**Lecture 8: Biomaterials (Cements)** By Dr Cheryl Fu # **Lecture 8: Biomaterials (Cements)** By Dr Cheryl Fu # Learning Objectives - Different permanent and temporary cements and their uses - Bonding/luting mechanisms - Clinical steps for cementing a permanent crown (glassy vs crystalline vs metallic) **Reading:** Chapter 30 Contemporary fixed prosthodontics + **Dental Luting Cements: An Updated Comprehensive Review** Artak Heboyan,¹,* Anna Vardanyan,¹ Mohmed Isaqali Karobari,²,³ Anand Marya,⁴,⁵ Tatevik Avagyan,⁶ Hamid Tebyaniyan,⁷ Mohammed Mustafa,⁸ Dinesh Rokaya,⁹,* and Anna Avetisyan¹⁰ # **Learning Objectives** - Different permanent and temporary cements and their uses - Bonding/luting mechanisms - Clinical steps for cementing a permanent crown (glassy vs crystalline vs metallic) ## **Reading** - Chapter 30 Contemporary fixed prosthodontics + - **Dental Luting Cements: An Updated Comprehensive Review** - Artak Heboyan,¹,* Anna Vardanyan,¹ Mohmed Isaqali Karobari,²,³ Anand Marya,⁴,⁵ Tatevik Avagyan,⁶ Hamid Tebyaniyan,⁷ Mohammed Mustafa,⁸ Dinesh Rokaya,⁹,* and Anna Avetisyan¹⁰ **Cements** Divided into temporary and permanent cements - Temporary cements such as zinc oxide eugenol/eugenol free cements covered in temporization Permanent cements can then be classified in many ways: - **Composition:** - Resin based vs Water based (GIC, zinc polycarboxylate and zinc phosphate) - **Bonding mechanism:** - Non adhesive luting vs micromechanical retention vs molecular adhesion # **Cements** Divided into temporary and permanent cements. - Temporary cements such as zinc oxide eugenol/eugenol free cements covered in temporization. Permanent cements can then be classified in many ways: - **Composition:** - Resin based vs Water based (GIC, zinc polycarboxylate and zinc phosphate) - ==Compomers== - **Bonding mechanism:** - Non adhesive luting vs micromechanical retention vs molecular adhesion # Luting **A Review of Dental Cements** *Kipp Wingo, DVM, DAVDC¹* > “A term sometimes used to refer to final placement of a fixed prosthodontic restoration is to “lute” the restoration. It derives from the Latin *lutum*, which means mud or clay. A “luting agent” is the substance—such as cement, wax, or clay—that coats a joint area to make a tight seal. Historically, luting agents were used to mechanically link restorations to a prepared tooth.” - Luting cements work based of mechanical friction by - Traditionally for cast restorations - The luting cement powder sets into a hardened matrix - However luting cements generally have solubility issues due to the matrix consisting of ionic salts Roll of sandpaper with red arrow pointing to it and a speaker icon nearby # **Luting** **A Review of Dental Cements** *Kipp Wingo, DVM, DAVDC¹* > “A term sometimes used to refer to final placement of a fixed prosthodontic restoration is to “lute” the restoration. It derives from the Latin *lutum*, which means mud or clay. A “luting agent” is the substance—such as cement, wax, or clay—that coats a joint area to make a tight seal. Historically, luting agents were used to mechanically link restorations to a prepared tooth.” - Luting cements work based of mechanical friction by - ==Traditionally for cast restorations with highly parallel preparations, which make removal nearly impossible without fracturing the cement.== - ==They have no molecular adhesion.== > [!example] Analogy > ==Similar to pressing two pieces of sandpaper together; the friction between the rough surfaces makes them difficult to slide against each other. The set cement acts as the gritty particles. Zinc Phosphate is a classic luting cement.== - Traditionally for cast restorations - The luting cement powder sets into a hardened matrix - However luting cements generally have solubility issues due to the matrix consisting of ionic salts **Micromechanical bonding** - Resin cements - Etching dentin/enamel (Phosphoric acid) - Etching glassy ceramics (hydrofluoric acid) - Sand blasting metal/zirconia crowns ## **Micromechanical bonding** - Resin cements - Etching dentin/enamel (Phosphoric acid) > [!note] > ==Similar to direct composite bonding, phosphoric acid is used to etch the dentin, removing superficial minerals and exposing the collagen fibril network. An adhesive (uncured resin monomers) is then infiltrated into this network and cured, creating a “hybrid layer” of interlocked resin and collagen.== - Etching glassy ceramics (hydrofluoric acid) > [!note] > ==The HF selectively dissolves the glassy silica phase of the ceramic, creating surface roughness and microporosities for the cement to lock into.== - Sand blasting metal/zirconia crowns > [!note] > ==These materials cannot be etched with HF acid. Airborne particle abrasion with materials like aluminum oxide is used to create a rough, opaque surface, increasing the surface area for mechanical interlocking.== **Molecular adhesion** - Physical forces such Van der Waals or chemical ionic bonding. - 10-MDP - At the moment cements still require other methods of retention (parallel walls) - Can not rely solely on this. ## **Molecular adhesion** - Physical forces such Van der Waals or chemical ionic bonding. - 10-MDP - At the moment cements still require other methods of retention (parallel walls) - Can not rely solely on this. > [!info] Current Status > ==Molecular adhesion alone is not sufficient for retention. It is used in combination with retentive preparation features (e.g., parallel walls) and micromechanical bonding to achieve durable clinical outcomes.== # Ideal Properties of Cements - Low film thickness - Suitable working time and setting time - High compressive strength - Similar elastic modulus as dentin - Biocompatible - Plaque/caries inhibition - Low solubility - Low microleakage - Easy removal of excess - High retention # **Ideal Properties of Cements** - Low film thickness - Suitable working time and setting time - High compressive strength - Similar elastic modulus as dentin - Biocompatible - Plaque/caries inhibition - Low solubility - Low microleakage - Easy removal of excess - High retention **Biocompatible and Antimicrobial Effects** - Cements should ideally not interact with bodily tissues, and not cause sensitivity or allergic reactions - Antimicrobial effects to prevent marginal caries. However evidence in inconclusive whether low level fluoride or other antimicrobial agents can provide long term inhibition. (Will the fluoride etc still be there in 10 years?) ## **Biocompatible and Antimicrobial Effects** - Cements should ideally not interact with bodily tissues, and not cause sensitivity or allergic reactions - Antimicrobial effects to prevent marginal caries. However evidence in inconclusive whether low level fluoride or other antimicrobial agents can provide long term inhibition. (Will the fluoride etc still be there in 10 years?) > [!tip] Fluoride Release in GIC > ==GICs contain fluoride and are theorized to act as a “fluoride bank,” releasing it into the oral environment and “recharging” during brushing. However, it is uncertain if therapeutic levels are maintained over the long term.