RESEARCH AND EDUCATION

Comparison of marginal and internal fit of 3-unit ceramic fixed

dental prostheses made with either a conventional or digital
impression
Ting-Shu Su, DDSa and Jian Sun, DDS, PhDb

The computer aided design/ ABSTRACT

computer aided manufacturing Statement of problem. For 20 years, the intraoral digital impression technique has been applied to
(CAD/CAM) technique has the fabrication of computer aided design/computer aided manufacturing (CAD/CAM) fixed dental
been used to produce ceramic prostheses (FDPs). Clinical fit is one of the main determinants of the success of an FDP. Studies of
restorations since the 1980s.1 the clinical fit of 3-unit ceramic FDPs made by means of a conventional impression versus a digital
Many CAD/CAM systems are impression technology are limited.
capable of designing and Purpose. The purpose of this in vitro study was to evaluate and compare the internal fit and
fabricating prostheses using marginal fit of CAD/CAM, 3-unit ceramic FDP frameworks fabricated from an intraoral digital
stone casts made from con- impression and a conventional impression.
ventional impressions. Resto- Material and methods. A standard model was designed for a prepared maxillary left canine and
rations generated in this second premolar and missing first premolar. The model was scanned with an intraoral digital
manner have proved success- scanner, exporting stereolithography (STL) files as the experimental group (digital group). The
ful both functionally and model was used to fabricate 10 stone casts that were scanned with an extraoral scanner, exporting
esthetically.2 However, air STL files to a computer connected to the scanner as the control group (conventional group). The
bubbles and deformation of STL files were used to produce zirconia FDP frameworks with CAD/CAM. These frameworks were
seated on the standard model and evaluated for marginal and internal fit. Each framework was
impression material (such as
segmented into 4 sections per abutment teeth, resulting in 8 sections per framework, and was
shrinkage or expansion) will observed using optical microscopy with ×50 magnification. Four measurement points were selected
affect the accuracy of the stone on each section as marginal discrepancy (P1), mid-axial wall (P2), axio-occusal edge (P3), and
cast, affecting the fit of the central-occlusal point (P4).
prosthesis.3 Therefore, intrao- Results. Mean marginal fit values of the digital group (64 ±16 mm) were significantly smaller than
ral scanners have been devel- those of the conventional group (76 ±18 mm) (P<.05). The mean internal fit values of the digital
oped to enhance the accuracy group (111 ±34 mm) were significantly smaller than those of the conventional group (132 ±44 mm)
of the definitive prostheses (P<.05).
while simplifying the proce- Conclusions. CAD/CAM 3-unit zirconia FDP frameworks fabricated from intraoral digital and
dure.4-6 conventional impressions showed clinically acceptable marginal and internal fit. The marginal
The accuracy and precision and internal fit of frameworks fabricated from the intraoral digital impression system were better
of the impression affects the fit than those fabricated from conventional impressions. (J Prosthet Dent 2016;-:---)
of indirect restorations, such as

Supported by medicine and engineering combination project of Shanghai Jiao Tong University grant YG2011MS07 and Shanghai leading academic discipline
project grant T0202, S30206.
a
Resident, Department of Prosthodontics, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology,
Shanghai, China.
b
Professor, Department of Prosthodontics, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine,
Shanghai Key Laboratory of Stomatology, Shanghai, China.

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the internal fit and marginal fit of CAD/CAM, 3-unit,

