Received: 25 April 2019 Revised: 10 July 2019
DOI: 10.1111/jerd.12527
RESEARCH ARTICLE
A clinical comparison of digital and conventional impression
techniques regarding finish line locations and impression time
Soudabeh Koulivand DDS, MSc1
Hakimeh Siadat DDS, MSc2 | Marzieh Alikhasi DDS, MSc2
1
Prosthodontic Department, Dentistry School,
Shahid Beheshti University of Medical Science,
Tehran, Iran
2
Prosthodontic Department, Dentistry School,
Tehran University of Medical Science,
Tehran, Iran
Correspondence
Dr. Hakimeh Siadat, DDS, MSc, Dental
Research Center and Department of
Prosthodontics, Tehran University of Medical
Sciences School of Dentistry, Tehran
1439955991, Iran.
Email: hsiadat@sina.tums.ac.ir
J Esthet Restor Dent. 2019;1–8.
Accepted: 25 August 2019
| Safoura Ghodsi DDS, MSc2 |
Abstract
Objective: This study compared digital and conventional impression techniques
regarding impression time, frequency of adjustments, and adaptation of cobalt-
chromium (Co-Cr) copings with supragingival and subgingival finish lines.
Materials and Methods: Thirty premolars prepared for single-unit metal-ceramic res-
torations with supragingival and subgingival finish lines (n = 15). Conventional
impression and digital scan of prepared teeth were made. Using computer aided des-
ign/computer aided manufacturing (CAD/CAM) system the copings were produced
by a milling machine from Co-Cr blocks and internal and marginal discrepancies were
measured using silicone replica technique. Data were analyzed using repeated mea-
sures ANOVA and Mann-Whitney test (alpha = .05).
Results: The impression technique had a significant effect on the magnitude of gap
(P < .001). The internal and marginal gaps in the digital technique (49.43 μ and
60.07 μ, respectively) were significantly lower than the values in the conventional
method (91.88 μ and 96.96 μ, respectively—P < .001). Finish line positions had no sig-
nificant effect on the fit and marginal gap of copings (P = .54 and .243, respectively).
The mean impression time (190 :2700 in conventional technique and 100 :3100 in digital
technique) was significantly shorter (P < .001) and the mean frequency of adjust-
ments (2.2 times for conventional and 1.3 times for digital technique) was signifi-
cantly lower in the digital technique (P < .001). The gingival biotype (thick or thin)
had no significant effect on marginal and internal fit (P = .052 and .319, respectively).
Conclusion: The digital technique was superior in terms of fit, impression time, and
frequency of adjustments. Finish line positions had no significant effect on the fit of
copings.
Clinical Significance: Using intraoral scanner promotes the fits of restorations in
supragingival and subgingival finish lines.
KEYWORDS
CAD-CAM, dental impression technique, finish line, intraoral scanner, marginal adaptation
wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 1
2 KOULIVAND ET AL.

1 | I N T RO D UC T I O N Gingiva management and tissue displacement are other factors

affecting accuracy of impressions and subsequent adaptation of resto-
Metal-ceramic restorations are suitable treatment options for poste- rations. Position of finish lines relative to gingival margins would influ-
rior teeth. They have long been used in dentistry and shown accept- ence the creation of hemostasis and the retraction of the gingiva.20-22
able long-term results.1,2 Biocompatible cobalt-chromium (Co-Cr) Clinicians have three choices in this respect: positioning the finish line

alloy has been commonly used for metal copings fabrication consider- at the level of the gingiva, supragingivally, or subgingivally.

ing the high cost of gold and allergic reactions caused by nickel- Supragingival placement of restoration margins has advantages such

chromium alloy. 3,4 as higher predictability of impression making and requiring no or mini-

