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Marginal Adaptation of Zirconium Dioxide Copings: Influence of The CAD/CAM System and The Finish Line Design
Marginal Adaptation of Zirconium Dioxide Copings: Influence of The CAD/CAM System and The Finish Line Design
Marginal Adaptation of Zirconium Dioxide Copings: Influence of The CAD/CAM System and The Finish Line Design
Purpose. The purpose of this study was to evaluate the marginal adaptation of zirconium dioxide copings made with 2
different CAD/CAM systems, the Lava All-Ceramic System (scanning definitive dies made with conventional impressions) and
the Lava Chairside Oral Scanner (scanning directly from the prepared tooth). In addition, the influences of 2 different finish
line configurations were also compared.
Material and methods. Forty human molar teeth were prepared to receive complete crowns. Twenty were prepared with a 90-
degree round shoulder and the other 20 with a 45-degree chamfer finish line. Zirconium dioxide copings were fabricated by
using CAD/CAM technology. The specimens were randomized; they included 10 teeth with round shoulder and 10 with
chamfer finish lines with the Lava All-Ceramic System, and 10 teeth with round shoulder and 10 with chamfer finish lines with
the Lava Chairside Oral Scanner. The marginal gaps were measured at 5 points on each side with stereomicroscopy at 40
magnification. Data were analyzed with 2-way ANOVA (a¼.05).
Results. The mean values of the measured marginal gap for the round shoulder group were 52.66 mm with the Lava All-
Ceramic System and 14.98 mm with the Lava Chairside Oral Scanner. The mean values for the chamfer group were 64.06 mm
for the Lava All-Ceramic System and 18.45 mm for the Lava Chairside Oral Scanner. Differences were identified when the
marginal gaps between the specimens with different CAD/CAM systems were compared. However, differences in the finish
line design were identified only between the round shoulder and chamfer with the Lava All-Ceramic System.
Conclusions. Restorations fabricated with the Lava Chairside Oral Scanner displayed smaller marginal gaps than those made
with the Lava All-Ceramic System. Nevertheless, all marginal gaps were within the range of clinical acceptability for both
groups. (J Prosthet Dent 2014;112:155-162)
Clinical Implications
Restorations manufactured with zirconium dioxide with a chairside
intraoral scanner displayed significantly smaller marginal gaps than
those made by scanning dental casts.
The longevity of a complete crown of discrepancy.1-7 Marginal discrepancy restoration.4,8 This is an important com-
restoration is affected by multiple fac- can be defined as the vertical distance ponent of fixed restorations, as a large
tors, including marginal adaptation, from the finish line of the prepara- marginal opening may lead to more
that could be better explained in terms tion to the cervical margin of the plaque accumulation, microleakage,
a
Doctoral student, Department of Prosthodontics, International University of Catalunya, Department of Prosthodontics, Autonomous
University of Nuevo León.
b
Professor, Department of Prosthodontics, International University of Catalunya.
c
Professor, Chairman of Department of Prosthodontics, International University of Catalunya.
d
Professor, Department of Endodontics, Autonomous University of Tamaulipas.
Euán et al
156 Volume 112 Issue 2
recurrent caries, and periodontal dis- dental laboratory, or centralized milling finish lines are likely the most popu-
ease.9-12 center. In the first approach, the digi- lar.1,2,4,5,7,14,45-48 However, the results
Historically, high noble cast re- talization instrument is an intraoral of studies that have evaluated the influ-
storations have shown smaller mar- camera, which substitutes for a con- ence of the finish line design on the
ginal discrepancies than base metal ventional impression. The milling pro- marginal adaptation are conflicting;
alloy, metal ceramic, or ceramic resto- cedures can be undertaken in a dental some authors have found signifi-
rations. Some studies have reported office when the restorative material is cant differences among them,4,7,39,49-52
marginal gaps smaller than 10 mm for resin, nanoceramic resin, or lithium whereas others have not.14,46,53-56
high-palladium-content alloys and disilicate blocks, but when the restor- The purpose of this study was to
for gold-platinum-palladium alloys,13,14 ative material is presintered zirconia, evaluate the accuracy of the marginal
whereas other studies have found mar- dental laboratory equipment must be adaptation of zirconium dioxide copings
ginal discrepancies between 18 and used. In the second approach, a defin- by comparing the marginal gaps of cop-
46 mm.15,16 Lofstrom and Barakat17 itive cast is fabricated from a conven- ings made with a CAD/CAM chairside
reported in an in vivo study using a tional impression and is transferred to system (the Lava COS [LCOS]) with
scanning electron microscope that clin- the laboratory. Three-dimensional data those made with CAD/CAM for labora-
ically acceptable margin discrepancies are produced from the definitive die tory production (the Lava All-Ceramic
range from 7 to 65 mm; however, gaps with a scanner, and the data are pro- System) (LS) (3M ESPE). In addition,
of up to 80 mm are difficult to perceive cessed with design software and sent the influence of the type of finish line on
clinically.18 Marginal openings from to the milling machine. In the third the marginal fit was studied.
