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All-ceramic crowns: bonding or cementing?

Article  in  Clinical Oral Investigations · January 2003

DOI: 10.1007/s00784-002-0183-2 · Source: PubMed

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Clin Oral Invest (2002) 6:189–197
DOI 10.1007/s00784-002-0183-2

REVIEW

Peter Pospiech

All-ceramic crowns: bonding or cementing?

Received: 24 Februar 2002 / Accepted: 23 September 2002 / Published online: 21 December 2002
© Springer-Verlag 2002

Abstract Despite the wide variety of all-ceramic sys-
tems available today, the majority of dental practitioners
hesitate to recommend and insert all-ceramic crowns.
This article regards the nature of the ceramic materials,
the principles of bonding and adhesion, and the clinical
problems of the acid-etch technique for crowns. Advan-
tages and disadvantages are discussed, and the influences
of different factors on the strength of all-ceramic crowns
are presented. Finally, the conclusion is drawn that con-
ventional cementing of all-ceramic crowns is possible
when the specific properties of the ceramics are taken in-
to consideration.
Keywords Dentin bonding · All-ceramic crowns ·
Cementing · Bonding · Adhesive luting
Introduction
Over the last 15 years, there has been increasing interest
in ceramic materials in industry as well as dentistry. This
resulted in the wide variety of all-ceramic systems avail-
able today. Nevertheless, the majority of dental practitio-
ners hesitate to recommend and insert all-ceramic
crowns in their patients. The main reasons for this seem
to be the fear of (early) failures (Fig. 1) and uncertainty
whether each all-ceramic crown should be fixed with a
resin cement, which complicates the clinical procedure.
The objective of this article was to discuss the advan-
tages and disadvantages of resin cements for fixing all-
ceramic crowns. Furthermore, it attempts to give clinical
guidelines concerning when bonding or cementing is
more promising.
Bonding
Bonding is a common and well-proven technology for
industrial applications. If the bonding procedure is car-
ried out successfully, a so-called compound system is
obtained: for a successful bond, the surfaces of the parts
to be bonded have to be thoroughly conditioned to obtain
a tight junction between the molecules of the bond and
the workpieces. This link must also be strong enough to
withstand stresses in the bonding agent which are gener-
ated by polymerization and shrinkage.
The fundamental requirement is a surface that is
clean, dry, and grease-free. Then the surface energy of
the workpiece can be increased: it has to be higher than

This material was partially presented at the satellite symposium

“Indirect tooth-colored restoratives and luting problems” during
the 37th annual meeting of the Continental European Division of
the International Association for Dental Research in Rome, Italy,
5–8 September 2001. The symposium and the printing costs were
graciously sponsored by Ivoclar Vivadent AG, Schaan, Liechten-
stein.

