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The ofcial journal of the Australian Dental Association

Australian Dental Journal


Australian Dental Journal 2011; 56:(1 Suppl): 6776 doi: 10.1111/j.1834-7819.2010.01297.x

A clinically focused discussion of luting materials


EE Hill,* J Lott*
*Department of Care Planning and Restorative Sciences, University of Mississippi School of Dentistry, Jackson, Mississippi, USA.

ABSTRACT
A luting agents primary function is to ll the minute void between an indirect restoration (denitive or provisional) and tooth (or implant abutment) and mechanically lock the restoration in place to prevent dislodgement during function. The purpose of this paper is to provide a clinically focused discussion on the broad spectrum of luting materials currently available to help the general practitioner make appropriate choices. Resins are typically formulated for a specic function or restoration and offer strength, aesthetics, exible working times, and very low solubility yet are technique sensitive, expensive and often hard to clean-up. Glass-ionomers offer good strength and optical properties plus the potential for uoride release recharge but may have short working times, are sensitive to moisture or dehydration early on, and take time to fully set. Resin-modied glass-ionomers are hybrid, dual-phase materials which are manipulated like glass-ionomer but set quicker and are stronger. Zinc phosphate cement, used successfully for over a century to lute well-tting metal and metal-ceramic denitive restorations, is a very inexpensive, rigid material which displays very high early compressive strength yet acidity and solubility can be problems. Polycarboxylate cement (a hybrid of zinc phosphate) has lower compressive strength but high tensile strength and may be less injurious to the pulp. Zinc oxide eugenol and zinc oxide noneugenol cements typically have good sealing abilities but their relatively low compressive and tensile strengths, inherent brittleness, and high solubility limit usage to provisional restorations or implant supported crowns. Claims for multipurpose or universal use by manufacturers can be somewhat confusing and overwhelming. Even so, the busy general practitioner must have sufcient knowledge to help choose an appropriate luting agent for each unique clinical situation.
Keywords: Cements, luting agents, biomaterials, resins, glass ionomer. Abbreviations and acronyms: RMGI = resin-modified glass-ionomer; ZOE = zinc oxide eugenol.

INTRODUCTION Dental restorations are either direct (a material placed into a prepared cavity as a soft mass which hardens) or indirect (a solid object fabricated outside the mouth and placed in or on a prepared tooth). Regardless of fabrication method or accuracy of t, an indirect restoration must be sealed with a luting agent. Its primary function is to ll the minute void between the tooth preparation (or implant abutment) and restoration and to mechanically lock the restoration in place to prevent dislodgement during function. Depending on the expected longevity of the restoration, a luting agent may be considered to be denitive (long term) or provisional (short term).1 At the beginning of the 20th century porcelain jacket crowns were made on amalgam dies and the lost wax technique for fabricating metal restorations was in its infancy. Luting agent selection was very simple, either weak thermoplastic gutta-percha, or rigid zinc oxide based cement was used depending on the retentive need.2 A century of technological progress increased the
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variety of indirect restorative options available and luting agents were developed to address strength, solubility, and aesthetic concerns.1 An extensive 2003 literature review indicated that loss of retention, recurrent caries, and aesthetics are very low frequency post-treatment clinical complications for either single crowns or xed partial dentures.3 Those ndings serve as a testament to the relatively high rate of clinical success for modern luting agents which include: resin, glass-ionomer, resin-modied glass-ionomer, polycarboxylate, zinc phosphate, zinc oxide eugenol and zinc oxide non-eugenol cements. Even so, the selection of the wrong luting agent or improper manipulation of the correct cement can signicantly affect an indirect restorations longevity. Ideally, luting agent selection should be based on the specic needs of each clinical situation and every restorative dentist should have a thorough knowledge of all available options. Unfortunately, the rapid proliferation of luting products and claims for multipurpose use by manufacturers can be somewhat confusing and overwhelming. Thus, the busy general
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EE Hill and J Lott practitioner may limit his her usage to only a few materials based on ease of use, convenience and familiarity.4 Several excellent reviews have appeared in the recent dental literature which provide in-depth background information on requirements, chemical nature, mechanism of action, and indications for various luting agents.1,58 The purpose of this paper is not to repeat comprehensive information but rather to provide a clinically focused discussion to help the general practitioner make appropriate choices from the many luting materials now available. A summary table of the authors recommendations is provided to help simplify the decision-making process (Table 1). Because of their current popularity and importance, denitive contemporary materials (resin, glass-ionomer and resin-modied glass-ionomer) will be discussed rst before turning our attention to more conventional and provisional luting cements. Denitive luting agents Resins Resin luting agents are unique in that a polymer matrix forms to ll and seal the tooth-restoration gap whereas other luting choices are true cements derived from mixing a powder and liquid which form a hydrogel matrix.1 Methyl methyacrylate based resin luting agents appeared in the early 1950s and were chemically comparable to direct acrylic lling materials of the time. As such, they did not adhere to tooth structure, underwent considerable polymerization shrinkage, had a relatively high coefcient of thermal expansion, absorbed water which contributed to microleakage at the tooth-resin interface, and excess removal was difcult. An extremely low solubility was their only superior physical characteristic compared to other denitive luting cements.9 Modern resin cements are a huge part of todays dental product market due to their versatility, high compressive and tensile strengths, low solubility and very favourable aesthetic qualities. Their major shortcomings are: difcult excess removal; technique sensitive; a restoration which has to be removed may have to be removed in pieces rather than intact; and they are relatively expensive per unit dose.1 Many manufacturers have added uoride to claim anticariogenic properties and to be competitive with glass-ionomers. The value of added uoride to resin has not been fully determined at this time and it has been suggested that when uoride toothpaste is used the anticariogenic potential of a luting agent to reduce secondary caries may not be relevant.10 As mentioned previously, resin luting agents form polymers, not cement, but the term cement is com68