50 to 120 mm are considered clinically approach, data sets produced in the The first null hypothesis was that no
acceptable in terms of longevity.7,18 dental laboratory are sent to the pro- difference would be found in the mar-
For computer-aided design/computer- duction center for fabrication with ginal fit of zirconium dioxide copings
aided manufacturing (CAD/CAM) res- the CAD/CAM device, and the restora- fabricated with the CAD/CAM chair-
torations, the generally acceptable tions are returned to the dental side system (LCOS) and the CAD/CAM
marginal gap discrepancies range be- laboratory.42,43 for laboratory production (LS). A sec-
tween 50 to 100 mm, because this pro- The recently introduced Lava ond null hypothesis was that no differ-
cess decreases the possibility of human Chairside Oral Scanner (LCOS) (3M ence would be found in the marginal fit
error and the inaccuracy inherent in ESPE) is based on the principle of active of zirconium dioxide copings in prepa-
different restoration materials.7,19-28 (optical) wave front sampling. Active rations with different finish line designs.
Esthetics is another important wave front sampling involves the gath-
requirement, and ceramic restorations ering of 3-dimensional information
have historically proved to be the most from a single-lens imaging system by MATERIAL AND METHODS
natural-looking.29-34 Advances in dental measuring the depth, based on the
ceramic materials and processing tech- defocus of the primary optical system. A pilot study was conducted to
niques, especially the development of Three sensors capture the clinical situ- determine the sample size required to
CAD/CAM systems and milling tech- ation from different angles. With achieve 80% power and 5% significance.
nology, have facilitated the use of dental these 3 images, taken simultaneously, The sample size to identify differences
ceramics with superior physical proper- 3-dimensional surface patches are pro- in the marginal discrepancy obtained
ties.35-39 Partially stabilized zirconia has duced in real time by means of pro- with the LCOS system and the LS sys-
a flexural strength of 900 to 1400 MPa prietary image processing algorithms tem was calculated, establishing a
and a fracture toughness of up to 10 using the in-focus and out-of-focus in- 2-sided a¼.05 with a power of 80%
MPa$m0.5, and these properties are formation.42-44 (b¼.20) to detect a difference between
significantly higher than those of other According to the manufacturer, the groups of 30 mm in the marginal
dental ceramic materials. In addition, high data redundancy that results from opening. Based on this sample size,
CAD/CAM systems do not require many overlapping pictures, together 40 extracted human molar teeth
fabrication steps such as waxing, in- with special image processing algo- without caries or anatomic defects
vesting, and casting.40 However, the use rithms, provides excellent image quality were included. Teeth were obtained by
of these new technologies requires other and, consequently, high accuracy. following the guidelines of the local
new procedures, including scanning, However, not enough scientific evi- human research ethics committee. All
software design, milling, and material dence is available to confirm this teeth, which were comparable in size,
processing, that require a considerable assertion. were cleaned with an ultrasonic scaler
learning curve.40,41 Another benefit of using zirconia- (Varios 350 NSK; Nakanishi) and
CAD/CAM systems are available based restorations is the ability to stored in 10% formaldehyde solution
in 3 different production approaches, select different finish line designs; cur- until they were used for the study. The
depending on their location: chairside, rently, modified shoulder and chamfer teeth were divided into 2 groups of 20
The Journal of Prosthetic Dentistry Euán et al
August 2014 157
teeth for each CAD/CAM system (LS
and LCOS). The teeth were then
mounted in a block of autopolymeriz-
ing resin (Nic Tone; MDC Dental),
prepared to receive ceramic crowns,
and subdivided into 2 groups by finish
line design: one group received a 1-mm-
wide 90-degree round shoulder and the
other received a 1-mm-wide 45-degree
chamfer. The instruments used for
the round shoulder finish lines were
flat-end tapered diamond rotary in-
struments (Axis modified shoulder No.
