Cementos y Adhesión Al Metal Okokokokok

D
entists place metal-

ceramic crowns with
high frequency in clin-
ical practice today, and
the cements or luting
agents used to retain these cast-
ings are critical to the clinical
success and longevity of these res-
torations.
1
Several new dental
cements and new forms of
delivery for these cements have
been introduced to the dental
market; however, high-quality
independent study results
regarding the clinical perform-
ance of cements often are lacking.
Furthermore, many researchers
collect data regarding cement per-
formance that do not relate
directly to potential clinical per-
formance. For example, previous
investigators have used shear-
bond strength tests to determine
the ability of commonly used
luting agents to retain simulated
high-noble metal-ceramic
crowns.
2,3
To better simulate clinical con-
ditions, some investigators have
tested the retentive strength of
cements by using axial dislodg-
ment forces with crowns
cemented on normally prepared
extracted human teeth.
4-7
Several
of these studies have involved
uniform conically shaped, circular
crown preparations
8,9
that result
in greater removal of tooth struc-
Dr. Johnson is a professor, Department of Restorative Dentistry, School of Dentistry, Box 357456, University of Washington, Seattle, Wash. 98195-7456, e-mail
gjohnson@u.washington.edu. Address reprint requests to Dr. Johnson.
Dr. Lepe is an associate professor, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle.
Dr. Zhang is an assistant professor, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle.
Dr. Wataha is a professor and the chair, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle.
Retention of metal-ceramic crowns
with contemporary dental cements
Glen H. Johnson, DDS, MS; Xavier Lepe, DDS, MS; Hai Zhang, DMD, PhD;
John C. Wataha, DMD, PhD
JADA, Vol. 140 http://jada.ada.org September 2009 1125
Background. New types of crown and bridge cement
are in use by practitioners, and independent studies are
needed to assess their effectiveness. The authors con-
ducted a study in three parts (study A, study B, and study
C) and to determine how well these new cements retain
metal-ceramic crowns.
Methods. The authors prepared teeth with a 20-degree taper
and a 4-millimeter length. They cast high-noble metal-ceramic copings, then
fitted and cemented them with a force of 196 newtons. The types of cements they
used were zinc phosphate, resin-modified glass ionomer, conventional resin and
self-adhesive modified resin. They thermally cycled the cemented copings, then
removed them. They recorded the removal force and calculated the stress of dis-
lodgment by using the surface area of each preparation. They used a single-factor
analysis of variance to analyze the data ( = .05).
Results. The mean stresses necessary to remove crowns, in megapascals, were
8.0 for RelyX Luting (3M ESPE, St. Paul, Minn.), 7.3 for RelyX Unicem (3M
ESPE), 5.7 for Panavia F (Kuraray America, New York) and 4.0 for Fuji Plus
(GC America, Alsip, Ill.) in study A; 8.1 for RelyX Luting, 2.6 for RelyX Luting
Plus (3M ESPE) and 2.8 for Fuji CEM (GC America) in study B; and 4.9 for
Maxcem (Kerr, Orange, Calif.), 4.0 for BisCem (Bisco, Schaumburg, Ill.), 3.7 for
RelyX Unicem Clicker (3M ESPE), 2.9 for iCEM (Heraeus Kulzer, Armonk,
N.Y.) and 2.3 for Flecks Zinc Cement (Keystone Industries, Cherry Hill, N.J.) in
study C.
Conclusions. Powder-liquid versions of new cements were significantly more
retentive than were paste-paste versions of the same cements. The mean value
of crown removal stress for the new self-adhesive modified-resin cements varied
appreciably among the four cements tested. All cements retained castings as
well as or better than did zinc phosphate cement.
Clinical Implications. Powder-liquid versions of cements, although less
convenient to mix, may be a better clinical choice when crown retention is an
issue. All cements tested will retain castings adequately on ideal preparations
because the corresponding removal stresses are comparable with or higher than
those associated with zinc phosphate. Powder-liquid resin-modified glass
ionomer cement, selected self-adhesive modified-resin cements and conventional
resin cements provide additional retention when desired.
Key Words. Dental cements; luting agents; resin-modified glass ionomer; self-
adhesive cement; crown retention; prosthodontics.
JADA 2009;140(9):1125-1136.
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AB STRACT
R E S E A R C H
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.
ture than occurs clinically. Preparations reduced
to this extent may result in an atypical dentin
substrate for bonding because at the surface, 96
percent of the dentin is intertubular, compared
with 12 percent near the pulp.
10
In addition, some
researchers have used prepared teeth with min-
imal, highly retentive tapers,
2,5
which has con-
founded the determination of a given cements
contribution to crown retention.
11
The most traditional cement used in dentistry
is zinc phosphate cement, which clinicians have
used successfully to retain cast restorations since
1879.
12
Three other cements that clinicians have
used with success during the last 30 years are
zinc polycarboxylate,
13,14
chemically cured glass
ionomer
15
and conventional resin in combination
with a dentin adhesive system. Researchers have
conducted extensive evaluations of these cements
ability to retain crowns.
4-10,16
Resin-modified glass ionomer cements were
developed in the late 1980s. They first were sold
as a filling material and liner,
17,18
but they later
were marketed as luting agents.
Self-adhesive modified-resin cement is the
newest type of cement to be introduced for luting
dental restorations. Hecht and Ludstech
19
sub-
mitted a patent application for this class of
cement in 2002, and Hecht and Richter
20
later
described the materials composition and reaction.
Since that time, as this type of cement has
increased in popularity,
21
several other competing
self-adhesive modified-resin cements have
appeared in the dental market. The goals for the
development of self-adhesive modified-resin
cement were simple handling, good mechanical
properties, favorable esthetics and effective adhe-
sion to tooth structure without the need for sepa-
rate bonding steps.
