You are on page 1of 8

Marginal and internal adaptation of

ceramic crown restorations fabricated
with CAD/CAM technology and the
heat-press technique
Hisham A. Mously, BDS, MS,a Matthew Finkelman, PhD,b
Roya Zandparsa, DDS, DMD, MSc,c and
Hiroshi Hirayama, DDS, DMD, MSd
Tufts University School of Dental Medicine, Boston, Mass; Faculty
of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
Statement of problem. The accuracy of chairside computer-aided design and computer-aided manufacturing (CAD/CAM)
restorations is questionable, and the effect of the die spacer settings is not well stated in the literature.

Purpose. The purpose of the study was to evaluate the marginal and internal adaptation of E4D crowns fabricated with
different spacer thicknesses and to compare these crowns with those fabricated with the heat-press technique.

Material and methods. The E4D system was used to fabricate 30 crowns for the first 3 groups, with different spacer thickness
settings: 30 mm, 60 mm, and 100 mm. In the fourth group, 10 lithium disilicate crowns were fabricated with the heat-press
technique. The occlusal gap, axial gap, vertical marginal gap, and absolute marginal discrepancy were evaluated by x-ray
microtomography. Statistical significance was assessed with the Kruskal-Wallis test (a¼.05). For post hoc analyses, the
Mann-Whitney U test was used alongside the Bonferroni correction for multiple comparisons (a¼.008).

Results. Within the CAD/CAM groups, the 30-mm spacer thickness resulted in the lowest median axial gap (90.04 mm),
whereas the 60-mm spacer thickness resulted in the lowest median occlusal gap (152.39 mm). The median marginal
gap values of the CAD/CAM-60 group (49.35 mm) and CAD/CAM-100 group (46.65 mm) were lower than those of the
CAD/CAM-30 group (55.18 mm). No significant differences among the CAD/CAM groups were observed for absolute
marginal discrepancy. The heat-press group had significantly different values than those of the CAD/CAM groups.

Conclusion. The spacer thickness and fabrication technique affected the adaptation of ceramic crowns. The heat-press group
yielded the best marginal and internal crown adaptation results. The 30- or 60-mm spacer settings are recommended for
the E4D CAD/CAM system. (J Prosthet Dent 2014;-:---)

Clinical Implications
The results of this study may aid in the clinical determination of the
most accurate spacer thickness settings for the optimal adaptation
of CAD/CAM crown restorations, thereby improving clinical success
and longevity.

Crown adaptation along with es- and longevity of crown restorations.1-7 internal gaps of crown restorations.
thetic value and fracture resistance Crown adaptation is defined by the Holmes et al8 stated that the internal
are important to the clinical success measurements of the marginal and gap is the perpendicular distance from

Assistant Professor, Division of Prosthodontics, Department of Oral and Maxillofacial Rehabilitation, Faculty of Dentistry,
King Abdulaziz University; Former Resident, Division of Postgraduate Prosthodontics, Department of Prosthodontics and
Operative Dentistry, Tufts University School of Dental Medicine.
Assistant Professor, Department of Public Health and Community Service, Tufts University School of Dental Medicine.
Clinical Professor, Division of Postgraduate Prosthodontics, Department of Prosthodontics and Operative Dentistry,
Tufts University School of Dental Medicine.
Professor, Division Head of Postgraduate Prosthodontics; Director, Graduate and Postgraduate Prosthodontics; Director,
Advanced Education in Esthetic Dentistry; and Director, Advanced Dental Technology and Research Program, Tufts University
School of Dental Medicine.

