Marginal and internal adaptation of

ceramic crown restorations fabricated

with CAD/CAM technology and the
heat-press technique
Hisham A. Mously, BDS, MS,a Matthew Finkelman, PhD,b
Roya Zandparsa, DDS, DMD, MSc,c and
Hiroshi Hirayama, DDS, DMD, MSd
Tufts University School of Dental Medicine, Boston, Mass; Faculty
of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
Statement of problem. The accuracy of chairside computer-aided design and computer-aided manufacturing (CAD/CAM)
restorations is questionable, and the effect of the die spacer settings is not well stated in the literature.

Purpose. The purpose of the study was to evaluate the marginal and internal adaptation of E4D crowns fabricated with
different spacer thicknesses and to compare these crowns with those fabricated with the heat-press technique.

Material and methods. The E4D system was used to fabricate 30 crowns for the rst 3 groups, with different spacer thickness
settings: 30 mm, 60 mm, and 100 mm. In the fourth group, 10 lithium disilicate crowns were fabricated with the heat-press
technique. The occlusal gap, axial gap, vertical marginal gap, and absolute marginal discrepancy were evaluated by x-ray
microtomography. Statistical signicance was assessed with the Kruskal-Wallis test (a.05). For post hoc analyses, the
Mann-Whitney U test was used alongside the Bonferroni correction for multiple comparisons (a.008).

Results. Within the CAD/CAM groups, the 30-mm spacer thickness resulted in the lowest median axial gap (90.04 mm),
whereas the 60-mm spacer thickness resulted in the lowest median occlusal gap (152.39 mm). The median marginal
gap values of the CAD/CAM-60 group (49.35 mm) and CAD/CAM-100 group (46.65 mm) were lower than those of the
CAD/CAM-30 group (55.18 mm). No signicant differences among the CAD/CAM groups were observed for absolute
marginal discrepancy. The heat-press group had signicantly different values than those of the CAD/CAM groups.

Conclusion. The spacer thickness and fabrication technique affected the adaptation of ceramic crowns. The heat-press group
yielded the best marginal and internal crown adaptation results. The 30- or 60-mm spacer settings are recommended for
the E4D CAD/CAM system. (J Prosthet Dent 2014;-:---)

Clinical Implications
The results of this study may aid in the clinical determination of the
most accurate spacer thickness settings for the optimal adaptation
of CAD/CAM crown restorations, thereby improving clinical success
and longevity.

Crown adaptation along with es- and longevity of crown restorations.1-7 internal gaps of crown restorations.
thetic value and fracture resistance Crown adaptation is dened by the Holmes et al8 stated that the internal
are important to the clinical success measurements of the marginal and gap is the perpendicular distance from

a
Assistant Professor, Division of Prosthodontics, Department of Oral and Maxillofacial Rehabilitation, Faculty of Dentistry,
King Abdulaziz University; Former Resident, Division of Postgraduate Prosthodontics, Department of Prosthodontics and
Operative Dentistry, Tufts University School of Dental Medicine.
b
Assistant Professor, Department of Public Health and Community Service, Tufts University School of Dental Medicine.
c
Clinical Professor, Division of Postgraduate Prosthodontics, Department of Prosthodontics and Operative Dentistry,
Tufts University School of Dental Medicine.
d
Professor, Division Head of Postgraduate Prosthodontics; Director, Graduate and Postgraduate Prosthodontics; Director,
Advanced Education in Esthetic Dentistry; and Director, Advanced Dental Technology and Research Program, Tufts University
School of Dental Medicine.

Mously et al
2 Volume
the internal surface of the restoration
to the axial wall of the preparation,
whereas the marginal gap is the per-
pendicular distance from the internal
surface of the restoration to the nish
line of the preparation.8 An increase in
the marginal or internal gap could
increase cement dissolution, thereby
increasing the potential for micro-
leakage, recurrent caries, and periodon-
tal disease.9-15 Furthermore, an increase
in the internal gap could decrease the
fracture strength of ceramic restorations
because these areas with a higher inter-
nal gap induce different load concen-
trations16-21
Paint-on die spacers have been used
successfully for the conventional lost-
wax and heat-press techniques to pro-
vide appropriate marginal and internal
gaps, thereby facilitating the complete
seating of crown restorations.22-25 In
contrast, the spacer thicknesses of
crown restorations fabricated with
chairside computer-aided design and
computer-aided manufacturing (CAD/
CAM) technology usually are deter-
mined during the softwares design
phase. However, the spacer thickness
setting most conducive to appropriate
crown adaptation remains unknown.
