Marginal Fit of Lithium Disilicate Crowns Fabricated Using

Conventional and Digital Methodology: A Three-Dimensional

Analysis
Nezrine Z. Mostafa, BDS, MSc/Dip Pros, PhD, FRCD(C),1 N. Dorin Ruse, MSc, PhD, MCIC, FADM,2
Nancy L. Ford, PhD,3 Ricardo M. Carvalho, DDS, PhD,2 & Chris C.L. Wyatt, BSc, DMD, MSc, Dip Pros1
1
Department of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada
2
Department of Oral Biological & Medical Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada
3
Department of Oral Biological & Medical Sciences, Centre for High-Throughput Phenogenomics, Faculty of Dentistry, The University of British
Columbia, Vancouver, Canada

Keywords
All-ceramic restoration; CAD/CAM; digital
workflow; marginal fit.
Correspondence
Nesrine Mostafa, Division of Prosthodontics
& Dental Geriatrics, University of British
Columbia - Faculty of Dentistry, Room 360-
2199 Wesbrook Mall, Vancouver, BC V6T1Z3
- Canada.
E-mail: nmostafa@dentistry.ubc.ca
Awarded 2nd place at the ACP Resident
Poster Competition at the 45th American
College of Prosthodontics Annual Meeting.
Orlando, FL, October 21–24, 2015.
The authors deny any conflicts of interest.
Accepted March 30, 2017
doi: 10.1111/jopr.12656
Abstract
Purpose: To compare the marginal fit of lithium disilicate (LD) crowns fabricated
with digital impression and manufacturing (DD), digital impression and traditional
pressed manufacturing (DP), and traditional impression and manufacturing (TP).
Materials and Methods: Tooth #15 was prepared for all-ceramic crowns on an
ivorine typodont. There were 45 LD crowns fabricated using three techniques: DD,
DP, and TP. Microcomputed tomography (micro-CT) was used to assess the 2D and
3D marginal fit of crowns in all three groups. The 2D vertical marginal gap (MG)
measurements were done at 20 systematically selected points/crown, while the 3D
measurements represented the 3D volume of the gap measured circumferentially at
the crown margin. Frequencies of different marginal discrepancies were also recorded,
including overextension (OE), underextension (UE), and marginal chipping. Crowns
with vertical MG > 120 μm at more than five points were considered unacceptable
and were rejected. The results were analyzed by one-way ANOVA with Scheffe post
hoc test (α = 0.05).
Results: DD crowns demonstrated significantly smaller mean vertical MG (33.3 ±
19.99 μm) compared to DP (54.08 ± 32.34 μm) and TP (51.88 ± 35.34 μm) crowns.
Similarly, MG volume was significantly lower in the DD group (3.32 ± 0.58 mm3 )
compared to TP group (4.16 ± 0.59 mm3 ). The mean MG volume for the DP group
(3.55 ± 0.78 mm3 ) was not significantly different from the other groups. The oc-
currence of underextension error was higher in DP (6.25%) and TP (5.4%) than in
DD (0.33%) group, while overextension was more frequent in DD (37.67%) than in
TP (28.85%) and DP (18.75%) groups. Overall, 4 out of 45 crowns fabricated were
deemed unacceptable based on the vertical MG measurements (three in TP group and
one in DP group; all crowns in DD group were deemed acceptable).
Conclusion: The results suggested that digital impression and CAD/CAM technology
is a suitable, better alternative to traditional impression and manufacturing.

Indirectly fabricated complete coverage restorations are fre-
quently needed to restore function and esthetics. All-ceramic
restorations became more popular over the last few decades due
to increased esthetic demands.1 These restorations can be fab-
ricated conventionally or digitally. Conventionally fabricated
crowns have been used for decades with proven long-term suc-
cess and survival.2 Accurate fit of the indirect restorations fab-
ricated using conventional methods relies on the accuracy of
impression, stone casts, wax patterns, investment, and casting.
