Marginal Adaptation of All-Ceramic Crowns on

Implant Abutments
Wael Att, DDS, DR MED DENT;*† Tomas Hoischen, DDS;* Thomas Gerds, DIPL-MATH, DR RER NAT;‡
Jörg Rudolf Strub, DDS, DR MED DENT, PhD*

ABSTRACT
Background: Studies focusing on the marginal accuracy of all-ceramic crowns on implant abutments are in short supply.
Purpose: This study evaluated the marginal accuracy of all-ceramic crowns on different implant abutments.
Materials and Methods: Ninety-six standardized maxillary central incisor crowns (48 alumina and 48 zirconia) were
fabricated for each of the six test groups (n = 16) (Ti1, titanium abutments–alumina crowns; Ti2, titanium abutments–
zirconia crowns; Al1, alumina abutments–alumina crowns; Al2, alumina abutments–zirconia crowns; Zr1, zirconia
abutments–alumina crowns; Zr2, zirconia abutments–zirconia crowns). The crowns were adhesively luted using a resin
luting agent. The marginal gaps were examined on epoxy replicas before and after luting as well as after masticatory
simulation at 200¥ magnification.
Results: The geometrical mean (95% confidence limits) marginal gap values before cementation, after cementation, and
after masticatory simulation were group Ti1: 39(37–42), 57(53–62), and 49(46–53); group Ti2: 43(40–47), 71(67–76), and
64(59–69); group Al1: 57(54–61), 87(85–90), and 67(65–69); group Al2: 66(63–69), 96(90–101), and 75(72–78); group Zr1:
54(51–57), 79(76–82), and 65(63–67); and group Zr2: 64(60–68), 85(80–91), and 75(70–81). The comparison between
non-cemented and cemented stages in each group demonstrated a significant increase in the marginal gap values after
cementation in all groups (p < .001), while the comparison between cemented and aged stages in each group showed a
significant decrease in the marginal gap values in groups Al1, Al2, and Zr1 (p < .0001). This reduction was not significant
for groups Ti1, Ti2, and Zr2 (p > .05).
Conclusion: The marginal accuracy of all tested restorations meets the requirements for clinical acceptance.
KEY WORDS: all-ceramic crowns, alumina, implant abutments, marginal accuracy, mastication simulator, zirconia

I mplant-supported restorations can be either screw

retained or cement retained, or both. The choice of
cementation versus screw retention seems to be based
authors have emphasized the advantages of the cement-
retained restoration, including its greater versatility
for aesthetics and simplicity of the technique.3 Other
mainly on the clinician’s preference. Several authors advantages include the potential for complete passivity
advocate that the screw-retained restoration offers of the cemented restoration and the option to use a
reversibility and more stability and security at the variety of materials for reconstruction, including all-
implant-abutment interface.1,2 On the other hand, some ceramic materials.4 These potential advantages have
made cement-retained implant restorations increasingly
popular.
*Department of Prosthodontics, University Hospital of Freiburg, Today, high-strength, all-ceramic materials are
Freiburg, Germany; †The Weintraub Center for Reconstructive Bio- increasingly being used for the fabrication of implant-
technology, UCLA School of Dentistry, Los Angeles, CA, USA; ‡Insti- supported restorations, especially in the aesthetic area
tute of Medical Biometrics and Medical Informatics, University of
Freiburg, Freiburg, Germany of the dental arch. The most widely used materials are
densely sintered high-purity alumina (Al2O3) and yttria
Reprint requests: Wael Att, Department of Prosthodontics, Dental
School, Albert-Ludwigs University, Hugstetter Str. 55, 79106 Freiburg, (Y2O3) partially stabilized zirconia (ZrO2). These high-
Germany; e-mail: [email protected] strength ceramics can be used for the fabrication of
© 2008, Copyright the Authors implant abutments and superstructures. Both materials
Journal Compilation © 2008, Wiley Periodicals, Inc. show improved optical and mechanical properties and
DOI 10.1111/j.1708-8208.2007.00079.x demonstrate differences in their microstructure and