Although chairside CAD/CAM tech-
nology has improved considerably over
the past few years, the accuracy of dental
restorations fabricated with these sys-
tems remains questionable. Many fac-
tors can affect the accuracy of these
restorations, including the type of dental
restoration, material properties,26 prep-
aration design,7,18 scanning device ac-
curacy, software design, spacer settings,
and milling machine accuracy.27 Few
studies, however, have examined these
factors and their effects on the marginal
and internal gaps of different dental
restorations.7,18,26,27
Most of these studies used either
subjective or inaccurate methods to
evaluate the marginal and internal gaps
of crown restorations,6 including the use
of the explorer, visual examination,28
and radiographic techniques.29 The
impression technique is a popular
method, which uses a putty-wash tech-
nique with low-viscosity impression
The Journal of Prosthetic Dentistry
material.6,30-32 This technique is
considered difcult and inaccurate when
the discrepancies are small because the
impression material may be distorted or
damaged.1,5,6 The prolometry method
is considered to be an accurate method,
except in restorations with overextended
margins.6,33 Scanning electron micro-
scopy for the study of presectioned
specimens also is a popular tech-
nique.19,34-36
Computerized x-ray microtomo-
graphy (micro-XCT), a nondestructive
method, produces high-resolution images
for both quantitative and qualitative
analyses of the tooth, bone, and im-
plants, which makes it a powerful tool
in dental research.6,37,38 Micro-XCT
has been used in dental research to
measure enamel thickness39 and dental
restorations,40,41 and to assess the
marginal and internal gaps of crown
restorations.6,38 No consensus has
been reached regarding the biologically
acceptable values of marginal and in-
ternal gaps. The clinically acceptable
value for the marginal gap has been
discussed in the literature, with pro-
posed values that range from 39 to
120 mm.9,42 Theoretically, the accept-
able marginal discrepancy for cemented
crown restorations ranges between 25
and 40 mm30,43,44; however, several
in vitro studies have reported mean
marginal gaps of 64 to 83 mm in CAD/
CAM-generated ceramic single-tooth
restorations.31,45-47 The internal gap of
conventional ceramic crowns has been
reported to be within the range of 123
to 154 mm.48,49 May et al5 reported
that the marginal t of the Procera
CAD/CAM system ranged between 54
and 64 mm, with an internal gap of 49
to 63 mm.
Thus, the accuracy of the chairside
CAD/CAM restorations remains ques-
tionable, and the effect of the spacer
settings has not been studied in detail.
The main objective of this in vitro study
was to evaluate the marginal and in-
ternal adaptation of lithium disilicate
restorations fabricated with a CAD/
CAM system and to compare them with
the conventional heat-press technique
by using micro-XCT. In particular, this
- Issue -
study aimed to evaluate the inuence of
different spacer thicknesses on the ac-
curacy of lithium disilicate restorations
fabricated with the E4D CAD/CAM
system. In addition, the accuracy of
lithium disilicate restorations fabricated
with the E4D CAD/CAM technology
was compared with the accuracy of
restorations fabricated with the con-
ventional heat-press technique. The null
hypotheses for this study were that
different spacer thicknesses will not in-
uence the marginal and internal
adaptation of the lithium disilicate
restorations and that different fabrica-
tion techniques will not inuence the
marginal and internal adaptation of the
lithium disilicate restorations.
MATERIAL AND METHODS
A complete coverage preparation on
the mandibular right rst molar was
made for a typodont model (Model
D95SDP-200; Kilgore Intl Inc) with a
coarse, tapered diamond rotary instru-
ment with a rounded end (no. 6856;
Brasseler USA). The following parame-
ters were used: total occlusal conver-
gence, 12 degrees; occlusal reduction,
2 mm; and chamfer nish line, 1 mm,
with rounded internal angle margins.
Then, 40 acrylic resin master dies were
fabricated by duplicating the prepared
tooth with an In-lab CAD/CAM system
(Tizian Cut 5; Schtz Dental Gmb)
(Fig. 1).
The master dies were divided into
4 groups (10 dies per group). Each
master die was assigned to each of
these 4 groups. The rst CAD/CAM
system was applied to the rst 3
groups, whereas the heat-press tech-
nique was applied to the fourth group.
Optical impressions of each master die
were obtained with an E4D camera
(E4D Dentist system; D4D Technolo-
gies), which was calibrated before each
master die was scanned. The E4D
software was then used to evaluate the
clarity of the scanning process. The
crown margins were marked manually
on the nish lines of the preparations.
Crown shape A was selected from the
available designs within the E4D library.
Mously et al
- 2014 3
The autogenesis feature was not manual milling device (Straumann was performed at 70 KVp and 114 mA,
selected. Scanning and design was per- gonyX; Straumann USA LLC). Each in- with an integration time of 300 ms.
formed by the same clinician (H.M.). dex was used to stabilize and position Two-dimensional images, with an im-
each surface (buccal, lingual, mesial, age size of 2048  2048 pixels and a
and distal) of the master die. By using a resolution of 10 mm, were recon-
Spacer settings for lithium disilicate
carbide round bur (no. H71; Brasseler structed from the x-ray shadow images.
