Cementation of Indirect Restorations: An Overview of

Resin Cements
Abstract:
The process of ensuring proper retention, marginal seal, and durability of indirect
restorations depends heavily on effective cementation. Careful consideration must be
made when selecting an adhesive cement for a given application. This article provides
information on resin cements that can guide clinicians in determining which type of
cement is best suited to their clinical needs regarding cementation of indirect
restorations. Emphasis is placed on successful cementation of all-ceramic restorations.

Cementation is a crucial step in the process of ensuring the retention, marginal seal,
and durability of indirect restorations.1 Since the introduction of the first all-porcelain
crown in the early 1900s, various cements have been used to adhere porcelain crowns
to tooth structure. Initially, only luting cements were available for use, which led to
many failures. Presently, another category has been addedthe adhesive cements.
Resin cements fall into this category of adhesive cements. Adhesive cements must
bond to a variety of different substrates, including dentin and enamel, porcelain and
other ceramics, gold and other metal alloys, and indirect resin composites. 2
There are several characteristics of resin cements that make them clinically superior
luting agents. Resin cements may have high bond strengths both to tooth structure and
porcelain, high tensile and compressive strengths, and the lowest solubility of the
available cements.3 Flexural propertiesincluding modulus and strengthare
important to prevent de-bonding during function, and resin cements have both a high
modulus and strength. In fact, they have the highest strength of the cements currently
in use.4,5
The disadvantages of resin cements are associated with their technique sensitivity and
difficulty with clean-up. Resin cements may change shade during curing and can
darken during their lifetime. This can be a crucial factor, especially since esthetics is a
particularly important characteristic for all-ceramic restorations.6 Because these
materials depend upon bonding, the operator must be careful to follow all steps in
proper order and with the recommended time for each step.6

Resin Cement Classifications

Resin cements may be classified according to their polymerization mechanisms into
light-cured, chemical-cured, and dual-cured (Table 1). They can also be classified by
their adhesive scheme: total-etch, self-etching, and self-adhesive (Table 2).7 The self-
adhesive resin cements may be referred to as all-in-one resin cements or universal
cements.6
The curing methods are a factor in dictating the potential uses of the cements. For
example, in cases where very little or no light-cure is possible, chemical-cure cement
is a better choice than either a dual-cure or, of course, a light-cure cement.6
Classification by Polymerization Mechanism
Light-Cure Resin CementsLight-cure resin cements utilize photo-initiators, which
are activated by light. The ability of light to penetrate all areas and activate the photo-
initiators is important with this type of cement. An advantage of light-curing cements
is that there can be an increased working time compared to the other cure types. The
clinician has the ability to remove excess cement before curing, and thus the finishing
time required is decreased.6
Another advantage of light-cure cements is their color stability compared to dual-cure
or chemical-cure resin cements.8 These cements are, therefore, suitable for esthetic
restorations and metal-free restorations.9,10 Light-polymerized resins are
recommended when cementing ceramic that is thin and fairly translucent, allowing the
transmission of light through it to reach the resin cement.1
Examples of light-polymerized cements include: RelyX Veneer Cement (3M
ESPE, www.3MESPE.com); Variolink Veneer (Ivoclar Vivadent
Inc., www.ivoclarvivadent.com); and Choice 2 Light-Cured Veneer Cement
(BISCO, Inc., www.bisco.com).
Dual-Cure Resin CementsDual-cure resin cements are capable of being cured by
means of both chemicals and light. Self-cure initiators that can cure the cement are
present. In addition, a curing light can be used to activate the photo-initiators that are
present in the cement.6 Dual-polymerized resin cements are indicated when the
ceramic is too thick or too opaque to allow transmission of light through it.11 Studies
have shown that these dual-cure resin cements still require light-curing to reach a high
degree of polymerization.12,13 These cements are used for metal-free restorations
where light-curing may be performed to quickly seal margins.6
Examples include: NX3 Nexus Third Generation (Kerr
Corporation, www.kerrdental.com); RelyX ARC Adhesive Resin Cement (3M
ESPE); and Variolink II (Ivoclar Vivadent Inc.).
Chemical-Cure Resin CementsChemical-cure resin cements polymerize with a
chemical reaction and are referred to as self-curing. This means that two materials
must be mixed together to initiate this reaction.6 These cements are especially useful
in areas where light-curing is difficult. Some examples include metal restorations,
endodontic posts, and ceramic restorations that prohibit the curing unit from
adequately polymerizing the resin cement.6
Chemically polymerized resin cements do not offer much selection in terms of shade
and translucency; therefore, dual-polymerized resin cements can be beneficial.
Additionally, accessible areas benefit from light polymerization with dual-
polymerized resin cements.14
Examples include: Panavia (Kuraray Dental, www.kuraraydental.com); and C&B
Cement (BISCO, Inc.).

