Journal of Dentistry 113 (2021) 103792

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Full length article

Trueness and precision of 3D-printed versus milled monolithic zirconia

crowns: An in vitro study
Henriette Lerner a, Katalin Nagy a, Nicola Pranno b, Fernando Zarone c, Oleg Admakin d,
Francesco Mangano d, *
a
Department of Oral Surgery, University of Szeged, Szeged, Hungary
b
Department of Oral and Maxillofacial Sciences, Sapienza University, Rome, Italy
c
Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
d
Department of Pediatric, Preventive Dentistry and Orthodontics, Sechenov First State Medical University, Moscow, Russia

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To compare the trueness and precision of 3D-printed versus milled monolithic zirconia crowns (MZCs).
Monolithic zirconia crowns Methods: A model of a maxilla with a prepared premolar was scanned with an industrial scanner (ATOSQ®, Gom)
3D printing and an MZC was designed in computer-assisted-design (CAD) software (DentalCad®, Exocad). From that stan­
Milling
dard tessellation language (STL) file, 10 MZCs (test) were 3D-printed with a Lithography-based Ceramic
Trueness
Clinical precision
Manufacturing (LCM) printer (CerafabS65®, Lithoz) and 10 MZCs (control) were milled using a 5-axis machine
(DWX-52D®, DGShape). All MZCs were sintered and scanned with the aforementioned scanner. The surface data
of each sample (overall crown, marginal area, occlusal surface) were superimposed to the original CAD file
(ControlX®, Geomagic) to evaluate trueness: (90-10)/2, absolute average (ABS AVG) and root mean square
(RMS) values were obtained for test and control groups (MathLab®, Mathworks) and used for analysis. Finally,
the clinical precision (marginal adaptation, interproximal contacts) of test and control MZCs was investigated on a
split-cast model printed (Solflex350®, Voco) from the CAD project, and compared.
Results: The milled MZCs had a significantly higher trueness than the 3D-printed ones, overall [(90-10)/2 printed
37.8 µm vs milled 21.2 µm; ABS AVG printed 27.2 µm vs milled 15.1 µm; RMS printed 33.2 µm vs milled 20.5 µm;
p = 0.000005], at the margins [(90-10)/2 printed 25.6 µm vs milled 12.4 µm; ABS AVG printed 17.8 µm vs milled
9.4 µm; RMS printed 22.8 µm vs milled 15.6 µm; p= 0.000011] and at the occlusal level [(90-10)/2 printed
50.4 µm vs milled 21.9 µm; ABS AVG printed 29.6 µm vs milled 14.7 µm; RMS printed 38.9 µm vs milled 22.5 µm;
p = 0.000005]. However, with regard to precision, both test and control groups scored highly, with no significant
difference either in the quality of interproximal contact points (p = 0.355) or marginal closure (p = 0.355).
Conclusions: Milled MZCs had a statistically higher trueness than 3D-printed ones; all crowns, however, showed
high precision, compatible with the clinical use.
Clinical significance: Although milled MZCs remain more accurate than 3D-printed ones, the LCM technique seems
able to guarantee the production of clinically precise zirconia crowns.

Abbreviations: MZC, Monolithic zirconia crown; CAD, computer-assisted-design; STL, standard tessellation language; LCM, Lithography-based Ceramic
Manufacturing; ABS AVG, absolute average; RMS, root mean square; CNC, computer numerical controlled; AM, additive manufacturing; SLA, stereolithography; DLP,
digital light processing; FDM, fused deposition modeling; SLS, selective laser sintering; SLM, selective laser melting; CI, confidence interval; RICP, robust iterative
closest point; SD, standard deviation; MD, mean difference; SRT, silicone replica technique; CSM, cross sectional method; TSM, triple scan method; MCT, micro
computed tomography; OCT, optical coherence tomography.
* Corresponding author: Department of Pediatric, Preventive Dentistry and Orthodontics, , Sechenov First State Medical University, Bol’shaya Pirogovskaya Ulitsa,
19c1 Moscow, Russia.
E-mail addresses: h-lerner@web.de (H. Lerner), katalin.nagy@universityszeged.com (K. Nagy), nicola.pranno@uniroma1.it (N. Pranno), fernandozarone@mac.
com (F. Zarone), admakin1966@mail.ru (O. Admakin), francescoguidomangano@gmail.com (F. Mangano).

