Review articles Annals and Essences of Dentistry

doi:10.5368/aedj.2014.6.3.4.5
ALL CERAMIC CEMENTATION: A KEY TO SUCCESSFUL RESTORATION
1 1
Saurabh Shrivastava Post Graduate resident
2 2
Surendra Agrawal Professor and Head
3 3
Swapnil Parlani Reader
4 4
Sumant Saoji Post Graduate resident
1,2,3,4
Department of Prosthodontics, Crown Bridge and Implantology,, Peoples College of Dental Sciences and Research
Centre, Bhopal, (M.P.) India.

ABSTRACT :. All-ceramic restorations are considered no more as future but established and scientifically documented
reality of our daily activities as dental practitioner. To ensure successful and long-term durability of all ceramic restorations,
one of the key requirements is adequate cementation. In spite of using all ceramic restorations so frequently in our routine
practice, very few are aware of exact bonding mechanism for it. This review enlightens us about all the aspects of all
ceramic cementation.

KEYWORDS: All-ceramic, restorations, bonding, cementation, Adhesion, , etching, sandblasting.

INTRODUCTION

The longevity and success of indirect restorations are
influenced by patient and operator. The patient manages
oral hygiene, diet and functional habits while the operator
manages tooth preparation, impression and cementation.
Cementation is a crucial step in the process of ensuring
the retention, marginal seal and durability of indirect
restorations. To achieve a successful outcome, the
clinician must understand the ceramic type, surface
treatment, cement to be used and procedure, because the
ceramic surface treatment before cementation varies
1
according to the type of ceramic used .
tooth adhesively so as to increase the restoration’s
1
resistance to fracture .
Particle-filled Glass
These types of ceramics consist of various amounts and
types of particles and a glassy matrix. They are of mainly
three types
- Leucite reinforced (Low-filled)
- Lithium disilicate reinforced (Intermediate filled)
- Glass infiltrated aluminium oxide ceramics

Types of Ceramics Leucite reinforced (Low-filled)

Dental ceramic systems can be classified according to Leucite-reinforced ceramics contain up to 45% by volume
their matrix material, filler and dopant. Three main of leucite which acts as crack deflectors and contribute to
categories of dental ceramics have been described in the increased resistance to crack propagation. They are
2,3
literature : indicated in esthetic veneers, anterior crowns, as layering
- Predominantly glass porcelain on leucite-reinforced, lithium disilicate, alumina,
- Particle-filled glass and or zirconia cores (IPS Empress Esthetic; Ivoclar Vivadent
- Polycrystalline (non-glass) ceramics. and OPC; Jeneric Pentron, Wallingford, Conn.). These
ceramics need to be cemented adhesively to improve their
1,4,5
Predominantly Glass strength .

It is also known as feldspathic ceramics. This ceramic is
highly esthetic, biocompatible, and resistant to abrasion
and compressive forces. It is used as a veneering material
over metal or ceramic copings, inlays, onlays and
porcelain veneers (CEREC Blocks; Sirona Dental System,
Ceramco 3; Dentsply, York, Pa.). It also is characterized
by low mechanical strength in comparison with other
ceramic types and must be cemented to the prepared
Lithium disilicate reinforced (Intermediate filled)
Lithium disilicate ceramics consist of about 65% by
volume of highly interlocking lithium disilicate crystals
dispersed in a glassy matrix. They are indicated in
Veneers, inlays, onlays, crowns and three-unit bridges –
anterior and premolar region (IPS e.max Press; Ivoclar
Vivadent and OPC 3G; Jeneric Pentron). This material can
be cemented adhesively or nonadhesively when used with

