Dental Records

Oral adipose body, its use in oral surgery. Raffo Lirios, M; Oggiani Rodriguez, V.

Cementing protocols for ceramic restorations.

Cementation Protocols for ceramic restorations

Authors

José Pedro Corts Rosario Abella

Director of Career and Postgraduate Dept., Faculty of Dentistry, Catholic Assistant of Fixed Prosthodontic Clinic, Faculty of Dentistry, Catholic University
University of Uruguay. Professor of Dental Surgery Clinic and Fixed of Uruguay.
Prosthodontics Clinic, School of Dentistry, Universidad Católica del Uruguay.
Former Adjunct Professor, Chair of Dental Operative II and Former Adjunct
Professor of the Area of ​Restorative Dentistry, Graduate School, Faculty of
Dentistry, University of the Republic of Uruguay

Submitted for review: November 1, 2013 Accepted for

publication: December 6, 2013

Summary
The current restorative dentistry in order to comply with the preventive, conservative and maximum preservation philosophy of natural dental structures, has
developed restorative materials that require various cementing techniques. With these materials it has already been proven that restorations are achieved with
excellent aesthetic and functional results.
Ceramic restorations can be cemented with various protocols depending on their composition, since they can be acid sensitive or acid resistant. Each one
needs a different cementation technique, in order to achieve retention, sealing and / or intimate support of the restoration itself.

This work proposes detailing the cementing protocols, since it is a fundamental stage of rehabilitation. Knowledge of techniques avoids failure and
optimizes long-term results.

Keywords: Bonded restorations, bonded porcelain, cemented, zirconia

Abstract
Current restorative dentistry has developed restorative materials that require different cementation techniques, to fulfill the preventive and conservative philosophy of
maximum preservation of natural dental structures It has been shown that these materials can achieve restorations with excellent aesthetic and functional results.

Depending on the composition of the ceramic restorations they should be cemented with different protocols, since they may be sensitive or resistant to acid. Each of
them needs a different bonding technique, in order to achieve retention, sealing and / or intimate support to the restoration itself.

This paper proposes detail cementation protocols since it is a critical stage of rehabilitation. The knowledge of techniques avoids failures and optimizes long-term results.

Keywords: bonded restorations, bonded porcelain, cementation, zirconia

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 Dental Records

Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

INTRODUCTION
All oral rehabilitation must always have as a prerequisite, an
orderly functional and aesthetic diagnostic planning and a
sequenced programming of procedures, the complexity of
which will vary according to the demands of the case. This
sequential therapeutic program is of great help to optimize
results and that the treatment is effective and efficient.

The current dental professional must thoroughly know each

material, identify its advantages, disadvantages, indications,
contraindications, and management protocols to optimize the
clinical prognosis. The objective of this work is to provide Fig. 1 Hydrofluoric acid (approx. 5%) from Ivoclar-Vivadent
information on the prosthetic stage of installation of ceramic
restorations, focusing on the cementation protocols, the
treatment of surfaces and the cements to be used according
to the case, obviously complied with and at the request of
diagnosis, planning, pre-prosthetic preparations and previous
prosthetic stages.

CERAMIC RESTORATIONS
Indirect aesthetic restorative materials have evolved and
improved their physico-chemical properties, and an
increasing number of metal-free ceramic systems are
available for clinical use.

Fig. 2 Ivoclar-Vivadent Multilink resin cement kit, which is also made up of:
They will require a different cementitious medium Monobond S which is silane, Chemical adhesive A and B with its two
depending on their composition, so it is of utmost components that are mixed at the time of use, and Metal / Zirconia Primer.

importance to know whether said structure will have intrinsic

resistance and may be conventionally cemented
(acid-resistant ceramics), or will require adhesive cementing
to achieve resistance. additional intrinsic mechanics
(acid-sensitive ceramics).

