RESEARCH AND EDUCATION

In vitro evaluation of marginal discrepancy of

monolithic zirconia restorations fabricated with different
CAD-CAM systems
Tamer A. Hamza, BDS, MSc, PhDa and Rana M. Sherif, BDS, MSc, PhDb

Although demand for esthetic ABSTRACT

restorations has increased, the Statement of problem. Dental laboratories use different computer-aided design and computer-
inherent weakness of ceramic aided manufacturing (CAD-CAM) systems to fabricate xed prostheses; however, limited
restorations limits their use, evidence is available concerning which system provides the best marginal discrepancy.
especially in areas with heavy
Purpose. The purpose of this in vitro study was to evaluate the marginal t of 5 different monolithic
occlusal forces or those for pa- zirconia restorations milled with different CAD-CAM systems.
tients with bruxism. Such prob-
lems, however, have been Material and methods. Thirty monolithic zirconia crowns were fabricated on a custom-designed
stainless steel die and were divided into 5 groups according to the type of monolithic zirconia
overcome with the introduction
crown and the CAD-CAM system used: group TZ, milled with an MCXL milling machine; group
of yttria-stabilized tetragonal CZ, translucent zirconia milled with a motion milling machine; group ZZ, zirconia milled with a
zirconia polycrystalline (Y-TZP)- dental milling unit; group PZ, translucent zirconia milled with a zirconia milling unit; and group
based restorations. In addition to BZ, solid zirconia milled using an S1 VHF milling machine. The marginal t was measured with a
the materials excellent esthetics binocular microscope at an original magnication of 100. The results were tabulated and
and tissue tolerance, compar- statistically analyzed with 1-way ANOVA and post hoc surface range test, and pairwise multiple
ed with metal ceramic restora- comparisons were made using Bonferroni correction (a=.05).
tions,1-7
its transformation Results. The type of CAD-CAM used affected the marginal t of the monolithic restoration. The
toughening property provides mean (SD) highest marginal discrepancy was recorded in group TZI at 39.3 2.3 mm, while the
high exure strength (up to 1200 least mean marginal discrepancy was recorded in group IZ (22.8 8.9 mm). The Bonferroni post
hoc test showed that group TZI was signicantly different from all other groups tested (P<.05).
MPa) and fracture toughness (6
8-10
to 9 MPa$m ). Conclusions. Within the limitation of this in vitro study, all tested CAD-CAM systems produced
Because of the opaque na- monolithic zirconia restorations with clinically acceptable marginal discrepancies; however, the
ture of zirconia, it can be ven- CAD-CAM system with the 5-axis milling unit produced the best marginal t. (J Prosthet Dent
2016;-:---)
eered with more translucent
feldspathic porcelain to achieve
the desired esthetics.8 However, despite the superior me- decreasing the number of light scattering sources such as
chanical properties of Y-TZP, clinical failures still occur at alumina particles. This led to the introduction of monolithic
the zirconia veneer interface in the form of ceramic veneer (anatomically contoured) zirconia restorations, which are
chipping and cracking.9 This failure has been reported to be formed from a single ceramic material and which eliminate
signicantly higher than that with metal ceramic restora- the risk of chipping a veneer porcelain. The use of mono-
tions.10 The translucency of zirconia has been improved lithic zirconia restorations also simplies the fabrication
without signicantly affecting its mechanical properties11 by procedure and saves time.12,13 Many manufacturers supply

a
Professor, Faculty of Oral and Dental Medicine, Misr International University, Cairo, Egypt.
b
Assistant Professor, Faculty of Oral and Dental Medicine Cairo University, Cairo, Egypt.

