RESEARCH AND EDUCATION

Accuracy of marginal fit and axial wall contour for lithium

disilicate crowns fabricated using three digital workflows
Ramtin Sadid-Zadeh, DDS, MS,a Anastasia Katsavochristou, DDS, MS,b Taylor Squires, BS,c and Michael Simon, BSd

Marginal adaptation is a key ABSTRACT

factor in the long-term success
of restorations produced using
computer-aided design and
computer-aided manufacturing
(CAD-CAM) technologies.1-3
Although marginal adaptation
is affected by both vertical
and horizontal discrepancies,
horizontal discrepancies can
be adjusted chairside.4 Thus,
together with the resistance
form, the marginal gap remains
a major determinant of the
longevity of CAD-CAM resto-
rations.5 Although luting agents
can compensate for discrep-
ancies in the marginal gap and
resistance form, degradation of
the luting agent occurs as a
result of occlusal forces and may
lead to secondary caries or
reduction in fracture resistance
of the crowns.6-14 Luting agents
fatigue as a result of micro-
leakage, changes in the elastic
modulus, and plastic deforma-
tion over timedconditions that
occur under dynamic occlusal
forces.15-17
The American Dental As-
sociation specification no. 8
Statement of problem. Comparative assessment of the effectiveness of computer-aided design and
computer-aided manufacturing (CAD-CAM) technologies used to fabricate complete-coverage
restorations is needed. A quantitative assessment requires precise documentation of the marginal
adaptation and external surface contour of fabricated restorations. Limited information is currently
available regarding the effects of milling mode on marginal adaptation and reproduction of the
external surface contour for CAD-CAMefabricated restorations.
Purpose. The purpose of this in vitro study was to evaluate the outcomes for 3 different
digital workflows on the marginal gap and the external surface contour reproducibility of
CAD-CAMefabricated lithium disilicate complete-coverage restorations.
Material and methods. Twelve Ivorine molars were prepared to receive lithium disilicate crowns. The
preparations were digitally recorded using 2 intraoral scanners (TRIOS 3; 3Shape A/S and Planmeca
PlanScan; E4D Technologies), and the restorations were designed using their associated design
software with reference to the anatomy of an unprepared tooth. The designed restorations were then
manufactured from lithium disilicate blocks using a 3-axis milling machine. Twelve restorations were
manufactured using the detailed mode (Planmeca PlanScan detailed mode [PPD-D]), and 12 using the
standard mode for the Planmeca system (Planmeca PlanScan standard mode [PPD-S]). Restorations
from the 3Shape system were fabricated using the detailed mode (TRIOS 3Shape detailed mode
[T3S-D]). The restorations were secured on their associated preparation with an elastomeric
material. The marginal gap of each restoration was then measured in the ImageJ software using
images captured by a stereo microscope at ×20 magnification. External surface reproducibility was
evaluated by measuring undercut at 4-line angles using a dental surveyor. Differences in the
marginal gaps of restorations fabricated using the 3 different workflows were compared by
Brown-Forsythe robust ANOVA, followed by a post hoc test (a=.05). Chi-square analysis (a=.05) was
used to evaluate differences in the contours of the external surface of the restorations, resistance
form, and marginal integrity produced using the 3 workflows.
Results. The mean marginal gap for restorations fabricated using the T3S-D workflow was 60 mm, a
distance significantly lower (P<.05) than that of PPD-D and PPD-S workflows, which yielded a
marginal gap of 95 mm for the detailed mode and 124 mm for the standard mode of milling.
Restorations fabricated using PPD-D and PPD-S workflows produced a significantly more
reproducible external surface contour than those fabricated using the T3S-D workflow.
Conclusions. Restorations fabricated using the T3S-D workflow produced the smallest marginal
gap. However, reproducibility of the external surface contour for this workflow was the worst of the
three workflows analyzed. (J Prosthet Dent 2020;123:121-7)

a
Assistant Professor, Department of Restorative Dentistry, School of Dental Medicine, University at Buffalo, Buffalo, NY.
b
Clinical Assistant Professor, Department of Restorative Dentistry, School of Dental Medicine, University at Buffalo, Buffalo, NY.
c
Dental student, School of Dental Medicine, University at Buffalo, Buffalo, NY.
d
Dental student, School of Dental Medicine, University at Buffalo, Buffalo, NY.

