Clinical outcomes of three different

crown systems with CAD/CAM

technology
Emily R. Batson, DDS, MS,a Lyndon F. Cooper, DDS, PhD,b
Ibrahim Duqum, DDS, MS,c and Gustavo Mendona, DDS, PhDd
University of North Carolina at Chapel Hill School of Dentistry,
Chapel Hill, NC
Statement of problem. Computer-aided design and computer-aided manufacturing (CAD/CAM) generated restorations
are gaining popularity. However, limited clinical evidence is available for single-unit posterior CAD/CAM restorations
fabricated with established and newer crown materials.
Purpose. The purpose of this clinical study was to assess the restoration quality of and gingival response to CAD/CAM
fabricated posterior single-tooth restorations with different processing technologies.
Material and methods. Twenty-two individuals in need of posterior complete coverage crowns were recruited under an
institutional review board approved protocol. Teeth were randomized to 1 of 3 groups: metal ceramic, lithium disilicate, and
monolithic zirconia. An unprepared or minimally restored tooth on the contralateral side was chosen as a control tooth
for gingival measurements with each participant. Teeth were prepared and scanned intraorally by 1 of 3 experienced
practitioners. A total of 32 restorations were digitally designed and fabricated with either milling technology or
rapid-prototype printing and casting with conventional porcelain application. Restorations were evaluated with modied
United States Public Health Service criteria for contour, marginal adaptation, occlusion, and shade. Gingival crevicular uid
volume and bleeding on probing were recorded preoperatively, at 1-month and 6-month postcementation visits. Polyvinyl
siloxane impressions were made of the buccal margin of cemented restorations and evaluated with microcomputed
tomography to assess marginal adaptation (horizontal discrepancy). The Mantel Haenszel row mean score was used to assess
whether the crown systems differed with respect to the modied United States Public Health Service criteria. Linear mixed
models were used to assess whether the average gingival volumes were affected by the explanatory variables (crown system,
tooth status [treated vs control], or visit). A generalized estimating equation approach was used to assess whether
bleeding on probing was affected by the explanatory variables. One-way ANOVA was used to assess marginal discrepancy
values among the crown systems (a.05 for all tests).
Results. Twelve metal ceramic, 10 lithium disilicate, and 10 zirconia restorations were fabricated for 22 participants. Zirconia
restorations were signicantly different from the other 2 crown systems (P<.001) with respect to occlusion. No occlusal
adjustment was needed on 80% of the zirconia restorations. The average gingival crevicular uid volumes did not differ among
crown systems, between treated and control groups, or over time. The average horizontal marginal discrepancy was
signicantly different between lithium disilicate and zirconia crowns (P.027), with zirconia crowns having the least amount
of horizontal marginal discrepancy.
Conclusions. Given the small sample size and limitations of this study, CAD/CAM-generated restorations for posterior teeth
made from different materials had acceptable clinical results. (J Prosthet Dent 2014;112:770-777)

This study was supported by an American Academy of Fixed Prosthodontics Stanley D. Tylman grant.
a

Former Resident, Department of Prosthodontics, University of North Carolina at Chapel Hill School of Dentistry, Private practice,
Colorado Springs, Colo.
b
Director and Stallings Distinguished Professor, Graduate Prosthodontics, University of North Carolina at Chapel Hill School of Dentistry.
c
Clinical Assistant Professor, Department of Prosthodontics, University of North Carolina at Chapel Hill School of Dentistry.
d
Clinical Assistant Professor, Department of Prosthodontics, University of North Carolina at Chapel Hill School of Dentistry.

The Journal of Prosthetic Dentistry

Batson et al

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771

Clinical Implications
Practitioners have multiple options for generating single-tooth
restorations with computer-aided design and computer-aided
manufacturing technology. Irrespective of available material choices,
a digital workow that involves intraoral scanning and digital design
may provide a clinically acceptable single-tooth restoration.