Mously et al
2 Volume - Issue -

the internal surface of the restoration material.6,30-32 This technique is study aimed to evaluate the influence of
to the axial wall of the preparation, considered difficult and inaccurate when different spacer thicknesses on the ac-
whereas the marginal gap is the per- the discrepancies are small because the curacy of lithium disilicate restorations
pendicular distance from the internal impression material may be distorted or fabricated with the E4D CAD/CAM
surface of the restoration to the finish damaged.1,5,6 The profilometry method system. In addition, the accuracy of
line of the preparation.8 An increase in is considered to be an accurate method, lithium disilicate restorations fabricated
the marginal or internal gap could except in restorations with overextended with the E4D CAD/CAM technology
increase cement dissolution, thereby margins.6,33 Scanning electron micro- was compared with the accuracy of
increasing the potential for micro- scopy for the study of presectioned restorations fabricated with the con-
leakage, recurrent caries, and periodon- specimens also is a popular tech- ventional heat-press technique. The null
tal disease.9-15 Furthermore, an increase nique.19,34-36 hypotheses for this study were that
in the internal gap could decrease the Computerized x-ray microtomo- different spacer thicknesses will not in-
fracture strength of ceramic restorations graphy (micro-XCT), a nondestructive fluence the marginal and internal
because these areas with a higher inter- method, produces high-resolution images adaptation of the lithium disilicate
nal gap induce different load concen- for both quantitative and qualitative restorations and that different fabrica-
trations16-21 analyses of the tooth, bone, and im- tion techniques will not influence the
Paint-on die spacers have been used plants, which makes it a powerful tool marginal and internal adaptation of the
successfully for the conventional lost- in dental research.6,37,38 Micro-XCT lithium disilicate restorations.
wax and heat-press techniques to pro- has been used in dental research to
vide appropriate marginal and internal measure enamel thickness39 and dental MATERIAL AND METHODS
gaps, thereby facilitating the complete restorations,40,41 and to assess the
seating of crown restorations.22-25 In marginal and internal gaps of crown A complete coverage preparation on
contrast, the spacer thicknesses of restorations.6,38 No consensus has the mandibular right first molar was
crown restorations fabricated with been reached regarding the biologically made for a typodont model (Model
chairside computer-aided design and acceptable values of marginal and in- D95SDP-200; Kilgore Intl Inc) with a
computer-aided manufacturing (CAD/ ternal gaps. The clinically acceptable coarse, tapered diamond rotary instru-
CAM) technology usually are deter- value for the marginal gap has been ment with a rounded end (no. 6856;
mined during the software’s design discussed in the literature, with pro- Brasseler USA). The following parame-
phase. However, the spacer thickness posed values that range from 39 to ters were used: total occlusal conver-
setting most conducive to appropriate 120 mm.9,42 Theoretically, the accept- gence, 12 degrees; occlusal reduction,
crown adaptation remains unknown. able marginal discrepancy for cemented 2 mm; and chamfer finish line, 1 mm,
Although chairside CAD/CAM tech- crown restorations ranges between 25 with rounded internal angle margins.
nology has improved considerably over and 40 mm30,43,44; however, several Then, 40 acrylic resin master dies were
the past few years, the accuracy of dental in vitro studies have reported mean fabricated by duplicating the prepared
restorations fabricated with these sys- marginal gaps of 64 to 83 mm in CAD/ tooth with an In-lab CAD/CAM system
tems remains questionable. Many fac- CAM-generated ceramic single-tooth (Tizian Cut 5; Schütz Dental Gmb)
tors can affect the accuracy of these restorations.31,45-47 The internal gap of (Fig. 1).
restorations, including the type of dental conventional ceramic crowns has been The master dies were divided into
restoration, material properties,26 prep- reported to be within the range of 123 4 groups (10 dies per group). Each
aration design,7,18 scanning device ac- to 154 mm.48,49 May et al5 reported master die was assigned to each of
curacy, software design, spacer settings, that the marginal fit of the Procera these 4 groups. The first CAD/CAM
and milling machine accuracy.27 Few CAD/CAM system ranged between 54 system was applied to the first 3
studies, however, have examined these and 64 mm, with an internal gap of 49 groups, whereas the heat-press tech-
factors and their effects on the marginal to 63 mm. nique was applied to the fourth group.