P. Pospiech (✉)
Department of Prosthetic Dentistry and Dental Materials Science,
Saarland University, Homburg Campus, Bldg. 71 N,
66424 Homburg/Saar, Germany
Phone: +49-6841-1624900
Fax: +49-6841-1624952
e-mail: zmkppos@uniklinik-saarland.de Fig. 1 Failure of an all-ceramic crown after 6 months in service
190
Fig. 2 a Wide contact angle on nonconditioned “cold” surface
with low surface energy. b Small contact angle and good wetting
of a preconditioned, high-energetic “hot” surface
the cohesive forces of the molecules of the bonding
agent, so that the highest possible wetting ability is ob-
tained [32, 34, 45, 60, 61, 130] (Fig. 2a, b). This results
in small contact angles between the bonding agent and
the tooth and restoration surfaces [51, 58].
The etching of dental ceramics with a glassy matrix
by means of hydrofluoric acid is highly effective: after
application of an additional silane coupling agent, a
strong link between the resin cement and the ceramic is
guaranteed [1, 5, 6, 10, 11, 52, 56, 59, 117, 126].
Sandblasting is an alternative conditioning procedure
for alloys or oxide ceramics (alumina or zirconium di-
oxide) with less or no glass content. The correct use of a
silicoating procedure (e.g. the Rocatec system) com-
bined with a silane coupling agent is reliable and leads
to well-proven bonding results [50, 65, 66, 102].
The surface energy of enamel doubles after etching
with phosphoric acid (37%) to 0.072 N/m, which leads
to a perfect wetting of the surface with the bond. Factors
that reduce surface energy are contamination with saliva
and breath moisture. Therefore, isolation with a rubber
dam is highly recommended and lowers stress input
during the clinical procedure [39, 68, 105, 111, 113,
123].
Dentin
Composition of dentin
While bonding to enamel is very successful because of its
inorganic composition and perfect etchability, dentin has
a different composition of inorganic and organic parts.
This unique structure and the tubule architecture play a
significant role: the tubule number varies from around
45,000/mm2 at the pulpal site to only 20,000 mm2 at the
amelodentinal junction [9, 44, 68, 112].
Table 1 List of surface energies of enamel and dentin. From [123]
Tooth substance Surface energy (N/m)
Untreated Enamel 0.028–0.032
Dentin 0.042–0.045
Etched Enamel 0.072
Dentin 0.027–0.030
The resulting surface energy of etched dentin is lower
than that of enamel and even lower than in unetched den-
tin (Table 1), because etching dissolves the inorganic
components of dentin. This further reduces the low con-
tent of hydroxyapatite and raises the percentage of colla-
gen on the surface. Consequently, the wetting ability of
the bonding agent is reduced [32, 34].
The permanent tubular fluid flow to the surface makes
perfect surface wetting more difficult with hydrophobic
bonding agents, and the resin curing is also limited by the
water and oxygen contents in the dentinal liquids. This
leads to a reduced conversion rate and an amount of
monomer which could also cause biological problems
such as allergic reactions or cytotoxic effects [47, 86].
Hydroxyethyl methacrylate (HEMA) and triethylengly-
col-dimethacrylate (TEGDMA) are the monomers which
could be released from resin-based luting agents. It was
described that after etching of thin dentin, the concentra-
tions of these monomers can be high enough to cause
substantial damage to the cells in the pulp [43, 47, 53,
104, 108, 109, 110], and even low-viscosity cements
could be pressed through the tubules into the pulp cham-
ber, especially in crowns, where the biggest number of tu-
bules is open and the largest dentin wound exists [2].
Quality of dentin
Dentin is a highly heterogenous material. Its quality var-
ies greatly between different patients and even within the
same patient (Fig. 3). That makes it very difficult to as-
sess the performance of the conditioning process.