20
These cements have demon-
strated high shear-bond strength to zirconia
ceramics under specific conditions
3,22
and low
microleakage when used on dentin but not when
ceramic veneers were cemented on enamel.
23
Manufacturers initially supplied, and still
offer, several cements in powder-liquid formula-
tions. For convenience, several of these same
types of cement are available in a paste-paste
consistency, some with automixing tips. Clini-
cians may assume that the two forms of the same
product are equivalent in terms of their proper-
ties; however, conversion from powder-liquid to
paste-paste formulations is not simple, because
the chemical constituents and the setting reaction
of a powder-liquid form may need to be altered to
create a paste version. It is not prudent to extrap-
olate study findings regarding powder-liquid
cement retention to retention of paste-paste for-
mulations; thus, tests of both types are needed.
The purpose of the series of studies we describe
here was to evaluate the ability of new luting
agents to retain high-noble metal-ceramic cast-
ings under clinically relevant conditions and to
characterize the nature of the failure of the
cement. The research hypothesis was that within
a cement test group, there were no clinically
significant differences among cements in terms of
crown removal stress. Whenever appropriate, we
compared paste-paste formulations with powder-
liquid formulations.
METHODS AND MATERIALS
Given the numbers of new cements and varia-
tions in delivery systems, plus a time-consuming
research methodology, we conducted the study in
three stages, designated as cement study A,
cement study B and cement study C. Table 1 lists
the cements used in each of the three groups.
In cement study A, we evaluated three types of
luting agents in common use. Included were a
conventional resin cement with dentin adhesive
and an alloy primer (Panavia F, Kuraray
America, New York City), two resin-modified
glass ionomers (Fuji Plus capsules, GC America,
Alsip, Ill.; RelyX Luting bottle and jar, 3M ESPE,
St. Paul, Minn.) and the first self-adhesive
modified-resin cement to be marketed (RelyX
Unicem capsules, 3M ESPE). Promotional
materials and the dental literature often refer to
this latter cement type as a self-adhesive com-
posite resin or self-adhesive resin. To avoid
confusion with traditional resin cements, we pro-
pose use of the term self-adhesive modified
resin for this new type of cement, because its
composition includes elements from traditional
glass ionomer, resin-modified glass ionomer, com-
pomer and conventional resin,
1
and its polymer-
ization reactions differ from those of traditional
resin.
20,24
In cement study B, we evaluated the new
paste-paste versions of two existing resin-
modified glass ionomer cements (Fuji CEM with
Conditioner, GC America; RelyX Luting Plus, 3M
ESPE) and compared them with an original
powder-liquid version (RelyX Luting). Before
cementing crowns with Fuji CEM, we applied a
1126 JADA, Vol. 140 http://jada.ada.org September 2009
R E S E A R C H
ABBREVIATION KEY. VPS: Vinyl polysiloxane.
dilute polyacrylic conditioner (Fuji Plus Condi-
tioner, GC America) to the tooth surface for 20
seconds and then rinsed the tooth, as recom-
mended in the instructions for use when stronger
adhesion is desired.
In cement study C, we evaluated three new
self-adhesive modified-resin paste-paste products
(iCEM, Heraeus Kulzer, Armonk, N.Y.; BisCem,
Bisco, Schaumburg, Ill.; Maxcem, Kerr, Orange,
Calif.) and the new paste-paste version of another
self-adhesive modified-resin cement (RelyX
Unicem Clicker, 3M ESPE). In addition, we
tested zinc phosphate cement (Flecks Zinc
Cement, Keystone Industries, Cherry Hill, N.J.)
to help establish the clinical significance of reten-
tion values because zinc phosphate has been used
successfully for a long period without the benefit
of the materials having a chemical attraction to
metal or dentin.
The laboratory and testing procedures we used
in this series of studies were similar to those
described in reports of previous studies.
6,7,22
Oral
surgeons stored recently extracted molars in a
liquid sterilant (0.5 percent sodium hypochlorite)
immediately after extraction. We cleaned teeth of
surface debris, sterilized them again in 0.5 per-
cent sodium hypochlorite and thereafter stored
them in tap water until we mounted them. As
specimens, we selected noncarious, unrestored
molars with diverging roots. We roughened and
embedded roots in stainless steel mounting rings
by using clear autopolymerizing resin with the
buccal cementoenamel junction positioned 1 mil-
limeter above the top of the ring. At all times, the
mounted specimens were stored in tap water,
which we changed frequently.
We sectioned the occlusal surface of each
mounted tooth specimen flat (by using a slow-
speed thin sectioning saw [11-4254-blade, Isomet,
Buhler, Evanston, Ill.]) and perpendicular to the
long axis of the ring and 5 mm above the top of the
stainless steel cylinder. We secured a high-speed
handpiece in an apparatus so that a diamond
tapered rotary cutting instrument was oriented at
a 10-degree angle from a vertical axis of the tooth
to create a standardized angle of convergence of 20
degrees (Figure 1). We selected a degree of conver-
gence higher than the ideal of 12 degrees to better
assess the contribution of the cement in crown
retention, as well as on the basis of study results
R E S E A R C H
TABLE 1
Description of cements used in the three crown retention studies.
CEMENT, BY STUDY
PORTION
TYPE CONSISTENCY LOT NO. DELIVERY
SYSTEM/MIXING
METHOD
MANUFACTURER
Study A
Panavia F With Alloy
Primer and ED Primer
(Liquid A and Liquid B)
Resin-based
composite
Paste-paste 488KA
alloy: 00122A
A-B: 000424
Tubes/hand mixed Kuraray America, New York
Fuji Plus Resin-modified
glass ionomer
Powder-liquid 0208053 Capsule/machine
mixed
GC America, Alsip, Ill.
RelyX Luting Resin-modified
glass ionomer
Powder-liquid 2PB Jar and bottle/
hand mixed
3M ESPE, St. Paul, Minn.
RelyX Unicem Self-adhesive
modified resin
Powder-liquid 243071 Capsule/machine
mixed
3M ESPE
Study B
Fuji CEM With Fuji Plus
Conditioner
Resin-modified
glass ionomer
Paste-paste 0310072
0303121
Tube dispenser/
hand mixed
GC America
RelyX Luting Resin-modified
glass ionomer
Powder-liquid Powder: 4AX
Liquid: 4LN
