Clinical Oral Investigations (2023) 27:263–271

https://doi.org/10.1007/s00784-022-04720-6

ORIGINAL ARTICLE

Evaluation of the marginal and internal fit of CAD/CAM crowns

designed using three different dental CAD programs: a 3‑dimensional
digital analysis study
Ra’fat I. Farah1 · Bandar Alresheedi1

Received: 25 February 2022 / Accepted: 7 September 2022 / Published online: 14 September 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Objectives The purpose of this in vitro study was to assess and compare the marginal and internal fit of machine-milled
crowns designed using three different CAD software programs.
Materials and methods Digital impressions of the master zirconia casts containing the prepared molar were obtained using an
intraoral scanner. The obtained standard tessellation language (STL) files were imported into three CAD software programs
(Multi-CAD, Blue-Sky CAD, and InLab), and crown designs were generated. Crown design digital STL files were used to
mill crowns with a five-axis dental milling machine. The internal and marginal fits of the fabricated crowns over the master-
prepared tooth were assessed using the triple-scan protocol and digital analysis techniques. The 3D marginal and internal
fit values of the fabricated crowns from the designs generated by the three CAD programs were evaluated and statistically
compared using one-way analysis of variance (ANOVA) and post hoc Tukey’s tests (α = 0.05).
Results There were no significant differences in the internal fit of the crowns designed by the three CAD programs (p > 0.05).
However, there were significant differences in the mean marginal fit (p = 0.009) of the crowns. The marginal fit values for the
InLab-designed crowns were significantly better than those for Multi-CAD (p = 0.03) and Blue-Sky CAD (p = 0.012) groups.
Conclusions All three CAD programs can design clinically acceptable crowns in terms of internal and marginal fit. InLab
crowns outperformed the Multi-CAD and Blue-Sky CAD programs in terms of marginal fit.
Clinical relevance It is critical to test the ability of newly released CAD programs to design acceptable virtual crowns that
can be transformed into actual crowns with optimal marginal and internal fit to existing clinical tooth preparations/conditions
to ensure the high technical quality and long-term success of fabricated crowns.

Keywords CAD/CAM · Computer-aided design · Internal fit · Marginal fit · Triple-scan protocol

Introduction in many aspects, such as standardized manufacturing pro-

Since the introduction of the first commercial in-office
computer-aided design and computer-aided manufacturing
(CAD/CAM) system in the 1980s, this industry has grown
significantly. CAD/CAM systems are now used across
many industries [1, 2]. This technology has tremendously
improved dental clinics and dental laboratory work in recent
years and has demonstrated very positive effects on dentistry
* Ra’fat I. Farah
Dr.rafat.farah@qudent.org; ri.farah@qu.edu.sa
1 associated data analysis software. The digital data are then
Department of Prosthetic Dental Sciences, College
of Dentistry, Qassim University, P.O. Box: 6700,
Al‑Mulaydah 51452, Qassim, Saudi Arabia
cesses that minimize inaccuracies and increases production
capacity and speed. Moreover, CAD systems allow the use
of new materials such as zirconia and titanium and enable
dentists to perform some types of indirect restoration during
the same visit [3, 4].
CAD/CAM systems have many applications in prostho-
dontics and restorative dentistry. These systems are usu-
ally composed of hardware and software that work together
through the three major steps of the restoration fabrication
workflow [5]. After acquiring physical geometries and their
spatial position data, these data are transformed into digi-
tal images by using different types of scanners with their
used to design the intended restoration using CAD software
installed on a computer with high-performance graphic