Zinc polycarboxylate cement Zinc phosphate cement

4 4

4 4 4

Resin-modied glass-ionomer cement

4 4

Glass-ionomer cement

4 4

Dual-afnity

4 4

4 4 4

4 4 4 4 *Eugenol containing provisional cements may decrease bonding. 4 4

Self-adhesive

4 4

Resin cements

One-Step etch-bond, resin

Table 1. Suggested uses of denitive luting agents

3-Step total etch bond, resin

4 4

4 4

4 4 4 4

All-metal crown onlay Metal-ceramic crown All-ceramic (silica) crown Alumina or zirconium crown Ceramic inlays onlays Veneers FPD, short span FPD, long span Cast or pre-fab metal post Non-metal post Poor retentive crown Cantilever prostheses Resin-bonded FPDs Provisional cement precautions*

Type of restoration

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Luting materials monly used to reect the materials function (to bind a restoration to tooth structure) rather than its chemistry. Although many improvements have been made, their chemistry is basically that of current resin-based composite direct lling materials whereby a silica or glass particle-lled polymer matrix seals and provides mechanical retention for the restoration. If the tooth is etched and a bonding agent is used and the restoration is etched or air abraded the retention becomes micromechanical which takes greater advantage of the resins high tensile strength.11 Resin luting agents are primarily designed and indicated for specic clinical situations where their positive qualities are needed most, i.e. to bond aesthetic all-ceramic or lab processed resin restorations or veneers; for luting metal or metal-ceramic restorations to tooth preparations that have reduced retention and resistance form (i.e. short tapered crown preparations or resin-bonded xed partial dentures); and for dowel (post) cementation in endodontically treated teeth.12 These materials are frequently categorized by mechanism of matrix formation: (1) self- or auto-curing; (2) light activated-curing; and (3) dual-curing. Four divisions can also be recognized based on bonding procedure and or use: (1) total etch, bond, plus resin; (2) one-step etch-bond, plus resin; (3) self-adhesive resin; and (4) dual-afnity adhesive resin. Etched, silane coated porcelain veneers are luted to a curved enamel surface and it is extremely important that the enamel be properly etched to maximize the strength of the micromechanical bond. A light activated resin luting system which involves separate etching of enamel (and dentine), followed by application of a bonding agent and cementation with resin is preferred (division 1 above) [example products: Ultra-Bond Plus (Den-Mat, Santa Maria, CA, USA), Variolink II (Ivoclar Vivadent, Amherst, NY, USA), Calibra (Dentsply, York, PA, USA)].13 Most of these cements have water soluble try-in pastes which are intended to match the cured resin but that is not always true so a trial sample of the set cement should be compared to the tryin paste prior to luting to help insure the desired aesthetic outcome. Opaque shades are also available to help mask dark tooth structure or to mimic less translucent adjacent metal-ceramic restorations (Fig 1). Dual-cure resins should be used cautiously for luting veneers because they may discolour with time due to their aromatic amine content.14 All-ceramic crowns, inlays and onlays made from silica-containing materials which etch with hydrouoric acid (those without alumina or zirconia cores) also benet from resin bonding. Based on multiple bench and clinical studies looking at fracture resistance and sealing, it is postulated that resin bonding helps diffuse stress and eliminate microcrack propagation on the internal aspect of porcelain restorations.15 Etching of a
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Fig 1. A highly opaque resin cement was used to lute these premolar veneers in an attempt to match the high value anterior metal-ceramic xed partial denture.