Computer-aided design and computeraided manufacturing (CAD/CAM)

dentistry has evolved dramatically in
the past 30 years. Most recently,
numerous CAD/CAM systems with
broad capabilities that range from
implant restoration design and fabrication to orthodontic appliance planning and manufacture have become
widely available for clinicians and
dental laboratories. In addition, demand for esthetic materials has increased1 in restorative dentistry, with
concurrent advances in materials science that provide new monolithic
materials that synergize with CAD/
CAM technology. Two materials, lithium disilicate (LD) and monolithic
zirconia (Zr), have become popular,
and both are fabricated with CAD/
CAM systems.2 A recent survey of
laboratory fabrication projections for
restorative materials estimates that, by
the year 2017, ceramic materials will
be used to fabricate approximately
42% of xed dental restorations.1
The adoption of digital manufacture
for crowns involves the professional
assessment of all attributes of the restoration. Notably, attention has been
focused on the t and marginal adaptation of CAD/CAM restorations.3
As discussed in a recent review by
Miyazaki et al,4 crown margins can
be difcult to capture with intraoral
scanning, not only because of their
design, but their proximity to gingival
tissues, adjacent teeth, and sulcular
uids. Other studies have concluded
no signicant difference among intraoral scanning, a scan of an impression,
or a gypsum cast.5,6 Gth et al7
examined the accuracy of digital
models with an in vitro experiment.

Batson et al

The direct intraoral capture of a prepared abutment found more accuracy

than the scanned polyether impression
or gypsum cast. Average marginal discrepancies of CAD/CAM restorations
have been reported, which ranged
from 35 to 71 mm, and clinical studies
with scanning electron microscopy
analysis have equivalent values.5,8-10
A clinical study by Brawek et al11 reported a mean marginal discrepancy
value of 51 mm for veneered Zr crowns
fabricated with intraoral scanning
techniques and digital fabrication.
Even with studies that found comparable marginal adaptation with
standard metal ceramic restorations,
the longevity of ceramic materials are
of concern, especially those with
veneering methods for improved esthetics. A 94.8% 8-year survival rate
was reported by Gehrt et al12 for 94
single-unit xed dental prostheses for
veneered LD restorations with a 5.5%
rate of chipping or fracturing of restorations. Fasbinder et al13 reported a
100% survival rate of 62 LD crown
restorations in 43 individuals over a
2-year recall period. No incidence of
crown fracture or chipping was reported nor relatively high alpha scores
for color and marginal adaptation.
Higher chipping rates of 15% to 25%
have been reported for veneered Zr
restorations.14,15 A monolithic restoration would appear to solve some of
the technical complications associated
with ceramic materials, despite limited
clinical data.
This prospective study compared
different CAD/CAM crown procedures.
The primary outcome measurement was
restoration quality assessed with modied United States Public Health Service

(USPHS) criteria. Secondary outcomes

included marginal adaptation measured
by microcomputed tomography (micro-CT) analysis and the gingival
response to CAD/CAM crown restorations evaluated at the level of inammation with gingival crevicular uid
(GCF) volume and bleeding on probing
(BOP). The null hypotheses were that no
difference would be found in crown
quality among metal ceramic (MC), LD,
and Zr crowns fabricated with CAD/
CAM technologies, no difference would
be found in gingival response among the
crown systems, and no difference would
be found in the marginal discrepancy
values between crown systems and
intraoral scanners.

MATERIAL AND METHODS

Patients of the University of North
Carolina (UNC) at Chapel Hill School
of Dentistry were screened and enrolled
in this study under institutional review
board approval (UNC institutional review board 11-2099). Before treatment
began, radiographs, tooth shade, GCF
volume, and BOP measurements were
recorded for all treated teeth as well
as a minimally restored or unprepared
control tooth on the contralateral side.
Shade was matched to a Vita Classic
shade guide for treated teeth. GCF
volume was collected on the buccal and
lingual surfaces of selected and control
teeth with crevicular uid strips (Periopaper; Oraow) and a Periotron 8000
(Oraow) according to the manufacturers instructions. BOP was measured
with a periodontal probe (UNC-15
Periodontal Probe; Hu-Friedy) on the
treated and control teeth. The crown
system was randomized to treated

