Cementing all-ceramic restorations
Recommendations for success
Marcos A. Vargas, DDS, MS; Cathia Bergeron, DMD, MS; Ana Diaz-Arnold, DDS, MS
T
he longevity and success of indirect restora-
tions are influenced by patient and oper-
ator. The patient dictates oral hygiene, diet
and functional habits. The operator man-
ages tooth preparation, impression and cementa-
tion. Cementation is a crucial step in the process of
ensuring the retention, marginal seal and dura-
bility of indirect restorations.
Dentistry has benefited from the introduction of
new types of ceramics. Better esthetics, increased
resistance to fracture, biocompatibility and
expanded clinical indications are some of the
advantages offered by contemporary ceramics.
Because each ceramic is unique in terms of its com-
position, choosing the appropriate ceramic and
cement for each clinical situation can be difficult
and confusing. To achieve a successful outcome, the
clinician must understand the ceramic type, sur-
face treatment, cementation material and pro-
cedure, because the ceramic surface treatment
before cementation varies according to the type of
ceramic used. In this article, we provide recommen-
dations that can guide clinicians to successful
cementation of all-ceramic restorations. (The table
summarizes the adhesive cementation procedures
discussed in this article.)
CEMENTATION PROCEDURES
Cementing procedures are either adhesive or non-
adhesive.1,2 Adhesive cementation involves the use
of an agent to promote bonding of the restorative
material to the substrate; it is a combination of
adhesive chemical bonding and micromechanical
interlocking. Nonadhesive (conventional) cemen-
tation involves the use of a luting agent to fill the
space between the restoration and the natural
tooth and relies solely on micromechanical reten-
tion.3 Indications for each type of cementation are
dictated by the composition of the ceramic, the
available preparation retention and resistance
form, and the field control at the time of cementa-
tion.4,5 Short, tapered preparations will benefit
20S JADA 142(4 suppl) http://jada.ada.org April 2011
Copyright © 2011 American Dental Association. All rights reserved.
AB STRACT
Background. Several all-ceramic restorative
systems of various compositions, properties and
indications are available to the dental practitioner.
Because of the large number of systems, the dental
team faces questions and decisions when choosing
the appropriate system and the appropriate means
of cementation.
Overview. The authors present a brief overview
of the cementation options for various types of all-
ceramic restorations. In this article, they discuss
the cementation of current all-ceramic restorations
and make clinical recommendations tailored to
each type of ceramic.
Conclusion and Clinical Implications.
The clinician must have a good understanding of
the ceramic type to determine whether a restora-
tion should be cemented adhesively or nonadhe-
sively. Other variables, such as isolation and prepa-
ration design, also influence the cementation
choice. Various ceramic types demand different
surface treatments before cementation. Choosing
and applying the appropriate surface treatment
and cementation procedure will contribute to long-
lasting restorations. The literature is lacking in
clinical trial results that validate current in vitro
data regarding cementation of all-ceramic
restorations.
Key Words. Cementation; dental cements;
dental porcelain.
JADA 2011;142(4 suppl):20S-24S.
Dr. Vargas is a professor, Department of Family Dentistry, College of Dentistry,
The University of Iowa, S-317 DSB, Iowa City, Iowa 52242-1001, e-mail
“marcos-vargas@uiowa.edu”. Address reprint requests to Dr. Vargas.
Dr. Bergeron is a clinical associate professor, Department of Operative
Dentistry, College of Dentistry, The University of Iowa, Iowa City.
Dr. Diaz-Arnold is a professor, Department of Family Dentistry, College of
Dentistry, The University of Iowa, Iowa City.
TABLE

Summary of adhesive cementation procedures, according to ceramic type.

CERAMIC FILLER SURFACE TREATMENT PRODUCT EXAMPLES
Predominantly Aluminum oxide Apply 10 percent hydrofluoric (HF) acid for Ceramco 3 (Dentsply, York, Pa.), IPS e.max
Glass 1 minute, rinse and dry; apply silane for Ceram (Ivoclar Vivadent, Amherst, N.Y.), Vita
1 minute, air dry VM 7 (Vita Zanhfabrik, Bad Säckingen,
Germany)
Particle-Filled Leucite Apply 5 percent HF acid for 1 minute, rinse IPS Empress Esthetic (Ivoclar Vivadent)
Glass and dry; apply silane for 1 minute, air dry