Fig. 3 Different dentin qualities of premolars in the same patients
Fig. 4 Closed tubules in an elder patient (from [112])
The age of the patient plays a significant role, because
dentin undergoes age-associated changes: young dentin
has wide and open tubules, but the older a patient is, the
lower the number of open tubules and the smaller their
diameters due to the composition of secondary and ter-
tiary dentin (sclerotic process) (Fig. 4). Complete occlu-
sion of the tubules occurs and prevents the desired tag
formation of the composite cements (Fig. 5). This leads
to further reduced bond strength, because the penetration
of resin into and via the dentinal tubules is responsible
for nearly 40% of that strength [111, 112, 129].
191
Fig. 5 Ideal tag formation after conditioning the dentin
Effect of caries and depth of cavity
Dentin affected by caries is in general sclerotic and al-
most not permeable. The acid etching of caries-effected
dentin does not significantly increase the permeability of
the tubular dentin [90, 91, 93]. The distance to the cavity
of the pulp also is important for bond strength. Numer-
ous studies revealed that the closer the bonding area is to
the pulp, the lower are the bonding strength values [92,
96, 103, 127].
Controlling successful etching procedure
While the etching of enamel with phosphoric acid leads
to a “frosty” surface - a sign of a successful procedure -
the ability to control the effect of dentin-bonding agents
on dentin is very poor. All those liquids are invisible and
not dyed, so there is no clinical control if all parts of the
surface are spread. It is also hard to obtain the correct
dryness or better wetness of the surface, which is ele-
mentary for a successful bond. Different kinds of dentin-
bonding agents deal with surface wetness and the obtain-
ing of a hybrid zone in different ways. Multiple bonding
agent generations and different concepts also lead to
confusion in dental practices. Last but not least, dentin-
bonding systems are highly sensitive to technique, espe-
cially when perfect moisture control cannot be guaran-
teed. There is absolutely no doubt that the use of rubber
dams allows the best moisture control [31, 41, 84].
Long-term stability of the dentin bond
There is no in vitro or in vivo evidence of the long-term
stability of dentin-bonding procedures. Conversely, there
are several indications that the bond weakens over time
under the influences of water, temperature, and occlusal
load [40]. Our own in vitro experiments showed that
192
dentin adhesion failed over time [97, 98, 99]. A clinical
study on porcelain laminate veneers bonded with early-
generation adhesives revealed that failures only occurred
when the veneers were partially bonded to dentin [28].
Whereas for the conditioning of enamel only one proce-
dure is necessary for good success, for decades there
have been many attempts at finding the right dentin-
bonding procedure, which finds its expression in numer-
ous “generations” of dentin-bonding agents [31].
For the above reasons, it seems opportune to differen-
tiate between the kinds of restorations when choosing
resin or conventional cements.
Restorations with margins located in the enamel
(inlays, onlays, partial crowns, veneers)
It is absolutely advisable to use resin cement for bonding
when the restoration margins are located in the enamel
and perfect moisture control by rubber dam is possible.
Bonding with enamel results in a compound system with
stabilization of the ceramic. That is the reason for the
high success rates of veneers and inlays. An excellent
overview of this subject is given by Manhart and Hickel
[76]. The studies of Höglund et al. revealed that cement-
ing ceramic inlays with a glass-ionomer cement leads to
significantly higher failure rates [54].
Restorations with margins partially located in the dentin
(inlays, onlays, partial crowns, veneers)
Restorations with margins partially located in the dentin
include most cases with inlay restorations or partial
crowns with deep interproximal cavities. Here it is nec-
essary to provide supragingival margins at the interprox-
imal sites and use rubber dams as well. Even though the
dentinal bond is not as durable as with enamel, it is pos-
sible to obtain a seal. If there is no chance of surgical
crown lengthening and a rubber dam is not applicable,
then conventional cementation of a metal-based restora-
tion must be used. The damage which could be caused is
too great: if even dentists cannot control the procedure,
then patients will never be able to control this site and
realize effective oral hygiene.
Restorations with margins located fully in the dentin
(full crowns)
In many cases, full crowns are made two or three times
when the margins of the replaced restorations are located
subgingivally and in the dentin: this causes clinical han-
dling problems. Perfect moisture control (i.e., with rub-
ber dam) is not possible if surgical crown lengthening is
not carried out. Sulcus fluid and saliva negatively affect
the quality of the bonding surface after preconditioning.
Especially in the posterior region, good clinical access to
the working area is difficult or even impossible. It is
hard to control an excess of the luting agent: an excess of
composite-based luting materials must be removed total-
ly before final polymerization, because chipping off ex-
cess resin cement after hardening could damage the
crown’s margins. The other possibility may lie in remov-
ing the cement with rotating instruments, but that takes
time and is difficult in posterior areas. Thin bonding lay-
ers are nearly invisible and hard to detect. Very often
some amount of excess cement remains in the sulcus and
leads to periodontal problems.
If a perfect bond between ceramic, dentin, and luting
agent is not guaranteed, there is also no guarantee of ob-
taining a compound system. That means the ceramic is
not stabilized, as in veneer or inlay cases, where even
thicknesses of 0.2 mm can be realized when ceramics are
bonded to enamel. In cases with restoration margins in
the dentin, it makes no sense to use resin cements, be-
cause the polymerization shrinkage of the composite
leads to gap formation, with its negative consequences of
bacterial invasion [7, 24].
Hybrid cements
Hybrid cements such as the so-called compomers (poly-
acid-modified resin cements) and the resin-modified
glass-ionomer cements (GIC) were developed with the
aim of combining the advantages of each material group.
The first goal was to find alternative “smart” filling mate-
rials, especially for sites with filling margins in enamel
and dentin. Only a few products were developed as mate-
rials for luting restorations [116]. The main problem with
these materials is that a hydrophilic component such as
GIC must be combined with the hydrophobic resin. Thus,
a hydrophilic resin such as HEMA is added, which leads
to a high degree of volumetric expansion because of wa-
ter uptake after polymerization [100]. This can result in
cracks in all-ceramic crowns when the tensile stress ex-
ceeds the strength of the ceramic used [67, 78].
The lower solubility [80] as a consequence of the res-
in component in hybrids might be desirable for filling
materials but does not play a very significant role for ce-
ments, because there is only a small gap at the crown’s
margins. As the solubility of a cement layer is dependent
on the fluid velocity and the width of the margin, there is
no problem for the cement line. The very successful use
of conventional zinc-phosphate cements and GICs
showed that the solubility is low enough when crowns
display a good fit.
Concern has been raised regarding the biocompatibili-
ty of hybrid materials, because they contain unpolymer-
ized groups of resins. Especially HEMA and TEGDMA
were suspected of causing pulpal damage due to their
ability to diffuse into the pulp [46, 48].
Meyer et al. came to the conclusion that polyacid-
modified resins behave more like composites than GICs
[83]. From that point of view, there seems to be no real
advantage of a compomer or resin-modified GIC over
conventional GICs, especially if we consider that com-

