RESEARCH ARTICLE

Influence of Tooth Preparation Design on Fitting

Accuracy of CAD-CAM Based Restorations
SABIT MELIH ATES, DDS, PhD, ZEYNEP YESIL DUYMUS, DDS, PhD

ABSTRACT
Objective: The purpose of this study was to evaluate the marginal f|t of different zirconia and metal frameworks and
compare them with each other on different f|nish line conf|gurations.
Materials and Methods: 20 stainless steel dies10 with shoulder and10 with chamfer f|nish line including 6 mm
preparation height and 3 degree axial angle simulating a 6 degree total occlusal covergence of the prepared tooth
were produced. After embedding the each group of die into the arch-shaped acrylic resin blocks, impressions were
made using silicone based impression material and120 casts were prepared subsequently.The dies were divided into
six groups each having 20 specimens (10 with shoulder,10 with chamfer f|nish line).Group CM consisted of Co-Cr
produced by conventional casting procedure, group MM of Co-Cr prepared by metal milling, group LM of Co-Cr
prepared by direct laser metal sinterization (DLMS), group ZZof Zirkonzahn (Zirkonzahn GmbH,Gais,Italy), group
LZof Lava Zirconia (3 M ESPE Dental AG, Seefeld,Germany) and group DZof DC-Zirkon (DCS Dental AG,
Allschwil, Switzerland). Stereomicroscope were used to evaluate the marginal f|t of frameworks and marginal gap
values obtained from the images were analyzed using Mann^Whitney U Test and Kruskal^Wallis H Test with
Bonferroni correction.
Results: The lowest value of marginal gap was identif|ed in the samples from the LZ group and the highest value was
identif|ed in those from ZZ in both f|nish lines.The effect of f|nish lines was not signif|cant for most groups but CM
frameworks with chamfer f|nish lines and the DZ frameworks with shoulder f|nish lines showed signif|cantly lower
marginal gap values.
Conclusion: The marginal gaps of the various tested zirconia and metal framework were within the range of clinical
acceptability (120 mm).

CLINICAL SIGNIFICANCE
The results of this in vitro study suggestthat margin preparation design and type of zirconia and metal framework
materials for various CAD-CAM systems have a signif|cant effect on marginal f|t of the resulting restorations.

INTRODUCTION clinically acceptable.2 The marginal discrepancy for

The accurate t of xed dental prostheses (FDPs) is
considered mandatory for a restoration to provide
acceptable longevity. Several authors1,2 evaluated
marginal gap values but there is no rm consensus on
what constitutes a clinically acceptable marginal t.
McLean and von Fraunhofer concluded that a
marginal opening of no more than 120 mm was
dental crowns is inuenced by several factors. Some
authors35 investigated these factors and demonstrated
that geometry of tooth preparation, cementation, and
laboratory procedures are affecting the marginal
adaptation.
The most popular method for FDPs framework
fabrication is the lost wax technique. However, despite

Department of Prosthodontics, Faculty of Dentistry, RecepTayyip Erdogan University, Rize,Turkey

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V DOI 10.1111/jerd.12208 Journal of Esthetic and Restorative Dentistry Vol 00  No 00  00^00  2016 1
 MARGINAL FIT OF CAD-CAM BASED RESTORATIONS Ates and Yesil Duymus

