See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/325662739

Recommended cementation for monolithic zirconia crowns

Article in Drug Invention Today · April 2018

CITATIONS READS

8 17,553

3 authors, including:

Padma Ariga Ashish R Jain

Saveetha Institute of Medical and Technical Sciences Tamil Nadu Dr. M.G.R. Medical University
55 PUBLICATIONS 1,017 CITATIONS 211 PUBLICATIONS 1,377 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Ashish R Jain on 20 June 2018.

The user has requested enhancement of the downloaded file.

 Research Article

Recommended cementation for monolithic zirconia crowns

Saloni Kachhara1, Padma Ariga2, Ashish R. Jain1*

ABSTRACT

Currently, there is not any best adhesion protocol for zirconia in the field of dentistry, especially in the restorations, where
there is a reduced mechanical retention. There is less literature available on which cement is the recommended cement for
the cementation of monolithic zirconia crowns. Zirconia-based ceramics show excellent mechanical strength and superior
fracture resistance due to an inherent transformation toughening mechanism. Various cement have been used to lute the
monolithic zirconia crowns, namely, the zinc phosphate cement, resin cement, glass ionomer cement, and the polycarboxylate
cement. Every cement has its own pros and cons. The purpose of this study was to perform a review of the literature about the
cementation of monolithic zirconia crowns, evaluating the properties of the luting cement most commonly used. The review
was performed through PubMed, and a bibliographic search on the international literature of the past 10 years was made.

KEY WORDS: All ceramic restoration, Dental cement, Luting, Monolithic zirconia, Resin cement

INTRODUCTION Monolithic zirconia is one of the newly developed

materials recently. It is basically core zirconia
All-ceramic restorations have been widely promoted without the veneering porcelain. Computer-aided
in the present times for their esthetic outcomes and design (CAD)/computer-aided manufacturing (CAM)
biocompatibility.[1-3] However, they too had their technique can be used to develop such crowns. These
weaknesses such as the inherent brittleness, low improve the quality with a high degree of homogeneity
flexural strength, and fracture toughness which and might also decrease the cost. Monolithic zirconia
limited their extensive use.[2] Zirconia-based crowns possess sufficient fracture resistance because
ceramics exhibited excellent mechanical strength and of their high strength. It is attributed to the phenomenon
superior fracture resistance as a result of an inherent of stress-induced transformation toughening present
transformation toughening mechanism which led to in them.[7]
its better use in the field of dentistry.[3] Translucent
veneering porcelains are generally added to the The transformation toughening phenomenon is
zirconia core materials for better esthetics. However, explained as below. Zirconia is available in three
layered zirconia restorations show great values for different crystal phases at three different temperatures,
failure. However, layered zirconia restorations show namely, monoclinic, tetragonal, and cubic. It is in the
great values for failure like fractures originating from monoclinic phase at room temperature which changes
the weak points, the veneer or the core/veneer interface into the tetragonal phase at higher temperatures from
which finally resulted in chipping or delamination of above 1070°C. At temperatures between 1170°C and
the veneer and also cracks extending through the core 2370°C, zirconia becomes stable in the tetragonal
materials.[4,5] One of the understood reasons for this phase. At even higher temperatures above 2370°C, it
fracture is the presence of complex intraoral tensile exists in the cubic phase. On addition of stabilizers
stress distributions in addition to inherent structural such as ceria, magnesia, or yttria, zirconia can
flaws of the material.[6] maintain the tetragonal phase at room temperature.
The transformation of martensitic tetragonal to
Access this article online monoclinic phase may be initiated by stress, like
Website: jprsolutions.info ISSN: 0975-7619
machining, wear, or water which causes a volume
expansion by 3–4%. This leads to stoppage of crack

1
Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 2Department of
Prosthodontics and Implant Dentistry, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital,
Saveetha University, Ponamalle High Road, Chennai - 600 127, Tamil Nadu, India. Phone: +91-9884233423.
E-mail: dr. ashishjain_r@yahoo.com