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Volume 112 Issue 4

teeth by using computerized software
(Random Allocation Software; http://
mahmoodsaghaei.tripod.com/Softwares/
randalloc.html). A total of 32 crowns
were fabricated for 22 participants.
Teeth that required a foundation
for appropriate resistance or retention
form were treated with either an
amalgam core (Sybralloy; Kerr Dental)
or composite resin core (Comp-Core;
Premier Dental). All the teeth were prepared by 1 of 3 experienced practitioners
(E.B., L.C., I.D.) by using standard recommended preparation guidelines of
1.5 to 2.0 mm occlusal reduction, and
1.0 to 1.5-mm axial reduction with a
deep chamfer margin circumferentially.
Margin placement was designated at no
more than 0.5 mm subgingivally. After
preparation, the teeth were isolated
from the gingival tissues by placing
appropriately sized plain displacement
cord (Ultrapak; Ultradent Products Inc)
and were scanned according to the type
of restoration assigned; MC and Zr restorations were assigned to the iTero
scanner (Align Technology, Inc), and
LD crowns were assigned to the E4D
scanner (Planmeca-E4D) linked to the
E4D milling unit. All the teeth were
scanned by using the recommended sequences or patterns as determined by
each scanner. Scanned preparations
were reviewed chairside, and, if necessary, adjustments were made and the
tooth rescanned. An intraocclusal record was made with an occlusal registration material for teeth assigned to the
LD group (Virtual CADbite; Ivoclar
Vivadent). MC and Zr crown intraocclusal scans were made as directed by

Table I.

the iTero scanner. Once scanning was

complete, an interim restoration was
fabricated from a bis-acryl material
(Integrity; Dentsply Caulk), polished,
and cemented with interim cement
(Temp-Bond NE; Kerr Dental).
Scans for MC and Zr crowns were
sent electronically to Align Technology
Inc. Preparation margins were marked
electronically by the clinician when signicant deviations were noted from the
default margin. Solid casts were ordered
for all MC and Zr restorations (Cadent
model; Align Technology Inc). One
dental laboratory fabricated all the MC
and Zr crowns. Both the MC and Zr
crowns were designed with digital design
software (3Shape software; 3Shape).
Die-space allowances were set within the
design software at 0.030 mm for Zr
crowns, and 0.040 mm for MC crowns
according to the type of material and the
manufacturers recommendations. MC
copings were produced by using rapid
prototype printing (3-dimensional
printing) technology and an appropriate polymer (Envisiontec Ultra 2 3-D
printer and EC 1000 Photopolymer;
EnvisionTEC). Printed copings were
invested and cast from a high noble alloy
followed by the application of porcelain
(Argedent Euro; The Argen Corporation
and IPS d.Sign, In-Line Porcelain;
Ivoclar-Vivadent). The Zr restorations
were fabricated by using milling technology (Wieland Mini-mill; Wieland
Dental). Intrinsically colored monolithic
Zr blocks (Zenostar; Wieland Dental)
were milled in the green state and then
sintered according to manufacturer
recommendations. If necessary, extrinsic

stains were added for characterization

(Empress stains; Ivoclar Vivadent).
The LD crowns were fabricated
with the CAD software within the E4D
system. The restorations were sent
electronically to the E4D mill, and LD
blocks (eMax CAD; Ivoclar Vivadent)
were milled in the selected shade. The
E4D design software die spacing
settings of 0.10 mm were used. After
milling, sintering was completed according to the manufacturers directions. Characterization and glazing
were completed with appropriate stains
(IPS eMax Ceram; Ivoclar Vivadent).
One clinician (E. B.) recorded the
modied USPHS crown-quality criteria
as listed in Table I during the crown
delivery appointment. All crowns were
tted by rst verifying the interproximal
contacts and then verifying the t with
addition silicone (black for ceramic,
white for MC; Fit-Checker; GC America
Inc) to disclose and verify the t of
the intaglio surface. Necessary internal
adjustments were made for MC crowns
with a carbide bur (no. 4 round bur;
Hu-Friedy). For Zr and LD crowns, adjustments were made on the prepared
tooth surfaces when possible with
a water-cooled ne diamond rotary instrument (Two-Striper Diamond; Premier Dental). Marginal t was veried
by explorer feel. Occlusion was evaluated with occlusal indicating paper
(Acculm; Parkell Dental), and any
necessary adjustments were made with
polishing wheels (Dialite polishers;
Brasseler Dental). If extensive adjustment was necessary, the crown was
reglazed. Once seated, the shade of the

