31
LUTING
AGENTS AND
CEMENTATION
PROCEDURES
KEY TERMS
cement luting agents
compressive strength microleakage
crown retention solubility
film thickness
INTERIM CEMENTATION
On many occasions, cementing a restoration on an
interim basis is advised so that the patient and
dentist can assess its appearance and function over
a time longer than a single visit. However, these trial
cementations should be managed cautiously. On one
hand, removing the restoration for definitive cemen-
tation may be difficult, even when temporary zinc
oxide–eugenol (ZOE) cement is used. To avoid this
problem, the interim cement can be mixed with a
little petrolatum or silicone grease. The modified
luting agent is applied only to the margins of the
restoration to seal them and yet allow subsequent
removal without difficulty. On the other hand, an
interim cemented restoration may come loose
during function. If a single unit is displaced, it can
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be embarrassing or uncomfortable for the patient. If
one abutment of a partial fixed dental prosthesis
(FDP) becomes loose, the consequences can be
more severe. If the patient does not return promptly
for recementation, caries may develop very rapidly.
Interim cementation should not be undertaken
unless the patient is given clear instructions about
the objectives of the procedure, the intended dura-
tion of the trial cementation, and the importance of
returning if an abutment loosens. If removing an
interim cemented fixed prosthesis is difficult, the use
of a crown-removal device such as the CORONAflex*
(see Chapter 32) is recommended.
DEFINITIVE CEMENTATION
Conventional Cast Restorations
Definitive cementation often does not receive the
same attention to detail as do other aspects of
restorative dentistry. Careless luting agent selection
can result in margin discrepancies and improper
*KaVo Dental Corporation, Lake Zurich, Illinois.
909
910 PART IV CLINICAL PROCEDURES: SECTION 2

occlusion and may even necessitate cutting the consist of an acid combined with a metal oxide base
restoration from the patient’s mouth and making a to form a salt and water. The setting mechanism
new one. The choice of cement depends first on results from the binding of unreacted powder parti-
whether a conventional casting or an adhesively cles by a matrix of salt to harden the mass. However,
bonded restoration, such as a ceramic inlay or resin- because they are ionic, these agents are susceptible
bonded partial FDP, is to be cemented. Traditional to acid attack and are therefore somewhat soluble in
dental cements can be used for cast crowns and oral fluids.1–4 Traditionally, the success of restorations
FDPs, but not where adhesion is needed. Adhesive cemented with these luting agents has been attrib-
resins are necessary for some restorations, but they uted to excellent adaptation between the casting and
can be difficult to use; in addition, there are no long- the prepared tooth. In vitro, however, cement disso-
term data to justify more general use with conven- lution is independent of the marginal width up to a
tional castings. certain critical value. After that, it increases only
slightly, which is explained by Fick’s first law of
diffusion.*5
Dental Cements
This study and others identify dissolution (rather
Most luting agents traditionally used for cast than physical disintegration) as the mechanism for
restorations are dental cements (Fig. 31-1). These cement erosion.6 They explain the success of cast
restorations, despite the prevalence of relatively
large subgingival marginal discrepancies, which are
difficult to detect even at 0.1 mm.7
Zinc phosphate cement
This traditional luting agent continues to be popular
for cast restorations. It has adequate strength, a film
thickness (thickness of the layer) of about 25 mm
(Fig. 31-2) (which is within the tolerance limits
required for making cast restorations),8 and a rea-

*According to Fick’s first law, the flux of a component of concentration

Fig. 31-1 across a membrane of unit area, in a predefined plane, is proportional to
Representative cement-based luting agents. the concentration differential across that plane.

120

100
Film thickness (␮m)

80

60

40 ANSI/ADA
Specification no. 96
20

0
Ketac-Cem

Tenacin

Durelon

Fuji

Metabond

Fleck’s

Geristore

Infinity

Den-Mat TFC

Panavia

Allbond

Marathon

Fig. 31-2
The film thickness of a range of luting agents was tested according to American Dental Association (ADA) specification No. 8 for
zinc phosphate cement (now American National Standards Institute [ANSI]/ADA specification No. 96) by White and Yu.64 Some of
the adhesive materials possessed unacceptably high film thicknesses, which may translate into clinical problems for complete restora-
tion seating. (From Rosenstiel SF, et al: Dental luting agents: a review of the current literature. J Prosthet Dent 80:280, 1998.)

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 911

Ayad et al Tjan and Li

Gorodovsky and Zidan Mojon et al
Wiskott et al Mausner et al
300

% retention of zinc phosphate

200

Zinc phosphate
100

0
Glass Resin Adhesive Polycarboxylate
ionomer resin
Fig. 31-3
Crown retention studies. Effect of luting agent. These six in vitro studies evaluated the effect of luting agent on crown retention.
The data were normalized as a percentage of the retention value with zinc phosphate cement. Adhesive resins had consistently
greater retention than zinc phosphate. Conventional resins and glass ionomers yielded less consistent results. (From Rosenstiel SF, et al:
Dental luting agents: a review of the current literature. J Prosthet Dent 80:280, 1998.)