== **Suitable working and setting time** - Ideally enough time to mix the cement, seat and clean up excess in appropriate time - Benefit of tack cure resin cement. - However if excess resin cement is not fully removed before final cure, will be extremely hard to remove excess ## **Suitable working and setting time** - Ideally enough time to mix the cement, seat and clean up excess in appropriate time - Benefit of tack cure resin cement. > [!note] > ==Resin cements offer the advantage of “command set” or “tack curing,” allowing the clinician to initiate the set when ready.== - However if excess resin cement is not fully removed before final cure, will be extremely hard to remove excess **Microleakage/Solubility** - Solubility of cements in the oral environment (water) can lead to microleakage at the marginal interface and possible loss of retention. - Zinc phosphate and zinc polycarboxylate have high solubility - Resin cements have low solubility ## **Microleakage/Solubility** - Solubility of cements in the oral environment (water) can lead to microleakage at the marginal interface and possible loss of retention. - Zinc phosphate and zinc polycarboxylate have high solubility - Resin cements have low solubility **Microleakage/Solubility** **Fleck = zinc phosphate** **HOWEVER ITS NOT APPROPRIATE TO SAY RESIN CEMENTS ARE PERFECT** <table> <thead> <tr> <th>Cement</th> <th>N</th> <th>Mean ± SD</th> </tr> </thead> <tbody> <tr> <td>Fleck <sup>a,b,e</sup></td> <td>15</td> <td>0.32 ± 0.70</td> </tr> <tr> <td>Fuji Plus <sup>a,d</sup></td> <td>15</td> <td>0.92 ± 0.53</td> </tr> <tr> <td>G-Cem <sup>b,d,e</sup></td> <td>15</td> <td>2.08 ± 1.10</td> </tr> <tr> <td>Panavia F2.0 <sup>c,e</sup></td> <td>15</td> <td>0.64 ± 0.78</td> </tr> <tr> <td>Total</td> <td>60</td> <td>1.74 ± 1.32</td> </tr> </tbody> </table> **Mean and Standard Deviation Values of Microleakage of the Cements in Restorations With Closed Margins (mm)** <table> <thead> <tr> <th>Cement</th> <th>N</th> <th>Mean ± SD</th> </tr> </thead> <tbody> <tr> <td>Fleck <sup>a,b</sup></td> <td>15</td> <td>1.92 ± 1.23</td> </tr> <tr> <td>Fuji Plus <sup>a,c</sup></td> <td>15</td> <td>0.77 ± 0.88</td> </tr> <tr> <td>G-Cem <sup>c,d</sup></td> <td>15</td> <td>1.25 ± 1.07</td> </tr> <tr> <td>Panavia F2.0 <sup>b,d</sup></td> <td>15</td> <td>0.18 ± 0.14</td> </tr> <tr> <td>Total</td> <td>60</td> <td>1.03 ± 1.11</td> </tr> </tbody> </table> Microleakage of Four Dental Cements in Metal Ceramic Restorations With Open Margins Reza Eftekhari Ashtiani, Babak Farzaneh, Mohadese Azarina, Farzad Aghdashi, Nima Dehghani, Alisooda Afshari, and Minu Mahshid **Fleck = zinc phosphate** **HOWEVER ITS NOT APPROPRIATE TO SAY RESIN CEMENTS ARE PERFECT > [!warning] Correlation vs. Causation > ==The link between solubility and microleakage is not definitive in the literature. Some studies find no significant difference in microleakage between high-solubility (e.g., zinc phosphate) and low-solubility (resin) cements, while other studies show a clear correlation.== ** **Microleakage of Four Dental Cements in Metal Ceramic Restorations With Open Margins** *Reza Eftekhari Ashtiani, Babak Farzaneh, Mohadese Azarina, Farzad Aghdashi, Nima Dehghani, Alisooda Afshari, and Minu Mahshid* **Mean and Standard Deviation Values of Microleakage of the Cements in Restorations With Closed Margins (mm)** <table> <thead> <tr> <th>Cement</th> <th>N</th> <th>Mean ± SD</th> </tr> </thead> <tbody> <tr> <td>Fleck <sup>a,b,e</sup></td> <td>15</td> <td>0.32 ± 0.70</td> </tr> <tr> <td>Fuji Plus <sup>a,d</sup></td> <td>15</td> <td>0.92 ± 0.53</td> </tr> <tr> <td>G-Cem <sup>b,d,e</sup></td> <td>15</td> <td>2.08 ± 1.10</td> </tr> <tr> <td>Panavia F2.0 <sup>c,e</sup></td> <td>15</td> <td>0.64 ± 0.78</td> </tr> <tr> <td>Total</td> <td>60</td> <td>1.74 ± 1.32</td> </tr> </tbody> </table> **Mean and Standard Deviation Values of Microleakage of the Cements in Restorations With Open Margins (mm)** <table> <thead> <tr> <th>Cement</th> <th>N</th> <th>Mean ± SD</th> </tr> </thead> <tbody> <tr> <td>Fleck <sup>a,b</sup></td> <td>15</td> <td>1.92 ± 1.23</td> </tr> <tr> <td>Fuji Plus <sup>a,c</sup></td> <td>15</td> <td>0.77 ± 0.88</td> </tr> <tr> <td>G-Cem <sup>c,d</sup></td> <td>15</td> <td>1.25 ± 1.07</td> </tr> <tr> <td>Panavia F2.0 <sup>b,d</sup></td> <td>15</td> <td>0.18 ± 0.14</td> </tr> <tr> <td>Total</td> <td>60</td> <td>1.03 ± 1.11</td> </tr> </tbody> </table> # Film thickness - Low film thickness preferred - ADA states a maximum film thickness of 25um for luting cements - Associated with better seating of crown and possibly lower marginal discrepancies. <table> <thead> <tr> <th colspan="4">Table 4 Correlation coefficients between film thickness and tensile bond strength of dental luting cements</th> </tr> <tr> <th>Alloy</th> <th>DURELON</th> <th>Fuji Ionomer TYPE I</th> <th>PANAVIA EX</th> </tr> </thead> <tbody> <tr> <td>Au-Ag-Cu</td> <td>-0.76</td> <td>-0.87</td> <td>-0.89</td> </tr> <tr> <td>Ag-Pd</td> <td>-0.78</td> <td>-0.83</td> <td>-0.92</td> </tr> <tr> <td>Ag-Pd (hardened)</td> <td>-0.78</td> <td>-0.86</td> <td>-0.86</td> </tr> <tr> <td>Ni-Cr</td> <td>-0.78</td> <td>-0.85</td> <td>-0.90</td> </tr> </tbody> </table> Bar chart showing Effect of film thickness on tensile bond strength of adhesive resin cement to different dental alloys # **Film thickness** - Low film thickness preferred - ADA states a maximum film thickness of 25um for luting cements - Associated with better seating of crown and possibly lower marginal discrepancies. > [!info] Correlation with Bond Strength > ==Some studies show a strong negative correlation between film thickness and microtensile bond strength, suggesting a thinner cement layer leads to a stronger bond.== <table> <thead> <tr> <th colspan="4">Table 4 Correlation coefficients between film thickness and tensile bond strength of dental luting cements</th> </tr> <tr> <th>Alloy</th> <th>DURELON</th> <th>Fuji Ionomer TYPE I</th> <th>PANAVIA EX</th> </tr> </thead> <tbody> <tr> <td>Au-Ag-Cu</td> <td>-0.76</td> <td>-0.87</td> <td>-0.89</td> </tr> <tr> <td>Ag-Pd</td> <td>-0.78</td> <td>-0.83</td> <td>-0.92</td> </tr> <tr> <td>Ag-Pd (hardened)</td> <td>-0.78</td> <td>-0.86</td> <td>-0.86</td> </tr> <tr> <td>Ni-Cr</td> <td>-0.78</td> <td>-0.85</td> <td>-0.90</td> </tr> </tbody> </table> # Elastic modulus and compressive strength - If cement has a similar elastic modulus as dentin, there will be less stress concentration at the interface - Some studies claim that fracture of ceramic restoration begin at the cement layer. - Fracture load of zirconia crowns may not be greatly affected by cement type - However chemical adhesion may be more important for lithium disilicate crowns **Weak adhesion between ceramic and resin cement impairs the load-bearing capacity under fatigue of lithium disilicate glass-ceramic crowns** Lucas Soldanha da Rosa *¹*, Helder Callegaro Velho *¹*, João Paulo Mendes Tribst *¹*, Luiz Felipe Valandro *²*, Cornelis Johannes Kleverlaan *³*, Gabriel Kalil Rocha Pereira *¹,⁴* **Conclusion** The chemical adhesion between cement and ceramic is essential for better fatigue behavior of lithium disilicate crowns with a simplified anatomy, especially in the occlusal portion, but the restoration performance is impaired when such adhesion is compromised. There is an increase in crown and cement stress concentration with the progressive loss of chemical bonding of the crown’s walls. Bar charts comparing fracture load (N) and compressive strength (MPa) for Phosphate cement, RelyX, and Panavia. Annotations indicate statistical significance and trends. # **Elastic modulus and compressive strength** - If cement has a similar elastic modulus as dentin, there will be less stress concentration at the interface - Some studies claim that fracture of ceramic restoration begin at the cement layer. - Fracture load of zirconia crowns may not be greatly affected by cement type > [!example] Zirconia Study > ==One study found that although zinc phosphate had significantly lower compressive strength than two resin cements, there was no significant difference in the final fracture strength of the zirconia crowns cemented with them.