Jar and bottle/
hand mixed
3M ESPE
RelyX Luting Plus Resin-modified
glass ionomer
Paste-paste BE4BA Tube dispenser/
hand mixed
3M ESPE
Study C
Flecks Zinc Cement Zinc phosphate Powder-liquid Powder: Q5LYA
Liquid: L74
Bottles/hand mixed Keystone Industries, Cherry
Hill, N.J.
iCEM Self-adhesive
modified resin
Paste-paste 071226 Tube dispenser/
automixing tip
Heraeus Kulzer, Armonk,
N.Y.
BisCem Self-adhesive
modified resin
automixing tip
Bisco, Schaumburg, Ill.
Maxcem Self-adhesive
modified resin
automixing tip
Kerr, Orange, Calif.
RelyX Unicem Clicker Self-adhesive
modified resin
hand mixed
3M ESPE
that showed that 20 degrees of convergence was
the mean taper for working dies observed by
dental technicians
25
and created by prosthodontic
specialists.
26
We performed axial reduction by
rotating a specimen in the fixture against a coarse
rotating diamond bur (Brasseler 6837 KR.31.016,
Brasseler USA, Savannah, Ga.) as shown in
Figure 1. Using water spray and a new diamond
rotary cutting instrument for each tooth specimen,
we reduced the axial surface to a depth of 1.5 mm
and an axial length of approximately 4 mm. We
refined the finish line with a flat fine diamond bur
(Brasseler 10839-014, Brasseler USA).
We made impressions of the prepared teeth
using a vinyl polysiloxane (VPS) impression
material (Aquasil Ultra Monophase, Dentsply
Caulk, York, Pa.); stainless steel caps served as
trays. We applied a VPS adhesive (Tray Adhesive,
Dentsply Caulk) in the internal surface of the
ring. We cast the impressions with Type IV
gypsum, then recovered and trimmed the
master die.
We acquired and used new die spacer kits for
each study. Using a different color for each layer,
we applied two layers of die spacer to each
working die in cement studies A and B to achieve
24 micrometers of cement space.
27
In cement study
C, the dental laboratory controlled cement space
by setting software to provide 30 m of space. The
maximum film thickness allowed for water-based
cements such as zinc phosphate cement is 25 m
28
;
however, the maximum film thickness specified
for resin-based cements is 50 m.
29
Even though
the maximum thickness allowed for resin-based
cements is twice as much as that allowed for
water-based cement, the results of a recent study
showed that resin-modified glass ionomer, con-
ventional resin and self-adhesive modified-resin
cements all met the 25-m standard when tested
two minutes after mixing.
30
The results of another
investigation showed that with immediate testing
of cement film thickness after mixing, nearly all
cements met the value of 25 m. However, with
testing delayed until 10 seconds before the end of
the stated working time, RelyX Luting Plus and
Fuji CEM exhibited film thicknesses of 50 m and
150 m, respectively.
31
Thus, the American Dental
Association Council on Scientific Affairs
31
recom-
mended that clinicians seat restorations promptly
after mixing a cement, a recommendation applic-
able to all cements but especially to those that are
glass ionomer based or resin based.
Researchers have investigated the effect of the
die spacer on crown seating and retention. When
the clinician uses traditional nonadhesive luting
agents for the cementation of full-coverage extra-
coronal restorations, frictional resistance between
the tooth and the restoration provides the best
retention form,
32
but a compromised marginal fit
may result if the cement space is not adequate for
the luting agent, which can result in incomplete
seating of the restoration.
33
Research has demon-
strated that the use of a die spacer not only
improves the fit of the cemented restoration but
also can result in increased retention of cemented
crowns.
25,34-39
Investigators achieved a better fit of
the casting and higher retention by providing
more surface coverage of the die spacer
40
and by
applying more layers of the die spacer.
41
There is
no consensus regarding the number of coats or
the ideal thickness of the die spacer required.
Table 2 provides additional detail regarding the
gypsum, die spacer, burnout crown form, sprue,
investment and casting alloy we and the dental
laboratory used to fabricate the crowns.
Before cementation, we calculated the area of
the axial and occlusal surface of each prepared
tooth. Because we standardized the angle of con-
vergence and axial length of the preparation, the
perimeter of the occlusal surface was proportional
to that of the axial surface area. We formed a thin
replica of the occlusal surface by placing autopoly-
merizing acrylic resin in the occlusal portion of
the impression for each prepared tooth. After
polymerization, we highlighted the occlusoaxial
line angle of the replica with a thin black line. We
R E S E A R C H
Figure 1. Setup for creating standardized preparation of mounted
specimens. The diamond bur is set to create a total angle of
convergence of 20 degrees and an approximate axial length of
4 millimeters.
digitized all of the occlusal replicas, along with
three circles of a known surface area and
perimeter, on a flatbed scanner. We used the digi-
tized images of the standard circles and occlusal
surfaces (Figure 2) to determine the length of the
perimeter and occlusal area of each specimen by
using specialized software (SCION Image, Scion,
Frederick, Md.). (We used the circles to confirm
the accuracy of calculations.) We measured the
axial length of each tooth specimen by using a
digital caliper with a measurement accuracy of
0.02 mm (CD-6 CS, Mitutoyo, Kawasaki, Kana-
gawa Prefecture, Japan). To arrive at the axial
surface area of each preparation, we multiplied
each tooths perimeter by its axial length. We
added the occlusal and axial surface areas to
obtain the total area. We ranked teeth according
to decreasing surface area and distributed them
into cementation groups equally so that each
group had similar mean surface areas.
The sample size for cement studies A and B
was 12 or 13 teeth, which was similar to that
used in earlier studies
6,7,22
and adequate for the
detection of clinically meaningful differences. We
conducted a sample size analysis by using data
from studies A and B before commencing study C.
The results of our analysis indicated that an
observation size of eight specimens would yield
adequate power; thus, we used the smaller
sample size. Table 3 shows sample size, mean
