RESEARCH AND EDUCATION

Effect of fabrication stages and cementation on the marginal

fit of CAD-CAM monolithic zirconia crowns
Ediz Kale, DDS, PhD,a Burak Yilmaz, DDS, PhD,b Emre Seker, DDS, PhD,c and Tuncer Burak Özcelik, DDS, PhDd

The evolution of computer- ABSTRACT

aided design and computer-
aided manufacturing (CAD-
CAM) technology has rapidly
increased the use of zirconia
ceramic restorations.1 With the
introduction of monolithic zir-
conia restorations, a major
drawback related to the clinical
use of traditional zirconia resto-
rations has been eliminated, that
is, the need to veneer the zirco-
nia framework with feldspathic
porcelain.2,3 Several studies4-9
have reported fracture, chip-
ping, or delamination of the
feldspathic porcelain layer over
the zirconia framework. Slow
cooling and slow heating regi-
mens have been integrated in
the veneering process in an
attempt to largely overcome the
problem.10 As a novel alterna-
tive dental prosthetic treatment
using monolithic zirconia, high-
strength tooth- or implant-
supported restorations can be
fabricated with acceptable
esthetic results in a reasonable
time and at a reasonable cost.3,11-18 Even after mechanical
and thermal aging, monolithic zirconia crowns can endure
much higher fracture loads19 than the average maximal
Statement of problem. Monolithic zirconia crowns fabricated using computer-aided design and
computer-aided manufacturing (CAD-CAM) technology have recently become an alternative
dental prosthetic treatment. The marginal fit of monolithic zirconia crown may be affected by
different stages of the fabrication procedures in the laboratory and cementation. Information
regarding the accuracy of fit of monolithic zirconia crowns at different stages of fabrication and
cementation is limited.
Purpose. The purpose of this in vitro study was to evaluate the effect of different stages of
fabrication and cementation on the vertical marginal discrepancy (VMD) of CAD-CAM fabricated
monolithic zirconia crowns.
Material and methods. Six ivorine right maxillary first molar typodont teeth with standardized
anatomic preparations for complete coverage ceramic crowns were scanned with a 3-dimensional
laboratory scanner. Crowns were designed using CAD software and milled from presintered
monolithic zirconia blocks in a 5-axis dental milling machine. A cement space of 25 mm for the
margins and a 50-mm space starting 1 mm above the finish lines of the teeth were virtually set
in the CAD software. A total of 144 measurements were performed on 6 specimens with 8
measurement locations in 3 different stages using stereoscopic zoom microscopy; after initial
production of the crowns (post-sintering group), after glazing (post-glazing group), and after
cementation (post-cementation group). The VMD values were statistically analyzed with 1-way
repeated measures ANOVA and the Holm-Sidak method (a=.05).
Results. Different stages of fabrication and cementation significantly affected the VMD of tested
crowns (P=.003). The mean VMD was 38 mm for post-sintering group, 38 mm for post-glazing group,
and 60 mm for post-cementation group, with statistical differences between the post-sintering
group, the post-cementation group (P<.002), and the post-glazing group and post-cementation
group (P<.003); there were no statistical differences between the post-sintering group and the
post-glazing group (P=.966).
Conclusions. Within the limitations of this in vitro study, glazing did not significantly change the
VMD of CAD-CAM monolithic zirconia crowns. Cementation significantly increased the VMD
values. (J Prosthet Dent 2017;118:736-741)
occlusal forces20 in the posterior section of the mouth. Initial
studies of the survival rate of monolithic zirconia crowns
have estimated fracture rates of between 0.2% and 0.7% for

a
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Mustafa Kemal University, Hatay, Turkey.
b
Associate Professor, Department of Restorative Science and Prosthodontics, The Ohio State University College of Dentistry, Columbus, Ohio.
c
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Eskişehir Osmangazi University, Eskisehir, Turkey.
d
Associate Professor, Department of Prosthodontics, Faculty of Dentistry, Başkent University, Ankara, Turkey.