Clinical Implications ceramic FDP frameworks fabricated from intraoral digital
With regard to marginal and internal fit impressions and conventional impressions.
requirements, digital impressions made with the
MATERIAL AND METHODS
Trios system are suitable for fabricating 3-unit
ceramic zirconia fixed dental prosthesis frameworks. A maxillary model (dental study model 500A; Nissin) was
scanned 10 times with a Trios intraoral digital scanner
(digital group). In addition, the model was used to
fixed dental prostheses (FDPs).7,8 The discrepancy be- fabricate 10 stone casts, which were scanned by the
tween the intaglio of the restoration and the abutment extraoral scanner 10 times and used as the control group
tooth is an important measurement for evaluating pros- (conventional group). All 20 scanning files were pro-
thesis fit.9,10 The values of marginal and internal dis- cessed by CAD/CAM system to produce 20 zirconia FDP
crepancies represent the corresponding fit after the frameworks (HT biological nano zirconia blank; Upcera ).
prosthesis is seated on the teeth.11,12 The fit of these frameworks was evaluated using the
Compared with conventional polyvinyl siloxane (PVS) replica method.30
impressions,13 intraoral digital scanning eliminates tray The maxillary left canine and second premolar were
selection, material dispensing, material setting, material prepared teeth with a 6-degree convergence angle. The
disinfection, impression packaging and shipping, gypsum occlusal preparation depth was 2 mm, and the axial
pouring, die sectioning and trimming, and articulation preparation was 1.5 mm. Distinct chamfer finish lines
and mounting.14 Digital impression limits the error were prepared and placed at the gingival level, and the
caused by distortion of conventional impression width was designed as 0.6 mm. The maxillary first pre-
materials.15,16 molar was designed as missing, and the pit of model was
The first commercially available digital intraoral filled with light-body silicone (Honigum; DMG). The rest
impression system was used in 1987 and is known as the of the maxilla was positioned with standard artificial
CEREC 1 system (Sirona Dental, Inc).17 Since then, teeth (Fig. 1A).
several digital intraoral impression devices have been For the control group (conventional group), the 2-step
developed. Other than CEREC, the Lava chairside oral impression method was used to make 10 putty-wash
scanner (COS), iTero (3shape), E4D (Planmeca/E4D impressions using a PVS impression material (Flexitime;
Technologies), and Trios (Custom Automated Pros- Heraeus Kulzer GmbH).31 The impression materials were
thetics) systems are some of the available intraoral digital used with metal impression trays (BSA stainless steel
impression units currently used in the dental field.15 trays; Zhermack) and tray adhesive (Universal Adhesive;
The Trios system works on the principle of ultrafast Heraeus Kulzer GmbH), according to the manufacturer’s
optical sectioning and confocal microscopy. It uses a instructions.30,32 Impressions were then disinfected and
quick scanning speed, capturing up to 3000 images per poured with gypsum (Die-Stone Labstone; Heraeus
second, which reduces the influence of relative move- Kulzer GmbH) 24 hours later. After the gypsum had set,
ment between the scanner probe and teeth. Ceramic 10 stone casts were disinfected and sent to the laboratory
crowns manufactured by the Trios system demonstrate for trimming and die sectioning by an experienced dental
satisfactory marginal fit.11 However, studies focusing on technician (J.S.). The whole workflow was performed at
multiunit FDPs made with the Trios system are still room temperature (23 C).33 The stone casts were scan-
lacking.18 ned (D800 3D scanner; 3shape), and the results were
The acceptable marginal fit for crowns has been converted to stereolithography (STL) format to produce
widely discussed in published reports, with the 10 STL files for 10 stone casts.
consensus that a marginal fit of 150 mm or less is desir- For the experimental group (digital group), a digital
able from a clinical standpoint.19-22 Although studies of scanner (Trios cart) was used to make digital impressions
different kinds of CAD/CAM systems have evaluated the of the original model. After starting the Trios system and
clinical fit of ceramic FDPs, data are insufficient con- preheating the scanner tip, the same operator (J.S.) used
cerning the marginal and internal fits of FDPs covering the scanner to scan the study model 10 times, according
both anterior and posterior teeth based on intraoral to the operating instructions. The appropriate software
digital impressions.23,24 Available studies mostly concern produced the digital impressions as 10 STL files.
anterior or posterior teeth.6,12,25-29 Therefore, the authors Design software (3Shape Dental System) was used to
selected the maxillary left canine and second premolar as design the 3-unit frameworks based on the 20 STL files
abutment teeth in this study so that FDP frameworks of the 2 groups. Design parameters were set at a cement
contained both anterior and posterior teeth. Accordingly, space of 40 mm on the marginal discrepancy, a cement
the purpose of this study was to evaluate and compare space of 60 mm on the internal discrepancy, and a 3-unit