https://doi.org/10.1016/j.jdent.2021.103792
Received 30 July 2021; Received in revised form 14 August 2021; Accepted 18 August 2021
Available online 2 September 2021
0300-5712/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
H. Lerner et al.
1. Introduction
Monolithic zirconia restorations manufactured by means of sub­
tractive methods (milling) represents a reliable treatment option in
modern prosthetic dentistry, as demonstrated in several clinical studies
[1–7].
However, milling has some limitations, such as the considerable
amount of raw material that is wasted (the material used for the supports
and remnants of milled discs, which cannot be re-used). During milling,
the burs are subject to abrasive wear, particularly when fully sintered
ceramic material blocks are milled [8]. These blocks are dimensionally
stable, but their milling can generate microcracks on the surface of the
ceramic, which can compromise the longevity of the restoration [8,9]. A
valid alternative is provided by using pre-sintered blocks or discs. The
use of these more workable materials does not damage the burs; how­
ever, the restorations are subject to dimensional changes after sintering,
which may partially affect the accuracy [8]. Finally, with milling, the
reproduction of surface geometry is dictated by the size of the milling
burs, and the number of working axes of the computer numerical control
(CNC) machine; therefore, in some applications (such as the milling of
individual zirconia abutments), milling suffers from a limited ability to
access smaller hollow areas and/or by-pass undercuts [8].
Modern additive manufacturing (AM) or 3D printing techniques
promise to solve these problems [8,10,11]. AM is now used by pros­
thodontists worldwide, for the fabrication of parts in resin (such as
models [12,13], interim restorations [14], denture bases [15]) and in
metal [16]. 3D printing allows the manufacture of extremely complex
objects, hollow inside or with a gradient of material, without the limi­
tations associated with other tools used for the classic molding, casting,
and milling techniques [8,10,11,16]. Furthermore, 3D printing elimi­
nates the waste of material, potentially reducing working time [8,11,
16].
Recently, technological evolution has paved the way for 3D printing
of zirconia [17–19]. Several printing technologies have been employed
to 3D print ceramics, including vat photopolymerization (stereo­
lithography [SLA], digital light processing [DLP]) [20–23], direct inject
printing [24,25], robocasting [26], fused deposition modeling (FDM)
[27], selective laser sintering (SLS) and selective laser melting (SLM)
technologies, direct energy deposition [28], sheet lamination, binder
jetting [29].
To date, however, few studies have addressed the topic of 3D-printed
zirconia prosthetic restorations [17,19,30–36]. As a result, some prob­
lems remain unsolved, such as porosity control [8,30], mechanical
reliability [31–33], sintering distortion, dimensional accuracy, and
staircase surface effects [34–36].
In particular, there are very few studies in the literature about the
accuracy of 3D-printed zirconia crowns [34–36]. One study has found
acceptable trueness [35], but another has reported poor accuracy of the
crowns, particularly regarding marginal tolerance, fit and prosthetic
adaptation [36]. It is therefore still unclear whether zirconia crowns
produced with 3D printing can be considered to be as accurate as those
milled with conventional methods [17,19,34–36].
Hence, the aim of this in vitro study was to compare the trueness and
precision of 3D-printed versus milled monolithic zirconia crowns
(MZCs). In particular, the study aimed to compare the trueness (i.e., the
correspondence between the printed/milled crowns and the reference
CAD file, evaluated by industrial optical scanning) and the clinical
precision (i.e., the marginal fit and quality of interproximal contacts,
inspected on the model) of MZCs obtained through two different pro­
duction processes, namely 3D printing (test group) versus milling (control
group).
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Journal of Dentistry 113 (2021) 103792
2. Materials and methods
2.1. Study design
A gypsum reference model of a dentate maxilla with a prepared tooth
(left first premolar) (Fig. 1) with 90◦ shoulder preparation, was scanned
with an industrial optical scanner (ATOS Q®, Gom GmbH, Braunsch­
weig, Germany) (Fig. 2). The standard tessellation language (STL) file of
this 3D acquisition (Fig. 3) was used to design a split-cast model (Fig. 4A,
B) and a monolithic crown (Fig. 5A,B,C), in computer-assisted-design
(CAD) software (DentalCad®, Exocad, Darmstadt, Germany). The
crown was designed for production in zirconia. The CAD file of this
crown (labeled as “reference crown”), saved in STL, was then printed with
a Lithography-based Ceramic Manufacturing (LCM) printer (Cerafab
S65®, Lithoz, Vienna, Austria). In total, 10 crowns (test group) were
printed and sintered in full accordance with the manufacturer’s in­
structions, and were ready for analysis. For the control group, the
“reference crown” STL file was milled with a 5-axis milling machine
(DWX-52D®, DGShape, a Roland Company, Hamamatsu, Japan). In
detail, 10 crowns (control group) were milled, sintered following the
manufacturer’s instructions, and were ready for inspection. The 10
crowns of the test group and the 10 crowns of the control group (Fig. 6)
were then scanned with the same aforementioned industrial optical
scanner (ATOS Q®). Each crown was scanned when seated on the
gypsum model, but also when free in space, in order that the entire
anatomy (external and internal surfaces) was captured. The STL files (10
per group) derived from these optical scans were then compared with
the reference CAD modeling file (“reference crown”), to evaluate true­
ness, using reverse engineering software (Control X®, Geomagic, Mor­
risville, NC, USA). Three sequences of superimpositions were performed.
First, the CAD file of the modeled crown used as a reference (“reference
crown”) was superimposed on each scan of the 3D-printed and milled
crowns, for the evaluation of the overall trueness of the crown surface.
Then, the reference CAD file was cut with dedicated tools to isolate, and
select exclusively, first the surface of the margins (“reference marginal”)
and then the external occlusal surface (“reference occlusal”). These sec­
tions were subsequently used as references and superimposed on the
scans of each individual test and control crown, for evaluation of mar­
ginal and occlusal trueness respectively (Fig. 7). All superimpositions
were performed inside the aforementioned software, where colorimetric
maps were generated (Figs. 8–11). Then, a Mathlab user-code script
(MathLab®, Mathworks) was developed to process the distance gaps
exported from this reverse engineering software, in a .CSV format. Using
Fig. 1. A gypsum model of a dentate maxilla with a prepared tooth (left first
premolar) served as reference for this study.
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 2. The industrial structured light scanner (ATOS Q®, Gom GmbH, Braunschweig, Germany) used in this study meets high metrological requirements, as it
incorporates technology features such as the Triple Scan PrincipleTM, Blue Light EqualizerTM and precise calibration as a self-monitoring system with active tem­
perature management. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Mathlab®, the main outcome variables, i.e., the trueness of:

i the entire crown surface;

ii the marginal areas;
iii the occlusal surface;

of the MZCs were computed, and expressed as:

i Absolute average (ABS AVG);

ii Root mean square (RMS);
iii (90˚− 10˚)/2 (where 90˚ is the 90th percentile and 10˚ is the 10th
percentile).

After having completed the trueness evaluation, the removable dies

Fig. 3. The standard tessellation language (STL) file of the reference model
acquired with the industrial optical scanner.
of the original CAD model on which the crown was designed, together
with the model itself, were 3D-printed with a DLP printer (Solflex 350®,
Voco, Cuxhaven, Germany). In all, 20 copies of the removable dies and a
copy of the model were printed (Fig. 12)—being useful for verifying the
clinical precision of each of the test and control MZCs, i.e., the quality of
the interproximal contact points, as well as the marginal adaptation.
This evaluation was made by two different experienced calibrated
prosthodontists using magnifying glasses (4.5x, Zeiss, Oberkochen,
Germany). For each of the outcome variables (interproximal contacts,
marginal closure) the two clinicians could express themselves in a vote
that described the anatomical quality of the restorations. The grades that
each clinician could assign were 5 (Excellent), 4 (Good), 3 (Sufficient), 2

Fig. 4. A split-cast model was designed in a computer-assisted-design/ computer-assisted manufacturing (CAD) software (DentalCad®, Exocad, Darmstadt, Ger­
many). A. Details of the removable die in position; B. The removable die free in the space.