ACID-SENSITIVE CERAMIC RESTORATIONS

Ceramic restorations sensitive to the action of hydrofluoric

acid are widely used for their biomimetic properties, because
they achieve satisfactory performance from a mechanical
point of view, both in the posterior and anterior sectors, they Fig. 3

achieve highly aesthetic and optical properties. they provide

excellent biocompatibility. Within this range of ceramics, the
most commonly used are glass-ceramic and feldspathic. The
resin-ceramic bond contributes to the longevity of the
restoration and this is achieved through micromechanical
and chemical bonding. For the treatment of the ceramic
surface, hydrofluoric acid must be applied, which reacts with
the glass matrix that contains silica and forms
hexafluorosilicates (Fig. 1). The result is a surface that will
present microscopically the appearance of a honeycomb.
Glass matrix

Fig. 4

38 ISSN 1510-8139 V volume X / n number 2 / D December 2013

 Dental Records

Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

Selectively removed leaves the crystal structure exposed for

the micromechanical retention of the ceramic. The objective
of modifying the porcelain surface before cementation is to
increase the surface area available for bonding and to
create retentions that increase the strength of the bond.
That etched surface also helps provide more surface energy
before placing the silane and adhesive system.
Organic-functional silanes promote wettability and bonding
to ceramics by depositing methacrylate groups, which will
bind to those of resins, thus promoting chemical bonding
between organic and inorganic (Fig. 2). Correct adhesion
provides high retention, improves marginal adaptation,
prevents microleakage, and increases fracture resistance of
both the tooth and the restoration (Corts, 2003; 2010). Acid Fig. 5

sensitive ceramics require a concentration of hydrofluoric

acid and etch time depending on its composition, so it is
imperative to act in each instance according to the
manufacturer's instructions. If the time or concentration were
excessive, the dissolution of the glassy matrix around the
crystals would be promoted, affecting the resistance to
bending of the ceramic and the adhesion properties. (Wolf
DM, 1993; Hooshmand T, 2008; Corts, 2008; Della Bonna,
2009; Villaça 2011).

Fig. 6
Adhesive bonding protocol for lithium disilicate-based
restorations (E-Max from Ivoclar- Vivadent) (Figs. 03 to
18).
● temporary removal and cleaning of dental surfaces

● fit test and esthetics restoration by restoration and later,

all together
● conditioning of each for cementing (it is also convenient
to carry out one restoration at a time):

♦ Recorded with hydrofluoric acid (4.5%) for 20 seconds.

(Fig. 03)
♦ Thorough washing and neutralization with sodium
bicarbonate for at least 1 minute and washing again (Figs. 04
Fig. 7
and 05).
♦ New cleaning with phosphoric acid now, which helps to
eliminate with certainty all the residual products of the previous
reaction (Fig. 06) ♦ Thorough rinsing and exhaustive drying with
alcohol of the entire internal surface, which should have an
opaque white appearance. and sugar cube-like in appearance.
(Figs. 07 and 08)

♦ Silane application and keep protected until the moment

of loading with the cementitious material. (Fig. 09)

♦ Application of a bonding to improve wettability,

immediately before loading the cement, blow to thin the
layer and DO NOT Fig. 8

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 Dental Records

Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

Fig. 9 Fig. 10

Fig. 11 Fig. 12

Fig. 13 Fig. 14

Figs. from 3 to 15. Images of the adhesive bonding protocol of lithium Fig. 17
disilicate restorations, detailed in the text itself.