porcelain restoration should be done carefully following the manufacturers instructions because it is possible to over-etch and have a lower than optimal bond between resin and ceramic.16 Since dentine is the primary tooth substrate for full coverage restorations, milder etching with a single step etch-bond agent is preferred followed by cementation with a light activated or dual-cured resin depending on the opacity of the ceramic (division 2 above) [example products: Multilink (Ivoclar Vivadent, Amherst, NY, USA), Clearl Esthetic Cement (Kuraray Medical, Tokyo, Japan)]. Excess removal for these types of cement is usually done after a very short (2 to 5 seconds) light cure with nal curing completed after initial clean-up. Care must be taken during the initial bulk removal of excess resin cement to insure the material is not pulled from under the restoration margin, creating a gap or void (Fig 2).

Fig 2. Care should be taken during the initial (bulk) removal of excess resin cement to insure material is not pulled from underneath the restoration margin.
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EE Hill and J Lott All-ceramic crowns and xed partial denture retainers made with high strength alumina and zirconia core materials do not need to be strengthened by resin bonding but may have visible margins or t discrepancies and can benet from using aesthetic, tooth shade, resin cement. It should be recalled that porcelain margins round to a degree during ring and various all-ceramic systems differ in their quality of marginal t.17,18 Therefore, more cement exposure may be anticipated for all-ceramic (or resin) restorations as compared to metal or metal-ceramic restorations and solubility, resistance to wear, and aesthetics all dictate the use of resin cement. Because these ceramics are relatively opaque, either dual- or self-curing resin cement should be used. When delivering metal or metal-ceramic restorations where luting agent strength and low solubility may be high priority issues, auto-curing self-adhesive, automixed or pre-encapsulated, resin luting agents may be useful (division 3 above) [example products: G-Cem (GC International, Tokyo, Japan), SmartCem2 (Dentsply Caulk, Milford, DE, USA), RelyX Unicem (3M ESPE, Pymble, NSW, Australia), Maxcem Elite (Kerr, North Ryde, NSW, Australia)]. Although a recent 38-month clinical study showed one product (Rely X Unicem) performed as well as zinc phosphate for luting metal-based xed partial dentures, there is little long-term clinical data to support a general recommendation for their routine use.19,20 If adequate preparation and resistance form exists or where moisture control and clean-up access may be problems, more conventional luting agents (glass-ionomer, resinmodied glass-ionomer or zinc phosphate) are often a better choice. Resins are often promoted for dowel (post) cementation in endodontically treated teeth.12,14 The use of a resin luting agent would seem reasonable if a resin core is to be placed to allow chemical bonding between exposed cement and core material. Light or dual-cured resins are not recommended for metal or opaque bre post cementation due to the uncertainty of sufcient curing before the core is subjected to stress (including tooth preparation and provisional crown removal). (Remember, the sole purpose of the post is to help retain the core.) Three-step etch and rinse or two-step self-etch resin bonding systems are preferred to lute posts (rather than single-step, self-etching self-priming resin cements) to optimize adhesion of the resin cement to dentine lining the canal space.12 Luting of a cast metal post or titanium post where an amalgam core will be placed can be accomplished with resin but zinc phosphate may be a better choice due to its longer working time, rigidity and extremely high early strength.1,21 Dual-afnity adhesive resins (those that bond to both tooth structure and various restorative materials) (division 4 above) [example products: Imperva Dual
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(Shofu, Kyoto, Japan), Panavia F 2.0 (Kuraray Medical), Super Bond C&B (Sun Medical, Shiga, Japan), C & B Metabond (Parkell, Edgewood, NY, USA)] should be considered to be a very specialized group of resin cements. They require a three-step procedure (etch, bond and resin) as do the materials in our rst division and display similar physical characteristics but they are uniquely different in that they have been chemically modied to have very high tensile strengths and tenaciously bond to etched enamel and electrolytic etched or micro-abraded base metal and noble metal alloys. Bonding to tooth structure is very technique sensitive and bonding to metal varies with the alloy and is enhanced with the use of special metal primers.1,22,23 Some have investigated the use of dual afnity resins to bond alumina or zirconia core ceramic restorations after surface modication to facilitate their use on teeth with short or over-tapered clinical crowns. Surface modication of these core ceramics with air abrasion followed by the use of adhesive phosphate monomers or silane coating has shown some promise but may possibly weaken zirconium.24 Palacios et al.25 reported that composite resin bonding (using Panavia F 2.0 (Kuraray)) of zirconium copings to extracted teeth was no more effective in enhancing retention than using resin-modied glass-ionomer or a self-adhesive resin cement. There is a learning curve for using these materials and manufacturers instructions should be followed explicitly for best results.1 Because they are relatively expensive, technique sensitive, and clean-up can be extremely difcult, the use of dual-afnity adhesive resins should typically be reserved for luting resinbonded xed partial dentures or crowns and conventional partial dentures where other luting agents may or have provided insufcient retention (Fig 3). To reap the full adhesive benets from resin bonding agents which are used with many of the resin cements