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H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 5. A monolithic single crown was designed in a computer-assisted-design (CAD) software (DentalCad®, Exocad, Darmstadt, Germany). The crown was designed
for production in zirconia. A. Occlusal view; B. Prospective view; C. View of the margins of the crown.

Fig. 6. Details of the 3D-printed and milled

monolithic zirconia crowns (MZCs). In total, 20
samples were manufactured. Ten MZCs (test
group, left of the picture) were 3D printed with
a lithography-based ceramic manufacturing
(LCM) printer (Cerafab S65®, Lithoz, Vienna,
Austria), and other 10 MZCs (control group,
right of the picture) were milled with a 5-axis
milling machine (DWX-52D®, DGShape, a
Roland Company, Hamamatsu, Japan). All
crowns were sintered following the manufac­
turer’s recommendation, and were ready for
analysis. Different colors were used in order to
facilitate the allocation of the samples in the
correct group, eliminating any risk of confu­
sion. (For interpretation of the references to
color in this figure legend, the reader is referred
to the web version of this article.)

Fig. 7. The STL files of the target models (20 in total, 10 per group) were compared with the reference CAD modeling file (“reference crown”), to evaluate trueness,
using a reverse engineering software (Control X®, Geomagic, Morrisville, NC, USA). Three sequences of superimpositions were performed. First, the CAD file of the
modeled crown used as a reference ("reference all crown") was superimposed on each scan of the 3D-printed and milled crowns, for the evaluation of the overall
trueness of the crown surface. Then, the reference CAD file was cut with dedicated tools, in order to select exclusively the occlusal surface (“reference occlusal”), and
the surface of the margins (“reference marginal”). These sections were subsequently used as references, and superimposed on the scans of each individual test and
control crown, for evaluation of the occlusal and marginal trueness, respectively.

(Insufficient) and 1 (Very poor). All collected trueness and precision
data were collected in dedicated electronic spreadsheets (Excel®,
Microsoft, Redmond, WA, USA) and were ready for statistical analysis.
2.2. Lithography-based ceramic manufacturing (LCM)
The Lithography-based Ceramic Manufacturing (LCM) process
developed by Lithoz (Vienna, Austria) is based on the layer-by-layer
curing of a ceramic suspension using visible (blue) light. The ceramic

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H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 8. Details of the colorimetric map generated in the reverse engineering software (Control X®, Geomagic, Morrisville, NC, USA) for the occlusal surface eval­
uation of the ten 3D-printed crowns (test group). For the occlusal evaluation, the same setting was used for all models, with the color scale ranging from a maximum
deviation of +200 μm to -200 μm, and the best result given by the deviations between +50 μm and -50 μm. The generated color map indicated an outward (red) or
inward (blue) deviation between the overlaid structures, while a minimal displacement (<50 μm) was indicated by green color. (For interpretation of the references
to color in this figure legend, the reader is referred to the web version of this article.)

Fig. 9. Details of the colorimetric map generated in the reverse engineering software (Control X®, Geomagic, Morrisville, NC, USA) for the occlusal surface eval­
uation of the ten milled crowns (control group). For the occlusal evaluation, the same setting was used for all models, with the color scale ranging from a maximum
deviation of +200 μm to -200 μm, and the best result given by the deviations between +50 μm and -50 μm. The generated color map indicated an outward (red) or
inward (blue) deviation between the overlaid structures, while a minimal displacement (<50 μm) was indicated by green color. (For interpretation of the references
to color in this figure legend, the reader is referred to the web version of this article.)

suspensions consist of photocurable resins, the respective ceramic
powder (e.g., zirconia) and additives for optimal processability. The
CAD file (STL-format) of the crown was split in layers by the computer
and projected, layer by layer, onto a ceramic suspension, which was
hardened/cured by photopolymerization, forming the so-called green
body. The green body consists of the shape-giving polymer and the
zirconia particles fixed within. In this study, all MZCs were fabricated
with a CeraFab System S65® Medical 3D printing system (Lithoz,
Vienna, Austria). CeraFab System S65® has a building envelope size of
102 × 64 mm. Parts up to a height of 320 mm can be printed with such
machines, so that up to 50 crowns can be printed simultaneously in the
same process. The lateral resolution of 40 µm and a variable layer height
between 10 and 100 µm allow for the fabrication of precision restora­
tions with minimal material consumption. The MZCs were produced
from the raw material LithaCon 3Y 210® (Lithoz, Vienna, Austria), a
ceramic suspension consisting of 3 mol% Yttria stabilized Zirconia (3-
TZP) ceramic powder. After 3D printing, the green bodies must undergo
post-treatment: they are cleaned of excess material with a cleaning fluid
(LithaSol 20®, Lithoz, Vienna, Austria) in specially developed cleaning
stations (CeraCleaning Station Ultra®, Lithoz, Vienna, Austria) and then
sintered to pure zirconium oxide in thermal post-processing. Sintering
was carried out in a LHTCT 08/16® furnace (Nabertherm, Lilienthal,
Germany) at temperatures of 1450 ◦ C with a dwell time of 2 h under
normal atmosphere (air) and without increased pressure. In this way, a
density of 99.4% is reached.
2.3. Trueness evaluation
The 3D comparisons were performed by means of reverse engi­
neering inspection software (Control X®, Geomagic, Morrisville, NC,
USA). Three comparison groups were identified to analyze the accuracy
of two different methods of fabrication. Simply put, three different se­
quences of superimpositions were performed inside the aforementioned
inspection software:

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H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 10. Details of the colorimetric map generated in the reverse engineering software (Control X®, Geomagic, Morrisville, NC, USA) for the margins surface
evaluation of the ten 3D-printed crowns (test group). For the margins surface evaluation, the same setting was used for all models, with the color scale ranging from a
maximum deviation of +50 μm to -50 μm, and the best result given by the deviations between +10 μm and -10 μm. The generated color map indicated an outward
(red) or inward (blue) deviation between the overlaid structures, while a minimal displacement (<10 μm) was indicated by green color. (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)