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Figure 1. A, Master model. B, FDP framework CAD image. C, Milled FDP zirconia framework. D, PVS film on abutment teeth. CAD, computer-aided
design; FDP, fixed dental prosthesis; PVS, polyvinyl siloxane.

framework thickness of 0.7 mm. The virtual frameworks Four measurement points were selected on each
were converted to 20 STL files (Fig. 1B). From the STL section as marginal discrepancy (P1), mid-axial wall (P2),
files, frameworks were milled with a milling machine axio-occusal edge (P3), and central-occlusal point (P4)
(Upcera) from presintered zirconia blocks (HT biological (Fig. 2). P1 was the perpendicular distance from the in-
nano zirconia blank) and then sintered (Zyrcomat 6000 ternal surface at the margin of the framework to the
MS; VITA Zahnfabrik) (Fig. 1C). No adjustments were marginal surface of the abutment tooth. P2 was the
made to the frameworks or the abutment teeth of the distance between the intaglio surface of the framework
study model. and the surface of the abutment tooth at the mid-axial
A replica method was used to evaluate the marginal wall. P3 was the bisector of the angle between the
and internal space between the frameworks and abut- straight line attached to the incisal edge and the straight
ment teeth.34 The intaglio surface of the retainers of line applied to the axial wall. P4 was the distance be-
frameworks were filled with a low-viscosity light-body tween the inner surface of the framework and the surface
PVS (Flexitime; Heraeus Kulzer GmbH ) and seated on of the abutment tooth at the central occlusal area (pre-
the abutment teeth with maximum finger pressure held molar) or the incisal edge (incisor). Data from P1 repre-
for 3 seconds. After 150 seconds, the frameworks were sented the marginal fit, and data from P2, P3, and P4
removed from the abutment teeth. The layer of PVS represented the internal fit of the framework.35 Up to 640
attached to the surface of the abutment teeth (Fig. 1D) points were measured for the 2 groups (4 points × 4
was surrounded by another light-body silicone (Honi- sections × 2 abutment teeth × 10 framework × 2 groups).
gum) to fix the PVS layer, which was sectioned mesio- All data were analyzed using statistical software (SAS
distally and buccolingually with a razor blade. Four v9.13; SAS Institute, Inc). The sample size calculation
sections per abutment tooth, resulting in 8 sections per was based on the number of replicas required for a 2-
framework, were observed using optical microscopy sample Student t test to demonstrate a 30-mm differ-
(SteREO Discovery V12 stereomicroscope; Carl Zeiss) ence in mean discrepancy between the 2 groups for each
at ×50 magnification. measurement point. The sample size was calculated as

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Table 1. Overview of fit of zirconia frameworks from experimental and

control groups
Maximum Minimum
Measurement Point Mean (±SD) (mm) (mm) N
Marginal discrepancy
Experimental group 63 (±16) 110 31 80
Control group 76 (±18) 130 44 80
P <.001
Internal discrepancy
Experimental group 110 (±40) 281 42 240
Control group 134 (±47) 250 47 240
P <.001