Fig 3. Dual afnity resin cements should typically be reserved for luting resin-bonded xed partial dentures or crowns conventional partial dentures where other luting agents may or have provided insufcient retention.
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Luting materials discussed above, the tooth should be thoroughly cleaned with pumice or prophy paste using a rubber cup to remove residual provisional cement and debris prior to luting. If possible, the use of eugenol containing provisional cement should be avoided when resin (and resin-modied glass-ionomer) will be used as the denitive luting agent since residual eugenol may decrease the effectiveness of some bonding agents. The use of various cavity cleansers [example products: Concepsis (Ultradent Products, South Jordan, UT, USA), Tubulicid (Global Dental Products, North Bellmore, NY, USA)] prior to etching or application of selfetching bonding agents has given both negative and positive results depending on the product and bonding agent combination.26 Glass-ionomer cement Glass-ionomer (glass polyalkenoate) cement [example products: AquaCem (Dentsply), Ketac Cem (3M ESPE), GlasIonomer (Shofu)] was formulated in 1969 by Wilson and Kent and by the late 1990s had become the most frequently used denitive luting agent worldwide. Its popularity has been attributed to ease of mixing, good ow properties, adhesion to tooth structure and base metals, cariostatic potential due to uoride release (as well as uoride recharge potential), good translucency, adequate strength, and relatively low cost per unit dose.1,27 It is primarily indicated for luting metal and metal-ceramic restorations although it can be used with high strength core (alumina or zirconium) all-ceramic crowns.1 The setting reaction for glass-ionomer cement (as for all dental cements except resin) is an acid-base reaction. In this instance, a uoride containing aluminosilicate glass reacts with poly(alkenoic acid)s to form a hydrogel matrix. Although the reaction appears simple, it is not. The cement undergoes an initial snap set then continues to mature going through several overlapping stages which may take up to several months to reach completion.28 The snap set requires the restoration be quickly and fully seated before the material loses its glossy appearance (Fig 4). If needed, the working time can be extended by handmixing on a cooled (but not moist) glass slab.29 The length of time required for complete setting to occur coupled with a modulus of elasticity (degree of stiffness) that is less than zinc phosphate (the traditional standard for luting cements) may suggest that its use be limited to single unit restorations (inlays, onlays, crowns) and short-span xed partial dentures (i.e. areas of limited functional stress).1 It is not recommended for luting posts because vibration from further tooth preparation may reduce the denitive mechanical retention provided by the cement. Physical properties of glass-ionomer can be highly variable depending on the powder liquid mixing ratio
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Fig 4. Glass-ionomer and resin-modied glass-ionomer must be used before loss of the glossy appearance.

so the manufacturers instructions for measuring should be strictly followed for optimal results.21 The use of self-contained mixing capsules (as provided by 3M ESPE for Ketac Cem) helps eliminate this variable (Fig 5). Two other negative traits of glass-ionomer cement are its past association with the occurrence of tooth sensitivity after restoration delivery and high early solubility. The tooth for which the restoration is intended should be dry but not excessively and the restoration should be seated with rm nger pressure