Each step requires attention to detail to minimize distortion
and to produce a crown with adequate fit.3 The introduction
of digital technology requires fewer steps (digital impressions
and computer-aided design/computer-aided manufacturing -
CAD/CAM) and provides a standardized approach for crown
fabrication that reduces the potential for error.3 Moreover, dig-
ital impressions are more efficient than traditional impressions,
as image acquisition is monitored live, allowing easy rescans
for ill-defined areas. An added benefit of digital impressions is
patient comfort and acceptance.3,4
The clinical success of all-ceramic restorations is based on
marginal integrity, anatomic form, and mechanical properties
of the material used.5 Marginal fit of the crown is an important

Journal of Prosthodontics 00 (2017) 1–9 

C 2017 by the American College of Prosthodontists 1
Conventionally, Digitally Fabricated LD Crown Marginal Fit
determinant of the long-term success. Marginal discrepancies
(MD) increase plaque accumulation and, consequently, the risk
of caries and periodontal disease;6-8 they also expose cement
and contribute to its dissolution.9
Clinically, marginal gap (MG) can be examined directly with
a mirror and a probe.6 The most commonly used in vitro tech-
niques for MG measurements are the direct viewing and cross-
sectioning techniques. The direct viewing method is nonde-
structive and inexpensive, but it is limited by projection error
and difficulty identifying reference measurement points.10 The
cross-sectioning technique is a destructive method that allows
for direct measurement of the marginal and internal fit, but it
does not permit longitudinal assessment of same specimens be-
fore and after different manufacturing stages or prior to clinical
placement.10 Microcomputed tomography (micro-CT) offers a
nondestructive evaluation of the marginal and internal gaps at
multiple sites and in multiple directions.11 The objective of
this study was to determine 2D and 3D marginal fit, using
micro-CT, of lithium disilicate (LD) crowns fabricated using
three methods: digital imaging and digital manufacturing (DD),
digital imaging and pressing (DP), and traditional impression
and pressing (TP). This study also recorded the prevalence of
marginal discrepancies in each group (i.e., overextended mar-
gins, underextended margins, and marginal chippings).
Materials and methods
Crown fabrication
Tooth #15 was prepared for an all-ceramic crown on an ivorine
typodont. The typodont was then digitized, using a 3Shape
D700 lab scanner (3Shape Inc., Warren, NJ), and the digital
file was used to produce a replica of the maxillary arch milled
in yttria-stabilized zirconia. A total of 45 LD crowns were
made from the master zirconia cast using three methods (n =
15/group): DD, DP, and TP. Digital impressions were taken
using a LAVA C.O.S. scanning unit (3M, Lexington, KY), fol-
lowing manufacturer’s instructions. Titanium dioxide powder
was lightly sprayed on the zirconia model prior to scanning
using a hand-held spray gun, with standardized time bursts (1
second) and distance (2 cm) to ensure homogeneity in the thick-
ness of the powder layer.12 The arch was scanned and displayed
on the monitor. Scanned STL files were sent to the laboratory
(Aurum, Calgary, Canada), which used Dental Wings Open
Software (DWOS) to digitally design DD crowns. Minimum
crown thickness was set to 1 mm, and the margin was slightly
enhanced by setting the horizontal margin thickness to 0.1 to re-
duce ceramic chipping during milling. IPS e.max CAD blocks
were milled using a five-axis milling engine operated through
Core3dcentres software (Las Vegas, NV). For the fabrication
of DP crowns, STL files obtained from the intraoral scan were
sent to In’Tech manufacturing center (3M ESPE, St. Paul, MN)
to generate stereolithography (SLA) polyurethane models with
removable dies. SLA models were used for the fabrication of
traditional pressed LD crowns via the lost-wax technique. TP
crowns were fabricated from 15 poly(vinyl siloxane) (PVS)
impressions (Dentsply Canada, Woodbridge, Canada) taken in
standardized acrylic resin custom trays painted with Caulk tray
adhesive (Dentsply Caulk, Milford, DE). PVS impressions were
poured with type IV stone (Whip Mix Corporation, Lexington,
2 Journal of Prosthodontics 00 (2017) 1–9 
Mostafa et al
KY), and pressed LD crowns were fabricated using the lost-wax
technique. No adjustments were made to the intaglio surfaces
or to the overhanging margins of the finished crowns.13
Virtual cement space prescribed for DD crowns was 20 μm.
For pressed crowns (DP and TP), one layer of a latex-based die
spacer (Rem-e-die; Ivoclar Vivadent, Schaan, Liechtenstein)
was applied over the entire die to within 0.5 mm of the margin
to form 20 μm die spacer thickness. A 20 μm cement space
was used in all study groups to minimize errors that might arise
from placing two layers of die spacer and because, often, the
digitally prescribed space is 20 μm.13
Micro-CT scanning
Master zirconia die was scanned with a LAVA COS scanner, and
45 duplicate dies were milled in polyurethane using five-axis
milling. Polyurethane, with a significantly lower radiopacity
than LD crowns, facilitated the assessment of MG by micro-
CT. LD crowns were seated on their respective duplicate dies
using finger pressure and were stabilized with utility wax at
the crown margin.11,13,14 Micro-CT scans were performed in
a Scanco Medical micro-CT100 scanner (Scanco Medical AG,
Brüttisellen, Switzerland). During the scan, crowns were seated
on their respective dies and stabilized individually in heavy
putty silicone in the sample holder of the micro-CT scanner.
