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Saudi Dent J
Saudi Dent J
The Saudi Dental Journal
1013-9052
1658-3558
Elsevier

S1013-9052(24)00195-0
10.1016/j.sdentj.2024.06.018
Original Article
Effects of cementation technique and cement thickness on the retention and amount of excess cement in implant-supported restorations
Abu-Obaid Ala’a aiabuobaid@ksu.edu.sa

Department of Prosthetic Dental Sciences, Collage of Dentistry, King Saud University, Riyadh, Saudi Arabia
13 6 2024
9 2024
13 6 2024
36 9 12031208
18 2 2024
4 6 2024
11 6 2024
© 2024 THE AUTHOR
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

To assess the amount of excess cement and the retentive strengths of two different cementation techniques (conventional cementation and practice abutment) using copings fabricated with three different cement thicknesses (20 μm, 35 μm, and 50 μm).

Materials and methods

Thirty zirconia copings were fabricated on screw retained abutments and randomly divided into three equal groups (n = 10) according to the cement thickness (20 μm, 35 μm, and 50 μm). Each group was cemented with tow cementation techniques. Cementation was performed with provisional cement (Temp-Bond). In the conventional cementation technique, cement was applied until each coping was approximately half filled, and the copings were subsequently placed on the implant–abutment assembly. Then, the copings were cleaned and cemented using the practice abutment cementation technique to remove excess cement prior to the process. Each technique was performed using copings with three different cement thicknesses (20 μm, 35 μm, and 50 μm). The specimens with the cemented copings were weighed on a high-precision analytical balance before and after removing the extruded cement, and the differences between the two measurements were calculated. Then, each specimen was subjected to a pullout test using a universal testing machine. The load required to dislodge the coping was recorded. The data were analyzed using two-way and one-way analysis of variance and independent sample t tests at a significance level of 0.05.

Results

The highest retention values were obtained for 20 μm cement thickness in the conventional technique and the practice abutment cementation technique. The amount of excess cement was the highest for the 50 μm cement thickness obtained for both cementation techniques, whereas the lowest mean values were recorded for the 20 μm cement thickness.

Conclusion

The conventional cementation technique is recommended over the practice abutment technique to increase the retention of crowns cemented with provisional cement. However, care must be taken to remove the extruded cement. A cement thickness of 20 μm is preferable for enhancing the retention of cemented crowns and for reducing the amount of excess cement when applying both conventional and practical abutment cementation approaches.

Keywords

Cement-Retained Restoration
Cementation Techniques
Cement Thickness
Retention
Excess Cement
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pmc1 Introduction

Cement- and screw-retained restorations are the main types of retention mechanisms used in implant prostheses. Both fixation methods have their advantages and disadvantages. Cement retained restorations are mostly used because of their benefits of improved aesthetics, eliminated occlusal access openings, passive fit, and simple fabrication (Ma and Fenton, 2015, Shadid and Sadaqa, 2012, Wittneben et al., 2017). However, the presence of excess cement has been associated with an increase in complications around soft tissues that may lead to peri-implantitis (Ferreiroa et al., 2015, Linkevicius et al., 2011, Shapoff and Lahey, 2012). Conversely, screw-retained restorations have the advantages of easy retrieval for maintenance and few technical and biological complications (Ragauskaitė et al., 2017, Wittneben et al., 2014). The main disadvantages of this approach include the risk of screw loosening and relatively poor aesthetics (Lee et al., 2010, Shadid and Sadaqa, 2012). The choice of retention mechanism is controversial and depends on the clinical situation of the patient and the preference and experience of the clinician (Sancho-Puchades et al., 2016, Taylor et al., 2000, Wittneben et al., 2014).