Fig 5. Encapsulation helps ensure accurate proportioning and mixing of cement (left to right: Unicem (3M ESPE), KetacCem (GC), Fuji Plus (GC)).
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EE Hill and J Lott recommended that the substrate tooth be carefully cleaned (very light or no pumicing) to maintain the smeared layer and the tooth surface be dry but not dehydrated.1,26 Placement of a resin-based sealer prior to cementation may also reduce the possibility of sensitivity for deep dentinal preparations and can enhance the retention of the cement.32 Resin-modied glass-ionomer cement Resin-modied glass-ionomer cement (RMGI) (resinmodied glass-polyalkenoate) is just what the name implies, it is a hybrid material derived from adding water soluble polymers or polymerizable resins to conventional glass-ionomer cement [example products: Fuji Plus (GC), Rely X Luting Cement (3M ESPE), Dyract Cem (Dentsply)]. These hybrids were created in the 1980s in an attempt to overcome the two important weaknesses of conventional glass-ionomer cement (low early strength and high solubility). Upon mixing, two unique reactions occur; the resin phase polymerizes quickly (either by chemical or light initiation) and the glass-ionomer phase proceeds slowly toward normal maturation via an acid-base reaction over an extended period of time.1 In general, fully set RMGI cements have superior physical and mechanical properties compared to conventional glass-ionomers. A very important characteristic retained from glass-ionomer is the cariostatic potential due to uoride release along with the capability for recharge from topical uoride. Even so, studies have shown that higher strength and lower early solubility may be offset to a degree by some loss of adhesion to tooth structure and a propensity for dimensional change due to uptake of water by the resin phase. Because of the possibility of hygroscopic expansion, these cements are not recommended for luting all-ceramic restorations that are susceptible to etching or posts.30 They are primarily indicated for luting metal and metal-ceramic restorations and have been shown to be safe, aesthetic and highly retentive when used with high strength alumina or zirconium core all-ceramic crowns.1,33,34 Clinically, mixing and manipulation of RMGI is very similar to conventional glass-ionomer; cleaning of the tooth is the same (the smeared layer should not be removed by heavy pumicing).26 The cement should be mixed closely following the manufacturers directions on a glass slab or mixing pad (if not pre-encapsulated) and the restoration quickly seated with rm nger pressure while the material has a glossy appearance. As soon as the cement begins to harden (snap set), removal of excess should begin (especially in interproximal areas). Excess removal must be done quickly (or removal can be extremely difcult) and carefully so as not to pull material out from under the restoration
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Fig 6. When using glass-ionomer or resin-modied glass-ionomer the restoration should be seated with rm nger pressure while maintaining a dry eld.

(Fig 6). The patient should not close on a cotton roll or stick (a common practice used with viscous zinc phosphate) to help avoid saliva contamination of the setting cement. Exposure to saliva, blood or water must be avoided to prevent loss of cement at the restoration margin for ideally 7 to 10 minutes after mixing (Fig 7). Extended dryness should also be avoided to prevent possible dehydration which can result in microcracking within the material.1,30 It was assumed that early reports of sensitivity after restorations were luted with glass-ionomer were due to the materials initial low pH which quickly rises upon setting. Several studies have shown the problem has a multifactorial origin and that traumatic manipulation (desiccation, over preparation, exposure to acidic retraction cord, etc.) of a vital tooth is typically the cause.1,21,31 To help avoid post-delivery sensitivity it is

Fig 7. Glass-ionomer must be protected from moisture exposure ideally for 7 to 10 minutes to reduce cement loss due to early solubility.
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Luting materials margins.29 As for glass-ionomer, the tooth should be well isolated and the material kept dry for 7 to 10 minutes to minimize loss of cement at the margins due to early solubility. The working times for RMGI and glass-ionomer cements can be quite variable so familiarity with using each material (or product) is important to prevent incomplete seating of the restoration. When in doubt, a trial mix is highly recommended. Zinc phosphate Zinc phosphate cement has been used for over a century to successfully seal and retain metal inlays onlays and crowns as well as metal-ceramic and feldspathic porcelain jacket crowns [example products: Flecks Zinc Phosphate Cement (Mizzy, Cherry Hill, NJ, USA), Hy-Bond Zinc Phosphate Cement (Shofupore), Zinc Phosphate Cement (SS White, Lakewood, NJ, USA)]. It is probably the best choice for cementation of a prefabricated post when an amalgam core sub-structure will be placed or for a cast metal post-core because of its high early strength.35 Owing to its lengthy clinical history, zinc phosphate cement serves as the standard to which other denitive luting agents are compared and remains a very useful luting agent for many well-tting indirect restorations.1 As for other true cements, zinc phosphate sets by an acid-base reaction and its physical properties are sensitive to several mixing variables (powder-liquid ratio, water content, mixing temperature, etc.). In general, when compared to other luting materials, its compressive strength is relatively high and tensile strength is low and it is very inexpensive per unit dose. It is a very stiff material and may be a good choice to consider when luting long span xed partial dentures or cantilevered prostheses. It holds solely by mechanical retention and does not bond to tooth structure. The liquid is buffered phosphoric acid so the mixed material reaches the tooth at a very low pH which quickly rises. As such, the smeared layer should be maintained to keep penetration into dentinal tubules to a minimum and a vital tooth should be cleaned with very light or no pumicing.26 The placement of two coats of cavity varnish or a resin sealer after tooth cleaning may help reduce the potential negative effect on a vital pulp. Zinc phosphate is always supplied as two batch matched bottles of powder and liquid which should not be interchanged with other similar kits from either the same or different manufacturers. Mixing for luting is done on a cool but dry glass slab with the powder brought into the liquid in small increments spreading with a spatula over a broad area for 60 to 90 seconds (Fig 8). This routine facilitates maximal powder incorporation while keeping the viscosity low enough for the material to ow sufciently to allow the restoration to fully seat. When lifting the spatula strings the mixture 2
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Fig 8. Zinc phosphate cement should be mixed over a broad area on a cool glass slab by bringing small increments of powder into the mix over 60 to 90 seconds to help control the viscosity.

