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Cementation of Indirect Restorations

A Clinical GuidePresented by

This booklet was compiled with scientific input from Markus B. Blatz, DMD, Dr Med Dent andUlrike Blatz, DMD, Dr Med Dent

The plethora of indirect restorative dental materials resulted in numeroustreatment options, each requiring a different approach for predictable clinicallongevity. The selection and proper application of dental cements and lutingagents for final insertion of indirect restorations are as crucial as therestorative material itself for pleasing esthetics and long-term functionalsuccess.

This article provides clinical guidelines for final cementation of thevarious indirect restorations baed on currently available data and lutingagents. The first part lists current indirect restorations and preferred lutingagents for their definitive insertion. Part two includes an illustrated step-by-step flowchart for the easy implementation of these recommendations using a current adhesive composite resin cement. Rationale and scientificbackground are discussed in the third part of this “Cementation Guide”.

0.0.1


A Clinical Guide

1.0Quick Reference Chart

TYPE OF RESTORATION RESTORATIVE MATERIAL POSSIBLE LUTING AGENTS PREFERRED CHOICE

Cast Metal and PFM Crown, FPD, Cast Metal Inlay/Onlay

PFM - Noble Alloys, Base Alloys • Adhesive Resin• Composite Resin• RM Glass Ionomer• Glass Ionomer• Zinc Phosphate• Polycarboxylate

• Adhesive Resin• RM Glass Ionomer• Glass Ionomer• Zinc Phosphate

Resin-Bonded FPD(Maryland Bridge)

PFM - Base Alloys • Adhesive Resin• Composite Resin

• Opaque AdhesiveResin

Tooth-ColoredInlay/Onlay

Composite Resin or Silica-based Ceramic

• Adhesive Resin• Composite Resin

• Adhesive Resin• Dual-Cure

Composite Resin

Laminate Veneer Composite Resin or Silica-based Ceramics


• Adhesive Resin• Light-cure or Dual-

Cure Composite Resin

Silica-Based All-Ceramic Crown

Silica-based Ceramics (e.g. IPSEmpress 1 or Eris, Ivoclar Vivadent)


• Adhesive Resin• Dual-cure or Self-Cure

Composite Resin

High-Strength All-Ceramic Crown/FPD

Glass-infiltrated Aluminum andZirconium Oxide (e.g., InCeram, Vita Zahnfabrik)

• Adhesive Resin• RM Glass Ionomer• Glass Ionomer


Densely-sintered Aluminum Oxide(e.g., Procera AllCeram, Nobelbiocare)



Zirconium Oxide (e.g., ProceraAllZirkon, Nobelbiocare; Lava, 3MESPE; Cercon, Dentsply)



1.0.0

Table 1:Type of restorations and their preferred luting agents. The following abbreviations are used: PFM = Porcelain-Fused-to-Metal FPD = Fixed Partial DentureComposite Resin = Conventional Bis-GMA Composite Resin

Luting AgentAdhesive Resin = Composite Resin Luting Agent Containing

Adhesive MonomersRM Glass Ionomer = Resin-Modified Glass Ionomer Cement

QUICK REFERENCE

CHART

General ConsiderationsA clean and dry working field is recommendedfor all cementation procedures and mandatoryfor predictable and successful application ofadhesive bonding techniques. The use of arubber dam is therefore recommendedwhenever adhesive bonding techniques areapplied.

Consider the use of retraction cords,especially when preparation margins arelocated subgingivally.

Precementation ProceduresAfter removal of the provisional restorationverify all clinically important parameters suchas esthetics, fit, interproximal contacts, andstatic/dynamic occlusion with appropriateinstruments and adjust when necessary. Then,follow the flowcharts for the different kinds ofmaterials and types of restorations and the useof a current adhesive composite resin cement.Whenever sandblasting is recommended, it isin reference to the internal surface and shouldbe done with 30-50 µm Al2O3 powder at an air pressure of 60-100 psi for 2-3 seconds per cm2.

2.0.1

2.0Cementation Step-By-StepProcedures

QUICK REFERENCE

CHART

2.1.1

1 Sandblastintaglio surfaceof therestoration.

2 Apply a thin coatof ALLOYPRIMER ifnoble/high-noblealloys are used.

Step 1Preparation of therestoration

2.1Basic CementationTechnique

BASICCEMENTATION

TECHNIQUE

Luting Agent: Adhesive Composite Resin (Panavia F 2.0)

2.1.21 Clean the

prepared toothstructure withfluoride-freepumice.

3 Isolate & dryworking field.

5 Mix one drop ofeach ED PRIMERII Liquid A &Liquid B, applyto both enamel& dentin toothstructures, leavefor 30 seconds.

2 Rinse tooth with water & dry gently.

4 Apply ALLOYPRIMER if toothstructure isreplaced withnoble alloy cast post & core.

6 Dry with gentleair stream -surface willappear glossy.

Step 2Preparation of theabutment tooth

BASICCEMENTATION

TECHNIQUE

2.1.3

1 Dispense & mixcement: dispenseequal amountsof PANAVIA F2.0 A PASTE and B PASTE.

1 Seat restoration& hold in placewith fingerpressure.

3 Cure cement mar-gins with a curinglight; 20 sec. foreach surface (con-ventional halogen or LED light); 5 sec.for each surface(Plasma arc or fasthalogen light).

