2 INSIDE DENTISTRY—NOVEMBER/DECEMBER 2007

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Simplifying the Cementation Protocol After reading this article, the

reader should be able to:

Christopher Pescatore, DMD ■ describe the difference

between adhesive resin
ABSTRACT cements and self-etch, self-
adhering cement systems.

Predictable tissue retraction and adhesive dentistry can be laborious and tedious tasks for many dental professionals. Putty or
paste tissue retraction has significantly improved the ability to achieve tissue management in less time in the most difficult situations.
Self-etching, dual-cure resin cements offer the clinician a simplified technique to cement non-metal restorations with little to no
sensitivity and significant bond strengths.
Dentistry, like many other profes-
sions, is consistently seeing revolutionary
technological changes. Product improve-
ments and the techniques that employ
them are allowing dental professionals to
provide more efficient dental care while sat-
isfying the esthetic concerns of their pa-
tients. The esthetic indirect restoratives
category of dental techniques has seen
tremendous growth, especially in the
bonding and cementation segments of
the procedures.1 The standard selection
of porcelain ceramic materials has been
marred by reputed high clinical fracture
rates and poor clinical longevity when used
in conjunction with traditional acid-based
cementation techniques.2 However, there
is significant in vivo and in vitro evidence
to support the notion that adhesive resin
cements can improve clinical longevity and
fortify indirect ceramic restorations.3 In
fact, the adhesive nature of some restora-
tions has been said to reinforce the re-
maining tooth structure by increasing
fracture toughness and stiffness, and evi-
dence suggests that adhesive resin cements
may boost the clinical longevity of porce-
lain prosthetics by decreasing the proba-
bility of crack initiation from the internal
aspect of the restorations.4
This new information, coupled with
the esthetic trends in dentistry, has in-
creased the study of various product lines
involved with indirect restorations, par-
ticularly dental cements. Permanent resin
cements are touted as the material of choice
for metal-free restorations, with an empha-
sis on self-etching products, which are
increasingly more popular because of their
ability to offer a simplified protocol, good
bond strength, and improved esthetics.5,6
RESIN CEMENTS
Before the advent of resin adhesive prod-
ucts, cements typically were formed by
an acid/base reaction in which the acidic
liquid and basic powder were combined;
the powders commonly were either zinc
oxide or aluminosilicate glasses while the
liquids were phosphoric acid, polyacrylic
acid, or eugenol.7 The choice of luting
cement is often dictated by its chemical and
mechanical properties and the clinical
situation at hand. Cement performance
preferences typically include: low viscosity
and film thickness, long working time with
rapid set at oral temperatures, low solubil-
ity, high compressive and tensile strengths,
adhesion to tooth structure and restora-
tive materials, anticariogenic properties,
and biocompatibility.
Adhesive resin cements are able to bond
both to tooth structure and restorative
material but they have some critical dif-
ferences. Resin cements typically are used
in conjunction with bonding agents to
facilitate micromechanical attachment
to both structures through bonding, thus
allowing for increased retention.8 These
products were developed to reduce post-
operative sensitivity, microleakage, mar-
ginal staining, and caries; also, they are
known to have a stronger ability than tra-
ditional cements to fill voids under restora-
tions.9,10 In today’s dental practice, there
are three main categories of resin cements:
• cements that use a total-etch adhesive
system (separate etch, adhesion, and
cement systems);
• cements that use an acidic self-etch-
ing adhesive system—not phosphoric
acid—to demineralize the tooth (com-
bined etch and bonding steps fol-
lowed by application of the cement);
and
• a select group of self-etch cements that
reportedly have self-adhesive charac-
teristics embedded in the cement, which
negates the necessity for a separate adhe-
sive application to the tooth.11
Dental cements have evolved to opti-
mize bonds to dental substrates. simplify
the application procedure, and reduce the
vulnerability to the clinician’s technique.12
Figure 1 Preoperative condition of the maxillary
left posterior teeth.
■ describe the proper clinical
insertion protocol for self-etch,
dual-curing resin cement use.
■ discuss the clinical aspect of
in-office CAD/CAM systems
and how to properly treat the
internal aspect of a porcelain
restoration before insertion.
The trend to eliminate steps from dental
procedures has been questioned in the
bonding agent arena and researchers have
found it necessary to test bond strengths
in the new category of self-etch cements.
Recent research conducted at the Uni-
versity of Frankfurt in Germany in the
Department of Prosthodontics demon-
strated that simplifying cementation by
eliminating the number of procedural
steps does not negatively affect the bond
to dentin.13 Manufacturers are aiming to
simplify processes and eliminate steps
while still maintaining the bond quality
between substrates.
SELF-ETCHING CEMENTS
Self-etching cements contain etchant, pri-
mer, and bonding components in one
delivery device. These cements appeal to
Figure 2 Preoperative condition of the mandibu-
lar left posterior teeth.