sonable working time. Excess material can be easily cements have different rheologic or flow properties
removed. than zinc phosphate, exhibiting thinning with
The toxic effects of zinc phosphate, or, more increased shear rate.13 This means that they are
specifically, phosphoric acid, are well documented.9 capable of forming low film thicknesses despite their
However, the success of the use of this material over viscous appearance. When the dentist unnecessarily
many years suggests that its effect on the dental pulp reduces the powder/liquid ratio, the solubility (how
is clinically acceptable as long as normal precautions susceptible something is to being dissolved) of the
are taken and the preparation is not too close to the cement increases dramatically (as much as three-
pulp. fold).14 This may be the cause of increased clinical
failures. By fabricating luting agents, including poly-
Zinc polycarboxylate cement carboxylate in encapsulated form, manufacturers
One advantage of this luting agent is its relative bio- have reduced problems arising from manipulative
compatibility,10 which may stem from the fact that variables.
the polyacrylic acid molecule is large and therefore The working time of polycarboxylate is much
does not penetrate into the dentinal tubule. shorter than that of zinc phosphate (about 2.5
Zinc polycarboxylate cement also exhibits specific minutes, in comparison with 5 minutes). This may
adhesion to tooth structure because it chelates the be a problem when multiple units are being
calcium (although it has no adhesion to gold cast- cemented. Residual zinc polycarboxylate is more dif-
ings). Because of its high viscosity, zinc polycarboxy- ficult to remove than zinc phosphate, and there is
late cement can be difficult to mix, but this problem some evidence15,16 that it provides less crown reten-
can be overcome by using encapsulated products.* tion than zinc phosphate (Fig. 31-3). Its selection
In clinical trials, polycarboxylate performs as well therefore should probably be limited to restorations
as or slightly better than zinc phosphate.11,12 with good retention and resistance form where
However, dentists have reported varying success minimum pulp irritation is wanted. Its use as a base
rates, and claims of inferior long-term retention have material and to block out minor undercuts in prepa-
been made. These problems may be related to the rations on vital teeth may also be worth considering.
powder/liquid ratio. At manufacturers’ recom-
mended powder/liquid ratios, mixed polycarboxy- Glass ionomer cement
late cement is very viscous. Some dentists may prefer This cement adheres to enamel and dentin and
a more fluid working consistency for reliable seating exhibits good biocompatibility. In addition, because
during cementation. However, polycarboxylate it releases fluoride,17,18 it may have an anticariogenic
effect, although this has not been documented clin-
*Durelon Maxicap, 3M ESPE United States, Inc., Norristown, Pennsylvania. ically.19 The set cement is somewhat translucent,

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912 PART IV CLINICAL PROCEDURES: SECTION 2

300
Study: White and Yu Cattani-Lorente et al
Kerby et al Miyamoto et al

Compressive strength (MPa)

250

200

150

100 ANSI/ADA
Specification no. 96

50

0
Zinc Polycarboxylate Glass Resin Resin Adhesive
phosphate ionomer ionomer resin
Fig. 31-4
Compressive strength of luting agents. Higher strength values were reported in these studies with the resin cements and glass
ionomers than with zinc phosphate or polycarboxylate. Resin-modified glass ionomer exhibited greater variation than did other
cements. (From Rosenstiel SF, et al: Dental luting agents: a review of the current literature. J Prosthet Dent 80:280, 1998.)

which is an advantage when it is used with the porce- 35 Zinc phosphate

Patient sensitivity (%)

lain labial margin technique (see Chapter 24).
The mechanical properties of glass ionomer
cement are generally superior compared with zinc
phosphate or polycarboxylate cements (Fig. 31-4). A
disadvantage is that during setting, glass ionomer
appears particularly susceptible to moisture con-
tamination20 and should be protected with a foil or
resin coat or by leaving a band of cement undis-
turbed for 10 minutes.21 The water changes the
setting reaction of the glass ionomer as cement-
forming cations are flushed away and water is
absorbed, which leads to erosion.22 Nevertheless,
zinc phosphate has also demonstrated significant
early erosion when exposed to moisture.18 Glass
ionomers should not be allowed to desiccate during
this critical initial setting period. The newer resin-
modified glass ionomers are less susceptible to early
moisture.23
Although glass ionomers have been reported to
cause sensitivity,24 there appears to be little pulpal
response at the histologic level,25 particularly if the
remaining dentin thickness exceeds 1 mm.26 Side
effects such as posttreatment sensitivity thought to
result from a lack of biocompatibility may actually be
a result of desiccation or bacterial contamination27 of
the dentin rather than irritation by the cement. The
anecdotal reports that glass ionomer causes more
post-treatment sensitivity have not been replicated in
clinical trials. Authors have reported little association
between the choice of zinc phosphate or glass
ionomer cement and increased pulpal sensitivity,
provided that manufacturers’ recommendations
were followed28–30 (Fig. 31-5). If postcementation
sensitivity becomes a problem, dentists should care-
fully evaluate their technique, particularly avoiding
30 Glass ionomer
25
20
15
10
5
0
Kern et al Johnson et al Bebermeyer and
Berg
at 1 to 5 months at 1 to 2 weeks at 1 week
n ⫽ 60 n ⫽ 203 n ⫽ 90
Fig. 31-5
Clinical trials28-30 that evaluated postcementation sensitivity of
patients with crowns cemented with zinc phosphate or glass
ionomer cement. Contrary to anecdotal evidence, those with
glass ionomer cemented crowns did not exhibit increased
postcementation sensitivity. (From Rosenstiel SF, et al: Dental luting
agents: a review of the current literature. J Prosthet Dent 80:280, 1998.)
desiccation of the prepared dentin surface.31 Resin-
modified glass ionomer materials have been reported
to provoke less posttreatment sensitivity. Again, this
information is anecdotal and has not been confirmed
by clinical research.32 A desensitizing agent may
prevent sensitivity, although it may also reduce reten-
tion, at least with some luting cements.16,33 Some for-
mulations of glass ionomer and resin cements are
radiolucent (Fig. 31-6), which may prevent the prac-
titioner from distinguishing between a cement line
and recurrent caries, as well as detecting cement
overhangs.34 The use of a glass ionomer luting agent
in general practice has been favorable35; however, any
reduction in caries activity that might be anticipated
by the fluoride content has not been demonstrated
by clinical research.36