discrepancy on incisor facial, incisor palatal, premolar

Figure 2. Representative replica cross-section with locations of mea-
facial, distal, and palatal teeth (P<.05).
surement points.
DISCUSSION
The results revealed a higher value of marginal and internal
320 measurement points per group, based on a signifi-
discrepancies in the conventional group. Therefore, the null
cance level of .05, a power of 80%, and a standard de-
hypothesis was rejected. With in vivo tooth preparation,
viation (SD) of ±20 mm in both groups for each
the experimental situation could be complex because of
measurement point. The Anderson-Darling test was
compromised vision and accessibility. In addition, many
used to test for a normal distribution, the Levene test was
clinical factors were present, besides impression material
used to test for homogeneity of variance, and the Mann-
and technique, which influence the quality of an impres-
Whitney U test was used to test for significant differences
sion, including the location of the finish line, periodontal
between the 2 groups regarding the marginal and in-
health, sulcal bleeding during impression making, saliva
ternal discrepancies of all abutment tooth surfaces (a=.05
flow rate, and patient compliance.3
for all the tests).
For the measurement of clinical fit, the replica method
is a noninvasive, effective, and nondestructive way of
RESULTS
investigating the fit between restorations and teeth.30
The results of the overall mean marginal and internal The method of maximum finger pressure was used to
discrepancies of both groups are shown in Table 1. The seat the frameworks on the abutment teeth. This method
values of the discrepancy in P1 represented the marginal is reliable to seat the restorations on the teeth according
discrepancy. Eighty points of P1 were measured per group, to an in vitro study by Kokubo et al13 and has been
revealing a mean ±SD marginal discrepancy of 64 ±16 mm applied in other studies.6,11,14 Four points (marginal
(61 ±10 mm for canines and 65 ±19 mm for premolars) for discrepancy, mid-axial wall, axio-occusal edge, and
the digital group and 76 ±18 mm (73 ±16 mm for canines central-occlusal point) were measured on every surface of
and 80 ±18 mm for premolars) for the conventional group. each abutment tooth. According to the reports by
The Mann-Whitney U test presented a significantly higher Holmes et al8 and Wettstein et al,10 marginal fit is re-
value for the conventional group (P<.001). The values of flected by the marginal discrepancy (P1), and internal fit
the discrepancies in P2, -3, and -4 represented the internal is reflected by the mid-axial wall (P2), axio-occusal (P3)
discrepancy. A total of 240 points of P2, -3, and -4 were edge, and central-occlusal (P3). Wostmann et al3 inves-
measured per group, revealing a mean internal discrep- tigated the influence of the impression technique and
ancy of 110 ±40 mm (111 ±34 mm for canines and 109 ±46 material on in vivo marginal accuracy by extracting the
mm for premolars) for the digital group and 134 ±47 teeth after impression making and measuring the mar-
mm(132 ±44 mm for canines and 136 ±50 mm for pre- ginal discrepancy under a microscope. Using PVS
molars) for the conventional group. The Mann-Whitney U impression material, they found discrepancies of 118 mm
test presented a significantly higher value for the con- for the 2-step versus 128 mm for the 1-step technique.
ventional group (P<.001). The 1-step technique was considered slightly inferior to
The results from the mean marginal and internal fit in the 2-step technique for subgingival margins. Based on
terms of every surface of every abutment tooth for the 2 this outcome, a 2-step technique was chosen for the
groups are shown in Tables 2 and 3. The Mann-Whitney conventional group in the present study.
U test results revealed that, for the conventional group, a This study revealed a mean marginal fit of 63 mm for
greater marginal discrepancy was found on incisor facial, the intraoral digital impression group and 76 mm for the
incisor distal, and premolar palatal and a greater internal conventional impression group, as well as a mean internal

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Table 2. Comparison of mean (±SD) surface-by-surface marginal discrepancy values (mm) of zirconia frameworks for experimental and control groups
Marginal Discrepancy N C-f C-m C-p C-d PM-f PM-m PM-p PM-d
Experimental group 10 59 (±13) 68 (±11) 65 (±15) 52 (±8) 62 (±17) 61 (±19) 71 (±10) 67 (±23)
Control group 10 76 (±16) 74 (±13) 68 (±19) 72 (±21) 71 (±14) 75 (±11) 90 (±20) 84 (±21)
P .019* .280 .786 .018* .244 .058 .018* .113
C, canine; d, distal; f, facial; m, mesial; p, palatal; PM, premolar.
*Significant differences between experimental and control group.

Table 3. Comparison of mean (±SD) surface-by-surface internal zirconia framework discrepancy values (mm) for experimental and control groups
Internal Discrepancies N C-f C-m C-p C-d PM-f PM-m PM-p PM-d
Experimental group 30 105 (±37) 126 (±34) 104 (±27) 109 (±40) 100 (±41) 109 (±48) 107 (±44) 121 (±45)
Control group 30 131 (±40) 140 (±46) 130 (±40) 128 (±45) 127 (±49) 128 (±45) 139 (±56) 149 (±56)
P .012* .163 .005* .090 .025* .126 .017* .040*

C, canine; d, distal; f, facial; m, mesial; p, palatal; PM, premolar.