THE JOURNAL OF PROSTHETIC DENTISTRY 121

122
Clinical Implications
The CAD-CAM technology offers dental
practitioners the ability to produce an acceptable
complete-coverage restoration. These results
confirm that the CAD-CAM technology may
produce complete-coverage restorations with
clinically acceptable marginal gaps and external
surface contour, depending on the selected
workflow.
suggests a film thickness of 25 mm to 40 mm for luting
agents.18 However, clinical evaluation of complete-
coverage restorations suggests that typical marginal
gaps, considered clinically acceptable for conventionally
cemented restorations, range between 120 mm and 150
mm.5,19 Moreover, the marginal gaps of CAD-CAM crowns
produced by multiple CAD-CAM systems are reported to
be between 58 mm and 200 mm, suggesting that this range
encompasses acceptable values.20-27 Although marginal
gaps between 25 mm and 40 mm are rarely achieved, these
small marginal gaps should be considered the goal.28
The effects of different technologies on the accuracy of
external surface reproductions based on preparation scans
are considered in the establishment of embrasure and
contact points with neighboring teeth, thereby impacting
the cleanability of interproximal surfaces. Moreover,
reproduction of the external surface affects CAD-CAM
retrofitted crowns for existing removable partial dentures
(RPDs). The successful use of the CAD-CAM technology
has been reported in the chairside production of survey
crowns fitted to the existing RPDs.29-32 However, similar to
laboratory CAD-CAM systems,33 a more critical evalua-
tion of chairside technologies is needed in the context of
reproduction of existing survey crowns.
Multiple factors may influence the accuracy of CAD-
CAM complete-coverage restorations. These include the
quality of tooth preparation,34 optical scanner,35-40
design software settings, manufacturing process (mode
of milling, number of axes in the milling machine, and
diameter of rotary instruments used to cut the internal
and external surfaces of the restoration), and type of
material used to fabricate the restoration. The purpose of
this study was to evaluate the marginal gaps and accu-
racy of the external surface contours of lithium disilicate
crowns fabricated by using 3 digital workflows and 2
different modes of milling. The authors are unaware of
previous studies assessing the accuracy of lithium dis-
ilicate crowns using various modes of milling. The null
hypothesis was that no difference would be found in the
marginal gap and reproduction of the external surface
contour of complete-coverage restorations fabricated
using the 3 digital workflows.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 123 Issue 1
MATERIAL AND METHODS
A pilot study was performed to estimate the sample size
needed to evaluate the marginal gap for CAD-CAM
lithium disilicate crowns. Crowns were fabricated using
2 different intraoral scanners and their associated design
software and fabricated using standard and detailed
milling modes. Four workflows were evaluated. The first
and second workflows used the Planmeca PlanScan in-
traoral scanner and design software (E4D Technologies),
followed by manufacturing of the designed restoration in
the standard milling mode (Planmeca PlanScan standard
mode [PPD-S]) or detailed milling mode (Planmeca
PlanScan detailed mode [PPD-D]). The third and fourth
workflows used the TRIOS 3 intraoral scanner and the
3Shape design software (3Shape A/S), followed by
manufacturing of the designed restoration in the stan-
dard milling mode (TRIOS 3Shape standard mode [T3S-
S]) or detailed milling mode (TRIOS 3Shape detailed
mode [T3S-D]). The specimens were prepared and
evaluated as described in the following paragraphs for
the large-scale study. Results from the pilot study re-
vealed that complete-coverage restorations fabricated
using the T3S-S workflow required significant internal
adjustment to be seated on their preparations. They had
a mean marginal gap of 188 mm, a value considered
unacceptable. As a result, the T3S-S workflow was
eliminated from the large-scale study.
A power analysis was performed for the remaining 3
workflows using the G*Power software. The total sample
size was calculated based on an effect size(f) of 0.8, an
alpha error probability of 0.05, and a power of 0.9. The
results of the power analysis revealed that a minimum of
8 specimens per workflow were needed to perform the
study. However, to increase the power, the study was
performed using 12 specimens per workflow.
Twelve Ivorine molar teeth (Kilgore International, Inc)
were prepared by 1 operator (R.S.-Z.) with a 2-mm
occlusal reduction with reference to the occlusal anat-
omy of the tooth and a 1-mm modified shoulder fin-
ishline width. The preparations were then smoothed with
a finishing bur, and the line angles were rounded. Each
preparation was digitally recorded using 2 intraoral
scanners (TRIOS 3; 3Shape A/S and Planmeca PlanScan;
E4D Technologies). Scanning was performed while the
preparations were mounted on a typodont (200 Series;
Kilgore International, Inc). The unprepared tooth used
for the surveying procedure was scanned along with each
preparation to represent the before-preparation scan. A
standardized scanning procedure was used for all
specimens.
Restorations were designed with reference to the
scans of unprepared teeth. The “Pre-op” design was
selected from the tooth library and applied to the prep-
aration at the design tab for designing PPD-S and
Sadid-Zadeh et al
January 2020
Figure 1. Internal parameters for designed restoration in Planmeca system. A, Spacer thickness. B, Margin ramp.
PPD-D crowns. No modification was applied to the
external design of the restoration. Only minor smoothing
at the margin was applied using the “Smooth Surface”
tool. Based on common practice in fixed prosthodontics,
a cement spacer (defined as “Spacer Thickness” in the