In fact, the biological problems of these restorations are caused by mal use of gingival retraction cord. However, supragingival placement
of restoration margins is not always feasible and, in some patients,
marginal misfit of crowns, which leads to luting agent dissolution,
restoration margins must be placed subgingivally.20 Impression making
plaque retention, and bacterial accumulation. As a result, the tooth
is more difficult when finish lines have been positioned subgingivally
becomes more susceptible to secondary caries and pulpitis. Felton
because some techniques (mechanical, chemical, surgical, and combi-
et al5 evaluated Effect of crown margin discrepancies on periodontal
nations of these methods) must be used to displace the gingiva to
health and noticed that an increase in marginal discrepancy between
accurately record the finish line in the impression.21
the casting and prepared tooth resulted in an increase of gingival
At present, despite the advances in digital dental science, conven-
inflammation. In addition, inadequate marginal adaptation can lead to
tional impressions may still be required for some cases with sub-
periodontal disease which is induced by subgingival microflora
gingival finish lines. Many in vitro and clinical studies have evaluated
changes and plaque retention.6
and compared the accuracy of digital and conventional impressions
The internal fit of restorations has been another factor affecting
and restorations.23-31 In these studies, although finish lines in some
clinical longevity and success of restorations.6,7 The cement space
teeth were extended subgingivally, the effect of finish line position on
between the inner surface of restoration and the prepared tooth must
the results was not considered.32-36 To the best of the authors' knowl-
be uniform to ensure complete seating of crown without compromis-
edge, no previous study has compared the accuracy of conventional
ing retention and resistant form. Excess internal gaps could result in
and digital impressions for fabrication of tooth-supported restorations
decementation of fixed restorations, reduced fracture strength and
with subgingival and supragingival finish lines. Thus, this study aimed
failures on the veneering material.6,8,9
to compare digital and conventional impression techniques regarding
The lost-wax technique and subsequent casting has been the con-
impression time, frequency of adjustments, and adaptation of Co-Cr
ventional method of metal coping fabrication.10 This technique, how- individual copings with supragingival and subgingival finish lines. The
ever, is time-consuming and may cause distortion of wax patterns and null hypothesis states that (a) impression technique will have no effect
irregularity of the cast metal.11 Computer-aided design/computer- on impression time and frequency of adjustments and (b) finish line
aided manufacturing (CAD/CAM) and direct metal laser sintering sys- position and gingival biotype have no significant effect on the mar-
tems were introduced to overcome the limitations of the casting tech- ginal and internal fit of copings fabricated by the conventional and
nique.10,12-14 In these methods intraoral or lab scanners provide digital impression techniques.
precise three-dimensional (3D) information of prepared tooth and
adjacent and opposing teeth, which is used for virtual designing of the
2 | MATERIALS AND METHODS
restoration. Transfer of digital information does not require disinfec-
tion as does the transfer of impressions to a laboratory or fabrication
This experimental clinical study was performed on patients presenting
of a gypsum cast for articulation. Therefore, the risk of reduction in
to the Prosthodontics Department of School of Dentistry, Tehran Uni-
dimensional accuracy has become minimized.15
versity of Medical Sciences requiring single crowns on premolar teeth.
Digital scanning can be performed extraorally and intraorally. The
Ethical committee of the university approved the study (ref. IR.TUMS.
extraoral technique includes scanning of casts by a laboratory scanner
DENTISTRY.REC.1396.3520).
and therefore, requires conventional impression making. The inaccura-
Sample size was calculated to be 26 (n = 13 in each of the two
cies associated with conventional impression making still exist.16
groups) using one-way ANOVA feature of PASS software considering
Intraoral scanners play a pivotal role in advancement of digital dental
minimum significant difference of 50 μ for the amount of gap, SD of
technology since they constitute the first step in complete digital fab-
42 μ and power of 83%. To increase accuracy, 15 teeth were included
rication of prosthetic restorations.17 Intraoral digital impression mak- in each group. Alpha and beta were considered to be .005 and .017,
ing increases patient cooperation and decreases the risk of distortion respectively.
of impression material.18,19 The inclusion criteria were presence of maxillary or mandibular
Limitations of digital impressions include additional costs related premolars requiring single-unit fixed restorations, absence of clinical
to purchasing an intraoral scanner, the need for participation in symptoms such as pain, infection, or periodontal disease in the
related courses and workshops and the need for constant updates to respective teeth, informed consent for participation in the study and
keep up with the growing technology.2 chamfer finish lines. The exclusion criteria were clinically visible
KOULIVAND ET AL. 3