736 THE JOURNAL OF PROSTHETIC DENTISTRY

December 2017
Clinical Implications
Simulated cement space can be set at 50 mm for the
clinically acceptable marginal fit of CAD-CAM
monolithic zirconia crowns in the molar region
when the tested cement is used for cementation.
at least 5 years of service in the molar region.16,18 In vitro
investigations have shown that monolithic zirconia crowns
with a minimal occlusal thickness of 0.7 mm for implant-
supported21 and 0.5 mm for tooth-supported15,17 restora-
tions can withstand the masticatory forces in the posterior
segment in the long term. This makes them a viable alter-
native for restorations in patients with limited interarch
distance,21 the need for preservation of tooth structure,3,19
and insufficient clinical crown length. Recent clinical evi-
dence has presented the results of monolithic zirconia res-
torations as wear-friendly to opposing dental enamel in their
polished state compared with glazed metal-ceramic resto-
rations placed in the premolar and molar regions.22 Addi-
tionally, the surface finishing state of monolithic zirconia
crowns does not affect their fracture resistance, being
significantly higher than conventional metal ceramic
crowns, even after prolonged artificial aging conditions.23
In addition to improved physical properties and es-
thetics, appropriate marginal adaptation is fundamental
for the long-term clinical success of ceramic restora-
tions.2,11,24-27 Excessive marginal discrepancy may lead to
unfavorable results for the supporting structure and its
peripheral tissues (periodontal or peri-implant).2,28-32
Although reports are not in agreement as to what
should constitute clinically acceptable maximum mar-
ginal discrepancy, many33-35 studies agree that it should
be less than 120 mm. Other researchers36,37 believe that
the marginal discrepancy should not be more than 100
mm in the era of CAD-CAM technology. Given the
importance of accurate marginal adaptation of restora-
tions, there has been much debate in published
articles.2,26
Studies have investigated the fitting precision of zir-
conia crown margins2,24-26,38-42 before or after veneering
process. Veneering may have a significant influence on
the marginal fit of zirconia restorations.43-45 However, as
monolithic zirconia crowns are not veneered but char-
acterized only with staining through glazing,46 how the
marginal fit of the monolithic zirconia crowns is affected
by the fabrication stages is important. Cementation may
also affect the marginal fit of ceramic crowns.24,26,47
However, to the best of the authors’ knowledge, re-
ports regarding the accuracy of fit for monolithic zirconia
crowns at different stages of fabrication are limited.48,49
The purpose of this in vitro study was to evaluate the
effect of different stages of fabrication and cementation
Kale et al
737
on the vertical marginal discrepancy (VMD) of CAD-
CAM monolithic zirconia crowns. The null hypothesis
was that no differences would be found in VMD values
obtained after different stages of fabrication, before and
after glazing of the crown and after cementation.
MATERIAL AND METHODS
This study used 6 ivorine right maxillary first molar
typodont teeth (1860P03FC EP-TPR-860 #3/CVC;
Columbia Dentoform) with standard anatomic prepara-
tions supplied by the manufacturer (0.5-mm axial
reduction, 360-degree chamfer margin) for complete
coverage ceramic restorations.49,50 The teeth were scan-
ned with a 3-dimensional (3D) laboratory scanner (D900;
3Shape), and CAD design software (Dental System;
3Shape) was used to design a crown with identical
external contours for each tooth. The designed crown
data were processed with CAM software (CORiTEC
iCAM V5; iMES-iCORE), and CAD-CAM ceramic
crowns were milled from presintered monolithic zirconia
blocks (StarCeram Z-Nature; H.C. Starck) in a 5-axis
computer numeric control dental milling machine
(CORiTEC 550i; iMES-iCORE) and sintered (Sinterofen
HT-S Speed; Mihm-Vogt) according to the manufac-
turer’s instructions. The crowns had a simulated cement
space of 25 mm around the margins and 50 mm starting 1
mm above the finish lines of the teeth (Fig. 1).
After they had been seated onto their corresponding
teeth,51 the VMDs of the crowns were measured cir-
cumferentially at 8 consecutive locations (mesiopalatal,
mesial, mesiobuccal, buccal, distobuccal, distal, dis-
topalatal, and palatal), using ×3.5 to ×180 magnification
zoom stereomicroscopy (SM-3TZZ-54S-10M; AmScope)
equipped with a 10 megapixels digital camera (MU1000;
AmScope) and light-emitting diode ring light (LED-54S;
AmScope).38,49,52 The camera attached to the microscope
was calibrated using a single calibration slide (MR100;
AmScope) with a precision stage micrometer (0.01
mm).38,49,52 The specimens were aligned perpendicularly
to the evaluation sight of the microscope and manually
rotated to measure each point.38,49,52
To standardize the measurement locations, a cast-
metal ring guide with 8 horn-like projections, each
indicating the locations to be measured, was fabricated to
fit the cervix of the typodont teeth.49 The measurements
were performed in real time on 3584×2748 resolution
live-video stream computer image at ×100 to ×120
magnification by means of software (AmScope x86,
v3.7.3980; AmScope), measuring the shortest distance
between 2 parallel lines drawn at the crown margin and
finish line of the teeth (Fig. 2).49 After measurement, the
crowns were glazed, and the VMDs were measured again