Modied United States Public Health Service criteria for crown evaluation

Marginal
Adaptation

Crown Contour

Shade

Ideal

Ideal

Ideal

S: Acceptable

Less than ideal

but acceptable

Less than ideal but minimal

or no changes required

Less than ideal but no

changes required

T: Acceptable/modications
needed

Less than ideal,

adjust or remake

Results
R: Excellent

V: Unacceptable

Remake

The Journal of Prosthetic Dentistry

Additions or
reductions necessary
Remake

Occlusion
Ideal
Less than ideal but no
changes required/minimal
adjustments necessary

Staining or other shade

modications required

Adjustments necessary

Remake

Remake

Batson et al

October 2014

773

crown was veried with the patient. All

the crowns were cemented with glass
ionomer cement (Ketac Cem; 3M ESPE).
The participants were recalled 1
month after cementation for GCF
volume and BOP measurements.
Postcementation measurements and
impressions were recorded by 1 practitioner (E. B.). After GCF volume and
BOP measurements, plain displacement cord (Ultrapak; Ultradent Products Inc) was placed along the buccal
side of the restored tooth, and a polyvinyl siloxane (PVS) impression was
made of the cemented crown with light
and heavy viscosities (Imprint 3; 3M
ESPE) in a quadrant impression tray
with appropriate adhesive (COE brand
[GC America Inc] and VPS Tray Adhesive [3M ESPE]). PVS impressions were
sectioned through the buccal and
occlusal surfaces of the impression to
display only the buccal section of the

Table II.

treated tooth. The sectioned impressions were scanned with a micro-CT

scanner (Scanco mCT 40 scanner;
Scanco Medical; Biomedical Research
Imaging Center at the UNC). Digital
Imaging and Communications in
Medicine (DICOM) les were created
with slices approximately 20 mm in
width and with approximately 6 mm
of resolution. Images were analyzed
with a DICOM viewer and linear
measuring tool (Image J software; U.S.
National Institutes of Health). Each
crown was measured at 6 locations 0.5
to 1.0 mm apart along the buccal
margin. Measurements were made
from the prepared crown margin of
the tooth to the closest horizontal
point of the crown restoration. Measurements were recorded as absolute
values that represent overextended
or underextended crown margins. The
patients were recalled 6 months after

cementation for GCF volume and BOP

measurements.
Descriptive statistics were performed with computerized software
(SAS v9.1; SAS). The Mantel Haenszel
row mean score statistic was used
to assess an association between the
crown system and the modied USPHS
criteria for acceptable; thus, the R, S,
and T values were combined for this
analysis. Linear mixed models were
used for buccal and lingual GCF volumes separately, and a generalized
estimating equation approach was
used for BOP. The explanatory variables
of interest were the between-subject
factor (crown system) and the withinsubject factors (visit and tooth status,
treated vs control). Because both
tooth status and visit were correlated
within the crown system, a Kronecker
product formulation was used in the
linear mixed models for the covariance

Crown ratings by using modied USPHS criteria

Unacceptable
or Rejected

Acceptable with
Modications

Acceptable

Excellent

MC

12

Zr

10

Crown System

Total

Marginal adaptation

LD

10

Total

20

32

MC

12

Zr

10

LD

10

Total

23

32

12

Zr

10

LD

10

Total

18

32

Contour

Shade
MC

Occlusion
MC

12

Zr

10

LD

10

Total

16

13

32

For USPHS Shade, P.06; for USPHS Contour, P.16; for USPHS Margins, P.07; for USPHS Occlusion, P.0005.
USPHS, United States Public Health Service; MC, metal ceramic; Zr, zirconia; LD, lithium disilicate.
a
Denotes statistically signicant values assessed by Mantel Haenszel row mean score statistic.

