CLINICAL STUDY

Cementation of Prosthetic Restorations: From

Conventional Cementation to Dental Bonding Concept
Marcela Filie Haddad, DDS, MR, Eduardo Passos Rocha, DDS, MR, PhD,
and Wirley Gon0 alves Assun0 ao, DDS, MR, PhD
Abstract: The cementation procedure of metal-free xed partial
dentures exhibits special characteristics about the porcelains and
cementation agents, which turns the correct association between
these materials necessary. Our purpose in this literature review was
to point the main groups of cements associated to metal-free restoration and discuss about the advantages, disadvantages, and recommendations of each one. Our search was conned to the electronic
databases PubMed and SciELO and to books about this matter.
There are essentially 3 types of hard cement: conventional, resin, or
a hybrid of the two. The metal-free restorations can be xed with
conventional or resin cements. The right choice of luting material is
of vital importance to the longevity of dental restorative materials.
Conventional cements are advantageous when good compressive
straight, good lm thickness, and water dissolution resistance are
necessary. However, they need an ideal preparation, and they are not
acid dissolution resistant. Conventional cements are indicated to porcelains that cannot be acid etched. Resin cements represent the choice
to metal-free restoration cementation because they present better
physical properties and aesthetic than conventional agents.
Key Words: Cementation, partial xed denture, dental bonding
(J Craniofac Surg 2011;22: 952Y958)

he use of ceramic materials has increased exponentially, because

of their lifelike appearance, uorescence, biocompatibility, durability, chemical stability, high compressive resistance, and their
thermal expansion being similar to tooth structure. However, brittleness and susceptibility to fracture are major disadvantages to their use.1
To reduce the ceramic material fracture susceptibility and to
increase the resistance, countless progresses in the composition and
processing techniques of such materials have been developed.2 In
addition to material composition, factors, such as tooth preparation
design, denitive luting cement, and tooth surface management, inuence the retention and longevity of denitive restorations.3

The cementation process is vital for the clinical success of

all-ceramic restorations. It has been purported that some all-ceramic
restorations may be cemented with zinc phosphate, glass ionomer,
or resin composite cements. Therefore, the success of the cementation process may depend on the composition of the ceramic
material.4,5
The mechanisms by which cements secure restoration to
prepared tooth include nonadhesive luting, micromechanical bonding, and molecular adhesion.6
The mechanical or nonadhesive luting happens when the
restoration is xed through the introduction of the cement in small
tooth and restoration surfaces irregularities. This luting type is favored by retentive preparations, which are long and near parallel and
have a large surface area. The micromechanical bonding happens
when the cement material is used on an irregular surface, and it
creates an effective micromechanical connection, presenting a tensile strength between 30 and 40 MPa. The molecular adhesion
mechanism is characterized by physical and chemical forces participation among 2 different substances molecules, but it demands an
appropriate preparation.2
Considering the variety of ceramic materials and cements for
their xation available in the market, as well the innovations about
self-etching resin luting agents, this literature review aims to integrate the existent information and to point the choice material for
metal-free restoration cementation in restorative dentistrys current
context.
Our purpose in this literature review was to point out the
major groups of cements associated to metal-free restoration and
discuss the advantages and disadvantages of each one, indicating the
current techniques and describing future tendencies and perspectives.

MATERIALS AND METHODS

Our search was conned to the electronic databases PubMed
and SciELO and to books about this matter. We used the search terms
all ceramic crowns, cementation, bonding, and metal-free.
Forty-eight studies and 4 books were included in our review.

LITERATURE REVIEW
From the Dentistry Program, Department of Dental Materials and Prosthodontics, School of Dentistry of Ara0atuba, University of Sao Paulo State
(FOA-UNESP), Sao Paulo, Brazil.
Received July 7, 2010.
Accepted for publication September 25, 2010.
Address correspondence and reprint requests to Marcela Filie Haddad,
DDS, MR, PhD Student, Faculdade de Odontologia de
Ara0atubaYFOA-UNESP, Departamento de Materiais Odontologicos
e Protese, Rua Jose Bonifacio, 1193, Vila Mendon0a, Ara0atuba,
Sao Paulo, Brasil; E-mail: [email protected]
The authors report no conicts of interest.
Copyright * 2011 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31820fe205

