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Ending
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Confusion
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A Key to Restoration Success
Michael DiTolla, DDS

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Dental Materials
Ending Cementation
Confusion in Dentistry
Michael DiTolla, DDS
ABSTRACT
Selecting the appropriate
cement is critical to ensuring
the success and longevity of
a restoration. The goal of this
article is to help clinicians
make appropriate cementation
decisions by discussing the
qualities of cements and
adhesives and then providing
three questions to answer
when considering cementation
methods.
LEARNING OBJECTIVES
• Describe the differences
between conventional
cementation and adhesive
bonding.
• Describe when to use various
methods of adhesive bonding
or conventional cementation.
• Explain how to disinfect
and treat various monolithic
restorations before either
cementing or bonding them
into place.
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C
hoosing the right luting material is of vital importance
to the longevity of dental restorative materials.1 There
are two primary methods of cementation: conventional
cementation and adhesive cementation. Conventional cementation
means just filling a gap, whereby the majority of the retention
comes from the preparation itself. Adhesive cementation means
using adhesives and primers to create a bond. Using a less than
ideal cementation protocol can negatively impact the result and
longevity of the procedure.
UNDERSTANDING CEMENTS AND ADHESIVES
The three most commonly used types of cement are conventional
cement, self-adhesive cement, and adhesively bonded cement. The
most commonly used conventional cements are resin-modified
glass-ionomers (RMGIs). RMGIs have advantages of both compos-
ite resins and glass-ionomers. These materials have an acid-base
reaction due to their glass-ionomer nature and can form a limited
chemical bond with the substrate.2 They are dependent on mechani-
cal retention, so sufficient preparation height and properly tapered
preparation walls are critical. They are optimal when there is a large
amount of retention and materials being used are strong enough.
The next step up, in terms of bond strength, is self-adhesive ce-
ment. With self-adhesive resin cements, the self-etching chemistry
is built into the cement itself, so no separate etching or priming
step is required. Although these cements provide chemical bond-
ing and improved bond strength compared with conventional
cements, their properties are inferior to adhesive cements.3
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
MAY 2019

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acid creates a more pronounced and retentive
etching pattern in enamel. Therefore, etch-and-
rinse bonding systems are often preferred for
preparations with little to no retention or when
large areas of enamel are still present.4 Etch-
and-rinse systems, however, can cause more
1 light through a restoration is doubtful.8
2 bond strength, fracture toughness, technique
3
Fig 1. Type of cement to use based on retentiveness of the
preparation. Fig 2. Bond strength and fracture toughness of
different types of cement. Fig 3. Degree of technique sensitivity and
moisture contamination involved with each type of cement.
4 CDEWORLD.COM | VOLUME 6 • NUMBER 142
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postoperative sensitivity and make restorations
harder to remove when they need to be replaced.
Adhesive cements may be further categorized
as light-cure, self-cure, and dual-cure.6 Light-
cured resin cements are indicated for thin, highly
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
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
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:
• What type of restoration will be placed?
• What restorative material was used to create
the restoration?
• How retentive is the preparation?
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1. What type of restoration will be placed?
Indirect restorations are chosen by dentists
based on the functional and esthetic require-
ments of the tooth being restored. Inlays and
onlays are considered to be more conserva-
tive restorations because they minimize tooth
structure removal when compared with a full
crown. Ceramic veneers are also considered to
be a more conservative restoration than a full
crown for patients who desire to improve the
appearance of their smile. Conservative restora-
tions such as inlays, onlays, and veneers tend
to be less retentive than full crowns and as a
result are typically adhesively bonded. Veneers
in particular must be adhesively bonded, due to
both the non-retentive nature of the preparation
and the need for an esthetic cement that will not
affect the shade of the veneer. Full crowns can
typically be conventionally cemented, but only
if the flexural strength of the crown material is
greater than 300 MPa. So a full crown fabricated
with leucite-reinforced glass-ceramic (which has
a flexural strength of 160 MPa) would need to be
adhesively bonded even though it is a full crown.
2. What restorative material was used to
create the restoration?
In addition to the type of restoration being fabricat-
ed, the restorative material selected by the clinician
plays a role in selecting a cement. Historically, con-
ventional cementation was the only choice available,
and the predominant restorations of the time, cast
gold and porcelain-fused-to-metal crowns, had more
than enough strength to be conventionally cemented.
It remains true today that any metal-based restora-
tions can be conventionally cemented, although they
can also be adhesively bonded if the preparation has
inadequate retention.
With the introduction of glass-ceramic materials,
the need to adhesively bond restorations became
even more important due to their comparatively
lower flexural strengths than metals. Most of the
early all-ceramic materials were designed to be
used as ceramic veneers, so adhesive resin cements
needed to be esthetic and color stable over time.
With the introduction of lithium disilicate and
zirconia oxide, dentists now had a tooth-colored
restorative material that could be conventionally
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.

