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Comparison of the Accuracy of Fit of Metal, Zirconia, and Lithium Disilicate

Crowns Made from Different Manufacturing Techniques

Article  in  Journal of Prosthodontics · February 2019

DOI: 10.1111/jopr.13029

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Comparison of the Accuracy of Fit of Metal, Zirconia,
and Lithium Disilicate Crowns Made from Different
Manufacturing Techniques
Khaled Q. Al Hamad, BDS MSc MRD RCSEd FDS RCSEd ,1 Firas A. Al Quran, BDS MSc PhD AOIA,1
Sendos A. AlJalam, BDS MClinDent MFD RCSI,1 & Nadim Z. Baba, DMD, MSD, FACP 2
1
Department of Prosthodontics, Faculty of Dentistry, Jordan University of Science & Technology, Irbid, Jordan
2
Advanced Specialty Education Program in Prosthodontics, Loma Linda University, School of Dentistry, Loma Linda, CA

Keywords
Accuracy; CAD/CAM; crown; digital;
conventional; fit; marginal fit.
Correspondence
Khaled Q. Al Hamad, Department of
Prosthodontics, Faculty of Dentistry, Jordan
University of Science and Technology, Irbid,
PO Box 3030, Irbid 22110, Jordan. E-mail:
kqalhamad@just.edu.jo,
kqalhamad@gmail.com
This study was supported by a grant from the
Jordan University of Science and Technology,
Irbid, Jordan.
The authors declare that there are no
conflicts of interest in this study.
Accepted January 29, 2019
doi: 10.1111/jopr.13029
Abstract
Purpose: To evaluate the accuracy of fit of metal, lithium disilicate, and zirconia
crowns, which were produced using different manufacturing techniques.
Materials and Methods: Ten patients in need of a molar crown were recruited. Eight
crowns were fabricated for each patient: 2 zirconia, 3 lithium disilicate (e.max), and
3 metal-ceramic crowns using conventional, conventional/digital, and digital tech-
niques. Marginal, axial, and occlusal gaps were measured using a replica technique.
Replicas were sectioned mesiodistally and buccolingually and were observed under
a stereomicroscope. A total of 32 measurements for each crown replica at 3 different
points (12 marginal, 12 axial, and 8 occlusal) were performed. Statistical analysis was
performed using two-way ANOVA and Tukey HSD tests.
Results: Marginal means ranged from 116.39 ± 32.76 µm for the conventional
metal-ceramic group to 147.56 ± 31.56 µm for the digital e.max group. The smallest
axial gap was recorded for the digital zirconia group (76.19 ± 23.94 µm), while the
largest axial gap was recorded for the conventional e.max (101.80 ± 19.81 µm) and
conventional/digital metal-ceramic groups (101.80 ± 35.31 µm). The conventional
e.max crowns had the smallest occlusal mean gap (185.59 ± 59.09 µm), while the
digital e.max group had the largest occlusal mean gap (295.38 ± 67.80 µm). Type of
crown had no significant effect on marginal (p = 0.07, f = 2.71), axial (p = 0.75, f =
0.29), or occlusal fit (p = 0.099, f = 2.4), while fabrication method had a significant
effect on axial gap only (p = 0.169, f = 1.82, p = 0.003, f = 6.21, and p = 0.144,
f = 2 for marginal, axial, and occlusal fit, respectively). Digital fabrication produced
significantly smaller axial gaps than the conventional method (p = 0.02), and the
conventional digital method (p = 0.005).
Conclusions: The type of crown and method of manufacturing had no effect on the
marginal and occlusal gap of single posterior crown, while the method of manufactur-
ing had a significant effect on the axial gap. The digital method produced the smallest
axial fit in comparison with the other methods, while the type of crown had no effect
on the axial gap.