2 Mix pastes for 20seconds & apply a thin & evenlayer of cement to the intagliosurface of therestoration.

2 Excess cementmay be removedby partially lightcuring the cementat the margins for2-3 seconds thenremoving theexcess with ahand instrument.

Or apply PANAVIAF OXYGUARD II on the margins & leave for 3 minutes.

• If OXYGUARD IIwas used, cleanafter 3 minuteswith water spray & cotton rolls.

Step 3Mix Cement

Step 4Insertion ofRestoration

20 sec. for each surface(conventional halogen orLED light); 5 sec. for eachsurface (Plasma arc or fasthalogen light)

2.1.41 Remove cured

excess cementwith explorer,scaler, or blade & polishrestoration ifnecessary.

Step 5Removal of ExcessCement and FinalAdjustments

2.2

2.2.1

1 Sandblastbonding surfaceof therestoration.

Step 1Preparation of the Restoration

Opaque adhesive composite resin luting agents(e.g., PANAVIA F 2.0) should be used forcementation of resin-bonded FPDs with a metalframe, since metal parts of the retainers mayreflect through the abutment teeth and causediscolorations.


Resin-Bonded Fixed Partial Denture (“Maryland Bridge”)

MARYLANDBRIDGE

2.2.21 Clean the


3 Isolate and dryworking field.

5 Mix one drop ofeach ED PRIMERII Liquid A &Liquid B & applyto both enamel& dentin toothstructures &leave for 30seconds.

2 Rinse tooth with water and dry gently.

4 Conditionenamel toothstructure with K ETCHANT GELfor 10 seconds.Then, rinse with water and air-dry.


Step 2Preparation of theAbutment Tooth

MARYLANDBRIDGE

2.2.3

1 Dispense & mixcement: dispenseequal amountsof PANAVIA F2.0 A PASTE &B PASTE.







Step 3Mix Cement


2.2.41 Remove cured



2.3.1

2 Apply silanecoupling agent (mix equal amountsof CLEARFIL SEBOND PRIMER with CLEARFILPORCELAIN BONDACTIVATOR) &leave for 5 seconds.Dry gently with air.

In addition to the preliminary try-in proceduresdescribed above, esthetic appearance of therestoration seated on the natural tooth should beverified with water, glycerin, and/or try-in pastes. Aspecial applicator (e.g., explorer with sticky wax) maybe used to simplify trial insertion and removal of therestoration and to prevent damage to marginal areas.Type, shade, and viscosity of the resin cement have tobe selected before the actual cementation procedure.The bonding surfaces of the restoration should bepretreated (sandblasting or acid etching) after try-inprocedures and necessary adjustments. Curedcomposite resin restorations should be sandblastedwith 30-50 µm Al2O3 powder at an air pressure of 60-100 psi for 2-3 seconds per cm2. Clean anddecontaminate the surface with K ETCHANT GEL,leave for 5 seconds and then rinse with water.


1 Sandblast(compositeresin) and acidetch (silica-based ceramic)bonding sur-faces of therestoration withK ETCHANTGEL.


2.3Tooth-coloredInlay/Onlay(Composite Resin or Silica-basedCeramic)

TOOTH-COLOREDINLAY/ONLAY

2.3.21 Clean the




4 Mix one drop ofeach ED PRIMERII Liquid A &Liquid B & applyto both enamel& dentin toothstructures &leave for 30seconds.



TOOTH-COLOREDINLAY/ONLAY

2.3.3

1 Dispense & mixcement: dispenseequal amounts of PANAVIA F 2.0A PASTE & BPASTE.



2 Mix pastes for20 seconds &apply a thin &even layer ofcement to the intagliosurface of therestoration.




Step 3Mix Cement

Step 4Insertion of restoration

2.3.41 Remove cured



2.4.1

1 Sandblast(compositeresin) and acidetch (silica-based ceramic)bonding sur-faces of therestoration withK ETCHANTGEL.

2 Apply silanecoupling agent (mix equal amountsof CLEARFIL SEBOND PRIMER with CLEARFILPORCELAIN BONDACTIVATOR) &leave for 5 seconds.Dry gently with air.


In addition to the preliminary try-in proceduresdescribed previously, esthetic appearance of therestoration seated on the natural tooth should beverified with water, glycerin, and/or try-in pastes.Type, shade, and viscosity of the resin cementshould be selected before the actual cementationprocedure. The bonding surfaces of the restora-tion should be pretreated after try-in proceduresand necessary adjustments. Cured compositeresin restorations should be sandblasted with 30-50 µm Al2O3 powder at an air pressure of 60-100 psi for 2-3 seconds per cm2. Clean anddecontaminate the surface with K ETCHANTGEL, leave for 5 seconds and then rinse with water.


2.4Laminate Veneer(Composite Resin or Silica-basedCeramic)

LAMINATE VENEER

2.4.21 Clean the



5 Mix one drop ofeach ED PRIMERII Liquid A &Liquid B, applyto both enamel& dentin toothstructures, leavefor 30 seconds.


4 Condition enameltooth structurewith K ETCHANTGEL for 10seconds. Then,rinse with water & air-dry.



LAMINATE VENEER

2.4.3

1 Dispense & mixcement: dispenseequal amounts ofPANAVIA F 2.0 A PASTE & BPASTE.

1 Seat restoration &hold restoration inplace with fingerpressure.




Or apply PANAVIAF OXYGUARD IIon the margins & leave for 3minutes.