Images were acquired at 90 kVp and 200 μA, through 180°
with 0.36° rotation step using 0.5 mm aluminum filter and
frame averaging of 2, to produce cross-sectional images of
20 μm resolution. Images were reconstructed using filtered
back projection reconstruction software.
Marginal fit assessment
Marginal gap (MG) volume measurements
The 3D volume of the gap measured circumferentially at the
crown margin was based on a standardized number of slices for
the selected region of interest (100 slices of each specimen) us-
ing MicroView software (GE Healthcare, Mississauga, Canada)
(Fig 1). The top reference slice was set at the intersection of
cavosurface margin with the axial wall of the preparation. The
bottom reference slice was set at the intersection of the prepa-
ration finish line with the cavosurface angle of the preparation.
Then, the marginal gap volume in the selected 100 slices of
each specimen was segmented. Segmentation was done using
region-growing method, and the resultant volume of the con-
nected voxels was recorded as the 3D volume for the marginal
gap. To ensure the accuracy of the volume measurements, the
3D MG was measured twice for three randomly selected spec-
imens, and the resultant 3D volumes were compared using
Pearson’s correlation (r2 ).
Vertical MG measurements
Vertical MG was measured (gold standard) to validate the MG
volume measurement. Vertical MG was measured according to
Holmes et al15 and is defined as the perpendicular measure-
ment from the cavosurface angle of the tooth to the opposing
crown margin (Fig 2). Our study employed a systematic cross-
sectional analysis of the vertical MG. This approach resulted
in 20 measurements (5 mesial, 5 distal, 5 buccal, 5 lingual)
C 2017 by the American College of Prosthodontists
Mostafa et al Conventionally, Digitally Fabricated LD Crown Marginal Fit

for each crown and a total of 300 measures per group around
the circumference of the crown margins (Fig 3). Mesiodistal
measurements were made every 70 slices, while buccolingual
measurements were made every 50 slices.

Marginal discrepancies
Frequency of occurrence of marginal discrepancies was
recorded at the same standardized points used for the verti-
cal MG measurements (n = 20 points per crown), resulting in
a total of 300 points per group around the circumference of the
crown margins. To minimize measurement error, vertical MG
measurement was modified based on the type of discrepancy as
described below:
r Overextended margin: recorded as the perpendicular
measurement from the cavosurface angle of the tooth to
the opposing crown margin (Fig 4).
r Underextended margin: recorded as the perpendicular Figure 3 Standardized slice selection for circumferential vertical MG
measurement from the crown margin to the opposing measurement. Mesiodistal measurements were made every 70 slices,
cavosurface margin of the tooth (Fig 5).
r Marginal chipping: recorded as the perpendicular mea-
while buccolingual measurements were made every 50 slices. A total
of 20 measurements were done for each crown (5 mesial, 5 distal, 5
surement from the external crown margin to the opposing buccal, 5 lingual) using this approach.
preparation line at the point in the shortest perpendicular
distance (Fig 6).

Figure 1 MG volume measurement: (A) Micro-CT image of a repre-

sentative crown seated on its corresponding dies showing standardized
selection for the region of interest from the crown margin to the axial Figure 4 Cross-sectional Micro-CT image of a crown seated on its cor-
wall of the preparation in the 3D space with the three coordinate axes responding die showing vertical MG measurement for an overextended
(x, y, and z), and (B) segmentation of the 3D volume of the marginal gap. margin.

Figure 5 Cross-sectional micro-CT image of a crown seated on its corre-

Figure 2 Vertical MG measurement from the cavosurface angle of the sponding die showing vertical MG measurement for an underextended
tooth to the opposing crown margin. margin.

Journal of Prosthodontics 00 (2017) 1–9 

C 2017 by the American College of Prosthodontists 3
Conventionally, Digitally Fabricated LD Crown Marginal Fit
Figure 6 Cross-sectional micro-CT image of a crown seated on its corre-
sponding die showing vertical MG measurement for porcelain chipping.
Figure 7 Micro-CT image of an unacceptable crown with open margins
(vertical MG >120 μm at more than five points).
Figure 8 3D MG volume for a representative specimen in each group
(DD, DP, TP). Yellow areas represent the cement space at the most
coronal slice, white areas represent segmentation of 3D volume of the
cement space at the predefined crown margin, and dark areas repre-
sent intimate fit of the crown margin to the cavosurface margin of the
preparation.
Acceptable and unacceptable crowns
As previously discussed, most in vitro studies16,17 have claimed
that the clinically acceptable MG should be less than 120 μm.
Therefore, crowns with vertical MG ࣘ 120 μm were considered
acceptable, while crowns with vertical MG >120 μm at more
than five points were deemed to be unacceptable and were
rejected (Fig 7). MG volumes for the unacceptable crowns
were also recorded for comparison.