Lithium disilicate Apply 5 percent HF acid for 20 seconds, rinse IPS e.max Press (Ivoclar Vivadent)
and dry; apply silane for 1 minute, air dry
Glass-infiltrated Perform air abrasion with tribochemical Vita In-Ceram Alumina, Vita In-Ceram Spinell
alumina silica coating or aluminum oxide; apply an and Vita In-Ceram Zirconia (Vita Zahnfabrik)
adhesion-promoting agent containing MDP*
and dry

Polycrystalline Aluminum oxide Perform air abrasion with aluminum oxide;
apply an adhesion-promoting agent
containing MDP and dry
Zirconium oxide Air abrasion with 50-micrometer aluminum
oxide powder at 7 pounds per square inch;
apply an adhesion-promoting agent
containing MDP and dry
* MDP: 10-methacryloyloxydecyl dihydrogen phosphate.
Procera Alumina (Nobel Biocare, Zurich)
Cercon Zirconia (Dentsply), Everest (KaVo,
Charlotte, N.C.), Lava Zirconia (3M ESPE,
St. Paul, Minn.), IPS e.max ZirCAD (Ivoclar
Vivadent)

from cementation via adhesive techniques,
because this process creates a dentin hybrid
layer that improves the mechanical retention of
the restoration.4 However, the use of bonding
agents requires additional steps and meticulous
isolation, which may not be feasible in the clin-
ical environment. Also, clinicians should ensure
that laboratory technicians use precise methods
to achieve proper adaptation, because the use
of adhesive cements will not compensate for
poor fit.
CERAMIC TYPES
When the clinician is selecting the cementation
procedure for all-ceramic restorations, it is
important that he or she know the composition
and structure of the ceramic used to fabricate
the restoration. Dental ceramic systems can be
classified according to their matrix material,
filler and dopant. Three main categories of
dental ceramics have been described in the liter-
ature: predominantly glass, particle-filled glass
and polycrystalline (nonglass) ceramics.6,7
Predominantly glass ceramics. This type
of ceramic is derived from feldspar minerals, sil-
icon and aluminum oxides. It is used as a
veneering material over metal or ceramic cop-
ings and frameworks.7,8 Additionally, it is used
to fabricate jacket crowns, inlays, onlays and
porcelain veneers. This ceramic is highly
esthetic, biocompatible, and resistant to abra-
sion and compressive forces. It also is character-
ized by low mechanical strength in comparison
with other ceramic types and must be cemented
to the prepared tooth adhesively so as to in-
crease the restoration’s resistance to fracture.9
Thus, nonadhesive cementation is not indicated
for feldspathic ceramic.10
The clinician needs to prepare or “condition”
predominantly glass feldspathic ceramics before
performing adhesive cementation. The clinician
etches the ceramics’ intaglio surface with a solu-
tion of hydrofluoric (HF) acid, in concentrations
between 5 and 10 percent, for approximately
one minute. This step provides an increased
surface area, micromechanical retention and a
clean surface (as described by Navez and col-
leagues11) for adhesive cementation (Figure 1).
The clinician places silane over the etched sur-
face to increase the wettability of the resin
cement and to interact chemically with both the
resin matrix and the hydroxylated porcelain
surface.12,13 Both etching and silanation are rec-
ommended, as some investigators have reported
higher veneer failure rates when ceramic is air
abraded and silanated but not etched with HF
acid.14,15 Hydrolyzed and unhydrolyzed silanes
are available. Hydrolyzed silanes most com-
monly are one-bottle systems with a short shelf
life; if the bottle’s contents are used after the
expiration date, it can be detrimental to the
bond.16 Unhydrolyzed or “inactive” silanes are
two-bottle systems that the clinician mixes
before application to ensure a fresh and active
silane and a longer shelf life than that of
ABBREVIATION KEY. HF: Hydrofluoric. MDP: 10-
methacryloyloxydecyl dihydrogen phosphate.

JADA 142(4 suppl) http://jada.ada.org April 2011 21S

Copyright © 2011 American Dental Association. All rights reserved.