Marginal and internal adaptation is essential for the success
of indirect restorations. Poor marginal fit can lead to harm-
ful effects on the tooth and periodontal tissues. These harmful
effects can include microleakage, plaque accumulation, and al-
teration in microflora.1 Poor internal fit can lead to reduced
retention and an increase in ceramic fracture.2 Although the
acceptable marginal fit for crowns has been widely discussed
in the literature, there is no consensus on the maximum ac-
ceptable marginal discrepancy.3-9 McLean and von Fraunhofer5
reported a threshold of 120 µm, but marginal fit values differ
depending on measurement location and restoration type,10-12
with reported values varying between 50 and 200 µm.3-7
The accuracy of fit for crowns made from conventional and
digital workflows has been investigated by numerous studies,
but the results of most current studies are inconsistent.13,14
While the superiority of the digital workflow was reported
by some studies,15,16 another study indicated that conventional
methods provided better marginal fit.17 Other authors, however,
reported that digital and conventional impressions produced re-
sults with similar accuracy.8,18-22

Journal of Prosthodontics 00 (2019) 1–7 

C 2019 by the American College of Prosthodontists 1
Crown Fit from Different Manufacturing Techniques
Marginal and internal adaptation values were reported to
be different depending on the type and material of indirect
restorations.23 The metal-ceramic restoration is commonly used
in dentistry because of its predictable results, well-documented
performance, and sound physical properties. New fabrication
methods using CAD/CAM technology have been proposed
for metal fabrication in order to omit several limitations of
the conventional techniques.24 Nevertheless, conflicting re-
sults have been reported on the comparison of fit between
conventional and CAD/CAM techniques. Conventional tech-
niques were reported to provide better fit than CAD/CAM
manufacturing.17,25,26 The opposite, however, was reported in
another study.27
The demand for all-ceramic restorations has increased in
recent years due to the increased attention to esthetics and
awareness of biocompatibility. Zirconia is a high-strength
material, and its use has increased rapidly with the evolu-
tion of CAD/CAM technology.28 Regarding the marginal fit
of zirconia restorations, conflicting reports have also been
documented.17,29-34 Lithium disilicate ceramic is a glass-
ceramic with improved strength. Similar to reports on zirco-
nia, reports on the marginal fit of lithium disilicate crowns
made from conventional and CAD/CAM techniques were not
consistent.18-20,24,33,35-44
Despite the extensive literature, a recent systematic review
reported low-quality evidence for marginal and internal fit of
full-coverage restorations.14 The limited in vivo studies and the
inconsistencies of current laboratory-based studies generated
inconclusive evidence. Therefore, the aim of this clinical study
was to evaluate the accuracy of fit of 3 types of crowns, metal,
lithium disilicate, and zirconia, which were produced using dif-
ferent manufacturing techniques. The null hypothesis was that
there was no effect of the crown type or method of fabrication
on the accuracy of fit of single crowns.
Materials and methods
Patients referred to the Department of Prosthodontics, Post-
graduate Dental Clinics, Jordan University of Science & Tech-
nology, Irbid, Jordan, were screened for possible inclusion in
the study. Subjects were included in the study based on the fol-
lowing criteria: subject was in need of a single posterior molar