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 913

Resin ionomer
mm/AI/4 mm
15
Glass Polycar- Zinc
Resins ionomers boxylates phosphates

Increasing radiopacity
12
Akerboom et al
Study:
El-Mowarty et al
9
Matsumara

Enamel
6
Dentin
3

Shofu HY-Bond ZP
Clearfill Inlay
Dual Cement
Porcelite Dual
Duo Cement
Estilux
Tulux
Dicor MCG
All-Bond
G-Cera
3M Indirect
Mirage Bond
Vitrebond LC
Ketac-Cam
Fuji Bond
Shofu HY-Bond GI
Durelon
Shofu Carbo
GC Carbo
Getz Zinc Phosphate
GC Elite
Fig. 31-6
Radiopacity of luting agents. In three in vitro studies, investigators compared the radiographic appearance of various luting agents
to aluminum. The data were normalized to account for different specimen thicknesses used by the investigators. Excess luting agent
is more difficult to detect if materials with lower values are chosen. In addition, margin gaps and recurrent caries are more difficult
to diagnose. (From Rosenstiel SF, et al: Dental luting agents: a review of the current literature. J Prosthet Dent 80:280, 1998.)

Zinc oxide–eugenol with and without desirable properties of glass ionomer (i.e., fluoride
ethoxybenzoic acid release and adhesion) with the higher strength and
Reinforced ZOE cement is extremely biocompatible low solubility of resins. These materials are less sus-
and provides an excellent seal. However, its physical ceptible to early moisture exposure38 than is glass
properties are generally inferior to those of other ionomer and are currently among the most popular
cements, which limits its use.37 In terms of com- materials in general practice. The materials exhibit
pressive strength, solubility, and film thickness, higher strength than the conventional cements;
another luting agent (e.g., zinc phosphate) should values are similar to the resin luting agents.39 Resin-
be used. The ethoxybenzoic acid (EBA) modifier modified glass ionomers should be avoided with
replaces a portion of the eugenol in conventional all-ceramic restorations because some brands have
ZOE cement, although the change improves com- been associated with fracture,40,41 which is probably
pressive strength without affecting its resistance to caused by their water absorption and expansion.42
deformation; the cement should be used only in
Resin luting agents
restorations with good inherent retention form in
which emphasis is on biocompatibility and pulpal Unfilled resins have been used for cementation since
protection. The EBA cement has a relatively short the 1950s. Because of their high polymerization
working time, and excess material is difficult to shrinkage and poor biocompatibility, these early
remove. products were unsuccessful, although they had very
low solubility. Composite resin cements with greatly
Resin-modified glass ionomer luting agents improved properties were developed for resin-
Resin-modified glass ionomers* were introduced in bonded prostheses (see Chapter 26) and are used
the 1990s in an attempt to combine some of the extensively for the bonded ceramic technique (see
Chapter 25). Resin cements are available with adhe-
sive properties (i.e., they are capable of bonding
*The terminology for some of the newer glass ionomer/resin combinations chemically to dentin).43 Bonding is usually achieved
is rather confusing. In this textbook, the term resin-modified glass ionomer
with organophosphonates, hydroxyethyl methacry-
has been used. Other terms used for luting agents and restorative materi-
als with a combination of glass ionomer and resin chemistries include com- late (HEMA), or 4-methacryloxyethyl-trimellitic
pomer (mostly composite with some glass ionomer chemistry), hybrid anhydride (4-META).44 These developments, and
ionomer (now considered obsolete), and resin-reinforced glass ionomer. their lack of solubility, have rekindled an interest in

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914 PART IV CLINICAL PROCEDURES: SECTION 2

the use of resin cements for crowns and conventional
fixed prostheses (Fig. 31-7). Resin luting agents are
less biocompatible than cements such as glass
ionomer, especially if they are not fully polymerized.
They also tend to have greater film thickness.45
Choice of Luting Agent
An ideal luting agent has a long working time,
adheres well to both tooth structure and cast alloys,
provides a good seal, is nontoxic to the pulp, has ade-
quate strength properties, is compressible into thin
layers, has low viscosity and solubility, and exhibits
good working and setting characteristics. In addi-
tion, any excess can be easily removed. Unfortu-
nately, no such product exists (Tables 31-1 and 31-2).
Zinc phosphate cement
Despite its limited biocompatibility in terms of pulp
irritation, zinc phosphate has a long history, and
its limitations are well documented. This factor is
important for cast restorations, which should be
designed for long-term service. Zinc phosphate
cement is probably still the luting agent of choice for
otherwise normal, conservatively prepared teeth.
Cavity varnish can be used to protect against pulp irri-
tation from phosphoric acid and appears to have little
effect on the amount of retention of the cemented
restorations.46 In addition, crowns cemented with zinc
phosphate displayed increased resistance to dislodg-
ment on preparations lacking resistance form.31
Zinc polycarboxylate cement
This agent is recommended on retentive prepara-
tions when minimal pulp irritation is important (e.g.,
in children with large pulp chambers).
Glass ionomer cement
This has become a popular cement for luting cast
restorations. It has good working properties, and is
more translucent than zinc phosphate.
Resin-modified glass ionomer luting agents
Currently among the most popular luting agents,
resin-modified glass ionomer luting agents have low
solubility, adhesion, and low microleakage* (Fig.
31-8). The popularity of these materials is derived
*The seepage of fluids and microorganisms at the interface between a
restoration and the walls of a cavity preparation.