Complete removal of excess cement to obtain a superior aesthetic appearance is a challenging procedure, especially for restorations with deep margins placed subgingivally (Linkevicius et al., 2011). Several scholars have suggested different cementation techniques to minimize the amount of extruded cement (Al-Johany et al., 2019, Dumbrigue et al., 2002, Rayyan and Makarem, 2016, Yuzbasioglu, 2014). The most common cementation method is the conventional technique first recommended by Ishikiriama et al. (1981), which involves placing the cement only on the occlusal or cervical half of the intaglio surface of the restoration. However, this placement may result in inadequate sealing of the implant–restoration interface (Dumbrigue et al., 2002). Another technique involves placing a venting hole on the palatal or occlusal surface (Patel et al., 2009, Schwedhelm et al., 2003). This approach provides a good fit for implant restoration and can reduce excess cement by facilitating flow through openings (Wang et al., 2023, Zaugg et al., 2018).

An additional technique involves the use of a precementation device or practice abutment (abutments or abutment analogs) (Begum et al., 2014, Dumbrigue et al., 2002, Santosa et al., 2010) or an abutment replica fabricated from vinyl polysiloxane putty (Chee et al., 2013, Wadhwani and Piñeyro, 2009), hot thermoplastics (Rayyan and Makarem, 2016) bis-acrylic temporary restorative material (Bhushan et al., 2017), or pattern resin (Liang et al., 2016). In this technique, the cement filled crown is placed extraorally on the practice abutment to extrude excess cement from the crown before it is quickly transferred and cemented intraorally (Dumbrigue et al., 2002). Previous researchers have shown that the application of abutment replicas for the cementation of implant-supported restorations decreases the discrepancy between the restoration and abutment, reduces cement residue, and increases restoration retention (Liang et al., 2016, Santosa et al., 2010). Chee et al. (2013) reported that least amount of excess cement was found when using a cementation device. Begum et al. (2014) observed that venting and practice abutment techniques are more suitable than half filled crown methods for reducing retained excess cement with optimal retention values.

Another approach to increase the retention of cemented restorations and reduce the amount of excess cement involves manipulating the type and amount of cement used. The retentive strengths of the different cements used for implant restorations show that there is no threshold value to ensure retention; moreover, the ranking of cements is considered an arbitrary guide for clinicians in deciding the amount of desired retention between castings and implant abutments (Mansour et al., 2002, Sheets et al., 2008). Squier et al. (2001) reported that highest bonding levels was found with zinc phosphate, followed by resinous cement, glass ionomer cement, and zinc oxide without eugenol cement. Frisch et al. (2015) reported sufficient retention of implant-supported restorations cemented with zinc phosphate using either conventional or replica cementation techniques. The ideal cement should be sufficiently strong to retain the crown but sufficiently weak to allow retrievability, if necessary (Gultekin et al., 2013, Santosa et al., 2010). In addition to the type of cement, the cement thickness can affect the retention of the final restorations. Computer-aided design/computer-aided manufacturing (CAD/CAM) systems offer the advantages of producing and adjusting the luting space thickness. These benefits allow the fabrication of relatively accurate restorations with reduced distortion and an increasingly passive fit (Strub et al., 2006). Cement thicknesses widely reported by different authors range from 20 to 40 µm (Mansour et al., 2002, Squier et al., 2001). Taylor et al. (2000) reported a cement space ranging from 25 µm to 50 µm to ensure accurate insertion and the formation of a uniform layer of luting material. Another scholar reported the smallest marginal gaps when using a 20–60 µm cement space with provisional CAD/CAM restorations (Özçelik et al., 2018). To the best of the authors’ knowledge, there is a lack of studies in the literature on the effects of different cementation techniques and cement thicknesses on cement-retained restorations. The aim of this study was to evaluate the effects of different cementation techniques on prosthesis retention and the amount of excess cement using different cement thicknesses. The null hypothesis was that the cementation technique and cement thickness would not significantly influence the retention of cemented implant-retained crowns or the amount of residual cement.