crown with a good level of oral hygiene as evidenced by the
absence of gingival and periodontal inflammation, subject was
compliant and able to sign an informed consent. Ten subjects
with an age range between 20 and 41 years old were included in
the study (6 subjects each in need of a mandibular molar crown,
4 subjects each in need of a maxillary molar crown). Teeth
that required extensive coronal reconstruction or subgingival
margins were not included in the study. All subjects provided
informed consent, and the study protocol was approved by the
institutional research board (IRB 30-106-2017).
A single operator (SA) performed the clinical procedures.
Tooth preparation was performed according to standard proto-
cols using a 1-mm tip, round-end, medium grit diamond bur
(Jota, Ruthi, Switzerland) to provide a 1-mm shoulder fin-
ish line with rounded internal line angles and placed at the
level of the gingival margin. Preparation depths were 1.5 to
2 mm occlusal reduction and 1 to 1.5 mm axial reduction.
2 Journal of Prosthodontics 00 (2019) 1–7 
Al Hamad et al
Figure 1 Flow chart showing the distribution of the 80 crowns, accord-
ing to the different groups.
All line angles were rounded. The final preparation was ver-
ified by a silicone guide (Elite HD+; Zhermack, Badia Pole-
sine, Italy), which was made using either an index or a wax-up
of the relevant tooth (Plastodent; Dentsply Sirona, York, PA).
Retraction cord (Ultra Pak E; Ultradent, South Jordan, UT)
impregnated in aluminum chloride hemostatic agent (ALUS-
TAT; Cerkamed, Stalowa Wola, Poland) was placed to expose
the margin prior to impression making. Digital working and
antagonist impressions and buccal occlusal registrations were
made with an intraoral scanner (CEREC Omnicam; Dentsply
Sirona, Salzburg, Austria). Vinylpolysiloxane (VPS) impres-
sions (heavy and light consistencies, Elite HD+) were made
subsequently in a one-step impression technique using a stock
tray (DOCHEM, Shanghai, China). Antagonist arch impression
was made with irreversible hydrocolloid (Zhermack). Occlusal
registration was performed using VPS bite registration material
(Occlufast Rock; Zermack). The impressions were cast in type
IV dental stone (Elite Rock; Zhermack) 24 hours later. Each
working cast was scanned using a laboratory scanner (Ceramill
Map 400; Amann Girrbach AG, Herrschaftswiesen, Austria).
All digital files were exported to dental CAD software (Exo-
cad GmbH, Darmstadt, Germany). Three metal-ceramic crowns
and 3 monolithic lithium disilicate crowns were fabricated for
each patient using the digital impression, the conventional im-
pression, and the digitized cast (1 crown per each impression
technique). Furthermore, 2 monolithic zirconia crowns were
made for each patient using the digital impression and the dig-
itized cast. In total, 80 crowns were fabricated, 8 crowns for
each patient (Fig 1).
All crowns were fabricated by an experienced technician.
Lithium disilicate (e.max) crowns and metal-ceramic crowns
were fabricated conventionally on the casts produced from the
conventional impression. A silicone index of the relevant tooth
or wax-up was used in the fabrication of the conventionally
manufactured crowns. Monolithic heat-pressed e.max crowns
were fabricated using lithium disilicate ingots (IPS e.max Press;
Ivoclar Vivadent, Schaan, Liechtenstein).
Metal-ceramic crowns were fabricated using cobalt
chromium (Co-Cr) base metal alloy (Dentsply Sirona) and
layered with a traditional powder/liquid mixture of a felds-
pathic ceramic (Vita Vm9; Vita Zahnfabrik, Bad Sackingen,
C 2019 by the American College of Prosthodontists
Al Hamad et al Crown Fit from Different Manufacturing Techniques