complete coverage restorations
USA) attached to the milling device, After computerized reconstruction of
4 reference indentations were prepared the images, Image J software (National
To fabricate the restorations, in the
on the buccal, lingual, mesial, and Institutes of Health) was used to eval-
CAD/CAM-30 group, the internal and
distal surfaces of each master die. uate and analyze the scans. The refer-
marginal gaps were set at 30 mm with
Because these indentations were iden- ence indentations were used to
a 1-mm marginal ramp; in the CAD/
tical in position and size for each standardize the images of each spec-
CAM-60 group, the internal and mar-
master die, they could be used to imen. By using the Image J software, 5
ginal gaps were set at 60 mm with a
standardize the computed tomography equidistant vertical cuts were made in
1-mm marginal ramp; in the CAD/
images for each specimen. the buccolingual direction, with 50 sli-
CAM-100 group, the internal and
The marginal and internal gaps ces between these cuts; in addition, 5
marginal gaps were set at 100 mm with
were evaluated by means of micro-XCT equidistant vertical cuts were made in
a 1-mm marginal ramp.
(mCT 40; Scanco Medical). Each spec- the mesiodistal direction, with 25 slices
imen was stabilized in the scanning between these cuts, depending on the
Milling process and crystallization tube and positioned perpendicularly to slice numbers of each specimen
the x-ray beam for scanning. Scanning (Fig. 2).
After each crown was designed with
the E4D software, the information was
electronically sent to the milling unit.
IPS e.max CAD lithium disilicate blocks
(Ivoclar Vivadent) were used to fabri-
cate the crowns. The standard mode
was selected for the milling process of
all the crowns. After the completion of
the milling process, all the crowns were
crystallized in a porcelain furnace.
In the heat-press group, each master
die was copied by using a polyether
impression material (Impregum Penta
Soft; 3M ESPE) to produce identical
stone dies with a Type IV dental stone
(Resin Rock; Whip Mix Corp). Two 1 Master die fabrication with acrylic resin block.
layers of die spacer (Euro Quick Set;
Kerr Dental Laboratory Products) were
applied to the stone dies. The layers
were applied uniformly with a brush,
starting 1 mm short of the nish lines of
the preparations. Next, an anatomic
contour waxing was created for each
master die. All of the anatomic contour
waxings were invested with ne-grained
phosphate-bonded investment material
(Multi Press Vest; GC America Inc).
Finally, the pressing process was
completed according to the manufac-
turers instructions. IPS e.max Press
lithium disilicate ingots were used to
fabricate the crowns. 2 Micro-XCT scan image (horizontal cut): 10 vertical cuts
Four silicone indices were attached obtained with 50 slices between buccolingual cuts and 25
with stone to the metal base of a slices between mesiodistal cuts.
Mously et al
4 Volume - Issue -

Twelve points of measurement The MG, AMD, OG, and AG were The statistical power was calculated
were selected for each vertical cut evaluated at 120 different points for with statistical software (nQuery
(2 measurements for vertical marginal each crown. The MG and AMD were Advisor, v7.0; Statistical Solutions Ltd).
gap [MG], 2 for absolute marginal measured by using the criteria for the The variance of means and common
discrepancy [AMD], 4 for occlusal gap evaluation of the marginal adaptation standard deviation were 257.3 and
[OG], and 4 for axial gap [AG]). Thus, provided by Holmes et al.8 The over- 15.8 (results from a pilot study), re-
20 measurements for MG and AMD, extended and underextended margins spectively; accordingly, a sample size
and 40 measurements for OG and AG for the AMD were both assembled as of n10 per group was considered
were obtained for each specimen positive values. The OG was measured adequate to obtain a type I error rate of
(Figs. 3, 4). All of the measurements separately from the AG for the evalua- 5% and a power greater than 99%. All
were averaged for each outcome. The tion of internal adaptation. All stan- the outcomes (AG, OG, MG, and
magnications and measurements of dardizations and measurements of the AMD) were analyzed separately. De-
the marginal and internal gaps were specimens were performed by the same scriptive statistics were computed for
made with the Image J software. clinician (H.M.). each group with SPSS v19.0. One-way
ANOVA was initially performed with
the Tukey honestly signicant difference
for post hoc tests; however, the analysis
could not be reported because of the
violation of the assumption of equal
variances among groups (P values of
the Levene test were less than .05).
Therefore, nonparametric testing was
undertaken: the Kruskal-Wallis test was
performed for each outcome, with
P<.05 considered to indicate statistical
signicance. Upon obtaining signicant
results, the Mann-Whitney U test
was used for post hoc analysis, with the
Bonferroni correction used to adjust
for multiple comparisons (P<.008
3 Micro-XCT scan image (zoomed at margin area): mea-
was considered to indicate statistical
surement of marginal gap (for overextended crown, perpen-
dicular distance between internal surface of crown and signicance).
master die margin was measured, whereas, for underextended
crown, perpendicular distance between internal surface of
master die and crown margin was measured) and absolute RESULTS
marginal discrepancy (distance between crown and master
die margins). A summary of the results of the
descriptive statistical analyses, which
showed the AGs (medians, interquartile
ranges, minima, and maxima) for
all the groups, is listed in Table I.