A B

Fig. 31-7
Representative resin luting agents. A, All-Bond. B, Panavia 21. C, C and B Metabond.

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 915

Table 31-1 COMPARISON OF AVAILABLE LUTING AGENTS

Ideal Zinc Poly- Glass Resin Composite Adhesive
Property material phosphate carboxylate ionomer ionomer resin resin
Film Low £25 <25 <25 >25 >25 >25
thickness
(mm)*
Working Long 1.5–5 1.75–2.5 2.3–5 2–4 3–10 0.5–5
time
(min)
Setting Short 5–14 6–9 6–9 2 3–7 1–15
time
(min)
Compressive High 62–101 67–91 122–162 40–141 194–200 179–255
strength
(MPa)
(see Fig.
31-4)
Elastic Dentin = 13.2 Not tested 11.2 Not 17 4.5–9.8
modules 13.7 tested
(GPa)† Enamel =
84–130‡
Pulp Low Moderate Low High High High High
irritation
Solubility Very low High High Low Very low High to Very low
very high to low
Microleakage Very low High High to Low to Very low High to Very low
(see Fig. very high very low very high to low
31-8)
Removal of Easy Easy Medium Medium Medium Medium Difficult
excess
Retention High Moderate Low/ Moderate High§ Moderate High
(see Fig. moderate to high
31-3)
*From White SN, Yu Z: Film thickness of new adhesive luting agents. J Prosthet Dent 67:782, 1992; see also Figure 31-2.
†
From Rosenstiel SF, et al: Strength of dental ceramics with adhesive cement coatings. J Dent Res 71:320, 1992.
‡
From O’Brien WJ: Dental Materials and Their Selection, 2nd ed, p 351. Chicago, Quintessence, Publishing, 1997.
§
From Cheylan JM, et al: In vitro push-out strength of seven luting agents to dentin. Int J Prosthodont 15:365, 2002.

mainly from the perceived benefit of reduced postce-
mentation sensitivity, although this benefit has not
been confirmed in clinical studies.47
Adhesive resins
Long-term evaluations of these materials are not
yet available, and so they cannot be recommended
for routine use; however, they are indicated for
all-ceramic and laboratory-processed composite
restorations. Laboratory testing yields high retention
strength values,48 but there is concern that stresses
caused by polymerization shrinkage, magnified in
thin films,49 lead to marginal leakage. Adhesive resin
may be indicated when a casting has become dis-
placed through lack of retention, and is recom-
mended for all-ceramic restorations.50
Preparation of the Restoration and Tooth
Surface for Cementation
The performance of all luting agents is degraded if
the material is contaminated with water, blood, or
saliva. Therefore, the restoration and tooth must be
carefully cleaned and dried after the evaluation pro-
cedure, although excessive drying of the tooth must

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916 PART IV CLINICAL PROCEDURES: SECTION 2

Table 31-2 INDICATIONS AND CONTRAINDICATIONS FOR LUTING AGENT TYPES

Restoration Indication Contraindication
Cast crown, metal-ceramic crown, partial FDP 1, 2, 3, 4, 5, 6, 7 —
Crown or partial FDP with poor retention 1 2, 3, 4, 5, 6, 7
MCC with porcelain margin 1, 2, 3, 4, 5, 6, 7 —
Casting on patient with history of post-treatment sensitivity Consider 4 or 7 2
Pressed, high-leucite, ceramic crown 1, 2 3, 4, 5, 6, 7
Slip-cast alumina crown 1, 2, 3, 4, 6, 7 5
Ceramic inlay 1, 2 3, 4, 5, 6, 7
Ceramic veneer 1, 2 3, 4, 5, 6, 7
Resin-retained partial FDP 1, 2 3, 4, 5, 6, 7
Cast post-and-core 1, 2, 3, 5, 6 4, 7

KEY:
Luting agent type Chief advantages Chief concerns Precautions
1. Adhesive resin Adhesive, low solubility Film thickness, history Moisture control
of use
2. Composite resin Low solubility Film thickness, Use bonding resin,
irritation moisture control
3. Glass ionomer Translucency Solubility, leakage Avoid early moisture
exposure
4. Reinforced ZOE Biocompatible Low strength Only for very retentive
restorations
5. Resin ionomer Low solubility, low Water sorption, Avoid with ceramic
microleakage history of use restorations
6. Zinc phosphate History of use Solubility, leakage Use for “traditional” cast
restorations
7. Zinc polycarboxylate Biocompatible Low strength, Do not reduce powder/
solubility liquid ratio
FDP, fixed dental prosthesis; MCC, metal-ceramic crown; ZOE, zinc oxide–eugenol.