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hardware with different tools for manipulating, editing, and
designing the 3D model or final future restorations. Finally,
the design is accepted. The design data are imported into the
CAM software to nest the restoration in the block or disc of
material and then control the manufacturing strategy of the
connected computer numerical control (CNC) dental mill-
ing machine to mill the intended restoration [5, 6].
The overall accuracy of any CAD/CAM workflow can be
considered the sum of all errors that occur during the fabrica-
tion process. Errors occurring at each step can be software or
hardware errors. Software is as essential as hardware in over-
all CAD/CAM performance and accuracy. Studies show that
similar hardware, such as intraoral scanners, performs very
differently depending on variations in the control software [7].
The accuracy and precision of any CAD/CAM workflow can
be validated by the accuracy and fit of the resultant fabricated
restoration. This demonstrates the ability of these systems to
fabricate a restoration that is well fitted to clinical conditions
with the same parameters as those preset/pre-established dur-
ing virtual restoration design, with the smallest cumulative
errors [8, 9]. One of these important parameters includes the
internal and marginal fit of indirect restorations, which is vital
for restoration success and longevity. A poor marginal fit may
lead to microleakage, dissolution of luting cement, second-
ary caries, and gingival inflammation. Additionally, a poor
internal fit can increase the cement thickness, prevent proper
restoration seating, alter retention, affect occlusion, and reduce
the fracture resistance of restorations. Most previous studies
recommend marginal and internal fit values in the range of
50–100 µm (the most favorable resin cement performance),
and CAD/CAD systems should be able to reproduce these
small parameter values in the fabricated restoration [10, 11].
Previous studies have investigated the marginal and inter-
nal fit of fixed dental prostheses fabricated using different
CAD/CAM systems with various commercially available
CAD/CAM materials [12]. Other studies have attempted to
test the effect of individual hardware components on mar-
ginal and internal fit, such as the use of different types and
brands of digital scanners and milling machines [13, 14].
However, only a few studies have discussed the effects of the
software. In a study by Lee et al. [15], the authors attempted
to validate CADs by testing the effect of different CADs on
restoration fit. In this study, fixed dental prosthesis design
3D files were virtually positioned over the master abutment
cast file to evaluate and measure the internal clearance using
a 3D analysis program without fabricating a real prosthe-
sis. In another study by Bayrak et al. [16], the authors used
micro-computed tomography to evaluate the fit of milled
ceramic inlays from three different CAD software program
designs. They concluded that CAD software programs affect
the marginal and internal fit of inlay restorations.
For many years, only a few CAD programs have been
commercially available. However, in the last decade, owing
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Clinical Oral Investigations (2023) 27:263–271
to the massive increase in digital technology in both divi-
sions, computer hardware and software have witnessed a
rapid increase in the number of available CAD programs.
Several new CAD programs have been developed. CAD
software is one of the variables that may affect the quality
of the fabricated fixed dental prosthesis (and its internal and
marginal fit) [3, 17]. Therefore, this study aimed to assess
the marginal and internal fit of a machine-milled crown
designed using three different CAD software programs. The
null hypotheses were as follows: First, there are no differ-
ences in the internal fit in machine-milled crowns designed
using different CAD software programs. Second, there are
no differences in the marginal fit in machine-milled crowns
designed using different CAD software programs.
Material and methods
In the training model jaws (AG-3 Frasaco GmbH, Tettnang,
Germany), the typodont maxillary right first molar ((no. 16)
was prepared with the following preparation parameters: a 0.7-
mm circumferential chamfer finish line, an internal angle of
115°, a 2-mm occlusal planer reduction, and a mean of 30° of
total occlusal convergence angle between parallel axial walls.
This large total occlusal convergence angle was designated to
facilitate and improve the trueness of the preparation’s digital
scans obtained [18]. Then, the adjacent teeth (no. 15, no. 17)
were removed, and their sockets were covered using utility red
wax. The model jaws (maxillary and mandibular) were digitized
using a laboratory-based scanner (Artica Autoscan; KaVo Dental
Corp.; Biberach, Germany) to obtain virtual models. The vir-
tual models were transferred to a dental model creator software
program to be cropped and add bases and alignment/articulat-
ing pins. This sectional master cast design with the removal of
adjacent teeth to the prepared tooth was used instead of the sin-
gle tooth master die design used in most previous internal and
marginal fit studies [19, 20]. This is because the sectional master
cast design preserves the advantages of single tooth master die
in allowing for a better and easier scan of the interproximal areas