The results of the Kruskal-Wallis test
were statistically signicant for AG
(P<.001). In the post hoc Mann-
Whitney U tests, the heat-press group
showed signicantly lower values
(median, 74.03 mm) than the CAD/
CAM-60 (127.68 mm; P<.001) and
CAD/CAM-100 (147.71 mm; P<.001)
groups but not the CAD/CAM-30
(90.04 mm; P.009) group. Within the
4 Micro-XCT scan image (vertical cut): Measurement of CAD/CAM groups, the 30-mm spacer
axial gap and occlusal gap (measured distances were thickness resulted in the lowest AG
perpendicular to ceramic crown and master die internal sur- (90.04 mm) compared with the 60-mm
faces at selected points). (127.68 mm; P < .001) and 100-mm

The Journal of Prosthetic Dentistry Mously et al

- 2014 5
(147.71 mm; P<.001) groups. The AG Table I. Descriptive statistics of AG for test groups
values of the CAD/CAM-60 group were
signicantly lower (P<.001) than those Internal AG (mm)
of the CAD/CAM-100 group (Table I). Group N Median* IQR Minimum Maximum
For OG, the results of the Kruskal-
Wallis test were statistically signi- CAD/CAM-30 10 90.04a 20.27 69.83 122.05
cant (P<.001). The heat-press group b
CAD/CAM-60 10 127.68 8.81 106.80 155.55
showed signicantly lower values CAD/CAM-100 10 147.71 c
40.71 135.35 199.85
(median, 128.11 mm) than the CAD/
Heat-press 10 74.03a 6.81 67.38 80.30
CAM-30 (160.49 mm; P.003), CAD/
CAM-60 (152.39 mm; P.003), and AG, axial gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
IQR, Interquartile range.
CAD/CAM-100 (227.38 mm; P<.001) *Groups with same letters do not exhibit statistically signicant difference.
groups. Within the CAD/CAM groups,
the 60-mm spacer thickness resulted in
the lowest OG (152.39 mm) compared Table II. Descriptive statistics of OG for test groups
with the 30-mm (160.49 mm; P.58)
and 100-mm (227.38 mm; P.001) Internal OG (mm)
groups, although the comparison with Group N Median* IQR Minimum Maximum
the 30-mm group was not signicant.
The OG values of the CAD/CAM-30 CAD/CAM-30 10 160.49a 78.30 105.73 217.43
group were signicantly lower (P.004) CAD/CAM-60 10 152.39a 35.17 82.63 206.88
than those of the CAD/CAM-100 group CAD/CAM-100 10 227.38 b
72.97 160.83 267.45
(Table II). c
Heat-press 10 128.11 18.86 106.88 147.95
For MG, the results of the Kruskal-
Wallis test were statistically signi- OG, occlusal gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
IQR, Interquartile range.
cant (P<.001). The heat-press group *Groups with same letters do not exhibit statistically signicant difference.
showed signicantly lower values
(median, 30.80 mm) than the CAD/
CAM-30 (55.18 mm; P<.001), CAD/
Table III. Descriptive statistics of MG for test groups
CAM-60 (49.35 mm; P<.001), and
CAD/CAM-100 (46.65 mm; P.005) Vertical MG (mm)
groups. Within the CAD/CAM groups,
the 60-mm and 100-mm spacer thick-
Group N Median* IQR Minimum Maximum
nesses resulted in the lowest MG, with CAD/CAM-30 10 55.18a 17.05 50.70 76.25
no statistically signicant difference a,b
CAD/CAM-60 10 49.35 14.95 32.30 56.10
between these 2 groups (P.63). The b
MG values of the CAD/CAM-30 group CAD/CAM-100 10 46.65 18.04 30.55 58.15
c
were signicantly higher than those of Heat-press 10 30.80 8.97 24.35 41.75
the CAD/CAM-100 group (P.007) MG, marginal gap; CAD/CAM, computer-aided design and computer-aided manufacturing;
but not the CAD/CAM-60 group IQR, interquartile range.
(P.029) (Table III). *Groups with same letters do not exhibit statistically signicant difference.
Finally, for AMD, the results of the
Kruskal-Wallis test were again statisti-
cally signicant (P<.001). The heat- Table IV. Descriptive statistics of AMD for test groups
press group showed signicantly lower AMD (mm)
values (median, 41.05 mm) than the
CAD/CAM-30 (100.35 mm; P<.001), Group N Median* IQR Minimum Maximum
CAD/CAM-60 (96.65 mm; P<.001),
CAD/CAM-30 10 100.35a 71.16 61.35 143.75
and CAD/CAM-100 (105.75 mm;
a
P<.001) groups. Within the CAD/CAM CAD/CAM-60 10 96.65 26.25 64.65 167.20
groups, the 60-mm spacer thickness
a
CAD/CAM-100 10 105.75 49.21 55.10 132.05
b
resulted in the lowest AMD; however, Heat-press 10 41.05 11.16 30.55 60.30
no statistically signicant difference was
AMD, absolute marginal discrepancy; CAD/CAM, computer-aided design and computer-aided
found among the CAD/CAM groups manufacturing; IQR, interquartile range.