218
 Marginal Adaptation of All-Ceramic Crowns on Implant Abutments 219

mechanism against flaw propagation.5,6 Y2O3 partially The aim of the present investigation was to evaluate
stabilized ZrO2 ceramic has twice the strength of Al2O3 the marginal accuracy of high-strength all-ceramic
ceramic.5,7 Recent developments in CAD/CAM tech- crowns on different implant abutments before and after
niques made it easier to fabricate high-quality, zirconia- luting, and after thermomechanical fatigue in a masti-
based abutments and restorations. The material has a cation simulator.
flexural strength of 900 to 1,200 MPa, Vickers hardness
of 1,200 Gpa, and Weibull modulus between 10 and MATERIALS AND METHODS
12.5,7 Because of its shade, the Al2O3 ceramic provides Ninety-six implants with a diameter of 4.3 mm and a
certain aesthetic advantages to the more whitish zirconia length of 15 mm (Replace Select®, Nobel Biocare AB,
ceramic.8 When used as an abutment material, the Al2O3 Göteborg, Sweden) were used in this study. The implants
ceramic is easier to prepare, thereby saving time during were divided into six groups of 16 specimens each.
the definitive abutment preparation, which is usually Thirty-two titanium abutments (Esthetic™ Abut-
performed intraorally. Clinical studies have demon- ment, Nobel Biocare AB) were used for the control
strated that the success rate of alumina abutments groups (Ti1, Ti2), whereas 32 industrially prefabricated
was between 93 and 98.1% after observation periods Al2O3 abutments (Esthetic Alumina Abutment, Nobel
between 1 to 5 years,9,10 whereas the success rate of zir- Biocare AB) and 32 industrially prefabricated ZrO2
conia abutments was 100% after an observation period abutments (Esthetic Zirconia Abutment, Nobel Biocare
of 4 years.4 AB) served as test groups (Al1, Al2, Zr1, Zr2). All abut-
The restoration of ceramic abutments with all- ments were straight and had standard dimensions, a
ceramic crown systems has been described in the litera- deep chamfer finish line of 0.5 mm depth, and a total
ture.4,8,11 High-quality restorations can be fabricated height of 9 mm. An incisal reduction of 2 mm (defini-
using Al2O3 or ZrO2 ceramic systems. Although the com- tive total height of 7 mm) was made for all abutments
bination of Al2O3- or ZrO2-based all-ceramic crowns using diamond rotary cutting instruments (bur no.
and high-strength ceramic abutments has been demon- 379EF 016, Gebr. Brasseler, Lemgo, Germany) with
strated to have appropriate strength for clinical applica- water spray application and the help of a silicone index
bility,12,13 no clinical data on the long-term success of (Twinduo, Picodent, Wippenfürth, Germany). Then,
such restorations are available yet. all abutments were scanned using a mechanical scanner
In addition to the physical properties and biocom- that operates by surface detection (Procera Piccolo
patibility, the marginal fit of any dental restoration is scanner, Nobel Biocare AB). Ninety-six copings (48
vital to its long-term success. Lack of adequate fit is Al2O3 and 48 ZrO2) were designed (CAD) using the
potentially detrimental to both the tooth and the software Procera (Procera CADDesign, version 1.2 Build
supporting periodontal tissues. Imperfect restoration 23, Nobel Biocare AB) with an overall thickness of
margins offer ideal recesses for plaque accumulation fol- 0.6 mm. The data were sent via modem to Nobel Biocare
lowed by adherence of oral bacteria.14 This may cause AB where the fabrication of copings took place. After
traumatic gingival irritations at teeth.15 Because the soft delivery, all copings were tried on and veneered. The
tissues of teeth and implants behave in the same manner, Al2O3 copings were veneered using Nobel Rondo veneer-
the marginal fit of crowns on implants is supposed to be ing ceramic (Nobel Biocare AB), whereas the ZrO2
an important factor for the implant and prosthetic suc- copings were veneered using Vita VM9 veneering
cess.3,16 The gap between the crown and the abutment ceramic (Vita Zahnfabrik, Bad Säckingen, Germany).
can act as a trap for bacteria, and thus, possibly cause Both veneering ceramics are low-fusing silicate-based
inflammatory reactions in the peri-implant soft tis- porcelains. Forty-eight Al2O3- and 48 ZrO2-based stan-
sues.16,17 In vitro evaluations reported mean values dardized maxillary central incisor crowns were fabri-
between 11 and 67.4 mm for the marginal gaps of metal– cated using a silicone index (height 11 mm, width
ceramic crowns cemented on implant abutments,18,19 8 mm). Afterward, all implants were embedded with
and between 65.9 and 168 mm for all-ceramic crowns autopolymerizing acrylic resin (Technovit® 4000,
cemented on metal implant abutments.20,21 So far, Heraues Kulzer, Wehrheim, Germany) at an inclination
there are no data about the marginal gap of implant- of 135° to the horizontal plane to simulate clinical con-
supported all-ceramic crowns on ceramic abutments. ditions.22 Then, groups Ti1, Al1, and Zr1 received Al2O3
220 Clinical Implant Dentistry and Related Research, Volume 10, Number 4, 2008

