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Dental luting agents: A review of the current literature

Stephen F. Rosenstiel, BDS, MSD,a Martin F. Land, DDS, MSD,b and Bruce J. Crispin, DDS, MSc
Columbus, Ohio
Statement of problem. The practice of fixed prosthodontic has changed dramatically with the introduc-
tion of innovative techniques and materials. Adhesive resin systems are examples of these changes that have
led to the popularity of bonded ceramics and resin-retained fixed partial dentures. Today’s dentist has the
choice of a water-based luting agent (zinc phosphate, zinc polycarboxylate, glass ionomer, or reinforced zinc
oxide-eugenol) or a resin system with or without an adhesive. Recent formulations of glass ionomer luting
agents include resin components (resin-modified glass ionomers), which are increasingly popular in clinical
practice.
Purpose. This review summarizes the research on these systems with the goal of providing information
that will help the reader choose the most suitable material.
Material. The scientific studies have been evaluated in relation to the following categories: (1) biocompati-
bility, (2) caries or plaque inhibition, (3) microleakage, (4) strength and other mechanical properties, (5)
solubility, (6) water sorption, (7) adhesion, (8) setting stresses, (9) wear resistance, (10) color stability, (11)
radiopacity, (12) film thickness or viscosity, and (13) working and setting times. In addition, guidelines on
luting-agent manipulation are related to available literature and include: (1) temporary cement removal, (2)
smear layer removal, (3) powder/liquid ratio, (4) mixing temperature and speed, (5) seating force and
vibration, and (6) moisture control. Tables of available products and their properties are also presented
together with current recommendations by the authors with a rationale. (J Prosthet Dent 1998;80:280-301.)

T he American Academy of Fixed Prosthodontics


Ad Hoc Committees on Research in Fixed Prostho-
dontics are charged to help sustain academic excellence
and interest in Fixed Prosthodontics. Their aim is to
disseminate knowledge though an annual literature
review of an area of scientific investigation or clinical
practice with relevance to the Fixed Prosthodontic
community. The Committee has selected Dental Lut-
ing Agents as this year’s choice.
OVERVIEW
Dental luting agents provide the link between a
fixed prosthesis and the supporting prepared tooth
structure. Traditionally, zinc phosphate cement has Fig. 1. Survival of fixed partial dentures. From Creugers et
been the most popular material, despite its well-docu- al.,1 meta-analysis of survival studies of conventional FPDs
mented disadvantages, particularly solubility and lack of since 1970. Data of 4118 FPDs were analyzed with calcu-
adhesion. These drawbacks notwithstanding, the suc- lated overall survival rate of 74.0% ± 2.1% after 15 years.
cess of fixed prostheses has been well-documented. A
recent meta-analysis of clinical data of conventional
fixed partial dentures (FPDs) revealed an overall sur- because they have addressed the disadvantages of solu-
vival rate of 74.0 ± 2.1% after 15 years (Fig. 1),1 which bility and lack of adhesion.
represents outstanding clinical success. Nevertheless, Glass ionomer cements are also popular, principally
many alternative materials have been introduced and because these materials release fluoride that may pre-
recently resin cements have become popular, primarily vent recurrent caries. The performance of glass
ionomer as a luting agent in general practice has been
aProfessor and Chairman, Section of Restorative Dentistry, Prostho- well-documented. In an 8-year follow-up of 1230 cast
dontics and Endodontics, The Ohio State University College of restorations, few complications were found.2 Newer
Dentistry, Columbus, Ohio. materials include the adhesive resins and the resin-
bAssociate Professor and Chairman, Department of Restorative
modified glass ionomer,3 although, as for all recently
Dentistry, Southern Illinois University, School of Dental Medi-
cine, Alton, Ill. introduced materials, long-term clinical studies are not
cProfessor of Fixed Prosthodontics, Director UCLA Center for yet available. (The terminology of some of the newer
Esthetic Dentistry, UCLA School of Dentistry, Los Angeles, Calif. glass ionomer/resin combinations is rather confusing.

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Table I. Comparison of available luting agents


Zinc Poly- Resin Adhesive
Property Ideal material phosphate carboxylate Glass ionomer ionomer Composite resin

Film thickness (µm)† Low <25 <25 <25 >25 >25 >25
Working time (min) Long 1.5-5 1.75-2.5 2-3.5 2-4 3-10 0.5-5
Setting time (min) Short 5-14 6-9 6-9 2 3-7 1 - 15
Compressive strength High 62-101 67-91 122-162 40-141 194-200 179-255
(MPa)
Elastic modulus Dentin = 13.7 13.2 nt 11.2 nt 17 4.5-9.8
(GPa)249 Enamel = 84-130250
Pulp irritation Low Moderate Low High High High High
Solubility Very low High High Low Very low Very low Very low
Microleakage‡ Very low High High to very high Low to very high Very low High to Very low
very high to low
Removal of excess Easy Easy Medium Medium Medium Medium Difficult
Retention§ High Moderate Low/moderate Moderate-to-high nt Moderate High
*Modified from Rosenstiel SF et al. Contemporary fixed prosthodontics. 2nd ed. St Louis: Mosby; 1995. p. 621.
†See Figure 16.
nt = Not tested.
‡See Figure 8.
§See Figure 13.

Table II. ANSI/ADA Specification No. 96 dental water-based cements. Requirements of dental cements (luting)
Maximum
Film Minimum Maximum acid-soluble
thickness compressive acid (As/Pb)
Chemical type Components max. (µm) Setting time (min) strength (MPa) erosion (mm/h) content (mg/kg)

Zinc phosphate Oxide powder (principally zinc 25 2.5 (minimum) to 70 0.1 2/100
oxide) and aqueous solution of 8 (maximum)
phosphoric acid
Zinc polycarboxylate Zinc oxide and aqueous 25 2.5 (minimum) to 70 2.0 2/100
solutions of polyacrylic acid 8 (maximum)
or similar polycarboxylic
compounds
Glass polyalkenoate Aluminosilicate glass powder 25 2.5 (minimum) to 70 0.05 2/100
(ionomer) and an aquaous solution of 8 (maximum)
an alkenoic or tartaric acid

In this review, the term resin-modified glass ionomer has phosphate, zinc polycarboxylate, and glass ionomer
been used, except in the figures and tables where the [also termed glass polyalkenoate]) are covered by the
abbreviated term resin ionomer is used. Other terms ISO Standard 9917:1991 and ANSI/ADA specifica-
used for luting agents and restorative materials with a tion No. 96 (which replaced ANSI/ADA specifications
combination of glass ionomer and resin chemistries Nos. 8, 9, 21, 61, and 66). This specification prescribes
include compomer [mostly composite with some glass maximum and minimum values for a range of standard
ionomer chemistry], hybrid ionomer [now considered laboratory tests (Table II) that must be achieved if a
obsolete], and resin-reinforced glass ionomer.) manufacturer is to submit their product for ADA Cer-
The dentist has a wide choice of many different tification.
products, each with advantages and disadvantages. No Therefore the aim of this review is to distill the
currently available luting agent is ideal for all situations recent scientific literature on luting agents and their
and much work has been reported on their properties. use, to help identify properties of an optimal luting
Table I summarizes available material classes and some agent, and to assess how currently available materials
of their properties. Water-based luting agents (zinc meet that ideal.