and internal gaps of different dental Thus, the accuracy of the chairside Optical impressions of each master die
restorations.7,18,26,27 CAD/CAM restorations remains ques- were obtained with an E4D camera
Most of these studies used either tionable, and the effect of the spacer (E4D Dentist system; D4D Technolo-
subjective or inaccurate methods to settings has not been studied in detail. gies), which was calibrated before each
evaluate the marginal and internal gaps The main objective of this in vitro study master die was scanned. The E4D
of crown restorations,6 including the use was to evaluate the marginal and in- software was then used to evaluate the
of the explorer, visual examination,28 ternal adaptation of lithium disilicate clarity of the scanning process. The
and radiographic techniques.29 The restorations fabricated with a CAD/ crown margins were marked manually
impression technique is a popular CAM system and to compare them with on the finish lines of the preparations.
method, which uses a putty-wash tech- the conventional heat-press technique Crown shape A was selected from the
nique with low-viscosity impression by using micro-XCT. In particular, this available designs within the E4D library.
The Journal of Prosthetic Dentistry Mously et al
- 2014 3
The autogenesis feature was not manual milling device (Straumann was performed at 70 KVp and 114 mA,
selected. Scanning and design was per- gonyX; Straumann USA LLC). Each in- with an integration time of 300 ms.
formed by the same clinician (H.M.). dex was used to stabilize and position Two-dimensional images, with an im-
each surface (buccal, lingual, mesial, age size of 2048  2048 pixels and a
and distal) of the master die. By using a resolution of 10 mm, were recon-
Spacer settings for lithium disilicate
carbide round bur (no. H71; Brasseler structed from the x-ray shadow images.
complete coverage restorations
USA) attached to the milling device, After computerized reconstruction of
4 reference indentations were prepared the images, Image J software (National
To fabricate the restorations, in the
on the buccal, lingual, mesial, and Institutes of Health) was used to eval-
CAD/CAM-30 group, the internal and
distal surfaces of each master die. uate and analyze the scans. The refer-
marginal gaps were set at 30 mm with
Because these indentations were iden- ence indentations were used to
a 1-mm marginal ramp; in the CAD/
tical in position and size for each standardize the images of each spec-
CAM-60 group, the internal and mar-
master die, they could be used to imen. By using the Image J software, 5
ginal gaps were set at 60 mm with a
standardize the computed tomography equidistant vertical cuts were made in
1-mm marginal ramp; in the CAD/
images for each specimen. the buccolingual direction, with 50 sli-
CAM-100 group, the internal and
The marginal and internal gaps ces between these cuts; in addition, 5
marginal gaps were set at 100 mm with
were evaluated by means of micro-XCT equidistant vertical cuts were made in
a 1-mm marginal ramp.
(mCT 40; Scanco Medical). Each spec- the mesiodistal direction, with 25 slices
imen was stabilized in the scanning between these cuts, depending on the
Milling process and crystallization tube and positioned perpendicularly to slice numbers of each specimen
the x-ray beam for scanning. Scanning (Fig. 2).
After each crown was designed with
the E4D software, the information was
electronically sent to the milling unit.
IPS e.max CAD lithium disilicate blocks
(Ivoclar Vivadent) were used to fabri-
cate the crowns. The standard mode
was selected for the milling process of
all the crowns. After the completion of
the milling process, all the crowns were
crystallized in a porcelain furnace.
In the heat-press group, each master
die was copied by using a polyether
impression material (Impregum Penta
Soft; 3M ESPE) to produce identical
stone dies with a Type IV dental stone
(Resin Rock; Whip Mix Corp). Two 1 Master die fabrication with acrylic resin block.
layers of die spacer (Euro Quick Set;
Kerr Dental Laboratory Products) were
applied to the stone dies. The layers
were applied uniformly with a brush,
starting 1 mm short of the finish lines of
the preparations. Next, an anatomic
contour waxing was created for each
master die. All of the anatomic contour
waxings were invested with fine-grained
phosphate-bonded investment material
(Multi Press Vest; GC America Inc).
Finally, the pressing process was
completed according to the manufac-
turer’s instructions. IPS e.max Press
lithium disilicate ingots were used to
fabricate the crowns. 2 Micro-XCT scan image (horizontal cut): 10 vertical cuts
Four silicone indices were attached obtained with 50 slices between buccolingual cuts and 25
with stone to the metal base of a slices between mesiodistal cuts.
Mously et al
4 Volume - Issue -