and seating of the fabricated crowns without possible interference
from interproximal contacts. Simultaneously, the presence of
other teeth and alignment/articulating pins allows for stable and
verifiable articulation during the registration scan and sufficient
points for software matching without overloading the system,
which is important for accurate and standardized 3D fit analysis
[21]. The designed models were then milled from white opaque
shade zirconia disc (DDBioZW, 3Y-TZP-A Ø 98.5X25 mm disc;
Dental Direkt GmbH; Spenge, Germany) using a dental milling
machine to fabricate the physical master casts (Fig. 1). Zirconia
was used as the final master cast material owing to its high wear
resistance and excellent mechanical characteristics [3].
A digital impression of the master zirconia casts was
obtained using a non-contact optical intraoral scanner
Clinical Oral Investigations (2023) 27:263–271
Fig. 1  Master zirconia casts
Fig. 2  Preparation parameters of the master die measurement by 2D
analysis program
(Omnicam; Dentsply Sirona Inc.; York, PA). The prepa-
ration parameters were verified using a software program
(LibreCAD Software; LibreCAD community) (Fig. 2).
Then, the generated 3D virtual images of the zirconia master
casts were exported using a software program (Sirona Connect
SW4.5; Dentsply Sirona Inc.; York, PA) in the open binary
standard tessellation language (STL) file format. Next, the mas-
ter casts STL files were imported into three CAD software pro-
grams: KaVo Multi-CAD (KaVo multiCAD DentalDB, KaVo
Dental Corp.; Biberach, Germany), CEREC InLab 16 (InLab
SW16.0; Dentsply Sirona Inc.; York, PA) and Blue-Sky CAD
software (Blue Sky Plan: crown and bridge module; Blue Sky
Bio LLC; Grayslake, IL) (Fig. 3). The crown designs were gen-
erated by the three programs using the same exported STL files.
For standardization, the crown designs in the three programs
were conducted by the same experienced technician. Further-
more, the three test CAD programs have almost automated
internal crown design after the technician traces/detects the fin-
ish line and pre-set the internal design parameters. The same
pre-established set of internal design parameters of a 50-µm
265
cement space for the axial and occlusal aspects and the area
of no cement space was set to 0.1 mm. This 0.1-mm value was
selected because it is the lowest allowable value for the area of
no cement space in the Blue-Sky CAD program. Therefore, for
standardization, the same value was set in Multi-CAD, and for
the InLab software, the determination area of no cement space
function tool was not available. Each software was used to gen-
erate ten crown designs for the prepared tooth.
The resultant crown designs from the three CAD programs
were exported as STL files, yielding 30 STL files (ten from
each CAD software). This sample size was deemed adequate
(for a confidence interval of 95% and 80% power) after using
means and standard deviations of the dependent variables for
all groups in web-based OpenEpi software to calculate the
optimal sample size [22]. The STL files were then imported
into CAM software (InLab CAM SW16.1; Dentsply Sirona
Inc.; York, PA). Thirty crowns were milled using a five-axis
CNC dental milling machine (inLab MC X5; Dentsply Sirona
Inc.; York, PA). The crowns were milled from the CAD/CAM-
reinforced composite blocks (Brilliant Crios Blocks A1 Lt 14
Cerec; Coltene Group; Altstätten, Switzerland) under cool-
ing conditions. CAD/CAM composite blocks were selected
to fabricate test crowns because a recent study showed that
composite permanent crowns have better internal and marginal
fit than that of ceramic crowns owing to their inherent resilient
property [23]. Furthermore, according to the data supplied by
the manufacturer, this reinforced composite block has good
mechanical properties, which renders it suitable for permanent
single-tooth restorations such as inlays, onlays, crowns, and
veneers. The milling machine used grinding burs for this type
of restoration, and a new set of burs was used to mill each of
the ten reinforced composite blocks to ensure consistent grind-
ing efficiency during the milling of all crowns.
3D marginal and internal fit assessment
The marginal of internal fit was assessed using the triple-scan pro-
tocol and digital analysis technique described by Park et al. [24],
and the following three scans were obtained: preparation, intaglio,
and external surfaces of the milled crown (attached to lower cast),
and registration scan of the crown on the prepared tooth (Fig. 4)
was obtained. Scans and 3D measurements for all the samples were
performed by the same researcher using the same intraoral digital
scanner and analysis software programs with high intra-rater reli-
ability (intraclass correlation coefficients, ICCs) were statistically
significant (P < 0.001), with a high correlation of 0.82). The scan
images were then cropped to remove unnecessary details using the
“Cut” function in the program (Sirona Connect SW4.5; Dentsply
Sirona Inc.; York, PA). The resultant upper and lower 3D image
files (with matching/articulating data) were exported as STL files.
The 3D analysis was performed by comparing the
meshes of the intaglio fitting and marginal surfaces with
the meshes of the corresponding surfaces in the master
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266 Clinical Oral Investigations (2023) 27:263–271