software) of 50 mm was input for the occlusal and axial
walls of the preparation, and a finishline width (defined
as “Margin Ramp” in the software) of 0.8 mm was
selected (Fig. 1).
To design crowns in the T3S-D workflow, the anat-
omy of the unprepared tooth was morphed into the
restoration design so that the definitive design followed
the anatomy of the unprepared tooth. A cement spacer
(defined as “Extra Cement Gap” in the software) of 50
mm and a finishline width (defined as “Distance to
Margin Line”) of 0.8 mm were selected. In the design
software used for the T3S-D workflow, the cement gap
was set to 25 mm, and the smooth distance was set to 0.2
mm. Figure 2 shows the definition for each set of values.
Designed restorations were fabricated from lithium
disilicate (IPS e.max CAD; Ivoclar Vivadent AG) using a
3-axis milling machine (PlanMill 40; E4D Technologies).
A sprue was set in the mid-buccal location before
sending the design to the milling machine. Designed
crowns in PPD-S and PPD-D workflows were sent to the
milling machine for manufacturing in 2 milling modes,
standard and detailed. Designed crowns in the T3S-D
workflow were sent to the milling machine using the
Job Supplier Software (E4D Technologies) for
manufacturing in the detailed milling mode. The PlanMill
40 uses a tapered rotary instrument (Two Striper; Pre-
mier) to mill the external surface of the restorations and 2
rotary instruments to mill the intaglio surfaces, depend-
ing on the milling mode (ellipsoidal rotary instrument for
the standard mode and conical rotary instrument for the
detailed mode).
After the crowns had been milled, the sprues were
removed, and the restorations were inserted into their
Sadid-Zadeh et al
123
Figure 2. Internal parameter for designed restoration in 3Shape system.
preparations. Overcontoured margins were modified
after assessing the restorations on their preparations. No
modifications were made on the intaglio surfaces of the
restorations. The restorations were then crystallized using
a processing oven (Programat CS2; Ivoclar Vivadent AG)
according to the manufacturer’s instructions.
For evaluation, the marginal gap was defined as the
perpendicular measurement from the internal surface of
the crown to the part of the preparation closest to the
finishline.4 Restorations were secured on their prepara-
tions with an elastomeric material (Fit Checker Blue; GC
America), and finger pressure was applied for 1 min-
ute.4,41 They were then placed under a constant load of
1.96 N for 1 minute at room temperature. A stereo-
optical microscope (SMZ-U; Nikon Instruments, Inc)
was used to capture images (×20) of the buccal, lingual,
mesial, and distal sides of each preparation and crown.
To standardize the imaging, 4 devices were fabricated for
the buccal, lingual, mesial, and distal sides of the un-
prepared tooth using polyvinyl siloxane (Lab Putty;
Coltène). Two nails were attached to a metal ruler, and
the ruler was indexed in the putty. Three locations were
THE JOURNAL OF PROSTHETIC DENTISTRY
124
Figure 3. A, Image captured by optical microscope. B, Vertical line drawn
to margin. C, Measurement made at margin.
marked on the ruler to ensure that the marginal gap was
measured at the same point of each mark for all speci-
mens. One operator (M.S.) measured marginal gaps. An
imaging software program (ImageJ; the National In-
stitutes of Health) was used to measure the marginal gap
of each restoration at 3 points per side, yielding a total of
12 data points per restoration. Using tools in the imaging
software, a vertical line was drawn from the defined point
to the margin of the restoration, and the marginal gap
was measured (Fig. 3). Then, fabricated restorations for
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 123 Issue 1
Table 1. Definitions for clinically evaluated parameters
Resistance Clinically acceptable: no rotation around x or y axis
form Not clinically acceptable: rotation around x and/or y axes
Marginal Explorer moves smoothly during occlusogingival movement
integrity at margin
Explorer catches during occlusogingival movement in limited
location, but marginal integrity clinically acceptable
Marginal integrity not clinically acceptable
Ranking of Rank restorations for each preparation from 1 to 3, with 1
restorations being the best choice.
1. ______2. ______ 3. ______
Figure 4. Device fabricated for 0.5-mm undercut at distobuccal location
of unprepared tooth.
each preparation were placed in 3 identical small boxes.
Boxes were placed in a bag and mixed. Restorations
were then randomly picked up from the bag by 1 of the
authors (M.S.), and they were assigned to a letter of A, B,
or C in order. After the randomization process, a blinded
and experienced clinician (R.S.-Z.) evaluated the resis-
tance form and marginal integrity using ×3 magnification
and an explorer based on the rubric presented in Table 1.
The clinician also scored the restorations from 1 to 3,
with 1 representing the best clinical outcome and 3
representing the worst.
The external surface contour of each crown was
evaluated by assessing the undercuts at the mesiobuccal,
distobuccal, mesiolingual, and distolingual line angles.
Four dental surveyor cast holders (Ney Lab Surveyor;
Dentsply Sirona) were used to locate undercuts on the
line angles of an unprepared tooth. Four typodonts (200
Series; Kilgore International, Inc) were used to tilt the
cast holders to locate 0.25-mm undercuts on the
mesiobuccal and distobuccal line angles and 0.5-mm
undercuts on the mesiolingual and distolingual line an-
gles using the dental surveyor undercut gauges. An
autopolymerizing resin (Pattern Resin LS; GC America)
was used to secure the location of each undercut using
gauges placed at each line angle (Fig. 4).
The restorations were secured on their associated
preparations using an elastomeric material (XLV Virtual
Sadid-Zadeh et al
January 2020 125

