RESEARCH AND EDUCATION

In vitro fit of CAD-CAM complete arch screw-retained titanium

and zirconia implant prostheses fabricated on 4 implants
Hadi AL-Meraikhi, DDS, MS, FACP,a Burak Yilmaz, DDS, PhD,b Edwin McGlumphy, DDS, MS,c
William Brantley, BS, MS, PhD,d and William M. Johnston, MS, PhDe

ABSTRACT
Statement of problem. Computer-aided designed and computer-aided manufactured (CAD-CAM) titanium and zirconia implant-supported
fixed implant prostheses on 4 implants have become popular. The precision and accuracy of their interface fit has not been widely researched.
Purpose. The purpose of this in vitro study was to compare the marginal fit of zirconia and titanium implant-supported screw-retained CAD-
CAM complete fixed dental prostheses (CFDP) fit with a standardized cast simulating the all-on-4 implant distribution.
Material and methods. Representation of an edentulous maxilla with 4 multiunit replicas embedded in sites corresponding to the positions
of the maxillary first molars and canines was chosen. Multiunit abutments were digitally scanned using scan bodies and a laboratory scanner.
CAD software was used to design screw-retained implant-fixed complete prostheses framework, and the file was sent to a milling machine for
CAM. Titanium (n=5) and zirconia (n=5) frameworks were milled on 4 implants, and the frameworks were scanned with an industrial
computed tomography (CT) scanner while applying the 1-screw test. The direct CT scans were reconstructed to generate a standard
tessellation language (STL) file from the voxel data set and transported to volume graphics analysis software from which measurements
were extracted. The circular mating surfaces of the corresponding framework interfaces to their representative multiunit abutment
replicas on the standard were measured for implant position left maxillary canine (LMC), implant position right maxillary canine (RMC)
and implant position right maxillary first molar (RMFM). In addition, color maps were generated to show the marginal discrepancy
between the mating surfaces using ±0.500 mm color scale ranges.
Results. The material type (zirconia or titanium) was not significant for 3D discrepancy measurements (P=.904). However, 3D discrepancy
measurement values were significantly different between RMC and RMFM within each group (P<.001). The mean 3D ±SD discrepancy
measurement for LMC for titanium was 48.2 ±2.6 mm. The mean ±3D discrepancy measurement for RMC for titanium was 74 ±15 mm and
84.4 ±12.1 mm for zirconia. The mean 3D discrepancy measurement for RMFM for titanium was 102 ±26.7 mm and 93.8 ±30 mm for zirconia. All
3D discrepancy measurements showed values <135 mm.
Conclusions. Within the limitations of the present in vitro study, implant-supported CAD-CAM fabricated titanium and zirconia complete fixed
dental prosthesis frameworks showed comparable marginal fit. Three-dimensional microgap measurements of frameworks showed clinically
acceptable misfit values. Absolute passive fit was not achieved. (J Prosthet Dent 2017;-:---)

Since the early days of osseointegration, the successful
rehabilitation of patients with edentulism has included
routinely splinting dental implants with a fixed dental
prosthesis (FDP).1-4 Splinting distributes occlusal forces,5-7
reduces stress levels around individual implants,8-10
decreases mechanical complications,11 and reduces the
overall treatment cost because fewer implants are
needed.12
The importance of a passive fit of frameworks for
implant-supported FDPs has been reported.12 However,

Supported by The Ohio State University Implant Research Fund.

a
Prosthodontist, Division of Prosthetic Dentistry, Hamad Medical Corporation, Doha, Qatar.
b
Associate Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University College of Dentistry, Columbus, Ohio.
c
Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University, College of Dentistry, Columbus, Ohio.
d
Professor, Interim Chair, Division of Restorative and Prosthetic Dentistry, and Director, Graduate Program in Materials Science, The Ohio State University,
College of Dentistry, Columbus, Ohio.
e
Professor, Division of Restorative and Prosthetic Dentistry, The Ohio State University, College of Dentistry, Columbus, Ohio.