== - However chemical adhesion may be more important for lithium disilicate crowns **Weak adhesion between ceramic and resin cement impairs the load-bearing capacity under fatigue of lithium disilicate glass-ceramic crowns** *Lucas Soldanha da Rosa ¹, Helder Callegaro Velho ¹, João Paulo Mendes Tribst ¹, Luiz Felipe Valandro ², Cornelis Johannes Kleverlaan ³, Gabriel Kalil Rocha Pereira ¹,⁴* **Conclusion** The chemical adhesion between cement and ceramic is essential for better fatigue behavior of lithium disilicate crowns with a simplified anatomy, especially in the occlusal portion, but the restoration performance is impaired when such adhesion is compromised. There is an increase in crown and cement stress concentration with the progressive loss of chemical bonding of the crown’s walls. **Compressive Strength** FIGURE 30-4 ■ Compressive strength of luting agents. In the studies cited, higher strength values were reported with the resin cements and glass ionomers than with zinc phosphate or polycarboxylate. Resin-modified glass ionomer exhibited greater variation than did other cements. ANSI/ADA, American Dental Association/American National Standards Institute. (From Rosenstiel SF, et al: Dental luting agents: a review of the current literature. J Prosthet Dent 80:280, 1998.) Bar chart comparing compressive strength (MPa) of various luting agents including Zinc phosphate, Polycarboxylate, Glass ionomer, Resin ionomer, and Adhesive resin, with data from White and Yu, Kerby et al, Cattani-Lorente et al, and Miyamoto et al. ANSI/ADA Specification No. 96 line shown for reference. ## **Compressive Strength** According to Rosenstiel SF, et al. in "Dental luting agents: a review of the current literature," higher strength values were reported with the resin cements and glass ionomers than with zinc phosphate or polycarboxylate. Resin-modified glass ionomer exhibited greater variation than did other cements. > [!abstract] Summary > - ==**Zinc Phosphate** has one of the lowest compressive strengths and is often used as a benchmark for comparison.== > - ==**Resin cements** generally exhibit the highest compressive strengths.== # Retention - Lithium disilicate crowns cemented adhesively with resin cement had a higher failure load compared to GIC. Additionally, fewer cases of debonding. **Effect of Different Luting Agents on the Retention of Lithium Disilicate Ceramic Crowns** Nicola Mobilo ¹,², Alberto Fasiol ¹, Francesco Mollica ² and Santo Catapano ¹ **Table 1. Mean failure loads (standard deviation) in N.** | Groups | Mean (sd) | |----------------|---------------| | Composite group | 306.6 (193.8) | | GIC group | 94.7 (48.2) | Bar chart comparing failure loads and debonding rates between Composite group (90% fractures, 10% debondings) and GIC group (60% fractures, 40% debondings). # **Retention** - Lithium disilicate crowns cemented adhesively with resin cement had a higher failure load compared to GIC. Additionally, fewer cases of debonding. **Effect of Different Luting Agents on the Retention of Lithium Disilicate Ceramic Crowns** *Nicola Mobilo ¹,², Alberto Fasiol ¹, Francesco Mollica ² and Santo Catapano ¹* **Table 1. Mean failure loads (standard deviation) in N.** | Groups | Mean (sd) | | :--- | :--- | | Composite group | 306.6 (193.8) | | GIC group | 94.7 (48.2) | # Retention - Mixed literature regarding zirconia crowns - Some suggest MDP containing cements promoted better bond strength - Some found no differences - We will review zirconia bonding towards the end of this lecture ## Bond strength and stability of 3 luting systems on a zirconia-dentin complex *Sebnem Begum Turker, DDS, PhD • Mutlu Ozcan, PhD • Gamze Mandali, DDS, PhD • Isil Damlı, DDS • Burcu Bugurman, DDS • Luiz Felipe Valandro, PhD* **Table 2.** Median and mean values (±SD) of shear bond strength (MPa) failure before and after aging procedure. Based on the results of Kruskal-Wallis and Mann-Whitney U-tests (α < .05). | | Immediate test | After aging | Mann-Whitney U-tests | |----------|--------------------------|--------------------------|----------------------| | | Median (P = 0.0001; Kruskal-Wallis = 21.3) | Median (P = 0.016; Kruskal-Wallis = 8.27) | | | | Mean (±SD) | Mean (±SD) | P value | | GI | 2.93 | 4.02 | 0.650 | | RMGI | 8.37 | 6.2 (3.7) | 0.049 | | MDP | 17.65 | 11.3 (6.4) | 0.049 | Abbreviations: GI, glass ionomer; RMGI, resin-modified glass ionomer; MDP, resin cement containing 10-methacryloyloxydecyl dihydrogen phosphate. - Mixed literature regarding zirconia crowns - Some suggest MDP containing cements promoted better bond strength - Some found no differences - We will review zirconia bonding towards the end of this lecture > [!note] > ==A textbook table comparing cements to zinc phosphate (as the standard) shows that **adhesive resin cements** generally provide a greater percentage of retention.== ## **Bond strength and stability of 3 luting systems on a zirconia-dentin complex** *Sebnem Begum Turker, DDS, PhD • Mutlu Ozcan, PhD • Gamze Mandali, DDS, PhD • Isil Damlı, DDS • Burcu Bugurman, DDS • Luiz Felipe Valandro, PhD* **Table 2.** Median and mean values (±SD) of shear bond strength (MPa) failure before and after aging procedure. Based on the results of Kruskal-Wallis and Mann-Whitney U-tests (α < .05). | | **Immediate test** | **After aging** | **Mann-Whitney U-tests** | | :--- | :--- | :--- | :--- | | | Median (P = 0.0001; Kruskal-Wallis = 21.3) | Median (P = 0.016; Kruskal-Wallis = 8.27) | | | | **Mean (±SD)** | **Mean (±SD)** | **P value** | | GI | 2.93 | 4.02 | 0.650 | | RMGI | 8.37 | 6.2 (3.7) | 0.049 | | MDP | 17.65 | 11.3 (6.4) | 0.049 | Abbreviations: GI, glass ionomer; RMGI, resin-modified glass ionomer; MDP, resin cement containing 10-methacryloyloxydecyl dihydrogen phosphate. # Retention Bar chart comparing percent retention of zinc phosphate across different luting agents (Glass ionomer, Resin, Adhesive resin, Polycarboxylate) with data from Ayad et al, Gorodovsky and Zidan, Tjan and Li, Mojón et al, Wiskott et al, and Mausner et al. A dashed line indicates the baseline for Zinc phosphate. Figure caption references crown retention studies and cites Rosenstiel SF, et al. **Zinc Oxide Eugenol** - Basic composition: - Zinc oxide + Eugenol + Rosin + Zinc Acetate - Low strength + high solubility in oral environment - A potential “sedative” effect for the pulp and otherwise biocompatible - Issues with eugenol inhibiting resin polymerization - Temporary cement # **Types of Dental Cements** ## **Zinc Oxide Eugenol** - **Basic composition:** - Zinc oxide + Eugenol + Rosin + Zinc Acetate - Low strength + high solubility in oral environment - A potential “sedative” effect for the pulp and otherwise biocompatible - ==Reinforced versions exist but are still mechanically inferior to permanent cements.