RESEARCH AND EDUCATION

Evaluation of the marginal and internal gaps of partially crystallized

versus fully crystallized zirconia-reinforced lithium silicate CAD-CAM
crowns: An in vitro comparison of the silicone replica technique,
direct view, and 3-dimensional superimposition analysis
Alaa El-Ashkar, BDS, MS,a Maha Taymour, BDS, PhD,b and Adel El-Tannir, BDS, MSDc

Zirconia-reinforced lithium ABSTRACT

silicate ceramics (ZLS) are
innovative glass-ceramics with
zirconia additions (z10% by
weight). The inclusion of zir-
conia in an ultrafine micro-
structure has been reported to
provide higher edge stability
during the milling process
than lithium disilicate.1-4
Zirconia-reinforced lithium
silicate ceramic computer-
aided design and computer-
aided manufactured (CAD-
CAM) blocks have been
developed as 2 products: VITA
SUPRINITY, which requires
crystallization to reach its
maximum mechanical and
optical properties, and CEL-
TRA DUO, which can be pol-
ished or glazed before
cementation without a crys-
tallization cycle.1-4
The lithium disilicate crys-
tallization process results in a
0.2% densification of the ma-
terial at 840  C.5,6 The mar-
ginal fit and adaptation affect
Statement of problem. The crystallization process of lithium disilicate crowns has been reported to
cause dimensional change, but whether the fit of chairside computer-aided design and computer-
aided manufactured (CAD-CAM) zirconia-reinforced lithium silicate crowns is affected is unclear.
Purpose. The purpose of this in vitro study was to evaluate with a 3-dimensional superimposition
analysis technique the marginal and internal adaptation of fully crystallized versus partially
crystallized zirconia-reinforced lithium silicate ceramic CAD-CAM fabricated crowns. Additionally,
the silicone replica technique and direct viewing of marginal gap values were compared with
the 3-dimensional superimposition analysis technique.
Material and methods. The marginal and internal adaptation of a fully crystallized zirconia-reinforced
lithium silicate (CELTRA DUO) were compared with those of a partially crystallized zirconia-reinforced
lithium silicate (VITA SUPRINITY) after crystallization. Sixteen crowns (n=8) were fabricated with a
chairside CAD-CAM system. The crowns and die and crown assembly were scanned with an optical
scanner for the 3-dimensional superimposition analysis. Four hundred sixty-eight measurements
were made for each crown, 78 in each 2-dimensional section. Marginal discrepancy was measured
by using the direct viewing technique. The internal adaptation of the shoulder area, axial space, and
occlusal space was measured by using the silicone replica technique. Both gap values were
compared with the 3-dimensional superimposition analysis results by using the independent t test.
The 2-way ANOVA was used to detect the effect of each variable (group and site) (a=.05).
Results. The VITA SUPRINITY crowns showed statistically higher marginal discrepancy values than the
CELTRA DUO crowns in both 3-dimensional superimposition analysis and the direct viewing method,
and the lingual aspect recorded the highest marginal discrepancy mean value when compared with
other aspects. The 3-dimensional superimposition analysis and the direct viewing method were
statistically similar (P=.076). The VITA SUPRINTY crowns showed higher internal gap mean values than
the CELTRA DUO crowns in both 3-dimensional superimposition analysis and silicone replica
techniques. The occlusal space recorded the highest mean value in both groups. Assessment by 3-
dimensional superimposition analysis and silicone replica techniques showed statistical difference in
internal gap values (P=.04).
Conclusions. CELTRA DUO showed better precision fit values than VITA SUPRINITY. Three-
dimensional superimposition analysis is a reliable method of evaluating marginal and internal
adaptation. (J Prosthet Dent 2021;-:---)

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Researcher, Faculty of Dentistry, Cairo University, Cairo, Egypt.
b
Assistant Professor, Fixed Prosthodontics Department, Faculty of Dentistry, Cairo University, Cairo, Egypt.
c
Professor, Fixed Prosthodontics Department, Faculty of Dentistry, Cairo University, Cairo, Egypt.

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determining the most appropriate cement space.