Twelve points of measurement The MG, AMD, OG, and AG were The statistical power was calculated
were selected for each vertical cut evaluated at 120 different points for with statistical software (nQuery
(2 measurements for vertical marginal each crown. The MG and AMD were Advisor, v7.0; Statistical Solutions Ltd).
gap [MG], 2 for absolute marginal measured by using the criteria for the The variance of means and common
discrepancy [AMD], 4 for occlusal gap evaluation of the marginal adaptation standard deviation were 257.3 and
[OG], and 4 for axial gap [AG]). Thus, provided by Holmes et al.8 The over- 15.8 (results from a pilot study), re-
20 measurements for MG and AMD, extended and underextended margins spectively; accordingly, a sample size
and 40 measurements for OG and AG for the AMD were both assembled as of n¼10 per group was considered
were obtained for each specimen positive values. The OG was measured adequate to obtain a type I error rate of
(Figs. 3, 4). All of the measurements separately from the AG for the evalua- 5% and a power greater than 99%. All
were averaged for each outcome. The tion of internal adaptation. All stan- the outcomes (AG, OG, MG, and
magnifications and measurements of dardizations and measurements of the AMD) were analyzed separately. De-
the marginal and internal gaps were specimens were performed by the same scriptive statistics were computed for
made with the Image J software. clinician (H.M.). each group with SPSS v19.0. One-way
ANOVA was initially performed with
the Tukey honestly significant difference
for post hoc tests; however, the analysis
could not be reported because of the
violation of the assumption of equal
variances among groups (P values of
the Levene test were less than .05).
Therefore, nonparametric testing was
undertaken: the Kruskal-Wallis test was
performed for each outcome, with
P<.05 considered to indicate statistical
significance. Upon obtaining significant
results, the Mann-Whitney U test
was used for post hoc analysis, with the
Bonferroni correction used to adjust
for multiple comparisons (P<.008
3 Micro-XCT scan image (zoomed at margin area): mea-
was considered to indicate statistical
surement of marginal gap (for overextended crown, perpen-
dicular distance between internal surface of crown and significance).
master die margin was measured, whereas, for underextended
crown, perpendicular distance between internal surface of
master die and crown margin was measured) and absolute RESULTS
marginal discrepancy (distance between crown and master
die margins). A summary of the results of the
descriptive statistical analyses, which
showed the AGs (medians, interquartile
ranges, minima, and maxima) for
all the groups, is listed in Table I.
The results of the Kruskal-Wallis test
were statistically significant for AG
(P<.001). In the post hoc Mann-
Whitney U tests, the heat-press group
showed significantly lower values
(median, 74.03 mm) than the CAD/
CAM-60 (127.68 mm; P<.001) and
CAD/CAM-100 (147.71 mm; P<.001)
groups but not the CAD/CAM-30
(90.04 mm; P¼.009) group. Within the
4 Micro-XCT scan image (vertical cut): Measurement of CAD/CAM groups, the 30-mm spacer
axial gap and occlusal gap (measured distances were thickness resulted in the lowest AG
perpendicular to ceramic crown and master die internal sur- (90.04 mm) compared with the 60-mm
faces at selected points). (127.68 mm; P < .001) and 100-mm

