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Ending
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Michael DiTolla, DDS

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Dental Materials
Ending Cementation
Confusion in Dentistry
Michael DiTolla, DDS

C
ABSTRACT hoosing the right luting material is of vital importance
Selecting the appropriate to the longevity of dental restorative materials.1 There
cement is critical to ensuring are two primary methods of cementation: conventional
the success and longevity of cementation and adhesive cementation. Conventional cementation
a restoration. The goal of this means just filling a gap, whereby the majority of the retention
article is to help clinicians comes from the preparation itself. Adhesive cementation means
make appropriate cementation using adhesives and primers to create a bond. Using a less than
decisions by discussing the ideal cementation protocol can negatively impact the result and
qualities of cements and longevity of the procedure.
adhesives and then providing
three questions to answer UNDERSTANDING CEMENTS AND ADHESIVES
when considering cementation The three most commonly used types of cement are conventional
methods. cement, self-adhesive cement, and adhesively bonded cement. The
most commonly used conventional cements are resin-modified
LEARNING OBJECTIVES glass-ionomers (RMGIs). RMGIs have advantages of both compos-
ite resins and glass-ionomers. These materials have an acid-base
• Describe the differences
reaction due to their glass-ionomer nature and can form a limited
between conventional
chemical bond with the substrate.2 They are dependent on mechani-
cementation and adhesive
cal retention, so sufficient preparation height and properly tapered
bonding.
preparation walls are critical. They are optimal when there is a large
• Describe when to use various amount of retention and materials being used are strong enough.
methods of adhesive bonding The next step up, in terms of bond strength, is self-adhesive ce-
or conventional cementation. ment. With self-adhesive resin cements, the self-etching chemistry
• Explain how to disinfect is built into the cement itself, so no separate etching or priming
and treat various monolithic step is required. Although these cements provide chemical bond-
restorations before either ing and improved bond strength compared with conventional
cementing or bonding them cements, their properties are inferior to adhesive cements.3
into place. There are two categories of adhesive systems: self-etching resin
cements and etch-and-rinse (the latter was formerly known as
total etch). Self-etch adhesives contain acidic monomers, which
etch and prime the tooth simultaneously.4 Etch-and-rinse systems
contain phosphoric acid to treat the enamel and dentin before
rinsing and subsequent application of an adhesive. Both etch-and-
rinse and self-etch systems form a hybrid layer as a result of resins
permeating the porous enamel and dentin.5 Generally, phosphoric

3 CDEWORLD.COM | VOLUME 6 • NUMBER 142 MAY 2019

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acid creates a more pronounced and retentive postoperative sensitivity and make restorations
etching pattern in enamel. Therefore, etch-and- harder to remove when they need to be replaced.
rinse bonding systems are often preferred for Adhesive cements may be further categorized
preparations with little to no retention or when as light-cure, self-cure, and dual-cure.6 Light-
large areas of enamel are still present.4 Etch- cured resin cements are indicated for thin, highly
and-rinse systems, however, can cause more translucent ceramic restorations because they al-
low the transmission of light to reach through to
the resin cement.7 These cements are comparative-
ly more color stable than self- and dual-cure resin
cements. Self-cure resin does not require light
for polymerization and is indicated with opaque
restorations because of the difficulty encountered
when attempting to light-cure through an opaque
restoration.7 Dual-cure resin cements can be light-
cured or self-cured, but light-cure is generally
recommended to achieve the best bond. Dual-cure
resin cements are indicated when transmission of
1 light through a restoration is doubtful.8
It is important to follow the manufacturer’s
instructions during adhesive cementation, in-
cluding use of the manufacturer’s adhesive and
resin cement combination, because studies have
found incompatibilities between some dual-cure
resin cements and simplified adhesive systems.9
In summary, the conventional cements re-
quire the least amount of steps, but retentive
preparation is extremely important. Additionally,
compared with both adhesive and self-adhesive
cements, conventional cements have a lower
2 bond strength, fracture toughness, technique
sensitivity, and moisture contamination (Figure
1 through Figure 3). Thus, not all restorations
require the same protocol. The following sec-
tions will cover three important questions used
to determine which type of cement, or adhesive,
is best for each scenario.

CEMENTATION SELECTION
The three important questions to consider when
determining the type of cement to use are:
3
• What type of restoration will be placed?
Fig 1. Type of cement to use based on retentiveness of the
• What restorative material was used to create
preparation. Fig 2. Bond strength and fracture toughness of
different types of cement. Fig 3. Degree of technique sensitivity and the restoration?
moisture contamination involved with each type of cement. • How retentive is the preparation?