Vol. VI Issue 3 Jul– Sep 2014 35

Review articles
full-coverage restorations; clinical studies have reported
4,5,6,7
no difference between the two types of cementation . ceramic and cement .
Glass infiltrated aluminium oxide ceramics
This category includes In-Ceram Alumina, In-Ceram
Spinell and In-Ceram Zirconia (Vita Zahnfabrik). In-Ceram
Spinell is indicated in anterior crowns, anterior inlays,
onlays and veneers; In-Ceram Alumina is indicated in
anterior and posterior crowns, anterior FPD’s and In-
Ceram Zirconia is indicated in posterior crowns and
posterior FPD’s. They are cemented conventionally rather
than adhesively, because etching glass with HF acid does
not appear to increase the retention of resin cements.
Some researchers have reported that 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 ceramic1,5,8,9,10.
Polycrystalline (non-glass) ceramics
Polycrystalline ceramics are densely sintered aluminum
oxide or zirconium oxide and are characterized by the
absence of glass in their composition. These ceramics
possess high toughness and strength. Zirconia is of
particular interest because of its transformation
toughening and colour masking properties due to its dense
crystalline structure (Procera Alumina; Nobel Biocare,
Zurich, Cercon Zirconia; Dentsply, Lava Zirconia; 3M
ESPE, St. Paul, Minn., IPS e.max ZirCAD; Ivoclar
Vivadent). They are indicated in anterior and posterior
crowns, bruxers – full-contour crowns, anterior and
posterior bridges (maximum 14-unit bridges, span
depends on product and number of abutments,
endodontically treated teeth, implant abutments, inlay
bridges, maryland bridges and block-out of darkened tooth
structure or cores. Polycrystalline ceramics most often are
cemented conventionally but, in certain circumstances,
adhesive cementation can be done. Use of air abrasion
with 50-micrometer aluminum oxide powder at 7.0 pounds
per square inch followed by application of a primer
containing MDP before application of the resin cement has
been recommended in instances where increased
1,5
retention is required .
Adhesive System
Adhesion or bonding is the process of forming an
adhesive joint, which consists of two substrates joined
together. Dental adhesives are solutions of resin
monomers that join a restorative material with a dental
substrate after the monomers set by polymerization. The
success of adhesive bonding relies on mechanical
bonding through micromechanical interlocking from
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Annals and Essences of Dentistry
surface roughening and chemical bonding between
11
Bonding to enamel and dentin
Dental adhesive joints may be more complex such as
the enamel–adhesive–composite– adhesive–porcelain
interface formed when a clinician bonds a porcelain
restoration (Fig.1).
12
In 1955, Buonocore reported the use of 85%
phosphoric acid to improve the retention of an acrylic resin
on enamel. The micromechanical nature of the interaction
of dental adhesives with enamel is a result of the
infiltration of resin monomers into the microporosities left
by the acid dissolution of enamel and subsequent
enveloping of the exposed hydroxyapatite crystals with the
polymerized monomers within the pores on the enamel
13
surface . This task is difficult to achieve as the bonding
process for enamel is different from that for dentin. That is,
14
dentin is more humid and more organic than enamel .
While enamel is composed of 96% hydroxyapatite
(mineral) by weight, dentin contains a significant amount
15
of water and organic material, mainly type-I collagen .
This humid and organic nature of dentin makes bonding to
this hard tissue extremely difficult.
The age of the patient also plays a significant role,
because dentin undergoes age-associated changes i.e.
young dentin has wide and open tubules, but the older a
patient is, the lower the number of open tubules and the
smaller their diameters due to the composition of
secondary and tertiary dentin (sclerotic process).
Complete occlusion of the tubules occurs and prevents the
desired tag formation of the composite cements. This
leads to further reduced bond strength, because the
penetration of resin into and via the dentinal tubules is
16
responsible for nearly 40% of that strength .
When tooth structure is cut with a bur or other
instrument, the residual components form a ‘‘smear layer’’
17