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Fig. 4. Effect of incomplete curing time on cytotoxic poten-


tial of resin luting agents. (From Caughman et al.25)

Fig. 2. Clinical trials that evaluated postcementation sensi-


tivity of crowns cemented with zinc phosphate or glass At the histologic level, luting agents appear to cause
ionomer cement. Contrary to anecdotal evidence, glass little pulpal response,16 particularly if the remaining
ionomer-cemented crowns did not exhibit increased postce- dentin thickness exceeds 1 mm.17 Side effects, such as
mentation sensitivity. posttreatment sensitivity, that have been ascribed to
lack of biocompatibility are probably due to desiccation
or bacterial contamination18 of the dentin rather than
irritation by the cement per se. Anecdotal reports that
state glass ionomer causes more posttreatment sensitiv-
ity have not been supported by clinical trials. Authors
have reported little association between the choice of
zinc phosphate or glass ionomer cement and increased
pulpal sensitivity, provided manufacturers’ recommen-
dations were followed (Fig. 2).19-21 If dentists in prac-
tice find postcementation sensitivity to be a problem,
they should carefully evaluate their technique, particu-
larly avoiding desiccation of the prepared dentin
surface. If they apply a desensitizing agent, this
may reduce retention, at least with some luting
Fig. 3. Biocompatibility of dental luting agents. Caughman et cements22,23; however, one study reported little or no
al.25 evaluated cytotoxic potential of luting agents on in vitro effect.24
cultures of gingival fibroblasts and oral epithelial cells. Inhi- When evaluating the relative biocompatibility of
bition of protein and RNA synthesis varied with material and various products based on laboratory studies, it is
cell type.
important to appreciate that products may rank
differently depending on the cell type used for testing
(Fig. 3).25,26 Therefore clinical selection should be
based on as wide a range of tests as possible. The bio-
IDEAL PROPERTIES
compatibility of resin luting agents is related to its
Biologic properties degree of conversion and complaints of sensitivity may
Biocompatible. An ideal dental luting agent should be due to incomplete polymerization of the resin
be biocompatible, that is, have little interaction with cement (Fig. 4).25,27 It has been found that polymer-
body tissues and fluids,4 be nontoxic, and have low ization of light-activated composite luting agents can-
allergic potential. Currently available materials general- not be accomplished predictably through a pre-
ly demonstrate good biologic performance, although processed resin restoration exceeding 2 mm in thick-
some adverse effects have been detected.5-10 Polycar- ness with a light exposure of 90 seconds or less,28 so a
boxylate or reinforced zinc oxide/eugenol cements self- or dual-cure product should be chosen for adhe-
have been recommended over the stronger zinc phos- sively cemented inlays.
phate and glass ionomer if pulpal irritation is a concern. Occasionally, patients exhibit allergies to dental
These cements are more biocompatible because the set- materials, although the incidence is relatively low.29
ting cement has a higher pH11-14 and restorations Allergy to the constituents of resin luting agents has
cemented with these cements exhibit lower bacterial been reported, by patients and dental personnel, but it
microleakage.15 is apparently quite rare.30-34

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Fig. 5. Fluoride concentration in artificial saliva after exposure to glass ionomer luting agents.
Muzynski et al.35 examined solubility of 4 glass ionomer cements by measuring fluoride
release from simulated dental restorations.

Caries or plaque inhibition. Caries is one of the pri-


mary causes of failure of cast restorations, so an ideal
luting agent would actively prevent caries at the
restoration-tooth interface. The popularity of the glass
ionomer luting cements is undoubtedly due to the flu-
oride release associated with these materials35 (Fig. 5)
and the presumed benefit of reduced caries. The goal of
caries prevention also justifies the incorporation of flu-
oride into other luting agents such as polycarboxy-
lates.36 However, the evidence for caries reduction
remains indirect. Glass ionomer luting cement has been Fig. 6. Effect of different luting agents on artificial caries pro-
shown in vitro to reduce demineralization around gression around class V inlay restorations. In this in vitro
crowns despite reduced solubility (wash out) of the experiment, Staninec et al.47 found that caries was much
material compared with zinc phosphate or polycar- more extensive at gingival margin, but choice of luting agent
boxylate cement.37 In vivo, glass ionomer cement has did not influence depth of lesion.
been shown to increase the fluoride ion concentration
in the saliva in the short-term.38 Glass ionomer
cemented orthodontic bands have been shown to colonies at the restoration margins. However, many
reduce artificial caries in vitro39,40 and to increase adja- available materials do possess antimicrobial properties
cent enamel fluoride levels.41 In vivo, they have been (Fig. 7),49,50 but their effects diminish rather rapidly
shown to modify the caries-causing organisms.42 When with time. It is unclear if the materials found to have
used as a restorative material, both conventional and higher in vitro antimicrobial properties, such as the
the resin-modified glass ionomers have been shown in resin-modified glass ionomer Vitrebond (3M Dental
vitro to reduce artificial caries43,44 and in vivo to re- Products, St. Paul, Minn.), have improved clinical per-
mineralize carious lesions45 and to enhance fluoride formance. Luting agents and dentin bonding agents
uptake by underlying dentin.46 However, in an in vitro have a lower antimicrobial effect than glass ionomer
experiment with Class V inlays, the choice of cement cements formulated for cavity liners or bases.51
(glass ionomer, zinc phosphate, or resin) was found to Researchers have incorporated antimicrobials into lut-
not influence the extent of artificial caries (Fig. 6)47 ing agents and demonstrated effectiveness in vitro,52,53
and doubt remains whether there is an actual clinical although the benefits of these formulations have yet to
benefit. The newer resin-modified glass ionomer mate- be reported clinically.
rials have been shown to release fluoride,48 although Microleakage. Microleakage of organisms around
this varies from product-to-product and, again, it is dental restorations has been implicated in adverse pul-
unclear if in vitro fluoride release is, in fact, a good pre- pal response and hence reduced restoration longevity.54
dictor of clinically significant caries protection. A restoration cemented with an ideal dental agent
An ideal luting agent possesses antimicrobial would be resistant to microleakage. Researchers have
properties that combat cariogenic bacteria on the pre- attempted to simulate leakage of bacteria and/or their
pared tooth and reduce the effect of future plaque toxins with the use of stains and exposure to radioac-

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Fig. 7. Antibacterial properties of luting agents. Antibacterial action of freshly mixed dental
luting agents was tested with cultures of carious debris by Coogan and Creaven.49 Resin-mod-
ified glass ionomer Vitrebond had significantly greater zone of inhibition than zinc oxide
eugenol, glass ionomer, and zinc phosphate. Panavia adhesive resin exhibited minimal
antibacterial action.