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Clinical Implications
CAD-CAM technology produces restorations with
clinically acceptable marginal t. However, milling
machines with 5 axes produce restorations with
better t than milling machines with 4 axes.

this type of restoration, either in the form of blocks or disks

to be used with different computer-aided design and
computer-aided manufacturing (CAD-CAM) systems.
Contemporary CAD-CAM systems differ in their scanning
methods, number of milling axes, and milling conditions,
wet or dry.14-16
Figure 1. Schematic of stainless steel die.
Marginal t is considered one of the most important
criteria in the evaluation of xed dental prostheses and is
Everest and Cerec CAD-CAM systems. Using software
one of the most signicant prerequisites for the long-
(EPI-info v6; Centers for Disease Control and Preven-
term success of ceramic restorations.17 The larger the
tion) for sample size calculation with b=.80 and a=.05, a
marginal discrepancy, the higher the plaque index and
sample size of n=6 for each group was determined.
loss of attachment and the more the luting material is
A custom-designed stainless steel die was fabricated
exposed to the oral environment.18 Furthermore, if the
using an engineering lathe (automatic feedback lathe
cement seal fails and allows bacterial percolation, sec-
BV20B-L; Bengu Dome Sitimaxhim tool) to simulate a
ondary caries, pulpal inammation, and eventually
maxillary rst premolar ceramic crown preparation
pulpal necrosis could result.19
(Fig. 1) with 6-mm occlusogingival height, 12 degrees of
Studies have evaluated the effect of using different
total occlusal convergence angle, and a at occlusal sur-
CAD-CAM systems on the marginal discrepancy of the
face. A U-shaped groove (3 mm long and 0.5 mm deep)
restoration; however, the results have been inconsistent.
was made on 1 side of the axial surface to facilitate the
Shim et al20 reported that different parameter settings
repositioning of the crowns during measurements and to
and different software versions can affect the t of a
prevent their rotation. The preparation was completed
CAD-CAM restoration. In contrast, Cho et al21 stated
with a 1-mm-wide shoulder nish line.
that the t of a CAD-CAM restoration is not affected by
Thirty monolithic zirconia crowns were fabricated on
the number of milling axes but is inuenced by digitali-
stainless steel dies and were equally divided into 5 groups
zation, data processing, and production process. Hamza
according to the type of monolithic zirconia crown and
et al22 stated that a CAD-CAM system with a 5-axis
CAD-CAM system used for milling (Table 1) as follows:
milling unit can improve productivity and precision of
group TZ Incoris TZI (TZI; Sirona) milled with the MCXL
the denitive restoration. Several studies have evaluated
milling machine (Sirona); group CZ, Ceramill Zolid white
the marginal t of ceramic crowns and have shown a
(CER, Amann Girrbach AG) milled with the Ceramil
high degree of variation in the different ceramic sys-
motion 2 milling machine (Aman Girbach AG); group
tems.23-36 Most investigators continue to use the criteria
ZZ, Zenostar zirconia (ZEN; Wieland) milled with the
established by McLean and von Fraunhofer,37 who, after
Wieland dental milling unit (Wieland); group PZ, Prettau
a 5-year clinical study of 1000 restorations in 1971,
zirconia (PZ; Zirkonzahn) milled with the Zirkonzan
concluded that 120 mm was the maximum acceptable
milling unit M1(Zirkonzan); and group BZ, Bruxzir solid
marginal opening (ranging from 100 to 120 mm).
zirconia (BRX, Glidewell) milled with the S1 dental
Therefore, the purpose of this in vitro study was to
milling machine (CNC machine, VHF).
evaluate the marginal discrepancy of monolithic zirconia
All fabrication procedures, including model scan-
restorations milled with different CAD-CAM systems.
ning, software designing, milling, and sintering pro-
The null hypothesis of the study was that the marginal
tocols were done according to the manufacturers
discrepancy of monolithic zirconia restorations would not
instructions for each zirconia brand and CAD-CAM
be affected by the type of CAD-CAM system used.
system used. To standardize the dimension and shape
of all the test monolithic zirconia crowns, 1 crown from
MATERIAL AND METHODS
group TZI was considered as a reference for all the other
The sample size was calculated from a power analysis of systems, and the processed crown was scanned and
the marginal t data of Hamza et al,21 who found a used to design the other monolithic crowns. The crown
statistically signicant difference between the Kavo parameters were identical and xed to have a marginal