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 Dental Records

Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

Limerize to avoid settling problems when taking the

restoration to the tooth. (Fig. 13)

● conditioning of the operative field and good humidity

control.
● dental conditioning for cementation by means of
prophylaxis and disinfection with chlorhexidine, etching with
phosphoric acid of the enamel, application of the dentin
adhesive system and / or simply a “bonding”, according to
whether or not there is exposed dentin, (all this from to one
piece at a time and protecting neighboring teeth with Teflon
Fig. 16
or similar) (Corts, 2008). It is NOT light curing at this time,
since all these thin and translucent restorations will easily
allow the passage of light to the dental structure in the final
light curing. (Figs. 10 to 12)

● loaded with the cementitious material (dual resin cement,

for example Variolink from Ivoclar-Vivadent, or “flow” resin)
and setting of the restoration, meticulous and exhaustive
elimination of excesses, and now, light-curing from all sides (
Figs. 14 and 15)

● readhesion with a bonding and resin flow on the margins
● polishing, finishing, and final checks
● fluorine topication
Figs. 16 to 18. Before and after the case aesthetically and functionally
solved, with the 5 Ivoclar-Vivadent E-Max lithium disilicate veneers /
veneers, image 17. Case solved by Dr. Rosario Abella

RESTORATIONS OF CERAMIC ACID- RESISTANT

They are polycrystalline ceramics of very high density and that

do not contain amorphous silica glass in their composition.
Their matrices are basically made of aluminum oxide or
zirconium oxide, which therefore do not react to etching
protocols with hydrofluoric acid. They are mainly used for the
manufacture of high-resistance structures, especially those
made of zirconia, and have become more popular today, due
to the wide range of possibilities and accuracy provided by
CAD-CAM systems (Computer Assisted Design-Computer
Assisted Machined / Computer Aided Design-Computer Aided Fig. 19
Manufacturing) (Conrad et al, 2007; Kelly, 2008; Della Bonna,
Kelly, 2008; Denry, Kelly, 2008; Della Bonna, 2009.)

These high resistance cores that have some limitations in

terms of aesthetics, are anatomically coated with other
feldspathic or vitreous ceramics to optimize them in that
regard; however, for many of these systems, some failures
have been reported due precisely to minor detachments of
these coatings due to cohesive failures (“chipping” or
“cracking”) (Conrad et al, 2007). In any case, they have
evolved and most are becoming more reliable from every
point of view. Neither zircon oxide-based restorations
Fig. 20

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Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

Conium or aluminum oxide are not indicated to be

adhesively cemented for strength reasons, and in this
sense they are more assimilated to conventional metal
restorations, even using zinc oxyphosphate cements,
conventional ionomer glass or resin modified. Of course,
resinous cements can also be used. It is important for
cases where there will be no relevant adhesion, that the
designs of the dental preparations have their own retention
and dislocation resistance forms, which is why total
coronary arteries have been the most commonly used.
(Figs. 19 to 21). However, it is also possible to use more
conservative and therefore more consistent design
restorations to comply with the philosophy of maximum
conservation of natural structures, with additional retention Figs. 19 to 21. Fixed 4-piece zirconia prosthesis (ZirkonLab Laboratory), to
of the type of “undercuts” to provide retention and stability replace the right upper first molar. Total crown retainers on premolars (14
and 15) and second molars (17). Case solved in the Clinic of Fixed
(Figs .22 to 25).
Prosthodontics of the Faculty of Dentistry of the Catholic University by Br.
Ma. Clara Rodriguez.

To optimize any of these substrates for adhesive cementation,

their silicatization or tribochemical treatment is recommended,
which is sandblasting with silica-modified alumina particles,
which impact the surface at high speed and penetrate up to 15
microns of said substrates. These systems, such as Co-Jet or
Rocatec from 3M ESPE, then leave the surfaces infiltrated with
silicon oxide, which is then silanized, thus favoring bonding
with resinous cement (Ozcan et al, 2003; Conrad et al , 2007;
Della Bonna, 2009). Another possibility is to treat zirconia or
metal surfaces with primers based on phosphate monomers
(MDP-methacryloxidecyl dihydrogen phosphate), which contain
a hydrophobic phosphate terminal that is to be chemically
adhered to zirconia, and another polymerizable methacrylate
that is will bind to the resin (Lehmann and Kern, 2009; Griffin
and et al, 2010). (Figs. 2 and 26) Even so, it should be stated,
that it would not occur in these cases, the "integration" or Fig. 22
"fusion" of the restorations to the teeth, as it happens with
those treated with hydrofluoric acid. (McLaughlin, 1984; Corts,
2003 and 2010).