Fig. 11. Details of the colorimetric map generated in the reverse engineering software (Control X®, Geomagic, Morrisville, NC, USA) for the margins surface
evaluation of the ten milled crowns (control group). For the margins surface evaluation, the same setting was used for all models, with the color scale ranging from a
maximum deviation of +50 μm to -50 μm, and the best result given by the deviations between +10 μm and -10 μm. The generated color map indicated an outward
(red) or inward (blue) deviation between the overlaid structures, while a minimal displacement (<10 μm) was indicated by green color. (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)

i The superimposition of each scanned test and control MZC onto the
reference CAD file of the whole crown (“reference crown”), to eval­
uate the overall trueness of the 3D-printed and milled crowns;
ii The superimposition of each scanned test and control MZC onto the
reference CAD file of the occlusal surface of the crown (“reference
occlusal”), to evaluate the trueness of the occlusal surface of the 3D-
printed and milled crowns;
iii The superimposition of each scanned test and control MZC onto the
reference CAD file of the marginal surface of the crown (“reference
marginal”), to evaluate the trueness of the marginal surface of the 3D-
printed and milled crowns.

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H. Lerner et al.
Fig. 12. The original computer-assisted-design (CAD) model on which the crown was designed and the removable die were 3D-printed with a digital light processing
(DLP) printer (Solflex 350®, Voco, Cuxhaven, Germany). In total, 20 copies of the removable dies were printed. The model and the removable dies were printed to
assess the clinical precision of each of the test and control monolithic zirconia crown (MZC), through the inspection of the marginal adaptation, and the quality of the
occlusal and interproximal contact points.
Each of the reference models (“reference crown”, “reference occlusal”
and “reference marginal”) was compared with the corresponding 20
target models: 10 fabricated by means of a 3D printing procedure and 10
fabricated by means of a milling procedure.
The procedure employed for each sequence of the superimpositions
was as follows:
i The first step consisted in importing the .STL files in Geomagic
Control X®. All files were firstly processed to fill holes and to elim­
inate mesh problems. Subsequently the reference 3D model was set
as “reference data” and the target model was set as “measured data”;
ii The second step consisted in the alignment process based on the best-
fit robust-iterative-closest-point (RICP) alignment algorithm that
was preceded by a rough alignment that was necessary to perform an
accurate best-fit alignment. A minimum of 100 iterations were set
per case and the distances between the reference CAD models and the
scans of the MZCs were minimized using a point-to-plane method;
iii The third step consisted in setting the comparison parameters before
starting the 3D comparison procedure. In order to calculate the de­
viation value for every vertex in the measured data, the sampling
ratio was set to 100%. Each measured vertex was defined by a
measured position vector Pm m m m
i (xi , yi , zi ) which is associated with a
reference position vector Pri (xri , yri , zri ) with i = 1 to n, where n is the
total number of compared points. By evaluating the vectors that go
from Pmi to Pi the distance gap vector Di (xi − xi , yi − yi , zi − zi ) can
r m r m r m r
be determined. The gap vectors were finally converted in scalar form
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
Di = r 2 r 2 r 2
(xmi − xi ) + (yi − yi ) + (zi − zi ) representing the devia­
m m
tion value at any given point. The gap distance was given in negative
form when the measured point was on the negative side of the
reference data. The software was therefore able to compute, for each
point, the distances between the surfaces of the superimposed
models, and to generate a colorimetric map useful to quantify and
qualify the distances between specific points, overall and in all
planes. The settings for the color scale ranged from a maximum de­
viation of + 50 μm to - 50 μm, to a minimum deviation of + 10 μm
and - 10 μm. With these settings, the map indicated outward (red) or
inward (blue) deviations between the overlaid structures, while
minimal displacements were indicated as green. The data retrieved
from these superimpositions for each IOS were saved in specific
electronic datasheets (Excel®, Microsoft, Redmond, WA, USA) ready
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Journal of Dentistry 113 (2021) 103792
for analysis, whereas the visual screenshots derived from each single
registration were saved in another format (PowerPoint®, Microsoft,
Redmond, WA, USA);
iv The fourth step consisted in exporting the distance gap map in .CSV
format. In fact, since the set of statistics obtained as output in Geo­
magic Control X® is not satisfactory for our purposes, i.e., to
compute absolute average (ABS AVG), root mean square (RMS) and
(90˚− 10˚)/ 2 (where 90˚ is the 90th percentile and 10˚ is the 10th
percentile), a Mathlab user-code script (MathLab®, Mathworks) was
developed to post-process the distance gaps exported from this
reverse engineering software, in a .CSV format;
v The distance gaps were imported in Matlab environment in the form
of raw data that was firstly sorted from highest to lowest and then
processed to compute the following statistical parameters, which
were the trueness outcomes of this study: minimum distance,
maximum distance, average (AVG), absolute average (ABS AVG),
root mean square (RMS), standard deviation (SD), variance, positive
average (ABS +), negative average (ABS− ), and (90˚− 10˚)/2 where 90˚
is the 90th percentile and 10˚is the 10th percentile.
2.4. Precision evaluation
The evaluation of the precision of the MZCs (test and control samples)
was performed on the 3D-printed removable dies from the original CAD
model on which the reference crown was designed. The master model
and 20 identical copies of the removable die were printed with a DLP
printer (Solflex 350®, Voco, Cuxhaven, Germany). The model and the
removable dies were used by two calibrated experienced prosthodon­
tists, for verifying the clinical precision of each test and control MZC,
through the inspection of the following parameters:
i quality of the interproximal contact points. The quality of the
interproximal contact points with the adjacent (mesial and distal)
teeth was verified by inserting the removable die inside the 3D-
printed master model and placing the corresponding MZC over it;
then, the operator checked the presence (or absence) of the inter­
proximal contacts visually, using magnifying glasses (Zeiss 4.5x®,
Zeiss, Oberkochen, Germany), and with a dental floss;
ii marginal adaptation. The quality of the marginal closure was
investigated through visual inspection under magnification (Zeiss
4.5x®, Zeiss, Oberkochen, Germany) after having placed each MZC
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

