Cementation of Indirect Restorations: An Overview of Resin Cements | Compendium 23/06/20 11:07

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Compendium
View Current Issue January 2013
Volume 34, Issue 1

Clinical Categories
Cementation of Indirect Restorations: An Overview of Resin
General Dentistry
Cements
Restorative Catherine Stamatacos, DDS; and James F. Simon, DDS, Med

Endodontics
Abstract:
Implantology
The process of ensuring proper retention, marginal seal, and durability of indirect restorations depends
Oral Surgery heavily on effective cementation. Careful consideration must be made when selecting an adhesive
cement for a given application. This article provides information on resin cements that can guide
Orthodontics clinicians in determining which type of cement is best suited to their clinical needs regarding
cementation of indirect restorations. Emphasis is placed on successful cementation of all-ceramic
Pediatric Dentistry restorations.

Periodontics
Cementation is a crucial step in the process of ensuring the retention, marginal seal, and durability of indirect
Prosthodontics restorations.1 Since the introduction of the first all-porcelain crown in the early 1900s, various cements have
been used to adhere porcelain crowns to tooth structure. Initially, only luting cements were available for use,
Specialty Care which led to many failures. Presently, another category has been added—the adhesive cements. Resin
cements fall into this category of adhesive cements. Adhesive cements must bond to a variety of different
substrates, including dentin and enamel, porcelain and other ceramics, gold and other metal alloys, and
Additional Categories indirect resin composites.2

There are several characteristics of resin cements that make them clinically superior luting agents. Resin
Business of Dentistry
cements may have high bond strengths both to tooth structure and porcelain, high tensile and compressive
strengths, and the lowest solubility of the available cements.3 Flexural properties—including modulus and
Infection Control
strength—are important to prevent de-bonding during function, and resin cements have both a high modulus
and strength. In fact, they have the highest strength of the cements currently in use.4,5
Pain Management
The disadvantages of resin cements are associated with their technique sensitivity and difficulty with clean-
Online Only up. Resin cements may change shade during curing and can darken during their lifetime. This can be a
crucial factor, especially since esthetics is a particularly important characteristic for all-ceramic restorations.6
Because these materials depend upon bonding, the operator must be careful to follow all steps in proper
Related Articles order and with the recommended time for each step.6

Digital WorkDow Across Multiple Resin Cement ClassiTcations

Practices Achieves EFcient and
Resin cements may be classified according to their polymerization mechanisms into light-cured, chemical-
Esthetic Results cured, and dual-cured (Table 1). They can also be classified by their adhesive scheme: total-etch, self-
Compendium, June 2020
etching, and self-adhesive (Table 2).7 The self-adhesive resin cements may be referred to as “all-in-one” resin
cements or universal cements.6

Teeth in Geriatric Patients: To The curing methods are a factor in dictating the potential uses of the cements. For example, in cases where
Restore or Extract? very little or no light-cure is possible, chemical-cure cement is a better choice than either a dual-cure or, of
Compendium, May 2020 course, a light-cure cement.6

ClassiTcation by Polymerization Mechanism

Biomechanics and Function:

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Cementation of Indirect Restorations: An Overview of Resin Cements | Compendium 23/06/20 11:07

Altering Paradigms to Treat a Light-Cure Resin Cements—Light-cure resin cements utilize photo-initiators, which are activated by light. The
Patient’s Esthetic Disability ability of light to penetrate all areas and activate the photo-initiators is important with this type of cement. An
advantage of light-curing cements is that there can be an increased working time compared to the other cure
Conservatively
types. The clinician has the ability to remove excess cement before curing, and thus the finishing time
Compendium, May 2020
required is decreased.6

Another advantage of light-cure cements is their color stability compared to dual-cure or chemical-cure resin
When Single-Tooth Dentistry Fails:
cements.8 These cements are, therefore, suitable for esthetic restorations and metal-free restorations.9,10
A Comprehensive Approach to Light-polymerized resins are recommended when cementing ceramic that is thin and fairly translucent,
Manage Risk and Restore Function allowing the transmission of light through it to reach the resin cement.1
Compendium, March 2020
Examples of light-polymerized cements include: RelyX™ Veneer Cement (3M ESPE, www.3MESPE.com);
Variolink® Veneer (Ivoclar Vivadent Inc., www.ivoclarvivadent.com); and Choice™ 2 Light-Cured Veneer
Impression-Making in 2020: How Cement (BISCO, Inc., www.bisco.com).
Long Before Analog Methods Are
Dual-Cure Resin Cements—Dual-cure resin cements are capable of being cured by means of both chemicals
Obsolete? and light. Self-cure initiators that can cure the cement are present. In addition, a curing light can be used to
Compendium, March 2020
activate the photo-initiators that are present in the cement.6 Dual-polymerized resin cements are indicated
when the ceramic is too thick or too opaque to allow transmission of light through it.11 Studies have shown
that these dual-cure resin cements still require light-curing to reach a high degree of polymerization.12,13
These cements are used for metal-free restorations where light-curing may be performed to quickly seal
margins.6

Examples include: NX3 Nexus® Third Generation (Kerr Corporation, www.kerrdental.com); RelyX™ ARC
Adhesive Resin Cement (3M ESPE); and Variolink® II (Ivoclar Vivadent Inc.).