Batson et al

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Volume 112 Issue 4

structure and compound symmetry
in the generalized estimating equation
method. One-way ANOVA was used to
determine whether the average horizontal marginal discrepancies differed
among the crown systems. For those
that were signicant, pairwise comparisons were used between the crown
systems and scanners. The Bonferroni
method was used to obtain adjusted P
values (a.05).

RESULTS
Six crowns (3 MC, 2 LD, 1 Zr) were
rejected for unacceptable marginal adaptation and were remade. Thus, the
remake rate because of clinically unacceptable marginal adaptation was
18.8%. These 6 crowns were among the
rst 12 fabricated, dening a learning
curve related to the software designation of margin location in design. Of
these six, 2 MC crowns were remade
with conventional impression and laboratory techniques, and were excluded
from the horizontal marginal discrepancy analyses. The remaining 4 crowns
that were remade were fabricated from
new intraoral scans and used the same
CAD/CAM processes for fabrication.
Three participants did not return for the

Table III.

Tables III and IV. The P values for all

explanatory variables associated with
the gingival volumes and BOP are provided in Table IV.
The average horizontal marginal
discrepancy as determined by micro-CT
analysis was statistically signicantly
different among the crown systems
(P.003). The number of crowns per
group and the type of horizontal
discrepancy as determined by micro-CT
analysis are displayed in Figure 1. A
study LD crown as seen by micro-CT
imaging is demonstrated in Figure 2.
Horizontal marginal discrepancy measurements made with micro-CT imaging are depicted in Figure 3. Pairwise
comparisons were used to determine
which systems differed. LD and Zr were
signicantly different (P.027), with
LD crowns having larger values of horizontal discrepancies. Descriptive statistics as well as pairwise comparisons
for horizontal discrepancy values are
given in Tables V and VI.

1-month recall visit, and 13 participants

did not return for the 6-month recall
visit. Twenty-nine crowns were evaluated
at the 1-month recall visit, and 19
crowns at the 6-month recall visit.
No statistically signicant association was found among crown types and
their marginal adaptation, shade, or
contour with the Mantel Haenszel row
mean score statistic. The majority
of restorations were scored in the
acceptable category with the USPHS
criteria. The distribution of crowns
graded within each USPHS criterion are
presented in Table II. Zr crowns were
statistically signicantly different from
LD and MC crowns for occlusion
(P<.001). Eighty percent of Zr crowns
had an excellent rating and needed
no occlusal adjustment. Fifty-eight
percent of MC restorations and 100%
of LD restorations needed occlusal
adjustment before insertion. No statistically signicant differences were found
among the 3 crown systems for GCF
volumes or BOP. GCF volumes and
BOP were not signicantly different
between the treated and the control
teeth or between visits. Descriptive statistics and P values for all explanatory
variables associated with the gingival
volumes and BOP are provided in

DISCUSSION
Although the crown systems did not
differ with respect to shade, contour,
and marginal adaptation, Zr crowns
were superior in crown occlusion. Few Zr

Descriptive statistics for gingival parameters and treated teeth (N32)

Visita
Gingival Parameter

Crown
System

Pretreatmentb

1-mo
Postcementationc

Buccal surface GCF volume, mean (SD)

MC

46.25 23.95

43.75 14.06

32.67 14.51

Zr

47.80 22.79

39.00 12.12

39.29 14.40

LD

32.00 9.56

44.13 24.51

43.33 19.10

MC

33.25 12.17

43.17 17.48

37.50 20.05

Zr

44.10 22.49

37.00 17.61

42.57 23.73

LD

39.40 16.77

56.88 23.74

39.83 15.72

MC

8/4 (67)

5/7 (42)

3/3 (50)

Zr

6/4 (60)

5/4 (56)

2/5 (29)

LD

5/5 (50)

2/6 (25)

2/4 (33)

Lingual surface GCF volume, mean (SD)

Bleeding on probing, yes/no (% of yes)

6-mo
Postcementationd

MC, metal ceramic; SD, standard deviation; GCF, gingival crevicular uid; Zr, zirconia; LD, lithium disilicate.
a
MC (n12 [missing0] at visit 0, n12 [missing0] at visit 2, n6 [missing6] at visit 3); Zr (n10 [missing0] at visit 0, n9 [missing1] at visit 2,
n7 [missing3] at visit 3); LD (n10 [missing0] at visit 0, n8 [missing2] at visit 2, n6 [missing4] at visit 3).
b
Visit 0.
c
Visit 2.
d
Visit 3.