Classification by Adhesive Scheme

Total-Etch Resin CementsTotal-etch resin cements use a 30% to 40% phosphoric
acid-etch to etch dentin and enamel. This etching procedure removes the smear layer,
and dentinal tubules are opened.2 After etching, the adhesive is then applied to the
preparation to bond the cement to the tooth. These cements and the adhesives used
with them can be light- or dual-cured.2 Total-etch resin cements have increased the
bond strengths of resin-based cements to nearly that of enamel bonding and have
significantly reduced microleakage.15 This category provides the highest cement-to-
tooth bond but also requires the most steps to bond ceramic, composite resin, or metal
to the tooth. This multi-step application technique is complex and consequently might
compromise bonding effectiveness,7 because each step represents a possible
contamination point.7
Examples include: RelyX ARC (3M ESPE); Variolink II (Ivoclar Vivadent Inc.);
Choice 2 (BISCO, Inc.); and Calibra (DENTSPLY Caulk, www.caulk.com).
Self-Etch Resin CementsSelf-etch systems apply a self-etching primer to prepare the
tooth surface, and mixed cement is applied over the primer. Bonds to tooth structure
using this category of cements are almost as high as those of the total-etch cements.2
Self-etching systems are popular among dentists because they are easy to use, but as a
general category they have demonstrated bond strength to enamel that is weaker than
that of total-etch systems.16 Therefore, the total-etch, three-step adhesive system of
some 30 years ago still sets the standard in terms of versatility and long-term
predictability.17
Resin cements that incorporate self-etching primers eliminate steps during application
with the goal of reducing operator errors and technique sensitivity and increasing ease
of use.18 However, it is imperative to follow the manufacturers instructions during
adhesive cementation, including use of the manufacturers adhesive and resin cement
combination, because investigators have found incompatibilities between some dual-
cure resin cements and simplified adhesive systems.19
Self-Adhesive Resin CementsA number of resin cements have been introduced as
one-component universal adhesive cements; they are said to have good bond
strengths to dentin, enamel, and porcelains without the need for separate bonding
agents.20-22 These self-adhesive cements can bond to an untreated tooth surface that
has not been micro-abraded or pretreated with an etchant, primer, or bonding agent;
thus, cementation is accomplished in a single step. These cements contain phosphoric
acid, which is grafted into the resin. Once mixing is initiated, the phosphoric acid
reacts with filler particles and dentin in the presence of water, forming a bond. The
resin is polymerized into a cross-linked polymer, as is the case with composite resin
bonding.9
Data from Burgess et al (2010)7 shows that most of these cements bond better to
dentin than to enamel. With most of the cements in this category, the bond to enamel
is improved when an etchant and bonding agent are applied.23 This selective-etch
approach uses an etchant or a self-etching primer before applying the self-adhesive
resin cement. In other words, selectively etching enamel and/or dentin surfaces and
indirect restorations may be incorporated to improve the bond of these self-adhesive
resin cements. However, a lower bond strength to dentin was shown when the
phosphoric acid pre-etch was applied.23 In contrast to enamel, when dentin is etched
with phosphoric acid and a bonding agent is applied with one of these cements, the
bond decreases.7 This negative effect of pre-etching of dentin for self-etch adhesives
has been shown many times in the literature.23 When tested without the pre-etch, self-
adhesive resin cements have been shown to produce fairly strong bonds to dentin.23-
26
Examples include: RelyX Unicem (3M ESPE), BisCem (BISCO, Inc.), Maxcem
Elite (Kerr Corporation), SpeedCEM (Ivoclar Vivadent Inc.).
In Simon et al (2011), it appears that the self-adhesive cements are on par with the
values seen for resin cements. A possible explanation for this observation is that the
self-adhesive cements are changing. For instance, older tests used RelyX Unicem
cement in capsule format, whereas in this newer test the Unicem Clicker Dispense
(3M ESPE) system was used. The cement was reformulated to accommodate the new
delivery system. The changes in observed strengths may be due to incremental
improvements made by the manufacturers.27

Additional Clinical Considerations and Advantages

When using resin-based cements, the internal surface of the restoration must be
treated differently than the surface of the tooth, because the surface treatment depends
upon the type of material (metal, ceramic, or zirconia) used for the restoration. The
surface of the tooth may need to be treated with phosphoric acid, while the surface of
the restoration may need to be treated with hydrofluoric acid, sandblasting, and
silanization.8
The excellent physical properties and ability of resin luting materials to facilitate
adhesive luting of restorations are distinct clinical advantages, because the clinician
may not always be able to achieve an ideal taper or crown height.28 In a recent study
by Simon et al,27 the tensile bond strength of ceramic crowns milled with computer-
assisted design/computer-assisted machining (CAD/CAM) technology was tested on
overly prepared teeth. This study found in a number of cases that the retention of the
crowns supplied by three leading adhesive cements was stronger than the ceramic
crown itself; however, these high bond strengths cannot be achieved on a consistent
basis.27
The efficiency by which the self-adhesive resin cements adapt to and seal margins is
critical for their success.2 Studies have found conflicting results when analyzing the
marginal seal and microleakage of resin cements.29,30 However, self-etch and total-
etch resin cements tend to have adequate marginal adaptation compared to glass
ionomers, resin-modified glass ionomers (RMGIs), and zinc phosphate cements.31
Because self-adhesive cements bond to tooth structure, excess cement should be
removed before setting to avoid damaging the weaker early bond.7 Self-adhesive
cements are dual-cured, and like all dual-cured cements, have reduced bond strengths,
color stability, and wear resistance in the self-cure-only mode.7 Therefore, the
clinician should light-activate all dual-curing cements at accessible restorative
margins to improve marginal integrity and wear resistance and to reduce staining.7

Conclusions
The key points for clinicians to bear in mind regarding resin-based cements are:
Bond strengths vary among specific cements, but total-etch cements generally
provide the greatest retention; self-etching systems are intermediate; and self-adhesive
cements can provide bond strength nearly equal to self-etching systems.7
Self-adhesive resin cements can create bond strengths to dentin that exceed the
strength of the ceramic material.27
High bond strengths can be achieved with self-adhesive resin cements on non-
retentive teeth.27
Large coefficients of variation indicate that the bond strength cannot consistently be
achieved.27
While in vitro data may show some cement bond differences among investigators,
self-adhesive cements perform well clinically.32 Although clinical evaluations are few
and short-term, the result of this review of self-adhesive resin cements would suggest
that these materials may be expected to show clinical performance similar to that of
other resin-based and nonresin-based dental cements.2 The handling properties of
these materials appear to be excellent, and their acceptance by the profession is
increasing.2

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