952

There are essentially 3 types of hard cement: conventional,

resin, or a hybrid of the two. Conventional cements rely on an acidbase reaction resulting in the formation of an insoluble salt (the
cement) and water. Resin cements set by polymerization.
The mechanisms of nonadhesive luting and micromechanical
retention are the main methods of action of conventional cements.
Molecular adhesion, on the other hand, is more signicant in the
case of resin cements and hybrid cements. Although some conventional cements have adhesive properties, such as zinc polycarboxylate and glass ionomer cement (GIC), these are limited by the
cements tensile strength. Furthermore, adhesion to noble metals
is negligible but can be improved in the case of GICs by the use
of tin plating. Texturing the tting surface of the crown, as after

The Journal of Craniofacial Surgery

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The Journal of Craniofacial Surgery

& Volume 22, Number 3, May 2011

sandblasting, increases the resistance of the cement to dynamic lateral loading.6 The following sections discuss the materials used in
metal-free restoration denitive cementation.

Conventional Cements
Conventional cements are zinc phosphate cement (ZPC),
polycarboxylate cement (PC), GIC, and zinc oxide eugenol cement.
Zinc phosphate cement and PC are presented as a powder (zinc
oxide) and liquid (phosphoric acid buffered with zinc and aluminum ions), which are mixed by hand.6 More recently developed PC
contains uoride salts, which may aid in caries prevention, changing
the work time, and making the material mix proprieties better.2
Zinc phosphate cement presents a critical mixing technique
and no chemical bonding (only micromechanical interlocking). It
has low tensile strength, which dictates the importance of preparation geometry in reducing the development of disruptive tensile
stresses within the cement lute, resulting in loss of retention of
the restoration.5 When this is compromised, adhesive luting systems
are recommended. On the other hand, PC bond strength to enamel is
greater than that to dentin.6
All cements are, to some extent, soluble. Zinc phosphate
cement and PC have a low solubility in water, but erosion leading
to loss of the cement lute and failure of the restoration is not normally associated with this cement, with crowns tending to be lost
more because of a poor retentive design of the preparation. However, cement erosion is seen in patients with acid regurgitation.7
Although zinc phosphate is acidic on mixing (pH 2Y3.5,
depending on brand), this acidity reduces over the rst 24 hours
and stabilizes at a near neutral pH of 6.5. Despite this acidity,
Brannstrom and Nyborg8 found no irritating effect on the pulp
per se, and, in practice, this potential irritant effect does not seem
to be signicant, but preparation trauma, temporization, and bacterial contamination may also have been responsible. Polycarboxylate cement is not as acidic on mixing (approximately pH 4.8) as zinc
phosphate. There appears to be little irritation to the pulp possibly
because there is little penetration of the large polyacrylic acid molecules into the dentin tubules.6
A dentin-bonding agent could be used, and anecdotally, this
has helped with some teeth, which have been sensitive after preparation, but controlled studies are needed to assess the long-term
consequences. If the dentin is to be etched, it is essential that the
primer seals all the open tubules, or sensitivity may worsen and
bacterial invasion may jeopardize the pulp.6
Zinc phosphate cement is indicated to porcelains that could
not be achieved by usual etching with hydrouoric acid crowns
and xed restoration cementation in great-effort areas.2
Polycarboxylate cement presents little recommendation as a
denitive cementation material because of its characteristics such
as low tensile strength (can deform under loading) and difculty to
obtain low lm thickness.9
Glass ionomer cement composition consists of a powder
(aluminosilicate glass powder) and an aqueous acid (polyalkenoic).
Encapsulated glass ionomer luting cements are also available and
have the advantage of providing the correct powder-liquid ratio.
Glass ionomer cement has a signicant advantage to ZPC in that it
forms a considerable bond to tooth tissue by reaction with the calcium salts in the tooth structure and releases uoride ions.10
Its pH during setting is even lower than that of zinc phosphate, and some concern has been expressed regarding postcementation hypersensitivity; however, these studies are not clinically
proven. Dentin desiccation may, on occasion, be responsible for
sensitivity as well as bacterial contamination.10 If the dentin is to
be etched, it is essential that the primer seals all the open tubules,
or sensitivity may worsen and bacterial invasion may jeopardize the