Fig. 8. Microleakage of luting agents. Comparison of data from 1 clinical and 5 laboratory
studies expressed as percentage of value obtained for zinc phosphate cement. Considerable
variation was reported with adhesive resins and resin-modified glass ionomer exhibiting low
microleakage values.

tive45 Ca solution. However, it is noted that no direct sumably because the weakest link is at the tooth/
correlation has been yet demonstrated between cement or cement/restoration interface.
microleakage rankings and clinical performance and
Mechanical properties
these results, like those of many laboratory tests should
be interpreted with caution. Nonadhesive resins have An ideal luting agent has sufficient mechanical prop-
increased microleakage compared with traditional erties to resist functional forces over the lifetime of the
cements,55,56 whereas adhesive resin systems have restoration. In addition, it resists degradation in the
reduced microleakage in in vitro57-64 and also in vivo65 oral environment and adheres to the underlying dentin,
testing (Fig. 8), which may account for their populari- again, over the lifetime of the restoration. Typically,
ty. The resin-modified glass ionomers appear to exhib- properties such as strength, solubility, and bond
it similar performance to the adhesive resins.66 These in strength are measured in vitro, for example, in accor-
vitro microleakage tests appear to be little influenced by dance with the American National Standards Insti-
the marginal adaptation of the cast restoration,67 pre- tute/American Dental Association (ANSI/ADA) test-

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Fig. 9. Compressive strength of luting agents. Higher strength values were reported in these
studies with resin cements and glass ionomers than with zinc phosphate or polycarboxylate.
Resin-modified glass ionomer exhibited greater variation than other cements.

ing protocol (Table II), and used to estimate material hardness testing.71 With respect to these properties,
quality and hence clinical performance. Testing is con- filled resin luting agents generally exhibit higher values
ducted under optimized conditions and carefully pro- in comparison to traditional and unfilled resin cements.
portioned mixing ratios. It should be noted that the Researchers have sought to improve the properties
mechanical properties of cements may be markedly dif- of dental luting agents by modifying their composition.
ferent if these conditions are altered. Examples include the addition of phytic acid to zinc
Strength and other mechanical properties. For a phosphate,85 N-acryloyl-substituted amino acid
restoration to function satisfactorily over many years, monomers to glass ionomer,86 and resin fibers to
the luting agent must have sufficient strength to resin.87 These studies reported improved mechanical
resist fracture and also longer-term cyclical fatigue properties; however, other experimental approaches
stresses.68,69 reported improved working properties but reduced
Compressive strength has been used as a predictor of strength.88
clinical performance (Fig. 9).70-74 For example, Poor clinical performance may be a consequence of
ANSI/ADA specification No. 96 (ISO 9917) for den- a material that exhibits high creep. Creep is time-
tal water-based cements requires a minimum compres- dependent deformation and has been measured for lut-
sive strength of 70 MPa at 24 hours (Table II). The ing agents. Cattani-Lorente et al.72 found that glass
compressive strength of glass ionomer cement, in par- ionomer luting agents had creep values from 0.6% to
ticular, continues to increase over several weeks to 2.0%, which was higher than the polycarboxylate they
about 200 MPa. This continued increase is thought to used as a control. Creep values for composites are sim-
be due to reconstruction of the silicate network.75 It is ilar to glass ionomer, at least for restoratives,89 whereas
unclear how valuable compressive strength data are in zinc phosphate cement exhibits little creep.90
selecting a clinical material, especially when choosing Some luting agents are markedly affected by changes
among different types of luting agent, for example, in temperature. This may be of clinical significance as
between a resin and a glass ionomer. Unfilled adhesive laboratory testing is generally conducted at room tem-
resin luting agents such as C&B Metabond (Parkell perature (23°C), whereas the materials are required to
Products, Farmingdale N.Y.) exhibit too much plastic function at 37°C. Mesu91 found that the strength of
deformation to be tested in this way.71 However, a cor- EBA-reinforced zinc oxide/eugenol cement was partic-
relation between high strength and low margin wear of ularly affected, whereas zinc phosphate was little
resin cements has been demonstrated in vitro.76 changed (Fig. 10). He did not test a glass ionomer
Investigators have evaluated other mechanical prop- cement, and the work has not been repeated with more
erties of luting agents to characterize the materials contemporary materials.
more fully and thereby predict their clinical behavior Clinicians will appreciate that a product that tests
more accurately. Work has included flexural well under well-controlled laboratory conditions may
strength,72,77 diametral tensile strength,71,72,78-81 not be a good choice if it is very sensitive to slight vari-
modulus of elasticity,82 fracture toughness,83,84 and ations in proportioning or manipulation.92 Bruce and

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Fig. 10. Compressive strength of traditional water-based Fig. 11. Solubility of luting agents. Reduction in size of
cements decreases with increasing temperature. Mesu91 cement films held between glass optical flats subjected to
found this to be most marked with EBA-reinforced zinc acetic acid was evaluated in vitro by Swartz et al.100 Data
oxide cement, which lost 50% of its strength from room to were shown to correlate well with in vivo disintegration.
mouth temperature. Reducing powder/liquid ratio increased disintegration rate,
particularly for polycarboxylate cement. GI, Glass ionomer;
PC, polycarboxylate; ZP, zinc phosphate.
Stevens93 found that a 30% reduction in the
powder/liquid ratio of zinc phosphate, which might be
used to facilitate the cementation of multiple units, matic effect on solubility.100,107 This may explain
resulted in a 26% reduction in compressive strength. reports of poor clinical performance of polycarboxylate
However, others have reported that a similar change in cement, despite relatively good performance in labora-
powder/liquid ratio had little adverse effect, at least on tory tests. Polycarboxylate cement material is
retention.94,95 The retention of crowns cemented with thixotropic; that is, it is semisolid when left standing
C&B Metabond adhesive resin also appears to be little but behaves as a fluid when subjected to stress. Practi-
affected by powder/liquid ratio.96 Increasing the pow- tioners or dental assistants may be tempted to mix the
der to liquid ratio of a cement will yield improved material too thinly— obtaining a consistency resem-
mechanical properties. Among others, this has been bling zinc phosphate cement—with greatly reduced
demonstrated for glass ionomer97; however, excessive strength and increased solubility.
quantities of powder are contraindicated as working Some cements, particularly the glass ionomers, have
properties will be adversely affected. been found to be especially sensitive to early mois-
Low solubility. An ideal luting agent is impervious to ture108-110 and should be protected with a foil or resin
oral fluids and resists dissolution over the lifetime of the coat or by leaving a band of cement undisturbed for 10
restoration. The ANSI/ADA specification No. 96 tests minutes. However, glass ionomers should not be
solubility with an impinging jet technique, which is allowed to desiccate during this critical initial setting
intended to reflect material quality rather than clinical period. The newer resin-modified glass ionomers are
performance per se. Traditional water-based luting less susceptible to early moisture.80
cements, such as zinc phosphate, do not have very low Water sorption. Resin cements, particularly the ure-
solubility (Fig. 11),37,98-103 and the success of restora- thane-based materials, are susceptible to water sorp-
tions cemented with these cements has been ascribed to tion,111,112 with less heavily filled materials exhibiting
excellent adaptation between the casting and the pre- greater sorption.113-115 Of the popular adhesive resin
pared tooth. However, cement dissolution has been luting agents, unfilled materials such as C&B
shown in vitro to be independent of the marginal width Metabond and the resin-modified glass ionomers
up to a certain critical value, and then to only increase exhibit the greatest water sorption (Fig. 12). Water
slightly, data explained by Fick’s first law of diffusion.104 sorption will adversely affect the mechanical properties
(Fick’s First Law states that the flux of a component of of the resin,116,117 although the resultant expansion
concentration across a membrane of unit area, in a pre- may be beneficial as it counteracts polymerization
defined plane, is proportional to the concentration dif- shrinkage.118
ferential across that plane.) This and other studies iden- Adhesive. When using a traditional nonadhesive lut-
tify dissolution rather than physical disintegration as the ing agent such as zinc phosphate, retention is depen-
mechanism for cement erosion.105 They explain the suc- dent on the geometric form of the tooth preparation
cess of cast restorations, despite the prevalence of rela- that limit the paths of displacement of the cast restora-
tively large subgingival marginal discrepancies, which are tion.119 In practice, ideal axial wall convergence is
difficult to detect even at 0.1 mm.106 rarely obtained,120 and lack of retention is a common
Modifying the powder/liquid ratio can have a dra- cause of fixed prosthesis failure.121 A reliable adhesive

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Fig. 12. Water sorption of resin luting agents. C&B-Metabond unfilled resin and resin
ionomers have increased water sorption compared with filled resins tested. (From Kerby RE,
et al. J Dent Res 1995;74:243; and Knobloch L, et al. J Dent Res 1996;75:372.)