The Journal of Prosthetic Dentistry

Batson et al

October 2014

775

P values from linear mixed and generalized estimating equation models

with 1 between-subject factor (crown system) and 2 within-subject factors (visit and
tooth status) for gingival crevicular uid volumes and bleeding on probing

Table IV.

Explanatory
Variable

Buccal
Surface

Lingual
Surface

Bleeding
on Probing

Crown system

.38

.71

.92

Time of measure

.49

.42

.25

Treated vs control

.47

.10

.17

Number of Crowns

10

Overextended
Underextended

8
6
4
2
0

PFM

LD

ZR

1 Number of crowns by group and type of horizontal

marginal discrepancy.

2 Sample micro
computed tomographic
image of buccal crown
margin of study lithium
disilicate crown.

crowns required intraoral occlusal

adjustment, whereas 100% of LD
crowns required occlusal adjustments
compared with only 58% of MC restorations. The Zr and MC restorations
were produced with the same intraoral
scanner, which underscores the potential accuracy of the intraoral scan, the
method of obtaining an intraocclusal
record, and the digital design and
fabrication of the Zr and MC

Batson et al

restorations. Of note, LD crowns were

made without articulated casts to
permit laboratory adjustments. No statistical signicance was found between
the MC and LD groups for occlusion.
The presence of a restoration near
or below the gingival margin may
induce localized inammation and
lead to future periodontal complications.16,17 Although this study had a
small sample size of short duration, it
did not support those ndings because
no statistically signicant differences
were found among the crown systems
or between the treated and control
teeth for GCF volumes or BOP.
Although an overall slight increase in
GCF volume was noted for the lingual
surfaces of treated teeth, it was not
statistically signicant. This could be
due to the small sample size. This
investigation may not contribute to
understanding the differences in tissue
responses to all ceramic versus MC
restorations. However, a recent study of
posterior 3-unit xed dental prostheses
observed no difference in gingival parameters for Zr and MC prostheses.18
This initial investigation of short
duration was designed to investigate

and compare the manufactured quality

of restorations with particular focus
on marginal integrity and the responses
to this interface. During the 6-month
period, no fractures or chipping of
crowns was noted. Although other
studies14,15 indicate the chipping of Zrcopingbased crowns to be a limitation, chipping complications were not
revealed at the 6-month time point. In
this investigation, monolithic Zr and
monolithic LD crowns were used. Longterm evaluations are needed to investigate their mechanical performance.
Despite the similarity in clinical
acceptance among all of the crowns,
measured differences in the overall horizontal contours of fabricated restorations were found between the 2 scanning
systems, specically with LD and Zr
crowns. Thus, the null hypothesis for
marginal discrepancy values was rejected. The use of a model that enables
contour renement for MC and Zr
crowns is a possible explanation for this
difference. LD crowns were fabricated
purely by digital design and milling in the
clinical setting, and without a cast or
dental technician involved. Zr and
MC crowns were digitally designed
and milled in a laboratory, and nished
on a solid model to verify contours.
The milling technology itself may further
inuence these restorations. In addition,
the type of preparation design deserves
mention because a deep chamfer margin
was chosen. Other published literature
has mentioned the use of a modied or
rounded shoulder as a better type of
margin design for ceramic restorations
that will be of a milled variety.10
This study evaluated the t of
cemented restorations. Other recent
measurements have been reported
that used the indirect replica measure
of interposed PVS material before
cementation11 and may not be directly
compared with the present data.
When direct measurements of restorative margins of ceramic systems have
been made, ranges of 7.5 to 161 mm
have been reported with both traditional and CAD/CAM fabrication
methods.3,19 When evaluated in
the laboratory, close marginal t

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Volume 112 Issue 4

bleeding on probing measurements indicates greater inammation for
restored teeth that have crowns with
larger marginal discrepancies. More
extensive clinical studies are needed to
assess the various parameters involved
with CAD/CAM fabricated restorations,
specically analyzing intraoral performance as related to postcementation t.