4 Journal of Prosthodontics 00 (2017) 1–9 
Mostafa et al
Table 1 MG volume measurements (n = 15 crown/group)
MG Volume (mm3 )
Mean STD
Procedure DD 3.32 a 0.58
DP 3.55 a, b 0.78
TP 4.16 b 0.59
Values with same superscript letters are not significantly different (p < 0.05).
Figure 9 Box plot of the MG volume measurements (n = 15
crown/group).
Statistical analysis
Power analysis, based on a previous study,18 indicated that
a sample size of 15 was required to detect significant mean
differences of 20 μm between the groups in the presence of
20 μm standard deviation. Differences in vertical MG and
MG volume between the three groups were analyzed by one-
way ANOVA with Scheffé’s post hoc test using SPSS software
(SPSS, Chicago, IL). Chi-square was used to assess differences
between the groups in marginal discrepancies. Statistical sig-
nificance was set at α = 0.05.
Results
MG volume measurements
Visualization of the 3D MG volume (Fig 8) demonstrated a
clear increase in the cement space around the circumference
of the crown margins between the three experimental groups
(DD < DP < TP). Quantitative analysis of the MG volume
(Table 1) demonstrated significantly smaller volume in DD
group as compared to TP group; however, the mean MG volume
for DP group was not significantly different from the other
groups (Fig 9). Correlation between repeated 3D MG volume
measurements was significant (r = 0.97).
Vertical MG measurements
The overall vertical MG measurements (n = 300 measure-
ments/group) are presented in Figure 10 and Table 2. DD group
C 2017 by the American College of Prosthodontists
Mostafa et al
Figure 10 Box plot of the vertical MG measurements at 20 standardized
points per crown (n = 300 measurements/group).
Table 2 Mean vertical MG measurements for each group at 20 stan-
dardized points per crown (n = 300 measurements/group)
Vertical MG (μm)
Mean
a
Procedure DD 33.30
DP 54.08 b
TP 51.88 b
Values with same superscript letters are not significantly different (p < 0.05).
demonstrated significantly smaller vertical MG compared to
DP and TP groups. For the DD group, no statistically signif-
icant differences in MG measurements were noted among the
different sites. The buccal site in the DP and TP groups had
a significantly lower vertical MG than the mesial, distal, and
lingual sites (Table 3).
2D vs. 3D measurements
The MG morphology was analyzed in cross section to explore
the relationship between 2D and 3D marginal gap measure-
ments (Fig 11). Crowns fabricated using the DD demonstrated
smaller vertical MG, but tended to have larger MG volume
at the line angles of the preparations. On the other hand, DP
and TP crowns showed larger MG measurements that were
consistent with MG volume measurements. They also showed
better internal adaptation at the line angle of the preparation as
compared to the milled group.
Marginal discrepancies
Frequency of marginal discrepancies was recorded at 20 stan-
dardized points per crown and a total of 300 points per group
around the circumference of the crown margins (Table 4).
Journal of Prosthodontics 00 (2017) 1–9 
C 2017 by the American College of Prosthodontists
Conventionally, Digitally Fabricated LD Crown Marginal Fit
Figure 11 A cross-sectional analysis of the marginal gap morphology in
buccolingual and mesiodistal directions for DD, DP, and TP groups.
Overextension was the most frequent marginal discrepancy in
all groups, and it was more common in the DD group than in
TP and DP groups. Underextension was more frequent in DP
and TP groups than in the DD group; however, there were no
significant differences in the occurrence of marginal chippings
between the three groups.
Unacceptable crowns
Four of 45 crowns fabricated were deemed unacceptable based
STD
on vertical MG measurements: three in TP group and one in DP
group; all crowns in the DD group were considered acceptable.
19.99 This means that the DD method resulted in 100% acceptable
32.34 crowns, while DP and TP resulted in 7% and 20% unaccept-
35.34 able crowns, respectively. Mean MG volume for unacceptable
crowns was 7 ± 1.3 mm3 .
Discussion
There has been considerable debate in the literature about the
accuracy of digitally fabricated indirect restorations. Results
vary from improved fit to more misfits of digitally fabricated
ceramic restorations when compared with the conventionally
fabricated crowns.18-20 Moreover, reported MG for ceramic
restorations is widely diverse and ranges from 7.5 to 206.3
μm. Such variation could be attributed to lack of coherence in
the definition of marginal fit along with differences in mea-
surement methods, method of fabrication (conventional vs.