Fig 9. When the mixing spatula lifts zinc phosphate away from the glass slab by 23 cm (about 1 inch), the material is ready for luting.

to 3 cm (Fig 9), it is placed in or on the restoration which is seated on a clean, dry tooth with rm steady pressure that should be maintained for several minutes to prevent pressure rebound. The initial set occurs about 5 to 9 minutes after mixing and the clinician should not hasten to remove excess cement for at least several minutes after the initial hardening to reduce the risk of saliva contact because the material is very soluble in the non-matured state.36 Zinc polycarboxylate Zinc polycarboxylate (zinc polyacrylate or zinc polyalkenoate) cement was developed by a British researcher, DC Smith, in the late 1960s and enjoyed great popularity over the following decade [example products: Durelon (3M ESPE), Poly F Plus (Dentsply), HyBond Polycarboxylate Cement (Shofu)]. It was the rst dental cement that would adhere to tooth structure and was recommended for use with well-tting metal and metal-ceramic restorations.1,28
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EE Hill and J Lott In original form, the powder was primarily zinc oxide (similar to zinc phosphate) and the liquid was a solution of polyacrylic acid. Later, the liquid became a complex mixture of several organic acids (polyalkenoic acid).28 Handmixing takes about 30 to 60 seconds and may be accomplished on either a glass slab (which may be cooled to extend the working time) or a paper pad, but unlike zinc phosphate, half to all the dispensed powder should be incorporated into the liquid at one time. Viscosity decreases as the rate of spatulation increases and the correct consistency for luting is when the spatula pulls up the mix but it strings back by its own weight; setting time is about 7 minutes.36 One product currently available, Durelon (3M ESPE), is sold premeasured and encapsulated ready for mixing. Like zinc phosphate, the pH of zinc polycarboxylate is very low when the tooth is rst exposed to the cement but penetration into dentinal tubules by the high molecular weight acid is considered to be minimal (if the smeared layer is maintained) and the histological response of the pulp is typically good. Compared to zinc phosphate cement, its early compressive strength is lower but the tensile strength is much higher and it has some adhesion to tooth structure although retention is primarily mechanical.36 Zinc polycarboxylate is somewhat different than the previously discussed true dental cements in that it may undergo signicant plastic deformation under dynamic loading for a long time after cementation which may suggest its use be limited to single unit restorations or short span xed partial dentures. (This property has motivated some clinicians to occasionally use zinc polycarboxylate for luting nonmetal provisional restorations where maximal retention is needed.) Also, it has relatively low resistance to erosion in an acidic environment so it may not be the best choice as a luting agent for patients who have gastric reux problems or frequently consume acidic beverages.28 Provisional luting agents Zinc oxide eugenol Zinc oxide eugenol (ZOE) reacts with eugenol via a complex acid-base type reaction to give a cement which has been used many years for luting provisional restorations [example products: TempBond (Kerr), TempoCem (DMG, Hamburg, Germany), Embonte (Dux Dental, Oxnard, CA, USA)]. The zinc oxide used in this cement must be prepared differently than that intended for zinc phosphate so the materials are not interchangeable. Formation of ZOE cement is unlike other aqueous dental cements in that an accelerator (commonly acetic acid) must be present and exposure to water hastens the set.28 Setting time may vary considerably depending on the age of the eugenol
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component. As provisional cement, ZOE is commonly dispensed as two pastes where equal parts are mixed until uniform in colour and working time varies greatly from product to product but is typically only a few minutes (a warm moist environment greatly reduces the setting time). Retention provided by ZOE for metal provisional crowns is typically proportional to the compressive strength which may or may not be true for non-metal crowns because the eugenol has a softening effect on the inner surface of acrylic crowns.36 Although the set material has excellent sealing ability, the physical properties (compressive strength, tensile strength, solubility, etc.) are so low in comparison to previously discussed cements that ZOE is not commonly used for luting denitive restorations. These materials also experience considerable