Cementation of Prosthetic Restorations

pulp.7 So, precautions should be taken to protect the pulp when

restorations will be cemented with this material. All deep areas of
the preparation should be protected with a ne layer of calcium
hydroxide cement.11
The higher solubility in water of GIC has been identied as a
problem when the cement is used for luting purposes. This solubility
is adversely affected by early moisture contamination, and the cement lute margins should be protected with a varnish after cementation, although this may be difcult when the crown margin is
subgingival. Solubility is not a great problem clinically once the
cement has set.12
Glass ionomer cement presents the same ZPC indications and
may be used as an alternative to this cement in patients who previously had a high caries rate.6
Zinc oxide eugenol cements were idealized to be a denitive
cementation material.6 Based on in vitro tests, this type of cement
was reported to have good strength and be less soluble than ZPC.13
Unfortunately, its performance was much poorer in vivo, and studies
have shown that it deteriorates much more rapidly in the mouth than
do other cements. It cannot be recommended as a denitive luting
agent for restorations. Eugenol-containing materials are commonly
used as temporary luting cements, because of their bacteriostatic
effect, low cost, ease of removal, and good sealing ability.11
During the fabrication of indirect restorations, provisional
restorations are placed with temporary luting cement to avoid sensitivity, infection, and tooth movement. The temporary luting cement is required to be removed from the dentin surface before
denitive cementation.14
Some studies found that eugenol-containing cements have
adverse effects on the bond strength of the denitive restoration.
These effects include changes in wettability, reactivity of the dentin,
and interaction with the polymerization of resin-based materials.15
Although other studies have not observed any detrimental effect on
bond strength when eugenol-containing cement is used,16 it was
suggested that the negative effect may not be caused by eugenol,
but by the presence of residual temporary luting cement.
Regardless of the denitive luting cement, whether conventional or resin-based cement is used, an effective tooth preparation
cleansing protocol seems to be a desirable procedure to avoid any
interference along the interface between the dentin surface and luting cement.14

Resin Cements
Resin cements are composites composed of a resin matrix,
for example, bis-GMA or urethane dimethacrylate, and a ller of
ne inorganic particles.12 Resin luting cements differ from restorative composites primarily in their lower ller content and lower
viscosity.
The success of ceramic restorations depends on obtaining a
strong, durable bond between the resin cement and dentin/enamel.17
The magnitude of these bonds is directly proportional to an adequate
cement polymerization. Polymerization is crucial for achieving optimal physical properties and satisfactory clinical performance of
resinous materials.18 Resin cements can be categorized according to
polymerization type: chemical cured, light cured, or dual-cured.3
Chemical-cured resin cement, which is mostly used for metallic restoration, requires a long setting time and has an uncontrollable working time; it is cured evenly even in clinical situations
that the light does not reach the cement material.3 In contrast, lightcured cement presents easier removal of excess cement, and command setting requires no mixing, and therefore, the cement is more
homogenous with reduced porosity. The lack of tertiary amines in
the cement composition provides excellent color stability. However,
the porcelain thickness could prevent complete photopolymerization