Clinical Implications A 3-dimensional triple-scan methodology pilot experi-
Clinical success and longevity rely on the best ment was carried out for the internal and vertical mar-
ginal gap measurements by using 1 crown from each ZLS
possible adaptation of the dental prosthesis.
type. For the 3DSA pilot testing, the method was
Accurate CAD-CAM restorations can be fabricated
compared with the silicone replica technique (SRT) and
from fully crystallized CELTRA DUO zirconia-
with the direct viewing of margins (DV) under a stereo-
reinforced lithium silicate blocks.
microscope, showing similar values. An additional pilot
study was carried out to evaluate the effect of the crys-
tallization process on both adaptation values with VITA
the survival rate of crowns, with poor marginal adapta-
SUPRINITY crowns (Fig. 1).
tion in affecting the longevity of fixed prostheses.5 The
The tested groups were according to the type of
marginal gap of lithium disilicate ceramics has been re-
material: group V, VITA SUPRINITY; and group C,
ported to be affected by crystallization.5 Majeed and Al-
CELTRA DUO. Considering that 468 measurements
Adel7 evaluated the marginal and internal adaptations of
would be made on each crown, the total of 16 crowns
lithium disilicate and VITA SUPRINITY, zirconia, and
was based on a power test calculation.5 The sample size
polymer-infiltrated ceramic network crowns, with VITA
(n=8) was sufficient to detect large effect sizes for main
SUPRINITY and lithium disilicate having the highest
effects and pair-wise comparisons, with a power of 80%
total gap values. Zimmermann et al8 tested the effect of
and a 95% confidence level.
postmilling glazing on the internal adaptation of CEL-
A typodont mandibular first molar (Frasaco) was
TRA DUO crowns and concluded that it had no effect on
prepared according to a conventional ceramic tooth
the internal adaptation values. However, information
preparation13 with a 1.2-mm circumferential rounded
regarding the effect of the crystallization process on the
shoulder finish line, an internal angle of 122 degrees, a 2-
fit of ZLS restorations is scarce.9
mm occlusal reduction, and a mean of 7.9 degrees of
In 2010, a measuring method was introduced by
convergence of the axial walls. The total convergence
Holst et al,10 who applied a triple scan protocol to
angle and the finish line angle were measured with a
evaluate the precision of fit of CAD-CAM implant su-
software program (AutoCAD 2017 Software; Autodesk
perstructures. In 2011, Holst et al11 reapplied the
Inc). The prepared typodont tooth was replicated in an
3-dimensional methodology to evaluate crown fit and
autopolymerizing resin (DuraLay; Reliance Dental
marginal adaptation to provide 3-dimensional informa-
Manufacturing LLC) master die, invested (BellaVest SH;
tion for the virtual registration of a digitized crown in
BEGO), and cast (Wiron Light, NiCr ingots; BEGO & Co)
relation to the abutment. The silicone replica technique
to form a Ni-Cr metal die. The metal die was finished,
has been commonly used because of its ability to mea-
polished, and examined for imperfections by the same
sure the internal adaptation of a dental prosthesis
investigator (A.T.) using magnifying loops (Designs for
without damaging the specimen tested.7,12 However, the
Vision, Inc).13,14
accuracy of measurements with the silicone replica
To enhance the precision of the optical scan, the
technique is unclear, and studies comparing the accuracy
master Ni-Cr metal die was sprayed (CEREC Optispray;
of the silicone replica technique with 2-dimensional
Dentsply Sirona) and scanned with a noncontact
sections of 3-dimensional superimposition analysis
extraoral scanner (3Shape D500 3D Scanner; 3Shape A/
(3DSA) are scarce.
S). A biogeneric crown design was generated by using a
The purpose of this in vitro study was to evaluate the
software program (inLab SW15.0; Dentsply Sirona) with
marginal and internal adaptation of CELTRA DUO
the cement space set at 50 mm for the axial and occlusal
versus VITA SUPRINITY zirconia-reinforced lithium sil-
aspects based on the pilot data.14,15 The crowns were
icate ceramic CAD-CAM crowns after crystallization by
milled with a 5-axis milling machine (inLab MC X5 five-
using the direct viewing method for vertical margin
axis milling unit; Dentsply Sirona).
assessment, the silicone replica technique for internal fit
The postmilling crystallization protocol of the VITA
assessment, and the 3-dimensional superimposition
SUPRINITY crowns (VITA Zahnfabrik) followed the
analysis technique. The null hypothesis was that the in-
manufacturer recommendations. The milled fully crys-
ternal and marginal gaps would not differ significantly
tallized CELTRA DUO (Dentsply Sirona) crowns were
between the materials or among the measurement
polished but did not receive a postmilling crystallization
methods.
or glazing cycle. All crowns were sealed in opaque en-
velopes that were then randomly numbered (www.
MATERIAL AND METHODS
random.org).
An appropriate methodology was developed after pilot For assessment of the vertical marginal gaps with
testing including with the 3DSA technique and for direct viewing, each crown was secured on the master