mobility of the respective teeth due to periodontal attachment loss

(mobility degree 2 or higher), nonuniform margin
(supragingival/subgingival) in different areas of the respective teeth,
probing depths more than 3 mm and mouth opening limitation. Five
senior postgraduate students of prosthodontics prepared the teeth
for metal-ceramic restorations following occlusal reduction of 2 to
2.5 mm, axial preparation of 1.5 to 2 mm and total occlusal conver-
gence of 10! to 20! .37 All teeth had chamfer finish lines. The maxi-
mum acceptable subgingival extension of finish line was half the
depth of gingival sulcus (1.5 mm).37 Teeth with deeper finish lines
were also excluded. Fifteen teeth had supragingival finish lines and
did not require gingival retraction cord for impression making served
as the supragingival finish line group. The remaining 15 teeth with
subgingival finish lines required placement of gingival retraction cord
for finish line exposure prior to impression making were allocated to
the subgingival finish line group. Also, the gingival biotype of the teeth
was determined as thin or thick by insertion of a periodontal probe
into the gingival sulcus and evaluation of its visibility through the gin-
gival margin.38 After tooth preparation provisional crowns were made
using an acrylic composite material (Visalys Temp—Kettenbach
GmbH & Co. KG) and putty index.
One week after tooth preparation, impressions were made of each
tooth using both digital and conventional impression techniques in F I G U R E 1 A, Digital scan of a prepared tooth with supragingival
one session. In all cases, after making the putty (A-silicone, Panasil, finish line. B, Buccal scan as occlusion registration record
Kettenbach GmbH & Co. KG, Germany) impressions, digital impres-
sions were made with gingival cord (#2, Ultrapak, Ultradent) packed in
the gingival sulcus for subgingival samples.33 The prepared teeth were
scanned by a Trios (3Shape, Denmark) intraoral scanner. First, the
quadrant of the prepared tooth was scanned and then, the opposing
quadrant was scanned. Buccal scanning was finally performed for
occlusion registration record (Figure 1). The gingival cord remained in
the gingival sulcus during scanning and removed just before the sec-
ond step of conventional impression, using X-light silicone (A-silicone,
Panasil, Kettenbach GmbH & Co. KG, Germany) impression material
(Figure 2). The impressions were poured with type 4 dental stone
(Dentona AG, Zero Stone, Germany) within 1 hour. The obtained casts F I G U R E 2 A, Conventional impression technique (additional
were scanned using an extraoral scanner (D700, 3Shape). One senior silicon putty and x-light). B, Impression of opposite arch (irreversible
postgraduate student of prosthodontic with 2 years' experience of hydrocolloid). C, Occlusion registration record (additional silicon)

practicing with Trios system performed all phases of conventional and

digital impression making.
copings (ensured by a dental explorer and radiography), the inner sur-
For each tooth two base metal copings were designed in Dental
Designer software (Dental Designer 2014, 3shape) using the files faces were filled with low-viscosity silicone (GC fit checker, GC Corp,

obtained from intraoral scanning and cast scanning; 40 μ cement Tokyo, Japan) and placed on the prepared teeth with maximum finger

space39
in all areas was designed except for 1 mm around the finish pressure for 10 seconds. After setting, the copings were removed and