crowns, whereas groups Ti2, Al2, and Zr2 received ZrO2

crowns.
All abutments of the test and control group(s) were
placed on the implants using titanium screws (Torque
Tite®, Nobel Biocare AB) and torqued to 35 Ncm
according to the manufacturer’s recommendations
using the torque control system (Nobel Biocare AB).
After 1 minute, the occlusal screws were retightened.
To ensure maximum bond strength between the
crowns and the different abutments, the abutment sur-
faces and the intaglio surfaces of the crowns were tribo-
chemically silicoated with the modified Rocatec method
(110 mm grain size Rocatec® Plus, 3M ESPE, Seefeld,
Germany) before definitive placement of the crowns. Figure 1 Representative image of the measurement of the
This technique has been shown to result in higher bond marginal gap on a resin replica.
strength to non-etchable high-strength ceramics and
can be performed clinically.23 Then, all crowns were hours until complete polymerization. Afterward, all
definitively placed on the abutments with finger pres- epoxy replicas were mounted on aluminum sample
sure to simulate clinical situation (approx. 3 min) using holders using cyanoacrylate adhesive. The replicas
a resin luting cement (Panavia 21, Kuraray, Tokyo, were analyzed with the help of a stereomicroscope
Japan). The pressure load in this method does not (Axioskope, Zeiss, Oberkochen, Germany). A digital
exceed 10 N.24 camera (3CCD-Iris, Sony, Köln, Germany) was
All test specimens were exposed to 1.2 ¥ 106 cycles mounted to the microscope and connected to a personal
of thermomechanical fatigue in a computer-controlled computer (model P 300, Pyramid, Freiburg, Germany).
dual-axis mastication simulator (Willytech, Munich, The marginal area of each replica was oriented perpen-
Germany) to simulate 5 years of clinical function.13 The dicularly and orthoradially on the computer monitor.
force was applied 3 mm below the incisal edge on the The digital image of the marginal gap (200¥ magnifica-
palatal aspect of the crown at a frequency of 1.6 Hz tion) was reproduced on a high-resolution computer
using a 6-mm-diameter ceramic ball (Steatite Hoechst monitor and examined by using a special evaluation
Ceram Tec, Wunsiedel, Germany) with a vertical move- software (analySIS® 3.0, Soft-Imaging Software GmbH,
ment of 6 mm and a horizontal movement of 0.3 mm. Münster, Germany). The distance between the external
The ceramic ball has a Vickers hardness similar to that of edge of the abutment and the external edge of the crown
enamel. A force of 49 N was chosen to simulate a load was defined as the marginal gap (Figure 1). After the first
within the clinical range.25,26 During testing, all speci- measurements, the replica was moved until the next
mens were subjected to simultaneous thermal cycling section of the marginal area appeared in view. For this
between 5 and 55°C for 60 seconds each, with an inter- stage, a special micro-mechanical device was employed.
mediate pause of 12 seconds, maintained by a thermo- Areas where the crown or the abutment margin could
statically controlled liquid circulator (Haake, Karlsruhe, not be precisely detected were excluded from the evalu-
Germany). ation. On average, 250 to 300 single measurements were
Replicas of all specimens representing the marginal performed for each specimen. The values measured
areas were fabricated in all three stages (before cemen- for each specimen were averaged and recorded in a
tation, after cementation, and after exposure to the summary table. Based on the averaged marginal gap
masticatory simulator). Impressions of the samples were values, means and confidence intervals for assessing
therefore taken with a polyvinyl-siloxane impression marginal gaps were computed for each group and for all
material (Dimension® Garant L and Permagum® Putty stages (initial, cemented, aged) of the investigation. The
Soft, 3M ESPE) and were poured in with an epoxy resin logarithmic transformation is an approved method for
(Alpa-Pur, Alpina, Geretsried, Germany). The poured robust statistical inference on location of data that origi-
impressions were degassed in a furnace at 60°C for 24 nate from skewed distributions. It leads to a stabilization
 Marginal Adaptation of All-Ceramic Crowns on Implant Abutments 221