its simplicity, it involves several steps and materials
that can introduce inevitable inaccuracies.6 To enhance
the predictability of the t of FDP frameworks,
advanced CAD-CAM technologies have been recently
introduced.79 These systems use metal milling or
direct laser metal sintering (DLMS) methods in CAM
units for metal framework production. Unlike the
milling technique, DLMS sinters a metal powder in
layers, which is then fused together by laser welding.
The advantages of these systems are its simplicity,
reduced cost, and manufacturing time.10,11
New high performance ceramics have been launched
for patients esthetic demands over the last decades.
Especially Y-TZP polycrystalline tetragonal zirconia has
become increasingly more popular in dentistry.
Zirconia ceramics offer excellent biocompatibility, low
plague accumulation, and mechanical strength
characteristics as well.12 Today different CAD-CAM
technologies can be used for the manufacturing
process of zirconia frameworks from sintered or pre-
sintered phase of Y-TZP zirconia. These systems
produce higher quality restorations by using
industrially prepared ceramic materials and a
standardized manufacturing process.1315
The marginal t can be described as the linear
distance between the nish line of the preparation and
the margin of the restoration. The methods for
measurement of marginal discrepancy are; cross-
sectional view, direct view of the crown on a die,
impression replica technique, and clinical
examination.2,16 The direct view is the most common
method to measure the marginal distortion using
scanning electron microscopy (SEM) or
stereomicroscope evaluation during the manufacturing
process.1720
signicant effect on the marginal t of ceramic
crowns.25
The purpose of this study was to evaluate the marginal
t of metal and zirconia frameworks fabricated on
different nish line congurations by measuring the
marginal gap between the framework and master die.
MATERIALS AND METHODS
Two types of specially designed stainless steel die were
machined at approximate dimensions of a molar tooth
preparation for this study. Stainless steel dies were
designed with a height of 6 mm axial wall and 6 degrees
total occlusal covergence, but 10 dies were produced
with a uniform heavy chamfer of 1.2 mm in width and
10 dies were produced with a uniform heavy shoulder
of 1.2 mm in width in terms of nish line design
(Figure 1). 20 small notches were made approximately
2 mm below the die margins as the reference point for
the marginal gap measurements. Metal dies were
embedded into the arch-shaped acrylic resin blocks with
parallelometer in order to simulate dental arch. Special
tray was fabricated on arc-shaped acrylic resin blocks
for impression procedures. Impressions were made
using the putty-wash technique with A-silicone
impression material (Elite HD, Zhermack, Badia
Polesine, Italy) and metal dies were duplicated in order
to produce framework materials. Impressions were
poured with type IV dental stone (GC Corporation,
Tokyo, Japan) and a total number of 120 dies 60 with
chamfer and 60 with shoulder nish line were created
subsequently. Cast dies were divided into 12 groups of

In addition to the evaluation of marginal t, the effect

of the type of margin conguration on the marginal
adaptation of frameworks also requires examination.21
Some in-vitro studies have shown that margin
conguration of metal and zirconia frameworks are
inuencing the marginal t of restorations.4,1824
Contrary to these ndings, some studies have also
shown that the margin congurations have no FIGURE 1. Schematic view of metal dies.