Received on: 22-02-2017; Revised on: 25-03-2018; Accepted on: 30-04-2018

566 Drug Invention Today | Vol 10 • Issue 4 • 2018

 Saloni Kachhara, et al.

propagation. Zirconia has a flexural strength ranging GIC

between 800 and 1200 MPa and a fracture toughness This cement is widely used for luting of prosthetic
ranging between 6 and 8 MPa.[8-11] crowns. It has several clinical advantages, including
physicochemical bonding to tooth structures, low
MATERIALS AND coefficients of thermal expansion, and long-term
METHODOLOGY release of fluoride. However, it has low mechanical
strength. This compromises its use in the high strength
A thorough search was performed through PubMed, region prosthesis. Hence, GIC would not be a preferred
a bibliographic search on the international literature. cement for ceramic restorations which require support
Studies from the past 10 years from January 2017 to from the cement.
January 2007 were searched. The following words were
searched: Cementation of dental zirconia, studies in Resin Cement
English language, in vitro studies, randomized clinical Resin cement are composed of bisphenol-A-glycidyl
trials, review, meta-analysis, monolithic zirconia, and methacrylate and other methacrylates. It has properties
crack propagation. Following words were excluded: such as high bonding strength, high compressive
Cementation of endodontic post, descriptive studies, strength, and low solubility. It is widely used as the
case reports, discussion articles, and opinion letter. choice of cement for ceramic restorations due to
Medical subject heading terms used were bonding, the disadvantages of other cement such as lack of
luting, zirconia ceramic, zirconium oxide ceramic, solubility, support, and adhesion. It plays a significant
bond strength, and surface treatments. Finally, using role in the final clinical success of the treatment.[16-19]
all this, a review was formulated.
From a study of Luthy et al.,[20] it was contemplated
DISCUSSION that bond strength of glass-ionomer cement and
conventional Bis-GMA-based composites was much
Monolithic zirconia crowns are gaining a lot of lower, especially after aging by thermocycling. The
popularity in the field of restorative dentistry. While combination of sandblasting and phosphate monomer
there are a variety of dental cement presently available 10 methacryloyloxydecyl dihydrogen phosphate
in the market including zinc phosphate cement (ZPC), (MDP) used for the cementation of crown is the best
polycarboxylate cement (PC), glass inomer cement for resin cement according to few recent studies.[21]
(GIC), and resin cement, for luting of crowns, there MDP monomer can make a chemical bond with metal
are no well-established guidelines for the selection of oxides, such as zirconium oxide.[20,22] The mean bond
cement for the monolithic zirconia restorations.[12] strength using macroshear test was higher in MDP-
Dental cement provide stability and retention to the based cement after physiochemical conditioning.
restorations in the complex oral environment. Retention They are also known as self-adhesive cement.
mechanisms may be further divided into chemical,
mechanical, and micromechanical elements. In general, Several authors have studied different cement and
2 or 3 mechanisms work together in combination, their role in adhesion. Various cement can be used
depending on the nature of the cement and material.[13] for different materials. Proos et al.[23] worked on the
Following are various kinds of cement used: influence of adhesive resin and ZPC on in-ceram
coping and gold coping, and their results suggested
ZPC
that the type of dental cement has a minor effect on
It has been initially counted as one of the most useful the resultant stress distribution. Kamposiora et al.[24]
cement for luting of crowns in spite of its various studied the stress level and distribution of the cement
drawbacks such as lack of adhesion, solubility, and low layer with four types of cement and found that zinc
hardness properties. Even now this cement is used for phosphate cement shows a greater stress value than
some all-ceramic systems, but its long-term effect is other cement materials. According to a study by
not yet established. Although CAD/CAM has greatly Abdelaziz et al.,[25] cement substrate bonding quality is
improved the final marginal accuracy of crowns, not affected by the size of sandblasting particles. Resin
there is the presence of large internal gaps which may cement bond better to different coping substrates.
require thicker cement layers for the abutments.[14,15] Self-adhesive resin cement is the best choice to bond
zirconia-based substrates.
PC
Polycarboxylate was the first cement discovered to A study by Nakamura et al.[26] on the effect of cement
exhibit adhesive properties to the tooth. However, it on fracture resistance of monolithic zirconia crowns
has low compressive strength and tensile strength. exhibited that crowns with a minimum thickness of
It may also undergo significant plastic deformation 0.5 mm may have a good resistance against fracture in
under functional force after set.[11] spite of any cement used.