Fig. 3  Study workflow. CAD,

computer-aided design; CAM,
computer-aided manufactur-
ing; STL, Standard Tessellation
Language

zirconia cast using a 3D point cloud processing software
(CloudCompare V2). Despite the ability to identify the
different levels of fit in the different areas of the crowns
(axial wall and occlusal), only marginal and internal fit
were selected, which is similar to many previous studies
and enables comparison. To facilitate the separation of
the virtual surfaces for 3D analysis, the demarcation line
between the internal and marginal surfaces was established
as an internal line angle where the surface steeply bent
toward the axial wall, as shown in Fig. 5 [25].

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Clinical Oral Investigations (2023) 27:263–271 267

Fig. 4  Registration scan of the crown placed on the prepared tooth

The software automatically computes the mean of numer-

ous selected point distances (mean of 8000 sign distance val-
ues for internal fit and 2800 values for marginal fit) between
corresponding meshes according to the spatial alignment
data recorded during bite registration scan and encoded in
the STL files (Figs. 6 and 7). The obtained mean 3D internal
and marginal fit data were tabulated for statistical analysis.

Statistical analysis

Preliminary assumption verification indicated that the internal

and marginal fit values were normally distributed for each CAD
program, as assessed by the Shapiro–Wilk test (p > 0.05). There
were no outliers, as shown by the boxplot, and the variance was
homogeneous, as assessed by Levene’s test of homogeneity of Fig. 5  The marginal fit surface indicated by brown shade and green
shade indicates internal fit surface
variances (p > 0.05). One-way analysis of variance (ANOVA)
(one for each dependent variable) was used to determine whether
there were significant differences in mean 3D internal and mar- Results
ginal fit values among the three experimental groups. When the
ANOVAs were significant, a post hoc Tukey’s test was used. The descriptive statistics for the internal and marginal fit values
Statistical analysis was performed using the statistical software are listed in Table 1. The results of one-way ANOVA revealed
program (IBM SPSS Statistics, v20.0; IBM Corp) (α = 0.05). no significant differences between the means of the internal

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Fig. 6  3D colored map of the

internal surfaces illustrating the
fit between the master die and
the intaglio of the milled crown

Fig. 7  3D colored map of the

marginal surfaces illustrating
the fit between the master die
and the intaglio of the milled
crown

fit of crowns designed by the three CAD programs (p = 0.584; Discussion

η2 = 0.039; η2 stands for (partial) eta squared which is meas-
ure of effect size for a one-way ANOVA), but there were sig-
nificant differences between the means of crown marginal fit
(p = 0.009; η2 = 0.339) (Table 2). The post hoc Tukey’s test
indicated that the mean marginal fit values for the crowns
designed by InLab were significantly better than those obtained
from the other two experimental groups. In contrast, no sig-
nificant differences were found between the Multi-CAD and
Blue-Sky CAD groups (Table 3).
The digital workflow followed in this study was standardized
using only the same intraoral scanner and milling machine. The
associated software was used throughout the experimental steps,
and the only variable was the CAD program. Additionally, all
digital data were exchanged between different software programs
in the same universal file format (open binary STL), in which
triangular facets encode only the representation of the surface
geometry of a 3D object [26]. Furthermore, the composite block