on the corresponding, 3D-printed removable die. The evaluation was were inspected with the non-parametric test of Mann-Whitney inde­
then completed by tactile analysis through a circumferential probing pendent samples, as indicated for small sample sizes. Significance level
at the crown positioned on the removable die, with a periodontal was set at 0.05 level.
probe. The purpose of this analysis was to assess the adaptation of the
MZC onto the 3D-printed die and the presence of any defect, misfit, 3. Results
gap or undercut.
Regarding the trueness evaluation, descriptive statistics for distance
For each of the outcome variables (interproximal contacts, marginal measurements and results of comparison were summarized in Table 1. A
closure) the two prosthodontists could score the anatomical quality of statistically significant difference in trueness was found between 3D-
the restorations, from a clinical perspective. The scores that each clini­ printed and milled crowns, in the three different evaluations (overall
cian could assign were 5 (Excellent), 4 (Good), 3 (Sufficient), 2 (Insuf­ crown: p = 0.000005; margins: p = 0.000011; occlusal surface:
ficient) and 1 (Very poor). For the evaluation of interproximal contact p = 0.000005). A significant difference in trueness was also found
points, the presence of harmonious contact points resulted in good among the assessments made within the 3D-printed and milled groups,
grades (5-4-3), whereas the absence (lack) of an interproximal contact, respectively. The results of estimation of (90-10)/2 distance medians
or the presence of an excessive contact that had to be removed or pol­ and Gini’s MDs, conditional on the crowns’ levels and manufacturing
ished, resulted in a bad grade (2-1). In the evaluation of the marginal process, were summarized in Table 2 and Figs. 13 and 14. Median dif­
adaptation, the prosthodontists carefully checked the presence of any ferences between (90-10)/2 distances measured on margins and occlusal
defect, misfit, gap or undercut of the MZC on the removable die. The levels were 26.9 µm [95% CI: 17.4; 29] and 8.2 µm [95% CI: 3.8; 16] for
perfect 360◦ adaptation of the MZC onto the removable die, without any printed and milled crowns, respectively. The results of estimation of ABS
visible or probable misfit or gap resulted in a good grade (5-4-3) whereas AVG distance medians and Gini’s MDs conditional on the crowns’ levels
bad grades (2-1) were assigned in case of defects, gaps, misfits. All these and manufacturing process were summarized in Table 3 and Figs. 15 and
data were collected in dedicated electronic spreadsheets (Excel®, 16. Median differences between ABS AVG distances measured on mar­
Microsoft, Redmond, WA, USA) and used for analysis. gins and occlusal levels were 13.1 µm [95% CI: 8.1; 13.8] and 4.2 µm
[95% CI: 1.9; 9.8], for printed and milled crowns respectively. Finally,
the results of estimation of RMS distance medians and Gini’s MDs,
2.5. Statistical analysis conditional on the crowns’ levels and manufacturing process, were
summarized in Table 4 and Figs. 17 and 18. Median differences between
For the trueness evaluation, data processing, analysis and visuali­ RMS distances measured on margins and occlusal levels are 17.3 [95%
zation were performed using R (version 3.6.3) environment for statis­ CI: 11.8; 18] micrometers and 6.4 [95% CI: 4.5; 10] micrometers for
tical computing (R Foundation for Statistical Computing, Vienna, printed and milled crowns.
Austria), boot 1.3-24 and 1.3-1 packages. Descriptive statistics for Finally, as regards clinical precision, the assessment made by the two
quantitative variables were presented as medians (1st and 3rd quartiles) prosthodontists was reported in Table 5 and Fig. 19. Both test (inter­
and means (± standard deviations). Medians and Gini’s mean difference proximal contact points: 4.40 ± 0.94; marginal closure 4.40 ± 0.88) and
(Gini’s MD, i.e. robust measure of variability, mean of all pairwise dif­ control (interproximal contact points 4.75 ± 0.44; marginal closure
ferences between observations) were used to measure the variation (htt 4.74 ± 0.44) groups scored highly, revealing excellent clinical precision
ps://www.semanticscholar.org/paper/Gini%E2%80%99s-Mean-differe
nce%3A-a-superior-measure-of-for-Yitzhaki/e4d00851cbbadf386e
Table 2
d051397cabff464a0d2585) with corresponding 95% adjusted bootstrap
Results of estimation of (90-10)/2 distances medians and Gini’s MDs conditional
percentile confidence intervals. Permutation Wilcoxon–Mann–Whitney on the crown’s levels and manufacturing process.
was used to compare manufacturing procedures, and permutation Wil­
Part Manufacturing Gini’s MD [95% CI] Median [95% CI]
coxon signed-rank was used to compare paired distance measurements
preformed in margins and occlusal levels, with mid p-value adjustment All crown Printed 1.66 [1.22; 2.29] 37.58 [36.15; 38.40]
in both settings. Milled 5.50 [3.96; 7.24] 19.42 [17.70; 23.75]
Margins Printed 2.97 [0.79; 6.62] 24.82 [23.83; 25.20]
For the precision evaluation, all collected data were instead pro­ Milled 0.93 [0.58; 1.41] 12.35 [11.40; 12.80]
cessed with statistical software (SPSS 25®, IBM, New York, NY, USA). Occlusal Printed 5.31 [3.11; 7.72] 51.20 [45.98; 52.81]
Average and confidence intervals (CI) 95% were assessed and Milled 6.54 [4.37; 8.96] 20.15 [17.11; 27.35]
comparative-error plots were obtained. Finally, significant correlations

Table 1
Descriptive statistics for distance measurements (in µm) and results of comparison. P – p-values for comparisons between printed and milled crowns; P* – for com­
parison between distance on margins and occlusal levels. Due to permutation character of these rank test p-values can take only discrete values [the similarity of p-
values is not an error].
Measurement Manufacturing All crown Margins Occlusal P*