Chemical-Cure Resin Cements—Chemical-cure resin cements polymerize with a chemical reaction and are
referred to as “self-curing.” This means that two materials must be mixed together to initiate this reaction.6
These cements are especially useful in areas where light-curing is difficult. Some examples include metal
restorations, endodontic posts, and ceramic restorations that prohibit the curing unit from adequately
polymerizing the resin cement.6

Chemically polymerized resin cements do not offer much selection in terms of shade and translucency;
therefore, dual-polymerized resin cements can be beneficial. Additionally, accessible areas benefit from light
polymerization with dual-polymerized resin cements.14

Examples include: Panavia™ (Kuraray Dental, www.kuraraydental.com); and C&B™ Cement (BISCO, Inc.).

ClassiTcation by Adhesive Scheme

Total-Etch Resin Cements—Total-etch resin cements use a 30% to 40% phosphoric acid-etch to etch dentin
and enamel. This etching procedure removes the smear layer, and dentinal tubules are opened.2 After
etching, the adhesive is then applied to the preparation to bond the cement to the tooth. These cements and
the adhesives used with them can be light- or dual-cured.2 Total-etch resin cements have increased the bond
strengths of resin-based cements to nearly that of enamel bonding and have significantly reduced
microleakage.15 This category provides the highest cement-to-tooth bond but also requires the most steps to
bond ceramic, composite resin, or metal to the tooth. This multi-step application technique is complex and
consequently might compromise bonding effectiveness,7 because each step represents a possible
contamination point.7

Five-time winner of the Cellerant’s Technology Award, the EyeSpecial C-III

camera from SHOFU enables staff to take impressive images for case
documentation, diagnosis and treatment planning, and patient
communication and education. This digital dental camera has eight pre-
programmed shooting modes

Examples include: RelyX ARC (3M ESPE); Variolink II (Ivoclar Vivadent Inc.); Choice 2 (BISCO, Inc.); and
Calibra® (DENTSPLY Caulk, www.caulk.com).

Self-Etch Resin Cements—Self-etch systems apply a self-etching primer to prepare the tooth surface, and
mixed cement is applied over the primer. Bonds to tooth structure using this category of cements are almost
as high as those of the total-etch cements.2

Self-etching systems are popular among dentists because they are easy to use, but as a general category
they have demonstrated bond strength to enamel that is weaker than that of total-etch systems.16 Therefore,
the total-etch, three-step adhesive system of some 30 years ago still sets the standard in terms of versatility
and long-term predictability.17

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Resin cements that incorporate self-etching primers eliminate steps during application with the goal of
reducing operator errors and technique sensitivity and increasing ease of use.18 However, it is imperative to
follow the manufacturer’s instructions during adhesive cementation, including use of the manufacturer’s
adhesive and resin cement combination, because investigators have found incompatibilities between some
dual-cure resin cements and simplified adhesive systems.19

Self-Adhesive Resin Cements—A number of resin cements have been introduced as one-component
“universal adhesive cements”; they are said to have good bond strengths to dentin, enamel, and porcelains
without the need for separate bonding agents.20-22 These self-adhesive cements can bond to an untreated
tooth surface that has not been micro-abraded or pretreated with an etchant, primer, or bonding agent; thus,
cementation is accomplished in a single step. These cements contain phosphoric acid, which is grafted into
the resin. Once mixing is initiated, the phosphoric acid reacts with filler particles and dentin in the presence
of water, forming a bond. The resin is polymerized into a cross-linked polymer, as is the case with composite
resin bonding.9

Data from Burgess et al (2010)7 shows that most of these cements bond better to dentin than to enamel. With
most of the cements in this category, the bond to enamel is improved when an etchant and bonding agent
are applied.23 This “selective-etch” approach uses an etchant or a self-etching primer before applying the
self-adhesive resin cement. In other words, “selectively etching” enamel and/or dentin surfaces and indirect
restorations may be incorporated to improve the bond of these self-adhesive resin cements. However, a
lower bond strength to dentin was shown when the phosphoric acid pre-etch was applied.23 In contrast to
enamel, when dentin is etched with phosphoric acid and a bonding agent is applied with one of these
cements, the bond decreases.7 This negative effect of pre-etching of dentin for self-etch adhesives has been
shown many times in the literature.23 When tested without the pre-etch, self-adhesive resin cements have
been shown to produce fairly strong bonds to dentin.23-26 Examples include: RelyX™ Unicem (3M ESPE),
BisCem® (BISCO, Inc.), Maxcem Elite™ (Kerr Corporation), SpeedCEM™ (Ivoclar Vivadent Inc.).

