The clinical procedures for cementation of zirconia restorations are similar to

those used when cementing gold crowns. The primary resistance and retention form
of the preparation is mainly responsible for the long-term success of the resto
ration. Because zirconia cementation uses a traditional cementation procedure, t
here are many material options.
Glass ionomer and resin modified glass ionomer cements are the most commonly use
d. My recommendation is to follow the recommended protocols for the brand you cu
rrently use.
When considering possible bonding of zirconia restorations to the tooth, realize
that the conventional methods applied to the bonding of silica-based ceramics a
re not successful. You cannot acid etch and silanate the intaglio surface as you
can with lithium disilicate (e.max) or other glass ceramic restorations.
Recently, new products have been developed that increase the bond of resin cemen
ts to zirconia. Data from outcome studies have confirmed that a combination of a
irborne particle abrasion (50 micron Al2O3 at 2.5 bar) and resin composites cont
aining 10-methacryloyloxydecyl dihydrogen phosphate (MDP) monomer, achieve a dur
able bond of zirconia to a prepared tooth. For example, the 3M Scotchbond Univer
sal Adhesive contains the MDP monomer, which optimizes its self-etch performance
when used in combination with Relyx Ultimate adhesive resin cement.
The bottom line is that cementation of zirconia restorations is highly successfu
l when there is adequate resistance and retention form. With current advancement
s of dental adhesives, it is now possible to increase the retention of the resto
ration of the bonding process with the appropriate materials.
Q I've been using lithium disilicate crowns frequently for the past several mon
ths. Recently, I had to cut off a bonded resin cemented restoration. The removal
procedure required several minutes, several burs, and I could not tell where th
e tooth structure began and the bonded restoration ended.
Should these restorations be bonded or cemented (luted) into place? I'm confused
after removing the bonded crown and finding it extremely difficult. Also, I fel
t that removing the bonded restoration was observably traumatic for the tooth.
A You're not the only one who's confused! Your question is currently one of the
most asked questions that we receive at Clinicians Report. Apparently many dent
ists are confused and have difficulty removing bonded zirconia or lithium disili
cate restorations. In my answer, I'll suggest some situations in which bonding o
f full-zirconia, zirconia-based, and lithium disilicate restorations is desirabl
e, and some situations in which bonding is probably negative.
When almost all tooth-colored restorations were porcelain-fused-to-metal, remova
l was relatively simple (Fig. 1). A slot was easily cut in the crown, and a scre
wdriver-shaped instrument was placed in the slot. With minimal rotation force on
the instrument, the crown usually separated from the tooth preparation, leaving
some cement on both the restoration and the tooth preparation.
Removal of a zirconia-based, full-zirconia, or lithium disilicate restoration i
s difficult, time consuming, and may mutilate the tooth preparation.
Full-zirconia or zirconia-based restorations
Are full-zirconia or zirconia-based crowns failing by separating from tooth stru
cture during service? The Clinicians Report in-depth research division, TRAC, ad
ministered by Dr. Rella Christensen, has a study now in its eighth clinical year
that sheds light on this subject. The study includes about 900 units of zirconi
a-based three- and four-unit FPDs. All of them were cemented with resin-modified
glass ionomer (3M RelyX Luting Cement). To date, none of the restorations have
separated from the tooth preparations. It is evident from this study that bondin
g of zirconia-based restorations is not necessary. This data could easily be ext
rapolated to full-zirconia restorations, since the only difference between full-

zirconia and zirconia-based restorations is that the zirconia-based restorations

have a layer of fired or pressed ceramic on the external surfaces, and this cha
racteristic would not influence retention of the fixed prostheses.
I can conclude that unless the full-zirconia or zirconia-based restorations have
inadequate mechanical retention available, they DO NOT need to be bonded, and t
hat bonding may actually be negative when the following characteristics are cons
idered. Resin bonding cements do not have any preventive potential, such as the
fluoride contained in resin-modified glass ionomer or conventional glass ionomer
cements. Additionally, bonding restorations makes them significantly more diffi
cult to remove when necessary compared to those restorations that are cemented w
ith resin-modified glass ionomer, conventional glass ionomer, or other older cem
ents.
What are the characteristics of a "retentive" tooth preparation? I suggest that
the tooth preparation for a full crown should have 4 mm or more of near-parallel
axial walls from the gingival margin to the occlusal table, and that retentive
tooth preparations should have no more than 20 degrees of lack of parallelism. S
uch retentive tooth preparations do not need bonding when planned for full-zirco
nia or zirconia-based restorations. Later, I'll discuss the few situations in wh
ich zirconia-based, full-zirconia, and lithium disilicate restorations may be be
tter when bonded and resin cement is used.
Lithium disilicate restorations (IPS e.max)
When considering removal difficulty, these restorations possess approximately th
e same negative characteristics as zirconia restorations. Additionally, their us
e has been primarily limited to single-tooth restorations, not requiring as much
retention as needed for fixed prostheses, while both full-zirconia and zirconia
-based restorations are accepted for use in multiple-tooth fixed partial denture
s. Lithium disilicate restorations are often even more difficult to remove than
zirconia restorations, since they beautifully match the color of the tooth, maki
ng differentiation of tooth structure from restorative material or cement almost
impossible. If lithium disilicate restorations are bonded with tooth-colored re
sin cement, our research has shown that it is extremely difficult to differentia
te the restorative material, the cement, and the tooth structure. In such cases,
crown removal almost always results in inadvertently cutting into remaining too
th structure and somewhat mutilating the underlying tooth structure of the tooth
preparation.
The remaining question is related to their service potential when conventional,
nonbonded cements are used. Are lithium disilicate restorations strong enough to
seat with resin-modified glass ionomer, conventional glass ionomer, or other no
nresin cements? Numerous clinical research projects have shown that these restor
ations can serve adequately when cemented with conventional, nonresin cements. (
See Clinicians Report October 2011, Vol. 4 Issue 10 for additional information.)
Consider the strength adequacy of seating single-unit lithium disilicate restora
tions with conventional nonresin cements, and the difficulty encountered in remo
ving these restorations when they're bonded. These characteristics lead me to co
nclude with the same recommendations I made previously for zirconia restorations
. Lithium disilicate restorations seated over RETENTIVE tooth preparations as de
scribed before can have conventional cementation (luting) instead of bonding. Co
nventional cements usually have relatively opaque color, which is easily discern
able from the tooth preparation. This easy differentiation from tooth structure
reduces or eliminates tooth preparation mutilation when restoration removal is n
ecessary (Fig. 2).
When is bonding preferred for zirconia or lithium disilicate restorations?
Tooth preparations with minimal retention
Good examples of this challenge are short mandibular second molars. These teeth
often have clinical crowns with a minimal amount of circumferential parallel too
th structure. If any tooth preparation for a zirconia or lithium disilicate rest
oration does not meet the recommendations for retentive tooth preparations I men
tioned earlier, bonding will help retain them.