surface areas of specimens and standard devia-
tions for all three cement studies.
We performed two weeks of provisional cemen-
tation to simulate clinical conditions by seating
the respective stainless steel caps with impres-
sion material, lined with a mix of provisional
cement without eugenol (Temp Bond NE, Kerr)
R E S E A R C H
Figure 2. Scans of poly(methylmethacrylate) replicas of the
occlusal surface of each prepared tooth. Also shown are circles of a
known circumference and area, used for calibration of software
that would calculate the perimeter and area of each specimen.
TABLE 2
Laboratory materials and procedures used in the production
of the high-noble ceramometal alloy castings.
LABORATORY
ITEM
MATERIAL (MANUFACTURER), ACCORDING TO CEMENT STUDY
A B C
Type IV
Gypsum
Prima Rock
(Whip Mix, Louisville, Ky.)
Prima Rock
(Whip Mix)
Resin Rock
(Whip Mix)
Die Spacer PDQ Die Spacer
(Whip Mix)
PDQ Die Spacer
(Whip Mix)
Software controlled
(Zeno Tech System,
Wieland Dental+Technik,
Pforzheim, Germany)
Burnout Crown
Form
Bellewax
(Kerr Dental Laboratory Products,
Orange, Calif.)
ProArt sculpturing wax, red
(Williams AG, Schaan, Liechtenstein)
Bellewax
(Kerr Dental Laboratory Products)
ProArt sculpturing wax, red
(Williams AG)
Computer-milled crown form
(Zeno PMMA Disk, Zeno Tech
System, Wieland Dental+Technik)
Sprue 10-gauge wax wire spool
(Freeman Manufacturing,
Akron, Ohio)
10-gauge wax wire spool
(Freeman Manufacturing)
10-gauge wax wire spool
(Freeman Manufacturing)
Phosphate-
Bonded
Investment
Finesse Investment
Powder and Liquid
(Dentsply Ceramco, York, Pa.)
Finesse Investment
Powder and Liquid
(Dentsply Ceramco)
Finesse Investment
Powder and Liquid
(Dentsply Ceramco)
High-Noble
Ceramometal
Casting Alloy
Special White
(45 percent gold, 39.8 percent
palladium, 6.5 percent silver)
(Dentsply Ceramco)
Special White
(Dentsply Ceramco)
Special White
(Dentsply Ceramco)
on the respective prepared teeth while the dental
laboratory fabricated the castings. When the cast-
ings were ready for cementation, the impression
caps with the provisional cement were removed,
along with gross cement particles. One of the
authors (G.H.J.) cleaned the prepared teeth with
a prophylaxis cup containing 2 percent glu-
taraldehyde and flour of pumice, then rinsed and
dried them gently, leaving them slightly moist.
One clinician (X.L.) mixed all cements,
according to manufacturers instructions, and
cemented the castings well within designated
working times. Table 1 provides the consistencies,
lot numbers and delivery systems of the cements.
For cements that were supplied as two separate
paste tubes or as a powder and liquid (such as
Panavia F, RelyX Luting and Flecks Zinc
Cement), one clinician (G.H.J.) weighed the
powder and liquid or catalyst and
base pastes on an electronic micro -
balance to ensure proper propor-
tioning, then another clinician
(X.L.) mixed the cement on a
mixing pad with a plastic spatula.
Capsules were mixed in a high-
frequency mixing unit (CapMix,
3M ESPE) for 10 seconds.
After mixing, the clinician (X.L.)
lined two crowns with cement and
initially seated them by using
strong finger pressure. The second
clinician (G.H.J.) then immediately
placed the assembled teeth and
castings in a loading device (Rimac
Spring Tester, Rimac Tools,
Dumont, N.J.). He then subjected
each crown to a total axial seating
force of 196 newtons (20 kilograms
of force) for twice the specified set-
ting time to allow for a slower set-
ting reaction at room temperature. The same clin-
ician removed excess cement from the crown
margins and stored the specimens for 24 hours at
34C in an atmosphere of 100 percent humidity.
After this storage period, he thermally cycled the
cemented castings in water at temperatures
between 5C and 55C for 2,500 cycles for speci-
mens in cement studies A and B and 5,000 cycles
for specimens in cement study C. He used a 20-
second dwell time in each hot and cold water con-
tainer. He increased the number of cycles to 5,000
in cement study C because longer cycling times
were becoming a standard for bond strength
testing of dentin adhesives.
42
After thermal cycling, the clinician subjected the
copings to dislodgment forces along the apico-
occlusal axis until they failed by using a universal
testing machine (Model TTMBL, Instron, Nor-
wood, Mass.) at a crosshead speed of 0.5 mm per
minute (Figure 3). He recorded the force at dislodg-
ment and calculated the stress of removal by using
the surface area of each tooth preparation. After
casting dislodgment, two examiners (G.H.J. and
either X.L. or H.Z.) examined each crown and tooth
preparation to determine the predominant nature
of the cement failure on the basis of the criteria
presented in Table 4. When the two examiners had
differing opinions of a particular specimens classi-
fication, they used a forced-consensus approach to
determine the mode of failure.
For each cement study, we analyzed the data to
R E S E A R C H
TABLE 3
Sample size and specimen surface area.
MATERIAL, BY CEMENT STUDY* NO. OF
SPECIMENS
MEAN SURFACE AREA
STANDARD DEVIATION
(SQUARE MILLIMETERS)
Study A
Fuji Plus 12 132 16
Panavia F With Alloy Primer and ED
Primer (Liquid A and Liquid B)
13 132 18
RelyX Unicem 13 132 15
RelyX Luting 13 131 16
Study B
Fuji CEM With Fuji Plus Conditioner 12 119 19
RelyX Luting 12 119 16
RelyX Luting Plus 12 119 15
Study C
Flecks Zinc Cement 8 135 17
iCEM 8 136 18
BisCem 8 133 18
Maxcem 8 133 16
RelyX Unicem Clicker 8 130 16
* Manufacturers are listed in Table 1.
TABLE 4
Classification of the nature
of failure after crown removal.
CLASSIFICATION DESCRIPTION
1 Cement principally on the prepared tooth
(greater than three-quarters of the axial
surface)
2 Cement on the internal aspect of the
casting and prepared tooth
3 Cement principally on the internal
aspect of the casting (greater than three-
quarters of the axial surface)
4 Fracture of tooth
determine stress of dislodgment with a single-
factor analysis of variance (ANOVA). Given sig-
nificant main effects, we conducted pairwise com-
parison of means by using the Newman-Keuls
procedure. We analyzed the data regarding type
of failure by using a
2
test for associations. We
conducted all hypothesis testing at the 95 percent
level of confidence.
RESULTS
Figure 4 provides the graphic results for casting