Drug Invention Today | Vol 10 • Issue 4 • 2018 567

 Saloni Kachhara, et al.

May et al.,[27] who studied the influence of the cement surface manipulations. Acta Biomater 2011;7:2994‑3002.
thickness and bonding condition on the feldspathic 6. Mosharraf R, Rismanchian M, Savabi O, Ashtiani AH.
Influence of surface modification techniques on shear bond
porcelain crown, found that the well-fitted, bonded strength between different zirconia cores and veneering
feldspathic crown can withstand a greater load than the ceramics. J Adv Prosthodont 2011;3:221-8.
non-bonded crown, but the bonding effect disappears 7. Denry I, Kelly JR. State of the art of zirconia for dental
under a large cement layer. applications. Dent Mater 2008;24:299-307.
8. Shimizu K, Oka M, Kumar P, Kotoura Y, Yamamuro T,
Makinouchi K, et al. Time-dependent changes in the
Not only the properties of cement but also the surface mechanical properties of zirconia ceramic. J Biomed Mater Res
of zirconia play an important role in adhesion. The 1993;27:729-34.
primary prerequisite for an effective adhesion of 9. Luthardt RG, Holzhüter M, Sandkuhl O, Herold V, Schnapp JD,
polymeric compounds is to have a clean surface Kuhlisch E, et al. Reliability and properties of ground Y-TZP-
zirconia ceramics. J Dent Res 2002;81:487-91.
free of contaminants which can be gained by surface 10. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of
conditioning. This can be achieved by various shear bond strengths of resin to densely-sintered high-purity
methods such as grinding zirconia specimen with zirconium-oxide ceramic after long-term storage and thermal
silicon carbide paper, use of various solvents, use of cycling. J Prosthet Dent 2004;91:356-62.
11. Ha SR. Biomechanical three-dimensional finite element
abrasives such as aluminum oxide (Al2O3) and silica, analysis of monolithic zirconia crown with different cement
air abrasion, cleaning agents, or primers. type. J Adv Prosthod 2015;7:475-83.
12. Kern M, Wegner SM. Bonding to zirconia ceramic: Adhesion
Although a lot of articles have been compared and methods and their durability. Dent Mater 1998;14:64-71.
analyzed in this review, more research needs to be 13. Manso AP, Silva NR, Bonfante EA, Pegoraro TA, Dias RA,
Carvalho RM. Cements and adhesives for all-ceramic
done. There is not a perfect cement for any material. All restorations. Dent Clin North Am 2011;55:311-32.
the cement have some advantages and disadvantages. 14. Pilo R, Cardash HS. In vivo retrospective study of cement
Depending on the material of the crown and various thickness under crowns. J Prosthet Dent 1998;79:621-5.
other factors, one should choose the cement which 15. Reich S, Wichmann M, Nkenke E, Proeschel P. Clinical fit of all-
ceramic three-unit fixed partial dentures, generated with three
best suites that particular case. different CAD/CAM systems. Eur J Oral Sci 2005;113:174-9.
16. Palacios RP, Johnson GH, Phillips KM, Raigrodski AJ.
CONCLUSION Retention of zirconium oxide ceramic crowns with three types
of cement. J Prosthet Dent 2006;96:104-14.
Basing on this literature review, we derive the 17. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: A review
of the literature. J Prosthet Dent 2003;89:268-74.
following conclusions: 18. Ernst CP, Cohnen U, Stender E, Willershausen B. In vitro