Fig. 6 Possible factors influencing the fracture strength of all ce-
ramic crowns
posite resins retain more mutans streptococci than glass-
ionomer cements [95].
Factors influencing the fracture resistance
of all-ceramic crowns
Factors that influence the fracture resistance of all-ce-
ramic crowns are compiled in Fig. 6. It becomes obvious
that the way the crown is definitely fixed on the tooth
does not alone tip the balance for long-term success. The
factors influence each other and cannot be regarded sep-
arately.
Ceramic materials
Dental ceramics can be divided into materials containing
crystals in a glass matrix and pure polycrystalline ceram-
ics with little or no glass content. In conventional feld-
spathic porcelains and glass ceramics, the brittle glass
structure predominates. Only the new CAD/CAM ceram-
ics use high-strength Al2O3 or ZrO2 as a core. The great
variety of these materials leads to some problems in ma-
terial testing, and there is still no worldwide gold stan-
dard for testing all-ceramic crowns, which leads to the
big differences in results [8, 12, 13, 14, 17, 19, 25, 26,
30, 38, 42, 64].
Strength, fracture toughness, and Weibull modulus of
the ceramics used are important factors for successful
restorations. The development of new systems led to
nearly ten times higher tensile strength values of ceram-
ics than with the old jacket crown materials. The same
relation is true for fracture toughness [76, 77, 102].
The Weibull calculation is a way to judge the quality
of a ceramic structure and therefore its reliability. If the
scattering of the tensile strength values of a ceramic is
high, the Weibull number is low, whereas a small scatter-
ing results in a high Weibull number. Ceramic materials
produced under controlled conditions and pressed into
blocks for CAD/CAM-manufacturing have high Weibull
193
moduli. Ceramics produced by technicians are more po-
rous and have more flaws. This results in a low Weibull
modulus and therefore in a higher likelihood of failure
[69, 89].
Flaws and voids in the structure and different elastic
moduli between crown, cement, and core can also influ-
ence stress development and fracture behavior in the
structure of a ceramic [4, 62, 63, 70, 107, 119, 121, 122].
Dental ceramics are highly influenced by aging, espe-
cially under the permanently wet conditions in the oral
cavity. A rule of thumb is that the initial strength values
can decrease to half during clinical service. That means
that ceramics must be chosen according to the expected
strength values [128].
Preparation and load
As well described by Shillingburg [115], the preparation
of a tooth plays a decisive role in the success of any res-
toration. Especially for all-ceramic crowns, it is advis-
able to attend to consistent wall thickness to avoid inter-
nal stresses. It is also important to provide rounded edg-
es, which lessens crack propagation in ceramics, because
any sharp angle can lead to the development of stress. A
comparison of all the literature dealing with preparation
design and strength is nearly impossible. Again, there is
no standard to which all authors refer, and too many
variables are unknown or not described [12, 13, 14, 22,
38, 81, 84, 125].
The force load on a crown in the biotope mouth is a
very individual factor. Chewing forces vary greatly. The
preparation of the tooth and the construction of the
crown should be carried out in such a way that the ce-
ramic is set only under compression, because its com-
pressive strength is ten times higher than the tensile
strength. That leads to the old demand of an anatomical
preparation form, e.g., the incisal edge of an incisor
should be inclined so that the opposite tooth will always
hit the edge perpendicularly, which leads to primarily
compressive stresses on the ceramics. The same is true
for preparation of the posterior teeth. A flat occlusal sur-
face causes different thicknesses in the ceramic and leads
to tensile stress development in dynamic occlusion posi-
tions.
Hojjatie and Anusavice showed that the direction of
the load influences fracture strength more than the ce-
ment line. Tilted forces and resulting shear stresses di-
minish the fracture strength of all-ceramic crowns [3,
55]. This was also found in an in vitro-study in which
shear stress was the decisive factor of failures for all-ce-
ramic crowns [57].
Handling of materials
Ceramics behave totally differently from metals or al-
loys, so dentists and technicians must change their be-
havior and develop a new “ceramic thinking”: ceramics
194
are brittle, and the covalent or ionic bindings of their
structure cannot “heal” under physiological conditions
when they are broken, as metallic bindings can. Grinding
ceramics without water cooling leads to local overheat-
ing of the structure. Rough diamonds or stones damage
the surfaces and lead to crack initiation or propagation
and also to an opening of pores and holes. Finally, the
water molecules attack especially the structure of the
glass matrix: cracks can propagate much more easily in