Table 2. Marginal gap (mean ±standard deviation) measured for Table 3. Contingency table for marginal integrity and resistance form of
complete-coverage restorations in each digital workflow restorations in each workflow
Mean ±SD (mm) Variable PPD-S PPD-D T3S-D
Tooth Surface PPD-S PPD-D T3S-D Marginal integrity
Mesial 99 ±79 72.2 ±61 61.3 ±38 Clinically acceptable 3 10 12
Distal 122.5 ±89 81.4 ±63 52.7 ±35 Not clinically acceptable 9 2 0
Buccal 148.4 ±82 132.4 ±72 57.6 ±29 Resistance form
Lingual 124.9 ±66 93.6 ±51 63.3 ±28 Clinically acceptable 0 5 12
Total 123.7 ±81a 94.9 ±66b 59.7 ±33c Not clinically acceptable 12 7 0

PPD-D, Planmeca PlanScan detailed mode; PPD-S, Planmeca PlanScan standard mode; PPD-D, Planmeca PlanScan detailed mode; PPD-S, Planmeca PlanScan standard mode;
SD, standard deviation; T3S-D, TRIOS 3Shape detailed mode. Means labeled (total) with T3S-D, TRIOS 3Shape detailed mode.
different superscript letters are significantly different (P<.05).

Acceptable Restoration (%)

XD; Ivoclar Vivadent AG). Then, the cast holders and their 120 Marginal integrity Resistance form
associated typodont were used to evaluate undercuts on 100
the defined line angles for the unprepared tooth and the 80
preparation-crown assembly. The undercuts on the
60
preparation-crown assembly were compared with those
40
on the unprepared tooth. The visual result was reported as
“yes” when the undercuts were identical to the unpre- 20
pared tooth and “no” when they were not. 0
Statistical analyses were performed using a statistical PPD-S PPD-D T3S-D
Digital Workflow for Fabrication of Restorations
software program (IBM SPSS Statistics, v19; IBM Corp).
Brown-Forsythe robust ANOVA followed by the Games- Figure 5. Clinically acceptable restorations (%) with marginal integrity
Howell multiple comparison post hoc test was used to and resistance form after clinical evaluation for each digital workflow.
compare differences in the mean marginal gap between PPD-D, Planmeca PlanScan detailed mode; PPD-S, Planmeca PlanScan
the 3 digital workflows (a=.05). Chi-square tests evalu- standard mode; T3S-D, TRIOS 3Shape detailed mode.

