SYSTEMATIC REVIEW

Marginal adaptation of zirconia complete-coverage fixed

dental restorations made from digital scans or conventional
impressions: A systematic review and meta-analysis
Mahtab Tabesh, DDS,a Farahnaz Nejatidanesh, DDS, MSc,b Ghazal Savabi, DDS,c Amin Davoudi, DDS,d
Omid Savabi, DDS, MSc,e and Hesam Mirmohammadi, DDS, MSc, PhDf

Complete-coverage restora- ABSTRACT

tions have a long history of use Statement of problem. Intraoral scanners have been increasingly used in recent years. However,
in dental practice around the the accuracy of digital scans as it affects marginal adaptation is unclear.
world.1 Accurate marginal and
Purpose. The purpose of this systematic review and meta-analysis was to compare the marginal
internal fit along with high adaptation of single-unit zirconia crowns fabricated with digital scans or with conventional impressions.
mechanical strength, good
interfacial adhesion to Material and methods. The electronic databases PubMed (MEDLINE), Cochrane Central Register of
Controlled Trials (CENTRAL), Web of Science (ISI), Scopus, and EMBASE were searched and
veneering material, and
complemented by a manual search. Risks of bias were assessed by using a modified
appropriate luting cement are methodological index for nonrandomized studies (MINORS). Mean ±standard deviation (SD)
key factors in their longevity. values of marginal accuracy of studies were extracted for both methods. Mean marginal
Dentin hypersensitivity, dental difference and 95% confidence interval (CI) were calculated to evaluate the marginal accuracy of
caries, cement dissolution, each method. Pooled data were statistically analyzed by using a random-effect model.
plaque retention, and peri- Results. Seventeen studies were used to perform the meta-analysis. Subgroup analysis was performed
odontal problems are conse- based on intraoral scanners. Standardized mean marginal difference and 95% CI of each subgroup were
quences of ill-fitting margins.1-3 as follows: Lava: -0.85 mm (95% CI: -1.67, -0.03) (P=.043); CEREC: -1.32 mm (95% CI: -2.06, -0.59) (P<.001);
Because of the cumulative na- iTero: -0.44 mm (95% CI: -1.35, 0.47) (P=.338); TRIOS: -1.26 mm (95% CI: -2.02, -0.51) (P=.001); unknown
ture of errors, it has not yet scanner: -0.21 mm (95% CI: -1.14, 0.72); all studies: -0.89 mm (95% CI: -1.24, -0.54) (P<.001).
been possible to achieve an Conclusions. Digital scanning of prepared teeth for single-unit zirconia restorations resulted in
ideal marginal fit with no gap.3 better marginal accuracy than conventional techniques using elastomeric impression
Different clinically acceptable materials. (J Prosthet Dent 2020;-:---)
marginal gap values have been
reported, ranging from 39 mm to 150 mm.2-6 Trueness and original geometry. The difference between trueness and
precision values have been used to determine the accu- precision is that precision indicates the deviations be-
racy of dental impressions. Trueness is established by the tween the impressions within a test group. Linear dis-
deviation of the tested impression method from the tance measurement is the most common method of

Supported by Dental Research Center, Isfahan University of Medical Sciences, Research Grant # 298095. Ethical code: IR.MUI.RESEARCH.REC.1398.373
a
Research Assistant, Dental Research Center, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
b
Professor of Prosthodontics, Dental Materials Research Center, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
c
Research Assistant, Dental Materials Research Center, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
d
Post graduate student of Prosthodontics, Dental Implants Research Center and Student Research Committee, School of Dentistry, Isfahan University of Medical Sciences,
Isfahan, Iran.
e
Professor of Prosthodontics, Dental Research Center, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
f
Researcher, Department of Cariology Endodontology, Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit, Amsterdam,
Netherlands.