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


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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
that the cement would show through, an esthetic
resin cement needed to be used for these other-
wise high-strength materials.
3. How retentive is the preparation?
In addition to the type of restoration being pre-
scribed and which material it is being fabricated
from, the retentive features of the preparation
itself must be taken into consideration. The pri-
mary considerations for the preparation are its
vertical height and the degree of taper of the walls.
For example, with an anterior tooth preparation
that has 5 or 6 mm of preparation height, typi-
cally any method of cementation may be used. In
contrast, with a lower molar, where it is common
to see only 3 mm of preparation height and an
overtapered proximal wall, an adhesive technique
must be used. As shown in Figure 4, if there is
a preparation height of 4 mm and preparation
taper of 12 degrees or less, any desired cement
may be used. At the same 4 mm of preparation
height, if the taper is greater than 16 degrees, an
adhesive cement should be used. Regardless of
how strong a given restorative material may be,
if the preparation lacks adequate retention, the
restoration must be adhesively bonded. In this
respect, question 3 is more important than the
other two questions in determining which method
of cementation will be used.
TREATMENT OF THE RESTORATION
In addition to choosing a proper cement for the
restoration, the treatment of the restoration itself
before cementation must be taken into account.
The intaglio surfaces of feldspathic ceram-
ics, leucite-reinforced ceramics, and lithium
6 CDEWORLD.COM | VOLUME 6 • NUMBER 142
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disilicate materials are etched by the dental labo-
ratory with hydrofluoric acid before being sent
to the dentist to remove portions of the glassy
matrix and increase the bond strength between
the cement and the restoration. This etching has
contributed significantly to their high clinical
success rates.10 Zirconia oxide cannot be etched
with hydrofluoric acid because of the lack of a
glassy matrix.11 As a result, the bond strength of
resin cements to feldspathic ceramics, leucite-
reinforced ceramics, and lithium disilicate ma-
terials is superior compared with zirconia oxide.
When the restoration is first tried in the patient’s
mouth, saliva comes in contact with the crown. As
a result, the restoration needs to be decontami-
nated before placement of a silane or primer.
Historically, dentists have been taught to de-
contaminate glass-ceramic restorations after try-
in with phosphoric acid, which works well for
decontaminating lithium disilicate restorations.
However, decontaminating a zirconia oxide res-
toration with phosphoric acid leads to predict-
able cement failures, especially with minimally
retentive preparations. There are now multiple
products on the market designed to decontami-
nate restorations while still allowing silanes and
primers to work effectively.
For feldspathic ceramics, leucite-reinforced ce-
ramics, and lithium disilicate materials, a ceramic
silane is placed on the intaglio surface of the crown
after disinfecting it, and this silane provides the
bond from the resin cement to the restoration itself.
Application of silane increases the wettability and
chemical bond.12 For zirconia oxide restorations,
a zirconia primer is placed inside the crown after
disinfection. Although this increases the strength of
the bond of the resin cement to the zirconia oxide
MAY 2019

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material, this bond would be stronger if zirconia
oxide could be etched with hydrofluoric acid, pro-
viding more micro-mechanical retention on the
surface of the restorative material.
CONCLUSION
Clinicians must be aware and informed in order
to choose the best method of cementation. As
discussed, many factors are involved, but the
three questions detailed in this article can be
used to reach an appropriate decision.
REFERENCES
1. Haddad MF, Rocha EP, Assunção WG. Cementation of
prosthetic restorations: from conventional cementation to den-
tal bonding concept. J Craniofac Surg. 2011;22(3):952-958.
2. Cardoso MV, Delmé KI, Mine A, et al. Towards a better
understanding of the adhesion mechanism of resin-modified
glass-ionomers by bonding to differently prepared dentin. J
Dent. 2010;38(11):921-929.
3. Shillingburg HT, Hobo S, Whitsett LD, et al.
Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago,
IL: Quintessence; 1997.
4. Ozer F, Blatz MB. Self-etch and etch-and-rinse adhesive
systems in clinical dentistry. Compend Contin Educ Dent.
7 CDEWORLD.COM | VOLUME 6 • NUMBER 142
PEER-REVIEWED
2 CDE CREDITS
2013;34(1):12-18.
5. 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.
6. Ladha K, Verma M. Conventional and contemporary
luting cements: an overview. J Indian Prosthodont Soc.
2010;10(2):79-88.
7. Vargas MA, Bergeron C, Diaz-Arnold A. Cementing all-
ceramic restorations: recommendations for success. J Am
Dent Assoc. 2011;142(2 suppl):20S-24S.
8. Pegoraro TA, da Silva NR, Carvalho RM. Cements for use
in esthetic dentistry. Dent Clin North Am. 2007;51(2):453-471.
9. Kanehira M, Finger WJ, Hoffmann M, Komatsu M.
Compatibility between an all-in-one self-etching adhe-
sive and a dual-cured resin luting cement. J Adhes Dent.
2006;8(4):229-232.
10. Della-Bona A. Important aspects of bonding resin to dental
ceramics. J Adhes Sci Tech. 2009;23(7-8):1163-1176.
11. Ho CCK. Clinical techniques: assessment and minimal
intervention. In: Wilson NHF, Millar BJ. Essentials of Esthetic
Dentistry: Principles and Practice of Esthetic Dentistry.
Elsevier; 2015:65-191.
12. Matinlinna JP, Lung CYK, Tsoi JKH. Silane adhesion
mechanism in dental applications and surface treatments: a
review. Dent Mater. 2018;34(1):13-28.
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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