* 2011 Mutaz B. Habal, MD

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953

Haddad et al

The Journal of Craniofacial Surgery

of the resin by reducing penetration of the curing light.19 Therefore, dual-cured resin cements afford better control during the cementation procedure and can be hardened in deep areas where
the curing light cannot penetrate; however, they present an excessive lm thickness when they are mixed in lower temperature,20
which may result in loosening of prosthetic restoration marginal
adaptation.
Many different ceramics are available on the market. They
have dissimilar compositions and crystal content, which could impact the quantity of light that passes through them for activation
of the resin-luting cement. Because more crystalline ceramics are
opaque, it could be expected that they would attenuate more light.21
The composition, thickness, opacity, and shade of the ceramic material may attenuate light from the curing unit that is used to polymerize the resin cement under the ceramic restoration.17,18,22
Lee et al23 evaluated the effect of the ceramic disks on the
curing speed of the cements during light exposure. They concluded
that dual-cured resin cements show different polymerization kinetics, depending on the curing conditions. Furthermore, when the ceramic restoration is thicker than 2 mm, the light exposure time should
be increased beyond the manufacturers recommendation. Because
of the differences in polymerization kinetics between resin cements
under various conditions, clinicians need to be aware of each resin
cement characteristics so they can choose the optimal materials for
different clinical situations.
Borges et al21 evaluated the effect of different ceramics on
light attenuation and the effect of different activation modes on
the microhardness of Rely X ARC (3M ESPE, St Paul, MN) resin
cement. They noted that the microhardness of the resin cement
was affected by the mode of activation and by the postactivation
testing time. The mean microhardness of the resin cement for
chemical activation and through all ceramics showed signicant
lower values compared with direct activation immediately and at
24 hours. The microhardness for 24 hours after activation was always
superior to the immediate postactivation test, except with direct activation. The most opaque ceramics resulted in the lowest microhardness values.
Bernardo et al3 evaluated the Knoop microhardness of 3 dualcured resin cements available in the market (Rely X Arc, Bistite II
DC [Tokuyama, Taitou-ku, Tokyo, Japan)], and Fill Magic Dual
Dement [Vigodent, Rio de Janeiro, Brazil]), when polymerized with
chemical activation or dual-cure activation. It was concluded that
the resin cements available in the market as dual-cure present behavior that is different from polymerization. Rely X ARC cement
obtained the highest Knoop microhardness values, and Bistite II DC
cement demonstrated higher values to chemical activation group
than dual-cure activation group, whereas the Dual Cement was not
polymerized with chemical activation, but showed intermediate
microhardness values for dual-cure activation group.
Resin cements have not only excellent aesthetic shade
matching potential, but also better exural and compressive strength
compared with other dental cements. In terms of shear and tensile
bond strength, resin cements are stronger than other types of cement; the adhesive nature of the resin cements results in restorations with superior retention and fracture resistance. Moreover,
minimal microleakage and lower water solubility occur with adhesive cementation.24 This feature has been demonstrated in vitro
with porcelain veneers25 and in vivo with porcelain inlays,26 which
were almost 5 times more likely to fracture when cemented with
conventional glass ionomer.
These results are according to the ndings of Groten and
Probster.27 They studied the inuence of different cementation
modes on the fracture resistance of feldspathic ceramic crown. It
was observed the resin composite presented the greatest fracture
resistance, followed by phosphate cement and GIC, respectively.

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Fleming et al28 point 2 theories to explain this fact: the rst

suggested that the resin modied defects by crack healing; the
second proposed that resin polymerization shrinkage strengthened
porcelains. Both theories imply a sensitivity of strengthening to
defect size.
The cementation technique with resin cements is indicated
to increase the all-ceramic restorations performance and to reduce
the invasive prepare effects,5,24 making these materials the ideal
choice for metal-free restoration cementation.
Resin cements present adhesion to several dental substrates.
The bond of the resin luting agent to the tooth structure is enhanced
by acid etching the tooth structure and by the use of a dental
adhesive.29
The secure union dentin/cement was related for the rst
time by Nakabayashi et al,29 and it was associated with the penetration of monomers into a demineralized dentin matrix, followed
by polymerization, which promotes a micromechanical bond via
hybrid layer formation.
Kanca30 found a signicant increase of dentin/cement bond
strength when the dentin was maintained humid after acid washing. After this work, added to hydrophilic monomers development,
the humid adhesion technique was introduced. Dentin should be
acid etched, washed, and maintained humid, and a primer should be
applied, improving substratum wettability and facilitating the hydrophobic resin cure. This technique, composed of 3 clinical steps,
promoted considerable increase of the dentin/cement union when
compared with previous adhesive techniques, which extolled the
dentin drying.31
The application of a separate acid-etching step is unnecessary when using self-etching resin luting agents. These materials
have become popular for their simplicity and because they require
fewer procedural steps when compared with previous systems that
used separate acid-conditioning and primer/adhesive steps.32 However, this simplication resulted in some inconvenience.
The monomers in self-etching composite luting agents contain phosphorylated methacrylates that have the ability to generate
self-adhesion. Furthermore, the presence of phosphoric acid groups
within the material creates an acidic bonding surface environment.
The low pH environment that is created provides for demineralization of the tooth surface, which, in turn, allows for subsequent
penetration of the resin cement into the demineralized bonding
surface. Once the resin cement polymerizes, micromechanical retention is achieved between the cement and tooth.32 Moreover, the
simplied-step systems present incompatibility to chemical-cured
composites.
Sanares et al33 demonstrated that when simplied-step adhesives are used together with chemical-cured composites, there is
an interaction of the residual acidic resin monomers from the adhesive inhibition layer with the binary peroxide-amine catalytic
components that is commonly used in chemical-cured resin composites. Acid resin monomers polymerized poorly in the presence
of peroxide-amine redox systems, as the tertiary amines were
neutralized by the acid resin monomers and lost their ability as
reducing agents in redox reactions. This allows them to react in a
nonaqueous medium with electrophiles, such as the acidic resin
monomers from the oxygen-inhibited adhesive resin layer.34 The
composite nonpolymerization in the interfacial region creates a
susceptible crack propagation area, resulting in lower bond strength.
Attempting to solve this problem, some manufactures add
chemical activators to conventional 2-step and 1-step systems.34
These activators are composed of catalysts that react with acid
monomers to generate free radicals. These free radicals start the
composites chemical polymerization.
However, chemical incompatibility is partially responsible for
the bonding value reduction when simplied-step adhesive systems
* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 22, Number 3, May 2011