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 MARGINAL FIT OF CAD-CAM BASED RESTORATIONS Ates and Yesil Duymus
10 specimens and six different framework materials
were used (Table 1).
After transferring cast dies to the CAD unit (3 Series,
Dental Wings Inc, Montreal, Canada), resin copings
for CM frameworks production were designed in a
thickness of 0.5 mm and the cement lm thickness
were adjusted as 30 mm with no space and 0.5 mm
away from the margin using the special design
software (DWOS Software v.4.0.3, Dental Wings Inc,
Montreal, Canada) (Figure 2). After designing, resin
copings were milled from PMMA block (Yamahachi
Dental, Aichi, Japan) in CAM unit (Yena Machines
Ltd, Istanbul, Turkey). CM copings were manufactured
using the lost-wax technique and the induction casting
machine (Mikrotek Ltd, Ankara, Turkey) but, the
complete contour resin copings, which were prepared
in CAM unit (Yena Machines Ltd, Istanbul, Turkey),
were used in order to standardize the casting
procedure instead of handling wax patterns during the
casting procedure. Resin copings were invested and
cast with a Co-Cr alloy (Bego GmbH, Bremen,
Germany) following the manufacturers instructions.
The same CAD-CAM technique was performed as
described above, using the same software adjustments
for producing MM frameworks. Co-Cr alloy block
(CopraBond K, Whitepeaks Dental Solutions GmbH&
Co. KG, Essen, Germany) was used instead of using a
milling resin block in the CAM unit (Yena Machines
Ltd, Istanbul, Turkey). The same data was sent for
production of the LM frameworks with Co-Cr powder
TABLE 1. Materials used in the study
Group Processing method
CM Conventional cast metal
framework
MM CAD-CAM
LM CAD-CAM
ZZ Manual design
Manual production
LZ CAD-CAM
DZ CAD-CAM
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V DOI 10.1111/jerd.12208
(Dentaurum GmbH, Ispringen, Germany) in a laser
sintering machine (Concept Laser GmbH, Lichtenfels,
Germany) and LM frameworks were produced
subsequently.
Before milling procedures, the replicas of ZZ
frameworks were prepared on cast die using PMMA
block. The same resin copings made of PMMA, which
were used in metal casting, were produced with CAD-
CAM in order to standardize the framework design.
They were xed and processed by a manual milling
unit (Zirkograph 025 ECO, Zirkonzahn GmbH, Gais,
Italy) and the milling procedure was performed with
Zirkonzahn block (Zirkonzahn GmbH, Gais, Italy).
Sintering was performed in a sintering furnace at
1,5008C for 8 hours.
The stone dies of LZ group were scanned by an optical
scanner (LavaScan-ST, 3M ESPE Dental AG, Seefeld,
Germany) and frameworks were designed using the
Lava Design software (3M ESPE Dental AG, Seefeld,
Germany). After designing, frameworks were created
from Lava blocks in a milling unit (Lavaform, 3M
ESPE Dental AG, Seefeld, Germany). Then, they were
stored at room temperature for 3.5 hours as a
preliminary drying procedure. Then, the temperature
was gradually increased to 1,5008C in 2.5 hours and
sintering was completed in 2 hours. The sintering
procedure, which lasted for approximately 8 hours,
was performed in the LavaTerm sintering unit (3M
ESPE Dental AG, Seefeld, Germany).
Material type Manufacturer
Co-Cr Bego GmbH,Bremen,Germany
Co-Cr metal block CopraBond K,Whitepeaks Dental Solutions
GmbH&Co.KG, Essen,Germany
Co-Cr metal powder Dentaurum GmbH,Ispringen,Germany
Y-TZP block (green stage) Zirkonzahn GmbH,Gais,Italy
Y-TZP block (pre- 3 M ESPE Dental AG, Seefeld,Germany
sinterized)
Y-TZP block (fully- DCS Dental AG, Allschwil, Switzerland
sinterized)
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 MARGINAL FIT OF CAD-CAM BASED RESTORATIONS Ates and Yesil Duymus
FIGURE 2. Images of framework design in CAD unit.
The stone dies of the DZ group were scanned using a
laser scanner (Preciscan, DCS Dental AG, Allschwil,
Switzerland) and the collected data were transmitted
to a computer, where the frameworks were designed
and calculated using designated software (DCS Dental
AG, Allschwil, Switzerland). The data were
subsequently forwarded to the machining center
(Precimill, DCS Dental AG, Allschwil, Switzerland)
where the frameworks were milled out from a fully
sintered Y-TZP block. Milling was completed in
approximately 3 hours. DZ frameworks were not
subjected to sintering because DCS blocks (DCS
Dental AG, Allschwil, Switzerland) were already
sintered.
All frameworks were checked using a caliper (Jensen
Dental Inc, Metzingen, Germany) and were
reprocessed to x the thicknesses at 0.5 mm.
All tested frameworks were individually seated on the
stainless steel dies without cementation and were
examined for absolute marginal discrepancy with
respect to the die using an image analysis software. This
method consisted of image analysis software in
combination with a stereomicroscope (Leica
Microsystems GmbH, Wetzlar, Germany) at 340
magnication (Figure 3). For all measurements, the
specimens were placed on a specially designed holding
4 Vol 00  No 00  00^00  2016 Journal of Esthetic and Restorative Dentistry
FIGURE 3. Stereomicroscope image of die-framework
interface from metal and zirconia specimens (340
magnification). (a) Image on shoulder finish line, (b) Image on
chamfer finish line.
device to apply a uniform static load of 10 N with the
help of a torque wrench (Zimmer Dental Inc, Carlsbad,
USA) (Figure 4). About 20 digital images of the margins
were captured at 20 predetermined measuring locations
on the die along the cervical region of each specimen.
Using this technique, a total of 20 single measurements
were made around each specimen and the mean of 20
measurements was recorded as the absolute marginal
discrepancy data of tested specimen and subjected to
the statistical analysis. The statistical analysis was
performed using statistical software SPSS 15.0 (SPSS
Inc, Chicago, USA) for Windows. The Kolgoromov
Smirnov test was indicated that the marginal
FIGURE 4. Specially designed holding device for marginal gap
measurements. Framework which was individually seated on
the stainless steel die placed in the metal ring and torque
wrench related pin applied the uniform load from occlusal
direction.
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TABLE 2. Mean, median, minimum, maximum, standard deviation values of marginal gap, and KruskallWallis H Test results
Value KruskalWallis H test