500 Study: White et al (in vivo) White et al Tjan et al

Blair et al Mash et al Tjan and Chiu
450
400
% of zinc phosphate

350
300
250
200
150
Zinc phosphate
100
50
0
Polycarboxylate Glass ionomer Resin ionomer Resin Adhesive resin
Fig. 31-8
Microleakage of luting agent. A comparison of data from one clinical study and five laboratory studies, expressed as a percentage of
the value obtained for zinc phosphate cement. Considerable variation was reported, with adhesive resins and resin-modified glass
ionomer exhibiting low microleakage values. (From Rosenstiel SF, et al: Dental luting agents: a review of the current literature. J Prosthet Dent 80:280,
1998.)

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 917

A B,C

D E

Fig. 31-9
Teeth and restorations must be carefully prepared immediately before cementation. A, These preparations need to be cleaned of
interim luting agent and dried but not excessively desiccated. B and C, A steam cleaner is convenient for removing traces of pol-
ishing compound from the restorations. D and E, Airborne particle abrasion of internal restoration surface.

be avoided to prevent damage to the odontoblasts

(Fig. 31-9). The casting is best prepared by airborne I
particle abrading the fitting surface with 50-mm L C
alumina. This should be done carefully to avoid
A B
abrading the polished surfaces or margins. Air abra- J M
sion has increased the in vitro retention of castings
by 64%.51 Alternative cleaning methods include
O N
steam cleaning, the use of ultrasonics, and the use of D
organic solvents.
Before the initiation of cement mixing, isolating
the area of cementation and cleaning and drying the K
P
tooth is mandatory. However, the tooth should never E
be excessively desiccated. Overdrying the prepared
tooth leads to postoperative sensitivity. (The tech- G H F
niques for moisture control, essential to proper Fig. 31-10
cementation, are described in Chapter 14.) If a non- Armamentarium for permanent cementation.
adhesive cement (zinc phosphate) is to be used, the
tooth should be cleaned,* gently dried, and coated Armamentarium (Fig. 31-10)
with cavity varnish or dentin-bonding resin. • Mirror (A)
• Explorer (B)
*Pumice and/or a chlorhexidine preparation such as Consepsis (Ultradent, • Dental floss (C)
South Jordan, Utah) is recommended. • Cotton rolls (D)

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 918 PART IV CLINICAL PROCEDURES: SECTION 2

• Prophylaxis cup (E) • Gauze squares (N)

• Flour of pumice (F) • Adhesive foil (O)
• Cement (powder and liquid) (G) • Plastic instrument (P)
• White stones (H)
• Cuttle disks (H) Step-by-step procedure
• Local anesthetic (if needed) (I) Zinc phosphate cement is used to illustrate a typical
• Saliva evacuator (J) procedure, but the steps may vary slightly, depend-
• Forceps (K) ing on the cement chosen (Fig. 31-11). The differ-
• Thick glass slab (chilled) (L) ences with glass ionomer are pointed out in the
• Cement spatula (M) description.

A B,C

D,E F,G

H,I J,K

Fig. 31-11
Cementation technique with zinc phosphate. A, Armamentarium. B, The powder is divided into small increments and mixed with
liquid on a cool slab over a large surface area. C, The consistency of the mix is evaluated by pulling out a “thread” of cement. The
thread should break at about 20 mm ( 3/4 inch). D and E, The internal surface of the restoration is coated. F, The restoration is seated.
G and H, Applying an orangewood stick with a rocking motion against the restoration ensures that all excess cement is expressed.
I, Complete seating is immediately verified with an explorer. J, When set, the excess cement is removed from around the margins.
A length of dental floss with a knot tied in it is useful for removing excess interproximally. K, Cemented restoration. (A to C, Courtesy
of Dr. J. H. Bailey; G, Reprinted from Campagni WV: The final touch in the delivery of a fixed prosthesis. CDA J 12(2):21, 1984.)