Step 3Mix Cement

Step 4Insertion of Restoration

2.4.41 Remove cured



2.5.1

1 Acid etch intagliosurface ofrestoration.

2 Apply silane coupling agent (mix equal amountsof CLEARFIL SEBOND PRIMER with CLEARFILPORCELAIN BONDACTIVATOR) & leave for 5 seconds.Dry gently with air.


In addition to the preliminary try-in proceduresdescribed previously, esthetic appearance of therestoration seated on the natural tooth should beverified. Type, shade, and viscosity of the resincement should be selected before the actualcementation procedure. The intaglio of silica-based ceramic crowns (e.g., leucite-reinforcedfeldspathic porcelain) should be acid etched aftertry-in procedures and necessary adjustments.


2.5Silica-based All-Ceramic Crown

SILICACERAMIC CROWN

2.5.21 Clean the




4 Mix one drop ofeach ED PRIMERII Liquid A &Liquid B, apply to both enamel & dentin toothstructures, leavefor 30 seconds.



SILICACERAMIC CROWN

2.5.3

1 Dispense andmix cement:dispense equalamounts ofPANAVIA F 2.0A PASTE and B PASTE.







Step 3Mix Cement


2.5.41 Remove cured



2.6.1

1 Sandblast theintaglio surface ofthe high-strengthceramic crown.


The intaglio surface of high-strength ceramiccrowns (e.g., glass-infiltrated or densely-sinteredaluminum-oxide ceramic, zirconium-oxideceramic) should be sandblasted after try-inprocedures and necessary adjustments. Sandblastwith 50-110 µm Al2O3 at 60-100 psi pressure for2-3 seconds per cm2. If restoration was alreadypretreated in the laboratory, clean anddecontaminate the surface with K ETCHANT GEL,leave for 5 seconds and then rinse with water.


2.6High-Strength All-Ceramic Crown(aluminum-oxide or zirconium-oxideceramic)

HIGH STRENGTHALL-CERAMIC

CROWN

2.6.21 Clean the




4 Mix one drop ofeach ED Primer IILiquid A & LiquidB, apply to both enamel & dentin toothstructures, leavefor 30 seconds.



HIGH STRENGTHALL-CERAMIC

CROWN

2.6.3

1 Dispense & mixcement: dispenseequal amountsof PANAVIA F2.0 A PASTE and B PASTE.





Or apply PANAVIAF OXYGUARD IIon the margins & leave for 3 minutes.


Step 3Mix Cement


2.6.41 Remove cured



Dental luting agents retain a laboratory-made (indirect) fixed restoration on thesupporting tooth.1 The selection and properapplication of luting agents for definitiveinsertion of indirect restorations arefundamental for long-term functionalsuccess and pleasing esthetics. The varietyof current treatment modalities and newindirect restorative dental materials mayrequire different luting materials andinsertion procedures.

The background and recommendations given are based on the currently availabledata and manufacturers’ information. Theyare prone to adaptations as new knowledgeevolves and new materials are developed.Controlled clinical trails will be necessary toverify some of the in-vitro data presented.

3.0.1

3.0Background

BACKGROUND/SUMMARY/

REFERENCES

Zinc phosphate cements have traditionallybeen the most popular luting materials1 andtheir reliability is documented by theexcellent clinical long-term survival rates ofcast metal crowns, cast inlays/onlays, andporcelain-fused-to-metal (PFM) restorations.2-6

Some advantages of zinc-phosphate cementsare easy handling, sufficient compressivestrength, and low cost. However, thesecements have some major disadvantagessuch as brittleness, high solubility, and lackof antibacterial and - most important -adhesive properties. Retention of an indirectrestoration cemented with traditional lutingagents depends mostly on geometric form(surface, height, angulation) of the toothpreparation. Consequently, such cementshave rather space-filling than retentivefunctions, which is important in light of thereportedly high number of prosthetic failuresdue to lack of retention.1,7 Some of thosedrawbacks have been solved with the devel-opment of glass ionomers8, which offer someadhesion to tooth structures and variousrestorative materials, and they also releasefluoride.1 Latest additions to this materialgroup are resin-modified glass ionomers,which combine some of the advantages ofglass ionomer and resin luting agents.9

Cast metal and PFM restorations yieldtremendous clinical success with the afore-

mentioned luting agents. However, adhesivebonding techniques are beneficial in variousclinical situations, such as excessive dis-lodging forces, compromised mechanicalretention, limited space for adequate toothpreparation, and occlusal contacts in excur-sions on short posterior restorations. Resinluting agents containing special adhesivemonomers (e.g., 10-methacryloyloxydecyldihydrogen phosphate (MDP)) that providechemical bonds to metal oxides10 have showna significant increase in retention of castrestorations when compared with zincphosphate, glass ionomer, or conventionalresin cements.1,11-14 Noble and high-noblealloys must be pretreated with special alloyprimers, tin plated, or silica-/silane-coated.