creep and ow under pressure even when fully set. Reinforcement using rosin, polystyrene, and poly(methyl methacrylate) have produced a few products marketed for denitive luting that still demonstrate relative low physical properties compared to other cements.28,36 In an attempt to improve the properties of ZOE cement, in the late 1950s, 2-ethoxybenzoic acid was added to form what is known as EBA modied ZOE cement [example product: SuperEBA (Bosworth, Skokie, IL, USA)]. Numerous other modications resulted in materials which were overall stronger than the strongest reinforced ZOE cements but an inherent brittleness and high solubility make their selection for denitive luting an unwise choice except for extremely well-tting metal restorations placed on very retentive preparations.28 Zinc oxide non-eugenol Because eugenol is toxic if placed in direct (or very near) contact with pulpal tissue and other adverse patient reactions have occurred (although rare) plus the presence of residual eugenol has an inhibitory effect on resin bonding, zinc oxide non-eugenol cements were developed [example products: TempoCem NE (DMG), Nogenol (GC), PreVISION CEM (Heraeus, Chatswood, NSW, Australia)].1,37,38 Retaining zinc oxide as the primary powder ingredient, a wide variety of organic acids have been substituted for eugenol to form dental cements that are not strong enough to be used for denitive luting but satisfactorily seal and retain well-tting provisional restorations. Their chemistry is so diverse and dental research is so slow that real time general statements about their physical properties and clinical performance cannot be made. Resin A relative recent proliferation of resin provisional cements offer the promise of materials that do not
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Luting materials cause some problems associated with ZOE and have higher retentive capabilities [example products: TempBond Clear (Kerr), Sensitemp (Sultan, Hackensack, NJ, USA), Temporary Resin Cement (Mizzy, Cherry Hill, NJ, USA)]. Lawson et al. reported that flexure strength correlated with retention for three resin-based provisional cements and that they were more retentive when tested against five other ZOE and zinc oxide non-eugenol cements.40 Very little independent research has been conducted on these materials. As a precaution, a resin-based sealer should not be placed to help control tooth sensitivity (a relatively new practice sometimes done after tooth preparation and before impression-making) to avoid possible bonding of the resin provisional cement to the preparation.26 Non-scientic comparative internet shopping indicates these materials may be more expensive than other provisional luting agents. How do you select a luting agent for an implant supported restoration? The basic function of a luting agent for an implant supported crown is to hold the restoration in place for x amount of time which is primarily determined at delivery. There are those who say that if an implant is ideally placed and the occlusion will be optimal (i.e. functional forces are directed only along the long axis of the implant) then an implant supported crown should be cemented with a relatively strong, denitive material such as resin, zinc phosphate or resin-modied glass-ionomer.1 There are also times when removal of an implant supported crown may be desirable to re-torque or tighten an abutment screw or facilitate cleaning of joined restorations so that a weaker, provisional luting material such as zinc oxide eugenol may be a better choice. Because connected implant components do not ex in function (as do teeth) and the t between metal implant abutments and crowns is usually very intimate, many clinicians have found that relatively weak luting agents can function for an indenite period of time for these restorations. Sheets et al. examined the retentive nature of various common luting agents along with several products sold specifically for use with cement-retained implant supported crowns and found retention provided for metal test crowns, in general, paralleled compressive strength for most materials (i.e. resin > zinc phosphate > resin-modified glass-ionomer > etc.).41 The answer to our question (How do you select a luting agent for an implant supported restoration?) is based on those unique factors that a clinician uses to decide how much and how long retention is needed for a particular restoration.