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES
1. Immediately before cementation, inspect all
preparation surfaces for cleanliness. Remove
any interim luting agent with a pumice wash or
hydrogen peroxide (see Fig. 31-9A). Because the
casting-cement interface is where failure occurs
when a crown is displaced, the casting should
be airborne particle abraded, steam cleaned, or
cleaned ultrasonically and washed with alcohol
to remove any remaining polishing compound
that might interfere with retention of the fin-
ished restoration (see Fig. 31-9B to E).
2. Isolate the area with cotton rolls and place the
saliva evacuator. On occasion, a rubber dam can
be used, but only rarely for extracoronal restora-
tions. Avoid using cavity cleaners to aid in
drying the preparation, because they may
adversely affect pulpal health.
3. Apply cavity varnish to reduce pulp irritation
from the zinc phosphate cement. Obviously, a
varnish should not be applied when an adhesive
material, such as resin, glass ionomer, or poly-
carboxylate, is used, because it would prevent
the material’s adhesion to dentin.
4. Cool the glass slab under running water, dry it,
and dispense the proper amount of powder and
liquid. The cooled slab retards setting and
allows additional powder to be incorporated in
the liquid. This results in higher compressive
strength and reduced solubility of the set
cement.
A paper mixing pad is generally used with glass
ionomer or polycarboxylate cements.
Frozen slab technique
This technique is a practical way to increase the
working time and reduce the setting time of zinc phos-
phate cement.52,53 The technique entails the use of a
50% increased powder/liquid ratio, and mixing is
performed on a frozen glass slab. There is no adverse
effect on compressive strength, solubility, or reten-
tion,54,55 and the pH rise in the cement may be accel-
erated.56 The frozen slab technique is reliable and
is particularly effective when multiple castings are to
be cemented. An incidental advantage of this tech-
nique is that the condensation that forms on the glass
slab facilitates cleanup of excess cement. Reduced-
temperature mixing has also been applied to glass
ionomer cements as a way of increasing working
time and increasing powder/liquid ratio. Film thick-
ness measurements suggest that the procedure is
beneficial.57
5. Divide the powder into small quantities (each
about one sixth of the total mix), and add them
one at a time to the liquid (see Fig. 31-11B).
After the first increment of powder has been
incorporated for 15 to 20 seconds, a second is
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919
added, and so on. During mixing, a large surface
area (e.g., 60% of the slab) should be used so that
the heat of the exothermic setting reaction is dis-
sipated. The mixing continues until all powder
has been incorporated (about 90 seconds). For
glass ionomer cement, the measured powder is
divided into two equal parts and mixed with a
plastic spatula. The first increment is rapidly
incorporated in 10 seconds, and the second
increment is incorporated and mixed for an
additional 10 seconds.
6. When the mixing procedure is completed,
check the consistency by lifting some cement off
the slab with the spatula (see Fig. 31-11C). The
cement is of proper consistency if it pulls into a
thread of about 20 mm (3/4 inch) in length before
“snapping” back onto the slab.
The consistency of properly mixed glass ionomer
is noticeably more viscous than zinc phosphate, but
the material thins out with seating pressure.
7. Apply a thin coat of cement to the clean inter-
nal surface of the restoration (see Fig. 31-11D
and E). To extend working time, the cement
should be applied to a cool restoration rather
than to a warm tooth.
8. Dry the tooth again with a light blast of air and
push the restoration into place (see Fig. 31-11F).
Final seating is achieved by rocking with an
orangewood stick until all excess cement has
escaped (see Fig. 31-11G). Seating the restora-
tion firmly with a rocking, dynamic seating force
is important (see Fig. 31-11H). Using a static
load may cause binding of the restoration and
lead to incomplete seating. Without rocking the
casting, increasing the load only seems to
increase the binding reaction.58 Excessive force
during seating should be avoided, especially
with metal-ceramic or all-ceramic restorations,
which may fracture.
9. After the casting is seated, check the margins to
verify that the restoration is fully in place (see
Fig. 31-11I). Protect the setting cement from
moisture by covering it with an adhesive foil
(e.g., Dryfoil*).
10. When it is fully set, remove excess cement with
an explorer. Early cement removal may lead to
early moisture exposure at the margins with
increased solubility. Some cements, such as
polycarboxylate or resin, tend to pull away from
the margins if excess removal is performed too
early and the integrity of many contemporary
cements is disturbed if finished in the first 24
hours.59 Dental floss with a small knot in it can
*Burlew-Jelenko Dryfoil, Heraeus Kulzer, Armonk, New York.
920 PART IV CLINICAL PROCEDURES: SECTION 2

A B,C

D E,F

G H

Fig. 31-12
Cementation with C&B-MetaBond resin cement. A, The brush-on separating film is applied to the prosthesis, the proximal teeth, in
order to prevent the adhesive from bonding where it is not wanted. B, The recommended dentin conditioner is applied for 10
seconds and rinsed off, and the tooth is dried. C and D, Four drops of base and 1 drop of catalyst are mixed for each crown. E, After
the preparation and interior of the crown are wetted with this mixed liquid, the powder is added (F). G, The casting is painted, and
the crown is seated. H, Excess resin is removed after it has completely set. Cleanup is greatly facilitated when the separating film is
used. It is important not to remove resin before it has fully set, because the rubbery material will pull away from the margins. (Cour-
tesy of Parkell Products, Farmingdale, New York.)

be used to remove any irritating residual cement
interproximally and from the gingival sulcus
(see Fig. 31-11J). The sulcus should contain no
cement. After the excess has been removed, the
occlusion can be checked once more with Mylar
shim stock.
11. Cements take at least 24 hours to develop their
final strength. Therefore, the patient should be
cautioned to chew carefully for a day or two.
Resin luting agents
Resin luting agents are available in a wide range
of formulations. These can be categorized on the
basis of polymerization method (chemical-cure,
light-cure, or dual-cure) and the presence of dentin-
bonding mechanisms. Metal restorations require a
chemically cured system, whereas a light- or dual-
cure system is appropriate with ceramics. Resins for-
mulated for cementing conventional castings must
have lower film thickness than materials designed
for ceramics or orthodontic brackets. However, this
may be achieved at the expense of filler particle
content and will adversely affect other properties
such as polymerization shrinkage.
Manipulative techniques vary widely, depending
on the brand of resin cement. For example, Panavia
EX* sets very rapidly when air is excluded. The direc-
tions call for the material to be spatulated in a thin
film. It sets rapidly if piled up on the mixing pad.
Another material, C&B-MetaBond,† is mixed in a
ceramic well that must be chilled to prevent prema-
ture setting. Mixing techniques for these materials
are illustrated in Figures 31-12 and 31-13.
*Kuraray America, Inc., New York, New York.
†
Parkell Products, Farmingdale, New York.

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 921

A B

C D

Fig. 31-13
A, Panavia resin cement. B, Measured powder and liquid are spatulated for 60 to 90 seconds. The mix becomes creamier as it is
mixed. The cement sets if oxygen is excluded, and so it should not be piled up. Instead, it should be spread out over a large surface
area. C, A thin coat of the cement is applied, the restoration is seated, and excess cement is removed. D, The cement is coated with
oxygen-inhibiting gel to promote polymerization. (Courtesy of J. Morita USA, Inc., Irvine, California.)