Microleakage and the possibledevelopment of hypersensitivity and/orsecondary caries are clinically importantfactors that can be reduced by the use ofadhesive resin systems.15-17 Filled resin lutingagents also exhibit superior mechanicalproperties, such as increases in flexuralstrength, fracture toughness, modulus ofelasticity, and hardness.1

Autopolymerizing or dual-cure resincements are recommended for insertion ofcast and PFM restorations.

3.1.1

3.1Cast metal and PFM crown,FPD, cast metalinlay/onlay

BACKGROUND/SUMMARY/

REFERENCES

Since the preparation for PFM resin-bondedfixed partial dentures (FPD) is not designedto facilitate mechanical retention, clinicalsuccess relies on the adhesive bond of themetal framework to the supporting toothstructure.18-21 If the tooth preparation isprimarily confined to the enamel structuresand adhesive bonding techniques areperformed appropriately (acid etching,bonding agent application), a predictableresin bond to the metal can be establishedwith the use of composite resin lutingagents containing adhesive monomers thatcan bond directly to the metal. Base metalalloys should be typically used for PFM

resin-bonded FPDs due to their stiffnessand susceptibility to form a surface oxidelayer. Adhesive resin luting agents providestrong resin bonds to this oxide layerwithout pretreatment of the base-metalframework other than sand-blasting withAl2O3. Noble and high-noble alloys must bepretreated with special alloy primers, tinplated, or silica-/silane-coated. Since themetal retainer wing may reflect throughthin abutment teeth and result in a grayishappearance, dual- or self-cure resincements of high opacity can be used tominimize this phenomenon and optimizethe esthetic outcome.

3.2.1

3.2Resin-Bonded Fixed Partial Denture (“Maryland Bridge”)

Ceramic inlays and onlays offer optimalesthetics, biocompatibility, and durability.2,22-24

Adhesive bonding techniques, compositeresin luting agents, and proper treatment ofthe ceramic and tooth surfaces are funda-mental for clinical success and increasedfracture resistance of silica-based (e.g., felds-pathic porcelain, leucite-reinforced feldspathicporcelain) all-ceramic restorations.2,25-27

A sufficient resin bond to silicateceramic materials relies on chemical bondingand micromechanical interlocking and can beachieved through surface roughening andapplication of a silane coupling agent.Grinding and air abrasion (e.g., alumium-oxide particles) may increase bond strength28-

31 but are not suitable for final insertion of all-ceramic restorations due to possible marginaldamage.32 Most studies recommend acidetching of the ceramic surface with 4% to 9.8% hydrofluoric acid (HF) for 2-3 minutes toachieve preferable surface texture androughness.33-39 HF acid gels are user friendlyand allow for chairside etching of the ceramicbonding surface after the completion of alltry-in procedures and alterations.

Silane coupling agents provide a chemi-cal covalent bond and micromechanical inter-locking to silica-based ceramics.40-44 Contam-ination of an etched and silanated restorationshould be avoided since it may negatively

affect etching patterns and decrease bondstrengths. If the restoration is contaminatedduring clinical try in with organic contam-inants, such as saliva, blood or a silicone fit-checking medium, phosphoric-acid etchingcan remove organic contaminants prior to HFacid etching and is more effective thansolvents such as acetone or alcohol.45

Silane coupling agents may havedifferent chemical compositions that must becompatible with the bonding agent and theresin cement.46 Therefore, it is of paramountimportance to stay within one bonding sys-tem and to closely follow the manufacturer’sinstructions for application procedures andtiming. Silane coupling agents are dispensedin single-bottle or multiple-bottle applications.

Composite-resin inlays and onlays expe-rience an increased popularity.47,48 Cured com-posite resins as used for indirect restorationslack an uncured resinous, oxygen inhibitionlayer, which is typical for freshly cured com-posite and offers excellent resin-to-resin bonds.Therefore, an indirect composite restorationmust be pretreated (e.g., sandblasting andapplication of a silane coupling agent).

The dentin and enamel tooth structuresare pretreated with the respective bondingagents. Dual- or chemical-activated resincements are recommended for insertion ofceramic and composite resin inlays/onlays.49

3.3.1

3.3Tooth-coloredInlay/Onlay(Composite Resin or Silica-basedCeramic)

Ceramic laminate veneers offer excellentlong-term clinical success.50-57 The non-invasive nature of this treatment modalityand the inherent brittleness of the typically-used feldspathic porcelain make resinbonding an absolute must. Silica-basedceramics are treated with HF acid and asilane coupling agent for predictable andlong-term durable resin bonds as describedabove (3.3). High bond strengths can alsobe achieved to the supporting toothstructure if the preparation design is kept tothe required minimum and mainly confined

to enamel. The esthetic appearance of thedefinitive restoration seated on the naturaltooth should be verified with water, glycerin,and/or try-in pastes. Type, shade, andviscosity of the resin cement should beselected before the actual cementationprocedure. The dentin and enamel toothstructures are pretreated with the respectivebonding agents.

Indirect laminate veneers may also befabricated of composite resins, which mustbe pretreated (e.g., sandblasting andapplication of a silane coupling agent).