In Simon et al (2011), it appears that the self-adhesive cements are on par with the values seen for resin
cements. A possible explanation for this observation is that the self-adhesive cements are changing. For
instance, older tests used RelyX Unicem cement in capsule format, whereas in this newer test the Unicem
Clicker™ Dispense (3M ESPE) system was used. The cement was reformulated to accommodate the new
delivery system. The changes in observed strengths may be due to incremental improvements made by the
manufacturers.27

Additional Clinical Considerations and Advantages

When using resin-based cements, the internal surface of the restoration must be treated differently than the
surface of the tooth, because the surface treatment depends upon the type of material (metal, ceramic, or
zirconia) used for the restoration. The surface of the tooth may need to be treated with phosphoric acid, while
the surface of the restoration may need to be treated with hydrofluoric acid, sandblasting, and silanization.8

The excellent physical properties and ability of resin luting materials to facilitate “adhesive” luting of
restorations are distinct clinical advantages, because the clinician may not always be able to achieve an ideal
taper or crown height.28 In a recent study by Simon et al,27 the tensile bond strength of ceramic crowns milled
with computer-assisted design/computer-assisted machining (CAD/CAM) technology was tested on overly
prepared teeth. This study found in a number of cases that the retention of the crowns supplied by three
leading adhesive cements was stronger than the ceramic crown itself; however, these high bond strengths
cannot be achieved on a consistent basis.27

The efficiency by which the self-adhesive resin cements adapt to and seal margins is critical for their
success.2 Studies have found conflicting results when analyzing the marginal seal and micro​leakage of resin
cements.29,30 However, self-etch and total-etch resin cements tend to have adequate marginal adaptation
compared to glass ionomers, resin-modified glass ionomers (RMGIs), and zinc phosphate cements.31

Because self-adhesive cements bond to tooth structure, excess cement should be removed before setting to
avoid damaging the weaker early bond.7 Self-adhesive cements are dual-cured, and like all dual-cured
cements, have reduced bond strengths, color stability, and wear resistance in the self-cure-only mode.7
Therefore, the clinician should light-activate all dual-curing cements at accessible restorative margins to
improve marginal integrity and wear resistance and to reduce staining.7

Conclusions
The key points for clinicians to bear in mind regarding resin-based cements are:

• Bond strengths vary among specific cements, but total-etch cements generally provide the greatest
retention; self-etching systems are intermediate; and self-adhesive cements can provide bond strength nearly
equal to self-etching systems.7

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• Self-adhesive resin cements can create bond strengths to dentin that exceed the strength of the ceramic
material.27
• High bond strengths can be achieved with self-adhesive resin cements on non-retentive teeth.27
• Large coefficients of variation indicate that the bond strength cannot consistently be achieved.27

While in vitro data may show some cement bond differences among investigators, self-adhesive cements
perform well clinically.32 Although clinical evaluations are few and short-term, the result of this review of self-
adhesive resin cements would suggest that these materials may be expected to show clinical performance
similar to that of other resin-based and nonresin-based dental cements.2 The handling properties of these
materials appear to be excellent, and their acceptance by the profession is increasing.2

References
1. Vargas MA, Bergeron C, Diaz-Arnold A. Cementing all-ceramic restorations: recommendations for success.
J Am Dent Assoc. 2011;142 Suppl 2:20S-4S.

2. Ferracane JL, Stansbury JW, Burke JT. Self-adhesive resin cements - chemistry, properties and clinical
considerations. J Oral Rehab. 2011;38(4):295-314.

3. Van Noort R. Introduction to Dental Materials. 2nd ed. St. Louis, MO: Mosby; 2002:257-278.

4. Powers JM, O’Keefe KL. Cements: How to select the right one. Dent Prod Rep. 2005;39:76-78,100.

5. Powers JM, Sakaguchi RL. Craig’s Restorative Dental Materials. 12th ed. Philadelphia, PA: Elsevier
Publishing; 2006:479-511.

6. Simon JF, Darnell LA. Considerations for proper selection of dental cements. Compend Contin Educ Dent.
2012;33(1):28-36.

7. Burgess JO, Ghuman T, Cakir D. Self-adhesive resin cements. J Esthet Restor Dent. 2010;22(6):412-419.

8. Peumans M, Van Meerbeek BV, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J
Dent. 2000;28(3):163-177.

9. Simon JF, de Rijk WG. Dental cements. Inside Dentistry. 2006;2(2):42-47.

10. Albers HF. Indirect bonded restoration supplement. In: Albers HF, Bonded Tooth Color Restoratives:
Principles and Techniques. Santa Rosa, CA: Alto Books; 1989:1-42.