removal stress for each cement and Table 5 pro-
vides the corresponding ANOVA statistical
results. In all three cement studies, we found sig-
nificant differences among the cements within the
specific study group. Figure 5 (page 1133) shows
the predominant mode of cement failure; the cor-
responding Pearson
2
statistical results for the
analysis of cement failure modes were P .000,
P .000 and P = .342 for cement studies A, B and
C, respectively. Thus, we observed significant dif-
ferences in failure mode among cements for the
first two studies, but no significant differences in
failure mode among cements in cement study C.
In cement study A, we compared three cement
types. The resin-modified glass ionomer cement
(RelyX Luting, 8.0 megapascals) and the self-
adhesive modified-resin cement (RelyX Unicem,
7.3 MPa) were most retentive, but not
statistically different (Figure 4).
Panavia F (5.7 MPa) and the other
resin-modified glass ionomer, Fuji Plus
(4.0 MPa), were less retentive. The
mode of cement failure for RelyX
Luting was 70 percent mixed, with
cement located on both casting and
dentin (Figure 5). For RelyX Unicem,
62 percent of specimens exhibited
cement primarily on the internal sur-
face of the casting (that is, greater than
three-quarters of the surface area), but
31 percent of the specimens failed by
reason of tooth fracture without crown
separation. For nearly all of the
Panavia F and Fuji Plus specimens, the
mode of failure was cement located on
the internal surface of the casting.
In cement study B, our focus was
comparing paste-paste and powder-
liquid formulations of resin-modified glass
ionomer cements (Figure 4). The powder-liquid
version of RelyX Luting served as a control. RelyX
Luting demonstrated the highest crown removal
stress (8.1 MPa), in which it differed statistically
significantly from the paste-paste cements Fuji
CEM (2.8 MPa) and RelyX Luting Plus (2.6 MPa);
the removal stresses of these latter two cements
R E S E A R C H
Figure 3. Testing until dislodgment of crown from preparation.
The investigator recorded the force at the time of casting separa-
tion and converted it to removal stress by using the cement contact
surface area of each sample.
TABLE 5
Single-factor analysis of variance results
for casting removal stress.
CEMENT STUDY SUMS OF
SQUARES
df*
MEAN
SQUARE
F RATIO
SIGNIFICANCE
A
Between groups 113.648 3 37.883 12.546 .000
Within groups 141.918 47 3.020
TOTAL 255.566 50
B
Between groups 237.995 2 118.997 130.268 .000
TOTAL 268.140 35
C
Between groups 33.504 4 8.376 13.799 .000
TOTAL 54.780 39
* df: Degrees of freedom.
F ratio: Mean square between groups divided by mean square within groups.
were not shown to differ statistically signifi-
cantly. The mode of cement failure varied for each
cement (Figure 5). For RelyX Luting, 50 percent
of the specimens exhibited a mixed failure in
which cement was located on both the internal
aspect of the crown and on the dentin, and 42 per-
cent of the specimens failed because of tooth frac-
ture without casting separation. All of the fail-
ures for the paste-paste RelyX Luting Plus had
cement located on the internal aspect of the
casting, whereas Fuji CEM exhibited 92 percent
mixed failures with cement located on the crown
and dentin.
We conducted cement study C to evaluate other
self-adhesive modified-resin cements and RelyX
Unicem Clicker, which was reformulated as a
paste-paste product. We included zinc phosphate
cement in this study to provide a clinically rel-
evant control with established clinical success.
Maxcem (4.9 MPa) was most retentive and dif-
fered statistically significantly from the other
cements tested. Results for the other cements, in
decreasing order of retention, were 4.0 MPa for
BisCem, 3.7 MPa for RelyX Unicem Clicker,
2.9 MPa for iCEM and 2.3 MPa for
Flecks Zinc Cement. Figure 4
shows the cements that did not
differ statistically significantly.
The primary mode of cement
failure was cement located on the
internal aspect of castings in 100
percent of the iCEM specimens, 88
percent of both the BisCem and the
RelyX Unicem Clicker specimens,
83 percent of the zinc phosphate
specimens and 62 percent of the
Maxcem specimens. The remaining
38 percent of the Maxcem speci-
mens demonstrated a mixed
failure.
DISCUSSION
The research hypothesis for this
study was that there were no dif-
ferences of clinical significance
among cements in their ability to
retain high-noble metal-ceramic
crowns. We rejected this hypoth-
esis in all three studies because we
recorded significant differences,
several of which were clinically
important. We discussed each type
of cement separately.
Zinc phosphate cement. In our study, a
mean stress of 2.3 MPa was required to remove
castings cemented with zinc phosphate. The suc-
cessful use of this cement for more than 100 years
strongly implies that all cements tested should
retain castings clinically at least as well as zinc
phosphate does, assuming the properties of the
newer cements remain unchanged in the intra-
oral environment across time. Early casting
retention studies in which researchers investi-
gated the effect of sealing dentin with adhesive
primers and with 5 percent glutaraldehyde
demonstrated retentive stresses for zinc phos-
phate in the range of 3 to 6 MPa,
6,7
a result com-
parable with what we observed in our study. In
these two earlier studies, investigators used the
axial surface area alone (without the occlusal
area) as the basis for the calculation of removal
stress. Thus, their values would be lower and
even more comparable with those in our study if
had they included the occlusal area. In another
study involving comparable methods but uniform
conical preparations, researchers reported a mean
crown removal stress of 1.7 MPa for zinc phos-
R E S E A R C H
Figure 4. Crown removal stress for cement studies A, B and C. Horizontal bars indicate
the mean crown removal stress for each cement; horizontal lines indicate standard devia-
tions. Vertical bars indicate the means that did not differ statistically at the 95 percent
level of confidence. MPa: Megapascals. Manufacturers are listed in Table 1.
Fuji Plus
Panavia F
RelyX Unicem
RelyX Luting
Fuji CEM
RelyX Luting Plus
RelyX Luting
Flecks Zinc Cement
iCEM
RelyX Unicem Clicker
BisCem
Maxcem
0 2 4 6 8 10
CROWN REMOVAL STRESS (MPa)
C
e
m
e
n
t
,