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Clinical Implications
CAD-CAM-fabricated complete-arch screw-retained
titanium and zirconia implant prostheses fabricated
on 4 implants have similar clinically acceptable
marginal fit values and may be used as a definitive
prosthesis material for the tested CAD-CAM and
implant systems.

to date, no consensus has been reached on the exact

level of misfit considered acceptable in implant
frameworks.13-15 Brånemark1 was the first to quantify
the passive fit of implant frameworks and proposed that
Figure 1. Master model.
the misfit should not exceed 10 mm. Jemt16 stated that a
misfit of approximately 150 mm is acceptable and intro-
passive fit for the framework and subsequently for the
duced the screw resistance test. More recently, Sahin
definitive prostheses.30
et al17 and Watanabe et al18 defined the passive fit of
Computer-aided design-computer-aided manufac-
implant-supported frameworks as one that does not
ture (CAD-CAM)-fabricated titanium implant frame-
exert any strains on the implants in the preloaded
works have been reported to have a high degree of
condition.
accuracy for complete-arch and partial-arch prostheses.31
The Sheffield test or “1-screw test” is one of the most
However, zirconia frameworks were confirmed to exhibit
popular tests for clinical evaluation of framework fit.13,16
an accurate fit only for partial-arch prostheses.31 On
When 1 screw on the most distal abutment is completely
natural teeth, Beuer et al32 and Sachs et al33 evaluated
tightened without creating a discrepancy between the
the marginal and internal fit of single crowns compared
rest of abutments and cylinders, the framework is
with 14-unit zirconia FDPs. The 14-unit FDPs showed
considered clinically acceptable.19,20 This method is
significantly higher marginal openings than single
particularly applicable for complete-arch frameworks, in
crowns when fabricated under the same conditions. The
which the discrepancy size tends to increase at the
literature on the fit of CAD-CAM implant-supported
unscrewed abutments. However, misfit is not detected in
complete prosthesis made from presintered zirconia is
3 dimensions and can be difficult to detect if the distor-
limited.34-47
tion occurs in the horizontal plane.19,20
The purpose of this in vitro study was to compare the
Mechanical and biological complications result from
marginal fit and discrepancy of complete-arch implant-
inadequately fitting implant frameworks. The most com-
supported screw-retained CAD-CAM zirconia and tita-
mon mechanical complications have been loosening or
nium FDPs. The null-hypothesis was that no difference
fracture of the implant prosthetic screws.17,21-23 Also,
would be found in 3D microgap values between zirconia
microgaps between the implant and framework may be
and titanium CAD-CAM FDP frameworks.
colonized by bacteria, which may be detrimental to the
remodeling process of the crestal bone and the overall
MATERIAL AND METHODS
health of the periimplant tissues.24 Misfits of 500 or even
1000 mm failed to produce negative effects on osseointe- A master model simulating an edentulous maxilla with
gration and bone remodeling in animal studies.25-29 4 implants (Nobel Active regular platform 4.3×13 mm;
However, all reported animal studies assessed the Nobel Biocare) simulating the all-on-4 concept (All-on-
stresses only in the unloaded condition. The stresses are 4 concept; Nobel Biocare Model) was used (Fig. 1). The
believed to rise significantly during function and may 2 anterior implants were in a parallel and vertical
cause a different outcome. Until clear guidelines regarding alignment, whereas the 2 posterior implants were
acceptable misfit are available, clinicians should strive for angled at 30 degrees in the sagittal plane. Straight
the best framework fit possible to decrease potential multiunit abutments (RP 2.5 mm; Nobel Biocare) were
complications.30 It can be assumed that the higher the placed at the maxillary right and left canine sites and
precision of fit of an implant-supported prosthesis, the 30-degree multiunit abutments (RP 3.5 mm; Nobel
less likely any biological or technical complications are Biocare) at the maxillary right and left first molar sites.
encountered in the long term.30 Although splinting of Based on a denture tooth arrangement, a complete-
implants for implant-supported FDPs has its advantages, arch resin prototype (Pattern Resin LS; GC America)
it may be extremely challenging to achieve an absolute was fabricated with 4 copings (Multiunit Titanium