Christopher Pescatore, DMD

Private Practice
Danville, California

Figure 3 Preoperative impression using a dis- Figure 4 Gingival retraction paste used to achieve
posable plastic bite tray and alginate alternative. proper exposure of the margins for optical impression.

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INSIDE DENTISTRY—NOVEMBER/DECEMBER 2007
Figure 5 Gingival retraction paste applied to
necessary areas on the lower left quadrant.
Figure 9 All porcelain restorations in place
and the excess cement extruding from the mar-
ginal areas.
modern clinicians as they allow the prac-
titioners to fill the restoration with resin
cement, seat the restoration, clean the ex-
cess, and cure; these cements also allow
for a chemical cure if desired. The inherent
features of self-etching cements are para-
mount to give clinicians who perform
fewer nonmetal restorations the ability
to fulfill their patients’ esthetic demands
easily and predictably. This is unlike
traditional adhesive resin cements that
require an etching gel for the enamel and
dentin, primer and adhesive components
in multiple bottles, or unidose carriers
followed by an application of cement.14 A
self-etching bonding system may be used
in conjunction with the cement to pro-
vide added insurance against postoper-
ative sensitivity and insufficient bond qual-
ity if clinicians would rather use a more
traditional approach.
With simpler, shorter cementation tech-
niques and computer-aided prosthetic
design, indirect procedures have never been
easier or quicker to accomplish. For certain
dental cases without periodontal symptoms
and with proper tissue management, pros-
thetic fabrication and insertion can be
completed with little waiting time for the
patient. This article will focus on using a
more simplistic self-etch cementation pro-
tocol with a chairside in-office CAD/CAM
restorative system to provide the ultimate
in dental predictability and customization.
CASE REPORT
A middle-aged woman presented with the
chief concern of seven existing full-coverage
restorations that required replacement
because of recurrent decay and compro-
mised margins (Figure 1 and Figure 2). She
underwent an oral examination and med-
ical history review, after which it was con-
cluded that she had no medical or dental
contraindications to treatment. The teeth
to be replaced were the upper left bicuspids
and first and second molars, and the lower
second bicuspid and first and second
Figure 6 Finished milled restorations after
glazing in a porcelain oven.
Figure 10 Easy removal of the excess cement
in the gel state with a scaler.
molars. It was decided that these new
restorations would be fabricated in-office
with the author’s chairside CAD/CAM
restorative system (CEREC® 3D, Sirona
Dental Systems Inc, Charlotte, NC).
A preoperative impression was taken
to assist in the fabrication of the provi-
sionals. An alginate alternative was used
because of its ease of use and dimensional
stability over time as compared with tra-
ditional powder alginate (Figure 3).6 The
teeth were covered with a talc-like powder
(which functions as a contrast medium for
taking the optical impressions) and the pre-
operative virtual impressions were taken. The
existing restorations were removed and the
presence of decay was verified with a caries
detector and a spoon excavator.
All decay was removed from the teeth
and any necessary buildups were placed
to eliminate undercuts or gain proper re-
tention form in the resulting preparations.
Before the optical scanning of the prepa-
rations for restoration design, the soft tis-
sue was retracted in the subgingival areas
with a putty-type retraction system (Fig-
ure 4 and Figure 5). A putty retraction
system was specifically chosen over tradi-
tional retraction cord or other hemostatic
agent because of these two methods’ poten-
tial for tissue (epithelial attachment) dam-
age and recession.15-17
After 2 minutes, the putty retraction
material was thoroughly rinsed away with
air/water spray and dried. The preparations
were powdered and several optical images
of the preparations were taken. Subse-
quently, the teeth were temporized with a
bis-Acryl material, and cemented with a
resin-based temporary cement.
Restoration Fabrication
The in-office CAD/CAM restorative sys-
tem was chosen because of its high suc-
cess rate18 and for its esthetic properties,
inherent strength, and fracture resistance