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Clinical Implications
The use of digital intraoral scanners should be a
clinically successful method for fabricating single-
unit tooth-supported zirconia restorations with high
marginal accuracy.
determining the accuracy of conventional intraoral im-
pressions with gypsum casts. However, they have been
restricted to a few measurement points.7,8
As the accuracy of the impression-making process has
an effect on the definitive prosthesis, attempts have been
made to refine this process by introducing different
materials and techniques.3 Digital scanning with intraoral
scanners (IOSs) as a part of a digital workflow has been
introduced to reduce errors and problems with conven-
tional impression techniques.9,10
With a computer-aided design and computer-aided
manufacturing (CAD-CAM) system, it is essential that
critical sites are correctly captured. Intraoral scanners use
a video technique or still photographic technique based
on triangulation or parallel confocal laser scanning, from
which a 3D image can be formed. In addition to these
basic principles, each manufacturer provides individual or
multiple techniques for data collection. Active wave-front
sampling (LAVA C.O.S. and Lava True Definition scan-
ner; 3M ESPE), active triangulation, optical microscopy or
videos (CEREC AC Bluecam and CEREC AC Omnicam;
Dentsply Sirona), and the parallel confocal method
(iTero, Invisalign; Cadent Inc, and TRIOS; 3Shape) are
examples of these data-collection systems.11,12
Digital scanning has been reported to reduce patient
discomfort and chairside time.2,10,13 Moreover, digital
scans are virtual and can be stored on computers to
eliminate storage space. If needed, they can be conve-
niently transferred to a dental laboratory.1,3,14
While both conventional and digital techniques have
been reported to be clinically acceptable and are widely
used, studies on the comparative accuracy of the tech-
niques are sparse or controversial.1,15,16 A systematic
review might prove beneficial in evaluating the accuracy
of these systems in a more comprehensive way. The main
focus of available systematic reviews comparing digital
scanning and conventional impressions has been on the
survival of restorations, time efficiency, operator
perception, patient satisfaction, and internal fit rather
than on marginal accuracy.10,11,17,18 Moreover, a wide
range of restoration types (single unit, short- and long-
span multiunit, and complete arch) and restoration
materials (zirconia, lithium disilicate, alumina, glass ce-
ramics) have been included in these review studies, while
more specifically designed reviews are lacking.4,10,17 The
null hypothesis for this systematic review was that no
THE JOURNAL OF PROSTHETIC DENTISTRY
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Table 1. Adopted keywords and searching strategy
((((crown OR dental crown OR dental prosthesis OR fixed
Searching
strategy prosthesis OR fixed prosthodontics OR fixed dental prosthesis OR
FPD OR full-coverage indirect restoration OR single-unit OR multi-
unit NOT implant)) AND (digital impression OR digital scanner OR
oral scanner OR intraoral scanner OR dental scanner OR Cerec
Bluecam OR Cerec Omnicam OR Cadent iTero OR Lava True
Definition OR TRIOS OR Planscan OR E4D OR MHT OR Carestream
3500 OR Zfx IntraScan)) AND (impression technique OR
conventional impression OR elastomer impression material OR
impression material OR polyvinyl siloxane OR PVS OR additional
silicone OR vinyl polysiloxane OR polyether)) AND (marginal
adaptation OR marginal fit OR marginal accuracy OR marginal
precision OR marginal gap OR marginal discrepancy OR marginal
misfit OR marginal vertical adaptation OR marginal vertical misfit
OR marginal vertical discrepancy OR marginal vertical accuracy
OR marginal vertical fit OR marginal vertical precision OR
marginal vertical gap)
difference would be found in the marginal accuracy of
single-unit zirconia complete-coverage crowns prepared
by digital scanning and conventional impression
methods.
MATERIAL AND METHODS
This systematic review was conducted according to the
guidelines of Preferred Reporting Items for Systematic
Reviews and Meta-analysis (PRISMA).19 The protocol of
this review was registered on PROSPERO with regis-
tration number CRD42019128875.
The population, intervention, comparison, outcome,
study design (PICOS) question was, “Do digital scans
and conventional impressions result in a statistically
insignificantly different marginal discrepancy in
complete-coverage single-unit dental restorations in any
kind of study design?”
The population consisted of prepared teeth for a
complete-coverage restoration but not implant abut-
ments. The intervention was a digital scan of these pre-
pared teeth by using an intraoral scanner of any kind.
The comparison was a conventional impression of such
prepared teeth with any impression material. The
examined outcome was marginal discrepancy between
the teeth and the restorations.
An electronic search was conducted in the following
databases: PubMed (MEDLINE), Cochrane Central
Register of Controlled Trials (CENTRAL), Web of Science
(ISI), Scopus, and EMBASE. The search was conducted
up to December 31, 2018, and limited to English lan-
guage studies. In addition, the reference lists of relevant
studies and review articles were screened for further
potential studies. Table 1 represents the terms used for
search in electronic databases and the searching strategy.
Experimental and clinical studies that compared dig-
ital scanning and conventional impressions for complete-
coverage restorations, reported marginal discrepancy,
and were published in English-language peer-reviewed
journals were identified. Animal studies, expert opinions,
literature reviews, and multiple publications based on the
Tabesh et al
- 2020 3