(P>.008) (Table IV). *Groups with same letters do not exhibit statistically signicant difference.

Mously et al
6 Volume
DISCUSSION
When considering the clinical pro-
perties of ceramic crowns and dental
luting agents, it is important to achieve
clinically acceptable restorations with
minimal marginal and internal gap.
Chairside CAD/CAM restorations are
currently used by a large number of
dentists all over the world; however, the
accuracy of these systems and restora-
tions is still questionable. This study
focused on looking at the effects of us-
ing different spacer thicknesses on the
accuracy of E4D CAD/CAM crowns
and comparing them with the accuracy
of conventional heat-pressed crowns. In
this in vitro study, the null hypotheses
were rejected because the thickness of
the spacer as well as the fabrication
technique directly affected the marginal
and internal adaptation of ceramic
crown restorations.
In this study, the MGs of the heat-
press group were signicantly lower
than those of the E4D-CAD/CAM
groups. The MG values (mean SD) for
the heat-press group were similar to
those reported by Cho et al50 (30.2
18.6 mm) for the pressable lithium
disilicate crowns prepared with a
chamfer nish line. These values were
within the range of the ideal marginal
gap for cemented restorations.5,30,43
Among the CAD/CAM groups, the
CAD/CAM-100 and CAD/CAM-60
groups showed similar MG values,
whereas the CAD/CAM-30 group had a
signicantly higher MG than the CAD/
CAM-100 group but not the CAD/
CAM-60 group. These results could be
attributed to the presence of in-
terferences in the CAD/CAM crowns
fabricated with lower spacer thicknesses.
In this study, the MGs measured in
the CAD/CAM groups were similar to
or slightly higher than those reported by
Renne et al7 (excellent preparation,
38.5 mm; fair preparation, 58.2 mm) in
crowns fabricated by using the same
CAD/CAM system, with 100-mm spacer
thickness and 0.25-mm marginal ramp
(default settings for E4D). These dif-
ferences could be attributed to the dif-
ference in the marginal ramp setting in
The Journal of Prosthetic Dentistry
the E4D software or to the variations in
the evaluation method. Several other
studies that used different CAD/CAM
systems reported higher MG values for
ceramic CAD/CAM crowns than those
reported in the present study.18,42,49
The heat-press group in this study
showed the lowest AG and OG values.
This could be due to the differences in
the fabrication technique and the die
spacer thicknesses. These values were
similar to those (50-100 mm) consid-
ered the most favorable internal
gap values for resin cement perfor-
mance.51-53 The AG and OG values for
the heat-press and CAD/CAM-30
groups were lower than those reported
by Souza et al18 (AG, 113.28 mm; OG,
244.32 mm) for crowns fabricated with
a large chamfer nish line; however,
only the CAD/CAM-60 and CAD/
CAM-100 groups in this study had
lower OG values. Similar internal gap
values also were reported in several
studies that used different CAD/CAM
systems.19,32,45,52 These different values
could be related to the differences in
the CAD/CAM systems, spacer thick-
nesses, and crown materials.
In this study, the AMD values for the
heat-press group were signicantly
lower than those of the CAD/CAM
groups; however, no signicant differ-
ences were observed among the CAD/
CAM groups. The AMD values for the
heat-press group were lower than those
reported by Pelekanos et al6 for all
groups (Wol-Ceram, 49.86 mm; Slip-
cast, 60.09 mm; Cerec in-Lab, 187.64
mm; and Celay, 179.36 mm). The
AMD values for all CAD/CAM groups
were lower than those reported by
Pelekanos et al6 (187.64 mm) for
aluminum oxide copings (In-Ceram
alumina) fabricated with the Cerec in-
Lab system. These lower values could
be related to the differences in the CAD/
CAM system, crown materials, and
preparation designs.
Similar to previous studies,6,38
micro-XCT was used to evaluate the
marginal and internal adaptation of the
ceramic crown restorations. This method
has several advantages over other tech-
niques, including the 3-dimensional
- Issue -
evaluation of the marginal and internal
gaps. Furthermore, it is easy to perform,
nondestructive, and more time efcient
and accurate than the other methods
used to evaluate marginal and internal
adaptations.6 The main disadvantages of
this method are radiation artifacts, which
are caused by the differences in the coef-
cient of radiation absorption among the
different materials6 and the difculty in
using luting agents because they have
some radiopacity that might affect the
evaluation of the cement gap.
