cement to choose from, and
often there is more than one viable option. An easy
place to start in the decision-making process is the
strength of the ceramic in conjunction with the
retentiveness of the preparation.
Generally, when esthetics is of high concern, low- to
medium-strength ceramics (feldspathic,
leucite-reinforced, lithium silicate, and lithium
disilicate) are selected. In these cases, using
high-strength cement (adhesive resin or esthetic resin)
will add strength to the restoration. When cementing a
veneer, esthetic resin cements provide a variety of
shades, translucencies, and try-in pastes. Light-cured
resin cements are less likely to change color when
cured and are recommended for veneers.
When using high-strength ceramic, such as zirconia,
with a retentive preparation, low-strength cement such
as a self-adhesive resin cement or resin-modied glass
ionomer (RMGI) can be used because it is not
necessary to rely on the cement for additional strength.
Zirconia-based ceramics are not glass ceramics;
therefore, the methods of mechanical and chemical

TABLE 1. Characteristics of resin cements. Reprinted by permission of Dental Consultants Inc

Self-adhesive resin
cements

Adhesive resin cements

Esthetic resin cements

Self-etchingno phosphoric acid or

special primer needed.

Bonding agent required for adhesion to

enamel and dentin and may not require
separate primer for adhesion to metallic or
ceramic restorations.

Bonding agent required for adhesion to

enamel and dentin and separate primers are
required for adhesion to metallic or ceramic
restorations.

Dual-cured.

Dual-cured.

Dual-cured or light-cured.

Fluoride-releasing.

Usually available in universal, translucent, and

opaque shades.

Usually available in VITA and translucent

shades.

Usually available in universal,

translucent, and opaque shades.

Higher strength than self-adhesive resin

cements.

Higher strength than self-adhesive resin

cements.

May require refrigerationbring to

room temperature before using.

May require refrigerationbring to room

temperature before using.

Special light-cured esthetic resin cements are

available for bonding all-ceramic veneers.

dentaladvisor.com

2014 Wiley Periodicals, Inc.

THE DENTAL

DOI 10.1111/jerd.12120

ADVISOR

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CONTEMPORARY ISSUES

FIGURE 2. Guidelines for cement

selection based upon strength of
ceramic and retentiveness of
preparation. Reprinted by permission
of Dental Consultants Inc.

bonding (hydrouoric acid-etch and silanation) used on

glass ceramics are not applicable. To form a strong
bond to zirconia-based ceramics, the bonded
surface must be mechanically roughened, free of
contaminants, and chemically primed prior to
cementation.

retention is not ideal, then the zirconia-based

restoration should be primed with ceramic primer and
bonded using esthetic or adhesive resin cement
(Figure 2).

SUMMARY
For zirconia-based restorations, micromechanical
roughening is accomplished through sandblasting
(airborne particle abrasion). Laboratory studies at The
Dental Advisor (Ann Arbor, MI, USA) have found that
sandblasting the intaglio surface with 50 um alumina
oxide at low pressure (2 bar) increases the surface area,
resulting in better resin bond strengths. Contaminants
after try-in can be removed with the use of a surface
cleaner (Ivoclean, Ivoclar Vivadent).
Zirconia-based ceramics require specic primers to
promote the chemical bond at the non-silica
oxidecement interface when the retention/resistance
from is compromised. These primers (Z-Prime Plus,
Bisco, Inc.) contain an acidic monomer (10-MDP
(10-Methacryloyloxydecyl dihydrogen phosphate)) and
are compatible with dual-cured resin cements.
Some ceramic primers (Clearl Ceramic Primer,
Kuraray America, Inc.; Monobond Plus, Ivoclar
Vivadent; Scotchbond Universal Adhesive, 3M ESPE)
will bond to both silica- and zirconia-based
restorations.
Zirconia-based restorations with good retention can be
cemented with traditional crown and bridge cements
(such as RMGI) or self-adhesive resin cements. If

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As dental materials evolve, there is a continual

push toward strong yet esthetic restorations. Just in the
last decade, we have witnessed tremendous progress in
terms of both strength and esthetics. Where once
low-strength, silica-based ceramics were the only
option for esthetic restorations, we now have
all-ceramic options that provide us four times the
strength. With the success of lithium disilicate
ceramics, it is clear that the dental industry is moving
toward acceptance of monolithic restorations. As such,
full-contour zirconia-based crowns and bridges are
being manufactured, oering higher translucency and
high strength. We will continue to see full contour
zirconia restorations grow in popularity because of
lower cost, higher strength, and conservative
preparation. As materials change, the evolution of a
truly universal cement will emerge, providing the
clinician with every setting option (light-, dual-, and
self-cure) contained in one kit.

SUGGESTED READING
Bunek SS, Powers JM. Crown and bridge cements: clinical
applications. Dent Today 2012;31:405.

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CONTEMPORARY ISSUES

Chen L, Suh BI, Brown D, et al. Bonding of primed zirconia

ceramics: evidence of chemical bonding and improved
bond strengths. Am J Dent 2012;25:1038.
Inokoshi M, De Munck J, Minakuchi S, Van Meerbeek B.
Meta-analysis of bonding eectiveness to zirconia
ceramics. J Dent Res 2014;93:32934.
McLaren EA, Whiteman YY. Ceramics: rationale for material
selection. Compend Contin Educ Dent 2010;31:
66672.

Contemporary Issues
Sabiha S. Bunek
Editor-in-Chief of THE DENTAL ADVISOR
3110 W. Liberty
Ann Arbor, MI 48103
Telephone: 734-665-2020 x108
Fax: 734-665-1648
E-mail: mary@dentaladvisor.com;
sabihabunek@gmail.com; drbunek@dentaladvisor.com

Sakaguchi RL, Powers JM, eds. Craigs restorative dental

materials. 13th ed. St. Louis (MO): Elsevier Mosby;
2012.

2014 Wiley Periodicals, Inc.

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