line. The minimum metal thickness was 300 μ and the lingual collar
height was 2 mm. Next, Co-Cr blocks (ARUM, Doowon, Daejeon,
Korea) were milled in a milling machine (VersaMil). All phases were
performed in the same laboratory.
For coping try-ins, the inner surfaces were coated with indicator
spray (Occlude Aerosol Indicator Spray, Pascal, UK) and adjusted using
no.2 carbide bur (Stoddard, UK) to simulate actual clinical conditions.
The frequency of adjustments required prior to complete seating of
the copings was recorded. After clinically acceptable seating of the
heavy silicone (Panasil heavy—Kettenbach GmbH & Co. KG, Germany)
was injected into the copings to support the first layer without
distortion.40-42
To assess the impression time in conventional technique, the time
spent for selection of impression tray, application of silicone adhesive,
putty preparation, impression making by putty and X-light silicone,
placement and removal of gingival retraction cord, impression making
from the opposite arch, occlusion registration record and writing the
lab note was calculated in minutes and seconds. For the digital
4 KOULIVAND ET AL.
technique, the time spent for uploading patient information into the
software, placement of gingival retraction cord, scanning of prepared
teeth and the opposite arch, buccal scanning of teeth in occlusion,
removal of gingival cord and writing the lab note was calculated.
The silicone material was carefully removed from the copings and
cut (along with the internal silicone support) buccolingually and
mesiodistally using a #15 scalpel.43 The thickness of the internal sili-
cone layer in marginal and axial surfaces (distal, buccal, lingual, and
mesial) were measured under a stereomicroscope (Leitz, DMBH Ger-
many) equipped with a digital camera (Dino-Lite 5MP Edge
AM7115MZT, Netherlands) at ×50 magnification (Figure 3). Internal
and marginal gaps were calculated according to Holmes et al,44 by
measuring the vertical distance from a point in the inner surface or
the casting margin to the axial wall or the margin of prepared tooth
(Figure 1). In the chamfer area, the amount of gap was measured in
two areas (maximum and minimum) and the mean value was consid-
ered as the gap in the chamfer area.
In each axial surface, the amount of gap in three areas (1 mm
above the chamfer area, middle area and 1 mm below the cusp tip)
was measured and the mean value was calculated and considered as
the axial gap. In the occlusal area, the amount of gap in three areas
(cusp tips and the central fossa) was measured on the buccolingual
section and the mean value was considered as the occlusal gap. Data
regarding internal and marginal gap, frequency of adjustments before
F I G U R E 3 Measuring gap under stereomicroscope (×50). A,
Occlusal gap. B, Marginal gap
seating and impression time were analyzed using repeated measures
ANOVA and Mann-Whitney test (alpha = .05).
3 | RESULTS
A total of 25 patients, including 11 males and 14 females, with 30 pre-
molar teeth requiring crowns were evaluated. Patients were between
19 and 48 years old. The teeth evaluated included 10 maxillary first
and 8 maxillary second premolars and 6 mandibular first and 6 mandib-
ular second premolars.
3.1 | Internal gap
Repeated measures ANOVA showed that the internal fit of copings
fabricated by the digital method was significantly superior to that of
copings fabricated by the conventional impression technique
(P < .001, Figure 4). The position of finish line (supragingival or sub-
gingival) and type of gingival biotype (thick or thin) had no significant
effect on the internal fit (P = .545, P = .319, respectively). The interac-
tion effect of the impression technique, position of finish line, and gin-
gival biotype was not significant on the internal fit (P = .962).
3.2 | Marginal fit
Repeated measures ANOVA showed that the marginal fit of copings
fabricated by the digital method was significantly superior to that of
copings fabricated by the conventional impression technique
(P < .001, Figure 5). The position of finish line (supragingival or sub-
gingival) and type of gingival biotype (thick or thin) had no significant
effect on the marginal fit (P = .24, P = .05, respectively). The interac-
tion effect of the impression technique, position of finish line, and gin-
gival biotype was not significant on the marginal fit (P = .979).
3.3 | Impression time
Repeated measures ANOVA showed that the impression time in the
digital technique was significantly shorter than that in the conven-
tional technique (P < .001). Position of finish line had no significant
effect on the impression time (P = .439). Gingival biotype (thick or
thin) had no significant effect on the impression time either (P = .943).
The interaction effect of the impression technique, position of finish
line and gingival biotype was not significant on the impression
time (P = .862).
3.4 | Frequency of adjustments prior to seating
The Wilcoxon signed ranks test showed that the frequency of adjust-
ments of the copings fabricated by the digital method was signifi-
cantly less than that of copings fabricated by the conventional
impression technique (P = .004). The Mann-Whitney test showed that
the position of finish line had no significant effect on the frequency of
adjustments required prior to complete seating of copings fabricated
KOULIVAND ET AL. 5