(90-10)/2 Printed 37.8 (1.4) 25.6 (3.6) 50.4 (4.7) 0.000977

37.6 (37.0‒38.5) 24.8 (24.1‒25.2) 51.2 (49.8‒52.7)
Milled 21.2 (4.7) 12.4 (0.8) 21.9 (5.8) 0.001953
19.4 (18.6‒24.4) 12.3 (12.1‒12.8) 20.1 (17.7‒25.8)
P 0.000005 0.000011 0.000005
Absolute average (ABS AVG) Printed 27.2 (1.3) 17.8 (1.1) 29.6 (2.5) 0.000977
27.3 (26.6‒28.1) 18.0 (17.0‒18.2) 30.2 (28.6‒31.0)
Milled 15.1 (2.2) 9.4 (0.4) 14.7 (3.8) 0.001953
14.6 (13.4‒16.2) 9.5 (9.3‒9.5) 13.1 (11.8‒17.6)
P 0.000005 0.000011 0.000005
Root Mean Square (RMS) Printed 33.2 (1.0) 22.8 (1.6) 38.9 (2.4) 0.000977
33.3 (32.8‒33.6) 22.7 (22.0‒23.0) 39.6 (37.9‒40.0)
Milled 20.5 (2.2) 15.6 (0.6) 22.5 (2.8) 0.001953
20.5 (18.5‒22.3) 15.7 (15.3‒15.7) 21.4 (20.6‒24.5)
P 0.000005 0.000011 0.000005

8
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 13. Box-plots represent (90-10)/2 distances conditional on the crown’s levels and manufacturing process.

Fig. 14. Results of estimation of (90-10)/2 distances medians and Gini’s MDs conditional on the crown’s levels and manufacturing process.

contact points (p = 0.355) and the marginal closure (p = 0.355). Finally,

Table 3
when testing if the investigator had an influence on the final evaluation,
Results of estimation of absolute average (ABS AVG) distances medians and
no differences among the scores given by the two prosthodontists were
Gini’s MDs conditional on the crown’s levels and manufacturing process.
reported, either for the interproximal contact points (p = 0.799) or for
Part Manufacturing Gini’s MD [95% CI] Median [95% CI] the marginal closure (p = 0.799).
All crown Printed 1.56 [1.13; 2.21] 27.34 [26.01; 28.16]
Milled 2.57 [1.84; 3.35] 14.58 [13.28; 16.05] 4. Discussion
Margins Printed 1.18 [0.72; 1.90] 18.00 [16.76; 18.17]
Milled 0.45 [0.27; 0.69] 9.48 [9.00; 9.50]
Occlusal Printed 2.85 [1.75; 4.22] 30.23 [27.29; 30.89] The marginal fit is a determining factor for the survival and long-
Milled 4.36 [2.96; 5.66] 13.07 [11.45; 17.16] term success of prosthetic restorations, particularly with tooth-
supported prostheses [37–41]. If a prosthetic crown does not close
properly, the marginal discrepancy between the dental structure and the
at the level of interproximal contact points and margins; therefore, no restoration can lead to dissolution of the cement [39,40], microleakage,
statistically significant difference was found in the precision among the risk of pulp inflammation [37] and formation of secondary caries [38,
different groups (test vs control groups), both for the interproximal 39], as well as inflammation of the periodontal tissues [39,41]. To date,

9
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 15. Box-plots represent absolute average (ABS AVG) distances conditional on the crown’s levels and manufacturing process.

Fig. 16. Results of estimation of absolute average (ABS AVG) distances medians and Gini’s MDs conditional on the crown’s levels and manufacturing process.

less than 25 µm [39,42,43].

Table 4
Monolithic zirconia is a widely used material today, for the manu­
Results of estimation of root mean squared (RMS) distances medians and Gini’s
facture of single crowns, short- and long-span bridges, and full-arch
MDs conditional on the crown’s levels and manufacturing process.
restorations, both on natural teeth and on implants [1–7,44]. This so­
Part Manufacturing Gini’s MD [95% CI] Median [95% CI] lution has been particularly appreciated in the case of single-tooth
All crown Printed 1.18 [0.74; 1.90] 33.30 [32.35; 33.64] restoration [2–5,44], and several studies have reported a marginal
Milled 2.65 [2.13; 3.12] 20.51 [18.10; 21.95] discrepancy for milled zirconia restorations between 15 and 120 µm
Margins Printed 1.55 [0.68; 2.94] 22.72 [21.73; 23.01]
[44-48]; in a recent systematic review based on 54 articles, a marginal
Milled 0.63 [0.34; 1.03] 15.65 [15.21; 15.70]
Occlusal Printed 2.75 [1.68; 4.02] 39.65 [36.34; 40.03] gap for milled monolithic crowns between 7.6 µm and 206.3 µm was
Milled 3.19 [2.10; 4.32] 21.42 [20.28; 25.23] reported [42].
However, few studies exist on 3D printing of zirconia in dentistry [8,
17–19,30–32] and, in particular, on the analysis of marginal gaps with
although there is no univocal consensus in the scientific literature, additively fabricated monolithic zirconia crowns [34–36].
marginal gaps between 50 and 120 µm are considered clinically In a recent in vitro study, Wang et al. [35] compared the trueness of
acceptable; however, the ideal would be to obtain a closure with a gap of MZCs fabricated with SLA and conventional milling. The authors used a

10
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

Fig. 17. Box-plots represent root mean square (RMS) distances conditional on the crown’s levels and manufacturing process.

Fig. 18. Results of estimation of root mean square (RMS) distances medians and Gini’s MDs conditional on the crown’s levels and manufacturing process.