== - Issues with eugenol inhibiting resin polymerization > [!warning] > ==Eugenol can inhibit the polymerization of resin cements, so eugenol-free alternatives are recommended if a resin cement will be used for the final restoration.== - Temporary cement **Zinc Phosphate** - Basic composition: - Zinc oxide + magnesium oxide + phosphoric acid + water + buffers - Popular cement for use in traditional cast restorations, (has been around since 1800s) - Acceptable film thickness of 25um - Ease of removal of the excess material after setting - Potential issues with biocompatibility due to the inclusion of phosphoric acid (pH 2 at time of cementing). However generally well tolerated if preparation is not too close to the pulp - Acceptable working time of about 5 minutes ## **Zinc Phosphate** - **Basic composition:** - Zinc oxide + magnesium oxide + phosphoric acid + water + buffers - Popular cement for use in traditional cast restorations, (has been around since 1800s) - Acceptable film thickness of 25um - Ease of removal of the excess material after setting - Potential issues with biocompatibility due to the inclusion of phosphoric acid (pH 2 at time of cementing). However generally well tolerated if preparation is not too close to the pulp > [!info] > ==The low initial pH (~2.0) is the primary cause of potential pulpal irritation.== - Acceptable working time of about 5 minutes # Zinc Polycarboxylate - **Basic composition** - Zinc oxide + polyacrylic acid - Attempts to address some biocompatibility issues from zinc phosphate by changing to polyacrylic acid - Also exhibits some adhesion to the tooth surface through chelation of calcium (but not to cast metal surfaces) - Potentially technique sensitive due to mixing of viscous powder and liquid (mitigated via capsules) - Additionally very short working time of under 3 minutes - Indicated for high retention preps, or close to pulp horns # **Zinc Polycarboxylate** - **Basic composition** - Zinc oxide + polyacrylic acid - Attempts to address some biocompatibility issues from zinc phosphate by changing to polyacrylic acid > [!info] Improved Biocompatibility > ==The large polyacrylic acid molecules are less likely to penetrate dentin tubules and irritate the pulp.== - Also exhibits some adhesion to the tooth surface through chelation of calcium (but not to cast metal surfaces) - Potentially technique sensitive due to mixing of viscous powder and liquid (mitigated via capsules) - Additionally very short working time of under 3 minutes - Indicated for high retention preps, or close to pulp horns # Glass ionomer cement (GIC) - **Basic composition** - Polycarboxylate + fluoraluminosilicate glass + water + tartaric acid - **Good biocompatibility + theoretically anticariogenic** - **Aesthetic due to translucency of the cement** - **Potential for water absorption during early setting which would lead to erosion of the weakened material** - **Ionic bonding to tooth structure** - **Concerns regarding possible post-op sensitivity not supported by literature when manufacturer followed** # **Glass ionomer cement (GIC)** - **Basic composition** - Polycarboxylate + fluoraluminosilicate glass + water + tartaric acid - **Good biocompatibility + theoretically anticariogenic** - **Aesthetic due to translucency of the cement** - **Potential for water absorption during early setting which would lead to erosion of the weakened material > [!tip] > ==A protective coating is sometimes advised to protect the cement during the early setting phase.== ** - **Ionic bonding to tooth structure** - **Concerns regarding possible post-op sensitivity not supported by literature when manufacturer followed** # Resin modified glass ionomer - Basic composition - GIC + resin - Due to the inclusion of resin and corresponding photoactivators, some of the issues of GIC cement were improved - Resin matrix improves the mechanical properties such as compressive and fracture strength compared to unmodified GIC - Also suggest improvement in retention and bond strength - Could be harder to remove excess. (Remember to tack cure) - Some studies say it is contraindicated for all ceramic crowns (risk of fracture after water absorption) # **Resin modified glass ionomer** - **Basic composition** - GIC + resin - Due to the inclusion of resin and corresponding photoactivators, some of the issues of GIC cement were improved - Resin matrix improves the mechanical properties such as compressive and fracture strength compared to unmodified GIC - Also suggest improvement in retention and bond strength - Could be harder to remove excess. (Remember to tack cure) - Some studies say it is contraindicated for all ceramic crowns (risk of fracture after water absorption) > [!warning] Contraindication Update > ==While some literature contraindicates its use for all-ceramic crowns due to hygroscopic expansion, modern RMGI materials are often indicated by manufacturers for use with zirconia and lithium disilicate, suggesting this issue may have been addressed.== # Resin based cements - **Basic composition** - Resin + filler (lower filler ratio for lower film thickness) - Similar to restorative composite (exactly the same steps required) - Offers micromechanical retention - Very high compressive strength - Least soluble - Technique sensitive (moisture control) - May be more expensive - Self cure, dual cure or light cure options - Removal of excess may be difficult if not removed at tack cure stage # **Resin based cements** - **Basic composition** - Resin + filler (lower filler ratio for lower film thickness) - Similar to restorative composite (exactly the same steps required) > [!note] > ==The lower filler ratio is similar to that of a flowable composite.== - Offers micromechanical retention - Very high compressive strength - Least soluble - Technique sensitive (moisture control) - May be more expensive - Self cure, dual cure or light cure options > [!info] > ==Dual-cure is common, ensuring a full set even in areas the curing light cannot reach.== - Removal of excess may be difficult if not removed at tack cure stage **Special mention: Panavia** Panavia - Resin cement with bifunctional monomer, 10-methacryloyloxydecylhydrogen-phosphate (MDP) - 10-MDP is able to interact with metal oxides via the hydrophilic phosphoric acid end group - 10-MDP also facilitate a chemical bond with dentin through the formation of MDP-Ca insoluble salts Structure of adhesive monomer MDP showing polymerisable group, hydrophobic group, and hydrophilic group ## **Special mention: Panavia** - Resin cement with bifunctional monomer, 10-methacryloyloxydecylhydrogen-phosphate (MDP) - 10-MDP is able to interact with metal oxides via the hydrophilic phosphoric acid end group - 10-MDP also facilitate a chemical bond with dentin through the formation of MDP-Ca insoluble salts > [!abstract] Mechanism of 10-MDP > ==1. The **hydrophilic phosphoric acid group** chemically bonds to metal oxides (like zirconium oxide in zirconia) and to calcium in the tooth's hydroxyapatite. 