CAD/CAM), sample size, and number of measurements per
specimen.10 Every attempt was made in this study to mini-
mize measurement error. Few studies have used micro-CT as
a nondestructive method for assessing marginal gap, marginal
discrepancy, and/or internal fit of crowns based on 2D assess-
ment similar to the cross-sectioning method,21-23 but this study
is the first study that provides careful 2D and 3D assessment of
MG, using micro-CT, of digitally and conventionally fabricated
LD crowns. A standardized and thorough approach was used
for MG measurements, even in the presence of MG discrep-
ancies, to minimize measurement error. The MG morphology
was characterized to further explain the relationship between
vertical MG and MG volume measurements. Moreover, the
5
Conventionally, Digitally Fabricated LD Crown Marginal Fit
Table 3 Mean vertical MG measurements on the buccal, lingual, mesial, and distal surfaces (n = 75 measurements/area/group)
Area Buccal
Procedure DD 34.27 ± 23.89 A, a
DP 44.92 ± 28.95 A, a
TP 38.83 ± 29.41 A, a
Values with same superscript letters are not significantly different (p < 0.05). Capital letters denote differences within each column. Small letters denote differences
within each row.
Table 4 Prevalence of marginal discrepancies recorded at 20 standardized points per crown (n = 300 points per group)
Overextension (%)
a a
Procedure DD 37.67
DP 18.75 b
TP 28.85 c
Values with same superscript letters are not significantly different (p < 0.05).
frequency of marginal discrepancies was investigated, which
was not previously reported in the literature.
An interesting finding in this study was that DD crowns had
significantly smaller MG volume than TP crowns; however,
no difference was found between DP crowns as compared to
the other groups (DD and TP). Our results are different from
Anadioti et al’s20 study, which demonstrated that crowns fabri-
cated from the conventional impression and fabrication method
produced the most accurate 3D marginal fits. Anadioti et al’s
study20 presented a 3D colored map of the MG around the
crown margin along with overall mean gap thickness (i.e., ce-
ment space), but this study is the first to quantitatively measure
3D MG volume around the crown circumference. Due to the
recent introduction of MG volume assessment and limited liter-
ature support, vertical MG measurements were done to validate
the 3D volume results.
For vertical MG measurements, the number of measurements
needed for the assessment of marginal fit is controversial. Sev-
eral studies based their results on 2 to 12 measurements per
sample.24-27 However, Groten et al28 recommended that 50
measurements are required per crown to obtain precise infor-
mation about the marginal gap size. Gassino et al29 claimed
that Groten et al’s28 results were inaccurate and concluded that
18 measurements are required to assess experimental crowns,
and 90 measurements are required for crowns fabricated from
an intraoral impression. Therefore, 20 measurements were con-
sidered sufficient to evaluate the marginal fit for in vitro fab-
ricated ceramic crowns30,31 and were employed in the current
study.
The DD group had a significantly smaller vertical MG than
the other groups, with no differences identified between DP
and TP groups. These results agree with two studies concurrent
to this study, which also revealed that digital workflow had a
more accurate marginal and internal fit in comparison to tra-
ditional techniques.13,18 Additionally, our results support the
6 Journal of Prosthodontics 00 (2017) 1–9 
Mostafa et al
Vertical MG (μm)
Lingual Mesial Distal
33.73 ± 15.75 A, a 28.40 ± 16.77 A, a 36.80 ± 21.82 A, a
61.38 ± 33.58 B, b 55.08 ± 34.06 B, b 54.92 ± 31.08 B, b
55.33 ± 33.22 B, b 58.17 ± 40.94 B, b 55.17 ± 34.32 B, b
MG discrepancies
Underextension (%) Chipping (%)
0.33 6.33 a
6.25 b 3.75 a
5.4 b 4.62 a
outcomes of other authors who have compared traditional and
digital workflows and found that the digital workflow produces
restorations with improved fit to those fabricated by traditional
technologies.19 The buccal site in the DP and TP groups had
a significantly lower vertical MG than the mesial, distal, and
lingual sites. The improved fit at the buccal surface compared
with other sites in pressed crowns (TP and DP) might be due to
improved accuracy of impression at this location. There is risk
of impression distortion, wax shrinkage, or ceramic shrinkage
combined with the susceptibility to human error in the tradi-
tional workflow. Therefore, one of the main advantages of the
digital workflow (DD group) is the consistency of the recorded
marginal fit (33.3 ± 19.99 μm) as compared to the DP and
TP groups (54.08 ± 32.34 μm and 51.88 ± 35.34 μm, respec-
tively), which could be attributed to the standardized approach
for crown fabrication that reduces the potential for error. Con-
versely, our results are again different from Anadioti et al’s20
study that reported better 2D marginal fit in crowns fabricated
from conventional impression and fabrication as compared to
other groups. Although Anadioti et al20 reported smaller 2D
MG values than those reported in the present study for TP
group (40 μm vs. 51.88 μm), their MG measurements were
larger than this study for DD (74 μm vs. 33.3 μm) and DP (75
μm vs. 54.08 μm) groups. These differences could be attributed
to the variations in the measurement methods, CAD/CAM sys-
tems, die spacer thicknesses, and preparation designs.