Table 5
Assessment of the clinical precision of the 3D printed (test) and milled (control) monolithic zirconia crowns (MZCs) performed by two different experienced pros­
thodontists. The parameters assessed were the quality of the marginal closure and the quality of the interproximal contact points. For each of the outcome variables
(interproximal contacts, marginal closure) the two prosthodontists could rate the anatomical quality of the restorations, from a clinical perspective. The rate each
clinician could assign was 5 (excellent), 4 (good), 3 (sufficient), 2 (insufficient) and 1 (very poor).
Prosthodontist 1 Prosthodontist 2 Overall
3D printed MZCs Milled MZCs 3D printed MZCs Milled MZCs 3D printed MZCs Milled MZCs
(test) (control) (test) (control) (test) (control)

Interproximal contact 4.40 (±0.96) 4.70 (±0.48) 4.40 (±0.96) 4.80 (±0.42) 4.40 (±0.94) 4.75 (±0.44)
points
Marginal closure 4.40 (±0.96) 4.70 (±0.48) 4.40 (±0.96) 4.80 (±0.42) 4.40 (±0.88) 4.74 (±0.44)

11
H. Lerner et al.
Fig. 19. Box-plot comparing averages at 95% confidence intervals (CI) for the precision of the MZCs at the level of interproximal contact points and margins. For
each of the outcome variables (interproximal contacts, marginal closure) the two investigators could rate the anatomical quality of the restorations, from a clinical
perspective. The rate each clinician could assign was 5 (excellent), 4 (good), 3 (sufficient), 2 (insufficient) and 1 (very poor). The values are distinguished between
tests and controls, and between the two investigators.
reference typodont model, which was prepared for a monolithic crown
and scanned with a desktop scanner [35]. A digital crown was designed
within CAD software, and the modeling file was used to fabricate 10
MZCs by additive manufacturing (CERAMAKER 900®; 3DCeram Co,
Limoges, France) and 10 MZCs by milling (DWX-50®, DGShape, a
Roland Company, Hamamatsu, Japan) [35]. The crowns were then
scanned with the same laboratory scanner, and the files thus obtained
were superimposed on the reference CAD model, to evaluate trueness
[35]. At the end of the study, the authors reported that the trueness of
the samples made through AM was not lower than that of those made by
milling [35].
These encouraging results were, at least in part, contradicted by a
subsequent in vitro study, where Revilla Leon et al. [36] measured and
compared the marginal and internal discrepancies of AM and milled
MZCs, using the silicone replica technique (SRT). In this study, an
individualized implant abutment was scanned with a laboratory scanner
and the authors designed an anatomical crown in CAD, which was
milled and printed in monolithic zirconia; finally, a third group of
crowns were 3D-printed, but splinted in two parts, to simulate the
structures of enamel and dentin [36]. Ten samples were produced for
each group, and the additive manufacturing samples were fabricated
with the aforementioned SLA machine (CERAMAKER 900®; 3DCeram
Co, Limoges, France), which processed a dedicated material (3DMix
ZrO2® paste; 3DCeram Co) [36]. A conventional 5-axis machine was
used for milling. The authors then employed the silicone replication
technique to measure marginal and internal discrepancies, using a x100
magnification microscope. At the end of the study, the authors found
significant differences in marginal and internal discrepancies between
the groups [36]. The milled MZCs, in fact, had the least degree of
marginal and internal discrepancies, compared to the 3D-printed crowns
(monolithic and splinted into 2 parts); on the other hand, within the
group of 3D-printed parts, the splinted crowns revealed lower values of
marginal discrepancy [36]. The authors concluded that the milled and
printed crowns that were splinted in two parts showed clinically
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Journal of Dentistry 113 (2021) 103792
acceptable marginal and internal discrepancies, while the group of
3D-printed MZCs showed marginal and internal discrepancies that were
unacceptable, and incompatible with clinical use [36].
The difference between the results reported by these two studies—­
which used, among other things, the same 3D printer for manufacturing
the prosthetic crowns—could reside in the different methodology and
evaluation criteria applied to evaluate the accuracy of the restorations.
In a recent study, Son et al. [43], have compared five different methods
(SRT, cross-sectional method [CSM], triple scan method [TSM],
micro-computed tomography [MCT], and optical coherence tomogra­
phy [OCT]) to evaluate the marginal and internal fit of a specially
designed coping on an abutment. The five methods showed significant
differences in the four regions that were assessed (p < 0.001) [43], and
the authors concluded that the marginal and internal fit showed sig­
nificant differences, depending on the method used for inspection [43].
Hence, the different methods employed to evaluate the marginal gap by
Wang [35] and Revilla-Leon [36] may justify these different results.
Wang et al. [35] in fact, scanned the crowns obtained by 3D printing and
milling with a dental desktop scanner, and they superimposed the .STL
files obtained on the reference CAD file of the prosthetic crown. At the
end of their evaluation, the mean trueness for the marginal surface only,
calculated with the RMS method, amounted to 34 (±5) µm in the
3D-printed crowns group, versus 35 (±7) in the milled crowns group
[35]. Revilla-Leon et al., instead, used an SRT, and found median (±
interquartile) marginal gaps of 37.5 µm (±50) and 146.0 µm (± 103.2)
for CNC and AM MZCs respectively [36].
In our present in vitro study, we have compared the trueness and
precision of MZCs produced by AM versus milling. The 3D-printed
crowns (test group) were manufactured using a novel method, the
LCM; the printer used was a CeraFab System S65® Medical 3D printing
system (Lithoz, Vienna, Austria). Our milled crowns (control group) were
manufactured with a modern 5-axis milling unit (DWX-52D®, DGShape,
a Roland Company, Hamamatsu, Japan). According to ISO 5725,
“trueness” refers to the closeness of agreement between the arithmetic
H. Lerner et al.
mean of a large number of test results and the true or accepted reference
value [49]. In our study, trueness was the exact dimensional corre­
spondence of each MZC (3D-printed or milled) with respect to the
reference CAD file used to manufacture it. This correspondence was
evaluated by 3D scanning each of the MZCs and superimposing the STL
files thus obtained onto the original reference CAD file. The superim­
position was performed in reverse engineering software, that uses an
RICP algorithm to minimize the difference between two clouds of points.
With RICP algorithms, one point cloud (vertex cloud), as the reference,
is kept fixed, while the other one, the source, is transformed to best
match the reference. The algorithm iteratively revises the trans­
formation (a combination of translation and rotation) needed to mini­
mize an error metric, usually a distance from the source to the reference
point cloud, such as the sum of squared differences between the co­
ordinates of the matched pairs. In our study, a point-to-plane method