CEMENTATION PROCEDURES FOR

CERAMIC VENEERS AND INLAYS
These restorations rely on resin bonding for retention
and strength. The cementation steps are critical to the
restoration’s success; careless handling of the resin
luting agent may be a key factor in their prognosis. B
B
Bonding is achieved by performing the following steps:
1. Etching the fitting surface of the ceramic with
hydrofluoric acid. A C D
2. Applying a silane coupling agent to the ceramic
material.
3. Etching the enamel with phosphoric acid.
4. Applying a resin-bonding agent to etched enamel
and silane.60
5. Seating the restoration with a composite resin
luting agent (Fig. 31-14).
The etching and silanating steps are presented in
Chapter 25. Fig. 31-14
Schematic of resin-bonding technique. A, Ceramic surface
Selection of Resin Luting Agent (etched and silanated); B, unfilled resin; C, resin luting agent; D,
etched enamel.
Composite resin luting agents are available in a
range of formulations. For veneers, a light-cured

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922 PART IV CLINICAL PROCEDURES: SECTION 2

• Brush
• Resin luting agent
• Curing light
• Fine grit diamonds
• Porcelain polishing kit
Step-by-step procedure (Fig. 31-16)
1. Clean the teeth with pumice and water (or a
chlorhexidine preparation). Isolate them with
the rubber dam or displacement cord. A luting
agent that contains ZOE should be avoided for
cementing interim restorations before resin
bonding, because eugenol inhibits the polymer-
ization of the resin. Cleansing with pumice
Fig. 31-15
leaves a ZOE residue mixed with pumice, which
Armamentarium for bonding procedure.
can inhibit bonding.62 Etching with 37% phos-
phoric acid after cleaning with pumice may be
material can be used. For inlays, a chemical-cure the best way to remove ZOE.63
material is preferred, to ensure maximum polymer- 2. Evaluate the restorations with glycerin or a try-
ization of the resin in the less accessible proximal in paste (see Fig. 31-16A). Verify fit, shade, and
areas. In clinical testing, restorations luted with insertion sequence.
chemically cured materials have performed better 3. Clean the restorations thoroughly in water with
than dual-cured luted restorations.61 ultrasonic agitation. Use acetone if luting resin
The shade of veneers can be modified by the was used to verify the shade at evaluation.* Dry
shade of the luting agent. To facilitate shade selec- the restorations.
tion, color-matched try-in pastes are available from 4. Etch and silanate the restorations as described
some manufacturers (e.g., Nexus*). in Chapter 25.
5. Acid etch the enamel; 37% phosphoric acid is
generally used and is applied for 20 seconds.
Bonding the Restoration Rinse thoroughly and dry.
6. Apply a thin layer of bonding resin to the prepa-
Armamentarium (Fig. 31-15) ration. Brush, rather than air thin, the bonding
• Mirror resin, because air thinning might inhibit
• Explorer polymerization. Do not polymerize this layer,
• Rubber dam kit because it might interfere with complete seating.
• Local anesthetic 7. For veneers, place a Mylar matrix strip at the
• Saliva evacuator mesial and distal surfaces of the prepared tooth
• Forceps (see Fig. 31-16B).
• Scalpel 8. Apply composite resin luting agent to the
• Curette restoration; be especially careful to avoid trap-
• Plastic instrument ping air. (Dual cure is recommended for inlay
• Dental tape and onlays; light cure is recommended for
• Mylar strips veneers) (see Fig. 31-16C).
• Cotton rolls 9. Position the restoration gently, removing excess
• Prophylaxis cup luting agent with an instrument (see Fig. 31-
• Flour of pumice 16D).
• Acid etchant 10. Hold the restoration in place while light-curing
• Porcelain etchant the resin. Do not press on the center of veneers;
• Silane coupling agent they may flex and break (see Fig. 31-16E).
• Acetone 11. Use dental tape to remove resin flash from the
• Glycerin or try-in paste interproximal margins of inlays and onlays
• Bonding agent before curing these areas.

*This technique requires care. The restoration should not be exposed to

*Kerr Corporation, Orange, California. the unit light; otherwise, the resin polymerizes prematurely.

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 923

A B

C D,E

F G

Fig. 31-16
Evaluation and bonding procedure. A, The veneers are evaluated very carefully. A drop of glycerin on the fitting surface aids in shade
assessment and provides retention. If necessary, the shade can be modified slightly with colored luting agents. The luting agent must
not polymerize during evaluation; in particular, the unit light must not shine directly on the restoration. The veneers are thoroughly
cleaned in acetone and are silanated according to the manufacturer ’s recommendations. B, The teeth are isolated, pumiced, and
etched. Mylar strips are placed between adjacent teeth. C, The veneers are filled with resin luting agent and gently seated. D, Excess
resin is removed with an explorer. E, The resin is polymerized. F, Gross excess resin is trimmed with a scalpel, and the margins are
finished with fine-grit diamonds and diamond polishing paste. G, The completed restorations.