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Clinical Oral Investigations (2023) 27:263–271 269

Table 1  Descriptive statistics of marginal and internal fit values (µm) for the three tested CAD program groups (mean ± standard deviation)
CAD group Number Mean ± SD (µm) Std. Error 95% CI for mean Min Max
Lower bound Upper bound

Internal fit InLab 10 80.0 (12.3) 3.9 71.2 88.8 60.0 95.0
MultiCAD 10 76.0 (13.3) 4.2 66.5 85.5 58.0 95.0
Blue-Sky CAD 10 81.1 (8) 2.5 75.4 86.8 67.0 93.0
Total 30 79.0 (11.3) 2.1 74.8 83.2 58.0 95.0
Marginal fit InLab 10 55.4 (7.5) 2.4 50.1 60.7 46.0 67.0
MultiCAD 10 64.8 (9.2) 2.9 58.2 71.4 48.0 74.0
Blue-Sky CAD 10 66.2 (6.5) 2.0 61.6 70.8 54.0 76.0
Total 30 62.1 (8.9) 1.6 58.8 65.5 46.0 76.0

CAD computer-aided design, CI confidence interval, Max maximum, Min minimum, SD standard deviation, Std. Error standard error

Table 2  One-way ANOVA Sum of squares df Mean square F P-value

results of marginal and internal
fit among the three tested CAD Marginal fit Between groups 689.867 2 344.933 5.708 .009*
program groups
Within groups 1631.600 27 60.430
Total 2321.467 29
Internal fit Between groups 150.867 2 72.033 .549 .584
Within groups 3701.300 27 131.293
Total 3852.167 29

CAD computer-aided design

*
Statistically significant (P < .05)

Table 3  Pairwise comparison of mean change in marginal fit values among the three tested CAD program groups
Dependent variable CAD CAD Mean difference Std. error P-value 95% CI
(I) (J) (I-J)
Lower bound Upper bound

Marginal Fit Tukey HSD InLab MultiCAD − 9.40* 3.74 .030* − 18.02 − .78
Blue-Sky CAD − 10.80* 3.74 .012* − 19.42 − 2.18
MultiCAD InLab 9.40* 3.74 .030* .78 18.02
Blue-Sky CAD − 1.40 3.74 .915 -10.02 7.22
Blue-Sky CAD InLab 10.80* 3.74 .012* 2.18 19.42
MultiCAD 1.40 3.74 .915 − 7.22 10.02

CI confidence interval, Std. Error standard error

*
Mean difference significant at .05 level

was used instead of ceramic material because it has lower wear
resistance. Therefore, it is easier to grind/mill, which reduces the
effect of the quality of milling burs, and it does not abrade the
zirconia master die [23, 27]. In addition, composite restorations
fit directly upon preparation, and post-sintering/crystallization
processes are not required, which may affect the accuracy and
fit of the restoration [28]. The triple scan method with digital
analysis was used to assess internal and marginal gaps. This
method uses the stitching process of acquired image technology,
performed through a best-fit alignment, and has been used in
previous studies. It is also considered a reliable and valid method
for assessing the adaptation values of dental restorations [29, 30].
The crown design STL files from the three programs were
similar in size, indicating similar restoration size, details, and
mesh density (number of triangles used to represent the object
surface). Based on the method described in this study, the
analysis of the milled crown fit demonstrated that the meas-
ured values of fit of milled crowns failed to reproduce the pre-
established design parameters, with larger average gap values
across all experimental groups, which is similar to the findings