2 Materials and methods

2.1 Specimen preparation

Thirty screw-retained titanium abutments (048.605 ITI system, Straumann AG, Basel, Switzerland) with heights of 5.5 mm were used. The implant analogs were mounted in cylinders filled with an epoxy resin-glass fiber composite (NEMA Grade G-10 rod, Piedmont Plastics, Charlotte, NC, USA) using a dental surveyor (J.M. Ney Co., Bloomfield, CT, USA). Each implant abutment was placed on its respective analog and torqued to 35 Ncm. The abutment screw access opening was filled with vinyl polysiloxane impression material (virtual, refill light body, regular set wash material; Ivoclar Vivadent, Italy). The abutments were scanned with an optical scanner (Cercon Eye; Dentsply, Germany) to fabricate thirty zirconia copings (Cercon Base; Degudent, Dentsply, York, PA) for the cement thicknesses (20 μm, 35 μm, and 50 μm). Each coping was air abraded with alumina particles at 0.25 MPa. Then, the zirconia copings (Fig. 1) were randomly divided into three equal groups (n = 10) according to different cement thickness and cementation technique. Each group (n = 10) was cemented with conventional cementation technique and the copings were cleaned and used again for cementation with the practice abutment technique.Fig. 1 Specimen used in the study.

2.2 Cementation of the copings

A provisional cement (Temp-Bond NE, Kerr, Italy) was used to cement the copings to the abutments in accordance with the manufacturer’s instructions. Equal amounts of base and accelerator were mixed, and a calibrated syringe was used to place a standardized amount of the cement (0.1 mL) in each coping (Santosa et al., 2010).

For conventional cementation, the mixed cement was placed on the intaglio surface of the coping until it was approximately half-filled. Then, the coping was placed on the abutment, and no additional procedures were conducted. In the practice abutment cementation technique, the coping was filled with the same amount of cement and then placed on an implant-practice abutment complex used for precementation (Santosa et al., 2010) (Fig. 2). The coping was immediately removed to avoid early setting, and finally seated on the abutment until the cement setting was complete. Each coping was applied to the abutment under finger pressure for 10 s before the abutment was subsequently loaded on its long axis under the pressure of a 2-kg weight for 5 min.Fig. 2 Implant-practice abutment complex used for precementation.

The specimen with the cemented coping was weighed on a high-precision analytical balance before removing the extruded cement (Radwag AS 220/C/2, Clarkson Laboratory & Supply, Inc., Chula Vista, USA) (Fig. 3), and the measurements were recorded. All excess cement at the margin of the implant crown coping was removed using a dental explorer, and the specimen was weighed again. The difference between the two measurements was calculated to determine the exact amount of extruded cement. The procedure was performed by a single investigator.Fig. 3 Cemented coping was weighed using a high-precision analytical balance.

2.3 Testing procedure

Twenty-four hours after cementation, each specimen was vertically secured in a universal testing machine (Instron 8500; Instron Corp., Norwood, MA, USA) and subjected to a pullout test at a crosshead speed of 0.5 mm/min. The load required for dislodgment of the coping was recorded in Newtons. Then, the coping and abutment were completely cleaned of all residual cement using a hand instrument, followed by rinsing in an ultrasonic bath with distilled water for 10 min.

2.4 Statistical analysis

The statistical analyses were performed using SPSS (version 16.0; SPSS, Inc., Chicago, IL, USA). Data distribution was evaluated using the Shapiro-Wilk and Kolmogorov–Smirnov tests. The uniaxial tensile strength data was normally distributed, whereas some of the data of the extruded excess cement was not normally distributed, and the square root of all data was calculated. After data transformation, normality was assumed, and the data were analyzed using two-way and one-way analysis of variance (ANOVA) and independent sample t tests. All the statistical analyses were performed at a significance level of P < 0.05.

3 Results

Table 1 presents a list of the mean uniaxial tensile strengths, standard deviations, and standard errors of each group.Table 1 Mean ± std. deviation and std. error of uniaxial tensile strength for each group (N).