S
t
u
d
y

A
C
e
m
e
n
t
,

S
t
u
d
y

B
C
e
m
e
n
t
,

S
t
u
d
y

C
phate cement.
8
Investi-
gators in another study
showed zinc phosphate
to require a low re -
moval force compared
with those required for
other cements,
9
but it is
difficult to make direct
comparisons with this
studys findings
because the investiga-
tors reported values for
crown removal as a
force rather than as a
stress.
Conventional
resin, resin-modified
glass ionomer and
self-adhesive
modified-resin
cements. Our results
suggested that all the
cements we tested
should retain crowns
adequately when tooth
preparations have a
low angle of conver-
gence, adequate axial
length and a well-fitting casting. However, in
some clinical circumstancessuch as short crown
preparations, nonideal taper, long-span fixed par-
tial dentures, cantilevered restorations and crown
recementationa dentist may wish to use a
cement with greater retentive properties. In our
study, we found greater crown retention with the
use of conventional resin cement with a separate
metal conditioner and dentin adhesive than with
zinc phosphate (5.7 MPa versus 2.3 MPa, respec-
tively); conventional resin cements often have
been the cement of choice when the clinician
desires greater casting retention. However, our
results show that resin-modified glass ionomer
cements or self-adhesive modified-resin cements
demonstrated even greater casting retention
(7.0-8.0 MPa) than did conventional resin
cements (5.7 MPa), and use of these newer
cements does not require metal conditioners and
dental adhesives. These retention values (Figure
4) are consistent with removal stresses reported
for three of the same cements investigated in an
earlier study by researchers who used the same
methodology but instead evaluated zirconia-based
crowns.
22
Interestingly, castings cemented with conven-
tional resin failed with cement located exclusively
on the internal surface of the crowns (Figure 5).
The results suggest that the recommended metal
primer functioned well because the crown
retained cement, but that the dentin adhesive
paired with this conventional resin cement did
not promote an effective bond to dentin. Failure
modes indicated that RelyX Luting bonded well
both to dentin and to the internal surface of the
crown and that the cohesive strength of this set
cement was high compared with the strength of
other cements. The bond of the new self-adhesive
modified-resin cement (RelyX Unicem) to dentin
did not appear to be as strong as that of RelyX
Luting, because 62 percent of the specimens with
RelyX Unicem failed with cement located princi-
pally on the internal surfaces of the crown (that
is, greater than three-quarters of the surface).
However, more than 30 percent of the specimens
experienced tooth fracture before crown separa-
tion, suggesting that the cement had high reten-
tive strength.
Yim and colleagues
8
reported that Fuji Plus
exhibited less crown retention stress than did
R E S E A R C H
Fuji Plus
Panavia F
RelyX Unicem
RelyX Luting
Fuji CEM
RelyX Luting Plus
RelyX Luting
Flecks Zinc Cement
iCEM
RelyX Unicem Clicker
BisCem
Maxcem
0 20 40 60 80 100
CEMENT FAILURE MODE (PERCENTAGE)
C
e
m
e
n
t
,