Identification
Records identified through Additional records identified
database searching through other sources
(n=339) (n=44)

Records after duplicates removed

(n=222)
Screening

Records screened Records excluded

(n=222) (n=183)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n=39) • Did not evaluate
Eligibility

marginal accuracy
(n=4)
• No quantitavie
Studies included in measurement
qualitative synthesis (n=1)
(n=19)
• Materials other
than zirconia was
used (n=12)
Included

Studies included in • No conventional

quantitative synthesis impression group
(meta-analysis) (n=1)
(n=17) • Pilot studies (n=2)

Figure 1. Search results flow diagram according to PRISMA.

Table 2. Modified methodological index for nonrandomized studies
same specimens or participants were excluded. The
(MINORS)
studies obtained by the mentioned search strategy were
Criteria for risk of bias assessment
imported to EndNote (X9; Clarivate Analytics) for 1. Clearly stated aim. 0: not reported, 1: reported but inadequate,
duplicate removal and reference management. Two re- 2: reported and adequate.
viewers (G.S., M.T.) independently screened the title and 2. Contemporary groups. 0: not reported, 1: reported but inadequate,
2: reported and adequate.
abstract of the studies yielded by the search strategy. To
3. Impression or scan method according to guideline. 0: not reported,
ensure reliability, the reviewers were calibrated with a 1: reported but inadequate, 2: reported and adequate.
random sample of 10% of the to-be-screened studies 4. Control groups. 0: not reported, 1: reported and adequate comparison
before embarking on the assessment. Full texts of with other digital methods, 2: reported and adequate comparison with
conventional methods.
selected studies were retrieved and screened for eligibility
5. Definitive restoration. 0: not reported, 1: framework, 2: crown.
based on the inclusion criteria. A third reviewer (O.S.) 6. Blindness of observer or statistician. 0: not reported, 1: only statistician
was consulted in cases of disagreement. blinded, 2: both blinded
The risk of bias for studies was assessed by using a 7. Adequate number of observations in each group. 0: 5-9, 1: 10-14, 2: 15+.
modified methodological index for nonrandomized 8. Adequate number of methods to determine gap. 0: 1, 1: 2, 2: 3+.
studies (MINORS).4 This tool consisted of 11 criteria for 9. Standard tooth preparation method. 0: not reported, 1: reported but
inadequate, 2: reported and adequate.
all studies and 2 added criteria specifically for in vivo
10. Power analysis. Justification of specimen size for both experimental and
studies. Each criterion was scored 0, 1, or 2 (where control groups needed to determine statistical significance 0: not reported,
0 showed high risk, 1 showed unclear risk, and 2 1: reported but inadequate, 2: reported and adequate.

showed low risk), and the sum for each study was
calculated. The maximum possible score was 22 for
in vitro studies and 26 for in vivo studies. Two reviewers
(M.T., O.S.) independently scored studies for risk of
bias, and discrepancies were discussed until a consensus
was reached.
11. Statistical analysis. 0: not reported, 1: reported but inadequate, 2: reported
and adequate.
Additional criteria for included in vivo studies
Prospective collection of data. 0: not reported, 1: reported but inadequate,
2: reported and adequate.
Baseline equivalence of groups. 0: not reported, 1: reported but inadequate,
2: reported and adequate.