The Journal of Prosthetic Dentistry Mously et al
- 2014 5
(147.71 mm; P<.001) groups. The AG Table I. Descriptive statistics of AG for test groups
values of the CAD/CAM-60 group were
significantly lower (P<.001) than those Internal AG (mm)
of the CAD/CAM-100 group (Table I). Group N Median* IQR Minimum Maximum
For OG, the results of the Kruskal-
Wallis test were statistically signifi- CAD/CAM-30 10 90.04a 20.27 69.83 122.05
cant (P<.001). The heat-press group b
CAD/CAM-60 10 127.68 8.81 106.80 155.55
showed significantly lower values CAD/CAM-100 10 147.71 c
40.71 135.35 199.85
(median, 128.11 mm) than the CAD/
Heat-press 10 74.03a 6.81 67.38 80.30
CAM-30 (160.49 mm; P¼.003), CAD/
CAM-60 (152.39 mm; P¼.003), and AG, axial gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
IQR, Interquartile range.
CAD/CAM-100 (227.38 mm; P<.001) *Groups with same letters do not exhibit statistically significant difference.
groups. Within the CAD/CAM groups,
the 60-mm spacer thickness resulted in
the lowest OG (152.39 mm) compared Table II. Descriptive statistics of OG for test groups
with the 30-mm (160.49 mm; P¼.58)
and 100-mm (227.38 mm; P¼.001) Internal OG (mm)
groups, although the comparison with Group N Median* IQR Minimum Maximum
the 30-mm group was not significant.
The OG values of the CAD/CAM-30 CAD/CAM-30 10 160.49a 78.30 105.73 217.43
group were significantly lower (P¼.004) CAD/CAM-60 10 152.39a 35.17 82.63 206.88
than those of the CAD/CAM-100 group CAD/CAM-100 10 227.38 b
72.97 160.83 267.45
(Table II). c
Heat-press 10 128.11 18.86 106.88 147.95
For MG, the results of the Kruskal-
Wallis test were statistically signifi- OG, occlusal gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
IQR, Interquartile range.
cant (P<.001). The heat-press group *Groups with same letters do not exhibit statistically significant difference.
showed significantly lower values
(median, 30.80 mm) than the CAD/
CAM-30 (55.18 mm; P<.001), CAD/
Table III. Descriptive statistics of MG for test groups
CAM-60 (49.35 mm; P<.001), and
CAD/CAM-100 (46.65 mm; P¼.005) Vertical MG (mm)
groups. Within the CAD/CAM groups,
the 60-mm and 100-mm spacer thick-
Group N Median* IQR Minimum Maximum
nesses resulted in the lowest MG, with CAD/CAM-30 10 55.18a 17.05 50.70 76.25
no statistically significant difference a,b
CAD/CAM-60 10 49.35 14.95 32.30 56.10
between these 2 groups (P¼.63). The b
MG values of the CAD/CAM-30 group CAD/CAM-100 10 46.65 18.04 30.55 58.15
were significantly higher than those of Heat-press 10 30.80 8.97 24.35 41.75
the CAD/CAM-100 group (P¼.007) MG, marginal gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
but not the CAD/CAM-60 group IQR, interquartile range.
(P¼.029) (Table III). *Groups with same letters do not exhibit statistically significant difference.
Finally, for AMD, the results of the
Kruskal-Wallis test were again statisti-
cally significant (P<.001). The heat- Table IV. Descriptive statistics of AMD for test groups
press group showed significantly lower AMD (mm)
values (median, 41.05 mm) than the
CAD/CAM-30 (100.35 mm; P<.001), Group N Median* IQR Minimum Maximum
CAD/CAM-60 (96.65 mm; P<.001),
CAD/CAM-30 10 100.35a 71.16 61.35 143.75
and CAD/CAM-100 (105.75 mm;
P<.001) groups. Within the CAD/CAM CAD/CAM-60 10 96.65 26.25 64.65 167.20
groups, the 60-mm spacer thickness
CAD/CAM-100 10 105.75 49.21 55.10 132.05
resulted in the lowest AMD; however, Heat-press 10 41.05 11.16 30.55 60.30
no statistically significant difference was
AMD, absolute marginal discrepancy; CAD/CAM, computer-aided design and computer-aided
found among the CAD/CAM groups manufacturing; IQR, interquartile range.
(P>.008) (Table IV). *Groups with same letters do not exhibit statistically significant difference.