F I G U R E 4 Comparison of internal gap

between conventional and digital group
considering position of finish lines and
gingival biotype

F I G U R E 5 Comparison of marginal
gap between conventional and digital
group considering position of finish lines
and gingival biotype
6 KOULIVAND ET AL.
by the digital and conventional impression techniques (P = .187 and
P = .081, respectively).
4 | DISCUSSION
Studies regarding the marginal fit of restorations fabricated by the
digital and conventional impression techniques are ongoing.33 Some
studies have shown smaller marginal gap and higher marginal accuracy
in restorations fabricated by the CAD/CAM technology following
scanning with an intraoral scanner compared to the conventionally
fabricated restorations.12-14 Higher frequency of errors in the conven-
tional method was related to longer process of fabrication and poten-
tial sources of errors.11 One clinical study35 compared three intraoral
scanners and found a significant difference in internal and marginal fit
of restorations among the three systems, which highlighted the pres-
ence of significant differences in the accuracy of various digital sys-
tems; this can explain the difference in the results of studies.
In this study, the marginal gap was 96.96 μ in the conventional
and 60.07 μ in the digital group; this difference was statistically signif-
icant (P < .001). These values were close to those reported by Pradies
et al,23 who reported 91.46 μ gap in the conventional and 76.33 μ in
the digital group. Ahrberg et al,32 reported 61.08 μ gap in restorations
fabricated from digital impressions. This value was 71.67 μ in a study
by Sakornwimon and Leevailoj.43 Some other clinical studies that used
Trios 3Shape 24,33
reported higher values of marginal gap compared to
our results. The reason may be that they did not clinically adjust the
restorations while we adjusted the internal surface of copings prior to
the fabrication of replica to better simulate the clinical setting. Differ-
ence in parameters such as the considered cement space, which was
40 μ in our study and 50 μ in the study by Berrendero et al,24 can also
explain the difference in the results. Some clinical studies reported
24,25,33,34
greater marginal gap compared to our values, which may be
attributed to the different types of restorations. According to Pak
et al,26 addition of porcelain to coping caused distortion and
decreased the fit of restorations. The discrepancy caused by the labo-
ratory processes has been reported to be 12 to 14 μm.45 The type of
digital system used and the type of restoration also could affect the
results. A systematic review stated that metal restorations fabricated
via the digital technique show the lowest amount of marginal gap
compared to zirconia and glass ceramic restorations.2
Internal gap could affect the marginal gap. A uniform internal gap
does not compromise the resistance of restoration and provides a
suitable space for cement layer. In our study, the internal gap was
91.88 μ in the conventional and 49.43 μ in the digital technique
(P < .05). The overall size of internal gap in our study agreed with that
in many clinical studies.31,40,43 Our value was lower than that reported
in some other studies,24,25,33,34 which may be due to the use of coat-
ing powder spray before scanning in some digital systems such as
Lava C.O.S. The thickness of this layer, could affect the restoration
fit.7 However, further studies are required on the effect of type and
thickness of powder spray on restoration fit.
Many in vitro and clinical studies have evaluated and compared
the accuracy of digital and conventional impression techniques and
the fit of obtained restorations.27,44 Despite the fact that the finish
line was subgingival in many clinical studies, the effect of this variable
on the fit of restorations was not evaluated.37,38 In our study, the
position of finish line had no significant effect on marginal gap.
Nedelcu et al,46 evaluated the effect of finish line position on its accu-
racy. The results showed that all seven intraoral scanners tested in
their study had lower accuracy wherever the finish line extended sub-
gingivally. However, the Trios scanner had the highest accuracy
among all, and use of true color technology in this scanner helped in
discrimination of tooth and gingiva at the margin. Their study had dif-
ferences with ours in terms of methodology, which could have
affected the results such as the difference in actual gingival tissue and
model and use of gingival retraction cord and occlusal view images for