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Table 3. Risk-of-bias assessment of included studies

7-
Evaluation 1-An2 2-Dauti3 3-Euan15 4-Cetik16 5-Lee20 `6- Seelbach21 Vennerstrom22 8-Ahrberg23
Clearly stated aim 2 2 2 2 2 2 2 2
Contemporary groups 2 2 2 2 2 2 2 2
Impression or scan method according to guideline 2 2 2 1 1 2 2 2
Control groups 2 2 2 2 2 2 2 2
Definitive restoration 1 1 1 2 1 2 2 1
Blindness of observer in statistical analysis 0 0 0 0 0 0 0 1
Adequate number of observations in each group 1 2 1 1 2 1 1 2
Adequate number of methods to determine gap 0 0 2 0 0 0 1 0
Standard tooth preparation method 2 2 2 2 2 1 2 2
Power analysis 0 0 2 0 2 0 2 0
Statistical analysis 2 1 2 1 2 2 2 2
Prospective collection of data (only for in vivo) - - - - - - - 2
Baseline equivalence of groups (only for in vivo) - - - - - - - 2
Total score 14 14 18 13 16 14 18 22

The following data were extracted from each study:
study design, sample size, objective of study, study
groups, scanners used for digital scan, material and
method used for conventional impression, material used
for crowns, method of gap measurement, type of misfit
measured (such as marginal gap, absolute marginal
discrepancy), position of teeth and mean, standard de-
viations, and median of marginal discrepancy.
The results were quantitatively pooled by using a
statistical software program (STATA 16; StataCorp).
Pooled mean differences and corresponding 95% confi-
dence intervals for marginal accuracy were calculated for
the meta-analysis. Heterogeneity among studies was
assessed by the I2 statistic that quantifies inconsistency
across studies and describes the percentage of the vari-
ability in effect estimates due to heterogeneity rather
than sampling error. An I2 value of 75% or more was
considered to indicate high heterogeneity. The evidence
of publication bias was assessed by using funnel plots.
RESULTS
The search in online databases revealed a total of 399
articles (PubMed: 102 articles, Web of Science: 121 arti-
cles, EMBASE: 70 articles, Cochrane: 9 articles, and
Scopus: 97 articles). After eliminating duplicates, a total
of 178 articles remained. A further 44 articles were
selected through manual search in reference lists of
relevant studies, providing a total of 222 articles to be
screened. After screening the titles and abstracts, the full
texts of 39 studies were retrieved and reviewed. Among
these, 4 studies did not measure marginal accuracy, 1
used a clinical probing method which did not report
any quantitative measurements on marginal adapta-
tion, 12 used materials other than zirconia, 1 did not
include a conventional impression group, and 2 were
pilot studies; these were all excluded. Consequently 19
studies2,3,15-18,20-34 were analyzed (Fig. 1). Risk of bias
was assessed based on a modified methodological in-
dex for nonrandomized studies (MINORS) (Tables 2
and 3). Generally, in vivo studies had lower risk of
bias, and the greatest risks were associated with
blinding, having an adequate number of methods to
determine gap, and power analysis (Fig. 2).
Eleven studies had an in vitro design, while the other
8 were clinical. In this systematic review, a total of 1068
participants were evaluated by using 4 different types of
intraoral scanners, namely Lava, CEREC, iTero, and
TRIOS. All studies evaluated only zirconia restorations
except for 3 of them which evaluated nickel-chromium
(Ni-Cr),20 Empress CAD,21 silver-palladium (Ag-Pd),21
or e.max22 in addition to zirconia. In all studies, the
measured mean marginal discrepancy was within the
determined acceptable clinical range except for 226,28
which reported that only the conventional method
exceeded the range (Supplementary Table 1).
The publication bias, as determined by funnel plot,
was within the acceptable range. Seventeen studies were
included in the quantitative analysis (Supplementary
Table 1). A subgroup analysis was performed based on
the different intraoral scanners used. As studies were of
high heterogeneity (I2=78.2%, P<.001), the inverse vari-
ables random-effect model was used for the meta-
analysis.
The standardized mean difference of digital scans and
conventional impressions was as follows. Six
studies3,15,21-24 evaluated Lava scanner (3M ESPE) where
a standardized mean difference of -0.85 mm (95% CI:
-1.67, -0.03) between digital scans and conventional
impressions was seen (P=.043). In studies that compared
the CEREC scanner (Dentsply Sirona) with conventional
impressions, the largest standardized mean difference