using the same sequence (Fig. 2A). The crowns were then
cemented to their respective teeth with a polycarboxylate
THE JOURNAL OF PROSTHETIC DENTISTRY
738
Figure 1. A, Scanned typodont tooth on CAD software (detecting path of
insertion). B, Simulated cement space on tooth image (50 mm). C, Virtual
crown design (distal view on CAD software).
cement (Adhesor Carbofine; SpofaDental) according to
the manufacturer’s instructions. The crowns were seated
with a rocking motion53 and maximum index finger
pressure (180-degree distal pad press) of a young adult
male (50 N)54 as in the clinical situation.48 During setting,
a static standardized force (40 N) directed onto the
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 118 Issue 6
central fossa of the crown parallel to the vertical axis of
the tooth was applied on each specimen for 5 mi-
nutes.17,53 The excess cement was removed, and after
setting, the VMD was measured again in the same
manner (Fig. 2B). All measurements and cementation
procedures were done by a single operator (E.K.).
A total of 144 measurements were performed on 6
specimens with 8 measurement locations in 3 different
stages (post sintering, post glazing, and post cementa-
tion) of the restoration with monolithic zirconia crowns.
The average value of the 8 measurement points was
calculated for each specimen and considered the
circumferential VMD value for the specimen at a certain
stage of measurement. The means ±standard deviations
(SD) were calculated for each stage of measurement and
statistically analyzed for significant differences with
1-way repeated measures ANOVA and the Holm-Sidak
method, using statistical software (IBM SPSS Statistics
v21.0; IBM Corp) (a=.05).
RESULTS
The results of 1-way repeated measures ANOVA indi-
cated that different stages of fabrication and cementation
significantly affected the VMD of tested crowns
(F=11.464; P=.003). The pairwise multiple comparison
(Holm-Sidak) test revealed statistical differences between
the post-sintering and post-cementation groups (P<.002)
and between the post-glazing and post-cementation
groups (P<.003), whereas no statistical differences were
found between the post-sintering and post-glazing
groups (P=.966). Table 1 shows the mean VMD, SD,
standard error, and minimum-maximum range values for
each group.
None of the VMD values measured in any of the 8
measurement locations in the post-sintering and post-
glazing groups was above the clinically acceptable
threshold of 120 mm, with only 1 value over 100 mm
measured in the post-glazing group. The VMD values
over 100 mm in post-cementation group were 6,
measured in 4 different specimens. The largest VMD per
measurement obtained in the post-cementation group
was 149 mm, which was 1 of only 2 values that exceeded
120 mm (Fig. 3).
DISCUSSION
The results of the current study showed significant dif-
ferences for VMD values in the post-glazing and post-
cementation groups and no differences between the
post-sintering and post-glazing groups, thus, the null
hypothesis was rejected. For the CAD-CAM-fabricated
monolithic zirconia crowns investigated in this study,
the smallest mean VMD value was observed in the post-
sintering group (38 mm). The mean VMD in the post-
glazing group (38 mm) was slightly higher with no
Kale et al
December 2017
Figure 2. A, Vertical marginal discrepancy measurement after glazing (original magnification ×100 to 120). B, Vertical marginal discrepancy
measurement after cementation (original magnification ×100 to 120). zc, zirconia crown; tt, typodont tooth; mrg, metal ring guide. *Cement material.
significant differences from those of the post-sintering
group, and the post-cementation group (60 mm) had a
significantly higher mean VMD than the other 2 groups.
A cement space set at 50 mm has been suggested for
the fabrication of clinically acceptable cast crown resto-
rations.55 This recommendation is supported by the re-
sults of a recent in vitro study of the VMD of monolithic
zirconia crowns with different virtual cement space set-
tings.49 Kale et al49 reported 53 mm of mean VMD
measured before cementation for glazed monolithic zir-
conia crowns fabricated with 50 mm of virtual cement
space. Among the individually measured values per
location, only 1 was reported to be on the edge of the
clinically acceptable threshold of 120 mm, with another
below that limit but still over 100 mm. In the current
study, the mean VMD calculated for the crowns post
glazing was 38 mm with only 1 individually measured
value over 100 mm. The results of the current study are
consistent with those in the study by Kale et al,49 taking
into account the comparable study design in regard to
CAD-CAM workflow, cement space settings, and resto-
ration materials used. The differences in VMDs between
these 2 studies may be attributed to the different sample
size and calculated SDs.
The glazing procedure did not significantly affect the
VMD of monolithic zirconia crowns in the present study.
Previous studies have reported that repeated firing cycles
and various veneering techniques may negatively affect
the marginal discrepancy of zirconia restorations by
inducing a tendency for distortion in the zirconia
framework.2,43-45 To the best of the authors’ knowledge,
the effect of glazing on the marginal accuracy of mono-
lithic zirconia crowns has not yet been investigated.
Further research is needed to investigate the effect of
glazing and repeated firing cycles on the marginal fitting