Adhesive bonding protocol of acid resistant

restorations: (Figs. 22 to 25)
● temporary removal and cleaning of dental surfaces

● fit test and esthetics restoration by restoration first and

all together afterwards, if they were more than one

● conditioning of each for cementing (it is also convenient

Fig. 23
to carry out one restoration at a time):

♦ Eventual tribochemical treatment of the internal surface

♦ Cleaning with alcohol and profuse drying of the

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 Dental Records

Cementing protocols
Oral adipose foruse
body, its ceramic
in oralrestorations.
surgery. Raffo Lirios, M; OggianiCorts, JP; Abella,
Rodriguez, V. R

Fig. 24 Figs. 22 to 25. Fixed 3-piece zirconia prosthesis (ZirkonLab Laboratory) to

internal surface of the restoration
replace the first upper left premolar (24). In this case, the partial retainers for
the maximum conservation of natural structures are; simplified inlay in the
palatine of the canine (23), and inlay MO inlay in the second pulp premolar
(25), previously reconstructed with Coltene Tenax titanium bolt and internal
adhesive band with composite resin and adhesive system. You can see in the
dental preparations and in the fixed prosthesis itself, the detail of the

♦ Application of silane or zirconia primer and keep undercuts to achieve their own retention and stability, which will collaborate
with the adhesive cementing that was made. Case also solved in the Clinic of
protected until the moment of loading with the Fixed Prosthodontics of the Faculty of Dentistry of the Catholic University by
cementitious material. ♦ Application of the chemical Br. Florencia Pereda.

adhesive to improve wettability, immediately before

loading the cement, blow to thin the layer to a minimum,
to avoid settling problems when bringing the restoration
to the tooth (in this case use chemical curing adhesive,
as the structures are opaque and not suitable for light
curing.

● conditioning of the operative field and good humidity

control.
● dental conditioning for cementing by means of prophylaxis
and disinfection with chlorhexidine, selective etching with
phosphoric acid of the enamel, application of the chemically
polymerizable dentin adhesive system, since the cement must
also be, due to the difficulty of passing light through the
restoration.

● mixing and loading of the self-curing cement, setting of

the restoration, careful and exhaustive elimination of
excesses and waiting for the polymerization time. (if the
cement also had the option of light-curing, light-cure the
excess cement for 3 seconds, to eliminate it “in toto”)
Fig. 26. Z-Prime Plus from Bisco, which favors a certain chemical bond between

● readhesion with a bonding and resin flow on the margins zirconium or alumina and the dental structure by means of resin cements.

● polishing, finishing, and final checks

● fluorine topication
Conventional cementing protocol of acid resistant
restorations: (Figs. 19 to 21)
● fit test and esthetics restoration by restoration first and
all together afterwards, if they were more than one
● conditioning of each for cementing
(also convenient to perform one restoration at a time):
♦ Cleaning with alcohol, profuse drying of the surface of
the restoration, and leaving the cement-loaded one
protected up to the moment
● conditioning of the operative field and good humidity
control.