Germany). All crowns were sintered according to standard pro-

tocols in a ceramic furnace (Programat P310; Ivoclar Vivadent).
Digital crowns were fabricated using the digital impressions
and the digitized casts. The crowns were designed using dental
CAD software (Exocad GmbH) and were milled using a 5-
axis milling machine (Ceramill Motion 2; Amann Girrbach).
A digital scan of the relevant tooth or wax-up was used as a
reference scan in designing the digital crown.
Soft Co-Cr blanks were used to fabricate CAD/CAM metal
substructure for the metal-ceramic crowns (Ceramil Sintron;
Amann Girrbach). Metal copings were sintered in an argon fur-
nace (Ceramill Argotherm 2; Amann Girrbach) and manually
layered with feldspathic porcelain (Vita VM9; Vita Zahnfab-
rik) similar to the conventionally manufactured metal-ceramic
restorations.
Digital monolithic e.max crowns were fabricated using glass-
ceramic blocks (IPS e.max CAD LT; Ivoclar Vivadent) and
sintered in a ceramic furnace (Programat P310). Monolithic Figure 2 A sample replica with occlusal view illustration of the segmen-
zirconia crowns were fabricated using dry milling of zirconia tation. Numbers 1 to 4 indicate the four sections obtained for measure-
blanks (Whitepeaks Dental Solutions, Wesel, Germany) and ment.
were sintered in a ceramic furnace (Ceramill Therm 3; Amann
Girrbach). All crowns were finished and polished according to
manufacturer’s instructions.
Crowns were tried in, and proximal contacts were adjusted
as needed to the best fit. Marginal and internal gaps were mea-
sured using the replica technique. The operator who performed
this procedure was unaware of the method of fabrication of the
crown. A fast-set light-body VPS was injected into the intaglio
surface of the crown and reseated on the tooth preparation with
firm finger pressure for 2.5 minutes according to the manu-
facturer’s recommendations. At complete setting of the fast-set
VPS, the crown was removed, and a fast-set VPS heavy-body
impression material was injected into the intaglio surface to
support the thin light-body VPS layer and was left to set for
2.5 minutes. After measurements, a crown was selected and ce-
mented in place according to standard prosthodontic protocols.
The silicone replicas were carefully removed from their relevant
crowns and were sectioned buccolingually and mesiodistally
with a razor blade to produce 4 sectioned parts per specimen
(Fig 2). The sectioned VPS material was placed parallel to a
horizontal plane. A stereomicroscope with 0.5× lens at 30×
magnification (SMZ168; Motic, RichmondCanada) was used
to measure the thickness of the silicon replicas at 3 points
marginally, 3 points axially, and 2 points occlusally for each
section (Fig 3). A total of 32 measurements were obtained for Figure 3 A sample of section 1 showing the marginal, axial, and oc-
each replica: 12 marginal points, 12 axial points, and 8 occlusal clusal measurement sites. [Color figure can be viewed at wileyonlineli-
points. A trained technician who was unaware of the relevant brary.com]
study groups performed the replica measurements.
The precision of the measurements was evaluated using the used to check for the validity of assumptions in the built model:
intraclass correlation coefficient (ICC)—a comparison of each a normal probability plot of residuals was used to check for the
measurement in one replica with its mirror image in the other normality assumption, and residual vs. fitted values plots were
part of the same replica—was performed for one group. An used to check for homogeneity.
ICC of 0.75 and above is considered good, and above 90 is
excellent.12 Marginal, axial, and occlusal fit means were cal- Results
culated using R statistical computing software for each group.
Two-way ANOVA was used to determine significant differ- Marginal, axial, and occlusal gaps of 80 crowns were evalu-
ences among the study groups. Pairwise differences among ated in this study. Each crown had 12 marginal, 12 axial, and
groups were performed using Tukey HSD test. P value of ࣘ 8 occlusal gap measurements. ICC showed good precision of
0.05 was considered significant. Model adequacy plots were measurement (above 0.75). The mean for marginal, axial, and

Journal of Prosthodontics 00 (2019) 1–7 

C 2019 by the American College of Prosthodontists 3
Crown Fit from Different Manufacturing Techniques Al Hamad et al

Table 1 Means, standard deviations, first quartile, median, third quartile of all groups (µm)

Group Mean∗ Standard deviation First quartile Median Third quartile

MARGINAL
Conventional MC 116.39 32.76 96.41 129.01 138.98
Conventional/digital MC 123.76 33.18 106.05 120.97 139.63
Digital MC 127.85 28.87 115.64 120.42 138.84
Conventional e.max 129.09 30.32 104.54 129.29 152.54
Conventional/digital e.max 116.82 36.85 87.14 122.14 146.64
Digital e.max 147.56 31.56 126.50 148.50 166.25
Conventional/digital Z 125.17 37.82 105.31 133.94 145.56
Digital Z 137.05 32.46 116.47 141.35 158.22
AXIAL
Conventional MC 87.09 31.88 63.22 78.11 99.97
Conventional/digital MC 101.80 35.31 82.63 91.64 119.96
Digital MC 85.39 35.66 67.04 72.02 86.76
Conventional e.max 101.80 19.81 83.77 98.62 120.22
Conventional/digital e.max 88.84 35.05 75.61 91.78 107.25
Digital e.max 79.98 27.71 66.05 79.29 81.77
Conventional/digital Z 97.44 24.56 78.68 105.44 116.46
Digital Z 76.19 23.94 62.05 78.99 94.99
OCCLUSAL
Conventional MC 208.77 77.01 154.20 195.93 247.55
Conventional/digital MC 203.32 74.77 163.37 186.03 217.61
Digital MC 203.10 46.83 166.11 214.73 235.20
Conventional e.max 185.59 59.09 141.44 177.33 240.13
Conventional/digital e.max 257.24 75.90 210.92 250.13 301.46
Digital e.max 295.38 67.80 253.50 292.50 329.50
Conventional/digital Z 286.89 70.76 223.20 278.48 347.20
Digital Z 224.47 51.93 181.73 235.00 260.59
*
Pairwise comparisons using Tukey HSD test showed no significant differences among the marginal, axial, and occlusal subgroups.