THE JOURNAL OF PROSTHETIC DENTISTRY El-Ashkar et al

- 2021
Figure 1. Vertical marginal gap values of VITA SUPRINITY. A, Before crystallization. B, After crystallization. Original magnification ×45.
Figure 2. Vertical marginal gap values. A, VITA SUPRINITY. B, CELTRA DUO.
Ni-Cr metal die by using a custom holding device.
Measurements were made with a stereomicroscope
(Eclipse E600; Nikon Instruments Inc) at ×45 magnifi-
cation.16 Three equidistant landmarks were measured
along the cervical circumference of each of the mesial,
buccal, distal, and lingual surfaces (Fig. 2).16
The silicone replica technique method was used to
measure the internal adaptation.16,17 The intaglio replicas
were made of light-body silicone impression material
(Elite HD+, light body, fast set; Zhermack GmbH) and
heavy-body silicone (Elite HD+, heavy body, fast set;
Zhermack GmbH). The replicas were sectioned into 4
equal segments in the mesiodistal and buccolingual di-
rections on a custom-made device (Fig. 3). Five points in
3 regions were measured on each section: shoulder area,
axial space, and occlusal space, yielding 13 internal
measurements for each crown (Fig. 4).9,17
For the 3DSA method, the 16 crowns were seated on
the master Ni-Cr metal die, scanned consecutively with
El-Ashkar et al
3
a noncontact optical scanner (3Shape D500 3D Scan-
ner; 3Shape, A/S), and saved as “The Reference STL”
files. The intaglio surfaces of the crowns were scanned
and saved according to their envelope number.10,11,18,19
The master Ni-Cr metal die scan was used as the third
scan. The alignment transformation of the standard
tessellation language (STL) files was performed with a
3D inspection software program (Solidworks premium
2017; Dassault Systèmes SE). The alignment trans-
formation of the STL files was performed on the x, y,
and z axis planes to be compared and stitched together
to achieve a uniform merge of the 3 scans. Manual
alignment-transformation of the scan data was per-
formed by selecting point-to-point or by using a
manipulator.17,18 The auto-alignment function pro-
duced malposition scans. The resultant combined 3D
image was sectioned in 2 directions, buccolingual and
mesiodistal, to verify the accuracy alignment trans-
formation procedure (Fig. 5).11,17
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Figure 3. Silicone replica sectioned into 4 segments on custom-made device. Original magnification ×45.

The vertical gap between the external region of the

master Ni-Cr metal die scan and the internal region of
the crown was extracted from the 3D image and cut in
the buccolingual and mesiodistal directions by means
of the multiple section function. The cut sections were
reproducible, standardized, and equidistant at 2 mm
apart (Fig. 6). The extracted gap layer was converted into
a solid body 3D layer, and the marginal and internal gaps
were measured by applying the 2D section (Figs. 6, 7). An
average of 78 points were measured in each section, 468
measurements of each specimen. The average of all
measured points was used in the statistical analysis.
Descriptive statistics were used for the results of each
group. Two-way ANOVA was used to detect the effect of
each variable (group and site) with the average mea-
surement values used. An independent t test determined
whether the vertical marginal gap differed between the 2 Figure 4. Internal gap values measured from silicone replica. A, VITA
methods (3DSA and direct viewing technique). The t test SUPRINITY. B, CELTRA DUO. Original magnification ×45.
also evaluated the internal gap difference between the 2
methods (3DSA and silicone replica methods) (a=.05). (98.9 ±18.4 mm) and the direct viewing technique (98.7
±13.1 mm) were statistically similar (P=.076).
In the internal gap 3DSA evaluations, VITA SUPRIN-
RESULTS
ITY recorded a higher mean ±standard deviation internal
With 3DSA, VITA SUPRINITY recorded a higher mar- gap value (120.2 ±23.0 mm) than CELTRA DUO (95.8 ±9.1
ginal gap mean ±standard deviation value (110.6 ±3.7 mm) (P=.009) (Table 2, Fig. 8) (a=.05). With the silicone
mm) than CELTRA DUO (83.7 ±1.0 mm) (Fig. 8) (P<.001). replica technique, VITA SUPRINITY recorded a statistically
Similarly, with the direct viewing method, VITA SU- similar internal gap mean ±standard deviation value
PRINITY recorded a higher marginal gap mean ±stan- (133.8 ±35.8 mm) to CELTRA DUO (119.4 ±19.3 mm)
dard deviation value (99.5 ±6.7 mm) than CELTRA DUO (P=.241) (Table 2, Fig. 4). For the mean internal gap values
(85.9 ±3.8 mm) (P<.001) (Table 1, Fig. 2). The marginal between the 3DSA and the silicone replica technique, the t
gap mean ±standard deviation values between 3DSA test was statistically different (P=.042). The occlusal space