are associated to chemical-cured composites. Tay et al35 observed

that coupling of composites after prolonged contact with hydrated
dentin bonded with simplied-step system is affected by the
intrinsic permeability of the adhesive. The adjunctive use of the
activator is only slightly effective in improving the coupling of
this adhesive with self/dual-cured composites. Although the use
of resin-free benzenesulfonic acid sodium salt solution completely eliminates the adverse chemical interaction, the inherent
permeability of the polymerized adhesive precludes optimal coupling of self-/dual-cured composites to bonded hydrated dentin.31,34,35
Acid resin monomers are much more aggressive than carboxylic monomers and exhibit a larger composite polymerization
reaction inhibition.36 Despite the acidogenic monomer potential, its
concentration interferes on bonding system acidity and on chemical incompatibility consequently. Despite presenting tertiary amine
accelerator, light-activated polymerization systems are not inhibited like chemical-activated systems.
Clinically, it is important that crown margins t the prepared tooth precisely to minimize plaque accumulation and therefore the risk of gingivitis, periodontitis, secondary caries, pulpitis,
and prosthesis failure.19,32
It has been suggested that solid sintered ceramics should be
bonded with an adhesive technique to achieve a stable long-term
bond to the tooth structure. In general, hydrouoric acid etching is
recommended to prepare the surface of the silica-based ceramics
for bonding with resin luting agents.4,37
Information about aluminum oxideYbased solid sintered ceramics union with a composite containing phosphate monomers is
limited. One alternative for obtaining stable, high bond strength to
the solid sintered ceramics is to apply cement containing MDP
(methacryloyloxydecyl dihydrogen phosphate), for example, Panavia
F (Kuraray, Chiyoda-ku, Tokyo, Japan).38,39
Borges et al,38 considering that surface treatment is an essential step in bonding a ceramic to resin and alumina ceramics
are particularly difcult to prepare for adequate bonding to composite resin cements, evaluated the bond strength between a densely
sintered alumina ceramic and bovine dentin with 2 adhesive resin
cements and a resin-modied GIC. They concluded that an MDPcontaining adhesive system (Panavia F) provides better extrusion
bond strength to a high-density alumina ceramic than a bis-GMA
resin luting agent system (RelyX ARC) or a resin-modied GIC
system (RelyX Luting). The results of this in vitro study suggest
that the resin luting agent, Panavia F, could be used to cement highdensity alumina restorations without airborne-particle abrasion
pretreatment.38
The phosphate ester radical forms a chemical bond to metal
oxides such as chromium, titanium, zirconium, and aluminum.
Therefore, when applied to densely sintered alumina, a resin luting agent containing MDP applied on the ceramic surface should
increase the bond strength.39
Theoretically, the best results obtained with Panavia for
All-Ceram and Procera bonding are the MDP acid monomer
presence and porcelain surface silane and primer application. In
this situation, silane has no adhesion effect, because the structure is practically aluminum oxide. The liquid does not evaporate, maintaining the internal surface humid, facilitating the
bond and composite penetration in the existent ceramic material microscopic irregularities. Another important point is that
the mixture accelerates the cement reaction, avoiding a partial
cure.40
Problems with the use of resin cements for luting full crowns
include adequately removing hardened excess resin from inaccessible margins is difcult excessive lm thickness with some materials,6 marginal leakage because of setting shrinkage, and severe
pulpal reactions when applied to cut vital dentin.10