TABLE 1 Results of Marginal Gap Analysis (mm) Before Cementation

Group: abutment-crown
(n = 16) Minimum Maximum Mean Median Iqr SD Geomean CI 95%

Ti1: Ti–Al2O3 35 50 40 39 (36–41) 4.38 39 37–42

Ti2: Ti–ZrO2 31 59 44 44 (41–47) 7.09 43 40–47
Al1: Al2O3–Al2O3 43 70 58 57 (54–62) 6.69 57 54–61
Al2: Al2O3–ZrO2 58 77 66 66 (62–69) 5.31 66 63–69
Zr1: ZrO2–Al2O3 45 69 54 54 (49–58) 6.02 54 51–57
Zr2: ZrO2–ZrO2 54 88 65 64 (62–65) 7.89 64 60–68

of variance estimators. Therefore, location was esti- and a decrease in these values after masticatory simula-
mated by geometric means instead of more familiar tion. The smallest average increase after cementation
arithmetic means. Estimates were supplemented with was recorded in group Ti1 (17.94 mm), followed by
95% confidence intervals. Paired t-test was implemented group Zr2 (20.93 mm), group Zr1 (24.97 mm), group
to test for differences in marginal gaps within the same Ti2 (27.5 mm), group Al2 (29.74 mm), and group Al1
groups at different stages, whereas unpaired t-test was (29.96 mm). After aging, the smallest average decrease
implemented to compare marginal gaps of test groups in the marginal gap values was observed in group
Al1 and Zr1 to control group Ti1, and test groups Al2 Ti2 (7.34 mm), followed by group Ti1 (7.79 mm), group
and Zr2 to control group Ti2. Estimations of confidence Zr2 (9.75 mm), group Zr1 (13.81 mm), group Al2
intervals and t-tests were based also on logarithmically (20.87 mm), and group Al1 (20.52 mm).
transformed values. The global significance level of 0.05 The comparison between non-cemented and
was achieved by correcting the p values according to cemented stages in each group demonstrated a signifi-
the Bonferroni–Holm method. All computations were cant increase in the marginal gap values after cementa-
performed with statistical software (R version 2.1.1, R tion in all groups (p < .001). Also, comparison of the
Foundation for Statistical Computing, Boston, MA, marginal gap between non-cemented and aged stages
USA). in each group showed significantly higher values after
aging in all groups (p < .05). The comparison between
RESULTS cemented and aged stages in each group showed a
All specimens survived thermomechanical fatigue in the decrease in the marginal gap values. The decrease was
mastication simulator. No screw loosening or abutment significant in groups Al1, Al2, and Zr1 (p < .0001), while
and/or restoration fractures were recorded. Summary it was not significantly different for groups Ti1, Ti2, and
statistics of marginal gaps in all groups are shown in Zr2 (p > .05).
Tables 1–3. Generally, all groups demonstrated an The marginal gap values of test groups Al1 and Zr1
increase in the marginal gap values after cementation were significantly larger than those of control group Ti1