occlusal gaps for all groups are shown in Table 1. The small-
est marginal mean was recorded for the conventional metal-
ceramic group (116.390 ± 32.76 µm), while the largest was
recorded for the digital e.max group (147.56 ± 31.56 µm). Re-
sults of the two-way ANOVA showed no significant effect of
the fabrication method (p = 0.169, f = 1.82), crown type (p =
0.074, f = 2.71), or interactions between them (p = 0.127, f =
1.97) on the marginal gap.
The smallest axial gap was recorded for the digital zirconia
group (76.19 ± 23.94 µm), whereas the largest was recorded
for the conventional e.max (101.80 ± 19.81 µm) and con-
ventional/digital metal-ceramic groups (101.80 ± 35.31 µm).
Fabrication method had a significant effect on axial gap (p =
0.003, f = 6.21). Digital fabrication method produced signif-
icantly smaller axial gaps than the conventional method (p =
0.02) and the conventional digital method (p = 0.005). No
significant differences in axial gap were found between the
conventional method and the conventional digital method (p
= 0.95). Crown type or the interaction between crown type
and fabrication method had no significant effect on axial gap
(p = 0.75, f = 0.29, and p = 0.55, f = 0.72, respectively).
The smallest occlusal mean was recorded for the conventional
e.max crowns (185.59 ± 59.09 µm), while the digital e.max
group had the largest occlusal mean (295.38 ± 67.80 µm). Fab-
rication method, crown type, or the interaction between them
had no significant effect on the occlusal gap (p = 0.144, f =
2, p = 0.099, f = 2.4, and p = 0.074, f = 2.42, respectively).
Pairwise comparisons between the subgroups showed no sig-
nificant differences (p > 0.05) for marginal, axial, or occlusal
gaps (Table 1).
Discussion
This study evaluated the marginal, axial, and occlusal fit of
3 types of molar crowns (metal, lithium disilicate, zirconia),
which were manufactured using conventional, cast digitization,
or digital methods. There was no significant effect for the type
of crown on marginal, axial, or occlusal fit, while the method
of manufacturing had an effect on the axial fit only. Thus, the
null hypothesis was partially rejected.
All crowns were tried in, and proximal contacts were adjusted
according to standard protocols before measurement. Regard-
ing the type of crown, metal-ceramic and zirconia crowns re-
quired fewer adjustments than e.max crowns. No trend was
observed regarding the method of manufacturing. This was a
subjective assessment, and no data were collected, as this was
not investigated in this study.
The results in this study of no difference between the
conventional and digital workflow on the marginal fit were
similar to several reports for lithium disilicate,18,19,35,36,39,41
zirconia,6,30,34 and metal crowns.22 However, this was differ-
ent from other reports, which documented the superiority of
the conventional technique for the fit of single crowns for
lithium disilicate,20,40 and metal,17,25,26 or the superiority of