3.4.1

3.4Laminate Veneer(composite resin or silica-basedceramic)

All-ceramic, especially silica-based ceramicrestorations need support through adhesivetechnologies and composite resin lutingagents,2,25 which is also true for full-coveragecrowns.2,26 Pretreatment and bonding methods oftooth and restoration surfaces are the same asfor ceramic inlays/onlays (3.3) and ceramiclaminate veneers (3.4).

3.5.1

3.5Silica-based All-Ceramic Crown

All-ceramic systems using non-silicate, high-strength ceramic materials (aluminium-oxideand zirconium-oxide ceramics) becomeincreasingly popular due to their estheticcharacteristics, mechanical properties, andbiocompatibility.2 Indications include full-coverage crowns and multiple-unit FPDs2,while some systems even offer laminateveneers58, resin-bonded fixed partial dentures(FPDs)59, and implant abutments. Long-termclinical studies revealed high success rates ofdensely-sintered alumina crowns cementedwith conventional luting agents.60, 61 However,a recent literature review25 suggests the useof adhesive bonding techniques for ceramicrestorations, especially in clinical situationsof compromised retention and high occlusalloads.62 Adhesive luting is mandatory forresin-bonded FPDs and laminate veneersindependent from the restorative material.

Reviews of the literature indicate thatbonding procedures used for silica-basedceramics are not efficient for high-strengthceramic materials.27,63 It is important todifferentiate between studies that test onlyshort-term bond strengths and studies thatinclude simulated aging parameters such aslong-term water storage and thermocyclingfor clinical relevance.27,63,64 The intagliosurfaces of restorations made from differentall-ceramic systems are unique due to the

use of different material compositions andfabrication procedures. Therefore, it isnecessary to apply bonding protocols thatwere tested on specimens that possess theactual intaglio surface of a certain system.27,63

Glass-infiltrated aluminum-oxide or zirconium oxide ceramic Glass-infiltrated aluminum-oxide ceramic(e.g., In-Ceram Alumina, Vita Zahnfabrik,Bad Säckingen, Germany) offers a flexuralstrength of 450 MPa.65 HF acid does notsufficiently roughen aluminum-oxideceramics.66 Air-particle abrasion with amicroetcher and Al2O3 abrasive particles is apractical method to successfully roughen thesurface of aluminum-oxide ceramics forenhanced mechanical bonds.63 Some silica-coating methods also achieve reliable anddurable resin bonds to glass-infiltratedalumina.67-69

A resin luting agent containing anadhesive phosphate monomer providedreliable and long-term durable resin bonds toair-particle-abraded glass-infiltrated aluminaceramic in several in-vitro68,70,71 as well as in-vivo studies.72 The adhesive functionalphosphate monomer MDP chemically bondsto metal oxides, including aluminum andzirconium oxides.10

3.6.1

3.6High-strength All-Ceramic Crown(aluminum-oxide or zirconium-oxideceramic)

There are no bonding studies to glass-infiltrated zirconium-oxide ceramics (e.g., InceramZirconia) available, but their composition suggestsbonding procedures and materials as used for otherhigh-strength ceramics.

Densely-Sintered Aluminum-Oxide CeramicProcera AllCeram73 (Nobel Biocare, Goteborg,Sweden) uses CAD/CAM technology for thefabrication of high-alumina (>99.9%) copings andframeworks that offer a flexural strength of 610MPa.73,74 While densely-sintered alumina restorationsyield high clinical success with conventionalcements,60,61 adhesive luting may be beneficial andoffers some advantages.25 Air-particle abrasion with amicroetcher (50 (m Al2O3 at 2.5 bar) has producedhigher resin bonds than other surface rougheningmethods including grinding and HF acid etching.66

One study revealed that conventional silane couplingagents and tribochemical silica coating fail toenhance the long-term resin bond to densely-sinteredalumina.76 Only air-particle abrasion and a compositeresin containing an adhesive phosphate monomerprovided high and long-term durable bondstrengths.76 Studies evaluating bond strength to theunique intaglio surface of Procera AllCeramrestorations recommend air-particle abrasion and theuse of a resin luting agent containing a phosphatemonomer in combination with a corresponding silanecoupling/bonding agent (Clearfil New Bond andClearfil Porcelain Bond Activator).77,78

Zirconium-oxide ceramicsZirconium-oxide ceramics have a very high flexuralstrength (over 1000 MPa)79 Contemporary CAD/CAMsystems (e.g. Procera Allzirkon, obel Biocare, Lava,3M ESPE, Cercon, Dentsply) use zirconium-oxideceramics for fabricating copings, frameworks, andimplant abutments. The high strength of densely-sin-tered zirconia restorations may allow inserted withtraditional luting agents. However, resin bondingmay become necessary in some clinical situationsand may offer some additional advantages.27 Onestudy revealed that air particle abrasion, silane appli-cation, and a conventional Bis-GMA resin cementprovided high initial bonds that failed spontaneouslyafter simulated aging.80 Tribochemical silica-coatingwas equally ineffective. Only air-particle abrasion anda phosphate-modified resin cement provided long-term durable resin bonds, which was confirmed byanother long-term study in which specimens weresubject to two years of water storage and repeatedthermocycling.81 The use of silane/bonding agentsand resin cements containing special adhesivemonomers was found to be the protocol of choicefor Procera AllCeram restorations.77 The same proto-col was successful for the intaglio surface of ProceraAllZirkon densely sintered zirconia restorations, andhave also demonstrated that, potentially, the signifi-cant ingredient is the silane/bonding agent, whichcontains special adhesive monomers.82 These findingshave be verified using Lava Zirconia specimens. How-ever, silica-/silane coating provided similar results.83

3.6.2

Conventional luting agents have a longhistory of excellent clinical success and their use is relatively simple and commonlyknown. Some clinical situations and treat-ment modalities, however, may require resin bonding. If resin bonding is selected for final insertion, the following conclusionsmay be drawn in respect to the specificrestorative material:• Resin luting agents containing adhesive

monomers provide high bond strengths tovarious, especially base metal alloys.Noble alloys should be specially pretreated(e.g., alloy primers).