THE JOURNAL OF PROSTHETIC DENTISTRY Tabesh et al

- 2020 5

9- 10-Al- 11- 12- 13- 14- 15- 16- 17- 18- 19-
Pradies24 Atyaa25 Bosniac26 Kocaagaoglu27 Zarauz28 Pedroche29 Rodiger30 Malaguti31 Sakornwimon32 Syrek33 Boeddinhaus34
2 2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 1 2 1 2 2 2
2 2 2 2 2 2 2 2 2 2 2
2 2 1 1 2 1 1 1 2 2 1
0 0 0 0 0 0 0 0 1 0 0
2 0 2 1 2 1 2 0 2 2 2
0 0 0 1 0 0 0 1 0 0 0
2 2 2 2 2 2 2 1 1 2 2
2 0 2 0 0 0 0 0 2 2 2
2 2 2 2 2 2 2 2 2 2 2
2 - 2 - 2 - 2 - 2 2 2
2 - 2 - 2 - 2 - 2 2 2
22 14 21 15 20 13 19 12 22 22 21

was -1.32 mm (95% CI: -2.06, -0.59) (P<.001).21,25-27 iTero
scanners (Cadent) were evaluated in 4 studies2,21,22,28
with a standardized mean difference of -0.44 mm (95%
CI: -1.35, 0.47), which was not statistically significantly
different (P=.338). The final subgroup evaluated TRIOS 3
scanners (3Shape),16,20,26,27,29,30 which showed a stan-
dardized mean difference of -1.26 mm (95% CI: -2.02,
-0.51) (P=.001). Intraoral scanners in 2 studies31,32 were
not reported, and the standardized mean difference was
-0.21 mm (95% CI: -1.14, 0.72), which was not statistically
significantly different (P=.660). Considering all studies, a
total standardized mean difference of -0.89 mm (95% CI:
-1.24, -0.54) was found (P<.001) (Fig. 3).
DISCUSSION
This systematic review and meta-analysis was conducted
to evaluate the marginal accuracy of single-unit zirconia
restorations made by using digital and conventional
impression techniques. Since the introduction of CAD-
CAM to dentistry, chairside digital technology has
developed.12-14 All impression materials, despite the at-
tempts to optimize their properties, undergo some
dimensional changes because of inherent or environ-
mental factors.29 No material has a 100% elastic recovery,
which means permanent deformation will occur during
the removal of the impression.25,27 The Type IV stone
needed for making the restorations has a linear expan-
sion of 0.06% to 0.5% after setting.8 Stone dies also have
poor resistance to abrasion.15,33 The digital workflow,
however, does not require a physical cast, and the
restoration is designed directly from the data obtained
with an intraoral scanner. Because each additional step in
a workflow contributes to greater cumulative errors, the
elimination of a step can enhance accuracy.33 With in-
traoral scanning, inaccuracies can be evaluated under
magnification, and corrective rescanning used to address
faulty areas caused by saliva, bleeding, or sulcus fluid.21,26
The meta-analysis demonstrated the superiority of
digital scans compared with the conventional method,
which led to the rejection of the null hypothesis. In
addition, an intraoral scanner (CEREC Omnicam) has
been reported to be more accurate than a laboratory
extraoral scanner.21,25-27 The superiority of this intraoral
scanner has been explained by its color streaming tech-
nology, which provides a continuous video capture with
an antishake property.25 The light emitted by the scanner
is of shorter wavelength, which is less subject to scat-
tering, bending, or transmission, resulting in more
accuracy.25
The studies evaluating TRIOS 3 intraoral scanners
also revealed the higher marginal accuracy of intraoral
scanning.16,26,27,29 This superiority was explained by dif-
ferences found in different versions of the software which
allow a lower setting for cement space; accordingly, a
lower marginal gap was reported.26 The differences be-
tween various intraoral scanning systems are explained
by the resolution of the optical scanning system and the
precision of the matching algorithm. A study of the Lava,
CEREC, and iTero intraoral scanners attributed the dif-
ference in accuracy to the resolution of the scanners.20 A
voxel size of less than 10 mm was reported for Lava,
whereas for CEREC, a resolution of 19 mm was reported.
As for the iTero scanner, the 3D information was
composed of images with about 50-mm distance in the z-
direction. The resolution in the x-y plane was not re-
ported, and the lower accuracy has been hypothesized to
be related to this physical limit of the device.21
In addition to the specific limitations of some intraoral
scanning systems, all scanners with mechanisms that rely
on emitting light and capturing the reflection have limi-
tations. Excessive reflection from shiny surfaces such as