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of previous studies that examined the marginal and internal fit
of CAD/CAM-fabricated crowns [23, 31].
The statistical analyses revealed no statistical differences
between the groups in terms of internal fit, which indicates the
acceptance of the first null hypothesis. The internal gap average
value for all groups was 79 µm ± 11, which is below the clinically
acceptable maximum limit reported in the literature (≤ 100 µm)
[32]. This result contradicts previous studies [15, 16]. The prepa-
ration used in this study was simple, with a large total occlusal
convergence angle with an easy path of insertion, no undercuts,
and no part smaller than the smallest milling bur used to prepare
the master zirconia casts (0.5 mm). Therefore, the importance of
software functions/tools such as blocking undercuts and consider-
ing the diameter of the milling burs during restoration design is
omitted from the results of this study. The diameter of the smallest
bur dictates the milling process accuracy. Therefore, any surface
detail less than the diameter of the milling bur is over-milled,
which contributes to a poorer fit and the formation of larger inter-
nal gaps [4, 33]. Consequently, if a more complex preparation
geometry was used in this study, the CAD program may not have
performed equivalently in terms of internal fit.
For the marginal gap, there were significant differences
between the groups, indicating the rejection of the second null
hypothesis. The best performance was observed for InLab with
a marginal gap of 55 µm ± 7. This result actually cannot be
attributed to inherent errors in the design software or hardware-
software incompatibility because the same design software and
hardware workflow produced almost similar crown internal fit/
adaptation among the three CAD groups despite the larger and
more complex geometry of the crown internal surface area in
relation to that of the marginal area. One possible justifica-
tion for these significant differences in marginal fit is the pre-
established marginal gap parameters in the CAD programs, as
both Blue-Sky and Multi-CAD have a function to manually
set the parameter of an area at the crown margin without the
cement space (similar to the conventional laboratory workflow
where the lab did not add a die spacer to 1 mm near the finish
line) [34], which was set by the technician at 0.1 mm in both
programs. However, in the InLab program, this parameter is
automatically set by the software, and there is an equivalent
option in the software to change it or set it manually, which
may cause the marginal gap differences. Despite the significant
differences, all three programs yielded crowns with clinically
acceptable marginal gaps of < 76 µm [35].
This study is one of the few studies that compared different
CAD software programs via a 3D digital analysis protocol;
consequently, it provides deeper insights into dental CAD
programs. However, it is important to indicate that this study
has the following drawbacks: First, the digital assessment
method is not error-free, and the stitching process through best-
fit alignment may result in a series of errors; therefore, the
final accuracy of measurements will depend on the scanning
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Clinical Oral Investigations (2023) 27:263–271
technique and correction algorithm/process within the control
scanner software [36, 37]. Second, despite their importance in
restoration quality and longevity, internal and marginal fit are
only part of the restoration evaluation criteria. Their evaluation
of a program alone is incomplete; there is a need to assess other
parameters, different types of tooth preparation with differ-
ent levels of complexities, and different types of restorations
to obtain a comprehensive base for more proper evaluation
and comparison. Furthermore, other aspects of CAD software
which may dictate the selection of CAD software, such as cost,
ease of use (design automation), user-friendly interface, availa-
bility of updates, maintenance, and technical support, presence
of other tools, work, and add-on modules that extend the range
of indications, facilitate and enhance the design experience
[33]. Further studies are needed to assess the different aspects
of CAD programs available in the dental market.
Conclusions
The following conclusions were drawn based on the find-
ings of this in vitro study:
1. The three tested CAD programs yielded clinically
acceptable crowns in terms of marginal and internal fit.
2. No significant differences were observed between the
tested CAD programs in terms of internal fit for the prepa-
ration and restoration parameters used in this study.
3. The best marginal fit was achieved using the InLab program,
which was significantly better than that achieved using the
Multi-CAD and Blue-Sky CAD programs for the prepara-
tion and restoration parameters used in this study.
Declarations
Ethics approval This article does not contain any studies with human
participants or animals performed by any of the authors. This study
was conducted in full accordance with the World Medical Association
Declaration of Helsinki.
Informed consent For this type of study, formal consent is not required.
Conflict of interest The authors declare no competing interests.
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