A comparison between 2D and 3D MG measurement based
on a cross-sectional analysis of the MG morphology was
then pursued to provide a complete picture of the marginal fit
of crowns fabricated using the three methods. This analysis
revealed that the DD group had smaller vertical MG, but it
demonstrated a larger gap at the line angles of the preparations.
This could be attributed to milling inaccuracies due to the
dimensions of the burs used. On the other hand, the DP and
TP groups demonstrated a larger vertical MG, consistent
C 2017 by the American College of Prosthodontists
Mostafa et al
with MG volume, and showed better adaptation at the line
angles of the preparation as compared to the milled group.
This could explain why the DD group had a significantly
smaller vertical MG but not a significantly lower MG volume
when compared to the DP group; however, it is important
to mention that external marginal fit is more important to
minimize microleakage and biological complications, while
small internal gaps at the line angle will be filled with cement.
We subsequently investigated the prevalence of marginal dis-
crepancies in each group. Overall, overextension was the most
frequent marginal discrepancy, a discrepancy that can be ad-
justed chairside with a polishing disk, while underextensions
and marginal chippings need to be repaired in the lab. Overex-
tension was significantly higher in the DD group (37.7 %) than
in the other groups (TP, 28.9%; DP, 18.8 %). This could be
due to marginal enhancement during computer-aided design of
DD crowns, which is routinely done to minimize chipping dur-
ing milling. It is important to mention that marginal enhance-
ment was set to only 0.1, while the default value is 0.25. This
approach resulted in similar occurrence of marginal chipping
between milled (DD) and pressed (DP and TP) crowns. Un-
derextension was significantly more frequent in the DP (6.3%)
and TP (5.4%) groups than in the DD (0.3%) group. Possi-
ble reasons for under extended margins in pressed LD crowns
could be wax pattern distortion and/or uneven expansion of
the investment material. In regard to comparison with the out-
comes of other reports, there were no available data. This is the
first study to report the prevalence of marginal discrepancies
in all-ceramic crowns fabricated using digital and conventional
techniques.
The ideal cement thickness for indirect restorations should
be 25 to 40 μm based on the type of cement.10 Although MGs
in this range have been considered a clinical goal, they are
difficult to achieve.32 Fransson et al16 and McLean and von
Fraunhofer17 stated that the clinically acceptable MG after ce-
mentation should be less than 150 μm and 120 μm, respec-
tively. Therefore, several in vitro studies considered MG up
to 120 μm to be clinically acceptable.13,20,33,34 In the current
study, any crown with vertical MG >120 μm at more than five
points was considered unacceptable. Four of 45 crowns fabri-
cated were deemed unacceptable: three in TP group and one
in DP group. Cross-sectional evaluation for the unacceptable
crowns revealed the presence of internal interferences at the
intaglio surface that prevented complete seating of the crowns
with subsequent open margin. This might be due to distortion
of the impression, wax shrinkage, or ceramic shrinkage in the
heat pressed groups (TP and DP). The complete digital work-
flow (DD group) resulted in 100% acceptable crowns, which
could be attributed to milling from LD monoblocks as well as
reduction in human error. The mean MG volume was 3.7 ±
0.65 mm3 for the acceptable crowns and 7 ± 1.3 mm3 for un-
acceptable crowns. Based on the presented data, crowns with
MG volume > 5.5 mm3 were deemed unacceptable. This value
could be used as a new criterion for unacceptable crowns in
future studies.
One of the limitations of this study was the use of duplicate
polyurethane dies during micro-CT assessment, to facilitate
image analysis based on different radiopacities. We did not as-
sess the accuracy of milled polyurethane dies in comparison to
Journal of Prosthodontics 00 (2017) 1–9 
C 2017 by the American College of Prosthodontists
Conventionally, Digitally Fabricated LD Crown Marginal Fit
the original zirconia die; however, polyurethane duplicate dies
were fabricated from one digital scan and milled from fully
polymerized blocks using five-axis mill and were randomly
assigned to the crowns. Therefore, any error generated in the
duplication process would be considered as a systematic error
and is not expected to significantly affect the reliability and ac-
curacy of the measurement technique. Patzelt et al35 evaluated
the accuracy of dental casts generated from different intraoral
scanners and indicated that casts generated from the Lava COS
scanner have clinically acceptable accuracy and are compara-
ble to conventional stone casts. Studies have also compared
the accuracy of polyurethane dies and type IV stone dies and
have indicated that they are comparable.36,37 Furthermore, pre-
vious studies reported that digital dies led to restorations of
comparable accuracy similar to polyurethane dies.38,39 Taken
together, casts generated from intraoral scanners have clinically
acceptable accuracy similar to conventional stone casts.