Fig. 13. Crown retention studies. Effect of luting agent. These 6 in vitro studies evaluated effect
of luting agent on crown retention. Data were normalized as percentage of retention value
with zinc phosphate cement. Adhesive resins had consistently greater retention than zinc
phosphate. Conventional resins and glass ionomers yielded less consistent results.

luting agent would therefore enhance fixed prostho- retention tests are performed by removing a standard-
dontic treatment. The effect of luting agents on casting ized casting from a stylized crown preparation in a ten-
retention has been assessed with in vitro studies. Adhe- sile mode and recording the failure load. When fatigue
sive resins such as Panavia (J. Morita USA Inc., Tustin, testing was performed, glass ionomer and composite
Calif.) have shown increased retention when compared resin luting agents were found to perform better than
with zinc phosphate, glass ionomer, or conventional zinc phosphate.138
resin cements (Fig. 13).122-128 Most adhere to the pre- The choice of foundation restoration material may
pared tooth by impregnating partially demineralized affect retention of the cemented crown. One study
dentin with hydrophilic resins, producing a so-called found that zinc phosphate cement retained crowns bet-
“hybrid layer.”129,130 Adhesion to gold-containing ter on amalgam than on composite resin cores.139 It is
alloys can be increased by tin-plating or using metal noted that resin cements are affected by eugenol-con-
primers.131-137 Typically, these laboratory adhesion or taining cements, which should be removed if the adhe-

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Fig. 14. Resin-to-metal bonding. Effect of luting agent. These 9 in vitro studies evaluated resin
luting agents for metal bonding, namely, for resin-retained restorations. Data were normal-
ized for Panavia phosphate-based adhesive resin. In most studies it was found to have high
retention values. Carboxylic-based C&B Metabond was found to be superior to Panavia in 1
study and greatly superior in another. However, it was similar or inferior in 5 studies.

sive is to be effective.22,140,141 Pulpal protection agents, formance of resin-to-metal bonding, which might sim-
such as calcium hydroxide or potassium oxalate, may ulate the clinical situation more closely. One study
reduce crown retention with zinc phosphate, glass found that an adhesive resin performed better than
ionomer, or resin cements. BIS-GMA for Co-Cr alloys but the reverse for Ni-Cr
Adhesive resin luting agents have the potential to alloys,158 a difference that might be attributable to
improve the performance of post and core restorations etching of the Ni-Cr. The theoretical basis for such
and laboratory studies have shown improved retention. variation has been explored with high adherence to Ni-
However, different products have been found to give Cr alloy being attributed to formulations with relative-
different retention values. For example, one study on ly polar monomers.159 Many of these studies and oth-
prefabricated posts found the C&B Metabond adhesive ers examined the effects of choice of alloy, its prepara-
resin had the greatest retention, and the Ketac-Cem tion, and the use of metal primers on bonding.160 Care
glass ionomer (ESPE, Norristown, Pa.) was equivalent should be taken in interpreting such results. A particu-
to Panavia adhesive resin and had better retention than lar adhesive system may test well under one set of con-
All-Bond 2 luting agent (Bisco, Itasca, Ill.).142 Anoth- ditions but these may not replicate how it is used by the
er study found no difference among air-abraded posts individual dentist.
cemented with resin luting agents, even though all Most adhesives are adversely affected by high
were more retentive than zinc phosphate.143 Converse- humidity, supporting the use of rubber dam during the
ly, when bonding titanium to tooth structure, Panavia bonding procedure; one study demonstrated this effect
and All-Bond 2 yielded significantly higher values than with the Panavia system.161 Also of clinical concern is
C&B Metabond.144 The practitioner is cautioned not the effect on the adhesive bond of ultrasonic vibration
to overinterpret the results of a single laboratory test as it is applied during a scaling procedure. However,
when making clinical decisions. one study found that 5 minutes of ultrasonic scaling
The availability of adhesive resin cements has popu- only diminished the adhesion of a composite system to
larized conservative prostheses such as porcelain inlays, Ni-Cr alloy by 9%.162
veneers and resin-retained FPDs. The latter especially All-ceramic restorations have become increasingly
demand a reliable bonding system, though most also popular because of their outstanding esthetics and the
recommend some mechanical tooth preparation to pro- availability of higher strength materials. An ideal luting
vide resistance form rather than relying exclusively on agent would provide a reliable bond to the ceramic and
adhesion. Laboratory studies have examined the effects tooth structure and also prevent fracture of the ceramic.
of the luting agent as well as metal and enamel prepa- Resin-bonding provides much better retention than
ration on the bond strength of resin-retained prosthe- conventional cements,163 and also appears to provide
ses.145-157 The summarized results of some of these strengthening. Laboratory studies have compared avail-
comparisons are illustrated in Figure 14, which reveals able resin luting systems for ceramics,164,165 although
considerable variation in performance. there is concern that some testing evaluates the strength
Some investigators have looked at the fatigue per- of the bonding resin rather than that of the bond