ated the effects of different digital workflows on the

resistance form and marginal integrity (a=.05). Descrip-
tive statistics were calculated to analyze the reproduction
of undercuts. The best-ranked workflow for each prep-
aration was reported descriptively.
RESULTS
The mean and standard deviation of the marginal gap for
each digital workflow are presented in Table 2. The equal
variance assumption was not met (P<.001), so the
Brown-Forsythe robust ANOVA followed by the Games-
Howell multiple comparison post hoc test was used to
compare the mean marginal gaps of the 3 digital work-
flows. The robust ANOVA revealed a significant differ-
ence (P<.05) between the workflows. The Games-Howell
multiple comparisons showed that the marginal gap for
the T3S-D workflow was significantly smaller (P<.05)
than that for the PPD-S and PPD-D workflows. In
addition, the PPD-D workflow yielded a significantly
smaller marginal gap (P<.05) than the PPD-S workflow.
Table 3 shows the number of crowns with “clinically
acceptable” and “clinically not acceptable” marginal
integrity and resistance form in each workflow. When
chi-square analysis was used to compare the marginal
integrity of the restorations based on the 1, 2, and 3
rankings (Table 1), the assumption of large expected
frequencies was not met. As a result, the 1 and 2 rankings
for marginal integrity were combined into a single
“clinically acceptable” category, and class 3 was consid-
ered “not clinically acceptable.” Then, chi-square analysis
was used to evaluate the effect of the digital workflow on
marginal integrity. The results showed no significant
differences (P>.05) in clinical evaluation of the marginal
integrity of restorations fabricated using the T3S-D and
PPD-D workflows. However, the marginal integrity of
PPD-S restorations was significantly (P<.05) worse than
that of the other workflows. The chi-square analysis also
showed that restorations fabricated using the T3S-D
workflow had a significantly better (P<.05) resistance
form than those fabricated using the PPD-D workflow
(Fig. 5). Similarly, restorations fabricated using the
PPD-D workflow had significantly better (P<.05) resis-
tance form than those fabricated using the PPD-S
workflow. When the blinded clinician ranked the resto-
rations, lithium disilicate crowns fabricated using the
T3S-D workflow were always selected as the first choice,
and the restorations fabricated using the PPD-D work-
flow were ranked as the second choice 92% of the time.
When chi-square analysis was used to evaluate the
impact of digital workflows on the reproduction of un-
dercuts, the assumption of large expected frequencies
was not met, so the results were reported descriptively.
Undercuts were reproduced in 71% of the predetermined
locations for the PPD-S workflow, 81% for the PPD-D
workflow, and 40% for the T3S-D workflow (Fig. 6).