In this study, 20 MG and 20 AMD
measurements were obtained to eval-
uate the marginal adaptation of
each ceramic crown. Similar to many
studies,6,7,54 20 measurements were
considered sufcient to evaluate the
marginal adaptation for crowns and dies
fabricated in vitro. Several other
studies18,49 used 50 measurements of
MG to evaluate marginal adaptation;
however, in these studies, the AMD,
which is considered important for the
appropriate evaluation of the marginal
adaptation and extension of ceramic
crowns, was not measured.6,8
In previous studies that used the
micro-XCT evaluation method,6,38 ver-
tical cuts were made in a circle with 18
degrees between each cut; however, in
this study, the vertical cuts were made
perpendicular to the tooth surface to
minimize possible measurement error as
a result of the angulation of the cut and
also to replicate the actual marginal and
internal gap values. Besides the spacer
thickness and the fabrication technique,
many other factors could have affected
the outcome of this study, including the
preparation design, scanning accuracy,
software, restoration material, and
consistency of milling machines. In this
study, the preparation design was
identical for all the master dies. Scan-
ning and design were performed by the
same practitioner, and the scanning
camera was equilibrated before each
scan. Factors associated with the milling
machine were evaluated before the
fabrication of each restoration, in-
cluding the condition of the diamond
rotary instruments and the quality of
the cooling and lubricating uids.
Mously et al
- 2014
Considerable controversy exists in
the literature regarding the ideal mar-
ginal and internal gap for ceramic
crowns.6,18 Regarding the ideal mar-
ginal adaptation, a few studies have
reported that the ideal MG should be
25 to 40 mm for cemented restora-
tions.5,30,43 Many other studies consid-
ered the MG values of 100 to 200 mm to
be clinically acceptable for cemented
restorations.2,7,30,55,56 More recent
studies have considered the clinically
acceptable values of MG to be less than
100 mm.5,6,18,49 In regarding the ideal
internal adaptation, many studies have
reported that an internal gap of 50 to
100 mm could result in the most favor-
able resin cement performance.51-53 An
internal gap value of 200 to 300 mm also
may be clinically acceptable, but this
requires in vivo conrmation.18,52,53,57
Therefore, the results of marginal and
internal gaps for all the groups pre-
sented in this study can be considered
clinically acceptable.
The limitations of the present study
were as follows. First, all the crowns
were tested without cementation be-
cause of the radiopacity of the luting
agent, which might alter the results of
this study. This is considered a limita-
tion of the micro-XCT scan method.
Second, only the standard mode of the
milling machine was evaluated, and
different settings may inuence the ac-
curacy of the results. Future studies
should consider comparing the adap-
tation of ceramic crown restorations
fabricated by using different milling
machines (3, 4, and 5 axes). Moreover,
evaluating the effect of the tting-
surface modication and cementation
on the marginal and internal adapta-
tion of ceramic restorations would be
benecial.
CONCLUSIONS
Within the limitations of this in vitro
study, the following may be concluded:
(1) different fabrication techniques
affected the marginal and internal
adaptation of ceramic crown restora-
tions; (2) the spacer thickness setting is
Mously et al
an important factor that should be
considered before fabricating ceramic
CAD/CAM restorations; (3) the heat-
press group yielded the best results
with respect to marginal and internal
crown adaptation; (4) among the CAD/
CAM groups, the CAD/CAM-30 group
yielded the lowest AG values, whereas
the CAD/CAM-30 and CAD/CAM-60
groups yielded the lowest OG values;
(5) when considering the results of
the marginal and internal adaptation
of all the CAD/CAM crowns, the 30- or
the 60-mm spacer settings were recom-
mended for the E4D CAD/CAM system.
REFERENCES
1. Luthardt RG, Bornemann G, Lemelson S,
Walter MH, Huls A. An innovative
method for evaluation of the 3-D internal
t of CAD/CAM crowns fabricated after
direct optical versus indirect laser scan
digitizing. Int J Prosthodont 2004;17:680-5.
2. Karlsson S. The t of Procera titanium
crowns. An in vitro and clinical study. Acta
Odontol Scand 1993;51:129-34.
3. Oden A, Andersson M, Krystek-Ondracek I,
Magnusson D. Five-year clinical evaluation of
Procera AllCeram crowns. J Prosthet Dent
1998;80:450-6.
4. Besimo C, Jeger C, Guggenheim R. Marginal
adaptation of titanium frameworks produced
by CAD/CAM techniques. Int J Prosthodont
1997;10:541-6.
5. May KB, Russell MM, Razzoog ME, Lang BR.
Precision of t: the Procera AllCeram crown.
J Prosthet Dent 1998;80:394-404.
6. Pelekanos S, Koumanou M, Koutayas SO,
Zinelis S, Eliades G. Micro-CT evaluation of
the marginal t of different In-Ceram alumina
copings. Eur J Esthet Dent 2009;4:278-92.
7. Renne W, McGill ST, Forshee KV,
DeeFee MR, Mennito AS. Predicting
marginal t of CAD/CAM crowns based on
the presence or absence of common
preparation errors. J Prosthet Dent 2012;
108:310-5.
8. Holmes JR, Bayne SC, Holland GA,
Sulik WD. Considerations in measurement
of marginal t. J Prosthet Dent 1989;62:
405-8.