• Cured composite resins used for indirectrestorations should be adhesively lutedafter adequate surface treatment.

• Clinical success of silica-based ceramicsrelies on resin bonding. Preferred surfacetreatment methods are acid etching withHF acid solutions and subsequentapplication of a silane coupling agent.

• The preferred surface treatment foralumina and zirconia frameworks is airparticle abrasion. A silane/bonding agentcontaining adhesive monomers employedwith a modified resin cement providepredictable and durable bond to densely-sintered alumina- and zirconia-basedrestorations.

3.7.1

3.7Summary

1. Rosenstiel SF, Land MF, Crispin BJ. Dental lutingagents: a review of the current literature. J ProsthetDent 1998;80:280-301.2. Blatz MB. Long-Term Clinical Success of All-Ceramic Posterior Restorations. Quintessence Int2002, 33:415-426.3. Studer SP, Wettstein F, Lehner C, Zullo TG, SchärerP. Long-term survival estimates of cast gold inlaysand onlays with their analysis of failures. J OralRehabil 2000; 27: 461-472.4. Jokstad A, Mjör IA, Quist V. The age of restorationin situ. Acta Odontol Scand 1994; 52: 234-248.5. Leempoel PJB, Eschen S, De Haan AFJ, Van’t HofMA. An evaluation of crowns and bridges in generaldental practice. J Oral Rehabil 1985; 12(6): 515-528.6. Smales RJ, Hawthorne WS. Long-term survival ofextensive amalgams and posterior crowns. J Dent1997; 25: 225-227.7. Walton JN, Gardner FM, Agar JR. A survey ofcrown and fixed partial denture failures: length ofservice and reasons for replacement. J Prosthet Dent1986;65:416-421.8. McLean JW, Wilson AD, Prosser HJ. Developmentand use of water-hardening glass-ionomer lutingcements. J Prosthet Dent 1984;52:175-181.9. McLean JW, Nicholson JW, Wilson AD. Suggestednomenclature for glass-ionomer cements and relatedmaterials. Quintessence INt 1994;25:587-589.10. Wada T. Development of a new adhesive materialand its properties. In: Gettleman L, Vrijhoef MMA,Uchiyama Y, eds. Proceedings of the InternationalSymposium on Adhesive Prosthodontics, 1986 June24, Amsterdam, Netherlands. Chicago: Academy ofDental Materials, 1986;9-18.11. Ayad MF, Rosenstiel SF, Salama M. Influence oftooth surface roughness and type of cement onretention of complete cast crowns. J Prosthet Dent1997;77:116-121.12. Tjan AH, Li T. Seating and retention of completecrowns with a new adhesive resin cement. J ProsthetDent 1992;67:478-483.

13. Gorodovski S, Zidan O. Retentive strength,disintegration, and marginal quality of luting cements.J Prosthet Dent 1992;68:269-274.14. Black SM, Charlton G. The retention of goldcrowns on human dentine preparations-a comparisonof eight cements. Restorative Dent 1989;5:39-41.15. Tjan AH, Dunn JR, Grant BE. Marginal leabkageof cast gold crowns luted with an adhesive resincement. J Prosthet Dent 1992;67:11-15.16. Strygler H, Nicholls JI, Townsend JD.Microleakage at the resin-alloy interface ofchemiocally retained composite resins for castrestorations. J Prosthet Dent 1991;65:733-739.17. White SN, Igles S, Kipnis V. In-vivo microleakageof luting cements for cast crowns. J Prosthet Dent1994;71:257-264.18. Probster B, Heinrich GM. 11-year follow-up studyof resin bonded fixed partial dentures. Int JProsthodont 1997;10:259-268.19. Dietschi D. Indications and potential of bondedmetal-ceramic fixed partial dentures. PractPeriodontics Aesthet Dent 2000;12:51-8.20. Djemal S, Setchel D, King P, Wickens J. Long-term survival characteristics of 832 resin-retainedbridges and splints provided in a post-graduateteaching hospital between 1978 and 1993. J OralRehabil 1999;26:302-20.21. Cobb DS, Vargas DA, Fridrich TA, BouschlicherMR. Metal surface treatment: characterization andeffect on composite-to-metal bond strength. OperDent 2000;25:427-33.22. Noack MJ, Roulet J-F. Tooth colored inlays. CurrOpin Dent 1991; 1: 172-178.23. Nathanson D. Principles of porcelain use as aninlay/onlay material. In: Garber DA, Goldstein RE,eds. Porcelain & Composite Inlays & Onlays: EstheticPosterior Restorations. Chicago: Quintessence, 1994:32-37.24. Dietschi D, Maeder M, Meyer J-M, Holz J. In vitroresistance to fracture of porcelain inlays bonded totooth. Quintessence Int 1990; 21: 823-831.