*Significant differences between experimental and control group.

fit of 110 mm for the intraoral digital impression group and investigate the marginal fit of a ceramic single crown
134 mm for the conventional impression group. The based on a digital impression (Lava COS) and a
marginal and internal fit of CAD/CAM zirconia FDPs met conventional impression, which reported 49 mm for
the clinical criterion with regard to both the digital and the digital group and 71 mm for the conventional
conventional groups. The better overall fit of the digital group−a significant difference. Similar results were
group could be explained by error caused by the procedure found in this study. An in vivo experiment evaluated
of conventional impression making. In the conventional the marginal fit of a single molar ceramic crown using
group, stone casts were produced from impressions made the Lava COS and CEREC AC systems and reported
from the original study model. The following steps were marginal discrepancies with acceptable clinical per-
carried out on stone casts. In the digital group, digital formance of 51 mm and 83 mm.28 Seelbach et al26
impressions were directly made by digital scanning with investigated the clinical adaptation of a ceramic sin-
an intraoral scanner of the original study model followed gle crown among Lava COS, CEREC AC, and the
by the CAD/CAM workflow. Every step in the in vitro iTero system. The mean values of the marginal fit of
study can cause errors; therefore, the procedures for the 3 impression methods were 48 mm, 30 mm, and 41
making conventional impressions and stone casts might mm. The internal fit was 88 mm, 29 mm, and 50 mm.
create more errors in the conventional group.12 Further- Currently available intraoral digital systems work on
more, errors caused by the expansion and contraction of various digital algorithmic principles, and these tech-
the materials were also inevitable. All the experiment niques have been proven able to create precise impres-
procedures were carried out at a temperature of 23 C. A sions directly from the oral cavity. In the study by
study by Corso et al33 indicated that PVS impression Tidehag et al,6 the iTero system showed a mean marginal
material demonstrate a contraction of 17 mm in the hori- discrepancy of 128 mm, which is still as good a fit as the
zontal line and 2 mm in the vertical line after storage at conventional hot-pressed glass ceramic crown in the
23 C. This could explain the significant difference in the conventional group. Despite the results of Boeddinghaus
results for the digital and conventional groups. et al,31 a mean marginal discrepancy of 148 mm of Cerec
Keul et al27 reported a marginal discrepancy of 127.23 OmniCam, greater than Trios and Lava TDeF, several
mm in a 4-unit zirconia framework based on the iTero Cerec systems provided satisfactory marginal fit for CAD/
intraoral system in an in vitro study. Almeida et al24 CAM ceramic crowns.25,26
compared the fit of 4-unit ceramic FDPs between the Both in the digital and conventional groups, the
intraoral digital method and the conventional impression values of marginal and internal fit were larger at the
method, revealing that marginal discrepancies were 63.96 incisor mesial and premolar distal aspects. The reason
mm for the digital group and 65.33 mm for the conven- may be that these 2 areas were close to adjacent teeth,
tional group and that the values of internal discrepancies which limited the amount of light; accordingly, the
were 58.46 mm for the digital group and 65.94 mm for the intraoral scanner was affected when capturing and
conventional group. Similar to the results of Almeida generating 3D data in adjacent spaces.
et al,24 this study also suggested a lower value of fit in the The procedures used for the study model do not
intraoral digital group. reproduce the clinical situation. Furthermore, in vivo
Studies of the adaptation of single crowns based studies with more digital systems are necessary to better
on intraoral digital impressions are mostly in vivo investigate and evaluate the performance of intraoral
studies. Syrek et al12 conducted an in vivo study to digital impression techniques.

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CONCLUSIONS 17. Rekow ED. Dental CAD/CAM systems: a 20-year success story. J Am Dent
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