Mean Median Min Max Sd Mean rank H p

bc
Shoulder CM 36.00 35.50 23.00 49.00 8.27 30.35 38.256 0.000

MMb 44.30 45.50 32.00 57.00 8.55 39.35

LMbc 32.10 28.50 20.00 66.00 14.16 21.40

ZZa 91.30 94.00 72.00 107.00 11.29 55.50

LZc 24.10 25.50 17.00 28.00 3.45 12.00

DZbc 33.00 30.00 20.00 56.00 11.15 24.40

Chamfer CMc 25.10 24.00 20.00 31.00 3.98 15.20 48.672 0.000

MMb 52.40 54.00 34.00 68.00 10.92 36.35

LMc 27.60 26.00 17.00 37.00 6.35 18.80

ZZa 99.90 95.50 68.00 147.00 27.84 53.80

LZc 24.20 23.50 13.00 47.00 10.23 13.10

DZab 75.00 67.00 53.00 132.00 22.69 45.75

*Same superscript letters indicate no statistically signif|cant differences between groups (p < 0.05).

discrepancy data were not normally distributed. The
mean values and standard deviations per group were
calculated. The KruskallWallis H Test with Bonferroni
correction was used to detect the differences between
framework materials. In addition, the MannWhitney
U Test was used to assess the inuence of nish line on
the marginal discrepancy. A signicance level of
p 5 0.05 was used for all comparisons.
frameworks with chamfer nish lines showed higher
marginal gap values, besides these differences were
signicant when compared with other framework
materials except the DZ group. The lowest marginal
gap values for chamfer nish lines was found in the
LZ group but these differences were only signicant
when compared with the MM, DZ, and ZZ groups
(p < 0.05).

Table 3 shows the means and standard deviations of

RESULTS
Table 2 shows the means and standard deviations of the
marginal gaps of each framework material in
micrometer. The KruskalWallis H test indicated that
the marginal adaptation was signicantly different
among tested framework materials in both nish lines
(p < 0.05). The mean marginal gap value of the ZZ
group was signicantly higher than the other groups in
shoulder nish line (p < 0.05). The LZ group showed
the lowest marginal gap values but these differences
were only signicant when compared with the MM and
ZZ groups in shoulder nish lines (p < 0.05). The ZZ
the framework groups by margin conguration. The
effect of nish lines was not signicant for most
groups. However the MannWhitney U test indicated
that there was signicant difference in the CM and DZ
groups (p < 0.05). The CM frameworks with chamfer
nish lines and the DZ with shoulder nish lines
showed lower marginal gap values.
DISCUSSION
This in-vitro study evaluated the marginal adaptation
of different framework materials on different nish line

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TABLE 3. Mean, median, minimum, maximum, standard deviation values of marginal gap on two different finish lines, and the Mann
Whitney U Test results (p < 0.05)
Value MannWhitney U

Mean Median Min Max Sd Mean rank U p

a
CM Shoulder 36.00 35.50 23.00 49.00 8.27 14.50 10.00 0.002

Chamferb 25.10 24.00 20.00 31.00 3.98 6.50

MM Shoulderc 44.30 45.50 32.00 57.00 8.55 8.25 27.50 0.089

Chamferc 52.40 54.00 34.00 68.00 10.92 12.75

LM Shoulderd 32.10 28.50 20.00 66.00 14.16 10.85 46.50 0.791

Chamferd 27.60 27.00 17.00 37.00 6.35 10.15

ZZ Shouldere 91.30 94.00 72.00 107.00 11.29 10.05 45.50 0.733

Chamfere 99.90 95.50 68.00 147.00 27.84 10.95

LZ Shoulderf 24.10 25.50 17.00 28.00 3.45 11.70 38.00 0.362

Chamferf 24.20 23.50 13.00 47.00 10.23 9.30

DZ Shoulderg 33.00 30.00 20.00 56.00 11.15 5.60 1.00 <0.001

Chamferh 75.00 67.00 53.00 132.00 22.69 15.40

*Same superscript letters indicate no statistically signif|cant differences between groups (p < 0.05).