accuracy of monolithic zirconia crowns with different
restoration thicknesses.
Kale et al
739
Table 1. Range of VMD measurements (mm) according to stage of
restoration procedure
Group No. of Specimens Mean ±SD SE Minimum Maximum
Post-sintering 6 38 ±11a 4 19 60
Post-glazing 6 38 ±12a,b 5 26 52
Post-cementation 6 60 ±15c 6 36 74
VMD, vertical marginal discrepancy. Different superscript letters indicate significant
difference between group pairs according to Holm-Sidak test (P<.05).
Several studies27,56,57 have reported VMD mean
values between 75 mm and 120 mm for veneered zirconia
crowns by measuring the thickness of low-viscosity sili-
cone (the replica technique). Berrendero et al56 indicated
that this method can simulate clinical cementation.
Comparing the results of the current study with the 60
mm of the VMD post cementation, those of Park et al27
with 75 mm, Huang et al57 with 84 mm, and Berrendero
et al56 with 107 mm to 120 mm of VMD for veneered
zirconia crowns with a simulated cement space of at least
50 mm, it appears that monolithic zirconia crowns have
improved VMD compared with veneered restorations.
This improvement might be due to the absence of
veneering in the monolithic zirconia crown fabrication
stages.45 Ji et al48 recently reported VMD mean values of
92 mm and 119 mm after cementation for 2 different
monolithic zirconia crown brands, using shoulder finish
line preparations, and 85 mm and 109 mm for identical
restorations with chamfer margins. The simulated
cement space set during the CAD-CAM was 30 mm, and
the type of luting agent was a resin cement, which may
explain the unfavorable performance of those crowns
compared with the crowns of the current study after
cementation. Cement space may significantly influence
the marginal accuracy of CAD-CAM fabricated mono-
lithic zirconia crowns, and 30 mm of virtual cement
thickness may significantly increase the VMD compared
with those of 50 mm.49 Using luting agents with different
THE JOURNAL OF PROSTHETIC DENTISTRY
740
160
Vertical Marginal Discrepancy (µm)
140
120
100
80
60
40 43.21
20
9.79
0
Post-sintering Post-glazing
Specimen 1 Specimen 2
Specimen 4 Specimen 5
Figure 3. Box plot diagrams of individually measured VMD values for
each group.
film thicknesses might have resulted in different post-
cementation marginal discrepancies,24 as studies have
shown that a significant difference in film thickness may
occur between resin-based and water-based luting
agents as used in the present study.58
The cementation process had a significant effect on
the VMD of CAD-CAM fabricated monolithic zirconia
crowns in the present study. This result is in agreement
with those of previous studies investigating the marginal
discrepancy of ceramic crowns before and after cemen-
tation.24 Evidence shows that an increase in VMD should
be expected as the consequence of forming film thickness
of luting agent or any other medium for definitive or
interim fixation of the crowns on their respective abut-
ments.24,58 The results of the present study revealed an
increase in VMD mean values of approximately 22 mm
after cementation, which is in agreement with previously
published studies58 and within the standards currently
set by the International Organization for Standardization
that require a film thickness that does not exceed the
limit of 25 mm at the time of seating for water-based
luting cements.59
In the current study, the mean VMD values calculated
for the tested stages of restoration with CAD-CAM
fabricated monolithic zirconia crowns were all within
the threshold of clinically acceptable value, 120 mm.
Among the individually measured values, only 2 excee-
ded that limit but were still under 150 mm as measured
post cementation. Reporting the peak values for each
measurement location to avoid misleading conclusions
regarding studies evaluating the marginal discrepancy of
crown restorations has already been emphasized.36,49
Matta et al36 have also calculated mean VMD values
below 100 mm for zirconia copings cemented with a
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 118 Issue 6
water-based luting agent under in vitro conditions,
drawing attention to the priority of detailed reporting of
148.88
the measurement results. They reported 12% of indi-
vidually measured values over 100 mm and 5% over 150
mm of VMD in a group of 5 specimens. In the present
study, individually measured values over 100 mm post
85.51
cementation were 12.5% for 6 specimens, correlating
with the results of previous publications.36
The results of this study should be interpreted
considering that only 1 type of zirconia brand and cement
were tested using 1 CAD-CAM system. These results
should be corroborated with those of other clinical
studies.
Post-cementation
CONCLUSIONS
Specimen 3
Within the limitations of this in vitro study, the following
Specimen 6 conclusions were drawn:
1. The glazing procedure had no significant effect on
the VMD of CAD-CAM monolithic zirconia crowns.
2. The cementation process significantly affected the
VMD of CAD-CAM monolithic zirconia crowns.
3. The mean VMD values were within the clinically
acceptable limits for all tested stages of fabrication
and cementation (<120 mm).
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Corresponding author:
Dr Ediz Kale
Mustafa Kemal University
Faculty of Dentistry
Department of Prosthodontics
31040 Antakya-Hatay
TURKEY
Email: dtedizkale@yahoo.com
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY