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Cementing all-ceramic restorations

Recommendations for success


Marcos A. Vargas, DDS, MS; Cathia Bergeron, DMD, MS; Ana Diaz-Arnold, DDS, MS

T
he longevity and success of indirect restora-
tions are influenced by patient and oper-
ator. The patient dictates oral hygiene, diet
AB STRACT
and functional habits. The operator man- Background. Several all-ceramic restorative
ages tooth preparation, impression and cementa-
systems of various compositions, properties and
tion. Cementation is a crucial step in the process of
indications are available to the dental practitioner.
ensuring the retention, marginal seal and dura-
bility of indirect restorations. Because of the large number of systems, the dental
Dentistry has benefited from the introduction of team faces questions and decisions when choosing
new types of ceramics. Better esthetics, increased the appropriate system and the appropriate means
resistance to fracture, biocompatibility and of cementation.
expanded clinical indications are some of the Overview. The authors present a brief overview
advantages offered by contemporary ceramics. of the cementation options for various types of all-
Because each ceramic is unique in terms of its com- ceramic restorations. In this article, they discuss
position, choosing the appropriate ceramic and the cementation of current all-ceramic restorations
cement for each clinical situation can be difficult and make clinical recommendations tailored to
and confusing. To achieve a successful outcome, the each type of ceramic.
clinician must understand the ceramic type, sur- Conclusion and Clinical Implications.
face treatment, cementation material and pro- The clinician must have a good understanding of
cedure, because the ceramic surface treatment the ceramic type to determine whether a restora-
before cementation varies according to the type of tion should be cemented adhesively or nonadhe-
ceramic used. In this article, we provide recommen- sively. Other variables, such as isolation and prepa-
dations that can guide clinicians to successful ration design, also influence the cementation
cementation of all-ceramic restorations. (The table
choice. Various ceramic types demand different
summarizes the adhesive cementation procedures
surface treatments before cementation. Choosing
discussed in this article.)
and applying the appropriate surface treatment
CEMENTATION PROCEDURES and cementation procedure will contribute to long-
Cementing procedures are either adhesive or non- lasting restorations. The literature is lacking in
adhesive.1,2 Adhesive cementation involves the use clinical trial results that validate current in vitro
of an agent to promote bonding of the restorative data regarding cementation of all-ceramic
material to the substrate; it is a combination of restorations.
adhesive chemical bonding and micromechanical Key Words. Cementation; dental cements;
interlocking. Nonadhesive (conventional) cemen- dental porcelain.
tation involves the use of a luting agent to fill the JADA 2011;142(4 suppl):20S-24S.
space between the restoration and the natural
tooth and relies solely on micromechanical reten-
Dr. Vargas is a professor, Department of Family Dentistry, College of Dentistry,
tion.3 Indications for each type of cementation are The University of Iowa, S-317 DSB, Iowa City, Iowa 52242-1001, e-mail
dictated by the composition of the ceramic, the “marcos-vargas@uiowa.edu”. Address reprint requests to Dr. Vargas.
available preparation retention and resistance Dr. Bergeron is a clinical associate professor, Department of Operative
Dentistry, College of Dentistry, The University of Iowa, Iowa City.
form, and the field control at the time of cementa- Dr. Diaz-Arnold is a professor, Department of Family Dentistry, College of
tion.4,5 Short, tapered preparations will benefit Dentistry, The University of Iowa, Iowa City.

20S JADA 142(4 suppl) http://jada.ada.org April 2011


Copyright © 2011 American Dental Association. All rights reserved.
TABLE

Summary of adhesive cementation procedures, according to ceramic type.


CERAMIC FILLER SURFACE TREATMENT PRODUCT EXAMPLES
Predominantly Aluminum oxide Apply 10 percent hydrofluoric (HF) acid for Ceramco 3 (Dentsply, York, Pa.), IPS e.max
Glass 1 minute, rinse and dry; apply silane for Ceram (Ivoclar Vivadent, Amherst, N.Y.), Vita
1 minute, air dry VM 7 (Vita Zanhfabrik, Bad Säckingen,
Germany)
Particle-Filled Leucite Apply 5 percent HF acid for 1 minute, rinse IPS Empress Esthetic (Ivoclar Vivadent)
Glass and dry; apply silane for 1 minute, air dry

Lithium disilicate Apply 5 percent HF acid for 20 seconds, rinse IPS e.max Press (Ivoclar Vivadent)
and dry; apply silane for 1 minute, air dry
Glass-infiltrated Perform air abrasion with tribochemical Vita In-Ceram Alumina, Vita In-Ceram Spinell
alumina silica coating or aluminum oxide; apply an and Vita In-Ceram Zirconia (Vita Zahnfabrik)
adhesion-promoting agent containing MDP*
and dry

Polycrystalline Aluminum oxide Perform air abrasion with aluminum oxide; Procera Alumina (Nobel Biocare, Zurich)
apply an adhesion-promoting agent
containing MDP and dry
Zirconium oxide Air abrasion with 50-micrometer aluminum Cercon Zirconia (Dentsply), Everest (KaVo,
oxide powder at 7 pounds per square inch; Charlotte, N.C.), Lava Zirconia (3M ESPE,
apply an adhesion-promoting agent St. Paul, Minn.), IPS e.max ZirCAD (Ivoclar
containing MDP and dry Vivadent)
* MDP: 10-methacryloyloxydecyl dihydrogen phosphate.

from cementation via adhesive techniques, to the prepared tooth adhesively so as to in-
because this process creates a dentin hybrid crease the restoration’s resistance to fracture.9
layer that improves the mechanical retention of Thus, nonadhesive cementation is not indicated
the restoration.4 However, the use of bonding for feldspathic ceramic.10
agents requires additional steps and meticulous The clinician needs to prepare or “condition”
isolation, which may not be feasible in the clin- predominantly glass feldspathic ceramics before
ical environment. Also, clinicians should ensure performing adhesive cementation. The clinician
that laboratory technicians use precise methods etches the ceramics’ intaglio surface with a solu-
to achieve proper adaptation, because the use tion of hydrofluoric (HF) acid, in concentrations
of adhesive cements will not compensate for between 5 and 10 percent, for approximately
poor fit. one minute. This step provides an increased
surface area, micromechanical retention and a
CERAMIC TYPES clean surface (as described by Navez and col-
When the clinician is selecting the cementation leagues11) for adhesive cementation (Figure 1).
procedure for all-ceramic restorations, it is The clinician places silane over the etched sur-
important that he or she know the composition face to increase the wettability of the resin
and structure of the ceramic used to fabricate cement and to interact chemically with both the
the restoration. Dental ceramic systems can be resin matrix and the hydroxylated porcelain
classified according to their matrix material, surface.12,13 Both etching and silanation are rec-
filler and dopant. Three main categories of ommended, as some investigators have reported
dental ceramics have been described in the liter- higher veneer failure rates when ceramic is air
ature: predominantly glass, particle-filled glass abraded and silanated but not etched with HF
and polycrystalline (nonglass) ceramics.6,7 acid.14,15 Hydrolyzed and unhydrolyzed silanes
Predominantly glass ceramics. This type are available. Hydrolyzed silanes most com-
of ceramic is derived from feldspar minerals, sil- monly are one-bottle systems with a short shelf
icon and aluminum oxides. It is used as a life; if the bottle’s contents are used after the
veneering material over metal or ceramic cop- expiration date, it can be detrimental to the
ings and frameworks.7,8 Additionally, it is used bond.16 Unhydrolyzed or “inactive” silanes are
to fabricate jacket crowns, inlays, onlays and two-bottle systems that the clinician mixes
porcelain veneers. This ceramic is highly before application to ensure a fresh and active
esthetic, biocompatible, and resistant to abra- silane and a longer shelf life than that of
sion and compressive forces. It also is character-
ized by low mechanical strength in comparison ABBREVIATION KEY. HF: Hydrofluoric. MDP: 10-
with other ceramic types and must be cemented methacryloyloxydecyl dihydrogen phosphate.

JADA 142(4 suppl) http://jada.ada.org April 2011 21S


Copyright © 2011 American Dental Association. All rights reserved.
polymerized resin cements.21
Self-adhesive resin cements have been devel-
oped in an attempt to decrease bonding steps and
improve ease of use. This approach combines the
adhesive and the cement in one step. Examples
include Rely X Unicem Self-Adhesive Universal
Cement (3M ESPE), SmartCem 2 (Dentsply, York,
Pa.) and SpeedCEM (Ivoclar Vivadent). Another
approach is to use a self-etching primer before
applying the cement, as seen in systems such as
Panavia F 2.0 (Kuraray, New York City) and Mul-
tilink Automix (Ivoclar Vivadent). Clinicians may
choose these cements because of their simplicity
and therefore their reduced potential for applica-
Figure 1. Microscopic view of the surface of a predominantly
tion errors. Unfortunately, results of in vitro
glass ceramic (Vita VM 7, Vita Zahnfabrik, Bad Säckingen, Ger- investigations have shown that these cements’
many), etched for one minute with 9.5 percent hydrofluoric acid. bond to enamel and dentin is less than that
demonstrated by a combination of adhesive sys-
hydrolyzed silanes.16,17 tems and resin cements.22,23
Adhesive cementation to enamel or dentin Particle-filled glass ceramics. These
requires the use of an adhesive system, followed ceramics consist of various amounts and types of
by application of a resin cement.2 Adhesive sys- particles and a glassy matrix. The inclusion of
tems can be either self-etching or total etching. particles improves the physical strength of the
Self-etching systems are popular among den- ceramic. As the number of particles increases and
tists because they are easy to use, but as a gen- the amount of glass decreases, the material’s
eral category they have demonstrated bond strength increases, but unfortunately some of the
strength to enamel weaker than that of total- translucency and esthetic properties are dimin-
etch systems.18 Therefore, the total-etch three- ished. According to their strength, the various
step adhesive system is considered the gold materials in this category can be used as
standard. It is imperative to follow the manu- veneering material or as copings.6
facturer’s instructions during adhesive cemen- Low-filled materials such as IPS Empress
tation, including use of the manufacturer’s Esthetic (Ivoclar Vivadent) and OPC (Jeneric
adhesive and resin cement combination, be- Pentron, Wallingford, Conn.) are filled with
cause investigators have found incompatibilities leucite. Their physical strength is relatively low
between some dual-cure resin cements and sim- in comparison with that of other filled glass
plified adhesive systems.19 materials, which is why they are indicated
Resin cements are polymerized via light, chem- mainly for veneers, inlays and onlays, as well as
icals or a dual process combining the two. Light- low-stress situations.7 These ceramics need to
polymerized resins are recommended when the be cemented adhesively to improve their
ceramic is thin and fairly translucent, allowing strength.9 The cementation procedure is similar
the transmission of light through it to reach the to that described previously for the predomi-
resin cement. Examples of light-polymerized nantly glass type of ceramic.
cements include Rely X Veneer Cement (3M Intermediate-filled material, such as IPS
ESPE, St. Paul, Minn.), Variolink Veneer (Ivoclar e.max Press (Ivoclar Vivadent) and OPC 3G
Vivadent, Amherst, N.Y.) and Choice 2 Light- (Jeneric Pentron), is reinforced with lithium di-
Cured Veneer Cement (Bisco, Schaumburg, Ill.). silicate and has strength and pleasing esthetic
Dual-polymerized resin cements are indicated properties sufficient to allow its use for veneers,
when the ceramic is too thick or too opaque to single crowns and copings. This material can be
allow transmission of light through it.20 Examples cemented adhesively or nonadhesively when
include NX3 Nexus Third Generation (Kerr, used with full-coverage restorations; clinical
Orange, Calif.), Rely X ARC Adhesive Resin studies have reported no difference between the
Cement (3M ESPE) and Variolink II (Ivoclar two types of cementation.24,25 Partial-coverage
Vivadent). Chemically polymerized resin cements restorations, such as inlay, onlay and porcelain
do not offer much selection in terms of shade and veneer restorations, require adhesive cementa-
translucency; therefore, dual-polymerized resin tion to increase their retention and fracture
cements can be beneficial. Additionally, accessible resistance. Full-coverage crowns can be
areas benefit from light polymerization with dual- cemented conventionally or adhesively

22S JADA 142(4 suppl) http://jada.ada.org April 2011


Copyright © 2011 American Dental Association. All rights reserved.
Figure 2. Microscopic view of the surface of a particle-filled Figure 3. Microscopic view of the untreated surface of a poly-
glass ceramic (IPS e.max Press, Ivoclar Vivadent, Amherst, N.Y.), crystalline ceramic (Everest, KaVo Dental, Charlotte, N.C.).
etched with 5 percent hydrofluoric acid for 20 seconds.

according to the preparation design. Conven- coating the ceramic with tribochemical silica
tional cementation is carried out with conven- and air abrading the intaglio surface, followed
tional luting agents such as resin-modified glass by the application of 10-methacryloyloxydecyl
ionomer cements, without the need for interme- dihydrogen phosphate (MDP) (a silane and
diate agents. Short, clinically nonretentive phosphate monomer) before using resin cement,
preparations should be cemented adhesively. improves the bond to this type of ceramic.27,28
Another consideration is field control, as it is Polycrystalline ceramics. Polycrystalline
imperative that the clinician achieve effective ceramics are densely sintered aluminum oxide
isolation to keep the field free of saliva and (Procera Alumina, Nobel Biocare, Zurich) or zirco-
other contaminants when using adhesive nium oxide (Cercon Zirconia, Dentsply; Everest,
cements. The adhesive cementation of particle- KaVo Dental, Charlotte, N.C.; Lava Zirconia, 3M
filled glass ceramics is similar to the technique ESPE; Vita In-Ceram YZ, Vita Zahnfabrik; IPS
used for predominantly glass ceramics; however, e.max ZirCAD, Ivoclar Vivadent) materials and
the clinician must modify the process of condi- are characterized by the absence of glass in their
tioning the restoration’s intaglio surface to composition6,7 (Figure 3). Because their atoms are
achieve optimal adhesion. Manufacturers rec- packed into regular arrays, these materials resist
ommend etching the intaglio surface of leucite- the propagation of cracks.29 These ceramics pos-
reinforced restorations with a solution of 10 per- sess high toughness and strength and can be used
cent HF acid for approximately 60 seconds for copings and frameworks.
before cementation. Lithium disilicate– Polycrystalline ceramics most often are
reinforced ceramic should be etched with a solu- cemented conventionally but, in certain circum-
tion of 5 percent HF acid for approximately 20 stances, can benefit from adhesive cementation.
seconds (Figure 2). The clinician then should Investigators have reported the use of air abra-
apply a silane, followed by an adhesive system sion with aluminum oxide or tribochemical silica
and a resin cement, similar to the protocol used application followed by application of an
for predominantly glass ceramics. adhesion-promoting agent to increase the bond
Another type of particle-filled glass is made strength of resin cements.30 Air abrasion increases
of a sintered core of aluminum oxide infiltrated the available surface area for bonding, yet it also
with molten glass. These ceramics have high appears to introduce quasiplasticity, as well as
strength and fracture toughness with minimal microcracks or potential fracture initiation sites.
glass content. Some products in this category Thus, the use of postsintering surface treatments
include In-Ceram Alumina (Vita Zahnfabrik, remains controversial, although low-pressure
Bad Säckingen, Germany), In-Ceram Spinell abrasion has been recommended.31 In vitro
(Vita Zahnfabrik) and In-Ceram Zirconia (Vita studies have shown that treating zirconium oxide
Zahnfabrik). They often are referred to as glass- restorations with a combination of tribochemical
infiltrated aluminum-oxide ceramics. They are silica and MDP or using a primer based on phos-
cemented conventionally rather than adhe- phate and carboxylate functional monomers (such
sively, because etching glass with HF acid does as Z-Prime Plus [Bisco]) or a primer combination
not appear to increase the retention of resin of MDP and a metal primer (such as Alloy Primer
cements.26 Some researchers have reported that [Kuraray]) enhanced the bond of resin-based

JADA 142(4 suppl) http://jada.ada.org April 2011 23S


Copyright © 2011 American Dental Association. All rights reserved.
luting cements.32-34 Furthermore, the use of a 13. Kitayama S Nikaido T, Takahashi R, et al. Effect of primer
primer containing MDP (such as Clearfil Ceramic treatment on bonding of resin cements to zirconia ceramic (published
online ahead of print Jan. 25, 2010). Dent Mater 2010;26(5):426-432.
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additional 37,500 thermal cyclings) when com- porcelain laminate veneers: a retrospective evaluation of 6.5 years. J
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625-628, 630, 632.
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24S JADA 142(4 suppl) http://jada.ada.org April 2011


Copyright © 2011 American Dental Association. All rights reserved.