2. The **hydrophobic methacrylate group** co-polymerizes with and bonds to the resin matrix of the cement. This creates a durable chemical bridge linking the tooth, the cement, and the restoration.== # Summary <table> <thead> <tr> <th>Restoration</th> <th>Indication</th> <th>Contraindication</th> </tr> </thead> <tbody> <tr> <td>Cast crown, metal-ceramic crown, partial FDP</td> <td>1, 2, 3, 4, 5, 6, 7</td> <td>—</td> </tr> <tr> <td>Crown or partial FDP with poor retention</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Casting on patient with history of post-treatment sensitivity</td> <td>1, 2, 3, 4, 5, 6, 7</td> <td>Consider 4 or 7</td> </tr> <tr> <td>Pressed, high-leucite, ceramic crown</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Slip-cast alumina crown</td> <td>1, 2, 3, 4, 6, 7</td> <td>5</td> </tr> <tr> <td>Ceramic inlay</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Ceramic veneer</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Resin-retained partial FDP</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Cast post-and-core</td> <td>1, 2, 3, 5, 6</td> <td>4, 7</td> </tr> </tbody> </table> **Key** <table> <thead> <tr> <th>LUTING AGENT TYPE</th> <th>CHIEF ADVANTAGES</th> <th>CHIEF CONCERNS</th> <th>PRECAUTIONS</th> </tr> </thead> <tbody> <tr> <td>1. Adhesive resin</td> <td>Adhesive, low solubility</td> <td>Film thickness, history of use</td> <td>Moisture control</td> </tr> <tr> <td>2. Self-etch adhesive resin</td> <td>Low solubility, ease of use, bonding to dentin</td> <td>Film thickness</td> <td>Moisture control</td> </tr> <tr> <td>3. Glass ionomer</td> <td>Translucency</td> <td>Solubility, leakage</td> <td>Avoid early moisture exposure</td> </tr> <tr> <td>4. Reinforced ZOE</td> <td>Biocompatible</td> <td>Low strength</td> <td>Only for very retentive restorations</td> </tr> <tr> <td>5. Resin ionomer</td> <td>Low solubility, low microleakage</td> <td>Water sorption, history of use</td> <td>Avoid with ceramic restorations</td> </tr> <tr> <td>6. Zinc phosphate</td> <td>History of use</td> <td>Solubility, leakage</td> <td>Use for “traditional” cast restorations</td> </tr> <tr> <td>7. Zinc polycarboxylate</td> <td>Biocompatible</td> <td>Low strength, solubility</td> <td>Do not reduce powder-to-liquid ratio</td> </tr> </tbody> </table> FDP, Fixed dental prosthesis; MCC, metal-ceramic crown; ZOE, zinc oxide-eugenol. # **Summary** <table> <thead> <tr> <th>Restoration</th> <th>Indication</th> <th>Contraindication</th> </tr> </thead> <tbody> <tr> <td>Cast crown, metal-ceramic crown, partial FDP</td> <td>1, 2, 3, 4, 5, 6, 7</td> <td>—</td> </tr> <tr> <td>Crown or partial FDP with poor retention</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Casting on patient with history of post-treatment sensitivity</td> <td>1, 2, 3, 4, 5, 6, 7</td> <td>Consider 4 or 7</td> </tr> <tr> <td>Pressed, high-leucite, ceramic crown</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Slip-cast alumina crown</td> <td>1, 2, 3, 4, 6, 7</td> <td>5</td> </tr> <tr> <td>Ceramic inlay</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Ceramic veneer</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Resin-retained partial FDP</td> <td>1, 2</td> <td>3, 4, 5, 6, 7</td> </tr> <tr> <td>Cast post-and-core</td> <td>1, 2, 3, 5, 6</td> <td>4, 7</td> </tr> </tbody> </table> **Key** <table> <thead> <tr> <th>LUTING AGENT TYPE</th> <th>CHIEF ADVANTAGES</th> <th>CHIEF CONCERNS</th> <th>PRECAUTIONS</th> </tr> </thead> <tbody> <tr> <td>1. Adhesive resin</td> <td>Adhesive, low solubility</td> <td>Film thickness, history of use</td> <td>Moisture control</td> </tr> <tr> <td>2. Self-etch adhesive resin</td> <td>Low solubility, ease of use, bonding to dentin</td> <td>Film thickness</td> <td>Moisture control</td> </tr> <tr> <td>3. Glass ionomer</td> <td>Translucency</td> <td>Solubility, leakage</td> <td>Avoid early moisture exposure</td> </tr> <tr> <td>4. Reinforced ZOE</td> <td>Biocompatible</td> <td>Low strength</td> <td>Only for very retentive restorations</td> </tr> <tr> <td>5. Resin ionomer</td> <td>Low solubility, low microleakage</td> <td>Water sorption, history of use</td> <td>Avoid with ceramic restorations</td> </tr> <tr> <td>6. Zinc phosphate</td> <td>History of use</td> <td>Solubility, leakage</td> <td>Use for “traditional” cast restorations</td> </tr> <tr> <td>7. Zinc polycarboxylate</td> <td>Biocompatible</td> <td>Low strength, solubility</td> <td>Do not reduce powder-to-liquid ratio</td> </tr> </tbody> </table> FDP, Fixed dental prosthesis; MCC, metal-ceramic crown; ZOE, zinc oxide-eugenol. - After ensuring permanent crown seats fully (covered in other lecture, and consent from patient to cement. - Zirconia vs Lithium Disilicate crowns # **Clinical Application: Cementing Permanent Crowns** - After ensuring permanent crown seats fully (covered in other lecture, and consent from patient to cement. - Zirconia vs Lithium Disilicate crowns > [!info] > ==The primary decision points for cement selection are whether the crown is **zirconia, lithium disilicate (glassy ceramic), or metal.**== **Glassy ceramic crowns** **Lithium disilicate, etc.** - **Lab steps:** - Prior to returning the crown, the lab may have already etched the internal fitting surface with hydrofluoric acid (eg ceram etch 9% hydrofluoric gel) Microscopic images showing surface etching effects at 1% HF for 20s and 120s **Glassy ceramic crowns** **Lithium disilicate, etc.** - **Lab steps:** - Prior to returning the crown, the lab may have already etched the internal fitting surface with hydrofluoric acid (eg ceram etch 9% hydrofluoric gel) - Silane coupling agent eg 3-methacryloxypropyltri-methoxysilane (MPS) forms bridge between the organic compounds in resin cements and inorganic ceramic molecules, hence improving the bond strength. Also increase surface energy and contact angle decreased for better resin/adhesive contact. **Influence of the Multiple Layers Application and the Heating of Silane on the Bond Strength between Lithium Disilicate Ceramics and Resinous Cement** *Uriel Paulo Coelho Silva¹, Andréa Peixoto Maia², Isaias Donizeti Silva¹, Milton Edson Miranda², William Cunha Brandt¹* Chemical structure diagram showing Silane (MTPS) bonding to Silica surface with covalent bond label **Glassy ceramic crowns** **Lithium disilicate, etc.** - **Lab steps:** - Prior to returning the crown, the lab may have already etched the internal fitting surface with hydrofluoric acid (eg ceram etch 9% hydrofluoric gel) - Silane coupling agent eg 3-methacryloxypropyltri-methoxysilane (MPS) forms bridge between the organic compounds in resin cements and inorganic ceramic molecules, hence improving the bond strength. Also increase surface energy and contact angle decreased for better resin/adhesive contact. Chemical structure diagrams showing Silane (MTPS) bonding to Silica surface, with annotations highlighting covalent bonds and hydrogen bonding interactions. ## **Glassy ceramic crowns (Lithium disilicate, etc.)