THE JOURNAL OF PROSTHETIC DENTISTRY AL-Meraikhi et al

- 2017
Figure 2. Resin prototype. A, Complete contour resin prototype. B, Completed facial cut back.
Abutment Level; Nobel Biocare) for screw retention
(Fig. 2A).
A facial matrix was used to control a 1.5-mm even cut
back on the facial aspect of all teeth except for the molars
bilaterally (Fig. 2B). The optimal fit of the resin prototype
on the master model was ensured by sectioning and
reassembling the sections with the same acrylic resin. All
4 screws were used to secure the resin prototype on the
master model to best fit the prototype of which a digital
scan would serve as the baseline. The master model and
resin prototype were both digitized with a laser scanner
(S600 ARTI; Zirkonzahn).
Implant scan bodies (Scanmarker NP RP; Zirkon-
zahn) were screwed on the abutments for the master
model scan. The resin prototype was scanned after
application of a scanning spray (Zirko Scanspray; Zir-
konzahn). After the scanning process, a CAD model was
constructed using software (Zirkonzahn). This CAD
model was the basis for milling the titanium and zirconia
frameworks (Fig. 3). All frameworks were fabricated with
the same equipment and materials by an experienced
dental technician. A new set of milling burs was used
after each framework milling procedure. A total of 5
zirconia frameworks were milled from a solid presintered
zirconia block (ICE Zirkon Translucent 95H16; Zirkon-
zahn) in a 5-axis +1 milling machine (Milling Unit M1
Heavy; Zirkonzahn). The software calculated the ex-
pected 20% linear shrinkage that is encountered after the
sintering process (http://www.zirkonzahn.com). All
frameworks were sintered for 9.5 hours to full density in a
special furnace (Zirkonofen700; Zirkonzahn) (Fig. 4A).
Then, a total of 5 titanium frameworks were milled from
a solid block (Titan Metall 95H14; Zirkonzahn) with the
same milling unit (Fig. 4B). All frameworks, whether
made from titanium or zirconia, were not adjusted or
finished in any way. Only the sprues that attached the
framework to the block were manually cut and smoothed
with a bur (EL2; SS White).
AL-Meraikhi et al
3
Figure 3. Three-dimensional computer-aided design model.
All measurements were obtained from the same
master model and by 1 trained investigator. The 1-screw
test was implemented for the quantitative assessment of
the discrepancy measurements. Before computed to-
mography (CT) scanning, each framework was tightened,
first by hand, on the master model with screws on the
implant position of the right maxillary canine and left
maxillary first molar to avoid any horizontal displace-
ment. Only the left maxillary first molar screw was then
tightened to a torque of 15 Ncm using a calibrated
manual torque wrench (Nobel Biocare), and the other
screw was then removed. All 5 titanium and 5 zirconia
frameworks were scanned with the same 1-screw test
protocol, using an industrial computed tomography (CT)
scanner (X-Tek XT H 225kV MCT Micro-Focus Industrial
CT Scanner; Nikon). All inspections were performed
using an instrument calibrated with standards traceable
to the international system of units through a national
metrological institute or a laboratory accredited by In-
ternational Organization for Standardization standard
17025 (http://www.iso.org/iso/home.htm). The expanded
measurement uncertainty was 11+30L mm, where
THE JOURNAL OF PROSTHETIC DENTISTRY
4 Volume
Figure 4. Completed restoration. A, Zirconia framework. B, Titanium
framework.
L=measured length in meters. Uncertainty was expressed
at approximately a 95% level of confidence using k=2.00.
The direct CT scans were reconstructed to generate a
standard tessellation language (STL) file from the voxel
data set and transported to a volume graphics analysis
software (PolyWorks; Innovmetric) from which mea-
surements were extracted. The 3D discrepancy mea-
surements among the circular mating surfaces, the
frameworks, and the implant abutments were measured
only for implant position (left maxillary canine [LMC];
right maxillary canine [RMC]; and right maxillary first
molar [RMFM]). The mating surfaces at the implant
position at the left maxillary first molar (LMFM) were not
reported as they were in contact. In addition, color maps
were generated to show the marginal discrepancy be-
tween the mating surfaces at positions LMC, RMC, and
RMFM, using a ±0.500 mm color scale range (Fig. 5).
Discrepancies were measured using planes created from
scan data of the mating surfaces LMC, RMC, and RMFM
(Fig. 6A, B). Planes were fitted to the data using a
maximum fit algorithm rather than a best-fit algorithm.
The maximum fit algorithm fits a plane at only the
highest eligible data points. This type of fit was used
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 5. Color map for discrepancy right maxillary canine in titanium.
Values in boxes are in mm.
because it best mimics how the surface would mate with
another surface (http://www.innovmetric.com). The
standard method for measuring the distance between 2
planes involves using 1 plane as a reference. The mea-
surements were made by creating a line normal to the
reference plane surface. This line was made to begin at
the reference plane and end at the centroid of the other
plane being considered. The 3D distance reported was
the length of this line (Fig. 6C). The measurements made
in this study used the flat abutment surfaces as the
reference plane.
The 3D discrepancy distances were analyzed by a
repeated measures analysis of variance (MIXED proced-
ure, SAS Proprietary Software v9.3; SAS Institute Inc)
using the maximum likelihood estimation method to
eliminate the need for normality and equality of vari-
ances. The factors were the material and discrepancy
distances, with all interactions included in the statistical
model. For this analysis, the repeated measure was
discrepancy distance, with the subject being the spec-
imen of each material (a=.05).
RESULTS
Results showed that the material type (zirconia or tita-
nium) was not significant for 3D discrepancy measure-
ments (P=.904). Differences in 3D microgap values
between zirconia and titanium CAD-CAM FDP frame-
works were not shown to be significant. However, 3D
discrepancy measurement values were significantly
different between RMC and RMFM within each group
±P<.001 (Table 1). The mean ±SD 3D discrepancy
measurement for ±LMC for titanium was 48.2 ±2.6 mm.
The mean ±SD 3D discrepancy measurement for ±RMC
for titanium was 74 ±15 mm and 84.4 ±12.1 mm for zir-
conia. The mean ±SD 3D discrepancy measurement for
AL-Meraikhi et al
- 2017 5