congurations. Results of this study showed that the
CAD-CAM manufacturing systems and the margin
design are affecting the t of frameworks.
In vitro results should be viewed cautiously because
the clinical situation cannot be completely simulated
in-vitro testing. However, an in-vitro study has the
advantages of providing standardized conditions with
respect to preparation design, technique, and
experimental performance, resulting in more repeatable
assessments.
In the present study, the stainless steel die was used as
an abutment. Several investigators have used metal or
acrylic resin dies, implant abutments, or natural teeth
to measure the marginal t.3,5,79,13,17,24 The
advantages of metal dies are standardized preparation
and lack of wear of the die during the manufacturing
processes and measurements.16 Prepared dies are then
replicated using a two-step impression technique.
W ostmann et al.26 indicated that one or two-step
impression techniques did not affect the marginal t of
restorations if the marginal region was dry during
impression procedures.
Die spacing techniques have specic differences for
each system and can affect the t of frameworks.
Weaver et al.6 conrmed that the amount of die relief
appeared to be a specic factor for t. Therefore, in
the present study, the die spacer was not applied to
the surface of the die for any restorations. Die space
was adjusted during design procedures executed using
special softwares and the differences, which can occur
during die spacing depending on the practioner, were
eliminated.
The precision of marginal t was evaluated by direct
viewing and external measurements as opposed to
sectioning. Direct viewing has the advantage of being
non destructive and, therefore, being applicable to
clinical practice.14 Various investigators4,5,8,24 have
used the direct viewing technique for the evaluation of
marginal t. The vertical marginal gap measurement
was selected as the most frequently used measurement