4 Journal of Prosthodontics 00 (2019) 1–7 

C 2019 by the American College of Prosthodontists
Al Hamad et al
the digital technique for lithium disilicate,16,24,37,38 and metal
crowns.27 This was also different from the studies that re-
ported better marginal fit for single zirconia crowns produced
by the digital technique compared to the cast digitization
technique.24,31,32 The differences with these studies could be
explained by the wide variations in measurement methods,
specimen design, sample size, and tooth selection. Thus, a di-
rect comparison with the relevant literature was difficult. A
recent systematic review reported low-quality evidence for the
marginal and internal fit of full-coverage restorations that sug-
gested similar performance for the digital and conventional
techniques.14
The results in this study were similar to several reports
that compared the marginal fit of different types of crowns.
Prasad and Al-Kheraif44 reported no significant difference
of the marginal fit between partially sintered zirconia and
leucite-reinforced glass-ceramics. Huang et al,33 in an in vivo
study, reported a better marginal fit of metal-ceramic crowns
manufactured using selective laser sintering in comparison
with CAD/CAM-fabricated e.max and zirconia crowns. The
2 CAD/CAM-fabricated crowns were not significantly differ-
ent from each other. In another in vivo study, Seelbach et al19
reported no significant differences in the marginal fit of 3 types
of crowns: LAVA, zirconia, and lithium disilicate crowns. Sim-
ilar marginal discrepancies were also reported for metal and
zirconia copings fabricated using direct scanning, impression
scanning, or lost-wax techniques.43
The means for the groups in this study were within the ranges
reported in the literature but were all greater than the 120 µm
reported by McLean and von Fraunhofer,5 except for the con-
ventional metal-ceramic group. A wide range of acceptable
marginal fit for crowns has been reported in the literature, with
several authors reporting values in the range of 50 to 200 µm.3-6
A recent study stated that there was no conclusive evidence on
an optimum fit of contemporary systems, with a diverse range
between 7.5 and 206.3 µm.10 It was difficult to directly com-
pare the results among different studies because of the variety
of restorative materials and CAD/CAM systems, the use of dif-
ferent terms to define marginal adaptation, and the presence of
different techniques for quantifying marginal fit.12 Most reports
were in vitro studies, with the aim of providing reproducibil-
ity and standardization of test parameters; however, in vitro
studies deviate from clinical conditions, limiting their clinical
relevance.
The values reported in this study could have been affected by
the variations in the preparation form and dimensions among
the 10 patients because the internal discrepancy could be re-
lated to the inability of the milling machine to reproduce fine
details.23 Furthermore, adaptation procedures before measure-
ment were reported to decrease the marginal and internal gaps.29
The intaglio of the single crowns was not adjusted in this study.
Similar to previous reports, the occlusal gap was larger than
the axial and marginal gaps in all groups, while the smallest ax-
ial values were provided by the digital technique.3,8,21,24 Digital
technology provided the least axial space due to the ability of
the technology to reproduce flat surfaces; however, this technol-
ogy was not able to provide homogenous thickness despite the
uniform cement spacer setting provided in the CAD software.
The cement gap could have been influenced by the diameter
Journal of Prosthodontics 00 (2019) 1–7 
C 2019 by the American College of Prosthodontists
Crown Fit from Different Manufacturing Techniques
and shape of the milling instruments, preparation form, quality
of acquisition, and processing of the digital data. Also, cement
gap thickness affected the marginal and internal adaptation of
crowns, with improved fit with increased cement space.29 The
default setting for each type of crown was used in this study, and
this might have affected the findings of this study in comparison
with other reports.
The replica technique is a nondestructive, accurate, and re-
liable evaluation that has been used commonly in both in vivo
and in vitro studies.9,12,24,35 Laurent et al9 reported that if ap-
propriate silicone is used, the cement space may be replicated
and its thickness measured regardless of the location. Also, no
significant difference between the silicone replica technique
and sectioning technique in measuring the marginal gap was
reported.7 The replica technique was adapted for precemen-
tation studies because of its shorter production time, lower
investment cost, and the need for less-complex equipment.12
However, the replica technique has limitations such as tear-
ing of the elastomeric film upon removal from the crown and
difficulty in identifying the crown margins and finish lines.22
There is no agreement in the literature on the amount
of the required measurements. Gassino et al11 reported 18
measurement points for experimental crowns and 90 for clin-
ical crowns to produce a sample mean value ±5 µm of the
true mean. Groten et al42 suggested 50 measurement points.
Nawafleh et al10 suggested testing a minimum of 30 specimens
at 50 measurements per specimen to produce reliable results.
In this study, 32 measurements were made for each crown, and
2560 in total for all 80 crowns. The mean for each group was
derived from a total of 120 measurements for the marginal and
axial gaps and 80 measurements for the occlusal gap.
This study had several limitations. Ten patients were included
in this study, similar to a previous report.18 However, increasing
the number of patients would increase the value and relevance
of the findings. Also, the quality of the crowns with regard
to the proximal, occlusal, and shade reproductions were not
investigated due to the time limitation of the clinical set-up.
Furthermore, the effect of variations in marginal and internal
discrepancy on the strength of the crown was not studied. These
are recommendations for further studies.
Conclusions
1. The type of the crown (namely, metal, zirconia, or lithium
disilicate) had no effect on the marginal and internal gaps
of single posterior crowns.
2. The method of manufacturing of different single poste-
rior crowns had no effect on the marginal and occlusal
gaps.
3. The digital method produced the smallest axial fit in
comparison with the conventional and cast digitization
methods.
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