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CONCLUSIONS Delivery of an indirect restoration involves selection of a material to seal and hold the restoration in place for the time required for service. Many factors besides the luting agent (preparation height, taper, oral hygiene, habits, etc.) determine a restorations longevity but none come into play as quickly as the physical qualities (strength, adhesion, solubility, etc.) of the luting agent. A few materials discussed above full most of the basic requirements of either a denitive or provisional luting agent yet each has unique shortcomings that may prevent their universal usage. The busy general practitioner need not (and cannot) know every minute detail of all the materials discussed above but must have sufcient knowledge to help choose an appropriate luting agent for each unique clinical situation. DISCLAIMER STATEMENT The authors do not endorse or have any nancial interest in any of the products or companies mentioned in the text. REFERENCES
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16. Alex G. Preparing porcelain surfaces for optimal bonding. Functional Esthetics and Restorative Dentistry 2008;1:3846. 17. Boyle JJ, Naylor WP, Blackman RB. Marginal accuracy of metal ceramic restorations with porcelain margins. J Prosthet Dent 1993;69:1927. 18. Beschnidt SM, Strub JR. Evaluation of the marginal accuracy of different all-ceramic crown systems after simulation in the articial mouth. J Oral Rehabil 1999;26:582593. 19. Behn M, Rosentritt M, Wimmer J, et al. Self-adhesive resin cement versus zinc phosphate luting material: a prospective clinical trial begun 2003. Dent Mater 2009;25:601604. 20. Radovic I, Monticelli F, Goracci C, Vulicevic ZR, Ferrari M. Selfadhesive resin cements: a literature review. J Adhes Dent 2008;10:251258. 21. Habib B, von Fraunhofer JA, Driscoll CF. Comparison of two luting agents used for the retention of cast dowel and cores. J Prosthodont 2005;14:164169. 22. McComb D. Adhesive luting cements classes, criteria, and usage. Compend Contin Educ Dent 1996;17:759773. 23. Petrie CS, Eick JD, Williams K, Spencer P. A comparison of three alloy surface treatments for resin-bonded prostheses. J Prosthodont 2001;10:217223. 24. Blatz MB, Chiche G, Holst S, Sadan A. Inuence of surface treatment and simulated aging on bond strengths of luting agents to zirconia. Quintessence Int 2007;38:745753. 25. Palacios RP, Johnson GH, Phillips KM, Raigrodski AJ. Retention of zirconium oxide ceramic crowns with three types of cement. J Prosthet Dent 2006;96:104114. 26. Hill EE, Rubel B. Vital tooth cleaning for cementation of indirect restorations: a review. Gen Dent 2009;57:392395. 27. Christensen GJ. Why is glass-ionomer so popular? J Am Dent Assoc 1994;125:12571258. 28. Wilson AD, Nicholson JW. Acid-base cements, their biomedical and industrial applications. New York: Cambridge University Press, 1993:103175, 197-222, 318-346. 29. Davidson CL, Mjor IA. Advances in glass-ionomer cements. Chicago: Quintessence Books, 1999:152170. 30. Mount GJ. An atlas of glass-ionomer cements: a clinicians guide. 3rd edn. New York: Martin Duntiz, 2002:173. 31. Diaz-Arnold AM, Vargas MA, Haselton DR. Current status of luting agents for xed prosthodontics. J Prosthet Dent 1999;81:135141. 32. Johnson GH, Hazelton LR, Bales DJ, Lepe X. The effect of a resin-based sealer on crown retention for three types of cement. J Prosthet Dent 2004;91:428435. 33. Snyder MD, Lang BR, Razzoog ME. The efcacy of luting allceramic crowns with resin-modied glass-ionomer cement. J Am Dent Assoc 2003;134:609612. 34. Ernst CP, Cohnen U, Stender E, Willershausen B. In vitro retentive strength of zirconium oxide ceramic crowns using different luting agents. J Prosthet Dent 2005;93:551558. 35. Habib B, von Fraunhofer JA, Driscoll CF. Comparison of two luting agents used for the retention of cast dowel and cores. J Prosthodont 2005;14:164169. 36. Craig RG, Powers JM. Restorative Dental Materials. 11th edn. St Louis: Mosby, 2002:594620. 37. Barkin ME, Boyd JP, Cohen S. Acute allergic reaction to eugenol. Oral Surg Oral Med Oral Pathol 1984;57:441442. 38. Bayindir F, Akyil MS, Bayindir YZ. Effect of eugenol and noneugenol containing temporary cement on permanent cement retention and microhardness of cured composite resin. Dent Mater J 2003;22:592599. 39. Abrams SH. Current concepts in temporary cement. Oral Health 1995;85:1920. 22, 24. 40. Lawson NC, Burgess JO, Mercante D. Crown retention and exural strength of eight provisional cements. J Prosthet Dent 2007;98:455460. 41. Sheets JL, Wilcox C, Wilwerding T. Cement selection for cementretained crown technique with dental implants. J Prosthodont 2008;17:9296.

Address for correspondence: Professor Edward E Hill Department of Care Planning and Restorative Sciences University of Mississippi School of Dentistry 2500 North State Street Jackson, Mississippi 39216 USA Email: EEHill@umc.edu

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