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Marginal and internal fit of zirconia based fixed

dental prostheses fabricated with different
concepts

Florian Beuer 1 Abstract: The purpose of this in vitro study was to compare the precision of fit of substructures
Natalie Korczynski 1 milled from semi-sintered zirconia blocks, fabricated with two different fabrication concepts.
Antonia Rezac 1 Three-unit, posterior fixed dental prostheses (FDP) were fabricated for standardized dies (n = 10)
Michael Naumann 2 with the laboratory Computer Aided Design (CAD)/Computer Aided Manufacturing (CAM)
Wolfgang Gernet 1 system Cercon® Brain (Brain) and the centralized CAD/CAM system Compartis Integrated
Systems (Compartis). After cementation to the dies, the FDP were embedded and sectioned. Four
John A Sorensen 3
cross-sections were made of each abutment tooth, and marginal and internal fit were evaluated
1
Department of Prosthodontics, under an optical microscope. A one-way analysis of variance (ANOVA) was used to compare data
Ludwig-Maximilians University,
Munich, Germany; 2Department of (α = 0.05). Mean gap dimensions at the marginal opening for Brain and Compartis were 56.0
Prosthodontics and Material Sciences, (±34.5) µm and 51.7 (±45.2) µm, respectively. Mean internal gap dimensions of 62.8 (±37.5) µm
University of Ulm, Germany; 3Pacific
to 164.6 (±33.4) µm were measured depending on the measurement location and the fabrication
Dental Institute, Portland, Oregon,
USA concept. Mean marginal openings and internal adaptations were not significantly different for both
systems. Three out of four measurement locations showed significantly different cement gaps.
Within the limitations of this study, the results suggest that the accuracy of both investigated
systems is satisfactory for clinical use. The laboratory fabrication exhibited similar accuracy
as the centralized manufacturing.
Keywords: zirconia, CAD/CAM, fit, FDP, all-ceramic

Introduction
In attempts to improve the strength and fracture toughness of dental prostheses, several
new ceramic materials and techniques have been developed during the last decades.
All-ceramic fixed dental prostheses (FDP) frameworks can be made from various
high-strength ceramic materials.1 Yttria-stabilized zirconia has proven clinical suit-
ability for posterior FDP.1–3
Similar to metal-ceramics, the fabrication of zirconia based FDP uses a high-
strength ceramic material for the framework, to provide resistance against cyclic
loading.1–3
Computer aided manufacturing (CAM) of zirconia substructures currently utilizes
two different strategies for the type of milling blocks used. The hardness of the zirconia
blocks and hence the difficulty in milling the substructures is determined by the degree
Correspondence: Florian Beuer of sintering of the blocks. Originally, blocks were fully sintered by a process known as
Department of Prosthodontics, Ludwig-
Maximilians University, Goethestr. 70, hot isostatic pressing (HIP). Milling the actual size of the substructure is associated
80336 Munich, Germany with disadvantages, such as high wear rates of the milling burs in the CAM machines
Tel +49 89 5160 9514
Fax +49 89 5160 9502
and prolonged milling time due to slower feed.4,5 Since there is no further sintering
Email [email protected] necessary and therefore no sintering shrinkage, the marginal fit of these substructures is