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itself.166 It should be emphasized that the treatment of sive or cohesive strength of the luting agent, failure will
the ceramic surface is important to achieving high bond occur.188,189
strength167-170 and contamination of the ceramic surface Wear resistance. Problems of luting agent wear are
will significantly reduce this value.171,172 Resin-modified seldom significant with traditional fixed prostheses.
glass ionomers have been suggested as an alternative to With ceramic and composite inlays, there is a concern,
resins for luting all-ceramic restorations, based on their particularly with increased restoration-tooth gap
laboratory performance. However, anecdotal reports of widths,190 although one clinical trial of CAD-CAM
fractured all-ceramic restorations have ascribed to the inlays found little clinically significant cement wear after
use of this class of luting agent.173 Until long-term clin- 4 years.191 These authors postulated that luting agent
ical data with these materials have been reported, clini- wear might be self-limiting because of simultaneous
cians may wish to exercise caution with resin-modified wear of the enamel margin. Luting agents have been
glass ionomers as a luting agent for all-ceramic restora- tested in vitro for wear, the authors concluding that
tions. At least one manufacturer (Dentsply/Caulk, Mil- wear performance is not well-correlated with mechani-
ford, Del.) has contraindicated the use of their resin- cal properties data.192 The use of surface-penetrating
modified glass ionomer (Advance) with all-ceramic sealants, while effective in reducing wear of composites,
crowns, porcelain veneers, and metal ceramic crowns do not appear to be effective in preventing wear of the
with porcelain margins. luting agent.193
There is evidence that the use of resin-bonding with
Esthetic properties
all-ceramic crowns has enhanced these restorations by
improving their fracture resistance. This strengthening The esthetic properties of luting agents are of con-
effect has been demonstrated in some, but not all, lab- siderable significance with the increasing use of translu-
oratory experiments82,174-178 and has been supported cent ceramic restorations, especially for anterior
with clinical data.179 The mechanism for the strength- restorations. Expanded kits of resin cements with acces-
ening is not known for certain, but it is probably due in sories, tints, opaque, and multiple shades are tailored to
part to prevention of crack propagation from the inter- anterior ceramic restorations and enable subtle shade
nal surface by the bonded resin.180 There have been corrections to be made.194 Water-soluble try-in pastes
experimental attempts to bond water-based cements to are recommended and should be accurately color
ceramic.181 If resin luting agents are used without matched to the cement shade. In practice, however, the
bonding to the ceramic restoration, there appears to be color of the try-in paste may differ significantly from
no strengthening compared with zinc phosphate or the cement. Of three shades of three brands tested by
glass ionomer.182 It is less clear if all-ceramic systems Balderamos et al.,195 all but two had easily detectable
that use a high-strength core, such as In-Ceram color differences, although these were considerably
(Vident, Baldwin Park, Calif.), are strengthened with reduced when placed behind a porcelain disk. When a
bonded resin luting. Theoretically, if the fracture initi- manufacturer does not supply an accurate try-in paste,
ates at the core/veneering porcelain interface, the the actual material can be used, but it must be prevent-
choice of luting agent would not affect strength.183 ed from polymerizing prematurely. On the other hand,
Low setting stresses. Glass ionomer and resin luting posterior restorations where esthetic demands are not
agents shrink during setting, which causes undesirable as great can usually be cemented with a “universal”
stresses in the set material.184,185 Contraction gaps can shade. These shades are typically light colored and have
occur at the dentin-cement interface that may be in the good translucency.
range of 1.6 to 7.1 µm. This is 3 to 10 times greater Color stability. When considering enhancing esthet-
than the wall-to-wall contraction in percentage ics by controlling the color of cements, the effect of
observed when resin composites are used as filling cement color change over time should be consid-
materials.185 To some extent these stresses are com- ered.196,197 The amine accelerator necessary for dual
pensated for by expansion due to water sorption.186 polymerization can cause the color of the luting agent
With glass ionomers especially, exposure to moisture to change over time.198 Therefore many practitioners
at the appropriate stage can be an important variable in prefer light-cured resin cements for luting of porcelain
clinical success. If exposure is too early, the mechanical veneers and other esthetic restorations because it is
properties of the luting agent are adversely affected. thought that they are more color stable.
Leaving the cement too long may lead to fracture with- However, Noie et al.199 have shown that, although
in the cement layer.118 Setting stresses in resin cements measurable color changes of dual resin cements were
are reduced if chemically activated rather than light- detected under accelerated aging, they were not found
cured formulations are used. This may be due to the to be visually perceptible. Their findings suggest that
increased porosity leading to increased free surface or the practitioner can use dual-cure resin cements in
oxygen inhibition that occurs as air is incorporated dur- esthetic areas with confidence. Another study involving
ing mixing.187 If the stresses are greater than the adhe- color stability of 5 dual-cure resin cements (Kerr

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THE JOURNAL OF PROSTHETIC DENTISTRY ROSENSTIEL, LAND, AND CRISPIN

Fig. 15. Radiopacity of luting agents. These 3 in vitro studies compared radiographic appear-
ance of various luting agents with aluminum. Data were normalized to account for different
specimen thickness used by investigators. Excess luting agent will be more difficult to detect
if materials with lower values are chosen. Also, margin gaps and recurrent caries will be more
difficult to diagnose.

Porcelite, Jelenko PVS System, Vivadent Heliolink, ty.207 It should be noted that C&B Metabond unfilled
Mirage FLC, Denmat Ultrabond) concluded that Heli- adhesive resin (Parkell) is radiolucent in its clear for-
olink showed the least and Porcelite the greatest color mulation. The tooth-colored formulation has recently
change. It was found that all dual-cure composite been established to impart radiopacity with a zirconium
cements tested exhibited some short- and long-term additive.
color changes.200
Working properties
Radiopacity. An ideal luting agent should be
radiopaque to enable the practitioner to distinguish Film thickness, viscosity. The film thickness of the lut-
between a cement line and recurrent caries, as well as ing agent can directly affect long-term clinical success.
detect cement overhangs.201 Combinations of compos- In vivo evaluation of film thickness for zinc phosphate
ite luting cements and/or glass ionomer cements may cement and resin-modified glass ionomer cement with
show gap-like features because of differences in and without the use of a bonding agent, has demon-
radiopacity. Therefore it is important that luting agents strated comparable results, the mean vertical opening
have greater radiopacity than dentin.202 Problems of of crowns cemented on periodontally hopeless
interpretations about the presence of secondary caries teeth was reported as 41.6 µm (standard deviation
or gaps near the restoration may then be avoided.203 46.6 µm).65
It is impossible to detect excess luting agent radi- Clinicians should be aware that the type of luting
ographically if that material is effectively radiolucent, so agent selected can directly affect film thickness
radiolucent cements should not be used with ceramic (Fig. 16).208-211 The metal type of the restoration on
inlay systems in particular. As the radiopacity of the lut- the other hand does not appear to be of clinically sig-
ing agent increases, the detection threshold for mar- nificant impact. However, the mixing technique has
ginal overhangs decreases; thus, a luting agent should been shown to result in potentially clinically significant
be chosen that is as radiopaque as possible. In an in variation and is of greater influence than the metal type
vitro study significant excess could not be detected in of the restoration being cemented. For instance,
association with radiopaque resin composite inlays, mechanical trituration may actually result in reduced
even with the most radiopaque materials, but could be film thickness for selected glass ionomer cements,212
detected adjacent to radiolucent porcelain inlays.204 theoretically a clinical benefit. Different cements may
In practice, available luting agents come in a wide require different cement spacing to ensure optimal
range of radiopacities.203,205,206 Figure 15 summarizes seating.213 The resultant crown elevation is thought to
data from these studies. Triphenyl bismuth is an exam- be a function of luting agent viscosity, which in itself is
ple of an additive to biomedical resin that increases a time-dependent property that further increases with
radiopacity. It has been shown to have low cytotoxici- an increase in temperature.214 Resin cements have been

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Fig. 16. Film thickness of range of luting agents was tested according to ADA Specification
No. 8 for zinc phosphate cement (Now ANSI/ADA specification No. 96) by White and Yu.71
Some adhesive materials were found to possess unacceptably high film thicknesses, which
may translate into clinical problems in attaining complete restoration seating.

shown to result in a significantly higher incidence of Extending the working time of glass ionomer
tilted castings, which demonstrated uneven cement cement may have minimal impact on the resulting film
thicknesses by comparison to zinc phosphate, glass thickness.223 In contrast, for resin luting agents, work-
ionomer, or polycarboxylate cements,215 presumably ing time does not affect film thickness adversely. Nei-
because of the higher viscosity of the resin. The clinical ther working nor setting time of resin luting agents
significance is, although a resin cement may be selected appear significantly influenced by variations in mass
for its advantageous mechanical and adhesive advan- ratio of base and catalyst up to ±20%.224 The working
tages, its manipulation may bring with it an increased time of dual-cure composite resin luting cements is sig-
risk of incomplete seating of the restoration. nificantly reduced by the use of a dual-cure adhesive.225
As film thickness increases, the tensile bond strength Borax reduces working time and setting time of glass
of cements to cast alloy decreases, although the oppo- ionomer cements, and also results in deteriorated
site has been reported for polycarboxylate cement.216 diametral, tensile, and compressive strengths, as well as
Adhesive resin cements may be affected in this deteriorated solubility characteristics, although fluoride
respect to a greater degree than are polycarboxylate release appears to be unaffected.88 Tartaric acid affects
cements.217 Film thickness is influenced by manipula- the setting of glass ionomer cement differently,
tive variables such as mixing temperature and pow- depending on its concentration. Low concentrations
der/liquid ratio. Cold mixing significantly reduces accelerate the development of viscosity, whereas higher
glass-ionomer film thickness at extended working times concentrations retard such. At intermediate concentra-
and increased powder/liquid ratios. 218 In contrast, tions, tartaric acid initially induces a lag period in the
dual-cure resin luting agents exhibit larger film thick- setting process during which viscosity remains relative-
nesses when mixed at lower temperatures.219 ly constant. This is followed by a sharp, exponential vis-
Working time and setting time. In addition to film cosity increase, its practical effect being prolonged
thickness, the setting time of luting agents is also influ- working time, followed by a sharpened setting. Tartar-
enced by temperature. As temperature increases, the ic acid is unique in this respect in that other hydroxy-
working and setting time of glass ionomer and resin acids either retard or accelerate viscosity development
luting agents decrease, more so for dual-cure through all stages of the reaction.226
cements.220 A frozen slab technique (–18°C to –24°C)
MANIPULATION
has been shown to extend the working time of zinc
phosphate cement. However, maximum compressive The continued development of glass ionomer
strength results when the slab temperature is between cements and dentin adhesives has led to a decline of the
+4°C and +8°C (refrigerator temperature).221 When use of traditional zinc phosphate materials. However,
mixing glass-ionomer cement, the use of a chilled slab there is concern that the actual clinical outcome may
will increase working time significantly.222 not be improved. The newer materials tend to be more