9. Felton DA, Kanoy BE, Bayne SC,
Wirthman GP. Effect of in vivo crown margin
discrepancies on periodontal health.
J Prosthet Dent 1991;65:357-64.
10. Hamza TA, Ezzat HA, El-Hossary MM,
Katamish HA, Shokry TE, Rosenstiel SF.
Accuracy of ceramic restorations made with
two CAD/CAM systems. J Prosthet Dent
2013;109:83-7.
11. Beschnidt SM, Strub JR. Evaluation of the
marginal accuracy of different all-ceramic
crown systems after simulation in the
articial mouth. J Oral Rehabil 1999;
26:582-93.
7
12. Beuer F, Neumeier P, Naumann M. Marginal
t of 14-unit zirconia xed dental prosthesis
retainers. J Oral Rehabil 2009;36:142-9.
13. Gonzalo E, Surez MJ, Serrano B, Lozano JF.
Comparative analysis of two measurement
methods for marginal t in metal-ceramic
and zirconia posterior FPDs. Int J Prostho-
dont 2009;22:374-7.
14. Groten MS, Girthofer S, Probster L. Marginal
t consistency of copy-milled all- ceramic
crowns during fabrication by light and
scanning electron microscopic analysis
in vitro. J Oral Rehabil 1997;24:871-81.
15. Eun R, Figueras-lvarez O, Cabratosa-
Termes J, Oliver-Parra R. Marginal adapta-
tion of zirconium dioxide copings: inuence
of the CAD/CAM system and the nish
line design. J Prosthet Dent 2014 Jan 17.
http://dx.doi.org/10.1016/j.prosdent.2013.
10.012.
16. Tuntiprawon M, Wilson PR. The effect of
cement thickness on the fracture strength of
all-ceramic crowns. Aust Dent J 1995;40:
17-21.
17. Alkumru H, Hullah WR, Marquis PM,
Wilson SJ. Factors affecting the t of porcelain
jacket crowns. Br Dent J 1988;164:39-43.
18. Souza RO, Ozcan M, Pavanelli CA, Buso L,
Lombardo GH, Michida SM, 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.
19. Nakamura T, Dei N, Kojima T,
Wakabayashi K. Marginal and internal
t of Cerec 3 CAD/CAM all-ceramic crowns.
Int J Prosthodont 2003;16:244-8.
20. Wiskott HW, Belser UC, Scherrer SS. The
effect of lm thickness and surface texture
on the resistance of cemented extracoronal
restorations to lateral fatigue loading. Int J
Prosthodont 1999;12:255-62.
21. Lang NP, Kiel RA, Anderhalden K. Clinical
and microbiological effects of subgingival
restorations with overhanging or clinically
perfect margins. J Clin Periodontol 1983;
10:563-78.
22. Donovan T, Wright W, Campagni WV.
Use of paint-on die spacers in preparations
with grooves. J Prosthet Dent 1984;52:384-8.
23. Campagni WV, Preston JD, Reisbick MH.
Measurement of paint-on die spacers used
for casting relief. J Prosthet Dent 1982;
47:606-11.
24. Eames WB, ONeal SJ, Monteiro J, Miller C,
Roan JD Jr, Cohen KS. Techniques to improve
the seating of castings. J Am Dent Assoc
1978;96:432-7.
25. Fusayama T, Ide K, Hosoda H. Relief of
resistance of cement of full cast crowns.
J Prosthet Dent 1964;14:95-106.
26. Alghazzawi TF, Liu PR, Essig ME. The effect
of different fabrication steps on the marginal
adaptation of two types of glass-inltrated
ceramic crown copings fabricated by CAD/
CAM technology. J Prosthodont 2012;21:
167-72.
27. Beuer F, Schweiger J, Edelhoff D. Digital
dentistry: an overview of recent developments
for CAD/CAM generated restorations.
Br Dent J 2008;204:505-11.
8 Volume
28. Bindl A, Mormann WH. Clinical and
SEM evaluation of all-ceramic chair-side
CAD/CAM-generated partial crowns. Eur J
Oral Sci 2003;111:163-9.
29. Weyns W, De Boever J. Radiographic
assessment of the marginal t of cast
restorations. J Prosthet Dent 1984;51:485-9.
30. Boening KW, Wolf BH, Schmidt AE,
Kastner K, Walter MH. Clinical t of Procera
AllCeram crowns. J Prosthet Dent 2000;
84:419-24.
31. Reich S, Wichmann M, Nkenke E,
Proeschel P. Clinical t of all-ceramic
three-unit xed partial dentures, generated
with three different CAD/CAM systems.
Eur J Oral Sci 2005;113:174-9.
32. Kokubo Y, Ohkubo C, Tsumita M,
Miyashita A, Vult von Steyern P,
Fukushima S. Clinical marginal and internal
gaps of Procera AllCeram crowns. J Oral
Rehabil 2005;32:526-30.
33. Mitchell CA, Pintado MR, Douglas WH.
Nondestructive, in vitro quantication of
crown margins. J Prosthet Dent 2001;
85:575-84.