Another limitation of this study would be that MG was mea-
sured without cementing crowns onto their respective dies, un-
like in a clinical situation. The presence of a cement layer might
change the results of the measurements obtained in this study.
Validation micro-CT studies comparing marginal adaptation
before and after cementation are currently in progress.
Conclusion
Based on the outcomes of this study, the following was con-
cluded:
1. The DD group resulted in statistically significant smaller
vertical MG than DP and TP groups and less MG volume
than the TP group; however, the mean vertical MG for
the three groups was within clinically acceptable MG
range.
2. The DD group was associated with more overextension
and less underextension than the DP and TP groups.
3. There were no significant differences in marginal chip-
ping between the three groups.
4. DD resulted in 100% acceptable crowns, while TP re-
sulted in 20% unacceptable crowns.
5. Mean MG volume was 3.7 ± 0.65 mm3 for the accept-
able crowns and 7 ± 1.3 mm3 for unacceptable crowns.
Therefore, crowns with MG volume > 5.5 mm3 could be
considered to be unacceptable.
The results of this study suggested that digital impressions
and CAD/CAM technology is a suitable, more accurate alter-
native to traditional impression and manufacturing.
References
1. Silva NR, Bonfante EA, Martins LM, et al: Reliability of
reduced-thickness and thinly veneered lithium disilicate crowns.
J Dent Res 2012;91:305-310
2. Pieger S, Salman A, Bidra AS: Clinical outcomes of lithium
disilicate single crowns and partial fixed dental prostheses: a
systematic review. J Prosthet Dent 2014;112:22-30
3. Ahlholm P, Sipila K, Vallittu P, et al: Digital versus conventional
impressions in fixed prosthodontics: a review. J Prosthodont 2016
Aug 2. https://doi.org/10.1111/jopr.12527. [Epub ahead of print]
7
Conventionally, Digitally Fabricated LD Crown Marginal Fit
4. Yuzbasioglu E, Kurt H, Turunc R, et al: Comparison of digital
and conventional impression techniques: evaluation of patients’
perception, treatment comfort, effectiveness and clinical
outcomes. BMC Oral Health 2014;14:10.
5. Conrad HJ, Seong WJ, Pesun IJ: Current ceramic materials and
systems with clinical recommendations: a systematic review. J
Prosthet Dent 2007;98:389-404
6. Felton DA, Kanoy BE, Bayne SC, et al: Effect of in vivo crown
margin discrepancies on periodontal health. J Prosthet Dent
1991;65:357-364
7. Valderhaug J, Heloe LA: Oral hygiene in a group of
supervised patients with fixed prostheses. J Periodontol
1977;48:221-224
8. Lang NP, Kiel RA, Anderhalden K: Clinical and microbiological
effects of subgingival restorations with overhanging or clinically
perfect margins. J Clin Periodontol 1983;10:563-578
9. Rossetti PH, do Valle AL, de Carvalho RM, et al: Correlation
between margin fit and microleakage in complete crowns
cemented with three luting agents. J Appl Oral Sci 2008;16:64-
69
10. Nawafleh NA, Mack F, Evans J, et al: Accuracy and reliability of
methods to measure marginal adaptation of crowns and FDPs: a
literature review. J Prosthodont 2013;22:419-428
11. Seo D, Yi Y, Roh B: The effect of preparation designs on the
marginal and internal gaps in Cerec3 partial ceramic crowns. J
Dent 2009;37:374-382
12. van Geelen M: The influence of powder on accuracy of digital
imprint techniques: Varying spraying duration. Master thesis,
Dept. Of Odontology, Umeå University Sweden, 2016.