Sadid-Zadeh et al THE JOURNAL OF PROSTHETIC DENTISTRY

126
Reproduction of Undercuts (%)
90
80
70
60
50
40
30
20
10
0
PPD-S PPD-D T3S-D
Digital Workflow for Fabrication of Restorations
Figure 6. Percentage of undercuts reproduced for each digital workflow.
PPD-D, Planmeca PlanScan detailed mode; PPD-S, Planmeca PlanScan
standard mode; T3S-D, TRIOS 3Shape detailed mode.
DISCUSSION
The null hypothesis that the digital workflow does not
impact the marginal gap and reproduction of the external
surface contour of restorations was rejected. In this study,
an elastomeric material was used to secure the restorations
on their associated prepared teeth because of its low film
thickness.5 Similar to the replica technique, this method
allows for evaluation of the marginal fit of restorations
fabricated using different workflows on a single prepara-
tion. An advantage of this technique over the replica
technique is that in the replica technique, the vertical cut at
the margin and the location of the cut cannot be precisely
determined for all specimens, leading to potential vari-
ability in measurement of the marginal gap. In contrast,
measurement of the marginal gap through a combination
of microscopy and the putty-ruler assembly provided ac-
curacy in vertical measurement at the margin and repro-
ducibility of measurement locations. One limitation of this
technique is that as in the replica technique, the marginal
gap is only measured at preset points, potentially missing
marginal discrepancies in other locations. Moreover, in
this technique, internal adaptation of the restorations
cannot be evaluated. However, the marginal integrity of
the crowns was also evaluated clinically across 360 degrees
of the crown margin by an experienced evaluator; as a
result, any undetected unacceptable marginal gaps not
recorded by digital photography should have been noted
in the clinical evaluation.
The marginal gap of crowns fabricated using the
T3S-D workflow was significantly (P<.05) smaller than
that of the other workflows. Differences between the
PPD and T3S workflows could result from the quality of
images captured during the scanning process.37,38 Images
captured by the intraoral scanner used in the PPD
workflow have been shown to have an unclear transition
area between the triangles with a high level of noise.38-40
A recent study25 found that fully digital fabrication of
a lithium disilicate crown by intraoral scanning and
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 123 Issue 1
milling resulted in a better vertical marginal fit (60 mm)
than fabrication of crowns using conventional techniques
(74 mm). A similar marginal gap for crowns produced
using the T3S-D workflow was reported in this study (60
mm), although the die material, intraoral scanner, design
software, and milling unit differed from those of the
previous study. The marginal gap values reported here
were also similar to those reported by Alqahtani26 (60
mm) and Yang et al27 (58 mm). Similar to this study, in the
studies by Alqahtani and Xang et al,26,27 a TRIOS
intraoral scanner was used to record the preparation, and
the 3Shape design software was used to design the
associated restoration. However, these studies did not
report the settings for the design software, and a 5-axis
milling machine was used to mill the restorations.26,27
The mean marginal gap was 123.7 mm for the PPD-S
workflow and 94.9 mm for the PPD-D workflow. In
contrast, Neves et al23 reported that the marginal gap for
crowns fabricated using the Planmeca system was 66.9 mm.
The different values may be due to a difference in the se-
lection of the die spacer, which was 100 mm for the study by
Neves et al.23 Unfortunately, the study did not specify the
marginal ramp setting and milling mode used for the
experiment, making direct comparisons difficult. In addi-
tion, the mean marginal gap for the PPD-S workflow was
higher than that reported by Renne et al34 using the same
workflow (123.7 mm versus 62.3 mm). This discrepancy may
be due to the selection of a much smaller marginal ramp
value and the use of a much thicker die spacer in their study.
These selections may compensate for the lack of smooth-
ness associated with a 1-mm finishline width, resulting in a
better marginal fit. However, changes in the setting may
also modify the resistance form of the restoration, which
was not evaluated in the study by Renne et al.34 The present
study evaluated the resistance form of the restorations
defined as rotation around the x or y axis. The results of
clinical evaluation showed that the resistant form of the
restorations fabricated using the T3S-D workflow was
significantly better than that of the other workflows