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cited.
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excellent.4,5 The demonstrated marginal values for this tech- the same scanning unit, software and porous zirconia are
nique are 60.4 and 74.0 µm.4 Another study showed that high used the CAM-milling machines are different.35 It might be
precision can be achieved using milling devices for densely questioned if the place of fabrication influences the precision
sintered zirconia.6 A second method of milling block fabri- of the prosthesis.
cation utilizes a semi-sintered zirconia material. The semi- Therefore the purpose of this investigation was to measure
sintered block has a chalk-like consistency, making it easily the marginal opening and internal adaptation of zirconia-
machineable in the CAM unit. After milling, the substructure based restorations to the working dies manufactured by the
is then sintered to full density. The post-milling sintering same CAD/CAM-system with exception of the milling unit.
results in a linear shrinkage in the range of 15% to 30% The working hypothesis states that; (1) both systems produce
and subsequent increase in density.2,7 The increased milling marginal openings below 120 µm and that (2) the centralized
efficiency of the softer semi-sintered block has the trade-off CAD/CAM system improves the marginal and internal fits
of a potential poorer fit from a 20% sintering shrinkage, the that laboratory CAD/CAM system.
scanning process, compensatory software design and milling.
Apart from the mechanical properties and esthetics, the long- Materials and methods
term clinical success of all-ceramic fixed prosthodontics can Die fabrication
be influenced significantly by marginal discrepancies. Poor A typodont model (Frasaco, Tettnang, Germany) with a
marginal adaptation increases plaque retention and changes missing mandibular right first molar was used. A 1.2 mm,
the distribution of the microflora, which can induce the onset 360-degree chamfer preparation was made on the second
of periodontal disease.2,7–10 Microleakage from the oral cavity premolar and second molar. To control axial reduction,
can cause endodontic inflammation.8 A clinical study on a a silicone impression (Optosil®, Heraeus Kulzer, Hanau,
CAM only system (DCM prototype of Cercon, DeguDent, Germany) was made prior to tooth preparation. Addition-
Hanau, Germany) reported poor marginal fit and a 22% rate ally, the provisional crown (Protemp 3™ Garant, 3M™ ESPE)
of secondary caries after 5 years.2 Currently chipping of the was used to verify the thickness, so the circumferential and
veneering porcelain appears to be one of the major draw- occlusal reduction could be quantified (Dial Caliper, Kori
backs of zirconia-based restorations.2,11–15 There is evidence Seiki, Tokyo, Japan). The preparation was completed with
available demonstrating the influence of excessive cement a surveyor (F1, DeguDent) using a carbide bur (Komet H
space on failure of the veneering porcelain.16 This thick 356 RGE 103.031, Brasseler GmbH, Lemgo, Germany) to
cement layer complicates the challenge to minimize stress ensure that the preparation had a total taper of 8-degree.
concentrations on the tensile surface of the restoration caused Twenty polyether impressions (Impregum™, 3M™ ESPE)
by the viscoplastic deformation of the adhesive material und were made with a metal impression tray (U3 # 141163
cyclic loading. It was reported that currently recommended Orbilock®, Orbis Dental, Münster, Germany) and poured in
cements flow under load.17–19 This flow increases the stress in a class IV resin-reinforced (ISO type IV) die stone (Resin-
the system consisting of substructure and veneering porcelain Rock, Whip Mix Europe, Dortmund, Germany). After the
dramatically.16,20,21 The increased stress propagates damage dies set, pins (Pindex System, Coltene Whaledent, Altstätten,
and may cause failure of the veneering porcelain.16 Switzerland) were placed in the appropriate locations, and
There is consensus between various authors that mar- the base of the cast was poured in the same dental stone. Dies
ginal openings below 120 µm are clinically acceptable.22–25 were removed from cast base, and trimmed to the preparation
Numerous studies have examined the marginal fit of porcelain margins. The same investigator made all impressions, and
crowns,4,6,8,26–34 however, in vitro measurement data for the all dies were fabricated by the same experienced technician.
marginal fit of Compartis Integrated Systems CAD/CAM- Twenty definitive casts with removable dies were fabricated
system have not been reported. There is evidence that and divided into two groups. The precision of fit of the sub-
centralized fabrication of zirconia substructures is superior structure was measured without veneering.8,36 The definitive
to laboratory systems regarding accuracy.33 However, this dies were sent to a dental laboratory.
study investigated three completely different CAD/CAM-
systems.33 The CAD/CAM system used in this study offers Laboratory CAD/CAM system
2 options of fabrication: The coping can be fabricated in the The digitalization of the dies was performed by a laser
dental laboratory (Cercon Brain, DeguDent) or in the milling scanner (Cercon eye, DeguDent®, Hanau, Germany) and
center (Compartis Integrated Systems, DeguDent). While the substructures were designed on the CAD program of the

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Dovepress Accuracy of zirconia substructures

system (Cercon art, DeguDent®). The construction of the The retainer was set back onto the definitive die with finger
retainers was carried out with a standardized protocol. The pressure, and the excess cement was removed. A special
settings were: a wall thickness of 0.4 mm and a virtual cement cementing device was used to ensure that the pontic was
layer of 20 µm starting 1 mm above the margin. loaded centrally at a force of 50 N for 10 minutes.42 The
Ten zirconia retainers were fabricated at the laboratory same team of an experienced dentist, who sat the retainer
of Munich dental school using the laboratory CAM unit onto the dies, and a dental assistant, who activated the cap-
of the system (Cercon Brain). The data were enlarged by sule of cement and started the mixing procedure, cemented
30% and the frameworks were milled from semi-sintered all substructures. The middles of both abutment teeth were
zirconia blanks (Cercon base 30 mm, DeguDent®). The marked on the die in order to have standardized sectioning.
milled, enlarged frameworks were sintered to full density at Twenty-four hours after cementation, every framework was
a temperature of 1623 K resulting in shrinkage to the desired embedded into gypsum (ResinRock, Whip Mix, Louisville,
dimensions. KY, USA) to prevent raptures and disruptions and cross-
sectioned (Accutom 2, Struers, Willich, Germany). The
Milling center CAD/CAM system pontic was discarded, and the abutment teeth were sectioned
Ten zirconia frameworks were fabricated by a milling center centrally from buccal to lingual and from mesial to distal
(Compartis Integrated Systems). The data of the designed according to the pencil-lines at the middles of both abut-
substructures were sent via Internet to the milling center and ment teeth, thus resulting in 8 specimens to be evaluated
the sintered substructures were sent back after 48 hours. for each framework.
All frameworks were examined for deformity and debris,
and steam-cleaned (Triton SLA, Bego, Bremen, Germany). Fit evaluation
All frameworks were returned to their respective dies and The measurement procedure was described in prior
controlled in terms of seating. In case of incomplete seating, studies.33,34 For each substructure, the following four mea-
an additional adaptation of the framework was performed surement locations were used to determine the precision of
using a standardized protocol according to the literature fit between the retainers and the dies:
and clinical practice.11,33,37–39 To identify areas that needed 1. Marginal Opening (MO): The marginal opening at the
correction, lipstick (Shine Délicieux, L’Oréal, Paris, France) point of closest approximation between the die and
was applied to the master cast, and the framework was ceramic margin of the retainer.
placed without force. The red spots inside the framework 2. Chamfer Area (CA): The internal adaptation of the
were removed using a redring diamond ball instrument retainer at the point of the biggest diameter.
(Komet 8801.016, Brasseler) with water-cooling spray. This 3. Axial Wall (AW): The internal adaptation of the crown
procedure was repeated until the marked indicator spots walls at the midpoint of the axial wall (2 mm occlusal to
disappeared and a uniform and even contact of the coping the margin of the die).
on the die was achieved. After each refinement the color 4. Occlusal Adaptation (OA): The internal adaptation of the
was removed from the die by a steam cleaner. The same surface of the crown to the die at the midpoint from the
experienced dental technician adapted and checked all the facial and proximal.
restorations. After the adaptation process the supervising
dentist controlled the seating. The examiner inter-agreement The fit of the substructures was evaluated using the
factor was 95%. scan line schema (Figure 1) planned for the investigation,
measurements were taken from the database at MO, CA,
Cementation process AW and OA measurement locations to evaluate the fit of
Additionally all retainers were cemented on the definitive all retainers. Data recorded at the different cross-sections
dies by glass ionomer (KetacCem Aplicap, 3M ESPE).40,41 of one specimen were averaged by the different measure-
The capsule of glass ionomer cement was activated for ment locations.
2 seconds (Aplicap Activator, 3M™ ESPE) and mixed
automatically (Rotomix, 3M™ ESPE) for 10 seconds. The Statistical analysis
abutments of the retainers were filled (Aplicap Applier, Data were imported in a statistical program (SPSS 16.0, SPSS
3M™ ESPE) with cement, and the cement was spaced out Germany, Munich, Germany). Mean data were calculated
by a disposable brush until the complete surface was coated. and analyzed with descriptive statistics. A one-way analysis

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Beuer et al Dovepress

300

Mean cement gap in µm

200
Fabrication Concept
In house
Compartis

100

0
CA AW OA MO
Measurement location
Figure 2 Mean gap dimension and standard deviation at marginal opening (MO),
chamfer area (CA), axial wall (AW) and occlusal adaptation (OA) measurement
locations for both investigated systems.

Figure 1 Crown to die diagram showing measurement locations to determine

marginal opening (MO; distance between A and B), chamfer area (CA; distance Mean gap dimensions between the system groups were
between C and D), axial wall (AW; distance between F and E) and occlusal adaptation
(OA; distance between G and H). significantly different at MO, CA and OA. The measurement
location AW did not demonstrate any significant differences
between both systems. The measurement locations showed
of variance (ANOVA) was carried out to detect statistical
significantly different values, while 4 homogeneous groups
difference between both investigated systems in terms of mar-
were detected (Tables 2 and 3).
ginal fit and internal fit at the different measurement locations.
To show the difference between the measurement locations
a one-way ANOVA and a post hoc test (Student-Newman-
Discussion
An acceptable Marginal gap for full crowns, as reported
Keuls) was used. The level of significance was set at 5%.
by Hung and colleagues, is 50 to 75 µm,30 whereas Weaver
and colleagues suggested 70 (±10) µm.28 The mean mar-
Results
ginal openings for both investigated systems were 56.0 µm
The mean Marginal gap dimension for Brain and Compartis
(Brain) and 51.7 µm (Compartis), respectively. Both systems
were 56.0 (±34.5) µm and 51.7 (±45.2) µm, respectively.
showed comparable MO to other investigated all-ceramic
The mean internal adaptation gap dimensions for Brain
systems,6–9,31,43 which means that the part of the working
were 100.3 (±42.7) µm (CA), 67.3 (±52.6) µm (AW), and
hypothesis concerning marginal fit, that would be clinically
161.2 (±119.7) µm (OA). Compartis showed mean internal
acceptable, can be supported.
adaptation gap dimensions of 99.7 (±32.4) µm (CA), 62.8
It has to be taken in account that in vitro studies offer
(±37.5) µm (AW), and 164.6 (±33.4) µm (OA) (Figure 2).
standardized and optimized conditions in terms of the
Table 1 presents the one-way ANOVA on the system
preparation design, impression technique or experimental
groups by MO, CA, AW and OA measurement locations.
performance. Therefore, the results of the present study show
the precision of CAD/CAM systems under ideal conditions.
Table 1 One-way ANOVAs of between-system factor by measure- A clinical evaluation of the Lava system reported a mean MO
ment locations (MO, CA,  AW and OA)
Source df Sum of Mean F value P value
squares squares
Table 2 One-way ANOVA on the measurement location factor
MO 1 17.047 17.047 0.012 0.915 (MO, CA,  AW, and OA)
CA 1 866.673 866.673 0.410 0.523 Source df Sum of Mean F value P value
AW 1 245.205 245.205 0.028 0.867 squares squares
OA 1 757.985 757.985 0.468 0.495 Complete data 3 779459.363 259819.788 96.154 0.000a
a
P = 0.05. a
P = 0.05.
Abbreviations: df, degrees of freedom; MO, marginal opening; CA, chamfer area.  AW, Abbreviations: df, degrees of freedom; MO, marginal opening; CA, chamfer area;
axial wall; OA, occlusal adaptation. AW, axial wall; OA, occlusal adaptation.

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Dovepress Accuracy of zirconia substructures

Table 3 Student-Newman-Keuls post hoc test on different Based on the literature there is evidence that the
measurement locations. fabrication concept has a major impact on the fit. Central-
Measurement location Subgroup 1
ized fabrication performed significantly better compared
MO 53.7 µma to a laboratory CAD/CAM system and a laboratory CAM
AW 64.0 µma system.33 However, the systems tested in that study used
CA 100.0 µmb different scanning devices, different CAD-software and dif-
OA 163.0 µmc ferent semi-sintered zirconia.33 No difference in accuracy
Notes: Different superscript letters indicate statistic difference of the presented between both fabrication concepts could be detected rejecting
groups.
Abbreviations: MO, marginal opening; CA, chamfer area;  AW, axial wall; OA, occlusal
the second part of the working hypothesis. When the same
adaptation. preparation model, scanning device, CAD-software, semi-
sintered zirconia material and sintering device are used the
milling machine seems to have no influence on the fit.
of 80 (±50) µm, which included inaccuracies caused by the The limitations of the present study were: (1) All frame-
CAD/CAM system and the clinical procedure.7 Measurements works were adapted, to avoid inaccuracies a standardized
on Procera crowns in vivo exhibited gap widths that were 61 to protocol was used. The same technician adapted all sub-
70 µm wider in bucco-lingual direction and 58 to 73 µm wider structures and at least two calibrated examiners verified as
in proximal locations than gap widths measured in vitro.32 being the best possible fit in their opinion. This influence can
According to May and colleagues. the MO was defined as the therefore be considered the minimal unavoidable degree of
closest distance between retainer and preparation to avoid that error inherent to the system. This procedure also reflects the
overextension or underextension of the retainer crown could manufacturing process in the dental laboratory. (2) The gap
affect the result.10,43 The cement space or internal adaptation dimensions were measured using the cross-section technique.
is considered to be a uniform space that facilitates seating As a result the precision was just measured at 8 defined areas
without compromising retention and resistance forms. This per retainer, which might not represent the complete fit.
is of paramount importance because all-ceramic restorations Cross sectioning might also cause damage to the specimens.
are more fragile compared to metal-ceramics, as ceramic is a Therefore all specimens were embedded in gypsum, cross-
brittle material and sensitive to tension. The precision of fit sectioned under water spray and low feeding rates to avoid
can influence the clinical prognosis. Tuntiprawon and Wilson possible inaccuracies through damaged specimens. (3) All
reported that all-ceramic crowns displayed greater compres- retainers were cemented onto their respective dies. Therefore
sive strength when the mean AW was at a gap dimension of the marginal fit could have been influenced by this procedure.
73 µm.27 Their study also showed that if the mean AW was However, as the used cement requires a space of 20 µm, it
increased to 122 µm, lower fracture strength occurred without is theorized that the luting space measured and represented
any significant improvement in seating.27 Both investigated by the cement width did not prevent the accurate seating of
CAD/CAM systems could fulfill this requirement. The the retainers as a result of hydraulic pressure. (4) All retain-
obtained data did not indicate that there were incidences of ers were produced and tested under ideal conditions, which
axial wall contact between dies and the retainers, which would might not reflect the precision in daily clinical use. Further
have been visible in the cross-sections. research should be carried out testing different spans of
As reported in a clinical investigation widest gap dimen- FDP and more available systems (CAM-technology, hand-
sions were found in OA.7 Thin cement layers (80 µm) at copying-technology).
measurement location OA have been reported to be more
favorable for the mechanical stability of zirconia based res- Conclusions
torations.21 There is also evidence that a lack of precision in According to the results of this study the following conclu-
internal fit can promote higher risks for veneering fracture.20 sions can be drawn:
Apart from mechanical properties of the material used, this 1. Both milling concepts tested demonstrated in-vitro
also has a clinical aspect. If too much space is lost as a result acceptable marginal openings.
of large interocclusal discrepancies, the intercuspal clearance 2. The differences of fit depended on the region of the
available for veneering is reduced. Despite this aspect, the retainer being evaluated.
result of the present study indicates that gaps were similar or 3. Laboratory milling of semi-sintered zirconia exhibited simi-
better to those of metal ceramic restorations.26,29 lar accuracy as centralized milled zirconia substructures.

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