http://www.diva-
portal.se/smash/get/diva2:1071855/FULLTEXT01.pdf. Accessed
3/29/17
13. Alfaro DP, Ruse ND, Carvalho RM, et al: Assessment of the
internal fit of lithium disilicate crowns using micro-CT. J
Prosthodont 2015;24:381-386
14. Syrek A, Reich G, Ranftl D, et al: Clinical evaluation of
all-ceramic crowns fabricated from intraoral digital impressions
based on the principle of active wavefront sampling. J Dent
2010;38:553-559
15. Holmes JR, Bayne SC, Holland GA, et al: Considerations
in measurement of marginal fit. J Prosthet Dent 1989;62:405-408
16. Fransson B, Oilo G, Gjeitanger R: The fit of metal-ceramic
crowns, a clinical study. Dent Mater 1985;1:197-199
17. McLean JW, von Fraunhofer JA: The estimation of cement
film thickness by an in vivo technique. Br Dent J
1971;131:107-111
18. Ng J, Ruse D, Wyatt C: A comparison of the marginal fit of
crowns fabricated with digital and conventional methods. J
Prosthet Dent 2014;112:555-560
19. Al-Rabab’ah MA, Macfarlane TV, McCord JF: Vertical marginal
and internal adaptation of all-ceramic copings made by
CAD/CAM technology. Eur J Prosthodont Restor Dent
2008;16:109-115
20. Anadioti E, Aquilino SA, Gratton DG, et al: 3D and 2D marginal
fit of pressed and CAD/CAM lithium disilicate crowns made
from digital and conventional impressions. J Prosthodont
2014;23:610-617
21. Demir N, Ozturk AN, Malkoc MA: Evaluation of the marginal fit
of full ceramic crowns by the microcomputed tomography
(micro-CT) technique. Eur J Dent 2014;8:437-444
8 Journal of Prosthodontics 00 (2017) 1–9 
Mostafa et al
22. Pimenta MA, Frasca LC, Lopes R, et al: Evaluation of marginal
and internal fit of ceramic and metallic crown copings using
x-ray microtomography (micro-CT) technology. J Prosthet Dent
2015;114:223-228
23. Neves FD, Prado CJ, Prudente MS, et al: Micro-computed
tomography evaluation of marginal fit of lithium disilicate
crowns fabricated by using chairside CAD/CAM systems
or the heat-pressing technique. J Prosthet Dent
2014;112:1134-1140
24. Quintas AF, Oliveira F, Bottino MA: Vertical marginal
discrepancy of ceramic copings with different ceramic materials,
finish lines, and luting agents: an in vitro evaluation. J Prosthet
Dent 2004;92:250-257
25. Kunii J, Hotta Y, Tamaki Y, et al: Effect of sintering on the
marginal and internal fit of CAD/CAM-fabricated zirconia
frameworks. Dent Mater J 2007;26:820-826
26. Souza RO, Ozcan M, Pavanelli CA, et al: Marginal and internal
discrepancies related to margin design of ceramic crowns
fabricated by a CAD/CAM system. J Prosthodont
2012;21:94-100
27. Renne W, McGill ST, Forshee KV, et al: Predicting marginal fit
of CAD/CAM crowns based on the presence or absence of
common preparation errors. J Prosthet Dent 2012;108:310-315
28. Groten M, Axmann D, Probster L, et al: Determination of the
minimum number of marginal gap measurements required for
practical in-vitro testing. J Prosthet Dent 2000;83:40-49
29. Gassino G, Barone Monfrin S, Scanu M, et al: Marginal
adaptation of fixed prosthodontics: a new in vitro 360-degree
external examination procedure. Int J Prosthodont
2004;17:218-223
30. Mously HA, Finkelman M, Zandparsa R, et al: Marginal and
internal adaptation of ceramic crown restorations fabricated with
CAD/CAM technology and the heat-press technique. J Prosthet
Dent 2014;112:249-256
31. Pelekanos S, Koumanou M, Koutayas SO, et al: Micro-CT
evaluation of the marginal fit of different In-Ceram alumina
copings. Eur J Esthet Dent 2009;4:278-292
32. Holden JE, Goldstein GR, Hittelman EL, et al: Comparison of
the marginal fit of pressable ceramic to metal ceramic
restorations. J Prosthodont 2009;18:645-648
33. Ural C, Burgaz Y, Sarac D: In vitro evaluation of marginal
adaptation in five ceramic restoration fabricating techniques.
Quintessence Int 2010;41:585-590
34. Yeo IS, Yang JH, Lee JB: In vitro marginal fit of three
all-ceramic crown systems. J Prosthet Dent 2003;90:459-464
35. Patzelt SB, Bishti S, Stampf S, et al: Accuracy of computer-aided
design/computer-aided manufacturing-generated dental casts
based on intraoral scanner data. J Am Dent Assoc
2014;145:1133-1140
36. Hwang YC, Park YS, Kim HK, et al: The evaluation of working
casts prepared from digital impressions. Oper Dent
2013;38:655-662
37. Kim SY, Kim MJ, Han JS, et al: Accuracy of dies captured by an
intraoral digital impression system using parallel confocal
imaging. Int J Prosthodont 2013;26:161-163
38. Chochlidakis KM, Papaspyridakos P, Geminiani A, et al: Digital
versus conventional impressions for fixed prosthodontics: a
systematic review and meta-analysis. J Prosthet Dent
2016;116:184-190, e112
39. Seelbach P, Brueckel C, Wostmann B: Accuracy of digital and
conventional impression techniques and workflow. Clin Oral
Investig 2013;17:1759-1764
C 2017 by the American College of Prosthodontists