Table 1. ANOVA summary for 3D discrepancy measurement (mm)

Effect Num DF Den DF F P
Discrepancy 2 15 14.7 <.001
Material 1 12.6 0.02 .904
Discrepancy×material 1 15 1.81 .198
Den, denominator; DF, degree of freedom; Num, numerator.

140 RMFM Discrepancy

120

RMC
100

3D Distance (µm)
80

60 LMC

Data not available

40

20

ia

ia

ia
um

um

um
on

on

on
ni

ni

ni
rc

rc

rc
ta

ta

ta
Zi

Zi

Zi
Ti

Ti

Ti
Material
Figure 7. Mean 3D discrepancy distances. LMC, left maxillary canine;
RMC, right maxillary canine; RMFM, right maxillary first molar.

microgap values between RMC and RMFM within each

Figure 6. CT image of discrepancy measurement. A, CT image of implant
position LMC. B, CT image of implant position RMC, and implant position
RMFM. C, 3D discrepancy measurement. CT, computed tomography;
LMC, left maxillary canine; RMC, right maxillary canine; RMFM, right
maxillary first molar.
±RMFM for titanium was 102 ±26.7 mm and 93.8 ±30 mm
for zirconia. All 3D discrepancy measurements showed
values <135 mm (Fig. 7).
From the ANOVA table, the effect of material type
(zirconia and titanium) was not significant on 3D mar-
ginal discrepancy (P=.904) and the 3D discrepancy
measurements were significant only within groups
(P<.001). A significant difference was found in the 3D
group.
For the overall difference in discrepancy distances
between the titanium and zirconia, the standard error
was 12.6 mm as provided by the solution of the ANOVA.
For a power of 95%, this results in a detectable effect size
of 1.08 mm or a detectable difference of 19.2 mm. For the
interaction between the materials and location factors,
the standard error was 15.5 mm as provided by the so-
lution of the ANOVA. For a power of 95%, this results in
a detectable effect size of 0.744.
DISCUSSION
The null hypothesis that no differences would be found
in 3D microgap values between zirconia and titanium
CAD-CAM FDP frameworks was accepted. Results of
this study agree with those of previous investigations that
absolute passive fit of FDPs does not yet exist.17,31,34
Dental reports present extensive information regarding
the fit of implant frameworks; however, there was no
agreement on a specified number to be considered
acceptable. Historically, misfits ranging from 10 to 150
mm were considered within the clinically acceptable
range.5,16 These values were reported considering specific