of debris on the surface . This debris forms a uniform
coating on enamel and dentin and plugs the entrance of
the dentinal tubules, reducing the permeability of dentin.
The smear layer is porous and permeable as a result of
submicron channels that allow the dentinal fluid to pass
14
through . The basic composition of the smear layer is
hydroxyapatite and altered collagen with an external
18
surface formed by gel-like denatured collagen . As the
smear layer constitutes a true physical barrier, it must be
dissolved or made permeable so the monomers in the
adhesives can contact the dentin surface directly. In spite
of different classifications of adhesive systems, the current
adhesion strategies depend exclusively on how dental
adhesives interact with this smear layer. One strategy
involves etch-and rinse (total etch) adhesives, which
remove the smear layer and superficial hydroxyapatite
36
Review articles
Fig 1. Adhesive joint formed between enamel and etched porcelain. HF, hydrofluoric acid
through etching with a separate acid gel. The second
strategy involves self-etch adhesives, which make the
11
smear layer permeable without removing it completely .
Etch-and-rinse strategy (Total etch)
In this strategy, dentin and enamel are treated with an
acid gel (commonly phosphoric acid) to remove the smear
layer and demineralized the most superficial
hydroxyapatite crystals. Following this chemical etching, a
mixture of resin monomers (primer/adhesive) dissolved in
19
an organic solvent is applied to infiltrate etched dentin .
The resin monomers permeate the water-filled spaces
between adjacent dentin collagen fibers that used to be
occupied by hydroxyapatite crystals. This infiltration
results in a hybrid tissue composed of collagen, resin,
residual hydroxyapatite, and traces of water (Fig. 2)
known as the resin–dentin interdiffusion zone, first
described in 1982 as the hybrid layer20. This intimate
micromechanical entanglement of resin monomers with
etched dentin may result in decreased postoperative
sensitivity, may make for a better marginal fit, and may
even act as an elastic buffer that compensates for the
polymerization shrinkage stress during contraction of the
11
restorative composite .
Self-etch (non-rinsing) strategy
These adhesives do not require a separate acid-etch
step as they condition and prime enamel and dentin
simultaneously by infiltrating and partially dissolving the
smear layer and hydroxyapatite to generate a hybrid zone
11
that incorporates minerals and the smear layer . The first
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Annals and Essences of Dentistry
self-etch nonrinsing adhesives were composed of two
solutions; an acidic primer and a bonding resin (Fig.3).
Recently, many clinicians have shifted to one-step self-
etch systems (also named all-in-one adhesives) in which
manufacturers have attempted to incorporate all the
primary components of an adhesive system (etchant,
primer, and bonding resin) into a single solution (Fig. 4).
All-in-one adhesives are user-friendly in that fewer steps
are required for the bonding protocol. The elimination of
separate etching and rinsing steps simplified the bonding
technique, making these systems more popular in daily
21
practice . Self-etch adhesives differ in their
aggressiveness. Therefore they are classified in three
categories according to acidity: mild, moderate, and
22
aggressive .
Enamel bonding with self-etch adhesives
The enamel bond strengths of the earliest self-etch
adhesives were lower than those associated with
adhesives that rely on a separate etching step. Because of
their higher pH, two-step self-etch adhesives result in
shallower enamel demineralization compared with that of
phosphoric acid. Nevertheless, roughening of enamel to
remove prismless enamel improves the enamel-bonding
11
ability of self-etch adhesives . All-in-one self-etch
systems are not as acidic as the phosphoric acid used
13
with the etch-and-rinse adhesives . This characteristic
has raised concerns about the performance of all-in-one
self-etch systems on intact enamel. Several in vitro
investigations have reported low resin–enamel bond
23,24,25
strength of all-in-one self-etch materials . Grinding
the enamel during a bevel or cavity preparation, for
37
Review articles Annals and Essences of Dentistry
Table 1. Summary of surface treatment procedures for different types of ceramics.