Mously et al
6 Volume - Issue -

DISCUSSION the E4D software or to the variations in evaluation of the marginal and internal
the evaluation method. Several other gaps. Furthermore, it is easy to perform,
When considering the clinical pro- studies that used different CAD/CAM nondestructive, and more time efficient
perties of ceramic crowns and dental systems reported higher MG values for and accurate than the other methods
luting agents, it is important to achieve ceramic CAD/CAM crowns than those used to evaluate marginal and internal
clinically acceptable restorations with reported in the present study.18,42,49 adaptations.6 The main disadvantages of
minimal marginal and internal gap. The heat-press group in this study this method are radiation artifacts, which
Chairside CAD/CAM restorations are showed the lowest AG and OG values. are caused by the differences in the coef-
currently used by a large number of This could be due to the differences in ficient of radiation absorption among the
dentists all over the world; however, the the fabrication technique and the die different materials6 and the difficulty in
accuracy of these systems and restora- spacer thicknesses. These values were using luting agents because they have
tions is still questionable. This study similar to those (50-100 mm) consid- some radiopacity that might affect the
focused on looking at the effects of us- ered the most favorable internal evaluation of the cement gap.
ing different spacer thicknesses on the gap values for resin cement perfor- In this study, 20 MG and 20 AMD
accuracy of E4D CAD/CAM crowns mance.51-53 The AG and OG values for measurements were obtained to eval-
and comparing them with the accuracy the heat-press and CAD/CAM-30 uate the marginal adaptation of
of conventional heat-pressed crowns. In groups were lower than those reported each ceramic crown. Similar to many
this in vitro study, the null hypotheses by Souza et al18 (AG, 113.28 mm; OG, studies,6,7,54 20 measurements were
were rejected because the thickness of 244.32 mm) for crowns fabricated with considered sufficient to evaluate the
the spacer as well as the fabrication a large chamfer finish line; however, marginal adaptation for crowns and dies
technique directly affected the marginal only the CAD/CAM-60 and CAD/ fabricated in vitro. Several other
and internal adaptation of ceramic CAM-100 groups in this study had studies18,49 used 50 measurements of
crown restorations. lower OG values. Similar internal gap MG to evaluate marginal adaptation;
In this study, the MGs of the heat- values also were reported in several however, in these studies, the AMD,
press group were significantly lower studies that used different CAD/CAM which is considered important for the
than those of the E4D-CAD/CAM systems.19,32,45,52 These different values appropriate evaluation of the marginal
groups. The MG values (mean SD) for could be related to the differences in adaptation and extension of ceramic
the heat-press group were similar to the CAD/CAM systems, spacer thick- crowns, was not measured.6,8
those reported by Cho et al50 (30.2 nesses, and crown materials. In previous studies that used the
18.6 mm) for the pressable lithium In this study, the AMD values for the micro-XCT evaluation method,6,38 ver-
disilicate crowns prepared with a heat-press group were significantly tical cuts were made in a circle with 18
chamfer finish line. These values were lower than those of the CAD/CAM degrees between each cut; however, in
within the range of the ideal marginal groups; however, no significant differ- this study, the vertical cuts were made
gap for cemented restorations.5,30,43 ences were observed among the CAD/ perpendicular to the tooth surface to
Among the CAD/CAM groups, the CAM groups. The AMD values for the minimize possible measurement error as
CAD/CAM-100 and CAD/CAM-60 heat-press group were lower than those a result of the angulation of the cut and
groups showed similar MG values, reported by Pelekanos et al6 for all also to replicate the actual marginal and
whereas the CAD/CAM-30 group had a groups (Wol-Ceram, 49.86 mm; Slip- internal gap values. Besides the spacer
significantly higher MG than the CAD/ cast, 60.09 mm; Cerec in-Lab, 187.64 thickness and the fabrication technique,
CAM-100 group but not the CAD/ mm; and Celay, 179.36 mm). The many other factors could have affected
CAM-60 group. These results could be AMD values for all CAD/CAM groups the outcome of this study, including the
attributed to the presence of in- were lower than those reported by preparation design, scanning accuracy,
terferences in the CAD/CAM crowns Pelekanos et al6 (187.64 mm) for software, restoration material, and
fabricated with lower spacer thicknesses. aluminum oxide copings (In-Ceram consistency of milling machines. In this
In this study, the MGs measured in alumina) fabricated with the Cerec in- study, the preparation design was
the CAD/CAM groups were similar to Lab system. These lower values could identical for all the master dies. Scan-
or slightly higher than those reported by be related to the differences in the CAD/ ning and design were performed by the
Renne et al7 (excellent preparation, CAM system, crown materials, and same practitioner, and the scanning
38.5 mm; fair preparation, 58.2 mm) in preparation designs. camera was equilibrated before each
crowns fabricated by using the same Similar to previous studies,6,38 scan. Factors associated with the milling
CAD/CAM system, with 100-mm spacer micro-XCT was used to evaluate the machine were evaluated before the
thickness and 0.25-mm marginal ramp marginal and internal adaptation of the fabrication of each restoration, in-
(default settings for E4D). These dif- ceramic crown restorations. This method cluding the condition of the diamond
ferences could be attributed to the dif- has several advantages over other tech- rotary instruments and the quality of
ference in the marginal ramp setting in niques, including the 3-dimensional the cooling and lubricating fluids.
The Journal of Prosthetic Dentistry Mously et al
- 2014 7
Considerable controversy exists in an important factor that should be 12. Beuer F, Neumeier P, Naumann M. Marginal
fit of 14-unit zirconia fixed dental prosthesis
the literature regarding the ideal mar- considered before fabricating ceramic
retainers. J Oral Rehabil 2009;36:142-9.
ginal and internal gap for ceramic CAD/CAM restorations; (3) the heat- 13. Gonzalo E, Suárez MJ, Serrano B, Lozano JF.