was adopted, and three different outcome variables, namely the ABS
AVG, RMS, and (90-10)/2 percentile method, were obtained for both test
and control groups in a computing platform (MathLab®, Mathworks),
and used for statistical analysis. The ABS AVG is one of the most
commonly used outcomes of in vitro studies evaluating trueness, and it is
considered better than the signed mean, since it avoids those positive
and negative deviations between reference and test objects that could
lead to results cancelling each other. The RMS error (equal to standard
deviation) is another common method used to evaluate trueness; finally,
the (90-10)/2 percentile is another method, whereby the highest and
lowest 10 percent of the surface are not taken into account, because of
margin effects and the different scan sizes of models.
At the end of our study, the conventional milling technique proved to
be more accurate than the new 3D printing technology, with statistically
significant differences in trueness between the milled and 3D-printed
samples in all three inspected areas (overall crown, marginal area,
occlusal surface), with all three methods applied (90-10/2, ABS AVG,
RMS). These results seem to confirm the evidence presented in the study
of Revilla-Leon et al. [36].
However, in our study, the differences between test (3D-printed) and
control (milled) samples appeared particularly marked at the level of the
occlusal surface, where the 3D-printed crowns showed the highest de­
viations. Although statistically significant, the difference in accuracy
between 3D-printed and milled MZCs was less marked in the marginal
area. This resulted in a significant difference in accuracy between the
different areas, even within the same groups (tests and controls).
In fact, in 3D printing the accurate reproduction of the cusps can
suffer from the presence of the printing supports, which must be posi­
tioned also at the occlusal level, unlike what happens in milled crowns.
When the dental technician removes these supports, there is a risk to
over or under polish; this can have an effect on the trueness of this
functional surface. However, in the present study the largest deviations
from the original CAD file were found in the occlusal grooves and pits of
the 3D printed crowns. These deviations today represent a limitation of
the LCM printing technique, which struggles to accurately reproduce
deep and narrow grooves, particularly where their presence determines
a marked asymmetry or discrepancy in the thickness of the crown walls.
In the CAD design of crowns to be printed through LCM, it is always
preferable to avoid modeling with deep and narrow grooves, because
this anatomy can cause problems in the printing process. Unfortunately,
in our present study, we did not perform an evaluation of the clinical
precision of the occlusion of the MZCs, since we did not have an
antagonist model. This is a limit of the study.
Nevertheless, the precision of the 3D-printed and milled crowns,
verified on the model through the analysis of parameters such as the
marginal fit, and the quality of the interproximal contacts, was similar
and fully in the range of clinical acceptability. This result seems to point
in the direction shown by Wang et al. [35]—who reported a RMS of
53 µm for the external surface, 38 µm for the intaglio surface, and 27 µm
for the intaglio occlusal surface of 3D-printed MZCs, versus 52, 43 and
41 µm for milled MZCs, respectively—and contradict the results of
13
Journal of Dentistry 113 (2021) 103792
Revilla-Leon et al. [36]. The best result, in terms of clinical precision,
obtained in our present study could be related to the different technol­
ogy for the fabrication of the 3D-printed MZCs, namely the LCM [50].
Naturally, the present in vitro study only investigated the
manufacturing accuracy of 3D-printed zirconia crowns, and their clin­
ical precision; it did not take into consideration the mechanical resis­
tance and strength of such restorations. This is a limitation of this work.
The scientific literature has not yet fully clarified whether 3D-printed
zirconia can be considered a mechanically reliable material, able to
withstand the prosthetic load in the medium and long term: to date, in
fact, few studies have addressed this topic, with various experimental
designs and consequently different results [30–34]. For this reason,
more scientific evidence is needed before to be able to draw any specific
conclusion about the potential for the clinical use of 3D-printed MZCs,
and to suggest the use of this technology for the fabrication of prosthetic
crowns in private dental centers. Our present study is only in vitro, as in
our research, the trueness of the MZCs was assessed through an indus­
trial scanner, on limited samples of test and control crowns. The evalu­
ation of clinical precision was also carried out in vitro, by only two
operators, on a split-cast model. In order to confirm the data emerging
from this research, further in vitro studies on more numerous samples of
MZCs are needed, also conducted using different evaluation methods
(CSM, SRT, TSM, MCT and OCT); in addition, clinical proof is needed, i.
e., the evaluation of the fit of the restorations in vivo. Randomized and
controlled clinical trials should therefore be conducted, preferably in a
University setting, in order to definitively validate the clinical use of
3D-printed zirconia restorations.
5. Conclusions
Within its limits (in vitro design, limited number of samples evalu­
ated, only one evaluation method), the present study compared the
trueness and precision of 3D-printed versus milled monolithic zirconia
crowns (MZCs), and found that milled MZCs have a statistically signif­
icant higher trueness than 3D-printed MZCs. In this study, both 3D-
printed and milled crowns showed high precision, compatible with the
clinical use. However, more research is certainly needed to evaluate the
clinical precision and mechanical resistance of 3D printed zirconia res­
torations, and to validate their clinical use.
CRediT authorship contribution statement
Henriette Lerner: Funding acquisition, Resources, Validation,
Investigation, Methodology, Writing – review & editing. Katalin Nagy:
Project administration, Validation, Methodology, Writing – review &
editing. Nicola Pranno: Data curation, Formal analysis. Fernando
Zarone: Supervision, Writing – review & editing. Oleg Admakin: Su­
pervision, Writing – review & editing. Francesco Mangano: Concep­
tualization, Investigation, Methodology, Software, Writing – original
draft, Visualization, Investigation.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
The authors are grateful to Master Dental Technician Uli Hauschild,
for the preparation of the model used for this study; to Dr. Davide Far­
ronato and Dr. Bidzina Margiani, for help with the statistical analysis; to
Dr. Daniel Bomze, Dr. Michael Djebali and Dr. Mouad El Ouafiq, for help
with preparing the 3D-printed and milled samples; and finally, to Dr.
Gabriele Graziosi, for help with the industrial optical scanner.
H. Lerner et al. Journal of Dentistry 113 (2021) 103792

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