Figure 1. Microscopic view of the surface of a predominantly
glass ceramic (Vita VM 7, Vita Zahnfabrik, Bad Säckingen, Ger-
many), etched for one minute with 9.5 percent hydrofluoric acid.
hydrolyzed silanes.16,17
Adhesive cementation to enamel or dentin
requires the use of an adhesive system, followed
by application of a resin cement.2 Adhesive sys-
tems can be either self-etching or total etching.
Self-etching systems are popular among den-
tists because they are easy to use, but as a gen-
eral category they have demonstrated bond
strength to enamel weaker than that of total-
etch systems.18 Therefore, the total-etch three-
step adhesive system is considered the gold
standard. It is imperative to follow the manu-
facturer’s instructions during adhesive cemen-
tation, including use of the manufacturer’s
adhesive and resin cement combination, be-
cause investigators have found incompatibilities
between some dual-cure resin cements and sim-
plified adhesive systems.19
Resin cements are polymerized via light, chem-
icals or a dual process combining the two. Light-
polymerized resins are recommended when the
ceramic is thin and fairly translucent, allowing
the transmission of light through it to reach the
resin cement. Examples of light-polymerized
cements include Rely X Veneer Cement (3M
ESPE, St. Paul, Minn.), Variolink Veneer (Ivoclar
Vivadent, Amherst, N.Y.) and Choice 2 Light-
Cured Veneer Cement (Bisco, Schaumburg, Ill.).
Dual-polymerized resin cements are indicated
when the ceramic is too thick or too opaque to
allow transmission of light through it.20 Examples
include NX3 Nexus Third Generation (Kerr,
Orange, Calif.), Rely X ARC Adhesive Resin
Cement (3M ESPE) and Variolink II (Ivoclar
Vivadent). 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-
22S JADA 142(4 suppl) http://jada.ada.org April 2011
Copyright © 2011 American Dental Association. All rights reserved.
polymerized resin cements.21
Self-adhesive resin cements have been devel-
oped in an attempt to decrease bonding steps and
improve ease of use. This approach combines the
adhesive and the cement in one step. Examples
include Rely X Unicem Self-Adhesive Universal
Cement (3M ESPE), SmartCem 2 (Dentsply, York,
Pa.) and SpeedCEM (Ivoclar Vivadent). Another
approach is to use a self-etching primer before
applying the cement, as seen in systems such as
Panavia F 2.0 (Kuraray, New York City) and Mul-
tilink Automix (Ivoclar Vivadent). Clinicians may
choose these cements because of their simplicity
and therefore their reduced potential for applica-
tion errors. Unfortunately, results of in vitro
investigations have shown that these cements’
bond to enamel and dentin is less than that
demonstrated by a combination of adhesive sys-
tems and resin cements.22,23
Particle-filled glass ceramics. These
ceramics consist of various amounts and types of
particles and a glassy matrix. The inclusion of
particles improves the physical strength of the
ceramic. As the number of particles increases and
the amount of glass decreases, the material’s
strength increases, but unfortunately some of the
translucency and esthetic properties are dimin-
ished. According to their strength, the various
materials in this category can be used as
veneering material or as copings.6
Low-filled materials such as IPS Empress
Esthetic (Ivoclar Vivadent) and OPC (Jeneric
Pentron, Wallingford, Conn.) are filled with
leucite. Their physical strength is relatively low
in comparison with that of other filled glass
materials, which is why they are indicated
mainly for veneers, inlays and onlays, as well as
low-stress situations.7 These ceramics need to
be cemented adhesively to improve their
strength.9 The cementation procedure is similar
to that described previously for the predomi-
nantly glass type of ceramic.
Intermediate-filled material, such as IPS
e.max Press (Ivoclar Vivadent) and OPC 3G
(Jeneric Pentron), is reinforced with lithium di-
silicate and has strength and pleasing esthetic
properties sufficient to allow its use for veneers,
single crowns and copings. This material can be
cemented adhesively or nonadhesively when
used with full-coverage restorations; clinical
studies have reported no difference between the
two types of cementation.24,25 Partial-coverage
restorations, such as inlay, onlay and porcelain
veneer restorations, require adhesive cementa-
tion to increase their retention and fracture
resistance. Full-coverage crowns can be
cemented conventionally or adhesively
Figure 2. Microscopic view of the surface of a particle-filled
glass ceramic (IPS e.max Press, Ivoclar Vivadent, Amherst, N.Y.),
etched with 5 percent hydrofluoric acid for 20 seconds.
according to the preparation design. Conven-
tional cementation is carried out with conven-
tional luting agents such as resin-modified glass
ionomer cements, without the need for interme-
diate agents. Short, clinically nonretentive
preparations should be cemented adhesively.