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- 2021 5

Figure 5. A, Buccolingual section showing alignment-transformation process. B, Gap layer extracted and converted into solid layer.

Figure 6. Three-dimensional gap model sectioned in 3 equidistant buccolingual sections and 3 mesiodistal sections with multiple section function. S, Q,
R: buccolingual cut sections with standard 2-mm distance between each. J, L, N: mesiodistal cut sections. J, first cut at 2-mm distance from surface; L, 4-
mm cut; N, 6-mm cut.

recorded the highest gap mean value in both methods,
124.5 ±34.6 mm with the 3DSA and 140.8 ±33.6 mm with
the silicone replica technique.
DISCUSSION
The popularity of CAD-CAM fabricated restorations has
increased recently, and contemporary CAD-CAM
ceramic crowns have marginal and internal adaptation
values within a clinically acceptable range.5,12 Studies on
the influence of the cement space and finish line
configuration have been inconsistent. Rustum et al20
reported that increasing the virtual cement space value
improved marginal fit. In the present study, the axial and
occlusal cement spaces were set at 50 mm based on the
pilot study and on the work of Kale et al,15 Soliman
et al,21 and Mously et al.22 The finish line design used in
the present study was a circumferential rounded shoulder
with an internal angle of 122 degrees, consistent with the
findings of Al-Zubaidi and Al-Shamma23 and Podhorsky
et al,24 who reported that a 120-degree shoulder
improved seating with a reduced vertical marginal gap.
The 122-degree shoulder finish line also facilitated
detection by the scanning devices better than the 90-
degree shoulder finish line.
Despite its established reliability, studies that
compared the accuracy of 3DSA to that of other evalu-
ation methods are sparse.10,25,26 The present research
used the 2D section of the 3DSA, consistent with the
triple scan protocol described by Holst et al10,11 and
applied by Zimmermann et al,8 Boitelle et al,18 and
Anadioti et al27 to evaluate the 2D and 3D marginal fit of

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Figure 7. Internal and marginal gap measurements of 2-dimensional section.

Figure 8. Three-dimensional superimposition analysis of internal and marginal gap values. A, VITA SUPRINITY. B, CELTRA DUO.

pressed and CAD-CAM-fabricated lithium disilicate
crowns, validating the 3DSA protocol for evaluating both
the marginal and internal fit of ceramic crowns. Nawafleh
et al16 recommended the direct view method as the most
frequently used one, a noninvasive method with repro-
ducible results for measuring the vertical marginal gap.
Unlike the cross-sectioning method, the silicone replica
technique replicates the complete cement space without
destroying the specimen.16,25 In the present study, the
silicone replica technique was preferred over the cross-
sectioning technique, as similar accuracy has been
reported.7,26
In the present study, CELTRA DUO showed better
marginal and internal adaptations values than VITA
SUPRINITY in all the tested specimens and methods.
Therefore, the null hypothesis was rejected. The values
were consistent with those found by Kim et al,5 Azarbal
et al,28 Yildirim et al,29 and Ural et al.30 The lingual
surface recorded the highest vertical marginal gap mean
value in all specimens. The total surface values were not
consistent with those reported by Asavapanumas and
Leevailoj,31 probably because different preparation de-
signs and marginal gap measuring methods were used.
Differences may have been associated with the brittle-
ness of the precrystallized state of VITA SUPRINITY and
its weak crystal structure, which may fracture during the
milling process.29-32
The difference between the CELTRA DUO and VITA
SUPRINITY adaptation values might be linked to the
crystallization shrinkage in the partially crystallized ZLS,
as only the VITA SUPRINITY crowns received the crys-
tallization cycle. Densification shrinkage has been