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Oral adipose
Cementing body, its
protocols foruse in oralrestorations.
ceramic surgery. Raffo Lirios, M; OggianiCorts,
Rodriguez, V. R
JP; Abella,

● dental conditioning for cementing by means of CONCLUSIONS

prophylaxis and disinfection with chlorhexidine.
● mixing and filling of the zinc oxyphosphate cement,
ionomer glass, or resin-modified ionomer glass, setting the
restoration, careful and exhaustive removal of excesses
and waiting for the setting time
● polishing, finishing, and final checks
● fluorine topication
This last protocol is undoubtedly much simpler and easier to
carry out, although of course it does not have the
advantages of cemented adhesive. It should also be noted
that the most modern self-adhesive resin cements are also
very simple to use, since it is only applied to the restoration
after cleaning and drying. However, if the detailed adhesive
cementation protocol is not used, the restorations should
have good retention of their own, since these cements have
been reported to offer lower retention values ​for zirconia and
dentin (Griffin et al, 2010). Therefore, in case of using them,
it is convenient to comply with the detailed adhesive bonding
protocol.
Sequential therapeutic programming is necessary for
treatment to be effective and efficient. Scheduling session by
session and stage by stage helps to optimize results.
Ceramic structures require different cementitious media
depending on their composition. It is very important to know if
said structure should be conventionally cemented or if it requires
adhesive cementing to achieve the success of the restoration.
Complying with the cementation protocols ensures a longer
duration and the success of the restorations. Above all, the
adhesive bonding protocol is extensive and highly sensitive to
the technique, and the intrinsic fusion between dental
structure-composite resin-ceramic depends on it.
Correct handling of techniques and protocols then helps to
meet biological, functional and aesthetic objectives,
respecting the philosophy of maximum conservation of
natural dental structures.

REFERENCES
Conrad HJ, Seong WJ, Pesun IJ ( 2007) Current ceramic material and systems with clinical recommendations: A systematic review J
Prosthet Dent 98 (5): 389
Corts JP ( 2003) Previous Adhered Indirect Restorations. In Henostroza G. (ed). Adhesion in Odont Rest of Alodyb. 1st .ed;
Ed. Maio, Curitiba, Brazil pp279
Corts JP ( 2008) Veneers or aesthetic fronts and their variants. In: Lanata EJ et al Atlas of Operativa dental Buenos Aires. Alfaomega
pp251
Corts JP ( 2010). Previous Adhered Indirect Restorations. In Henostroza G. (ed). Adhesion in Odont Rest of Alodyb. 2nd ed; Ed.
Ripano SA Madrid, Spain pp346
Denry I, Kelly R, ( 2008) State of the art of zirconia for dental applications Dent Mat 24: 299
Della Bonna A, Kelly R. ( 2008) The clinical success of all ceramic restorations J Am Dent Assoc 139 (9Suppl): 8S

Della Bona A. ( 2009) Bonding to ceramics: scientific evidences for clinical dentistry. São Paulo: Medical Arts
Griffing JD, Suh BI, Chen L, Brown DJ ( 2010) Surface treatments for zirconia bonding; a clinical perspective Canadian J Rest Dent &
Prosth Winter: 23
Hooshmand T, Parvizi S, Keshvad A. ( 2008) Effect of surface acid etching on the biaxial flexural strength of two hot-pressed glass
ceramics. J Prosthodont 17: 415-419.
Kelly RJ ( 2008) What is this stuff anyway? J Am Dent Assoc 139: 4S
Lehmann F, Kern M, ( 2009) Durability of resin bonding to zirconia ceramic using different primers J Adhes Dent 11 (6): 478

McLaughlin G, ( 1984) Porcelain fused to tooth- a new esthetic and reconstructive modality. Compend Contin Educ Dent 5: 430

Ocene M, Vallittu PK, ( 2003) Effect of Surface conditioning methods on the bond strenght of luting cement to ceramics. Dent Mater 19
(8): 725
Villaça Zogheib L, Della Bonna A, Tomomitsu Kimpara E, Mccabe JF, ( 2011) Effect of hydrofluoric acid etching duration on the
roughness and flexural strength of a lithium disilicate-based glass ceramic. Arm. Dent.
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Wolf DM, Powers JM, O'Keefe KL. ( 1993) Bond strength of composite to etched and sandblasted porcelain. Am J Dent 6: 155.

José Pedro Corts

jpcorts@ucu.edu.uy

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