Tensile Retention of Lithium Disilicate and Zirconia Crowns Cemented to One-Piece Zirconia Implants: A Pilot In Vitro Study of Cementation Protocol, Resin Cement, and Micro-CT Cement Morphology

This pilot in vitro study explored the tensile retention of lithium disilicate and monolithic zirconia crowns cemented onto zirconia one-piece implants using two resin cements and two cementation protocols. In addition, the relationship between micro-computed tomography (micro-CT)-derived cement layer characteristics and retention was explored for lithium disilicate crowns. Thirty-two implant–crown assemblies were prepared using 16 lithium disilicate and 16 zirconia crowns. Specimens were cemented with either an adhesive resin cement (Panavia V5) or a self-adhesive resin cement (SpeedCem Plus) using two protocols: conventional apical-half cementation (AH) and an abutment-assisted apical-half protocol (A-AH). Cement thickness and porosity for lithium disilicate crowns were obtained from a previously published micro-CT analysis of the same specimens; no micro-CT measurements were available for the zirconia specimens. Tensile pull-out testing was performed using a universal testing machine. The primary outcome was the maximum recorded force at the first observed mechanical failure, irrespective of the mode of that failure, so that all 32 specimens contributed a value. Failure occurred by crown debonding in 27 specimens, by crown fracture in 4 and by implant fracture in 1. For the primary outcome, the maximum recorded force was lower for lithium disilicate than for zirconia crowns (medians 347.20 versus 596.05 N; exact Mann–Whitney p = 0.017) and lower with the A-AH than with the AH protocol (medians 304.24 versus 614.38 N; p < 0.001), whereas the difference between the two resin cements was not statistically significant (medians 438.88 versus 550.83 N; p = 0.210). The highest observed mean maximum load was recorded for zirconia crowns cemented with Panavia V5 using the AH protocol (729.9 ± 237.7 N), whereas the lowest observed mean maximum load was recorded for lithium disilicate crowns cemented with Panavia V5 using the A-AH protocol (219.7 ± 105.1 N). In a secondary, cause-specific exploratory analysis restricted to crown debonding (27 events, 5 specimens censored at fracture), Cox proportional hazards regression on the applied-force scale gave hazard ratios of 3.75 (95% CI 1.40–10.01) for lithium disilicate versus zirconia, 6.47 (2.39–17.53) for A-AH versus AH and 1.82 (0.76–4.39) for Panavia V5 versus SpeedCem Plus. For lithium disilicate crowns, exploratory factorial ANOVA indicated that cementation protocol was associated with differences in cement thickness (p = 0.035), while cement type was associated with differences in porosity (p < 0.001). All 16 lithium disilicate cement thickness observations lay between 253.29 and 254.96 µm, a total span of 1.67 µm. Within that extremely restricted range, a univariable exploratory Cox model expressed per 0.1 µm gave a hazard ratio for debonding of 1.24 (95% CI 1.03–1.48; p = 0.024); this is an unadjusted association across a range that is itself associated with cementation protocol, and it does not demonstrate a clinically meaningful or independent effect of cement thickness. No association was detected for total porosity (0.959 per percentage point, 0.717–1.283); that interval is wide and indicates absence of evidence rather than evidence of no association. Within the limitations of this pilot in vitro study—four specimens per subgroup, wide confidence intervals and no adjustment for multiplicity—the findings suggest that crown material and cementation protocol may be associated with retention patterns. They are exploratory and hypothesis-generating and require confirmation in larger, independently powered studies.