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Table 1. Descriptive statistics of 3-dimensional superimposition analysis Table 2. Descriptive statistics of 3-dimensional superimposition analysis
marginal gap results and direct viewing method marginal gap results and silicone replica technique internal gap results (mean ±standard
(mean ±standard deviation) deviation)
95% CI 95% CI
Mean ±SD Mean ±SD
Variable (mm) Min. Max. Low High P Variable (mm) Min. Max. Low High P
3-Dimensional VITA 110.6 ±3.7 105.4 116.4 109.0 112.2 <.001 3-Dimensional VITA 120.2 ±23.0 91.4 184.3 93.8 146.6 .009
superimposition SUPRINITY superimposition SUPRINITY
analysis CELTRA DUO 83.7 ±1.0 81.2 88.0 82.9 84.6 analysis CELTRA DUO 95.8 ±9.1 69.7 123.9 83.5 108.2
Direct viewing VITA 99.5 ±6.7 90.7 111.3 92.6 105.1 <.001 Silicone replica VITA 133.8 ±35.8 107.6 210.8 103.8 163.8 .241
method SUPRINITY technique SUPRINITY
CELTRA DUO 85.9 ±3.8 79.1 95.8 82.3 90.1 CELTRA DUO 119.4 ±19.3 82.8 151.2 103.2 135.5

CI, confidence interval; Max, maximum; Min, minimum; SD, standard deviation. CI, confidence interval; Max, maximum; Min, minimum; SD, standard deviation.

correlated with the higher marginal discrepancies of the
partially crystallized ZLS group compared with the fully
crystallized ZLS group. Ritzberger et al33 stated that zir-
conia acts as a nucleating agent, controls the internal
nucleation, and influences the crystallization by
hampering crystal growth. With increasing ZrO2 content,
the lithium silicate and meta-silicate crystals become
smaller, and the densification increases with a reduction in
particle size for close packed arrangement.7,34-36 There-
fore, the densification shrinkage of ZLS is controlled and
has minimal effect because of its microstructure.37
Consistent with Yildirim et al,29 the adaptation of VITA
was better than that of lithium disilicate because of zir-
conia particles in the microstructure. Similarly, Kim et al5
reported variation in the marginal and internal fit of
lithium disilicate ceramic crowns before and after the
crystallization process in all the measured areas. Gold
et al6 and Azarbal et al28 suggested that the densification
shrinkage of the glass matrix ceramic during the crystal-
lization process might cause an increase in the gap size.
The occlusal region recorded the highest internal gap
value when measured by both the silicone replica and
3DSA methods. The increased gap could have been
related to the scanner accuracy, the STL format conver-
sion, or the application of powder. These errors were
minimized by standardizing the die scan: A single die
scan was used in both the crown fabrication and in the
3DSA, and powder was used to minimize the scanning
errors and eliminate variables. The obtained values were
consistent with those reported by Park et al,12
Boitelle et al,18 Yildirim et al,29 and Anadioti et al.38
The 3DSA method showed lower values than the sili-
cone replica technique, possibly because the light-body
impression material might elevate the crown slightly
and increase the internal gap values. With the 3DSA and
the direct viewing methods, the cement space was not
occupied. Also, with the silicone replica technique,
selecting the same exact point in the 3D section and the
equivalent point in the replica can be problematic.16
Thus, the comparison would have been more reliable
if the measurements had been made at the same exact
sites for each method. However, this was extremely
difficult to achieve and was a limitation of the present
study. Further investigations are required to understand
the influence of the preparation design, digital design
settings, software program version, cement space, and
milling parameter variations on the accuracy of CAD-
CAM restorations.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. CELTRA DUO had better precision fit than VITA
SUPRINITY, with significant differences in marginal
and internal discrepancies. All values were within a
clinically acceptable range.
2. After their crystallization cycle, the effect of the
crystallization process was evident in the VITA
SUPRINITY crowns. The densification shrinkage
during the crystallization process affected the mar-
ginal and internal adaptation of the VITA
SUPRINITY crowns.
3. The 3-dimensional superimposition methodology is
a reliable and valid method for assessing the
adaptation values of dental restorations.
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Corresponding author:
Dr Alaa El-Ashkar
Department of Fixed Prosthodontics
Cairo University
1 El-Saraya St, Cairo
EGYPT.
Email: alaas.elashkar@dentistry.cu.edu.eg
Acknowledgments
The authors thank Dr Omnia Nabil for her contribution in the 3D superimposition
analysis method and for her assistance in this article.
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.07.024
El-Ashkar et al