S
t
u
d
y

A
C
e
m
e
n
t
,

S
t
u
d
y

B
C
e
m
e
n
t
,

S
t
u
d
y

C
> 3/4 on Dentin
Mixed Failure
> 3/4 on Casting
Tooth Fracture
Figure 5. Horizontal bars indicate the distribution for modes of failure for each type of cement based
on an examination of the specimens after crown removal. The color code for mode of failure is in the
key, and values represent the percentage frequency of the failure mode for each cement. Cement studies
A, B and C are separated with dotted lines. Manufacturers are listed in Table 1.
Panavia 21 (Kuraray America) with a dentin
adhesive, a result consistent with those of our
study, in which we compared Fuji Plus with
Panavia F. But when we tested a second resin-
modified glass ionomer, we noted differences in
casting retention for cements of the same type:
Fuji Plus exhibited one-half the crown retention of
RelyX Luting. We noted a high standard deviation
associated with the mean of Fuji Plus compared
with those of the other three products we tested.
Because the failure analysis showed the cement
located on the internal aspect of the casting, we
determined that a weak and variable bond to
dentin may have been the cause of the high
standard deviation. GC America, the manufac-
turer of Fuji Plus, recommends that clinicians use
a dilute polyacrylic acid dentin conditioner if they
want to achieve greater adhesion. Because it may
increase the retentive stress, we used this dentin
conditioner in cement study B.
Powder-liquid versus paste-paste resin-
modified glass ionomer cements. We found
large, clinically important differences in the
results of cement study B, in which we compared
paste-paste formulations of resin-modified glass
ionomer cements with an original powder-liquid
version. The newer paste-paste products exhib-
ited only one-third of the casting retention (with
removal stresses of 2.6-2.8 MPa) of the powder-
liquid version (requiring removal stress of 8.1
MPa) (Figure 4). Furthermore, the result for
RelyX Luting was virtually the same in cement
studies A and B (Figure 4) despite the use of
products with different lot numbers, suggesting
excellent reproducibility. The modes of failure
(Figure 5) help explain these differences to some
extent. All specimens of paste-paste RelyX Luting
Plus exhibited cement on the casting at separa-
tion, in contrast to specimens of powder-liquid
RelyX Luting, for which the failure mode was
mixed or there was tooth fracture. On the basis of
these results, it appears that the new paste-paste
version of this particular cement does not pro-
mote the same degree of adhesion to dentin as
does the powder-liquid version. Retention of cast-
ings by Fuji CEM (another paste-paste formula-
tion) was 30 percent less than that recorded for
the powder-liquid version (Fuji Plus), despite use
of the elective dentin conditioner for the former;
the mode of cement failure was mixed. This low
magnitude of retentive stress suggests that the
cohesive strength of Fuji CEM was low overall.
The difference between paste-paste and powder-
liquid formulations might have been even greater
had we used the dentin conditioner for Fuji Plus
in study A. Our results strongly suggest that it
may be prudent for clinicians always to use the
dentin conditioner with these two cements.
A reason for the differences we observed
between powder-liquid and paste-paste versions
of these cements may be that the two versions of
the cement are simply not the same and that cre-
ation of a functional paste-paste system requires
different ingredients and chemistry. Because
water is needed to initiate any glass ionomer
reaction in a resin-modified glass ionomer
hybrid cement, it is likely that manufacturers
formulated a new aqueous base paste to allow
this reaction to take place. Traditional chemical
initiators are water sensitive; thus, one can
assume that new initiators were developed to
create the proper setting times and long-term sta-
bility of the paste-paste cement.
Most practitioners likely will assume equiva-
lence of paste-paste and powder-liquid formula-
tion for cements of the same type and manufac-
turer. Our results have significant import for
clinical practice because they showed paste-paste
formulations of resin-modified glass ionomer
cements to have inferior retention. The paste-
paste versions of resin-modified glass ionomer
cements retained castings as well as did zinc
phosphate cement and, therefore, are reasonable
choices in ideal clinical circumstances. However,
when the clinician desires additional retention,
we strongly recommend use of the powder-liquid
version of the cement. One potential disadvantage
of the powder-liquid system is the deleterious
effect of moisture contamination of the powder. If
the bottle cap is not secured tightly or if the
cement is used in a humid environment, the
powder can absorb moisture; this in turn can
degrade the catalyst and cause the setting time to
increase appreciably. Thus, dental health care
personnel always should take precautions after
dispensing powder and liquid to cap the bottles
tightly. If the setting reaction appears to be slow,
the clinician should procure a new box of cement.
Self-adhesive modified-resin cements.
Soon after the introduction of RelyX Unicem, sev-
eral other self-adhesive modified-resin cements