25. Burke FJ, Fleming GJ, Nathanson D, MarquisPM. Are adhesive technologies needed to supportceramics? An assessment of the current evidence. JAdhes Dent 2002;4:7-22.26. Blatz MB, Sadan A, Kern M. Bonding to silica-based ceramics: clinical and laboratory guidelines.Quintessence Dent Technol 2002;25: 54-62.27. Blatz MB, Sadan A, Kern M. Resin-ceramicbonding - a review of the literature. J Prosthet Dent2003;89:268-274.28. Semmelmann JO, Kulp PR. Silane bondingporcelain teeth to acrylic. J Am Dent Assoc1968;76:69-73.29. Jochen DG, Caputo AA. Composite resin repair ofporcelain denture teeth. J Prosthet Dent1977;38:673-9.30. Ferrando JM, Graser GN, Tallents RH, Jarvis RH.Tensile strength and microleakage of porcelain repairmaterials. J Prosthet Dent 1983;50:44-50.31. Yamamoto H, Munakata K, Sekiguchi S. Shearadhesive strength of dental adhesive cements toporcelains. Influence of porcelains and surfacetreatment methods. J Jpn Prothodont Soc1986;30:207-15.32. Kern M, Thompson VP. Sandblasting and silicacoating of a glass-infiltrated alumina ceramic: Volumeloss, morphology, and changes in the surfacecomposition. J Prosthet Dent 1994;71:453-61. 33. Blatz MB, Sadan A, Maltezos C, Blatz U,Mercante D, Burgess JO. In-vitro Durability of theResin Bond to Feldspathic Ceramics. Am J Dent2003, in press.34. Bailey LF, Bennet RJ. Dicor surface treatments forenhanced bonding. J Dent Res 1988;67:925-31.35. Müller G. Ätzen und Silanisieren dentalerKeramiken [Etching and silanizing of dental ceramics].Dtsch Zahnärztl Z 1988;43:438-441.36. Wolf DM, Powers JM, O’Keefe KL. Bond strengthof composite to porcelain treated with new porcelainrepair agents. Dent Mat 1992;8:158-61.

3.8.1

3.8References

37. Chen JH, Matsumura H, Atsuta M. effect ofdifferent etching periods on the bond strength of acomposite resin to a machinable porcelain. J Dent1998;26:53-8.38. Sorensen JA, Engelman MJ, Torres TJ, Avera SP.Shear bond strength of composite resin to porcelain.Int J Prosthodont 1991;4:17-23.39. Chen JH, Matsumura H, Atsuta M. Effect ofetchant, etching period, and silane priming on bondstrength to porcelain of composite resin. Oper Dent1998;23:250-7.40. Bailey JH. Porcelain-to-composite bond strengthsusing four organosilane materials. J Prosthet Dent1989;61:174-7.41. Stokes AN, Hod JAA, Tidmarsh BG. Effect of 6-month water storage on silane treated resin/porcelainbonds. J Dent 1988;16:294-7.42. Suliman AH, Swift EJ, Perdigao J. Effects ofsurface treatment and bonding agents on bondstrength of composite resin to porcelain. J ProsthetDent 1993;70:118-12043. Barghi N. To silanate or not to silanate: making aclinical decision. Comp Contin Edu 2000;21:659-664.44. Söderholm KJM, Shang SW. Molecular orientationof silane at the surface of colloidal silica. J Dent Res1993;72:1050-4.45. Nicholls JI. Tensile bond of resin cements toporcelain veneers. J. Prosthet. Dent. 1988;60:443-47.46. Matsumura H, Kato H, Atsuta M. Shear bondstrength of feldspathic porcelain of two luting cementsin combination with three surface treatments. JProsthet Dent 1997;78:511-17.47. Van Dijken JWV. 5-6 year evaluation of directcomposite inlays. J Dent Res 1994;73:327 (Abstract).48. Collins CJ, Bryant RW. Clinical evaluation ofposterior composite resin restorations: eight-yearfindings. J Dent Res 1995;74,404 (Abstract).49. Krämer N, Lohbauer U, Frankenberger R. Adhesiveluting of indirect restorations. Am J Dent2000;13:60D-76D.50. Horn HR. Porcelain laminate veneers bonded toetched enamel. Dent Clin North Amer 1983;27:671-5.51. Cho GC, Donovan TE, Chee WW. Clinical