(P<.05). This factor contributed strongly to the selection of
crowns fabricated using the T3S-D workflow as the best
choice. In contrast, the differences between marginal gap
data reported by different studies might be inevitable. For
example, Renne et al24,34 reported an average marginal gap
of 81 mm, a higher marginal gap than that reported in their
previous study, although the protocol remained the same.
The authors are unaware of a study that has evaluated
the external surface contour of an existing surveyed crown
using an intraoral scanner. Workflows used in this study
did not reproduce 100% of the undercuts. However, the
PPD-S and PPD-D workflows reproduced the pre-
determined undercuts better than the T3S-D workflow.
These data differ from those of CAD-CAM crowns eval-
uated using a laboratory scanner, which exhibited signif-
icantly smaller gaps in all of the clasp regions and
Sadid-Zadeh et al
January 2020
significantly higher retentive forces for RPDs compared
with conventionally fabricated restorations.33 In addition,
the data gathered from the present study do not support
data from clinical reports that used intraoral scanners to
capture and fabricate retrofitted crowns.30-32 The present
study was limited as only 4 predetermined locations were
used to evaluate the reproduction of the external surface
contour. Future research should evaluate the reproduction
of the external surface contour of CAD-CAM retrofitted
crowns by measuring the undercut at multiple locations
and by assessing the retentive force of the RPD framework.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. Lithium disilicate crowns fabricated using the T3S-D
workflow produced the smallest marginal gap, with
acceptable marginal fit and resistance form.
2. However, none of the workflows reproduced 100%
of the external surface contour.
REFERENCES
1. Heymann HO, Bayne SC, Sturdevant JR, Wilder AD Jr, Roberson TM. The
clinical performance of CAD/CAM generated ceramics inlays. A four year
study. J Am Dent Assoc 1996;127:1171-81.
2. Baig MR, Tan KB, Nicholls JI. Evaluation of the marginal fit of a zirconia
ceramic computer-aided machined (CAM) crown system. J Prosthet Dent
2010;104:216-27.
3. Pak HS, Han JS, Lee JB, Kim SH, Yang JH. Influence of porcelain veneering
on the marginal fit of Digident and Lava CAD/CAM zirconia ceramic crowns.
J Adv Prosthodont 2010;2:33-8.
4. McLean JW, von Fraunhofer JA. The estimation of cement film thickness by
an in vivo technique. Br Dent J 1971;131:107-11.
5. Holmes JR, Bayne SC, Holland GA, Sulik WD. Considerations in
measurement of marginal fit. J Prosthet Dent 1989;62:405-8.
6. Jacobs MS, Windeler AS. An investigation of dental luting cement solubility
as a function of the marginal gap. J Prosthet Dent 1991;65:436-42.
7. Yoshida K, Tanagawa M, Atsuta M. In-vitro solubility of three types of resin
and conventional luting cements. J Oral Rehabil 1998;25:285-91.
8. Knobloch LA, Kerby RE, Seghi R, Berlin JS, Lee JS. Fracture toughness of
resin-based luting cements. J Prosthet Dent 2000;83:204-9.
9. Buchalla W, Attin T, Hellwig E. Brushing abrasion of luting cements under
neutral and acidic conditions. Oper Dent 2000;25:482-7.
10. Alvarez-Arenal A, Gonzalez-Gonzalez I, Pinés-Hueso J, deLlanos-
Lanchares H, del Rio Highsmith J. The effect of compressive cyclic loading on
the retention of cast single crowns cemented to implant abutments. Int J
Prosthodont 2016;29:80-2.
11. Tuntiprawon M, Wilson PR. The effect of cement thickness on the fracture
strength of all ceramic crowns. Aust Dent J 1995;40:17-21.
12. Alkumru H, Hullah WR, Marquis PM, Wilson SJ. Factors affecting the fit of
porcelain jacket crowns. Br Dent J 1988;164:39-43.
13. Wiskott HW, Belser UC, Scherrer SS. The effect of film thickness and surface
texture on the resistance of cemented extracoronal restorations to lateral
fatigue loading. Int J Prosthodont 1999;12:255-62.
14. Souza RO, Ozcan M, Pavanelli CA, Buso L, Lombardo GH, Michida SM,
et al. Marginal and internal discrepancies related to margin design of ceramic
crowns fabricated by a CAD/CAM system. J Prosthodont 2012;21:94-100.
15. Karimipour-Saryazdi M, Sadid-Zadeh R, Givan D, Burgess JO, Ramp LC,
Liu PR. Influence of surface treatment of yttrium-stabilized tetragonal
zirconium oxides and cement type on crown retention after artificial aging.
J Prosthet Dent 2014;111:395-403.
16. Li ZC, White SN. Mechanical properties of dental luting cements. J Prosthet
Dent 1999;81:597-609.
17. Indrani DJ, Cook WD, Televantos F, Tyas MJ, Harcourt JK. Fracture
toughness of water- aged resin composite restorative materials. Dent Mater
1995;11:201-7.
18. American Dental Association. Guide to dental materials and devices. 8th ed.