** - **Lab steps:** - Prior to returning the crown, the lab may have already etched the internal fitting surface with hydrofluoric acid (eg ceram etch 9% hydrofluoric gel) - Silane coupling agent eg 3-methacryloxypropyltri-methoxysilane (MPS) forms bridge between the organic compounds in resin cements and inorganic ceramic molecules, hence improving the bond strength. Also increase surface energy and contact angle decreased for better resin/adhesive contact. > [!abstract] Silane Function and Application > - ==**Function:** Silane acts as a chemical bridge. One end bonds to the inorganic silica on the ceramic surface, while the other (organofunctional) end bonds to the organic resin matrix of the cement.== > - ==**Application:** The silane is applied, agitated for ~20 seconds to allow for chemical reaction, and then thoroughly air-dried to evaporate solvents.== **Influence of the Multiple Layers Application and the Heating of Silane on the Bond Strength between Lithium Disilicate Ceramics and Resinous Cement** *Uriel Paulo Coelho Silva¹, Andréa Peixoto Maia², Isaias Donizeti Silva¹, Milton Edson Miranda², William Cunha Brandt¹* # Zirconia crowns **Zirconia:** - **Lab steps:** - Not able to be etched - Micromechanical surface treatments - Airborne particle abrasion to increase surface roughness (Pressure ~1 bar) - Chemical surface treatments - Hot acid treatment (eg sulfuric acid and hydrogen peroxide) - Silica coating (aluminum oxide particle coated with silica) **Effects of airborne-particle abrasion protocol choice on the surface characteristics of monolithic zirconia materials and the shear bond strength of resin cement** *Ji-Eun Moon*, *Sung-Hun Kim*, *Joi-Bong Lee*, *Jung-Suk Han*, *In-Sung Yeo*, *Seung-Ryong Ha* ## **Zirconia crowns** - **Lab steps:** - Not able to be etched - **Micromechanical surface treatments** - Airborne particle abrasion to increase surface roughness (Pressure ~1 bar) > [!warning] > ==Care must be taken to avoid excessive pressure, which can create microcracks and weaken the zirconia.== - **Chemical surface treatments** - Hot acid treatment (eg sulfuric acid and hydrogen peroxide) - Silica coating (aluminum oxide particle coated with silica) **Effects of airborne-particle abrasion protocol choice on the surface characteristics of monolithic zirconia materials and the shear bond strength of resin cement** *Ji-Eun Moon, Sung-Hun Kim, Joi-Bong Lee, Jung-Suk Han, In-Sung Yeo, Seung-Ryong Ha* **Glassy ceramics** - After try in completed - Fitting surface cleanser: Katana or Ivoclean - Otherwise can use phosphoric acid to remove saliva contaminants ## **Cleaning and Surface Contamination** > [!note] > ==After try-in, the internal surface of the crown is contaminated with saliva, blood, or try-in paste. This contamination lowers the surface energy and prevents the cement from properly wetting and bonding to the surface.== ### **Glassy ceramics** - After try in completed - Fitting surface cleanser: Katana or Ivoclean - Otherwise can use phosphoric acid to remove saliva contaminants > [!warning] Phosphoric Acid Use > ==While phosphoric acid can clean the surface, the literature is mixed. Some studies suggest it can weaken the final bond strength, possibly by over-etching the delicate surface. Universal cleaners (e.g., Ivoclean) are generally the more predictable option.== # Glassy ceramics **Protocol for Removal of Clinically Relevant Contaminants from Glass Ceramic-based Restorations** Thorsten Bock<sup>a</sup> / Mutlu Özcan<sup>b</sup> --- ## IAAD WORKING INSTRUCTIONS **Question:** What is the best cleaning method to remove saliva, blood, and silicone disclosing medium contaminants from etched and silanized bonding surfaces of glass ceramic restorations? **Answer:** During intraoral try-in of ceramic restorations, the bonding surfaces may come in contact with saliva or occasionally blood.<sup>1,5</sup> The resulting persistent protein contamination from saliva in particular was shown to hinder adhesion of resin cements to glass ceramics.<sup>1,5–7,9</sup> Similarly, the use of silicone-based materials during checking the fit of indirect glass ceramic restorations contaminates the bonding surfaces with silicone residues, also impeding adhesion of resin cements.<sup>5,10,11</sup> Water spray, alcohol, and acetone do not seem effective in removing saliva residues from glass ceramics,<sup>1,5,7</sup> but 35% to 37% phosphoric acid gel application presented effective cleaning.<sup>1,3–5</sup> Several studies also demonstrated that cleaning pastes with particles (eg, Ivoclean) could also remove saliva contaminants from both glass and oxide-based ceramic surfaces.<sup>2–4</sup> Since durable adhesion of glass-ceramic restorations is crucial, especially in minimally invasive restorations, the following surface cleaning sequence can be recommended to eliminate contaminants from ceramic surfaces, based on the available scientific reports. Figure with copyright seal and university logo **Protocol for Removal of Clinically Relevant Contaminants from Glass Ceramic-based Restorations** *Thorsten Bockª / Mutlu Özcanᵇ* --- #### **IAAD WORKING INSTRUCTIONS** **Question:** What is the best cleaning method to remove saliva, blood, and silicone disclosing medium contaminants from etched and silanized bonding surfaces of glass ceramic restorations? **Answer:** During intraoral try-in of ceramic restorations, the bonding surfaces may come in contact with saliva or occasionally blood.¹,⁵ The resulting persistent protein contamination from saliva in particular was shown to hinder adhesion of resin cements to glass ceramics.¹,⁵⁻⁷,⁹ Similarly, the use of silicone-based materials during checking the fit of indirect glass ceramic restorations contaminates the bonding surfaces with silicone residues, also impeding adhesion of resin cements.⁵,¹⁰,¹¹ Water spray, alcohol, and acetone do not seem effective in removing saliva residues from glass ceramics,¹,⁵,⁷ but 35% to 37% phosphoric acid gel application presented effective cleaning.¹,³⁻⁵ Several studies also demonstrated that cleaning pastes with particles (eg, Ivoclean) could also remove saliva contaminants from both glass and oxide-based ceramic surfaces.²⁻⁴ Since durable adhesion of glass-ceramic restorations is crucial, especially in minimally invasive restorations, the following surface cleaning sequence can be recommended to eliminate contaminants from ceramic surfaces, based on the available scientific reports. # What about zirconia? **Cleaning Zirconia Surface Prior To Bonding: A Comparative Study of Different Methods and Solutions** *Taiseer A. Sulaiman, DDS, PhD¹; Ali Altak, DDS,¹ Awab Abdulmajeed, DDS, MS²; Brandon Rodgers, BS,¹ & Nathaniel Lawson, DMD, PhD³* ¹Division of Comprehensive Oral Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, North Carolina ²Department of General Practice, School of Dentistry, Virginia Commonwealth University, Richmond, Virginia ³Division of Biomaterials, University of Alabama School of Dentistry, Birmingham, Alabama **Conclusion:** Air-borne particle abrasion: best outcome to restore previous uncontaminated surface bond strengths. Followed by HF acid or intaglio cleaners ### **What about zirconia?