4 CDEWORLD.COM | VOLUME 6 • NUMBER 142 MAY 2019

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1. What type of restoration will be placed? 2. What restorative material was used to
Indirect restorations are chosen by dentists create the restoration?
based on the functional and esthetic require- In addition to the type of restoration being fabricat-
ments of the tooth being restored. Inlays and ed, the restorative material selected by the clinician
onlays are considered to be more conserva- plays a role in selecting a cement. Historically, con-
tive restorations because they minimize tooth ventional cementation was the only choice available,
structure removal when compared with a full and the predominant restorations of the time, cast
crown. Ceramic veneers are also considered to gold and porcelain-fused-to-metal crowns, had more
be a more conservative restoration than a full than enough strength to be conventionally cemented.
crown for patients who desire to improve the It remains true today that any metal-based restora-
appearance of their smile. Conservative restora- tions can be conventionally cemented, although they
tions such as inlays, onlays, and veneers tend can also be adhesively bonded if the preparation has
to be less retentive than full crowns and as a inadequate retention.
result are typically adhesively bonded. Veneers With the introduction of glass-ceramic materials,
in particular must be adhesively bonded, due to the need to adhesively bond restorations became
both the non-retentive nature of the preparation even more important due to their comparatively
and the need for an esthetic cement that will not lower flexural strengths than metals. Most of the
affect the shade of the veneer. Full crowns can early all-ceramic materials were designed to be
typically be conventionally cemented, but only used as ceramic veneers, so adhesive resin cements
if the flexural strength of the crown material is needed to be esthetic and color stable over time.
greater than 300 MPa. So a full crown fabricated With the introduction of lithium disilicate and
with leucite-reinforced glass-ceramic (which has zirconia oxide, dentists now had a tooth-colored
a flexural strength of 160 MPa) would need to be restorative material that could be conventionally
adhesively bonded even though it is a full crown. cemented if desired. However, if the preparation

Conventional Cement/ Conventional Cement/ Conventional Cement/

Self-Adhesive Cement/ Self-Adhesive Cement/
Self-Adhesive Cement/ Self-Adhesive Cement/ Self-Adhesive Cement/
Adhesive Cement Adhesive Cement
Adhesive Cement Adhesive Cement Adhesive Cement

Conventional Cement/ Conventional Cement/

Self-Adhesive Cement/ Self-Adhesive Cement/ Self-Adhesive Cement/ Self-Adhesive Cement/ Adhesive Cement
Adhesive Cement Adhesive Cement Adhesive Cement Adhesive Cement

Adhesive Cement Adhesive Cement Adhesive Cement Crown Lengthening Crown Lengthening

4
Fig 4. Type of cement to use based on preparation height and degree of preparation taper.

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Regardless of how strong a given restorative

material may be, if the preparation lacks adequate
retention, the restoration must be adhesively bonded.
lacked retention or the material was thin enough disilicate materials are etched by the dental labo-
that the cement would show through, an esthetic ratory with hydrofluoric acid before being sent
resin cement needed to be used for these other- to the dentist to remove portions of the glassy
wise high-strength materials. matrix and increase the bond strength between
the cement and the restoration. This etching has
3. How retentive is the preparation? contributed significantly to their high clinical
In addition to the type of restoration being pre- success rates.10 Zirconia oxide cannot be etched
scribed and which material it is being fabricated with hydrofluoric acid because of the lack of a
from, the retentive features of the preparation glassy matrix.11 As a result, the bond strength of
itself must be taken into consideration. The pri- resin cements to feldspathic ceramics, leucite-
mary considerations for the preparation are its reinforced ceramics, and lithium disilicate ma-
vertical height and the degree of taper of the walls. terials is superior compared with zirconia oxide.
For example, with an anterior tooth preparation When the restoration is first tried in the patient’s
that has 5 or 6 mm of preparation height, typi- mouth, saliva comes in contact with the crown. As
cally any method of cementation may be used. In a result, the restoration needs to be decontami-
contrast, with a lower molar, where it is common nated before placement of a silane or primer.
to see only 3 mm of preparation height and an Historically, dentists have been taught to de-
overtapered proximal wall, an adhesive technique contaminate glass-ceramic restorations after try-
must be used. As shown in Figure 4, if there is in with phosphoric acid, which works well for
a preparation height of 4 mm and preparation decontaminating lithium disilicate restorations.
taper of 12 degrees or less, any desired cement However, decontaminating a zirconia oxide res-
may be used. At the same 4 mm of preparation toration with phosphoric acid leads to predict-
height, if the taper is greater than 16 degrees, an able cement failures, especially with minimally
adhesive cement should be used. Regardless of retentive preparations. There are now multiple
how strong a given restorative material may be, products on the market designed to decontami-
if the preparation lacks adequate retention, the nate restorations while still allowing silanes and
restoration must be adhesively bonded. In this primers to work effectively.
respect, question 3 is more important than the For feldspathic ceramics, leucite-reinforced ce-
other two questions in determining which method ramics, and lithium disilicate materials, a ceramic
of cementation will be used. silane is placed on the intaglio surface of the crown
after disinfecting it, and this silane provides the
TREATMENT OF THE RESTORATION bond from the resin cement to the restoration itself.
In addition to choosing a proper cement for the Application of silane increases the wettability and
restoration, the treatment of the restoration itself chemical bond.12 For zirconia oxide restorations,
before cementation must be taken into account. a zirconia primer is placed inside the crown after
The intaglio surfaces of feldspathic ceram- disinfection. Although this increases the strength of
ics, leucite-reinforced ceramics, and lithium the bond of the resin cement to the zirconia oxide