12. Do not undercure the resin cement. Allow at
least 40 seconds for each area.
13. Remove resin flash with a scalpel or sharp
curette (see Fig. 31-16F).
14. Finish accessible margins and occlusion with
fine diamonds, using water spray. Use finishing
strips for the interproximal margins.
15. Polish adjusted areas with rubber wheels or
points and then with diamond polishing paste.
REVIEW OF TECHNIQUE
Figure 31-17 illustrates the cementation of six max-
illary anterior metal-ceramic crowns.
1. The preparations are thoroughly cleaned; the
clinician makes sure all interim luting agent is
removed (see Fig. 31-17A).
2. The restorations are seated, and a readily accessi-
ble area of the margin is examined with an
explorer (see Fig. 31-17B); this evaluation pro-
vides a reference for complete seating during
cementation.
3. The restorations are thoroughly cleaned with air
abrasion, steam cleaning, or ultrasonics (see Fig.
31-17C).
4. The luting agent is mixed according to the manu-
facturer’s recommendations (see Fig. 31-17D).
5. The restorations are seated to place with a firm
rocking pressure (see Fig. 31-17E).
6. The accessible margin area is quickly reexam-
ined to ensure complete seating (see Fig.
31-17F).
7. Once the luting agent has completely set, all
excess is removed (see Figs. 31-17G and H).

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 924 PART IV CLINICAL PROCEDURES: SECTION 2

A B,C

D E

F G,H

Fig. 31-17
Technique review. A, The preparations are thoroughly cleaned; all interim luting agent should be removed. B, The restorations are
seated, and a readily accessible area of the margin is examined with an explorer. C, The restorations are thoroughly cleaned with
airborne particle abrasion, steam cleaning, or ultrasonics. D, The luting agent is mixed according to the manufacturer’s recommen-
dations. E, The restorations are seated to place with a firm rocking pressure. F, The accessible margin area is quickly reexamined to
ensure complete seating. G and H, Once the luting agent has completely set, all excess is removed.

SUMMARY recommendations, and the restoration is seated, with

Proper moisture control is essential for the cemen-
tation step. The restoration must be carefully pre-
pared for cementation, including the removal of
all polishing compounds. Airborne particle abrading
the fitting surface is recommended. The luting agent
of choice is mixed according to the manufacturer’s
the use of a rocking action. The luting agent must
be protected from moisture during its initial set.
Removal of excess luting agent from the gingival
sulcus is crucial for continued periodontal health.
Additional steps are necessary for adhesively
bonded restorations. These steps must be carefully
sequenced according to the manufacturer’s directions.

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Chapter 31 LUTING AGENTS AND CEMENTATION PROCEDURES 925

? STUDY QUESTIONS

?
1. Discuss the principal differences in chemistry, physical properties, and manipulative variables for three
different types of luting agents. How do the differences affect their clinically indicated use?
2. What are properties of the “ideal” luting agent?
3. Compare the recommended techniques for mixing zinc phosphate cement and Panavia EX.
4. Describe how the tooth and the restoration are prepared before a metal-ceramic crown is cemented with
glass ionomer cement. How does this change when a different luting agent is selected?
5. Discuss the steps involved in cementation of two laminate veneers on the maxillary central incisors.

GLOSSARY*
ac·cel·er·a·tor \ăk-sĕl¢a-rā¢ter\ n (1611) 1: a substance
that speeds a chemical reaction 2: in physiology, a
nerve, muscle, or substance that quickens movement or
response
ad·her·ence \ăd-hîr¢ens, -enz\ n (1531): the act, quality, or
action of adhering; persistent attachment
ad·he·sion \ăd-hē¢zhun\ n (1624) 1: the property of
remaining in close proximity, as that resulting from the
physical attraction of molecules to a substance or molec-
ular attraction existing between the surfaces of bodies in
contact 2: the stable joining of parts to each other, which
may occur abnormally 3: a fibrous band or structure
by which parts abnormally adhere—comp CAPSULAR
FIBROSIS, FIBROUS A., INTRACAPSULAR A., MYOFI-
BROTIC CAPSULAR CONTRACTURE
1
ce·ment \sı̆-mĕnt\ n (14c) 1: a binding element or agent
used as a substance to make objects adhere to each
other, or something serving to firmly unite 2: a material
that, on hardening, will fill a space or bind adjacent
objects- syn luting agent
ce·men·ta·tion \sĕ¢mĕn-tā¢shun\: 1: the process of attach-
ing parts by means of cement 2: attaching a restoration
to natural teeth by means of a cement (GPT-4)
com·po·mer \kŏm¢pō-mĕr\ n (1998): a poly-acid modified
composite resin, composed of glass filler, acid-modified
dimethacrylate resin, and a photo initiator
hybrid ionomer \hı̄¢brı̆d ı̄¢a-nō¢mĕr\: a conventional glass
ionomer that has been modified to include methacrylate
groups in the liquid component. It may contain photo-
initiators. Setting is by an acid-base reaction with light
and dual cure polymerization syn—RESIN-MODIFIED
GLASS IONOMER
*Reprinted in part from The Journal of Prosthetic Dentistry, Vol. 94, No. 1,
The Glossary of Prosthodontic Terms, 8th Edition, pp. 10–81, © 2005,
with permission from The Editorial Council of The Journal of Prosthetic
Dentistry.
1
lute \lōōt\ n (15c): a substance, such as cement or clay,
used for placing a joint or coating a porous surface to
make it impervious to liquid or gas—see CEMENT
luting agent: any material used to attach or cement indi-
rect restorations to prepared teeth
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926 PART IV CLINICAL PROCEDURES: SECTION 2
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