11. Pegoraro TA, da Silva NR, Caevalho RM. Cements for use in esthetic dentistry. Dent Clin North Am.
2007;51(2):453-471.

12. Hasegawa EA, Boyer DB, Chan DC. Hardening of dual-cured cements under composite resin inlays. J
Prosthet Dent. 1991;66(2):187-192.

13. el-Badrawy WA, el-Mowafy OM. Chemical versus dual curing of resin inlay cements. J Prosthet Dent.
1995;73(6):515-524.

14. Vrochari AD, Eliades G, Hellwig E, Wrbas KT. Curing efficiency of four self-etching, self-adhesive resin.
Dent Mater. 2009;25(9):1104-1108.

15. Swift EJ Jr, Bayne SC. Shear bond strength of a new one-bottle dentin adhesive. Am J Dent.
1997;10(4):184-188.

16. Cekic I, Ergun G, Lassila LV, Vallittu PK. Ceramic-dentin bonding: effect of adhesive systems and light-
curing units. J Adhes Dent. 2007;9(1):17-23.

17. De Munck J, Van Landuyt K, Peumans M, et al. A critical review of the durability of adhesion to tooth
tissue: methods and results. J Dent Res. 2005;84(2):118-132.

18. Christenson GJ. Should resin cements be used for every cementation? J Am Dent Assoc.
2007;138(6):817-819.

19. Kanehira M, Finger WJ, Hoffmann M, Komatsu M. Compatibility between an all-in-one self-etching
adhesive and a dual-cured resin luting cement. J Adhes Dent. 2006;8(4):229-232.

20. Simon JF, de Rijl W. Shear bond strength of Empress to dentin using four resin cements. AADR Oral
Presentation 886, 2006 Annual Meeting, Orlando, FL.

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21. de Rijk W, Simon JF. Shear Bond Strengths of Resin Cements to Dentin and Ceramic. Poster, CEREC 20-
year celebration in Vegas. Las Vegas, NV, October 14, 2006.

22. Hollis W, Pecora NF, de Rijk WG. An Evaluation of the Shear Bond Strength of Four Universal Cements to
Five Prosthodontics Substrates. Kerr University. http://www.kerrdental.com/index/kerrdental-cements-
maxcemelite-3rdparty-2. Accessed September 27, 2012.

23. De Munck J, Vargas M, Van Landuyt K, et al. Bonding of an auto-adhesive luting material to enamel and
dentin. Dent Mater. 2004;20(10):963-971.

24. Al-Assaf K, Chakmakchi M, Palaghias G, et al. Interfacial characteristics of adhesive luting resins and
composites with dentine. Dent Mater. 2007;23(7):829-839.

25. Yang B, Ludwig K, Adelung R, Kern M. Micro-tensile bond strength of three luting resins to human
regional dentin. Dent Mater. 2006;22(1):45-56.

26. Bitter K, Paris S, Pfuertner C, et al. Morphological and bond strength evaluation of different resin cements
to root dentin. Eur J Oral Sci. 2009;117(3):326-333.

27. Simon JF, de Rijk, Hill J, Hill N. Tensile bond strength of ceramic crowns to dentin using resin cements. Int
J Comput Dent. 2011;14(4):309-319.

28. Zidan O, Ferguson GC. The retention of complete crowns prepared with three different tapers and luted
with four different cements. J Prosthet Dent. 2003;89(6):565-571.

29. Rosentritt M, Behr M, Lang R, Handel G. Influence of cement type on the marginal adaptation of all-
ceramic MOD inlays. Dent Mater. 2004;20(5):463-469.

30. Frankenberger R, Lohbauer U, Schaible RB, et al. Luting of ceramic inlays in vitro: marginal quality of self-
etch and etch-and-rinse adhesives versus self-etch cements. Dent Mater. 2008;24(2):185-191.

31. Olms C, Boeckler A, Lautenschlager C, Setz J. Clinical study of postoperative sensitivity for new self-
adhesive resin cement [abstract]. J Dent Res. 2008;87(spec iss B). Abstract 3142.

32. Burgess JO, Truxillo J, Mercante D. Dentin and enamel bond strength of three cements [abstract]. J Dent
Res. 2003;82(spec iss B). Abstract 1616.

Related Content:

A CE article, Considerations for Proper Selection of Dental Cements, is available from CDEWorld at
dentalaegis.com/go/cced290

About the Authors

Catherine Stamatacos, DDS
Assistant Professor
Director
Research and Education
Department of Restorative Dentistry
College of Dentistry
University of Tennessee Health Science Center
Memphis, Tennessee

James F. Simon, DDS, Med

Professor
Director, Division of Esthetic Dentistry
College of Dentistry
University of Tennessee Health Science Center
Memphis, Tennessee

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