Ceramic Filler Surface Treatment

Predominantly Aluminum oxide Apply 10 percent hydrofluoric (HF) acid for 1 minute, rinse and dry;
Glass
apply silane for 1 minute, air dry
Particle-Filled Leucite Apply 5 percent HF acid for 1 minute, rinse and dry; apply silane for 1
Glass
minute, air dry
Lithium disilicate Apply 5 percent HF acid for 20 seconds, rinse and dry; apply silane for
1 minute, air dry
Glass-infiltrated Perform air abrasion with tribochemical silica coating or aluminum
alumina
oxide; apply an 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

instance, makes the substrate more receptive for bonding
25,26
with all-in-one self-etch systems . Despite the
increased popularity of self-etch adhesives, etching with
phosphoric acid is still considered the golden standard
11
against which new materials are tested .
Dentin bonding with self-etch adhesives
In spite of their low technique sensitivity and user-
friendliness, all-in-one adhesives have resulted in low
23,24
bonding effectiveness in vitro while their clinical
reliability has often been questioned. Another drawback
associated with all-in-one adhesives is their behavior as
semi-permeable membranes. These materials allow the
movement of water across the bonded interface, which
25,26
potentially leads to hydrolytic degradation . restorations
analyses have demonstrated that acetone-based all-in-
one adhesives result in a hybrid layer 0.2 to 0.5 mm thick,
interfacial gaps, and limited resin penetration into the
dentinal tubules.
Other factors include Porosities (or blisters) occur at
the enamel and dentin bonding interfaces because most
all-in-one adhesives behave as semi-permeable
25,27
membranes . These porosities may be a result of water
accumulation either caused by an osmotic gradient or by
monomer–solvent phase separation upon evaporation of
the acetone. The number and size of these blisters may
11
also depend on the intensity of the air-drying step .
Methods of mechanical bonding for ceramic