of the porcelain blocks used after oven
glazing.19 After the optical images of the
Figure 7 Cleaning of preparations with a 2%
chlorhexidine solution before try-in of the
restorations.
Figure 11 Flossing interproximally to remove
excess cement before full curing.
preparations were obtained, the restora-
tions were fabricated using the CEREC 3D
Correlation mode. The Correlation mode
takes the preoperative condition, reproduces
it over the preparations, and allows it to
be further modified by the clinician to
obtain the desired occlusal and esthetic
result. After the restorations were milled,
they were stained and glazed in a porcelain
oven to obtain the desired surface gloss
(Figure 6). Preparing the internal aspect of
the restorations involved micro-abrading
with a micro-ether containing 50-µ alu-
minum oxide powder to prevent damage
to the margins, and rinsing with water
and drying for approximately 5 seconds.
A 9.5 % hydrofluoric acid gel was applied
for 1 minute, rinsed with water for approx-
imately 20 seconds, and dried thoroughly.
Insertion Appointment
The temporary restorations were removed
and the teeth were examined for any
temporary cement debris and cleaned with
2% chlorhexidine (Figure 7). The all-porce-
lain restorations were tried in to verify fit,
contacts, and esthetics. After mutual ap-
proval from the patient and clinician, the
restorations were removed. The internal
aspect of these restorations was cleaned
again with 37% phosphoric acid for 10 sec-
onds to re-acidify the internal surface. A
silanating agent was applied and air-dried.
Typically, with an adhesive total-etch
technique, an unfilled resin is applied to
the internal aspect of the restoration at this
time. In this case, the unfilled resin was
not necessary on the internal aspect be-
cause a dual-curing resin cement system
was implemented.
Tissue management was then obtained
by the application of the same putty-type
retraction system (Figure 8). After 2 min-
utes, the putty retraction material was thor-
oughly rinsed away with air/water spray
and dried. The teeth were then cleaned
again with 2% chlorhexidine, rinsed, and
dried without reaching desiccation.20 The
CONTINUING
eDucaTion 3
Figure 8 Gingival retraction paste used to
achieve tissue control before placing the restorations.
Figure 12 Curing with two light sources.
restorations were filled with a dual-cure
resin cement system, Maxcem™ (Kerr
Corporation, Orange, CA), seated, and
remained undisturbed for 90 seconds be-
fore light-curing (Figure 9).6 This waiting
period was mandatory for the self-adhe-
sive chemistry in the cement to be fully
effected. The cement reached a gel state
and was easily removed with a hand-
scaler (Figure 10). To ensure no movement
of the restorations while cleaning cement
interproximally, the restorations were
tacked down mid-cervically on the buc-
cal with a 4-mm turbo tip in a LED cur-
ing light. Interproximal cleaning was ac-
complished with waxed floss (Figure 11)
and final curing was performed on both
the buccal and lingual aspects with two
LED lights simultaneously for 20 seconds
(Figure 12), followed by occlusal curing
for 20 seconds. Marginal finishing was per-
formed with an 8-fluted carbide bur and
composite points and cups. Interproximal
finishing involved using medium- and
fine-composite finishing strips. Occlusion
was checked and slight adjustments were
performed before the final polishing of these
areas with porcelain polishing points.
The final results are shown in Figure 13
and Figure 14.
CONCLUSION
Because of the high esthetic demands of
patients, dentists are performing a larger
number of tooth-colored procedures, espe-
cially with regard to bonded porcelain
restorations. Therefore, it behooves cli-
nicians to seek education about the latest
improvements to ensure that patients receive
the most advanced form of treatment. In
cases using newer self-etching, dual-cur-
ing resin cements the dentist has the abil-
ity to place a highly esthetic porcelain
(or resin) restoration with very predictable
results. The results are predictable not
only in longevity but also with regard to
lack of sensitivity and other technique-
related issues. There are two theories to
 CONTINUING
4
eDucaTion
Figure 13 Restored lower left quadrant with
all-porcelain CAD/CAM restorations.
Figure 14 Restored upper left quadrant with
all-porcelain CAD/CAM restorations.
explain the decrease in postoperative sen-