the presence of a moist atmosphere [69, 76, 124]. Thus it
is highly advisable to create smooth and scratch-free sur-
faces to assure the best conditions for high longevity, be-
cause the strength of glass, glass-ceramics, and even
high-strength oxide ceramics (ZrO2) is a function of the
integrity of the surface [20, 49, 100, 124].
Tooth substance, compound system, and luting agent
The nature of a compound system was already described
earlier. If a strong and durable bond can be obtained, the
use of a resin cement is superior to conventional cemen-
tation.
In vitro studies have given a manifold picture. Some
studies conclude that resin-bonded crowns are more frac-
ture-resistant than cemented ones [8, 23, 71, 72, 84].
However, a closer look at the methods reveals that, in all
cases, only short-term results were presented in which
crowns were loaded until fracture immediately or within
a few days after bonding. In those cases, a higher bond
to the tooth substance can be assumed.
Other studies and our own in vitro studies came to the
result that, after long-term storage and a thermocycling
procedure, the fracture strength of cemented crowns was
not significantly different from that of bonded crowns
[79, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99]. So
clinical implications are difficult to draw from in vitro
results, especially considering that dentin is such a het-
erogeneous material that also alters its physiological and
mechanical behavior after extraction, compared to the in
vivo situation.
In vivo studies are rare and mostly retrospective [35,
36, 114]. They show the same heterogeneous results as
the in vitro studies, but there is no clear evidence that the
choice of resin cement or conventional cement plays the
decisive role.
Malament and Socransky reported that acid-etched
Dicor restorations luted to dentin showed slightly better
results than those luted with glass-ionomer or zinc-phos-
phate cements. There was no difference between these
two conventional cements.
A prospective study on that problem was carried out
by Edelhoff et al. [29], who provided patients with more
than 400 anterior crowns partly cemented with a zinc-
phosphate cement and partly bonded by a dual-curing
resin cement. After 4 years, there was no significant dif-
ference between the fracture rates: only one crown frac-
tured in each group. There was, however, a significantly
higher percentage of discoloration in the resin-fixed
Fig. 7 Pros and cons for the use of resin cements in fixing all-ce-
ramic crowns
group. This might be an effect of poor bonding between
dentin and the resin cement and probably a higher water
uptake of the composite materials. There were also poor-
er results in the sulcus bleeding indices of the resin
groups. No differences were detected by patients or den-
tists when the esthetic effect of the crowns was estimated
on visual analogue scales. Ödmann and Andersson re-
ported that after 5 to 10.5 years, 87 Procera AllCeram
crowns placed in 50 patients showed a success rate of
97.7%. All crowns were conventionally cemented with
glass-ionomer or zinc-phosphate cements [88].
Summary: pros and cons of crown bonding
Regarding the points in Fig. 7, one can see only one
point that might speak for fixing crowns with resin-ce-
ments: the esthetics might be negatively affected by con-
ventional cements. Nevertheless, the clinical results in
the study of Edelhoff et al. [29] do not support this hy-
pothesis, and it is also questionable whether the higher
opacity of conventional cements plays a role at thick-
nesses of 50–150 µm.
It is a clinical fact that grease-free, clean, and dry sur-
face conditions cannot be fulfilled in most cases. Conse-
quently, the bond can be so bad that polymerization
shrinkage of the resin luting media plays a major role in
quality of the bond. Plaque accumulation is also higher
with resins than with other materials in the oral cavity,
which could lead to secondary caries or discoloration in
the marginal area. The longevity of dentin bonding is
still questionable and needs further investigation. Com-
pared to conventional GICs, the use of hybrid cements
has more disadvantages (water uptake and questionable
biocompatibility) than advantages.
Conclusion
The conclusion can be drawn that the stability of all-ce-
ramic crowns might be better when they are bonded to
enamel. If enamel is not available, the advantages of res-
in cements are questionable. From the clinical and prac-

tical points of view, there seems to be greater benefit in
using glass-ionomer cements, which are “adhesive,” re-
lease fluoride, and have been clinically well-proven over
years. Nevertheless, ceramics have different material
traits than alloys. Dentists and technicians have to adopt
a “ceramic thinking” to recognize the specific require-
ments of ceramics. Then, successful clinical work with
all-ceramic systems is possible, even if crowns are “on-
ly” conventionally cemented.
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