Because of the high hydrophilic nature of the acidic
monomers and the high water concentration required for
ionization of the acidic monomers in all-in-one self-etch
solutions, these materials are likely to have resin– enamel
bonds compromised over time. An inadequate resin
penetration into tooth substrates may result in accelerated
25
degradation of the structure of the bonding interface . As
polymerization shrinkage stresses the bonding interface,
dentin adhesives that do not resist these stresses result in
low bond strengths, marginal gaps, recurrent caries, and
pulpal irritation
27,28
. of resin composites, that is, enabling a micromechanical
The magnitude of dentin bond strengths depends on
the degree of infiltration of the resin monomers into the
collagen pretreated with an acidic conditioner or with
29
phosphoric acid . The author’s electron microscopy
Vol. VI Issue 3 Jul– Sep 2014
Hydrofluoric acid etching
It is considered to be one of the most common surface
treatment methods for adhesive cementation to ceramic
restorations. Phosphoric acid (H3PO4) or hydrofluoric
acids (HF) etching are commonly recommended methods
used to surface roughen silica-based ceramics (Glass
30
filled and Particle filled) . HF removes the glassy matrix of
glass ceramics creating a high surface energy substrate
with microporosities for the penetration and polymerization
interlocking. However, HF etching does not produce any
change in arithmetic roughness (Ra) of ZrO2. The lack of
silica also removes the chemical bonding between silica–
silane necessary for silanization.The negligible effect of
the HF on the ZrO2 surface occurs due to the absence of
31
glassy matrix, resulting in low bond strength values .
38
Review articles
Intertubular
Fig. 2. Interaction of one-bottle etch-and-rinse adhesives with dentin.
Surface grinding
Surface grinding is a commonly used alternative for
roughening the surface of ZrO2 to improve mechanical
bonding. There are several methods used for surface
grinding like grinding using abrasive paper or wheels (SiC
or Al2O3) or particle air-abrasion using Al2O3 or other
abrasive particles ranging in size from 50 to 250
micrometer. However, research has shown that surface
grinding techniques, using tradition resin cements, have
no significant effect on increasing the bond strength of
zirconia to resin cements. Another problem with these
techniques is that they can create surface microcracks.
These flaws act as crack initiation sites that can decrease
30
strength and apparent fracture toughness .
Sandblasting
Guazzato et al and Kosmac et al showed that
sandblasting produced the most effective tetragonal to
monoclinic phase change when compared to fine
polishing, grinding with an abrasive wheel, or grinding
using a diamond bur. Sandblasting is able to induce
transformation at low temperature, with minimal surface
32,33
damage .
Fused glass micro pearls
Slurry of micropearls was painted on a ZrO2 surface and
fired in a furnace. The fused glass film increased surface
roughness of ZrO2, allowing increased micro-retention.
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Annals and Essences of Dentistry
The silica-rich film also allows for silanization of ZrO2
before bonding, making it possible to form siloxane bonds
to resin cement. Derand et al. showed that use of this
fused micro-pearl film significantly increased the bond
strength of ZrO2 (11.3-18.4MPa) compared to untreated or
30,34
silanized ZrO2 (0.5–1.5MPa) .
Selective infiltration etching [SIE]
A novel surface roughening technique that has been
explored for ZrO2 is selective infiltration etching. SIE uses
a heat-induced maturation process to pre-stress surface
grain boundaries in ZrO2 to allow infiltration of boundaries
with molten glass. The glass is then etched out using HF,
creating a 3D network of inter-granular porosity that allows
nano-mechanical interlocking of resin cement. The
advantage of SIE is that it only involves grains that are
exposed to molten glass, allowing control of the area to be
etched. Aboushelib et al showed that using SIE on ZrO2
resulted in increased microtensile bond strength
(49.8±2.7MPa) when compared to particle air-abraded
ZrO2 (33.4±2.1MPa). The use of SIE improved nano-
mechanical retention of zirconia by increasing the surface
30,35
area available for bonding .
Hot chemical etching
The use of a hot chemical etching solution has been
proposed to etch the wings of Maryland bridges.
Application of hot chemical etching solution produces a
36
surface roughness that is significantly greater than SIE .
39
Review articles
Chemical bonding
Silane coupling agent
Organo-silanes, generally referred to as “silanes” in
dentistry, are compounds that contain a silicon (Si) atom
or atoms which are similar to orthoesters in structure, and
display dual reactivity. One end of a silane molecule is
organically functional (e.g., vinyl–CH-CH2, amino–NH2),
and can polymerize with an organic matrix (e.g., a
methacrylate). The other end is generally comprised of
alkoxy groups (e.g., methoxy–OCH3, ethoxy–OCH2CH3),
which can react with a hydroxylated surface, like
30
porcelain (Fig. 4). Silanes are also believed to promote
surface wetting, which enhances potential
micromechanical retention with low viscosity resin
cements
37,38
. Traditional silane chemistry is not truly
effective with ZrO2, as it possesses a relatively non-polar
surface, is more chemically stable than silica-containing
ceramics, and not easily hydrolyzed .
30
Hydrolyzed and unhydrolyzed silanes are available.
Hydrolyzed silanes most commonly are one-bottle
systems with a short shelf life; if used after expiration date,
can be detrimental to the bond. 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 dual polymerized resin
1
cements .
Fig. 3. Interaction of two-bottle self-etch adhesives with dentin.
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Annals and Essences of Dentistry
Tribochemical silica coating
Tribochemical silica coating with impact energy of
blasted silicate particles produces bonding between the
silicate and the targeted surface by mechano-chemical
reaction. Application of a tribochemical coating, before