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 MARGINAL FIT OF CAD-CAM BASED RESTORATIONS Ates and Yesil Duymus
to quantify the t of restorations.14 In this study,
vertical marginal gap was measured using the direct
viewing technique and stereomicroscope.
There are no denite standards for the number of
measurements when evaluating the marginal gap and
the number of points per crown used in previous
studies has varied considerably. Groten et al.27
suggested that, ideally 50 points, or at least 20 to 25
measurements should be made for each crown.
Conversely, Gassino et al.18 reported that the
minimum number of measurements required to ensure
relevant results for gap analysis was 18 for
experimental crowns. In the current study, for each
test group containing 10 sample and 20 measurements
per sample were made for a more accurate result.
In the current study, the tested crowns were not
cemented to the die before evaluation because when
specimens are cemented, they would lose the precision
of the primary adaptation, thereby allowing cement
type, the viscosity, and cementation techniques would
inuence the results.14 Total t of restoration is
dependent on the adaptation of frameworks so
frameworks were not veneered in this study. All
external factors affecting marginal t were not taken
into consideration and directly the production results
of frameworks on two types of margin congurations
were evaluated. Specially designed torque wrench was
used during the evaluation of marginal adaptation and
all frameworks were kept stable in the same position
with the help of this device under the
stereomicroscope.13
In the current study, the mean marginal gap for the
CM group were found as 36.00 mm on shoulder nish
line and 25.10 mm on chamfer nish line, which are
lower than earlier studies.8 In this study, new
techniques are combined with the conventional
methods and CAD-CAM fabricated resin copings were
used in casting procedures instead of using wax
patterns during lost wax technique. Also, it was easy to
maintain the standardization of resin copings and
improved tting accuracy can be acquired by using
this method. Shiratsuchi et al.21 found 23.96 to 25.72
lm for metalceramic crowns on chamfer nish line
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V DOI 10.1111/jerd.12208
and Bottino et al.22 found lower marginal gap values in
chamfer nish line for metal crowns. These results
seem to be in agreement with this study. The marginal
gap of the MM group was higher than the CM and
LM groups. Ortorp et al.10 explained these results by
wear of the milling burs when milling such a hard
material as Co-Cr. Burs must be changed often to
compensate this situation. The marginal gap of 32.10
mm on shoulder nish line and 27.60 mm on chamfer
nish line was found for the LM group which seems to
be in agreement with the study of Ortorp et al.10
There is a lack of information about Co-Cr metal
milling and the DLMS system in literature, so it is
difcult to compare the results of different studies.
In this study, the mean marginal gap for the ZZ was
found as 91.30 mm on shoulder nish line and
99.90 lm on chamfer nish line. These results were
the highest marginal gap values obtained in this study.
Subas et al.5 and Karatasl et al.8 also found similar
results for the ZZ group. Although the resin copings
were used for manufacturing the ZZ group, manual
milling units could be the reason for this highest
marginal gap values. The LZ group showed the lowest
marginal gap values in both nish lines. These results
seem to be lower than some of the previous studies of
this system.20 Euan et al.24 found the marginal gap
values of 50.13 lm on shoulder nish line and 63.56
lm on chamfer nish line and they concluded that
nish lines affected the t of Lava system. However,
Euan et al.24 used clinically prepared teeth, which was
far from being an ideal and standardized prepared die,
this could explain the larger values for the marginal
gap. These differences between the current and
previous studies may be the result of the design of the
studies. The marginal gap values in this study for the
LZ group is similar to the mean marginal gap of 24.60
lm detected on implant abutments.8 In the current
study, the mean marginal gap for the DZ group was
found as 75.00 mm on chamfer nish line, which is in
agreement with earlier studies.8 Despite that, the mean
marginal gap of DZ group on shoulder nish line was
found as 33.00 mm, which was signicantly lower than
chamfer group. Milling of fully sintered zirconia blocks
is difcult and it is hard to form the curvature of
chamfer nish line with this type of zirconia blocks.
Journal of Esthetic and Restorative Dentistry Vol 00  No 00  00^00  2016 7
 MARGINAL FIT OF CAD-CAM BASED RESTORATIONS Ates and Yesil Duymus
This could be the result of higher marginal gap values
of the DZ group on chamfer nish line.8,9
Recommended nish line types for optimal marginal
adaptation are the types of shoulder, shoulder bevel,
and chamfer.15 Several studies19 showed no signicant
differences between the types of shoulder and chamfer
nish line, nevertheless several studies23 demonstrated
that shoulder nish line was more accurate for all-
ceramic restorations which is in agreement with this
study. A clinical study of 1,000 restorations over a
5-year period concluded that 120 mm is the maximum
clinically acceptable marginal mist.2 Therefore, the
marginal gaps recorded in this study met all these
clinically acceptable standards.
The limitations of this research include measuring the
vertical marginal gap only. The horizontal relationship
was not quantied. Also the effect of aging on the
marginal adaptation of frameworks was not tested in
this study and should be further investigated in
combination with in-vivo studies.
CONCLUSIONS
As an alternative of milling techniques, the DLMS
technique exhibited satisfactory results and this CAD-
CAM technique will become popular in dentistry. Best
t was found in the Lava Zirconia group, besides the
Zirkonzahn group showed the highest marginal gap
values. The t of conventional cast frameworks and
DC-Zirkon frameworks were affected from the nish
line design; the conventional cast frameworks with
chamfer nish line and the DC-Zirkon frameworks
with shoulder nish line showed better results.
All systems tested the marginal gaps in compliance
with the standards of clinical acceptability.
DISCLOSURE AND ACKNOWLEDGEMENTS
The authors do not have any nancial interest in any
of the companies whose products are included in this
article. This study was supported by the Scientic
8 Vol 00  No 00  00^00  2016 Journal of Esthetic and Restorative Dentistry
Research Projects of Ataturk University, Erzurum,
Turkey (Project No: 2010/142).
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Reprint requests: Sabit Melih Ates,DDS,PhD,RecepTayyip Erdogan
University,Faculty of Dentistry,Department of Prosthodontics, 53100,
Rize,Turkey;Tel.: 1904642220000; Fax: 1904642220002; email:
melih_ates@hotmail.com
Journal of Esthetic and Restorative Dentistry Vol 00  No 00  00^00  2016 9