6 CDEWORLD.COM | VOLUME 6 • NUMBER 142 MAY 2019

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material, this bond would be stronger if zirconia 2013;34(1):12-18.

oxide could be etched with hydrofluoric acid, pro- 5. Cekic I, Ergun G, Lassila LV, Vallittu PK. Ceramic-dentin
viding more micro-mechanical retention on the bonding: effect of adhesive systems and light-curing units. J
surface of the restorative material. Adhes Dent. 2007;9(1):17-23.
6. Ladha K, Verma M. Conventional and contemporary
CONCLUSION luting cements: an overview. J Indian Prosthodont Soc.
Clinicians must be aware and informed in order 2010;10(2):79-88.
to choose the best method of cementation. As 7. Vargas MA, Bergeron C, Diaz-Arnold A. Cementing all-
discussed, many factors are involved, but the ceramic restorations: recommendations for success. J Am
three questions detailed in this article can be Dent Assoc. 2011;142(2 suppl):20S-24S.
used to reach an appropriate decision. 8. Pegoraro TA, da Silva NR, Carvalho RM. Cements for use
in esthetic dentistry. Dent Clin North Am. 2007;51(2):453-471.
REFERENCES 9. Kanehira M, Finger WJ, Hoffmann M, Komatsu M.
1. Haddad MF, Rocha EP, Assunção WG. Cementation of Compatibility between an all-in-one self-etching adhe-
prosthetic restorations: from conventional cementation to den- sive and a dual-cured resin luting cement. J Adhes Dent.
tal bonding concept. J Craniofac Surg. 2011;22(3):952-958. 2006;8(4):229-232.
2. Cardoso MV, Delmé KI, Mine A, et al. Towards a better 10. Della-Bona A. Important aspects of bonding resin to dental
understanding of the adhesion mechanism of resin-modified ceramics. J Adhes Sci Tech. 2009;23(7-8):1163-1176.
glass-ionomers by bonding to differently prepared dentin. J 11. Ho CCK. Clinical techniques: assessment and minimal
Dent. 2010;38(11):921-929. intervention. In: Wilson NHF, Millar BJ. Essentials of Esthetic
3. Shillingburg HT, Hobo S, Whitsett LD, et al. Dentistry: Principles and Practice of Esthetic Dentistry.
Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago, Elsevier; 2015:65-191.
IL: Quintessence; 1997. 12. Matinlinna JP, Lung CYK, Tsoi JKH. Silane adhesion
4. Ozer F, Blatz MB. Self-etch and etch-and-rinse adhesive mechanism in dental applications and surface treatments: a
systems in clinical dentistry. Compend Contin Educ Dent. review. Dent Mater. 2018;34(1):13-28.

7 CDEWORLD.COM | VOLUME 6 • NUMBER 142 MAY 2019

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Dental Materials
Ending Cementation Confusion in Dentistry
Michael DiTolla, DDS

1.  What are the two primary methods of cementation? 6. Compared with both adhesive and self-adhesive
A. conventional and adhesive cements, conventional cements have lower what?
B. bonding and etched A. bond strength and fracture toughness
C. conventional and mechanical B. technique sensitivity
D. chemical and polymerization C. moisture contamination
D. all of the above
2. Which of the following is a commonly used type of
cement? 7. When determining the type of cement to use, what
A. conventional must be considered?
B. self-adhesive A. the type of restoration that will be placed
C. adhesively bonded B. the restorative material used to create the restoration
D. all of the above C. the retentiveness of the preparation
D. all of the above
3. Self-adhesive resin cements provide:
A. separate etching and priming steps. 8. Which type of restorations in particular must be
B. improved bond strength compared with conventional adhesively bonded?
cements. A. inlays
C. d ecreased bond strength compared with conventional B. onlays
cements. C. veneers
D. superior properties to adhesive cements. D. full crowns
4. What are the two categories of adhesive systems? 9. What is/are the primary consideration(s) in regard to
A. self-etching resin cements and etch-and-rinse the preparation?
B. chemical and mechanical A. vertical height
C. acidic and alkaline B. the degree of taper of the walls
D. full coverage and partial coverage C. A and B
D. none of the above
5. Light-cured resin cements are indicated for what type
of restorations? 10. Which of the following cannot be etched with
A. thin, opaque restorations hydrofluoric acid?
B. thick, opaque restorations A. feldspathic ceramics
C. all-metal restorations B. leucite-reinforced ceramics
D. thin, highly translucent ceramic restorations C. lithium disilicate
D. zirconia oxide

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*November 2018 Independent Clinicians Report (Volume 11, Issue 11)