TABLE 2 Results of Marginal Gap Analysis (mm) After Cementation

Group: abutment-crown
(n = 16) Minimum Maximum Mean Median Iqr SD Geomean CI 95%

Ti1: Ti–Al2O3 46 78 58 57 (51–65) 9.19 57 53–62

Ti2: Ti–ZrO2 55 88 72 73 (67–77) 8.34 71 67–76
Al1: Al2O3–Al2O3 81 95 87 86 (84–92) 4.70 87 85–90
Al2: Al2O3–ZrO2 81 114 96 95 (88–102) 10.57 96 90–101
Zr1: ZrO2–Al2O3 68 91 79 79 (76–82) 5.68 79 76–82
Zr2: ZrO2–ZrO2 66 110 86 84 (82–88) 10.53 85 80–91
222 Clinical Implant Dentistry and Related Research, Volume 10, Number 4, 2008

TABLE 3 Results of Marginal Gap Analysis (mm) After Artificial Aging

Group: abutment-crown
(n = 16) Minimum Maximum Mean Median Iqr SD Geomean CI 95%

Ti1: Ti–Al2O3 39 61 50 52 (45–54) 6.76 49 46–53

Ti2: Ti–ZrO2 50 78 64 63 (57–73) 9.42 64 59–69
Al1: Al2O3–Al2O3 62 73 67 67 (64–69) 3.37 67 65–69
Al2: Al2O3–ZrO2 63 85 75 76 (70–78) 5.81 75 72–78
Zr1: ZrO2–Al2O3 58 74 65 64 (62–67) 4.26 65 63–67
Zr2: ZrO2–ZrO2 53 91 76 76 (72–81) 8.87 75 70–81

at all stages (p < .0001). The comparison between the microleakage and disintegration of the cement
groups Al1 and Zr1 before cementation showed no film.
significant differences (p > .05), whereas group Zr1 The microscopic analysis has been performed with a
demonstrated significantly higher values than Al1 after stereomicroscope with 200¥ magnification. The type of
cementation (p < .01). No significant differences were microscopes and magnifications used by investigators
found in the marginal gap values between both groups for the evaluation of marginal gap varies considerably.
after artificial aging (p > .05). Digital microscopes, stereomicroscopes, light micro-
The marginal gap values of test group Al2 were scopes, and electron microscopes have been used with
significantly larger than the control group Ti2 before various magnifications.19,20,28 In an in vitro study,
cementation (p < .0001), after cementation (p < .0001), approximately 50 measurements along the margin of
and after artificial aging (p < .05). Similarly, group Zr2 a crown yielded clinically relevant information.29 A con-
showed significantly larger marginal gap values than sistent estimate for the size of the gap with an overall
group Ti2 before cementation (p < .0001), after cemen- impact on the measurement error was typically in a
tation (p < .01), and after artificial aging (p < .05). No range of 18 mm (SD). In this study, 250 to 300 measure-
significant differences were found for comparisons of ments were made along the complete margin of each
the marginal gap values between groups Al2 and Zr2 at abutment. This number is enough to give a consistent
all stages (p > .05). estimate for the gap size.
The geometric mean marginal gap values before
DISCUSSION cementation ranged between 39 mm (group Ti1) and
Today, there is no standardized technique available for 66 mm (group Al2). The differences in the values
the examination of the marginal gap of dental restora- between different groups can be attributed to the effect
tions. Several techniques to examine the marginal gap of the fabrication procedure of the crowns. The Procera
such as direct viewing, sectioning, impression taking to system creates an enlarged metal die on the basis of the
make replicas, and explorative and visual examinations three-dimensional data from the prepared abutment
have been reported. Important parameters such as con- with the use of the subtractive approach. This enlarge-
sistency of the measuring point, reproducibility of ment takes into account shrinkage associated with sin-
the method used, and the use of sectioning have all tering the final restoration to achieve its final strength.
been considered.27 In this study, replica technology was Powder, which is either alumina or zirconia, is com-
employed to examine the changes in marginal gap pacted under pressure onto the metal die, creating an
values at different stages or between different groups. oversized block by means of an additive approach. Then,
This technique is less costly and time consuming for the block is milled away to create the outer contours
the user to create test specimens than other methods of the restorations. Finally, the oversized restoration is
(eg, cross-section preparation technique). In addition, removed from the die and sintered to make the material
the technique allows long-term studies because sacri- as dense as possible and to shrink it to its correct size.30
ficing of samples is not required. However, the replica The shrinkage, which varies among different materials,
technique does not provide any information regarding creates a marginal gap between the restoration and the
 Marginal Adaptation of All-Ceramic Crowns on Implant Abutments 223