Tabesh et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume
Clearly stated aim
Contemporary groups
Impression/scan method according to guideline
Control groups
Definitive restoration
Blindness of observer / in statistical analysis
Adequate number of observations in each group
Adequate number of methods to determine gap
Standard tooth preparation method
Power analysis
Statistical analysis
Prospective collection of data (only for in vivo)
Baseline equivalence of groups (only for in vivo)
0%
Figure 2. Risk of bias according to modified MINORS.
metallic restorations or saliva-coated teeth may lead to
incorrect data acquisition. However, light obstruction or
shadowing can lead to loss of the whole shadowed part.
Direct access to the to-be-scanned area is essential,
which might prove unsatisfactory in retromolar regions
or preparations with subgingival finishing lines.
Furthermore, light scanning causes significant surface
noise, which is eliminated by software filtering. This
process rounds the sharp edges, and some surface detail
is lost, producing a phenomenon called overshoot as
digital scanners create virtual peaks near sharp edges.13,25
Limitations of the present systematic review
and meta-analysis were the heterogeneity of the
selected studies, including the different methods of
preparing teeth, the fabrication of the restorations,
and the evaluation of the marginal gaps. Most
studies16,20,22,23,25,26,28,29,33,34 evaluated marginal gap
according to the study by Holmes et al6; however, some
studies2,15 evaluated absolute marginal discrepancy, 2
THE JOURNAL OF PROSTHETIC DENTISTRY
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10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low risk of bias Moderate risk of bias High risk of bias
studies3,30 used both measurements, and 4
studies21,27,31,32 did not report precisely how the dis-
crepancies in the marginal regions were assessed. Most
clinical studies used the replica technique to assess the
marginal gap, which has the advantage of being inex-
pensive and straightforward to perform.26 In vitro studies
used a stereomicroscope, scanning electron microscopy
(SEM), optical microscope, digital photography, and
coordinate-measuring machine (CMM) in addition to the
replica technique. Moreover, in most studies, posterior
teeth were evaluated; only 1 study2 exclusively evaluated
anterior teeth and found conventional impressions more
accurate in terms of marginal discrepancy. The longer
and more angled shape of prepared anterior teeth causes
limitations for intraoral scanners.13,26 Studies also
differed in terms of evaluating copings or veneered
crowns. The veneering porcelain can cause distortion or
the inadequate fit of zirconia copings, which may un-
dergo significant changes during the veneering process,
Tabesh et al
- 2020 7