CONCLUSIONS

3 A, Delimitation of crown and tooth margins

to measure horizontal discrepancies. Example of
(B) underextended margin, (C) overextended margin,
(D) ideal margin.

Table V.

Descriptive statistics for horizontal marginal discrepancy

Crown System

Mean (SD) Horizontal

Marginal Discrepancy (mm)

Range (mm)

LD

113.8 43.2

11.0-260.0

Zr

68.5 33.4

15.0-190.0

MC

92.4 20.6

23.0-210.0

SD, standard deviation; LD, lithium disilicate; Zr, zirconia; MC, metal ceramic.

Pairwise comparisons
among crown systems

Table VI.

Group 1 Group 2

df P

LD

Zr

8.07

.03

LD

MC

1.89

.54

Zr

MC

2.50

.38

LD, lithium disilicate; Zr, zirconia; MC metal

ceramic.

(approximately 30 mm) was dened for

the E4D system but was found to be
affected by preparation quality.20 The
milling of 2 varieties of Zr copings
recently has been found to achieve
mean absolute marginal discrepancies
of 51 mm but also found that 71% of
1 group of copings were overextended
horizontally.21 Matta et al22 conrmed
the clinically acceptable t of CAD/
CAM single crowns, but they too
revealed horizontal discrepancies in
the range of 100 to 150 mm. The
fabrication of acceptable tting clinical

restorations is afrmed by the current

laboratory experimental literature and
limited clinical research.
The quality of t and gingival responses has been correlated clinically.16,17 In this study, a statistical
difference in horizontal marginal t was
measured between CAD/CAM Zr and
LD crowns. Yet, gingival inammation
(GCF volumes and BOP) was similar at
the 6-month evaluation period. This
time period may have been too short to
observe these effects. However, inammatory changes at induced interproximal overhangs have been found to
occur in this period of time.17 Alternatively, the marginal discrepancy differences (averages of approximately 60 vs
110 mm) may not be biologically relevant in this population and this time
frame. Furthermore, Zr- and LD- related
biolms may differ from MC biolm,
which could alter the inammatory
responses recorded. Although not
reaching statistical signicance, the

The Journal of Prosthetic Dentistry

Within the limitations of this study,

the following conclusions can be drawn.
Posterior single-tooth restorations fabricated from intraoral scans by using CAD/
CAM technology have acceptable results
for shade, contour, marginal adaptation,
and occlusion. MC, LD, and monolithic
Zr had no differences in gingival response,
and Zr and LD crowns had differences in
horizontal discrepancy values.

REFERENCES
1. U.S. Dental Prosthetics and CAD/CAM
Devices Market. iData Research Inc. 2011.
Available at: www.idataresearch.com. Last
accessed June 12, 2014.
2. Hamza TA, Ezzat HA, El-Hossary MM,
Katamish HA, Shokry TE, Rosenstiel SF. Accuracy of ceramic restorations made with two
CAD/CAM systems. J Prosthet Dent
2013;109:83-7.
3. Oliver-Parra R. Marginal adaptation of
zirconium dioxide copings: inuence of
the CAD/CAM system and the nish
line design. J Prosthet Dent 2014;112:
155-62.
4. Miyazaki T, Hotta Y, Kunii J, Kuriyama S,
Tamaki Y. A review of dental CAD/CAM: current status and future perspectives from 20
years of experience. Dent Mater J 2009;28:
44-56.
5. da Costa JB, Pelogia F, Hagedorn B,
Ferracane JL. Evaluation of different methods
of optical impression making on the marginal
gap of onlays created with CEREC 3D. Oper
Dent 2010;35:324-9.
6. Kokubo Y, Tsumita M, Sakurai S, Suzuki Y,
Tokiniwa Y, Fukushima S. Five-year clinical
evaluation of In-Ceram crowns fabricated
using GN-I (CAD/CAM) system. J Oral
Rehabil 2011;38:601-7.
7. Gth JF, Keul C, Stimmelmayr M, Beuer F,
Edelhoff D. Accuracy of digital models obtained by direct and indirect data capturing.
Clin Oral Invest 2013;17:1201-8.
8. Biscaro L, Bonglioli R, Soattin M, Vigolo P.
An in vivo evaluation of t of zirconium-oxide
based ceramic single crowns, generated with
two CAD/CAM systems, in comparison to
metal ceramic single crowns. J Prosthodont
2013;22:36-41.

