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Clinical Outcomes of Three Different Crown Systems With CAD/CAM Technology
Clinical Outcomes of Three Different Crown Systems With CAD/CAM Technology
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 modified
United States Public Health Service criteria for contour, marginal adaptation, occlusion, and shade. Gingival crevicular fluid
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 modified 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 (a¼.05 for all tests).
Results. Twelve metal ceramic, 10 lithium disilicate, and 10 zirconia restorations were fabricated for 22 participants. Zirconia
restorations were significantly 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 fluid volumes did not differ among
crown systems, between treated and control groups, or over time. The average horizontal marginal discrepancy was
significantly different between lithium disilicate and zirconia crowns (P¼.027), 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;-:---)
Batson et al
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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 workflow that involves intraoral scanning and digital design
may provide a clinically acceptable single-tooth restoration.
Computer-aided design and computer- The direct intraoral capture of a pre- (USPHS) criteria. Secondary outcomes
aided manufacturing (CAD/CAM) pared abutment found more accuracy included marginal adaptation measured
dentistry has evolved dramatically in than the scanned polyether impression by micro–computed tomography (mi-
the past 30 years. Most recently, or gypsum cast. Average marginal dis- cro-CT) analysis and the gingival
numerous CAD/CAM systems with crepancies of CAD/CAM restorations response to CAD/CAM crown restora-
broad capabilities that range from have been reported, which ranged tions evaluated at the level of inflam-
implant restoration design and fabri- from 35 to 71 mm, and clinical studies mation with gingival crevicular fluid
cation to orthodontic appliance plan- with scanning electron microscopy (GCF) volume and bleeding on probing
ning and manufacture have become analysis have equivalent values.5,8-10 (BOP). The null hypotheses were that no
widely available for clinicians and A clinical study by Brawek et al11 re- difference would be found in crown
dental laboratories. In addition, de- ported a mean marginal discrepancy quality among metal ceramic (MC), LD,
mand for esthetic materials has in- value of 51 mm for veneered Zr crowns and Zr crowns fabricated with CAD/
creased1 in restorative dentistry, with fabricated with intraoral scanning CAM technologies, no difference would
concurrent advances in materials sci- techniques and digital fabrication. be found in gingival response among the
ence that provide new monolithic Even with studies that found com- crown systems, and no difference would
materials that synergize with CAD/ parable marginal adaptation with be found in the marginal discrepancy
CAM technology. Two materials, lith- standard metal ceramic restorations, values between crown systems and
ium disilicate (LD) and monolithic the longevity of ceramic materials are intraoral scanners.
zirconia (Zr), have become popular, of concern, especially those with
and both are fabricated with CAD/ veneering methods for improved es- MATERIAL AND METHODS
CAM systems.2 A recent survey of thetics. A 94.8% 8-year survival rate
laboratory fabrication projections for was reported by Gehrt et al12 for 94 Patients of the University of North
restorative materials estimates that, by single-unit fixed dental prostheses for Carolina (UNC) at Chapel Hill School
the year 2017, ceramic materials will veneered LD restorations with a 5.5% of Dentistry were screened and enrolled
be used to fabricate approximately rate of chipping or fracturing of res- in this study under institutional review
42% of fixed dental restorations.1 torations. Fasbinder et al13 reported a board approval (UNC institutional re-
The adoption of digital manufacture 100% survival rate of 62 LD crown view board 11-2099). Before treatment
for crowns involves the professional restorations in 43 individuals over a began, radiographs, tooth shade, GCF
assessment of all attributes of the res- 2-year recall period. No incidence of volume, and BOP measurements were
toration. Notably, attention has been crown fracture or chipping was re- recorded for all treated teeth as well
focused on the fit and marginal ad- ported nor relatively high alpha scores as a minimally restored or unprepared
aptation of CAD/CAM restorations.3 for color and marginal adaptation. control tooth on the contralateral side.
As discussed in a recent review by Higher chipping rates of 15% to 25% Shade was matched to a Vita Classic
Miyazaki et al,4 crown margins can have been reported for veneered Zr shade guide for treated teeth. GCF
be difficult to capture with intraoral restorations.14,15 A monolithic resto- volume was collected on the buccal and
scanning, not only because of their ration would appear to solve some of lingual surfaces of selected and control
design, but their proximity to gingival the technical complications associated teeth with crevicular fluid strips (Perio-
tissues, adjacent teeth, and sulcular with ceramic materials, despite limited paper; Oraflow) and a Periotron 8000
fluids. Other studies have concluded clinical data. (Oraflow) according to the manufac-
no significant difference among intrao- This prospective study compared turer’s instructions. BOP was measured
ral scanning, a scan of an impression, different CAD/CAM crown procedures. with a periodontal probe (UNC-15
or a gypsum cast.5,6 Güth et al7 The primary outcome measurement was Periodontal Probe; Hu-Friedy) on the
examined the accuracy of digital restoration quality assessed with modi- treated and control teeth. The crown
models with an in vitro experiment. fied United States Public Health Service system was randomized to treated
Table I. Modified United States Public Health Service criteria for crown evaluation
Marginal
Results Adaptation Crown Contour Shade Occlusion
S: Acceptable Less than ideal Less than ideal but minimal Less than ideal but no Less than ideal but no
but acceptable or no changes required changes required changes required/minimal
adjustments necessary
T: Acceptable/modifications Less than ideal, Additions or Staining or other shade Adjustments necessary
needed adjust or remake reductions necessary modifications required
Batson et al
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was verified with the patient. All the treated tooth. The sectioned impres- cementation for GCF volume and BOP
crowns were cemented with glass ion- sions were scanned with a micro-CT measurements.