sitivity after the use of a self-etching cemen-
tation system. The first is based on the
idea that etching and the priming are done
consecutively, theoretically rendering it
impossible to etch deeper than the primer
can penetrate.6 The second theory pos-
tulates that because the collagen is sup-
ported during the whole process, sensitivity
is eliminated or kept to a minimum.21 When
enamel is still present or unprepared, most
manufacturers recommend etching the
enamel with phosphoric acid for 15 seconds
before applying the self-etching cement.22
Recent advances in the self-etching
arena have enabled the clinician to place
an all-ceramic restoration in a very similar
fashion to a conventional cemented porce-
lain-fused-to-metal restoration. This is
because of the simplistic nature of the
dual-curing resin cement system. With
this combination, inlays, onlays, and full-
coverage all-ceramic restorations can be
placed with confidence and meet the high
esthetic demands of today’s dental patient.
REFERENCES
1. Kugel G, Ferrari M. The science of bonding:
from first to sixth generation. J Am Dent
Assoc. 2000;131(Suppl):20S-25S.
2. Malament KA, Socransky SS. Survival of
Dicor glass-ceramic dental restorations
over 14 years: Part I. Survival of Dicor com-
plete coverage restorations and effect of
internal surface acid etching, tooth position,
gender, and age. J Prosthet Dent. 1999;
81(1):23-32.
3. Pagniano RP, Seghi RR, Rosenstiel SF, et al.
The effect of a layer of resin luting agent on
the biaxial flexure strength of two all-ceramic
systems. J Prosthet Dent. 2005;93(5):459-466.
4. Caron GA, Murchison DF, Cohen RB, Broome
JC. Resistance to fracture of teeth with various
preparations for amalgam. J Dent. 1996;
24(6):407-410.
5. Pegoraro TA, da Silva NR, Carvalho RM.
Cements for use in esthetic dentistry. Dent
Clin North Am. 2007;51(2):453-471.
6. Miller MB. Dental adhesives. In: Miller MB,
ed. REALITY: The Information Source for
INSIDE DENTISTRY—NOVEMBER/DECEMBER 2007
Esthetic Dentistry. Vol. 20. Houston, TX:
REALITY Publishing Co; 2006.
7. Anusavice KJ. Phillips’ Science of Dental
Materials. W.B. Saunders Co: Philadelphia,
Pa; 1996:555-581.
8. El-Mowafy O. The use of resin cements in
restorative dentistry to overcome retention
problems. J Can Dent Assoc. 2001;67(2):
97-102.
9. Burke FJ, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quintessence Int. 1994;25(5):335-340.
10. Dietschi D, Maeder M, Meyer JM, Holz J. In
vitro resistance to fracture of porcelain inlays
bonded to tooth. Quintessence Int. 1990;
21(10):823-831.
11. Burgess JO, Latta MA, White RC. Dual Cure
Resin-based Cements: Expert Panel Dis-
cussion. ADA Professional Product Review.
[serial online] 2006;1(2):1-12.
12. Ferrari M, Tay FR. Technique sensitivity in
bonding to vital, acid-etched dentin. Oper Dent.
2003;28:3-8.
13. Piwowarczyk A, Bender R, Ottl P, Lauer HC.
Long-term bond between dual-polymerizing
cementing agents and human hard dental
tissue. Dent Mater. 2007;23(2):211-217.
14. Freedman G. Fifth-generation bonding sys-
tems. Predictable posterior composite restora-
tions. Dent Today. 1996;15(11):68-75.
15. Azzi R, Tsao TF, Carranza FA Jr, Kenney EB.
Comparative study of gingival retraction meth-
ods. J Prosthet Dent. 1983;50(4):561-565.
16. Donovan TE, Gendara BK, Nemetz H. Review
and survey of medicaments used with gingival
retraction cords. J Prosthet Dent. 1985;
53(4):525-531.
17. Shaw DH, Krejci RF, Kalkward KL, Wentz
FM. Gingival response to retraction by ferric
sulfate (Astringedent). Oper Dent. 1983;8(4):
142-147.
18. Mormann W. The evolution of the CEREC
system. Paper presented at: The CEREC
20th Anniversary Experience; October 13,
2006; Las Vegas, NV.
19. Chen HY, Hickel R, Setcos JC, Kunzelmann
KH. Effects of surface finish and fatigue
testing on the fracture strength of CAD/CAM
and pressed ceramic crowns. J Prosthet
Dent. 1999;82(4):468-475.
20. Gwinnett AJ. Effect of cavity disinfection on
bond strength to dentin. J Esthet Dent. 1992;
4(Suppl):11-13.
21. Perry RD. Clinical evaluation of total-etch
and self-etch bonding systems for prevent-
ing sensitivity in Class 1 and Class 2 restora-
tions. Compend Contin Educ Dent. 2007:
28(1):12-14.
22. Lopes GC, Thys DG, Klaus P, et al. Enamel
acid etching: A review. Compend Contin
Educ Dent. 2007;28(1):18-25.
 CONTINUING
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Simplifying the Cementation Protocol