detection of finish line while a 3D model was used for the fabrication
of restorations in the digital technique.
Results showed that the overall impression time was 19 minutes
and 27 seconds in the conventional and 10 minutes and 31 seconds
in the digital technique. The difference in this respect was significant
between the two groups (P < .001). The impression time decreased to
13 minutes and 4 seconds in the conventional and 8 minutes and
48 seconds in the digital technique in teeth with supragingival finish
lines, since there was no need for placement of gingival retraction
cord. Shorter impression time in the digital technique was expectable
since it has fewer steps, there is no setting time and in contrast to the
conventional technique, the impression can be corrected without
repeating. Studies that compared digital and conventional tech-
niques28-30 confirmed the presence of a significant difference
between the two methods, which is supported by our findings. How-
ever, another study31 showed this difference in time decreases to less
than 2 minutes when the entire arch is scanned because the scanning
time of full arch is considerably longer than the time spent for scan-
ning of one quadrant. Another study29 reported a significant associa-
tion between the number of prepared teeth and digital scanning time
such that by an increase in number of prepared teeth, the scanning
time increased as well while no such association existed in the con-
ventional technique.
In study, the frequency of adjustments needed prior to complete
seating of copings was 2.2 times for the conventional and 1.3 times
for the digital technique (P < .001). Search of the literature yielded no
study on quantitative assessment and comparison of frequency of
adjustments. Boeddinghaus et al,35 reported maximum of three times
use of fit checker for crown adjustment but did not disclose the num-
ber of restorations requiring adjustment or the difference in fre-
quency of adjustments required by the crowns based on their
impression technique. Some other studies did not mention anything
about the adjustment of the internal crown surface prior to the fabri-
cation of replica23-25,34,43 or did not make any adjustment at all.40
To interpret the results of our study regarding the fit of copings,
limitations of clinical studies must be considered. The problem with
measurement of cement space or gap in clinical studies is the inability
to directly observe the space because the ideal method of assessment
KOULIVAND ET AL.
of accuracy of restoration, which is sectioning and observation under
a microscope, is obviously not possible. In these studies, a silicone
replica is fabricated for measurement of gap, which is a noninvasive
technique with acceptable accuracy.41,42 This technique is simple and
affordable; however, use of silicone or resin to support the internal
layer may cause dimensional changes in this layer and subsequent
error in measurement of its thickness.34 Another shortcoming of this
technique is the two-dimensional nature of sections, which does not
allow measurements at the periphery of samples.42 Future studies are
required to assess and compare the fit of multiple-unit restorations
with subgingival finish line fabricated by the digital and conventional
techniques. Comparison of marginal gap in subgingival finish lines
among different intraoral scanners is interesting topics for future
research.
5 | CO NC LUSIO N
According to the results of this study, the amounts of internal gap and
marginal gap in restorations fabricated by the digital technique were
lower than the corresponding values in the conventional method.
Position of finish line and gingival biotype had no significant effect on
these variables. Impression time was significantly shorter in the digital
method and the digitally fabricated copings required significantly
fewer adjustments. Position of finish line had no significant effect on
the frequency of adjustments required.
ACKNOWLEDGMENTS
This project was funded by Grant # 34904 from the Dental Research
Center, Tehran University of Medical Sciences.
DIS CLOSUR E STATEMENT
The authors do not have any financial interest in companies whose
materials are included in this article.
ORCID
Soudabeh Koulivand https://orcid.org/0000-0001-9322-6495
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How to cite this article: Koulivand S, Ghodsi S, Siadat H,
Alikhasi M. A clinical comparison of digital and conventional
impression techniques regarding finish line locations and
impression time. J Esthet Restor Dent. 2019;1–8. https://doi.
org/10.1111/jerd.12527