Another consideration is field control, as it is
imperative that the clinician achieve effective
isolation to keep the field free of saliva and
other contaminants when using adhesive
cements. The adhesive cementation of particle-
filled glass ceramics is similar to the technique
used for predominantly glass ceramics; however,
the clinician must modify the process of condi-
tioning the restoration’s intaglio surface to
achieve optimal adhesion. Manufacturers rec-
ommend etching the intaglio surface of leucite-
reinforced restorations with a solution of 10 per-
cent HF acid for approximately 60 seconds
before cementation. Lithium disilicate–
reinforced ceramic should be etched with a solu-
tion of 5 percent HF acid for approximately 20
seconds (Figure 2). The clinician then should
apply a silane, followed by an adhesive system
and a resin cement, similar to the protocol used
for predominantly glass ceramics.
Another type of particle-filled glass is made
of a sintered core of aluminum oxide infiltrated
with molten glass. These ceramics have high
strength and fracture toughness with minimal
glass content. Some products in this category
include In-Ceram Alumina (Vita Zahnfabrik,
Bad Säckingen, Germany), In-Ceram Spinell
(Vita Zahnfabrik) and In-Ceram Zirconia (Vita
Zahnfabrik). They often are referred to as glass-
infiltrated aluminum-oxide ceramics. They are
cemented conventionally rather than adhe-
sively, because etching glass with HF acid does
not appear to increase the retention of resin
cements.26 Some researchers have reported that
Copyright © 2011 American Dental Association. All rights reserved.
Figure 3. Microscopic view of the untreated surface of a poly-
crystalline ceramic (Everest, KaVo Dental, Charlotte, N.C.).
coating the ceramic with tribochemical silica
and air abrading the intaglio surface, followed
by the application of 10-methacryloyloxydecyl
dihydrogen phosphate (MDP) (a silane and
phosphate monomer) before using resin cement,
improves the bond to this type of ceramic.27,28
Polycrystalline ceramics. Polycrystalline
ceramics are densely sintered aluminum oxide
(Procera Alumina, Nobel Biocare, Zurich) or zirco-
nium oxide (Cercon Zirconia, Dentsply; Everest,
KaVo Dental, Charlotte, N.C.; Lava Zirconia, 3M
ESPE; Vita In-Ceram YZ, Vita Zahnfabrik; IPS
e.max ZirCAD, Ivoclar Vivadent) materials and
are characterized by the absence of glass in their
composition6,7 (Figure 3). Because their atoms are
packed into regular arrays, these materials resist
the propagation of cracks.29 These ceramics pos-
sess high toughness and strength and can be used
for copings and frameworks.
Polycrystalline ceramics most often are
cemented conventionally but, in certain circum-
stances, can benefit from adhesive cementation.
Investigators have reported the use of air abra-
sion with aluminum oxide or tribochemical silica
application followed by application of an
adhesion-promoting agent to increase the bond
strength of resin cements.30 Air abrasion increases
the available surface area for bonding, yet it also
appears to introduce quasiplasticity, as well as
microcracks or potential fracture initiation sites.
Thus, the use of postsintering surface treatments
remains controversial, although low-pressure
abrasion has been recommended.31 In vitro
studies have shown that treating zirconium oxide
restorations with a combination of tribochemical
silica and MDP or using a primer based on phos-
phate and carboxylate functional monomers (such
as Z-Prime Plus [Bisco]) or a primer combination
of MDP and a metal primer (such as Alloy Primer
[Kuraray]) enhanced the bond of resin-based
JADA 142(4 suppl) http://jada.ada.org April 2011 23S
luting cements.32-34 Furthermore, the use of a
primer containing MDP (such as Clearfil Ceramic
Primer [Kuraray]) without air abrasion improved
the in vitro long-term adhesion (150 days with an
additional 37,500 thermal cyclings) when com-
pared with conventional cementation.31,35 It is
believed that these adhesion-promoting agents
produce chemical bonds to zirconium oxide.32-34
Therefore, use of air abrasion with 50-micrometer
aluminum oxide powder at 7.0 pounds per square
inch followed by application of a primer con-
taining MDP before application of the resin
cement has been recommended in instances in
which increased retention is required.
CONCLUSION
The high demand for esthetically pleasing resto-
rations has resulted in the development and
introduction of various dental ceramics. The
dentist must choose not only the appropriate
ceramic, on the basis of functional and esthetic
demands, but also the cement and the cementa-
tion procedure for each system and clinical situ-
ation. The clinician should give special consider-
ation to the use of adhesives, resin cements and
field isolation and adhere strictly to manufac-
turers’ instructions. ■
Disclosure. None of the authors reported any disclosures.
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