Technique	Mean ± std. Deviation	Std. Error	
Conventional Procedure	20 μm	87.83 ± 4.17	1.32	
35 μm	68.83 ± 5.53	1.75	
50 μm	69.39 ± 2.11	0.67	


	
Practice Abutment	20 μm	48.87 ± 1.05	0.33	
35 μm	37.17 ± 1.31	0.41	
50 μm	30.55 ± 1.62	0.51	

After applying the conventional and practice abutment cementation techniques, the highest means of tensile strength were 87.83 ± 4.17 N and 48.87 ± 1.05 N, respectively, for the sample with the 20-μm cement thickness. The lowest mean values were obtained for the specimen with the 35 μm cement thickness 68.83 ± 5.53 N after applying the conventional technique and for that with the 50 μm cement thickness 30.55 ± 1.62 N after applying the practice abutment technique. Two-way ANOVA (Table 2) revealed the significant effects of the specific cementation technique, cement thickness, and interaction conditions between these two factors on the retention force of the cemented copings (P < 0.05).Table 2 Two-way ANOVA results for the uniaxial retention force of the cemented copings.

Source	Type III Sum of Squares	df	Mean
Square	F	Sig.	
Corrected Model	24027.713a	5	4805.543	498.434	0.000	
Intercept	195673.709	1	195673.709	20295.397	0.000	
Technique	19966.599	1	19966.599	2070.948	0.000	
Cement Thickness	3886.088	2	1943.044	201.534	0.000	
Technique * Cement Thickness	175.026	2	87.513	9.077	0.000	
Error	520.629	54	9.641			
Total	220222.052	60				
Corrected Total	24548.343	59				
a R Squared = 0.979.

For the conventional cementation technique, Tukey’s post hoc test for multiple comparisons showed a significant difference in the mean uniaxial tensile strength of the sample with the 20 μm cement thickness compared with the strengths of the other groups (P = 0.00). However, no significant differences were found between the specimens with 35 μm and 50 μm cement thicknesses (P > 0.05). However, a statistically significant difference was found among all the groups cemented using the practice abutment technique (P = 0.00). An independent sample t test demonstrated statistically significant differences in the tensile strengths resulting from samples subjected to different cementation techniques and cement thicknesses (P = 0.00).

Regarding the effects of cementation technique and cement thickness on the amount of extruded excess cement, the highest means of excess cement after applying the conventional and practical abutment cementation techniques were 0.094 ± 0.019 g and 0.024 ± 0.016 g, respectively, for the sample with the 50 μm cement thickness. The lowest mean values were 0.063 ± 0.029 g and 0.010 ± 0.005 g for the 20 μm cement thickness (Fig. 4). For both cementation techniques, Dunnett’s T3 test for multiple comparisons showed a significant difference in the mean of the extruded cement between the 20 μm and 50 μm cement film thicknesses (P < 0.05). However, no significant differences were found for the 35 μm compared with the 20 μm and 50 μm cement film thicknesses (P > 0.05). Independent sample t tests demonstrated statistically significant differences in the extruded cement under different cementation technique or cement thickness conditions (P = 0.00).Fig. 4 Mean of extruded excess cement (g) for the tested groups.

4 Discussion

Improving the retention of implant-supported cement-retained crowns and reducing the amount of residual cement have important clinical implications. Several approaches have been used for this purpose, such as applying modified cementation methods (Chee et al., 2013), creating a vent hole (Wadhwani and Chung, 2014, Wang et al., 2023), minimizing the amount of cement used (Frisch et al., 2015), and performing various modifications in the geometric design of the abutment (Negahdari et al., 2021, Rathod et al., 2021, Reddy et al., 2015).

The null hypothesis in this study was rejected, as significant differences were found between the conventional method of cementation and the use of a practice abutment in terms of the amounts of extruded cement and the levels of retention for samples with different cement thicknesses.

The cementation techniques used in this study were selected because of their extensive use in clinical settings. Moreover, cementation was performed using interim cement (Temp-Bond) because of its low tensile strength and high solubility, allowing possible retrieval of the copings and easy removal of excess cement (Akca et al., 2002, Carnaggio et al., 2012). A standardized amount of cement (0.1 mL) was applied to all copings to reduce the variation that could affect the amount of residual cement.