retentive strength of zirconium oxide ceramic crowns using
Sandblasting with Al2O3 is the best surface treatment different luting agents. J Prosthet Dent 2005;93:551-8.
for improving adhesion between resin cement and 19. Pospiech P. All-ceramic crowns: Bonding or cementing? Clin
zirconia. Although some studies have indicated Oral Investig 2002;6:189-97.
20. Matinlinna JP, Heikkinen T, Ozcan M, Lassila LV, Vallittu PK.
sandblasting with Al2O3 as potentially damaging for Evaluation of resin adhesion to zirconia ceramic using some
mechanical properties of the material, it is the best organosilanes. Dent Mater 2006;22:824831.
surface treatment for improving adhesion between 21. Wolfart M, Lehmann F, Wolfart S, Kern M. Durability of the
resin cement and zirconia. Silanization and acid resin bond strength to zirconia ceramic after using different
surface conditioning methods. Dent Mater 2007;23:45-50.
etching are not effective on zirconia because it is inert 22. Luthy H, Loeffel O, Hammerle C. Effect of thermocycling
and without glassy matrix on which those substances on bond strength of luting cements to zirconia ceramic. Dent
act. Resin cement with MDP monomer is the Mater 2006;22:195-200.
recommended cement for monolithic zirconia crowns. 23. Proos KA, Swain MV, Ironside J, Steven GP. Influence of
cement on a restored crown of a first premolar using finite
element analysis. Int J Prosthodont 2003;16:82-90.
REFERENCES 24. Kamposiora P, Papavasilious G, Bayne SC, Felton DA. Finite
element analysis estimates of cement microfracture under
1. Bachhav VC, Aras MA. Zirconia-based fixed partial dentures: complete veneer crowns. J Prosthet Dent 1994;71:435-41.
A clinical review. Quintessence Int 2011;42:173-82. 25. Abdelaziz KM, Al-Qahtani NM, Al-Shehri AS,
2. Raigrodski AJ, Chiche GJ, Potiket N, Hochstedler JL, Abdelmoneam AM. Bonding quality of contemporary dental
Mohamed SE, Billiot S, et al. The efficacy of posterior three- cements to sandblasted esthetic crown copings. J Investig Clin
unit zirconium-oxide-based ceramic fixed partial dental Dent 2012;3:142-7.
prostheses: A prospective clinical pilot study. J Prosthet Dent 26. Nakamura K, Mouhat M, Nergård JM, Lægreid SJ, Kanno T,
2006;96:237-44. Milleding P, et al. Effect of cements on fracture resistance of
3. Sailer I, Gottnerb J, Kanelb S, Hammerle CH. Randomized monolithic zirconia crowns. Acta Biomater Odontol Scand
controlled clinical trial of zirconia-ceramic and metal-ceramic 2016;2:12-9.
posterior fixed dental prostheses: A 3-year follow-up. Int J 27. May LG, Kelly JR, Bottino MA, Hill T. Effects of cement
Prosthodont 2009;22:553-60. thickness and bonding on the failure loads of CAD/CAM
4. Rekow ED, Silva NR, Coelho PG, Zhang Y, Guess P, ceramic crowns: Multi-physics FEA modeling and monotonic
Thompson VP. Performance of dental ceramics: Challenges for testing. Dent Mater 2012;28:e99-109.
improvements. J Dent Res 2011;90:937-52.
5. Mochales C, Maerten A, Rack A, Cloetens P, Mueller WD,
Zaslansky P, et al. Monoclinic phase transformations of
Source of support: Nil; Conflict of interest: None Declared
zirconia-based dental prostheses, induced by clinically practised

568 Drug Invention Today | Vol 10 • Issue 4 • 2018

View publication stats