847KR; Axis Dental, Kerr Corp) and for
1 Digitalized definitive dies produced with Lava Design
the chamfer finish lines torpedo-shaped
System.
diamond rotary instruments (Axis No.
879K; Kerr Corp).
All preparations had an anatomic
occlusal reduction of 2 mm, a 6-degree
axial convergence obtained with the
taper of the diamond rotary in-
struments and evaluated with a sur-
veyor (Bio Art), an axial reduction of
1.0 to 1.5 mm, and a finish line located
0.5 mm above the cementoenamel
junction. The same prosthodontist pre-
pared all of the specimens, which were
then approved by another experienced
prosthodontist.
For group LS, impressions of each
tooth were made with a polyether 2 Scanning of 3.6 with Lava Chairside Oral Scanner. Four
impression material (Impregum Penta first molars were scanned in each typodont.
medium and Impregum soft; 3M
ESPE). A light-body impression mate- (Fig. 2), and a thin dusting of titanium the margin of the coping. For all prep-
rial was injected around the tooth dioxide powder was applied to facilitate arations, the limit of the finish line was
preparations, and the teeth were then the scanning of the preparation and of determined automatically by the design
inserted into custom-made trays filled the rest of the arch. The scans were software (Lava Design System; 3M
with regular body material. After the individually evaluated for completeness ESPE). The copings were milled with a
impression, the prepared teeth were before their acceptance. A laboratory 3-axis CNC 500 milling machine (3M
stored again in a fresh 10% formalde- prescription was completed for the ESPE).
hyde solution. Definitive dies were system, and the files were sent elec-
fabricated with Type IV dental stone tronically to the authorized Lava center. Evaluation of marginal adaptation
(Elite Rock Fast; Zhermack) prepared After the digital impressions, the pre-
with an automatic vacuum mixer, ac- pared teeth were stored again in a fresh The copings were placed on their
cording to the proportions indicated by 10% formaldehyde solution. corresponding teeth and fixed with a
the manufacturer. After fabrication, all For both groups, all copings were C-clamp (Truper). The margins of each
casts were sent to an authorized Lava designed according to the manufac- coping were initially evaluated with a
center for production of the zirconium turer’s instructions, and all had the dental explorer (EXD 11/12; Hu-Friedy)
copings (Fig. 1). same characteristics: a 0.5-mm wall and 2.5 magnification loupes (Task
In group LCOS, human molar teeth thickness, a 0.35-mm reinforcement of Vision), and clinically acceptable mar-
were mounted in 5 typodonts. In each the restoration edge, and a 0.02-mm ginal adaptation was found in all cop-
typodont, 4 molars were adapted, space for luting agent, which was initi- ings without the need for any internal
simulating the position of the first ated at a distance of 1.2 mm from the adjustment. Then, the marginal dis-
molar in each quadrant. The typodonts margin of the coping and increased to crepancies of all specimens were eval-
were adapted to a dental simulator 0.05 mm at a distance of 2.3 mm from uated with a stereomicroscope (EZ4D;
Euán et al
158 Volume 112 Issue 2
3 Measurements of marginal discrepancies. A, Chamfer group, Lava Chairside Oral Scanner. B, Round shoulder group,
Lava Chairside Oral Scanner. C, Chamfer group, Lava All-Ceramic System. D, Round shoulder group, Lava All-Ceramic
System.