Cementation of Prosthetic Restorations

Hybrid Cements
Resin-modied glass ionomer (RMGI) cement is a hybrid of
traditional GIC with small additions of light-curing resin and generally has the advantages of both in that they are purported to
combine the strength and insolubility of resin with the uoride release of GIC.19
Compomers are composed of resin and glass ionomer but
are more closely related to composites with the glass ionomer setting reaction occurring slowly as moisture is absorbed into the set
resin matrix.6 Researches are necessary for evaluation of the clinical
action of this material.
Self-cured RMGI cements are not recommended for cementation of most all ceramic crowns because of anecdotal concerns
regarding higher clinical failure rates (3Y12 months after the cementation procedure). This was believed to occur following water
uptake and subsequent excessive expansion of the cement, leading to crack initiation within the ceramic crown.5,19
These results are according to dental advisor recommendations. There are reports of high-strength porcelain crowns fracturing after cementation with RMGIs, possibly as a result of
expansion of the cement from water sorption. In view of these
concerns, it is best to restrict the use of RMGIs and compomers
to metal restorations. Furthermore, when cementing porcelain or
composite restorations, a better aesthetic result can be achieved
with composite resin cements.6

Cement Properties
Many types of cement have been developed and continue
to be available. This diversity of choice suggests that no one cement meets all of the requirements of an ideal cement; however, some are more suitable than others for certain applications.
There are many researches7,10,41Y45 pointing the main characteristics that an ideal cementation material should present, for
example:
& Biocompatibility: The available materials demonstrate good biological behavior. Allergenic reactions are the possible adverse
effect (observed in a very low incidence).10 A small pulpal reaction can be observed in a histological analysis, mainly if the
remaining dentin exceeds the thickness of 1 mm.7 The effect of
cements on the pulp causing injuries is a very researched subject,
and bacterial contamination resultant of the cements insertion
seems to be the main factor.
& Adhesion: This is the main factor for microleakage reduction.7
As RMGIs or resinous cements suffer contraction and stress
generation or bonding loosening, causing oral uids and microorganism inltration and postoperative sensitivity.46,47 Pulpal protection agents (calcium hydroxide) may reduce the stress
presented by crowns cemented with ZPC, GIC, and resin
cement.10
& Solubility: Solubility should be low or null when the material
is in contact to oral uids, because the cements are continually exposed to acids and continuous pH and temperature
changes.7
& Microleakage/margin mist: An ideal cementation material
should be resistant to marginal mist, once the microorganisms penetration around the restorations is directly related with
several pulpal reactions and longevity reduction consequently.
Fluoride-containing materials present important effect to caries
prevention. Rossetti et al43 evaluated the existence of correlation
between in vitro margin t and a new microleakage technique
for complete crowns cemented with 3 different luting agents
(ZPC, RMGI, resin cement). They concluded that cast crowns
cemented with RMGI and resin cement had lower microleakage
scores than ZPC.