34. Bindl A, Mormann WH. Marginal and
internal t of all-ceramic CAD/CAM
crown-copings on chamfer preparations.
J Oral Rehabil 2005;32:441-7.
35. Gu XH, Kern M. Marginal discrepancies
and leakage of all-ceramic crowns: inuence
of luting agents and aging conditions. Int J
Prosthodont 2003;16:109-16.
36. Siervo S, Bandettini B, Siervo P, Falleni A,
Siervo R. The CELAY system: a comparison
of the t of direct and indirect fabrication
techniques. Int J Prosthodont 1994;
7:434-9.
37. Swain MV, Xue J. State of the art of Micro-CT
applications in dental research. Int J Oral Sci
2009;1:177-88.
38. Krasanaki ME, Pelekanos S, Andreiotelli M,
Koutayas SO, Eliades G. X-ray microtomo-
graphic evaluation of the inuence of two
preparation types on marginal t of CAD/
CAM alumina copings: a pilot study. Int J
Prosthodont 2012;25:170-2.
The Journal of Prosthetic Dentistry
39. Spoor CF, Zonneveld FW, Macho GA. Linear
measurements of cortical bone and dental
enamel by computed tomography: applica-
tions and problems. Am J Phys Anthropol
1993;91:469-84.
40. Verdonschot N, Fennis WM, Kuijs RH,
Stolk J, Kreulen CM, Creugers NH. Genera-
tion of 3-D nite element models of restored
human teeth using micro-CT techniques. Int J
Prosthodont 2001;14:310-5.
41. De Santis R, Mollica F, Prisco D, Rengo S,
Ambrosio L, Nicolais L. A 3D analysis of
mechanically stressed dentin-adhesive-
composite interfaces using X-ray micro-CT.
Biomaterials 2005;26:257-70.
42. Tan PL, Gratton DG, Diaz-Arnold AM,
Holmes DC. An in vitro comparison of
vertical marginal gaps of CAD/CAM titanium
and conventional cast restorations.
J Prosthodont 2008;17:378-83.
43. Christensen GJ. Marginal t of gold inlay
castings. J Prosthet Dent 1966;16:297-305.
44. Oilo G, Evje DM. Film thickness of dental
luting cements. Dent Mater 1986;2:85-9.
45. Bindl A, Windisch S, Mormann WH. Full-
ceramic CAD/CIM anterior crowns and
copings. Int J Comput Dent 1999;2:97-111.
46. Lin MT, Sy-Munoz J, Munoz CA,
Goodacre CJ, Naylor WP. The effect of tooth
preparation form on the t of Procera cop-
ings. Int J Prosthodont 1998;11:580-90.
47. Sulaiman F, Chai J, Jameson LM,
Wozniak WT. A comparison of the marginal
t of In-Ceram, IPS Empress, and Procera
crowns. Int J Prosthodont 1997;10:478-84.
48. Grey NJ, Piddock V, Wilson MA. In vitro
comparison of conventional crowns and a
new all-ceramic system. J Dent 1993;21:47-51.
49. Lee KB, Park CW, Kim KH, Kwon TY.
Marginal and internal t of all-ceramic
crowns fabricated with two different CAD/
CAM systems. Dent Mater J 2008;27:422-6.
50. Cho SH, Nagy WW, Goodman JT,
Solomon E, Koike M. The effect of multiple
rings on the marginal integrity of pressable
ceramic single crowns. J Prosthet Dent
2012;107:17-23.
- Issue -
51. Mormann WH, Bindl A, Luthy H, Rathke A.
Effects of preparation and luting system on
all-ceramic computer-generated crowns.
Int J Prosthodont 1998;11:333-9.
52. Mou SH, Chai T, Wang JS, Shiau YY. Inu-
ence of different convergence angles and
tooth preparation heights on the internal
adaptation of Cerec crowns. J Prosthet Dent
2002;87:248-55.
53. Molin MK, Karlsson SL, Kristiansen MS.
Inuence of lm thickness on joint bend
strength of a ceramic/resin composite joint.
Dent Mater 1996;12:245-9.
54. Gassino G, Barone Monfrin S, Scanu M,
Spina G, Preti G. Marginal adaptation of
xed prosthodontics: a new in vitro
360-degree external examination procedure.
Int J Prosthodont 2004;17:218-23.
55. McLean JW, von Fraunhofer JA. The estima-
tion of cement lm thickness by an in vivo
technique. Br Dent J 1971;131:107-11.
56. Yeo IS, Yang JH, Lee JB. In vitro marginal t of
three all-ceramic crown systems. J Prosthet
Dent 2003;90:459-64.
57. Sorensen JA, Munksgaard EC. Interfacial
gaps of resin cemented ceramic inlays. Eur J
Oral Sci 1995;103:116-20.
Corresponding author:
Dr Hisham A. Mously
Tufts University School of Dental Medicine
1 Kneeland Street, Boston, MA 02111
E-mail: dr.mously@gmail.com
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Mously et al