silanization, significantly enhances bond strength between
a treated substrate and resin cement. Cleaning of a
tribochemical coated ZrO2 before resin bonding can be
30
deleterious to bond strength . (Fig. 5)
39
Nishigawa et al determined that ultrasonic cleaning
of tribochemical coated ZrO2 before silanization and resin
bonding significantly decreases bond strength. Cleaning
for 2 or 5 min resulted in bond strength statistically similar
to air-abrading alone before bonding. Ultrasonic cleaning
results in decreased silica content on the surface. This
decrease, along surface morphology changes, is thought
to cause the loss of bond strength. Air pressure has also
been shown to affect bond strength when applying a
tribochemical coating. Increasing pressure increases the
amount of silica on the ZrO2 surface. It is thought that
increasing air pressure, which increases kinetic energy of
particles, causes an increase in surface roughness and
the number of particles that contact the surface. This
increases mechanical retention the amount of silica
available for chemical bonding.
40
Review articles
Fig 4. Idealized illustration of how silane compounds chemically bond to inorganic silica (left side of figure) and
to a polymerizing organic matrix (right side of figure – the double bond circled in red would be broken during a
free radical driven polymerization process, facilitating covalent bonding with the polymerizing organic matrix).
Silicoating
Applying a silica layer to ZrO2-based ceramics is
silicoating. Silicoating involves pyrolytically applying a
silica coating on a substrate surface, followed by
application of silane, before bonding using resin cement.
Using a lab device, butane gas is burned with atmospheric
oxygen and guided over a container filled with tetraethoxy
silane. The gas is lit and the silane decomposes in the
flame, coating the material with a layer of SiOx–C
fragments that bond adhesively to the surface of the
40
material .
Plasma spray coating
Another form of silicoating uses a plasma spray
technique to deposit a siloxane coating on ZrO2. Derand et
al used a high-frequency generator to deposit
hexamethyldisiloxane (HMDS) on the surface of ZrO2.
When polymerized, HMDS acts like a silane, resulting in a
siloxane bond between ZrO2 and resin cement. The
application of the plasma produced a bond strength that
was significantly greater than untreated or silanized ZrO2
but was significantly less than ZrO2 coated with a film of
porcelain micropearls
Vapour phase deposition
Application of a unique vapor-phase deposition
technique, in which a chloro-silane gas (SiCl4) is combined
with water vapour to form a SixOy functionalized surface
on a ZrO2 substrate. The process uses molecular vapor
deposition (MVD), an enhancement on conventional vapor
deposition, to deposit ultra-thin, uniform coatings on
substrates using an in-situ surface plasma treatment.
Piascik et al. showed that ZrO2 coated with a SixOy film,
followed by silanization and resin cement bonding,
enhanced bond strength. Zirconia with a film thickness of
2.6nm had significantly greater bond strength than
tribochemical-coated ZrO2 and was comparable to
porcelain. The ZrO2 that was bonded using a 23nm SixOy
film had a significantly lower bond strength than the 2.6nm
34
film coated ZrO2 but greater than untreated ZrO2 . Based
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Annals and Essences of Dentistry
on these results, Piascik et al. stated that it is possible that
bond strength of the SixOy film is dependent on film
thickness and decrease in bond strength could be caused
by a lack of chemisorption in the additional layers
deposited on the ZrO2 surface after the initial deposited
41
layer .
Primers
Primers improve bonding between resin cements and
various restorative materials and can be classified based
on the substrate (silica-based ceramics, alumina, zirconia,
alloy) for which they are intended to be used. Silane
Primer (silane coupling agent) is based on silane used
with silica-based ceramics (feldspathic porcelain, leucite-
reinforced ceramic, lithium disilicate ceramic). Ceramic
Primer is based on an acidic adhesive monomers used
with alumina- and zirconia-based ceramics. Ceramic
primers may contain silane and metal primers. 10-
methacryloyloxydecyl dihydrogen phosphate or MDP-
containing resin cement continues to be the popular
choice for luting ZrO2 prosthetics in clinical applications
due to their low incident of failure and loss of retention.
Acidic monomers rapidly hydrolyze silane coupling agents,
producing the siloxane bonds necessary for chemical
bonding. Acidic nature of MDP enhances the polysiloxane
bonding produced by silane coupling agents and results in
42
improved retention of resin cements to ZrO2 . Table 1.
Summarizes surface treatment procedures for different
types of ceramics.
CONCLUSION
The increasing demand for esthetically pleasing
restorations has resulted in the development and
introduction of newer dental ceramics. The dentist must
select not only the appropriate ceramic, on the basis of
functional and esthetic demands, but also the cement and
the cementation procedure for each type of ceramic and
clinical situation. For the successful outcome, clinician
should give special consideration to the use of adhesives,
resin cements and field isolation and adhere strictly to
manufacturers’ instructions.
41
Review articles
Fig. 5. Illustration of the tribochemical silica coating process. Silica coated alumina particles are driven into
the ceramic surface under high air pressure. This creates local energy which facilitates transfer of silica onto
the ceramic surface. A potential problem is the creation of damage to the surface of the ceramic via the air
abrasion process, which could accelerate fatigue.
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Corresponding Author
Dr. Saurabh Shrivastava. BDS,
Post Graduate Resident,
Department of Prosthodontics, Crown Bridge
and Implantology,
Peoples College of Dental Sciences &
Research Centre, Bhopal, (M.P.) India.
Email:- drsaurabh11@gmail.com
Ph: +91 9977014554
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