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6 Volume
implant systems and fabrication techniques, and there is
still an ongoing debate about the clinically acceptable
misfit for dental frameworks. Although a clinically
acceptable threshold for marginal misfit for tooth- or
implant-borne FDPs has not yet been supported by
definitive scientific evidence,15 it has also been
commonly claimed to be below 120 mm.48-50 However,
based on their clinical observations, some clinicians51,52
claim that the limit of marginal misfit may be up to 200
mm.
In a recent review by Abduo31 on the fit of CAD-CAM
implant frameworks, milled titanium and zirconia
frameworks were found to have comparable fit.35-37 One
study even found a slightly better fit for the zirconia
frameworks.38 However, those studies used short-span
3-unit fixed implant prostheses. More recently, Katsou-
lis et al39 compared the precision of fit of long-span
versus short-span implant-supported screw-retained
FDPs made from CAD-CAM titanium. In that study, all
frameworks showed clinically acceptable values. How-
ever, short-span FDPs were significantly more precise
than long-span prostheses. In another study40 from the
same group, the precision of fit of a CAD-CAM implant-
supported complete-arch prosthesis made from presin-
tered zirconia was compared with titanium. Their results
showed that the titanium frameworks had the most
consistent precision.
The direct comparison of results from this study with
those of previous studies in regard to discrepancy mea-
surement is difficult because the definition of passive fit
and measuring methods used were not standardized.
Some authors used the fit with all screws tightened for
their measurements.31,41,42 Most of those studies found
that when all the retaining screws were fully tightened,
the vertical discrepancies were eliminated, even for dis-
crepancies ranging from 30 to 500 mm.43,44 However, in
this situation, the fit can be achieved under strain, which
is then subjected to occlusal load from a range of different
vectors and may result in fatigue loading and
complications.
Some authors have suggested that the machining
tolerance could help minimize the final distortion. Pas-
sive fit could occur if the machining tolerance was more
than or equal to the final distortion.45 However, the
machining tolerances for different systems and tech-
niques may vary. The in vitro methods for the quantita-
tive assessment of the marginal discrepancy reported
differed in various studies. A microscope was used in
several studies for the direct measurement of the inter-
face, although, this method is only able to detect
distortion in 2 dimensions and is only able to measure
the vertical discrepancy.30,40,41,46 Because distortion can
occur in 3 dimensions, this method may be not sufficient.
Other studies measured the discrepancy distances
THE JOURNAL OF PROSTHETIC DENTISTRY
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indirectly from sectioned impression materials injected
between the implant and framework interface.47 This
technique is prone to inconsistencies because of manual
discrepancies and errors.14
Advances and improvements in CT scanning have led
to their extensive use in industry. Some of the major uses
for CT scanning have been in the nondestructive testing
of components such as flaw detection, failure analysis,
metrology, and reverse engineering. In this study, a
highly accurate industrial CT scanner was used to scan
the completed restoration at the same time as 3D
microgap values were obtained with the aid of the 1-
screw test. This method has the advantage that X-rays
can penetrate the framework to digitize the internal
surface of the framework (for example, the abutment/
implant interface). The accuracy of the industrial CT
scanner depends on the size and density of the material
to be scanned. The final accuracy of the data set is called
measurement uncertainty and can be determined for this
particular industrial CT scanner using the formula
(11+30L) mm, where L equals length measured in meters
(www.nikonmetrology.com). The length is determined
from the size of the part being measured. In this case, the
frameworks were about 53 mm across at their longest
(0.053 meters). From the formula mentioned above,
11+30 (0.053) equals 12.59 mm, and 12.59 mm is the
measurement uncertainty across the surface of the
framework. The measurements in this study were much
smaller (less than 1 mm); therefore, 11+30 (0.001) or 11.3
mm would be estimated for the final measurement un-
certainty and could be considered as a measurement
error. Measurement uncertainty also considers factors
beyond the accuracy of the equipment being used such as
repeatability, environmental factors, and the accuracy of
the equipment used to calibrate the CT scanner.
A possible limitation of this study was that dental
scanners use point clouds while industrial CT scanners
use voxels to acquire the surface data of a specimen. To
transfer the acquired data from the dental and industrial
CT scanners into the inspection software for comparison,
a 3D CAD model has to be generated in the form of an
stereolithography file. During the generation of STL
datasets from both methods (point clouds, voxel), the
accuracy of measurements might have been affected. The
focus of this study was on the fit and distortion of
frameworks that started with the CAD procedure and
ended with the CAM in milling. All frameworks were
fabricated on the same master model to minimize
manual errors. However, inaccuracies in the clinical
recording of the positions of the implants may also
contribute to the final misfit of the frameworks. Future
studies should evaluate the overall fit after clinical digital
impressions and CAD-CAM fabrication of these frame-
works. In addition, only 1 site (implant at the maxillary
AL-Meraikhi et al
- 2017
left first molar site) was used to secure the screw for the
1-screw test used in this study. The fit of the framework
may differ when 1 screw is used in different implant sites
to evaluate the fit discrepancy at the other implant sites.
Future studies should use a similar technique but secure
the screw at different sites to measure the discrepancies
at the nonsecured interfaces.
CONCLUSIONS
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. Implant complete-arch CAD-CAM titanium and
zirconia frameworks showed no significant differ-
ences in fit.
2. Three-dimensional marginal discrepancy measure-
ments of both zirconia and titanium frameworks
showed clinically acceptable misfit values.
3. Absolute passive fit was not achieved with either of
the materials and CAD-CAM systems tested in this
study.
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