appeared on the dental market, most as paste-
paste versions. In cement study C, we evaluated
four such cements and zinc phosphate cement.
The retentive stresses for the self-adhesive group
ranged from 2.9 to 4.9 MPa, and the retentive
R E S E A R C H
stress for zinc phosphate was 2.3 MPa. Similar to
the trend we observed in cement study B, a paste-
paste version of a self-adhesive cement yielded
significantly lower crown retentive stresses than
did the comparable powder-liquid version tested
in cement study A. Values for RelyX Unicem in
cement study A and for RelyX Unicem Clicker in
cement study C were 7.3 MPa and 3.7 MPa,
respectively. Because we tested these two
cements at different times and in different
groups, we must exercise care in making direct
comparisons. However, we used identical method-
ologies for the three sequential studies. Further-
more, RelyX Luting cement performed similarly
in two studies, suggesting that at least some com-
parisons of RelyX Unicem and RelyX Unicem
Clicker are appropriate.
In cement study A, the casting retention for
RelyX Unicem was high (7.3 MPa). This retention
stress correlates to a mean removal force of 951 N
(97 kg of force) applied to a preparation surface
area of 132 mm
2
and is, under most circum-
stances, much greater than ever needed clinically,
assuming the bond and cement properties remain
unchanged across time. Of significant clinical
note is that a crown cemented with this level of
retention must be prepared with a coarse dia-
mond rather than be sectioned, loosened and
lifted off, as is done with a crown cemented with
zinc phosphate cement.
The dominant failure mode for self-adhesive
modified-resin cements was cement located on the
internal surface of the crown and not on the
dentin. We observed this same result for the
powder-liquid encapsulated RelyX Unicem in
cement study A, and it is consistent with the find-
ings of De Munck and colleagues
43
and supported
by the results of a review
1
that showed these
types of cements to have little infiltration into
dentin. We observed no tooth fractures during
debonding in study C, which suggests that the
adhesion to dentin of these self-adhesive cements
was not as great as that of the powder-liquid
cements RelyX Luting and RelyX Unicem. How-
ever, the retentive values are comparable with or
greater than those of zinc phosphate, indicating
that retention would have been adequate for the
entire group in many clinical circumstances.
Study limitations. Although we took several
measures to ensure the clinical relevance of our
study design, the study has limitations. For
example, the extracted teeth, although hydrated
at all times, may not have had the same proper-
ties as those of vital molars. Also, crowns in vivo
are bathed in saliva and other media, and they
experience intraoral stress across long periods.
The only means we used to simulate intraoral
stresses in this series of studies was thermocy-
cling at 5C and 55C. An improvement would be
to subject the cemented crowns to thermomechan-
ical cycling not one time for 2,500 to 5,000 cycles,
but once per month for six months, to allow the
cement and associated bonds to age further.
Finally, the high-noble metal-ceramic alloy we
used is relevant but not used by all dentists, and
other alloys may influence the retention of cast-
ings to some extent.
CONCLUSIONS
On the basis of results from this study, and in
consideration of the studys limitations, we can
conclude that all cements tested retained metal-
ceramic castings as well as or better than the
long-used standard, zinc phosphate cement.
When the clinician sees a need for additional
crown retention, he or she may prefer to use a
conventional resin cement with a dentin adhe-
sive, a resin-modified glass ionomer cement or a
self-adhesive modified-resin cement. For the
latter two types of cements, we found powder-
liquid formulations to be more retentive than the
corresponding paste-paste systems. Our cement
failure data suggested that the cement-dentin
bond was more established with the powder-
liquid formulations of resin-modified glass
ionomer cement than with any of the self-
adhesive modified-resin cements tested.
Disclosure. The studies described in this article were supported in
part by 3M ESPE, St. Paul, Minn., and Heraeus Kulzer, Armonk, N.Y.
The authors acknowledge the following companies for donation of
cements: 3M ESPE, St. Paul, Minn.; Heraeus Kulzer, Armonk, N.Y.;
Kuraray America, New York City; GC America, Alsip, Ill.; and Bisco,
Schaumburg, Ill. They acknowledge Whip Mix, Louisville, Ky., for
donation of dental gypsum. Finally, they acknowledge the Nakanishi
Dental Laboratory, Bellevue, Wash., for assistance with crown
production.
The authors thank emeritus University of Washington School of Den-
tistry faculty member Dr. David Bales and former dental students
Drs. Timothy Gatten, David Newell and Andrew Heidergott for their
assistance with tooth preparation, impressions and formation of
working dies.
Results of these studies were presented at the general sessions of the
International Association for Dental Research in 2003 (June 28,
Gteborg, Sweden), 2005 (March 12, Baltimore, Md.) and 2008 (July 3,
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R E S E A R C H

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