** **Cleaning Zirconia Surface Prior To Bonding: A Comparative Study of Different Methods and Solutions** *Taiseer A. Sulaiman, DDS, PhD¹; Ali Altak, DDS,¹ Awab Abdulmajeed, DDS, MS²; Brandon Rodgers, BS,¹ & Nathaniel Lawson, DMD, PhD³* **Conclusion:** Air-borne particle abrasion: best outcome to restore previous uncontaminated surface bond strengths. Followed by HF acid or intaglio cleaners. > [!tip] Clinical Recommendation > ==Using a universal cleaning paste like **Ivoclean** or **Katana Cleaner** is a practical and effective method for chairside decontamination of zirconia.== # Glassy ceramics ## Variolink® Esthetic LC Eingliederung von Inlays (Stärke < 2 mm) (Glaskeramik, z.B. IPS e.max®) ### Einprobe - Variolink Esthetic Try-in ### Restauration - Monobond Etch & Prime - Adhese Universal - Bluephase Style ### Präparation - Metal Etch (optional) ### Befestigung - Variolink Esthetic LC - Bluephase Style - Liquid Strip - Fluor Protector Diagram showing steps for the application of Variolink® Esthetic LC for inlay cementation, including trial fitting, preparation, restoration, and fixation procedures. # **Clinical Protocols for Specific Cement Systems** ## **Variolink® Esthetic LC** *Eingliederung von Inlays (Stärke < 2 mm) (Glaskeramik, z.B. IPS e.max®)* > [!tip] Recommended Workflow > ==Prepare the restoration first, then the tooth, to prevent contamination of the prepared tooth surface.== ### **Einprobe (Try-in)** - ==Use the corresponding try-in gel to check fit, margins, and shade.== ### **Restauration (Restoration Preparation)** 1. ==Rinse off try-in gel.== 2. ==Apply a universal cleaner **(Ivoclean)** to the intaglio surface, rub, rinse thoroughly, and dry.== 3. ==Apply a silane coupling agent **(e.g., Monobond Plus)**. Agitate for the recommended time (e.g., 20 seconds).== 4. ==Thoroughly air-dry the surface to evaporate the solvent. **Do not rinse.**== ### **Präparation (Tooth Preparation)** 1. ==Isolate the tooth, preferably with a **rubber dam**.== 2. ==**Etch** the tooth (total-etch or selective-enamel etch protocol).== 3. ==Rinse thoroughly and gently air-dry.== 4. ==Apply a universal adhesive **(e.g., Adhese Universal)** to the entire bonded surface.== 5. ==Air-thin the adhesive to evaporate the solvent and create an even layer.== 6. ==**Light cure** the adhesive.== ### **Befestigung (Cementation)** 1. ==Apply **Variolink Esthetic** cement to the intaglio surface of the crown.== 2. ==Seat the crown firmly. Have the patient bite on a cotton roll to ensure full seating.== 3. ==**Tack cure** for **1-2 seconds** on each surface (buccal, lingual, interproximal).== 4. ==Remove all excess cement with a scaler. Floss through the contacts, pulling the floss out to the side (not occlusally) to avoid dislodging the crown.== 5. ==Apply an oxygen-inhibition layer blocker **(e.g., Liquid Strip/glycerin gel)** around all margins.== 6. ==**Final cure** all margins through the gel for the recommended time (e.g., 10-20 seconds per surface).== 7. ==Rinse, check occlusion, and polish. A final bitewing radiograph is recommended to confirm complete removal of excess cement.== *Eingliederung von Inlays (Stärke < 2 mm) (Glaskeramik, z.B. IPS e.max®)* ### **Einprobe (Try-in)** - Variolink Esthetic Try-in ### **Restauration** - Monobond Etch & Prime - Adhese Universal - Bluephase Style ### **Präparation (Preparation)** - Metal Etch (optional) ### **Befestigung (Cementation)** - Variolink Esthetic LC - Bluephase Style - Liquid Strip - Fluor Protector Step-by-step illustrated procedure for using Variolink Esthetic LC with glassy ceramics (e.g., IPS e.max), including try-in, restoration preparation, tooth preparation, adhesive application, light curing, and sealing steps. # Zirconia **Cementation of ceramic oxide restorations: PROCERA™, IN-CERAM™, CERCON™ and other zirconia prostheses.** 1. Mix equal amounts of ED PRIMER II A&B and apply to the tooth. Then, wait 30 sec. *ED PRIMER II initiates set of cement.* 2. Gently air dry. 3. Dispense equal amounts of paste A&B. 4. Mix paste A&B for 20 sec. 5. Apply the mixture of the paste to the sandblasted crown. Figure showing steps for cementation of zirconia restorations with labeled diagrams and instructions. # Zirconia **PANAVIA™ F 2.0** Cementation of ceramic oxide restorations: PROCERA™, IN-CERAM™, CERCON™ and other zirconia prostheses. --- **6** Remove excess cement. (For easy clean up, partially light-cure the excess cement for 2-3 sec. with conventional halogen or LED light, then remove the excess.) --- **7-a** Light cure the margins. 20 sec. per surface (Conventional halogen or LED light) 5 sec. per surface (Plasma arc or fast halogen light) **OR** **7-b** Self cure material by applying OXYGUARD II to the margins. Then, wait 3 min. --- Diagram showing steps for cementing zirconia restorations with Panavia F 2.0, including light curing and self-curing options. ## **PANAVIA™ F 2.0 for Zirconia** *Cementation of ceramic oxide restorations: PROCERA™, IN-CERAM™, CERCON™ and other zirconia prostheses.* 1. Mix equal amounts of ED PRIMER II A&B and apply to the tooth. Then, wait 30 sec. *ED PRIMER II initiates set of cement.* 2. Gently air dry. 3. Dispense equal amounts of paste A&B. 4. Mix paste A&B for 20 sec. 5. Apply the mixture of the paste to the sandblasted crown. > [!tip] > ==Apply the mixed cement **inside the crown**, not on the tooth.== 6. Remove excess cement. (For easy clean up, partially light-cure the excess cement for 2-3 sec. with conventional halogen or LED light, then remove the excess.) 7. **Cure the margins:** - **Light cure:** 20 sec. per surface (Conventional halogen or LED light) OR 5 sec. per surface (Plasma arc or fast halogen light) - **OR** - **Self cure:** Apply OXYGUARD II to the margins. Then, wait 3 min. **Metal crowns/PFM crowns** **PANAVIA™ F 20** *Cementation of precious & semi-precious metal crowns, PFM crowns, bridges, inlays and onlays.* 1. Sandblast, wash & dry. 2. Apply ALLOY PRIMER to internal surface of precious metal restoration. 3. Mix equal amounts of ED PRIMER II A&B. Apply to the tooth. Then, wait 30 sec. *ED PRIMER II initiates set of cement.* 4. Gently air dry. 5. Dispense equal amounts of paste A&B. 6. Mix paste A&B for 20 sec. Figure showing step-by-step cementation procedure for metal crowns/PFM crowns with labeled illustrations. **Metal crowns/PFM crowns** **1** Cementation of precious & semi-precious metal crowns, PFM crowns, bridges, inlays and onlays. **PANAVIA™ F 2.0** Total cure dental adhesive system --- **7** Apply mixture of the paste. **8** Remove excess cement. (For easy clean up, partially light-cure the excess cement for 2-3 sec. with conventional halogen or LED light, then remove the excess.) --- **OR** **9-a** Light cure the margins. 20sec. per surface (Conventional halogen or LED light) 5sec. per surface (Plasma arc or fast halogen light) **9-b** Self cure material by applying OXYGUARD II to the margins. Then, wait 3 min. ## **PANAVIA™ F 2.0 for Metal crowns/PFM crowns** *Cementation of precious & semi-precious metal crowns, PFM crowns, bridges, inlays and onlays.