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THE JOURNAL OF PROSTHETIC DENTISTRY ROSENSTIEL, LAND, AND CRISPIN

Table III. Indications and contraindications for luting agent types


Restoration Indicated Contraindicated

Cast crown, metal ceramic crown, FPD 1,2,3,4,5,6,7


Crown or FPD with poor retention 1 2,3,4,5,6,7
MCC with porcelain margin 1,2,3,4,6,7 Possibly 5
Casting on patient with history of posttreatment 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 FPD 1,2 3,4,5,6,7
Cast post and core 1,2,3,4,5,6,7
Key: Luting Agent Type Chief Advantages Chief concerns Precautions
1. Adhesive resin Adhesive, low solubility Film thickness, history of use Moisture control
2. Composite resin Low solubility Film thickness, irritation Use bonding resin, moisture control
3. Glass ionomer Fluoride release Solubility, leakage Avoid early moisture exposure
4. Reinforced ZOE Biocompatible Low strength Only for very retentive restorations
5. Resin ionomer Low solubility, fluoride Water sorption, history of use Avoid with ceramic restorations
6. Zinc phosphate History of use Solubility, leakage Use for “traditional” cast restorations
7. Zinc polycarboxylate Biocompatible Low strength, solubility Do not reduce powder/liquid ratio

technique sensitive and their use may entail additional cementation may be important to clinical success. A
steps that could widen the gap between their perfor- 1 to 2 µm thick smear layer is formed during tooth
mance under ideal conditions and their performance in preparation with smear plugs (below the smear layer)
everyday practice. As an example, the more critical usually extending 1 to 2 µm into dentinal tubules but
manipulation of the newer materials has led to occasionally penetrating as far as 10 µm.233 The smear
problems related to marginal leakage and to pulpal layer reduces dentin permeability and limits the
sensitivity.227 strength of dentin bonding agents because of the rela-
tively low cohesive forces holding the smear layer
Temporary cement removal
together and to the dentin. Its removal results in high-
Temporary cements that contain eugenol are a con- er bond strength of dentin adhesives,234 ideally leaving
cern when resin luting agents are used, as eugenol has the smear plug to reduce dentin permeability and sen-
been shown to inhibit resin polymerization, although sitivity.235 However, smear layer removal is undesirable
the formulations used as provisional luting agents have a when a dentinal adhesive is used that is reliant on the
less dramatic effect than USP zinc oxide-eugenol.228 presence of calcium.236 Thus, when the smear layer has
Noneugenol-containing formulations are available, with been removed, as after extensive contact with etchants
the eugenol replaced by an aromatic oil. However, such as hemostatic agents,237 alternative bonding
1 study demonstrated that both residual zinc oxide- agents, relying on bonding with dentinal collagen, may
eugenol (ZOE) and noneugenol containing temporary be preferable to the more conventional types that rely
cements reduced the tensile bond strength of resin lut- on calcium bonding. The enamel also acquires a smear
ing agents.140 In practice, all traces of temporary cement layer during grinding that is often removed, namely, by
should be thoroughly removed if adhesion is to be max- etching before adhesive bonding. The removal of the
imized. Air abrasion with Al2O3 will effectively remove enamel smear layer may improve resistance of the
residual ZOE cement residue, but neither alcohol nor restoration to leakage.
organic solvents will.229 Similarly, cleansing with pumice
Powder/liquid ratio
will leave a ZOE residue mixed with pumice that can
inhibit bonding.230 Etching with 37% phosphoric acid Variations in powder/liquid ratio will affect mechan-
after cleaning with pumice may be an alternative means ical properties of some cement types. For example, the
of ZOE removal.231 The retention of cast crowns maximum bond strength obtained with polycarboxy-
cemented with zinc phosphate cement or resin-modified late and glass ionomer cements may be improved by
glass ionomer or composite resin cores exposed to ZOE increasing the respective powder/liquid ratios97; how-
does not appear to be affected, although the hardness of ever, as the powder/liquid ratios of glass ionomer
the composite core is reduced.232 cement are increased, removal of excess cement
becomes more problematic238 and possibly leads to
Smear layer removal
increased intrapulpal temperature rise.239 As actual
The treatment of the dentin smear layer before powder/liquid ratios used in clinical practice may be

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ROSENSTIEL, LAND, AND CRISPIN THE JOURNAL OF PROSTHETIC DENTISTRY

Table IV. Comparison of traditional (powder/liquid) luting agents (manufacturers’ data)


Product name Manufacturer Type Composition Shelf life (RT) Working time Setting time

Bondalcap C Ivoclar/Vivadent Polycarboxylate Powder= zinc oxide; magnesium oxide 2 yrs 2 min 5 min
Liquid = polyacrylic acid
Durelon ESPE Polycarboxylate Powder = zinc oxide; tin fluoride 2 yrs 2.5 min 10 min
Liquid = phosphoric acid
Fleck’s Mizzy Zinc phosphate Powder = zinc oxide 2 yrs 3.5 min 7/11.5 min
Liquid = phosphoric acid
Fuji I GC America Glass ionomer Powder = fluoroaluminumsilicate glass; 3 yrs 2 min 5 min
polyacrylic acid; liquid polybasic
carboxylic acid
Fynal Dentsply/Caulk Reinforced ZOE Powder = zinc oxide; polymer 3 yrs 4 min 5 min
Liquid = eugenol; acetic acid
Glasionomer Shofu Glass ionomer Powder = fluoroaluminumsilicate glass 4 yrs 2.5 min 6.5 min
Liquid = polyacrylic acid
GlassLute Pulpdent Glass ionomer Powder = fluoroaluminumsilicate glass 3 yrs 3 min 6 min
Liquid = polyacrylic acid
Hy-Bond-PC Shofu Polycarboxylate Powder = zinc oxide; magnesium oxide; 4 yrs 2.5 min 6 min
zinc fluoride; strontium fluoride; tannic acid
Liquid = copolymer of acrylic acid and
3-butene 1,2,3 tricarboxylic acid
Hy-Bond-ZP Shofu Zinc phosphate Powder = zinc oxide; magnesium oxide; 4 yrs 2.5 min 8 min
zinc fluoride; strontium fluoride; tannic acid
Liquid = phosphoric acid; aluminum
phosphate
Ketac-Cem ESPE Glass ionomer Powder = calcium aluminum fluorosilicate 2 yrs 3.5 min 7 min
Radiopaque glass; polycarbonic acid
Liquid = tartaric acid water
Liv Carbo GC America Polycarboxylate Powder = zinc oxide; aluminum oxide; 3 yrs 2.25 min 5.25 min
magnesium oxide; sodium fluoride
Liquid = polyacrylic acid
PolyCarb Pulpdent Polycarboxylate Powder = zinc oxide; polyacrylic acid 5 yrs 2 min 7 min
WaterSet Liquid = water
Tenacin Dentsply/Caulk Zinc phosphate Powder = zinc oxide; magnesium oxide 5 yrs 1.5 min 8 min
Liquid = phosphoric acid; aluminum
trihydrate
Tyloc-Plus Dentsply/Caulk Polycarboxylate Powder = zinc oxide; polycarboxylic acid; 1 yr 1.75 min 7 min
magnesium hydroxide; calcium aluminum
silicate stannous fluoride
Liquid = water
Vivaglass Ivoclar/Vivadent Glass ionomer Powder = aluminum fluorosilicate glass; 1.5 yrs 2.5 min 5.5 min
Cem polyacrylic acid; ytterbium trifluoride
Liquid = polyacrylic acid; tartaric acid