In this study, samples with 20 μm cement thicknesses subjected to conventional and practical abutment cementation techniques had significantly greater tensile strengths than the other specimens. This finding was in agreement with that of Mehl et al. (2013), who reported a decrease in crown retention with a cement thickness of 50 µm compared with 15 µm. Another author (Gultekin et al., 2013) revealed that increasing the cement space from 20 to 40 µm caused significantly greater retention of high-strength resin-based cements but not low-strength cements (such as Temp-Bond NE) due to variations in the viscosity and size of the filler particles, which affect the difference in brittleness (Gultekin et al., 2013, Pan et al., 2007). The decrease in tensile strength with increasing cement thickness could be caused by improper distribution of the cement in large spaces, which could increase the number of formed voids. Another cause could be the lack of micromechanical interlocking in large cement spaces, which could result in easy displacement of the restoration.

Both cementation techniques significantly increased the amount of extruded cement as the cement thickness increased from 20 μm to 50 μm, with relatively low amounts of cement being extruded after applying the practice abutment technique. This finding was in agreement with that of Canullo et al. (2016), who reported significantly fewer cement remnants and greater voids with extraoral cementation than with intraoral cementation, regardless of the cement thickness and low adhesivity cement content. Another recent in vitro study (Zaugg et al., 2018) revealed that the use of a custom analog reduced the amount of excess cement by 32.1 % compared with that of standard cementation. The majority of the excess cement was displaced before the crown was placed on the abutment (Galván et al., 2015). In contrast to the findings of another study, the application of a resin abutment replica for cementation with a marginal gap of approximately 50 μm decreased the discrepancy between the restoration and abutment and reduced the residue of the resin cement compared with other cementation techniques. However, the tensile strength of the restorations increased (Liang et al., 2016). This increase could be due to the use of a greater amount of permanent resin cement than that used with conventional cementation.

The results of this study showed significantly lower retentive strength and a smaller amount of extruded cement with the use of practice abutments than with conventional cementation. This finding was in agreement with the results of previous studies and could be explained by the release of a large amount of cement before definitive cementation, which resulted in the distribution of a thin layer of cement on the intaglio of the restoration (Jimenez and Vargas-Koudriavtsev, 2016, Zaugg et al., 2018). Furthermore, an insufficient amount of cement could negatively affect retention. Although the practice abutment cementation technique significantly reduced the amount of residual cement compared to the conventional technique, the retentive strength was reduced to approximately 50 %, and this approach was not a preferable method of cementation for crowns cemented with low tensile strength provisional cement. This finding was in agreement with that of Jimenez and Vargas-Koudriavtsev (2016), who reported that the preseating protocol reduced the amount of residual cement. However, this approach is not recommended because it could significantly reduce the retentive strengths of cemented restorations.

Both cementation techniques showed lesser amounts of excess cement and enhanced the retention of the restoration when the cement thickness is 20 μm. However, compared to conventional cementation, practice abutment cementation might not be clinically feasible because it requires an additional procedure, is time-consuming, and needs a luting agent with a long working time.

There are several possible limitations to this study, such as the lack of intraoral environment simulation or thermocycling and the inclusion of only one type of cement. In addition, the reuse of abutments may change the retention values of the restorations.

The tested cementation techniques with different cementation thicknesses were used to determine the proper combination for crown cementation. However, further clinical studies are necessary to identify the appropriate cementation technique for each clinical situation.

5 Conclusions

Within the limitations of this in vitro study, the following conclusions were drawn:1. Compared to the practice abutment cementation technique, the conventional cementation technique is better for increasing the retention of crowns cemented with provisional cement; thus, the conventional approach is recommended.

2. A cement thickness of 20 μm is preferable for enhancing the retention of cemented crowns and reducing the amount of excess cement using either conventional or practice abutment cementation techniques.

Ethical statement

Not required for this In Vitro study.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

The authors would like to thank the College of Dentistry Research Center and Deanship of Scientific Research at King Saud University, Saudi Arabia for supporting this research project (FR0380).
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