* > [!info] Protocol Summary > ==The protocol is identical to the zirconia protocol, with one key difference in restoration preparation: - **Restoration Preparation:** After the lab has sandblasted the metal surface, apply **Alloy Primer** to the intaglio surface of the crown instead of a zirconia-specific primer. The tooth preparation and cementation steps remain the same.== *Cementation of precious & semi-precious metal crowns, PFM crowns, bridges, inlays and onlays.* 1. Sandblast, wash & dry. 2. Apply ALLOY PRIMER to internal surface of precious metal restoration. 3. Mix equal amounts of ED PRIMER II A&B. Apply to the tooth. Then, wait 30 sec. *ED PRIMER II initiates set of cement.* 4. Gently air dry. 5. Dispense equal amounts of paste A&B. 6. Mix paste A&B for 20 sec. 7. Apply mixture of the paste. 8. Remove excess cement. (For easy clean up, partially light-cure the excess cement for 2-3 sec. with conventional halogen or LED light, then remove the excess.) 9. **Cure the margins:** - **Light cure:** 20sec. per surface (Conventional halogen or LED light) OR 5sec. per surface (Plasma arc or fast halogen light) - **OR** - **Self cure:** Apply OXYGUARD II to the margins. Then, wait 3 min. # Guidelines ## Production - **Lithium disilicate (LS₂)** - Zirconium oxide (ZrO₂) ## Cementation - Etching - Cleaning with Al₂O₃ at a maximum pressure of 1 bar (15 psi). - Try-in - Cleaning after try-in - Conditioning - Cementation adhesive - Cementation self-adhesive / conventional --- **IPS e.max® CAD** **IPS e.max® Press** **IPS e.max® ZirCAD** **Monobond Etch & Prime®** **IPS® Ceramic Etching Gel** **Variolink® Esthetic or Multilink® Automix Try-In Liquid Strip** **Ivoclean®** **Monobond® Plus** **Variolink® Esthetic** **Multilink® Automix** **Speedcem® Plus** **Vivaglass® CEM** Flowchart illustrating dental material production and cementation steps with associated products. # **Guidelines** > [!abstract] Manufacturer Recommendations (Ivoclar Example) > - ==**Lithium Disilicate (e.max):** Clean with **Ivoclean**, apply **Monobond Plus** (silane), and cement with **Variolink Esthetic**.== > - ==**Zirconia:** Clean with **Ivoclean**, (no silane needed), and cement with a self-adhesive or MDP-containing cement (e.g., Panavia, SpeedCEM).== | | **Production** | **Cementation** | | :--- | :--- | :--- | | **Material** | - Lithium disilicate (LS₂) <br> - Zirconium oxide (ZrO₂) | | | **Product** | **IPS e.max® CAD** <br> **IPS e.max® Press** <br> **IPS e.max® ZirCAD** | | | **Process** | | **Etching** <br> - Monobond Etch & Prime® <br> - IPS® Ceramic Etching Gel | | | | **Cleaning with Al₂O₃** at a maximum pressure of 1 bar (15 psi). | | | | **Try-in** <br> - Variolink® Esthetic or Multilink® Automix Try-In Liquid Strip | | | | **Cleaning after try-in** <br> - Ivoclean® | | | | **Conditioning** <br> - Monobond® Plus | | | | **Cementation adhesive** <br> - Variolink® Esthetic <br> - Multilink® Automix | | | | **Cementation self-adhesive / conventional** <br> - Speedcem® Plus <br> - Vivaglass® CEM | **Rely X Unicem 2 Automix** - Another cement available in clinic Two types of tips Image showing a 3M ESPE RelyX Unicem 2 Automix syringe with two types of application tips highlighted. # **Rely X Unicem 2 Automix** - Another cement available in clinic - Two types of tips **Rely X Unicem 2 Automix** - Marketed as a “dual curing, self-adhesive resin cement for indirect restorations” - Resin cement (like Variolink aesthetic), but it is self adhesive and does not require etching and bonding. - Think of it like “self-etch adhesives” vs “two step etch and rinse adhesives” - Achieves demineralization via acidic monomers (carboxylic acid or phosphoric acid functional groups). - Methacrylated phosphoric esters - However due to limited demineralization and infiltration, may not have good bond strength to enamel. - Dual cure with a setting time of about 6 minutes - Marketed as a “dual curing, self-adhesive resin cement for indirect restorations” - Resin cement (like Variolink aesthetic), but it is self adhesive and does not require etching and bonding. - Think of it like “self-etch adhesives” vs “two step etch and rinse adhesives” - Achieves demineralization via acidic monomers (carboxylic acid or phosphoric acid functional groups). - Methacrylated phosphoric esters - However due to limited demineralization and infiltration, may not have good bond strength to enamel. > [!warning] > ==The demineralization is less aggressive than with phosphoric acid. The bond to enamel may be less effective than with etch-and-rinse systems. A selective enamel etch may be beneficial to improve bond strength.== - Dual cure with a setting time of about 6 minutes **Rely X Unicem 2 Automix** - **Instructions for use:** - Clean tooth, rinse and slightly dry with 2-3 bursts of air, but **DO NOT OVERDRY**. - After appropriate cleaning and pretreatment of the fitting surface, dispense into the crown with the “standard tip”. - Continue with steps for clean up as per regular resin cements ## **Instructions for use:** - Clean tooth, rinse and slightly dry with 2-3 bursts of air, but **DO NOT OVERDRY**. - After appropriate cleaning and pretreatment of the fitting surface, dispense into the crown with the “standard tip”. - Continue with steps for clean up as per regular resin cements > [!note] > ==Seat the crown, tack cure, remove all excess cement, and perform the final cure. The cleanup process is the same as for other resin cements.== # Self adhesives cements - **Benefits:** - Simplified clinical procedure - Cementation of root canal glass fibre posts (due to shape of root canal and C factor, lower polymerization shrinkage may be beneficial) - **Disadvantages** - Long term bond strength may be lower than that of conventional resin cements (Mixed results) Skupien JA, Sarkis-Onofre R, Cenci MS, MORAES RR, Pereira-Cenci T. A systematic review of factors associated with the retention of glass fiber posts. Brazilian oral research. 2015 Jun 16;29:1-8. Sarkis-Onofre R, Skupien JA, Cenci MS, Moraes RR, Pereira-Cenci T. The role of resin cement on bond strength of glass-fiber posts luted into root canals: a systematic review and meta-analysis of in vitro studies. Operative dentistry. 2014 Jan 1;39(1):E31-44. # **Self adhesives cements** - **Benefits:** - Simplified clinical procedure - Cementation of root canal glass fibre posts (due to shape of root canal and C factor, lower polymerization shrinkage may be beneficial) - **Disadvantages** - Long term bond strength may be lower than that of conventional resin cements (Mixed results) **References:** - Skupien JA, Sarkis-Onofre R, Cenci MS, MORAES RR, Pereira-Cenci T. A systematic review of factors associated with the retention of glass fiber posts. Brazilian oral research. 2015 Jun 16;29:1-8. - Sarkis-Onofre R, Skupien JA, Cenci MS, Moraes RR, Pereira-Cenci T. The role of resin cement on bond strength of glass-fiber posts luted into root canals: a systematic review and meta-analysis of in vitro studies. Operative dentistry. 2014 Jan 1;39(1):E31-44. **Thanks for listening** Anything you want to recap? **Thanks for listening** Anything you want to recap? 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