* 2011 Mutaz B. Habal, MD

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Haddad et al

& Bond strength to dentin: The ideal material should present enough mechanical properties to resist functional forces,
fractures, and fatigues that stress causes. Some mechanical
properties presented by hard cements, as elasticity module and
bond strength to dentin when traction and compression forces are
applied, have been a theme for many studies that presented results of several behaviors. However, those results usually exhibit
the highest values for resinous cements, with loads addition,
when compared with traditional agents and the resinous cements
without load.10
& Radiopacity: An ideal material should be possible to be observed
through a radiographic image, with the cement line, caries, and
marginal cement excess.
& Aesthetic properties: The properties of the cementation agents
have a considerable importance primarily because of dental restorations using all-ceramic material aesthetic properties, such as
high translucence. Therefore, cementation kits contain watersoluble pastes to facilitate the cement color choice.44 Color stability is an important factor and should be considered; amine
accelerator can induce a color change when dual-cured resin cements are used.
& Proportions of powder and liquid: An alteration in the correct
proportion can affect some materials mechanical properties7 and
working and cure time.42 Bruce and Stevens41 related 2.6%
compressive strength loosening when there was a reduction of
30% in ZPC proportion, and Myers et al42 afrm that GIC proportion increase makes the cement excess removal difcult and
causes an intrapulpal temperature increase.
& Mixing: The material should result in a homogeneous mix that
presents the consistency recommended by each manufacturers
material. A special attention should be paid to some machines
that promote automatic mixing, which allows reproducibility
because of the homogeneous material mix.
& Cement lm thickness: The interposition of a cement lute inevitably affects crown seating.19 Consequently, the art of cementation is to choose cement with an inherently low lm thickness
and use techniques that allow it to escape while the crown is
being seated. An important factor that inuences the vertical
seating of crowns and hence marginal adaptation is the amount
of cement loaded into the crown before cementation.48 Different cementation materials need different lm thicknesses to
ensure complete seating,22 and the cement lm thickness is inuenced by manipulation variables, such as temperature and
powder-liquid proportion. Cement ow can be hindered by preparation features, which cause a buildup of hydrostatic pressure.48
Thus, retentive preparations, which are long and near parallel and
have a large surface area, are most at risk of not being able to be
fully seated.
Die spacing is the most common method of achieving space
for the cement lute. It involves painting several layers of die relief
agent over the whole of the die but avoiding the nish line. An
increased cement space results in more rapid seating with decreased
deformation of the restoration. Die spacing results in a slightly loose
t of a crown on its preparation.32

Fixed Partial Denture Denitive

Cementation Technique
Some cares should be taken to metal-free denitive cementation. Cementation is a critical step, involving bonding materials,
which present a limited working time; and the restorations are very
fragile before the cementation step.
These restorations should be handled carefully when checking on the dental preparation to avoid cracks. It is important to
evaluate the porcelain compositions resistance and to choose the

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& Volume 22, Number 3, May 2011

ideal treatment and cementation system. Primarily, we need to

evaluate if the porcelain can be etched by hydrouoric acid. In
general, hydrouoric acid etching is recommended to prepare the
surface of the silica-based ceramics. High-strength all-ceramic
materials (zirconia and alumina) cannot be etched.40

Prebonding Treatment for Ceramic Surfaces

The bond of the resin luting agent to the tooth structure is
enhanced by acid etching the tooth structure and by using a dental adhesive. The penetration of monomers into a demineralized
dentin matrix, followed by polymerization, promotes a micromechanical bond via hybrid layer formation.29 In a similar manner,
the intaglio surface of the ceramic restoration must be prepared to
optimize the micromechanical bond between the ceramic and the
resin.4,37
Different porcelains require a determinate prebonding treatment. They are as follows:
& Airborne-particle abrasion of the material with 50-Km aluminum
oxide (1 bar, during 5 seconds). This procedure is possible
through some techniques able to change the restorative material
structure to favor the adhesion, such as Rocatec and CoJet, which
create microretentive features. The adhesion takes effect after
silane application. This procedure removes residuals of the internal surface of the prosthesis and creates microretentive
features.45
Previous studies have shown that the all-ceramic restorations
based on densely sintered high-purity alumina resist forming
microretentive surfaces after hydrouoric acid etching and airborneparticle abrasion surface treatment.37
Borges et al4 showed that the ceramic surface of densely
sintered alumina was not etched by hydrouoric acid because it
does not contain a silica phase. Furthermore, airborne-particle abrasion of the material with 50-Km aluminum oxide caused attening of the alumina crystals rather than creation of microretentive
features, for example, Procera AllCeram. Furthermore, airborneparticle abrasion of the material with 50-Km aluminum oxide caused
attening of the alumina crystals rather than creation of microretentive features, and the air abrasion of the intaglio surface of
zirconia crowns can cause a transformation from the tetragonal to
the monoclinic phase, which severely ages the restoration and
reduces its life expectancy.40
& Hydrouoric acid etching 7% to 10%, for 20 seconds to 4 minutes,
to promote a micromechanicl interlocking. This acid creates microporosities within the glass phase of the ceramic substrate.32
Hydrouoric acid etching for more than 4 minutes should promote changes in the material structure, making it fragile and
resulting in restoration failure. Feldspathic ceramics and Empress
2 (or IPS e.max) need 60-second etching; leucite-based ceramics
need an etching time until 2 minutes; lithium-disilicateYbased
ceramics need 20 seconds.2
After the prosthetic etching, the restoration should be washed
with water for 1 minute, ultrasonically cleaned for 5 minutes, and
dried with compressed air.2
It has been suggested that solid sintered ceramics should be
bonded with an adhesive technique to achieve a stable long-term
bond to the tooth structure. In general, hydrouoric acid etching is
recommended to prepare the surface of the silica-based ceramics for
bonding with resin luting agents.4,37
& Silane agent application on the etching surface, maintained for
5 minutes and dried with compressed air. Silane will react with
porcelain crystallization phase and organic cement agent phase,
acting on chemical structures union.49
* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 22, Number 3, May 2011