Chicago: American Dental Association; 1978. p. 135-7.
Sadid-Zadeh et al
127
19. Fransson B, Oilo G, Gjeitanger R. The fit of metal-ceramic crowns, a clinical
study. Dent Mater 1985;1:197-9.
20. Karlsson S. The fit of Procera titanium crowns: an in vitro and clinical study.
Acta Odontol Scand 1993;51:129-34.
21. n-Sung Y, Jae-Ho Y, Jai-Bong L. In vitro marginal fit of three all-ceramic
crown systems. J Prosthet Dent 2003;90:459-64.
22. May KB, Russell MM, Razzoog ME, Lang BR. Precision of fit: the Procera All
Ceram crown. J Prosthet Dent 1998;80:394-404.
23. Neves FD, Prado CJ, Prudente MS, Carneiro TA, Zancopé K, Davi LR, et al.
Micro-computed tomography evaluation of marginal fit of lithium disilicate
crowns fabricated by using chairside CAD/CAM systems or the heat-pressing
technique. J Prosthet Dent 2014;112:1134-40.
24. Renne W, Wolf B, Kessler R, McPherson K, Mennito AS. Evaluation of the
marginal fit of CAD/CAM crowns fabricated using two different chairside
CAD/CAM systems on preparations of varying quality. J Esthet Restor Dent
2015;27:194-202.
25. Ng J, Ruse D, Wyatt C. A comparison of the marginal fit of crowns fabricated
with digital and conventional methods. J Prosthet Dent 2014;112:555-60.
26. Alqahtani F. Marginal fit of all-ceramic crowns fabricated using two extraoral
CAD/CAM systems in comparison with the conventional technique. Clin
Cosmet Investig Dent 2017;16:13-8.
27. Yang X, Lv P, Liu Y, Si W, Feng H. Accuracy of digital impressions and fitness
of single crowns based on digital impressions. Materials (Basel) 2015;8:
3945-57.
28. Holden JE, Goldstien G, Hittelman EL, Clark EA. Comparison of the
marginal fit of pressable ceramic to metal ceramic restorations. J Prosthodont
2009;18:645-8.
29. Marchack BW, Chen LB, Marchack CB, Futatsuki Y. Fabrication of an all-
ceramic abutment crown under an existing removable partial denture using
CAD/CAM technology. J Prosthet Dent 2007;98:478-82.
30. Schoenbeck P. Retro-fitting a CEREC crown to a removable partial denture.
Dent Today 2008;27:110-3.
31. Yoon TH, Chang WG. The fabrication of a CAD/CAM ceramic crown to fit an
existing partial removable dental prosthesis: a clinical report. J Prosthet Dent
2012;108:143-6.
32. El Kerdani T, Roushdy S. The use of CAD/CAM technology for fabricating
cast gold survey crowns under existing partial removable dental prosthesis. A
clinical report. J Prosthodont 2017;26:321-6.
33. Ozawa D, Suzuki Y, Kawamura N, Ohkubo C. Fabrication of crown
restoration retrofitting to existing clasps using CAD/CAM: fitness accuracy
and retentive force. J Prosthodont Res 2015;59:136-43.
34. Renne W, McGill ST, Forshee KV, DeFee MR, Mennito AS. Predicting
marginal fit of CAD/CAM crowns based on the presence or absence of
common preparation errors. J Prosthet Dent 2012;108:310-5.
35. Brawek PK, Wolfart S, Endres L, Kirsten A, Reich S. The clinical accuracy of
single crowns exclusively fabricated by digital workflow the comparison of
two systems. Clin Oral Investig 2013;17:2119-25.
36. Tsirogiannis P, Reissmann DR, Heydecke G. Evaluation of the marginal fit of
single-unit, complete-coverage ceramic restorations fabricated after digital
and conventional impressions: a systematic review and meta-analysis.
J Prosthet Dent 2016;116:328-35.
37. Patzelt SB, Bishti S, Stampf S, Att W. Accuracy of computer-aided design/
computer-aided manufacturing-generated dental casts based on intraoral
scanner data. J Am Dent Assoc 2014;145:1133-40.
38. Lim JH, Park JM, Kim M, Heo SJ, Myung JY. Comparison of digital intraoral
scanner reproducibility and image trueness considering repetitive experience.
J Prosthet Dent 2018;119:225-32.
39. Renne W, Ludlow M, Fryml J, Schurch Z, Mennito A, Kessler R, et al.
Evaluation of the accuracy of 7 digital scanners: an in vitro analysis based on
3-dimensional comparisons. J Prosthet Dent 2017;11:36-42.
40. Hack GD, Sebastian B, Patzelt M. Evaluation of the accuracy of six intraoral
scanning devices: an in-vitro investigation. ADA Professional Product Review
2015;10:1-5.
41. Ucar Y, Akova T, Akyil MS, Brantley WA. Internal fit evaluation of crowns
prepared using a new dental crown fabrication technique: laser-sintered
Co-Cr crowns. J Prosthet Dent 2009;102:253-9.
Corresponding author:
Dr Ramtin Sadid-Zadeh
Department of Restorative Dentistry
University at Buffalo School of Dental Medicine
215 Squire Hall
Buffalo, NY 14214-8006
Email: rsadidza@buffalo.edu
Acknowledgments
Statistical analysis was performed by Dr Elaine Davis, Professor at Department of
Oral Diagnostic Sciences, School of Dental Medicine.
Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2018.11.003
THE JOURNAL OF PROSTHETIC DENTISTRY