omer cement (Ketac-Cem; 3M ESPE). scanner (Scanco mCT 40 scanner; Descriptive statistics were per-
The participants were recalled 1 Scanco Medical; Biomedical Research formed with computerized software
month after cementation for GCF Imaging Center at the UNC). Digital (SAS v9.1; SAS). The Mantel Haenszel
volume and BOP measurements. Imaging and Communications in row mean score statistic was used
Postcementation measurements and Medicine (DICOM) files were created to assess an association between the
impressions were recorded by 1 prac- with slices approximately 20 mm in crown system and the modified USPHS
titioner (E. B.). After GCF volume and width and with approximately 6 mm criteria for acceptable; thus, the R, S,
BOP measurements, plain displace- of resolution. Images were analyzed and T values were combined for this
ment cord (Ultrapak; Ultradent Prod- with a DICOM viewer and linear analysis. Linear mixed models were
ucts Inc) was placed along the buccal measuring tool (Image J software; U.S. used for buccal and lingual GCF vol-
side of the restored tooth, and a poly- National Institutes of Health). Each umes separately, and a generalized
vinyl siloxane (PVS) impression was crown was measured at 6 locations 0.5 estimating equation approach was
made of the cemented crown with light to 1.0 mm apart along the buccal used for BOP. The explanatory variables
and heavy viscosities (Imprint 3; 3M margin. Measurements were made of interest were the between-subject
ESPE) in a quadrant impression tray from the prepared crown margin of factor (crown system) and the within-
with appropriate adhesive (COE brand the tooth to the closest horizontal subject factors (visit and tooth status,
[GC America] and VPS Tray Adhesive point of the crown restoration. Mea- treated vs control). Because both
[3M ESPE]). PVS impressions were surements were recorded as absolute tooth status and visit were correlated
sectioned through the buccal and values that represent overextended within the crown system, a Kronecker
occlusal surfaces of the impression to or underextended crown margins. The product formulation was used in the
display only the buccal section of the patients were recalled 6 months after linear mixed models for the covariance
Marginal adaptation
MC 3 0 8 1 12
Zr 1 0 5 4 10
LD 2 1 7 0 10
Total 6 1 20 5 32
Contour
MC 0 2 7 3 12
Zr 0 0 9 1 10
LD 0 3 7 0 10
Total 0 5 23 4 32
Shade
MC 0 2 6 4 12
Zr 0 6 3 1 10
LD 0 1 9 0 10
Total 0 9 18 5 32
Occlusion
MC 0 0 7 5 12
a
Zr 0 0 2 8 10
LD 0 3 7 0 10
Total 0 3 16 13 32
For USPHS Shade, P¼.06; for USPHS Contour, P¼.16; for USPHS Margins, P¼.07; for USPHS Occlusion, P¼.0005.
USPHS, United States Public Health Service; MC, metal ceramic; Zr, zirconia; LD, lithium disilicate.
a
Denotes statistically significant values assessed by Mantel Haenszel row mean score statistic.
Table III. Descriptive statistics for gingival parameters and treated teeth (N¼32)
Visita
Crown 1-mo 6-mo
b
Gingival Parameter System Pretreatment postcementationc postcementationd
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
Lingual surface GCF volume, mean (SD) 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
Bleeding on probing, yes/no (% of yes) 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)
MC, metal ceramic; SD, standard deviation; GCF, gingival crevicular fluid; Zr, zirconia; LD, lithium disilicate.
a
MC (n¼12 [missing¼0] at visit 0, n¼12 [missing¼0] at visit 2, n¼6 [missing¼6] at visit 3); Zr (n¼10 [missing¼0] at visit 0, n¼9 [missing¼1] at visit 2,
n¼7 [missing¼3] at visit 3); LD (n¼10 [missing¼0] at visit 0, n¼8 [missing¼2] at visit 2, n¼6 [missing¼4] at visit 3).
b
Visit 0.
c
Visit 2.
d
Visit 3.
Batson et al
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Table IV. P values from linear mixed and generalized estimating equation models and compare the manufactured quality
with 1 between-subject factor (crown system) and 2 within-subject factors (visit and of restorations with particular focus
tooth status) for gingival crevicular fluid volumes and bleeding on probing on marginal integrity and the responses
to this interface. During the 6-month
Explanatory Buccal Lingual Bleeding
period, no fractures or chipping of
Variable Surface Surface on Probing crowns was noted. Although other
studies14,15 indicate the chipping of Zr-
Crown system .38 .71 .92
coping–based crowns to be a limita-
Time of measure .49 .42 .25
tion, chipping complications were not
Treated vs control .47 .10 .17 revealed at the 6-month time point. In
this investigation, monolithic Zr and
monolithic LD crowns were used. Long-
10
term evaluations are needed to investi-
Overextended
Number of Crowns
CONCLUSIONS
Batson et al
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9480 Briar Village Point Suite 300
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