experiences with bonded porcelain laminate veneers. JCalif Dent Assoc 1998;26:121-7.52. Dumfahrt H, Schaffer H. Porcelain laminateveneers. A retrospective evaluation after 1 to 10 yearsof service: Part II—Clinical results. Int J Prosthodont2000;13:9-18.53. Friedman MJ. Ask the experts. Porcelain veneers. JEsthet Restor Dent 2001;13:86-7.54. Fradeani M. Six-year follow-up with Empressveneers. Int J Periodontics Restorative Dent1998;18:216-25.55. Gilmour AS, Stone DC. Porcelain laminateveneers: a clinical success? Dent Update 1993;20:167-9, 171-3.56. Kreulen CM, Creugers NH, Meijering AC. Meta-analysis of anterior veneer restorations in clinicalstudies [Dutch]. Ned Tijdschr Tandheelkd2001;108:260-5.57. Peumans M, Van Meerbeek B, Lambrechts P,Vanherle G. Porcelain veneers: a review of theliterature. J Dent 2000;28:163-77.58. Hager B, Oden A, Andersson B, Andersson L.Procera AllCeram laminates: a clinical report. JProsthet Dent 2001;85:231-232.59. Kern M, Knode H, Strub JR. The all-porcelain,resin-bonded bridge. Quintessence Int 1991;22:257-262.60. Oden A, Andersson M, Krystek-Ondracek I,Magnusson D. Five-year clinical evaluation of ProceraAllCeram crowns. J Prosthet Dent 1998; 80(4): 450-456.61. Odman P, Andersson B. Procera AllCeram crownsfollowed for 5 to 10.5 years: a prospective clinicalstudy. Int J Prosthodont 2001;14:504-509.62. Burke FJT. Fracture resistance of teeth restoredwith dentine-bonded crowns. Quintessence Int1996;27:115-121.63. Blatz MB, Sadan A, Kern M. Adhesivecementation of high-strength ceramic restorations:clinical and laboratory guidelines. Quintessence DentTechnol 2003, 26:47-55.64. Sadan A, Blatz MB, Soignet D. Influence ofsilanization on early bond strength to sandblasted

densely sintered alumina. Quintessence Int2003;34:172-6.65. Seghi RR, Sorensen JA. Relative flexural strengthof six new ceramic materials. Int J Prosthodont1995;8:239-46.66. Awliya W, Oden A, Yaman P, Dennison JP,Razzoog ME. Shear bond strength of a resin cement todensely sintered high-purity alumina with varioussurface conditions. Acta Odontol Scand 1998;56:9-13.67. Kern M, Thompson VP. Sandblasting and silicacoating of glass-infiltrated alumina ceramic: volumeloss, morphology, and changes in the surfacecomposition. J Prosthet Dent 1994;71:453-461.68. Kern M, Thompson VP. Bonding to glassinfiltrated alumina ceramic: adhesive methods andtheir durability. J Prosthet Dent 1995;73:240-249.69. Ozcan M, Alkumru HN, Gemalmaz D. The effectof surface treatment on the shear bond strength ofluting cement to a glass-infiltrated alumina ceramic.Int J Prosthodont 2001;14:335-339.70. Isidor F, Stokholm R, Ravnholt G. Tensile bondstrength of resin luting cement to glass infiltratedporous aluminium oxide cores (In-Ceram). Eur JProsthodont Restor Dent 1995;3:199-202.71. Madani M, Chu FCS, McDonald AV, Smales RJ.Effects of surface treatments on shear bond strengthsbetween a resin cement and an alumina core. JProsthet Dent 2000;83:644-647.72. Kern M, Strub JR. Bonding to alumina ceramic inrestorative dentistry: clinical results over up to 5 years.J Dent 1998;26:245-9.73. Andersson M, Oden A. A New All-Ceramic Crown:A Dense-Sintered, High-Purity Alumina Coping WithPorcelain. Acta Odontol Scand 1993;51:59-64.74. Zeng K, Oden A, Rowcliffe D. Flexure tests ondental ceramics. Int J Prosthodont 1996;9:434-9.75. Zeng K, Oden A, Rowcliffe D. Evaluation ofmechanical properties of dental ceramic core materialsin combination with porcelains. Int J Prosthodont1998;11:183-9.76. Friederich R, Kern M. Resin bond strength todensely sintered alumina ceramic. Int J Prosthodont2002;15:333-338.

77. Blatz MB, Sadan A, Arch GH, Lang BR. In vitroevaluation of long-term bonding of Procera AllCeramalumina restorations with a modified resin lutingagent. J Prosthet Dent. 2003;89:381-7.78. Blatz MB, Sadan A, Blatz U. The Effect of SilicaCoating on the Long-Term Resin Bond to the IntaglioSurface of Procera AllCeram Restorations.Quintessence Int 2003;34:542-7.79. Ashizuka M, Kiyohara H, Okuno T, Kubota Y.Fatigue behavior of tetragonal zirconia polycrystals (Y-TZP) containing 2 and 4 mol% Y2O3 (Part 2). JCeram Soc Jpn Inter Ed 1988;96:731-6.80. Kern M, Wegner SM. Bonding to zirconia ceramic:adhesion methods and their durability. Dent Mater1998;14:64-71.81. Wegner SM, Kern M. Long-term resin bondstrength to zirconia ceramic. J Adhesive Dent2000;2:139-47.82. Blatz MB, Sadan A, Martin J, Mang B. In-vitroevaluation of shear bond strength of resin to densely-sintered high purity zirconium oxide ceramic after long-term storage and thermocyclying. J Prosthet Dent2004, in press.83. Blatz MB, Sadan A, Bulot d, Holst S. influence ofsurface treatment on the long-term bond to zirconium.J Dent Res 2004;83:Spec Iss A; Abstr. 1543.

3.8.2


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