Batson et al

October 2014
9. Syrek A, Reich G, Ranftl D, Klein C, Cerny B,
Brodesser J. Clinical evaluation of
all-ceramic crowns fabricated from
intraoral digital impressions based on the
principle of active wavefront sampling.
J Dent 2010;38:553-9.
10. Baig M, Tan K, Nicholls J. Evaluation of the
marginal t of a zirconia ceramic computeraided machined (CAM) crown system. J
Prosthet Dent 2010;104:216.
11. Brawek P, Wolfart S, Endres L, Kirsten A,
Reich S. The clinical accuracy of single
crowns exclusively fabricated by digital
workow: the comparison of two systems.
Clin Oral Investig 2013;17:2119e225.
12. Gehrt M, Wolfart S, Rafai N, Reich S,
Edelhoff D. Clinical results of
lithium-disilicate crowns after up to
9 years of service. Clin Oral Invest 2013;
17:275-84.
13. Fasbinder D, Dennison J, Heys D,
Neiva G. A clinical evaluation of chairside
lithium disilicate CAD/CAM crowns: a
two-year report. J Am Dent Assoc
2010;141:10S-4.
14. Sailer I, Feher A, Filser F, Gauckler L,
Luthy H, Hmmerle C. Five-year clinical
results of zirconia frameworks for posterior
xed partial dentures. Int J Prosthodont
2007;20:383-8.

Batson et al

777
15. Raigrodski AJ, Chiche GJ, Potiket N,
Hochstedler JL, Mohamed SE, Billiot S, et al.
The efcacy of posterior three-unit zirconium-oxide-based ceramic xed partial
dental prostheses: a prospective clinical pilot
study. J Prosthet Dent 2006;96:237-44.
16. Felton D, Kanoy B, Bayne S, Wirthman B.
Effect of in vivo crown margin discrepancies
on periodontal health. J Prosthet Dent
1991;65:357-64.
17. Lang N, Kiel R, Anderhalden K. Clinical and
microbiological effects of subgingival restorations with overhanging or clinically perfect
margins. J Clin Periodontol 1983;6:563-78.
18. Pelaez J, Cogolludo PG, Serrano B,
Serrano JF, Suarez MJ. A four-year
prospective clinical evaluation of zirconia
and metal-ceramic posterior xed
dental prostheses. Int J Prosthodont
2012;25:451-8.
19. Nawaeh NA, Mack F, Evans J, Mackay J,
Hatamleh MM. Accuracy and reliability
of methods to measure marginal adaptation of
crowns and FDPs: a literature review.
J Prosthodont 2013;22:419-28.
20. Renne W, McGill S, Forshee K, DeFee M,
Mennito A. Predicting marginal t of CAD/
CAM crowns based on the presence or
absence of common preparation errors.
J Prosthet Dent 2012;108:310-5.

21. Grenade C, Mainjot A, Vanheusden A. Fit of

single tooth zirconia copings: comparison
between various manufacturing processes.
J Prosthet Dent 2011;105:249-55.
22. Matta R, Schmitt J, Wichmann M, Holst S.
Circumferential t assessment of CAD/CAM
single crowns: a pilot investigation on a new
virtual analytical protocol. Quintessence Int
2012;43:801-9.
Corresponding author:
Dr Emily R. Batson
9480 Briar Village Point Suite 300
Colorado Springs, CO 80920
E-mail: drbatson@pickledental.com
Acknowledgments
The authors thank Lee Culp, Jack Marrano, and
Eric Hill of Microdental DTI for their assistance in
crown fabrication, and Kevin Guley of Biomedical
Research Imaging Center, UNC at Chapel Hill for
assistance with micro-CT imaging.
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.