Tooth Preparation
First, ensure there is no retained temporary cement or trapped
gingival tissue. The preparation should be cleaned and dried with air,
but the preparation should not be desiccated.2 Denitive cementation procedure requires preparation isolation by gingival retraction
and nish-line exposure, impeding preparation contamination with
gingival uids and saliva.

Cementation
& With conventional cements:
The cement should be mixed according to the manufacturers
instructions. After this, the t surface should be coated (do not
overll). Apply cement to preparation only if cementing a post.
The crown should be seated quickly with rm nger pressure until all excess cement has been pressed from the margins.
Seating force must be adequate to ensure complete seating of the
crown onto the preparation, but sudden excessive force may result
in elastic strain of the dentin, creating a rebound effect, which results
in the crown being partly dislodged when the force is removed.50
Pressure should be maintained for about 1 minute. Maintaining pressure beyond this time has no appreciable additional effect.51 Excess cement should be left until after the cement sets.52
After cleanup, a nal evaluation of the cemented crown can be
made including rechecking the occlusion.
& With resin-based cements:
There are 2 ways to realize this procedure: One way consists of acid-etching and priming in 2 steps. The second option is to
choose a self-etching dual resin cement to simplify steps and promote a complete bonding.40 Etching is recommended to prepare
the porcelain surface. After silane application, the surface should
be primed and thinned with soft air spray to avoid silane accumulation in internal angles of the restoration2 and then light cured.
After isolation, the preparation should be etched with phosphoric acid 37% for 15 seconds (healthy dentin) or for 30 seconds
(sclerotic dentin), washed, dried, and primed, except when selfetching systems are used. Apply a light-cured bonding system on
preparation and setting before the restoration cementation or apply
a dual system and light cure after the cementation? This is a frequent doubt. When there is the possibility that the restoration will
not completely set because of bonding system early cure (accumulated in preparation angles), the best choice is a dual-cure or
chemical-cure system. However, when aesthetic metal-free restorations are cemented with these systems, color changes can occur
because of amine oxidation. Therefore, in these situations, the best
choice is a light-cure system.2
The cementation material should be mixed according to
manufacturers instructions, and the restoration t surface should
be coated with cement. Then, the restoration should be seated
quickly with rm nger pressure until all excess cement has been
expressed from the margins. Removal of excess before setting is
recommended as it can be very difcult to remove the excess cement after setting.52
After cleanup, a nal evaluation of the cemented crown can
be made including rechecking the occlusion. One alternative for
obtaining stable, high-bond strength to the solid sintered ceramics
is by porcelain surface cleaning after cementation containing MDP
(Panavia 21 and Panavia F) application.38
Therefore, there is a doubt: What is the conventional cementation vantage to metal-free restoration cementation? Conventional cements present vantages in cases of preparation with low
quality to bonding-technique realization, such as radicular nish
line, very dark dentin, and metal-free crown cementation on metal

Cementation of Prosthetic Restorations

posts.2 As a routine part of maintenance, dentists should provide a

nightguard to any patient suspected of performing parafunctional
activities,27,40 independently of the chosen cementation system.

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* 2011 Mutaz B. Habal, MD

Copyright 2011 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.