crowns.6,18 Regarding the ideal mar- press group yielded the best results Comparative analysis of two measurement
ginal adaptation, a few studies have with respect to marginal and internal methods for marginal fit in metal-ceramic
and zirconia posterior FPDs. Int J Prostho-
reported that the ideal MG should be crown adaptation; (4) among the CAD/ dont 2009;22:374-7.
25 to 40 mm for cemented restora- CAM groups, the CAD/CAM-30 group 14. Groten MS, Girthofer S, Probster L. Marginal
tions.5,30,43 Many other studies consid- yielded the lowest AG values, whereas fit consistency of copy-milled all- ceramic
ered the MG values of 100 to 200 mm to the CAD/CAM-30 and CAD/CAM-60 crowns during fabrication by light and
scanning electron microscopic analysis
be clinically acceptable for cemented groups yielded the lowest OG values; in vitro. J Oral Rehabil 1997;24:871-81.
restorations.2,7,30,55,56 More recent (5) when considering the results of 15. Euán R, Figueras-Álvarez O, Cabratosa-
studies have considered the clinically the marginal and internal adaptation Termes J, Oliver-Parra R. Marginal adapta-
tion of zirconium dioxide copings: influence
acceptable values of MG to be less than of all the CAD/CAM crowns, the 30- or of the CAD/CAM system and the finish
100 mm.5,6,18,49 In regarding the ideal the 60-mm spacer settings were recom- line design. J Prosthet Dent 2014 Jan 17.
internal adaptation, many studies have mended for the E4D CAD/CAM system.
reported that an internal gap of 50 to
16. Tuntiprawon M, Wilson PR. The effect of
100 mm could result in the most favor- cement thickness on the fracture strength of
able resin cement performance.51-53 An all-ceramic crowns. Aust Dent J 1995;40:
internal gap value of 200 to 300 mm also 1. Luthardt RG, Bornemann G, Lemelson S, 17-21.
Walter MH, Huls A. An innovative 17. Alkumru H, Hullah WR, Marquis PM,
may be clinically acceptable, but this Wilson SJ. Factors affecting the fit of porcelain
method for evaluation of the 3-D internal
requires in vivo confirmation.18,52,53,57 fit of CAD/CAM crowns fabricated after jacket crowns. Br Dent J 1988;164:39-43.
Therefore, the results of marginal and direct optical versus indirect laser scan 18. Souza RO, Ozcan M, Pavanelli CA, Buso L,
digitizing. Int J Prosthodont 2004;17:680-5. Lombardo GH, Michida SM, et al. Marginal
internal gaps for all the groups pre-
2. Karlsson S. The fit of Procera titanium and internal discrepancies related to margin
sented in this study can be considered crowns. An in vitro and clinical study. Acta design of ceramic crowns fabricated by a
clinically acceptable. Odontol Scand 1993;51:129-34. CAD/CAM system. J Prosthodont 2012;
The limitations of the present study 3. Oden A, Andersson M, Krystek-Ondracek I, 21:94-100.
Magnusson D. Five-year clinical evaluation of 19. Nakamura T, Dei N, Kojima T,
were as follows. First, all the crowns Procera AllCeram crowns. J Prosthet Dent Wakabayashi K. Marginal and internal
were tested without cementation be- 1998;80:450-6. fit of Cerec 3 CAD/CAM all-ceramic crowns.
cause of the radiopacity of the luting 4. Besimo C, Jeger C, Guggenheim R. Marginal Int J Prosthodont 2003;16:244-8.
adaptation of titanium frameworks produced 20. Wiskott HW, Belser UC, Scherrer SS. The
agent, which might alter the results of by CAD/CAM techniques. Int J Prosthodont effect of film thickness and surface texture
this study. This is considered a limita- 1997;10:541-6. on the resistance of cemented extracoronal
tion of the micro-XCT scan method. 5. May KB, Russell MM, Razzoog ME, Lang BR. restorations to lateral fatigue loading. Int J
Second, only the standard mode of the Precision of fit: the Procera AllCeram crown. Prosthodont 1999;12:255-62.
J Prosthet Dent 1998;80:394-404. 21. Lang NP, Kiel RA, Anderhalden K. Clinical
milling machine was evaluated, and 6. Pelekanos S, Koumanou M, Koutayas SO, and microbiological effects of subgingival
different settings may influence the ac- Zinelis S, Eliades G. Micro-CT evaluation of restorations with overhanging or clinically
curacy of the results. Future studies the marginal fit of different In-Ceram alumina perfect margins. J Clin Periodontol 1983;
copings. Eur J Esthet Dent 2009;4:278-92. 10:563-78.
should consider comparing the adap- 7. Renne W, McGill ST, Forshee KV, 22. Donovan T, Wright W, Campagni WV.
tation of ceramic crown restorations DeeFee MR, Mennito AS. Predicting Use of paint-on die spacers in preparations
fabricated by using different milling marginal fit of CAD/CAM crowns based on with grooves. J Prosthet Dent 1984;52:384-8.
the presence or absence of common 23. Campagni WV, Preston JD, Reisbick MH.
machines (3, 4, and 5 axes). Moreover,
preparation errors. J Prosthet Dent 2012; Measurement of paint-on die spacers used
evaluating the effect of the fitting- 108:310-5. for casting relief. J Prosthet Dent 1982;
surface modification and cementation 8. Holmes JR, Bayne SC, Holland GA, 47:606-11.
Sulik WD. Considerations in measurement 24. Eames WB, O’Neal SJ, Monteiro J, Miller C,
on the marginal and internal adapta-
of marginal fit. J Prosthet Dent 1989;62: Roan JD Jr, Cohen KS. Techniques to improve
tion of ceramic restorations would be 405-8. the seating of castings. J Am Dent Assoc
beneficial. 9. Felton DA, Kanoy BE, Bayne SC, 1978;96:432-7.
Wirthman GP. Effect of in vivo crown margin 25. Fusayama T, Ide K, Hosoda H. Relief of
discrepancies on periodontal health. resistance of cement of full cast crowns.
J Prosthet Dent 1991;65:357-64. J Prosthet Dent 1964;14:95-106.
CONCLUSIONS 10. Hamza TA, Ezzat HA, El-Hossary MM, 26. Alghazzawi TF, Liu PR, Essig ME. The effect
Katamish HA, Shokry TE, Rosenstiel SF. of different fabrication steps on the marginal
Accuracy of ceramic restorations made with adaptation of two types of glass-infiltrated
Within the limitations of this in vitro
two CAD/CAM systems. J Prosthet Dent ceramic crown copings fabricated by CAD/
study, the following may be concluded: 2013;109:83-7. CAM technology. J Prosthodont 2012;21:
(1) different fabrication techniques 11. Beschnidt SM, Strub JR. Evaluation of the 167-72.
affected the marginal and internal marginal accuracy of different all-ceramic 27. Beuer F, Schweiger J, Edelhoff D. Digital
crown systems after simulation in the dentistry: an overview of recent developments
adaptation of ceramic crown restora- artificial mouth. J Oral Rehabil 1999; for CAD/CAM generated restorations.
tions; (2) the spacer thickness setting is 26:582-93. Br Dent J 2008;204:505-11.