Table V. Comparison of resin-modified glass ionomer luting agents (manufacturers’ data)


Product name Manufacturer Type Composition Shelf life Working time Setting time

Advance Dentsply/Caulk Powder/liquid Powder = strontium aluminum fluorosilicate glass 1.5 yrs 4 min 2 min
Liquid = OEMA acid monomer
Fuji Plus GC America Powder/liquid Powder = fluoroaluminumsilicate glass 2 yrs 2-2.5 min 5 min
Liquid = copolymer of acetic acid/maleic acid; HEMA
Vitremer 3M Dental Powder/liquid Powder = fluoroaluminum silicate glass 2 yrs 2.5 min 10 min
Liquid = polycarboxylate acid modified with
pendant methacrylate; HEMA

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THE JOURNAL OF PROSTHETIC DENTISTRY ROSENSTIEL, LAND, AND CRISPIN

Table VI. Comparison of available resin luting agents (manufacturers’ data)


Product name Manufacturer Filler content Particle size Curing Shelf life (RT)

C&B Luting Composite Bisco 46% 5 µm Self 2 yrs


C&B-Metabond Parkell Unfilled Self 2 yrs*
Cement-It! Jeneric/Pentron 68% 1 µm Self 2 yrs*
Choice Porcelain Veneer System Bisco 80% 6 µm Dual 2.5 yrs
Dicor MGC Dentsply/Caulk 74% 2-4 µm Dual 1 yr
Dual Cement Ivoclar-Vivadent 61% Microfill Dual 2 yrs
Duo Cement Coltene/Whaledent 71% 0.5 µm Dual 6 mo*
Duo-Link Bisco 67% 1 µm Dual 3 yrs
EnForce Dentsply/Caulk 66% 1 µm Light/dual 1 yr
FLC Vision Mirage Dental Systems 71% 4 µm Light/dual 1 yr*
Flexi-Flow Essential Dental Systems 63% 8 µm Self 2 yrs
Imperva Dual Resin Cement Shofu Inc. 77% 3 µm Dual 2 yrs
Insure/Insure Lite Cosmedent 75%/71% 1.5 µm Light/dual 3 yrs
Lute-It! Jeneric/Pentron 65% 0.8 µm Light/dual *
Nexus Kerr 68% 0.6 µm Light/dual 1.5-2 yrs
Opal Luting Composite 3M 82% 1.4 Light/dual 3 yrs
Panavia J. Morita 75% n/a Self *
Panavia 21 J. Morita 77% n/a Self *
Permalute Ultradent Products 70% 1.5 Dual 2 yrs
Scotchbond Resin Cement 3M 78% 1.4 Dual 3 yrs
Twinlook Heraeus Kulzer 73% 0.7 Dual 13 mo
Ultra-Bond Den-Mat n/a n/a Light/dual 14 mo
Variolink II Ivoclar-Vivadent 73% 1 Light/dual 1.5 yrs
*Refrigeration recommended.
†Manufacturer recommends using the “B” paste for try-in.
‡Long if cement spread out thinly.
§With Oxyguard.
¶Manufacturer plans to introduce.

Table VII. Committee’s current choices (1997)


Restoration Dr. Rosenstiel Rationale Dr. Land Rationale

Cast crown, metal Fleck’s (zinc phosphate) History of clinical use Fuji I (glass ionomer) Documented use, working
ceramic crown, FPD properties, fluoride
Crown or FPD with Panavia 21 High laboratory Panavia 21 High laboratory retention
poor retention (adhesive resin) retention values (adhesive resin) values
MCC with porcelain Ketac Cem Esthetics Fuji I (glass ionomer) Documented use, working
margin (glass ionomer) properties, fluoride
Casting on patient with Fleck’s Prevent sensitivity with Durelon Biocompatibility
history of posttreatment (zinc phosphate) bonding agent (polycarboxylate)
sensitivity
Pressed, high-leucite, EnForce (composite) Bonding, ease of clean-up Dual cement Ease of use, clean-up
ceramic crown (dual-cure resin)
Slip-cast alumina crown Ketac Cem Esthetics, Dual cement Ease of use, clean-up
(glass ionomer) non-bonded restoration (dual-cure resin)
Ceramic inlay EnForce (composite) Bonding, ease of clean-up Dual cement Ease of use, clean-up
(dual-cure resin)
Ceramic veneer Nexus (light-cured resin) Multiple shades and Choice (dual-cure resin) Water-soluble try-in pastes
try-in pastes.
Bonding
Resin-retained FPD Panavia 21 High laboratory Panavia 21 High laboratory retention
(adhesive resin) retention values (adhesive resin) values
Cast post and core Fleck’s (zinc phosphate) History of use Fuji I (glass ionomer) Documented use, working
properties, fluoride

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ROSENSTIEL, LAND, AND CRISPIN THE JOURNAL OF PROSTHETIC DENTISTRY

Resin family Working time Setting time Shades available Viscosities available Try-in pastes

BIS-GMA 3-4 min 6-7 min 2 1 (low) No


PMMA 1 min 10 min 2 1 (low) No
BIS-GMA/UDMA/HDDMA 3 min 4 min 1 1 (low/medium) No
BIS-GMA/UDMA 5 min 7 min 10 1 (high) Yes
BIS-GMA/UDMA 3-4 min 11 min 3 1 No
UDMA 4-6 min 14-20 min 1 1 (low) No
BIS-GMA 4 min 8 min 1 1 (low/medium) No
BIS-GMA 3.5 min 8 min 1 1 (low/medium) No
BIS-GMA/TEGDMA 3 min 6 min 6 1 No
BIS-GMA 2 min 8 min 8 No
BIS-GMA 3.5 min 5 min 2 1 (low) No
UDMA/TEGDMA 0.5 min 7.5 min 3 1 No
BIS-GMA 5 min 8-8.5 min 7 plus 6 tints 2 (medium, low) Yes
BIS-GMA/UDMA/HDDMA 3.5 min 4.5 min 4 1 (low) Yes
BIS-GMA 4 min 10 min 3 2 (medium, high) Yes
BIS-GMA 3 min 6 min 7 No†
BIS-GMA ‡ 1 min§ 3 1 (low) No
BIS-GMA ‡ 1 min§ 3 1 (low) No
BIS-GMA 5 min 6-8 min 6 1 No¶
BIS-GMA 3 min 6 min 1 No
BIS-GMA 5 min 4.5 min 1 1 (medium) No
BIS-GMA n/a n/a 9 No
BIS-GMA 4 min 15 min 5 3 (low, high, very high) Yes