abutment and can be usually compensated through surface treatment prior to cementation. Air abrasion,
veneering. At this stage, the dental laboratory proce- which is an essential step of the Rocatec method, prior to
dures, the manual skills, and the experience of the dental cementation has been reported to cause marginal defects
technician have a decisive influence on the size of the and widen the gap between the crown and the abut-
marginal gap.31 Consequently, all restorations employed ment.27,38 Therefore, it is always advisable to use careful
in the present study were fabricated by the same master air abrasion techniques to minimize marginal gap
technician to ensure that these factors did not change for defects.27 The effect of Rocatec treatment on the mar-
the individual test groups. Previous literature reported ginal gap values obtained in this study after cementation
that precementation marginal gaps in the range of 20 to was not examined, and therefore, there is a need to
70 mm are generally acceptable.32 Hence, the marginal evaluate it in further studies.
gap values before cementation reported in this study are Because of inclination of specimens and force appli-
also within the acceptable limits. cation, the force dynamics are different between the
It is well known that the marginal gap generally palatal and labial aspects of the specimen. Tensile forces
increases after cementation, which is indeed the clinical are created on the palatal aspect, whereas compressive
situation.20,27 Thus, to have a correct idea of the mar- forces are created on the labial aspect. Therefore, it can
ginal gap, it is necessary to evaluate it after cementa- be expected that there are differences in the marginal
tion. In this study, the geometric mean marginal gap gap values between different aspects of the restoration.
values after cementation ranged between 57 mm (group This issue was not examined in this study and will be
Ti1) and 96 mm (group Al2). The average increase in evaluated in a future investigation. The measurement of
the size of the marginal gap after cementation ranged the marginal discrepancies after artificial aging showed
from 17.94 mm (group Ti1) to 29.96 mm (group Al1). geometrical mean values between 49 mm (group Ti1)
The clinically acceptable values defined for marginal and 75 mm (group Zr2). The decrease in the marginal
gap after cementation were reported to be <120 mm.18,33 gap values after artificial aging ranged between 7.34 mm
Other studies consider marginal gap between 50 and (group Ti2) and 20.52 mm (group Al1). Such a decrease
100 mm as the clinically acceptable limit.34,35 The can be explained by considering that after artificial
increase in the marginal gap value after cementation aging, a certain degree of degradation of the cement film
can be explained by the volume requirement of the is occurring.39 Some portions of the cement film might
cement used, depending on particle size flow proper- have been washed out during the aging procedure
ties and consistency.36 Film thickness has been reported leading to a clearer image and created the possibility for
to play an important role in the bond strength of resin more precise measurements of the marginal gap. An
cements. In an in vitro study, 4-point bending strength assessment of the density of the cement seal through
test of ceramic–cement–ceramic sandwiches with dif- microleakage analysis is recommended to provide
ferent cement layer thickness (20, 50, 100, and 200 mm) further information about this issue.
was applied.35 Bond strength in the 20-mm-thick films
was significantly lower than in the thicker ones. The CONCLUSIONS
authors concluded that taking into account the physi-
Within the limits of this study, it can be concluded that
cal and clinical properties of resin-based luting agents,
marginal accuracy of implant-supported all-ceramic
a marginal gap in the scale of 50 to 100 mm is ideal for
restorations on ceramic abutments meets the require-
resin cements and seems to optimize performance. For
ments for clinical acceptance. More scientific data of the
the resin cement used in this study (Panavia), an
marginal gap of implant-supported all-ceramic restora-
average film thickness of 30 mm has been reported to
tions must be generated under clinical conditions.
be reasonable for optimal performance.37 Thus, the
obtained values are within the mentioned limits, and
the increase after cementation seems to be appropriate ACKNOWLEDGMENTS
for optimizing the performance of the resin cement The authors thank Nobel Biocare AB for support of this
used. study. The technical assistance of the dental laboratory
Another factor that may have contributed to Woerner Zahntechnik, Freiburg, Germany, is highly
increasing the size of marginal gap after cementation is appreciated.
224 Clinical Implant Dentistry and Related Research, Volume 10, Number 4, 2008

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