Mously et al
8 Volume - Issue -

28. Bindl A, Mormann WH. Clinical and 39. Spoor CF, Zonneveld FW, Macho GA. Linear 51. Mormann WH, Bindl A, Luthy H, Rathke A.
SEM evaluation of all-ceramic chair-side measurements of cortical bone and dental Effects of preparation and luting system on
CAD/CAM-generated partial crowns. Eur J enamel by computed tomography: applica- all-ceramic computer-generated crowns.
Oral Sci 2003;111:163-9. tions and problems. Am J Phys Anthropol Int J Prosthodont 1998;11:333-9.
29. Weyns W, De Boever J. Radiographic 1993;91:469-84. 52. Mou SH, Chai T, Wang JS, Shiau YY. Influ-
assessment of the marginal fit of cast 40. Verdonschot N, Fennis WM, Kuijs RH, ence of different convergence angles and
restorations. J Prosthet Dent 1984;51:485-9. Stolk J, Kreulen CM, Creugers NH. Genera- tooth preparation heights on the internal
30. Boening KW, Wolf BH, Schmidt AE, tion of 3-D finite element models of restored adaptation of Cerec crowns. J Prosthet Dent
Kastner K, Walter MH. Clinical fit of Procera human teeth using micro-CT techniques. Int J 2002;87:248-55.
AllCeram crowns. J Prosthet Dent 2000; Prosthodont 2001;14:310-5. 53. Molin MK, Karlsson SL, Kristiansen MS.
84:419-24. 41. De Santis R, Mollica F, Prisco D, Rengo S, Influence of film thickness on joint bend
31. Reich S, Wichmann M, Nkenke E, Ambrosio L, Nicolais L. A 3D analysis of strength of a ceramic/resin composite joint.
Proeschel P. Clinical fit of all-ceramic mechanically stressed dentin-adhesive- Dent Mater 1996;12:245-9.
three-unit fixed partial dentures, generated composite interfaces using X-ray micro-CT. 54. Gassino G, Barone Monfrin S, Scanu M,
with three different CAD/CAM systems. Biomaterials 2005;26:257-70. Spina G, Preti G. Marginal adaptation of
Eur J Oral Sci 2005;113:174-9. 42. Tan PL, Gratton DG, Diaz-Arnold AM, fixed prosthodontics: a new in vitro
32. Kokubo Y, Ohkubo C, Tsumita M, Holmes DC. An in vitro comparison of 360-degree external examination procedure.
Miyashita A, Vult von Steyern P, vertical marginal gaps of CAD/CAM titanium Int J Prosthodont 2004;17:218-23.
Fukushima S. Clinical marginal and internal and conventional cast restorations. 55. McLean JW, von Fraunhofer JA. The estima-
gaps of Procera AllCeram crowns. J Oral J Prosthodont 2008;17:378-83. tion of cement film thickness by an in vivo
Rehabil 2005;32:526-30. 43. Christensen GJ. Marginal fit of gold inlay technique. Br Dent J 1971;131:107-11.
33. Mitchell CA, Pintado MR, Douglas WH. castings. J Prosthet Dent 1966;16:297-305. 56. Yeo IS, Yang JH, Lee JB. In vitro marginal fit of
Nondestructive, in vitro quantification of 44. Oilo G, Evje DM. Film thickness of dental three all-ceramic crown systems. J Prosthet
crown margins. J Prosthet Dent 2001; luting cements. Dent Mater 1986;2:85-9. Dent 2003;90:459-64.
85:575-84. 45. Bindl A, Windisch S, Mormann WH. Full- 57. Sorensen JA, Munksgaard EC. Interfacial
34. Bindl A, Mormann WH. Marginal and ceramic CAD/CIM anterior crowns and gaps of resin cemented ceramic inlays. Eur J
internal fit of all-ceramic CAD/CAM copings. Int J Comput Dent 1999;2:97-111. Oral Sci 1995;103:116-20.
crown-copings on chamfer preparations. 46. Lin MT, Sy-Munoz J, Munoz CA,
J Oral Rehabil 2005;32:441-7. Goodacre CJ, Naylor WP. The effect of tooth Corresponding author:
35. Gu XH, Kern M. Marginal discrepancies preparation form on the fit of Procera cop- Dr Hisham A. Mously
and leakage of all-ceramic crowns: influence ings. Int J Prosthodont 1998;11:580-90. Tufts University School of Dental Medicine
of luting agents and aging conditions. Int J 47. Sulaiman F, Chai J, Jameson LM, 1 Kneeland Street, Boston, MA 02111
Prosthodont 2003;16:109-16. Wozniak WT. A comparison of the marginal E-mail:
36. Siervo S, Bandettini B, Siervo P, Falleni A, fit of In-Ceram, IPS Empress, and Procera
Siervo R. The CELAY system: a comparison crowns. Int J Prosthodont 1997;10:478-84. Copyright ª 2014 by the Editorial Council for
of the fit of direct and indirect fabrication 48. Grey NJ, Piddock V, Wilson MA. In vitro The Journal of Prosthetic Dentistry.
techniques. Int J Prosthodont 1994; comparison of conventional crowns and a
7:434-9. new all-ceramic system. J Dent 1993;21:47-51.
37. Swain MV, Xue J. State of the art of Micro-CT 49. Lee KB, Park CW, Kim KH, Kwon TY.
applications in dental research. Int J Oral Sci Marginal and internal fit of all-ceramic
2009;1:177-88. crowns fabricated with two different CAD/
38. Krasanaki ME, Pelekanos S, Andreiotelli M, CAM systems. Dent Mater J 2008;27:422-6.
Koutayas SO, Eliades G. X-ray microtomo- 50. Cho SH, Nagy WW, Goodman JT,
graphic evaluation of the influence of two Solomon E, Koike M. The effect of multiple
preparation types on marginal fit of CAD/ firings on the marginal integrity of pressable
CAM alumina copings: a pilot study. Int J ceramic single crowns. J Prosthet Dent
Prosthodont 2012;25:170-2. 2012;107:17-23.

The Journal of Prosthetic Dentistry Mously et al