Dr. Crispin Rationale lower than manufacturers’ recommendations, impaired


Vitremer/Fuji Plus (resin-ionomer) Solubility, adhesion, fluoride mechanical properties may result on a frequent basis.
For example, in 1 study of glass ionomer restoratives,
C&B Metabond/Panavia 21 High laboratory retention assistants were asked to mix according to their clinical
values practice (5.0:1). Both the compressive and diametral
Vitremer/Fuji Plus (resin-ionomer) Solubility, adhesion, fluoride strengths of the material were found to be about half
that of specimens mixed to the ideal powder/liquid
Vitremer/Fuji Plus (resin-ionomer) Solubility, adhesion, fluoride
ratio (6.8:1).92
Mechanical mixing speed
Dual cure composite Adhesion low solubility
Increased mechanical mixing time does not appear
Panavia 21 Laboratory research to speed up the setting time of glass ionomer
cements.240 Neither does a change in mixing speed of
Dual cure composite Adhesion low solubility encapsulated glass ionomer cements nor its 7-day com-
pressive strength appear to affect either the working or
Light cured composite Increased working time, setting time.241 However, excessively slow mixing
adhesion, translucency, speeds will result in the presence of unmixed powder
esthetics being expressed from capsules before the expression of
Panavia 21 (adhesive resin) History of successful clinical
mixed cement, which may adversely affect the mechan-
use
ical properties of the set cement, so dentists should
Panavia 21 (adhesive resin) Retention (uses Rexillium III
castings)
check the performance of mechanical mixers (amal-
gamators) periodically.242

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THE JOURNAL OF PROSTHETIC DENTISTRY ROSENSTIEL, LAND, AND CRISPIN

Fig. 17. Effects of seating method on film thickness as measured by ANSI/ADA specification
No. 96.

the patients opening and closing movements246


(Fig. 17). However, prolonged and sustained use of
ultrasonic vibration may adversely affect resulting bond
strength, as early as after 1 minute for zinc phosphate
cement, and after 5 minutes for adhesive resin and glass
ionomer cement.247
Moisture control
Maintenance of a dry field during the initial setting
reaction may be more critical for glass ionomer cements
than for polycarboxylate or zinc phosphate cements.
The water changes the setting reaction of the glass
ionomer as cement-forming cations are washed out and
Fig. 18. Comparative cost of some popular luting agents. water is absorbed, leading to erosion248; nevertheless,
zinc phosphate has also demonstrated significant early
erosion when exposed to moisture.109 Leaving a band
of excess glass ionomer cement, expressed during seat-
ing of the crown and undisturbed for 10 minutes, pre-
Seating force/vibration
vented significant erosion in a wet field.109
Seating force and choice of luting material strongly
COST
influence the resulting film thickness. 243 During
cementation procedures, patients cannot be relied on Low cost is an advantage of any material, although
to maintain equal force over time as a continuous the cost of luting agent is probably relatively insignifi-
decrease in occlusal force has been demonstrated.244 cant compared with other costs associated with fixed
The optimal seating force is probably cement specific prosthodontics. Figure 18 depicts the approximate rel-
and can be reduced through the use of venting proce- ative cost of available luting agents. The traditional
dures.245 Dynamic seating methods generally are supe- cements are considerably less expensive than the newer
rior to static loading and significantly reduce resulting formulations.
film thicknesses. Seating under a dynamic load, such as
SELECTION OF LUTING AGENTS
when a patient is instructed to close down forcefully
on an orangewood stick that is then moved Although no available product satisfies all the
superiorly/inferiorly and posteriorly/anteriorly has requirements of an ideal luting agent, the outstanding
been shown to result in improved, almost complete, clinical performance of traditionally fabricated indirect
seating of crowns. This may be particularly important restorations should be appreciated before the practi-
when composite cements are used. Ultrasonic vibration tioner is willing to abandon traditional materials for the
appears to be more effective in this respect than the use latest formulation. Nevertheless, the advent of adhesive
of an electromallet or reliance on pressure exerted by techniques has allowed the modern dentist to expand

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ROSENSTIEL, LAND, AND CRISPIN THE JOURNAL OF PROSTHETIC DENTISTRY

services, and many procedures cannot be provided with 16. Heys RJ, Fitzgerald M, Heys DR, Charbeneau GT. An evaluation of a
glass ionomer luting agent: pulpal histological response. J Am Dent
traditional water-based luting agents. In practice, sever- Assoc 1987;114:607-11.
al materials are needed to provide comprehensive 17. Pameijer CH, Stanley HR, Ecker G. Biocompatibility of a glass ionomer
patient care. Although some materials are contraindi- luting agent. 2. Crown cementation. Am J Dent 1991;4:134-41.
18. Torstenson B. Pulpal reaction to a dental adhesive in deep human cavi-
cated for certain techniques, the best choice is not ties. Endod Dent Traumatol 1995;11:172-6.
always clear. Table III presents the indications, con- 19. Johnson GH, Powell LV, DeRouen TA. Evaluation and control of post-
traindications, and primary precautions for the luting cementation pulpal sensitivity: zinc phosphate and glass ionomer luting
cements. J Am Dent Assoc 1993;124:38-46.
agent types. Tables IV through VI list currently avail- 20. Bebermeyer RD, Berg JH. Comparison of patient-perceived postcemen-
able products and their properties. In Table VII, our tation sensitivity with glass-ionomer and zinc phosphate cements. Quin-
current choices are listed with a rationale for their selec- tessence Int 1994;25:209-14.
21. Kern M, Kleimeier B, Schaller HG, Strub JR. Clinical comparison of post-
tion. operative sensitivity for a glass ionomer and a zinc phosphate luting
cement. J Prosthet Dent 1996;75:159-62.
SUMMARY 22. Mausner IK, Goldstein GR, Georgescu M. Effect of two dentinal desensi-
tizing agents on retention of complete cast coping using four cements. J
Dental luting agents form the link between a fixed Prosthet Dent 1996;75:129-34.
restoration and the supporting tooth structure. This lit- 23. Pameijer CH, Hulten J, Glantz PO, Randow K. Influence of low-viscosi-
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Restorative Dent 1992;12:195-205.
and working properties of an ideal material and sum- 24. Swift EJ Jr, Lloyd AH, Felton DA. The effect of resin desensitizing agents
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tables are presented that include pertinent properties of 26. Kasten FH, Pineda LF, Schneider PE, Rawls HR, Foster TA. Biocompati-
the various classes of luting agents, indications, con- bility testing of an experimental fluoride releasing resin using human gin-
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28. Breeding LC, Dixon DL, Caughman WF. The curing potential of light-
Dr. Crispin would like to acknowledge Vasiliki Bazos, DDS, for activated composite resin luting agents. J Prosthet Dent 1991;65:512-8.
her unselfish and comprehensive assistance in the preparation of Dr. 29. Kallus T, Mjor IA. Incidence of adverse effects of dental materials. Scand
Crispin’s portion of this article. J Dent Res 1991;99:236-40.
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