Christopher Pescatore, DMD

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1. When used in conjunction with traditional acid-based 6. Resin cements are known to have a stronger ability
cementation techniques, the standard selection of than traditional cements to:
porcelain ceramic materials has been marred by: a. prevent microleakage entirely.
a. high clinical fracture rates. b. fill voids under restorations.
b. poor clinical longevity. c. fill carious lesions.
c. substandard fillers. d. prevent recession.
d. a and b
7. In today’s dental practice, there are how many categories
2. Evidence suggests that adhesive resin cements may of resin cements?
boost the clinical longevity of porcelain prosthetics by: a. one
a. decreasing the probability of crack initiation b. three
from the occlusal aspect. c. five
b. decreasing the probability of crack initiation d. seven
from the external aspect.
c. decreasing the probability of crack initiation 8. According to the author, which procedures have never
from the internal aspect. been easier or quicker to accomplish with simpler,
d. decreasing the probability of crack initiation shorter cementation techniques and computer-aided
from the lingual aspect. prosthetic design?
a. direct
3. Before the advent of resin adhesive products, powders b. indirect
that helped form cements were typically: c. temporary fabrication
a. zinc oxide or aluminosilicate glass. d. veneer placement
b. zinc oxide or glass ionomer.
c. glass ionomer or aluminosilicate glass. 9. One theory that explains the decrease in postoperative
d. zirconia or zinc oxide. sensitivity after the use of a self-etching cementation
system is that:
4. The liquids that helped form cements were typically: a. there is hardly any etching occurring.
a. phosphoric acid. b. the concentration of the etch is not strong enough.
b. polyacrylic acid. c. it does not contain an acidic etchant.
c. eugenol. d. it is impossible to etch deeper than the primer
d. all of the above can penetrate.

5. Cement performance preferences typically include 10. A second theory that postulates why postoperative
which of the following? sensitivity is decreased with a self-etching cementation
a. high viscosity and film thickness system is:
b. shorter working times a. the collagen is supported during the whole process.
c. high solubility b. the self-etching material does not have to be
d. biocompatibility scrubbed into the dentin like in a total-etch
technique.
c. the self-etching material is thicker and therefore
more supportive and stronger.
d. the cement layer is much thinner and therefore
no pooling can occur.

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