Study %
ID SMD (95% CI) Weight

Lava
Ahrberg et al. (2016) –0.35 (–1.02, 0.33) 5.05
Dauti et al. (2016) 0.03 (–0.85, 0.91) 4.47
Euan et al. (2014) –6.08 (–8.26, –3.91) 1.82
Vennerstorm et al. (2014) –0.83 (–1.75, 0.09) 4.35
Seelbach et al. (2013) –0.43 (–1.32, 0.45) 4.44
Paradies et al. (2015) –0.22 (–0.73, 0.29) 5.51
Subtotal (I2=82.5%, P<.001) –0.85 (–1.67, –0.03) 25.64
.
Cerec
Al–Atyaa et al. (2018) –2.42 (–3.75, –1.09) 3.27
Bosniac et al. (2018) –0.68 (–1.04, –0.32) 5.86
Kocaagaoglu et al. (2017) –1.61 (–2.64, –0.59) 4.05
Seelbach et al. (2013) –1.23 (–2.19, –0.27) 4.22
Subtotal (I2=66.0%, P=.032) –1.32 (–2.06, –0.59) 17.40
.
iTero
An et al. (2014) 0.71 (–0.19, 1.62) 4.38
Zaraus et al. (2016) –1.36 (–1.96, –0.75) 5.25
Vennerstorm et al. (2014) –0.21 (–1.09, 0.67) 4.46
Seelbach et al. (2013) –0.79 (–1.70, 0.12) 4.36
Subtotal (I2=80.0%, P=.002) –0.44 (–1.35, 0.47) 18.46
.
3shape
Cetic et al. (2017) –0.65 (–1.55, 0.25) 4.40
Lee et al. (2018) –0.36 (–1.09, 0.36) 4.92
Pedroche et al. (2016) –1.15 (–2.11, –0.20) 4.25
Rodiger et al. (2017) –0.06 (–0.68, 0.56) 5.21
Cetic et al. (2017) –3.92 (–5.47, –2.37) 2.78
Kocaagaoglu et al. (2017) –3.92 (–5.47, –2.37) 2.78
Bosniac et al. (2018) –0.67 (–1.03, –0.31) 5.86
Subtotal (I2=84.5%, P<.001) –1.26 (–2.02, –0.51) 30.20
.
Not Mentioned
Malaguti et al. (2016) –0.87 (–2.18, 0.44) 3.31
Sakornwimon et al. (2017) 0.13 (–0.56, 0.82) 5.00
Subtotal (I2=42.8%, P=.186) –0.21 (–1.14, 0.72) 8.31
.
Overall (I2=78.2%, P<.001) –0.89 (–1.24, –0.54) 100.00
NOTE: Weights are from random effects analysis

–8.26 0 8.26
Figure 3. Standardized mean difference and confidence intervals of marginal gaps categorized by intraoral scanners used. Negative values favor digital
and positive values favor conventional impressions. Weight of each study in percentage shown on right.

and incorrect contours of the veneer in proximal areas
may hinder complete seating of the crowns, increasing
the marginal gap.24,28,29 Also the differences in CAD-
CAM systems should not be neglected. The diameter
and shape of milling instruments vary in different sys-
tems, which can affect the access of a large-diameter
cutting tool to some parts of the intaglio surface.15,25
Most studies reported a mean marginal discrepancy
within the clinically acceptable range. However, this
does not hold true if third quartiles are considered, as in
the study by Pradies et al.24 Therefore, in both reporting
the results and interpreting them, the range of data and
the quartiles should both be considered. Current
evidence suggests that, even though digital scans lead
to reduced marginal discrepancies, both conventional
impressions and digital scanning produce clinically
acceptable results. The choice of conventional or digital
workflow is left to other factors such as availability and
cost-effectiveness.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. Digital scanning of prepared teeth for single-unit
zirconia restorations results in better marginal

Tabesh et al THE JOURNAL OF PROSTHETIC DENTISTRY

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accuracy than conventional techniques using
impression elastomers.
2. However, this finding cannot be extrapolated for
longer-span prostheses, and more studies are
needed.
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Comparison of the marginal fit of lithium disilicate crowns fabricated with
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Corresponding author:
Dr Amin Davoudi
School of Dentistry
Isfahan University of Medical Sciences
Hezar-Jarib Ave, Isfahan, 8174673461
IRAN
Email: amindvi@yahoo.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.01.035
Tabesh et al