Leica) and a coupled digital camera. Windows; SPSS Inc); a correlation CAD/CAM technique and finish line
Finally, the marginal discrepancy was analysis with 2-way ANOVA at .05 sig- (P<.05); however, no significant dif-
measured with image analysis software nificance levels was used to determine ferences were found for the interaction
(Image-Pro Plus, version 6.0.0.260; any difference in marginal adaptation between the CAD/CAM technique and
Media Cybernetics). for zirconia copings made with the LS finish line (Table II).The mean of the
and with the LCOS and also to identify marginal gaps was significantly lower
Measurements the influence of the finish line design on (P<.001) for group LCOS (14.99 mm
marginal adaptation. Additionally, for round shoulder and 18.46 mm for
To determine the marginal adapta- repeated-measures ANOVA was used to chamfer finish line) than for group LS
tion, the criterion proposed by Holmes compare the 20 measurements on each (52.67 mm for round shoulder and
et al,8 who defined the vertical marginal specimen. 64.07 mm for chamfer finish line)
opening as the distance from the edge (Fig. 4). When the influence of the fin-
of the crown to the edge of the finish RESULTS ish line was compared, only group LS
line preparation, was followed. The exhibited a difference in the mean
measurements of the marginal gaps Table I shows the mean of the marginal gap; the mean gap observed
were made at 5 equidistant points on marginal gaps or vertical marginal in the round shoulder preparations was
each of the 4 axial walls for a total of openings (mm), standard deviation statistically lower (52.67 mm) than that
20 marginal adaptation evaluation sites (mm), and misfit statistical comparison in the chamfer preparations (64.07 mm)
for each coping (Fig. 3). of the CAD/CAM systems and the finish (P¼.011).
After measuring, the data obtained lines. No significant correlation was found
from the photographs were statisti- The results showed significant dif- in the marginal opening values of the 2
cally analyzed (SPSS, version 15.0 for ferences in marginal gaps with the CAD/CAM systems with the finish line
The Journal of Prosthetic Dentistry Euán et al
August 2014 159
Table I. Means of marginal discrepancies (mm) of zirconium dioxide copings marginal misfit of the zirconium dioxide
and P values copings made with the LCOS were
significantly lower than the measured
CAD/CAM Lava All-Ceramic Lava Chairside Oral
misfit of copings made with the LS. The
Finish Line System Scanner P second null hypothesis was rejected
only in group LS, where the finish line
Chamfer 64.07 5.83 18.46 4.49 <.001
had influence; nevertheless, the results
Round shoulder 52.67 10.93 14.99 5.20 <.001
do not support rejection for group
P .011 .74 LCOS.
CAD/CAM, computer-aided design/computer-aided manufacturing. Recent studies have reported mar-
Significant at P<.05. ginal discrepancies for CAD/CAM res-
torations that range from 24 to 110
mm.7,19-21 This range agrees with this
Table II. Results of correlation analysis for effect of CAD/CAM technique, finish study’s findings for group LS, in which
line design, and their interactions on mean marginal gap the means were 52.67 mm for round
Sum of Mean shoulder and 65.07 mm for chamfer
finish lines. However, group LCOS dis-
Source of Variation Squares df Square F P
played better results, with marginal
Corrected model 18 053* 3 6017.768 119.893 <.001 discrepancies below 19 mm (14.99 mm
Finish line design 553 1 552.792 11.013 .002 round shoulder and 18.46 mm cham-
fer). These values are similar to the
CAD/CAM technique 17 343 1 17 343.060 345.528 <.001
marginal gaps found by other authors
Finish line design 157 1 157.450 3.137 .085
for noble metal cast restorations.13-17
CAD/CAM technique
The differences in the mean mar-
Error 1807 36 50.193
ginal gap values between the 2 groups
Total 76 245 40 of copings could be the result of the
Corrected total 19 860 39 multiple steps (clinical and laboratory)
required during impression procedures,
CAD/CAM, computer-aided design/computer-aided manufacturing.
*R2¼.909 (corrected R2¼.901). the manufacture of the definitive dies,
the adaptation of the restorations to
the models, or some combination of
70 those factors. A recent study has found
60 that polyether impression material ex-
Chamfer
50 hibits a 1.49% dimensional change,22
Round shoulder
40 whereas another study evaluated Type
µm
Euán et al
162 Volume 112 Issue 2
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