THE JOURNAL OF PROSTHETIC DENTISTRY Hamza and Sherif

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Table 1. Material used

Group Type Of Zirconia Restoration CAM Used Manufacturer
TZ Incoris TZI MCXL milling machine Sirona Dental Systems Inc
CZ Ceramill Zolid translucent zirconia Ceramil motion 2 milling machine Amann Girrbach AG
ZZ Zenostar zirconia Wieland dental milling unit Wieland
PZ Prettau zirconia translucent zirconia Zirkonzan milling unit M1 Zirkonzan GmbH
BZ Bruxzir solid zirconia S1 dental milling machine Glidewell Dental Labs, VHF Camfacture AG

Table 2. Descriptive statistics

95% CI for Mean
Surface N Mean (mm) SD SE Lower Bound Upper Bound Minimum Maximum
TZ1 24 39.3 2.3 0.47 38.29 40.23 34.42 43.67
Pz 24 19.4 7.1 1.4 16.39 22.37 7.72 30.06
Cz 24 25.1 8.2 1.68 21.63 28.60 13.44 40.05
Bz 24 22.8 8.9 1.82 19.04 26.60 9.86 35.77
Zz 24 27.3 11.4 2.32 22.45 32.05 9.95 43.60
Total 120 26.8 10.5 0.96 24.86 28.66 7.72 43.67

Bz, Bruxzir solid zirconia; CI, condence interval; Cz, Ceramill Zolid translucent zirconia; Pz, Prettau zirconia translucent zirconia; TZ1, Incoris TZI; Zz, Zenostar zirconia.

space of 50 mm and an adhesive space of 1 mm from the
nish line.
All tested crowns were individually seated on the
stainless steel die and examined for vertical marginal
discrepancy distance, using a binocular microscope (SZ-
PT; Olympus Corp) at a magnication of 100. To ensure
accurate seating of the crowns on the metal die and to
hold them in place during measurements, a custom-
designed holding device was used to apply a static load
on the crowns during the examination procedure. Eight
predetermined measurement locations along the
circumference of each crown were selected (4 line angles:
mid-buccal, mid-lingual, mid-mesial, and mid-distal),
and digital images of the margins were then captured
and analyzed using image analysis software (Optimas
v6.5; Media Cybernetics). The vertical marginal t of each
crown was recorded, and the data obtained were
collected, tabulated with a spreadsheet (Excel 2013;
Microsoft Corp), and analyzed with statistical software
(SPSS v16; SPSS Inc). Data were mean SD, and 1-way
ANOVA was used to compare between groups to eval-
uate the effect of the CAD-CAM system used on the
marginal t of monolithic restorations (a=.05). Post hoc
surface range tests and pairwise multiple comparisons
were used with Bonferroni correction to determine sta-
tistically signicant differences (a=.05).
RESULTS
The 1-way ANOVA test for the groups with df 4, F=20.7,
and P<.001 showed that the type of CAD-CAM used
affected the accuracy of the marginal t of monolithic
restoration. The highest marginal discrepancy was
recorded in group TZI (mean 39.3 2.3 mm, whereas the
least marginal discrepancy was recorded in group BZ
(mean 22.8 8.9 mm). The Bonferroni post hoc test
showed that group TZI differed signicantly from all
other tested groups (P<.05). No signicant differences
were found among the other 4 tested groups (PZ, BZ, ZZ,
CZ; P>.05) (Tables 2, 3).
DISCUSSION
The null hypothesis of the study, which stated that the
type of CAD-CAM used would not affect the marginal t
of monolithic zirconia restorations, was partially rejected
as the marginal accuracy of the TZI group was lower than
that of other tested groups.
Monolithic zirconia ceramic restorations have high
exure strength with no incidence of porcelain veneer
delamination and require only conservative tooth prep-
aration, thus improving their clinical success and reli-
ability.7 Marginal accuracy is an important criterion for
any xed prosthodontic restoration, and a precise t
between the restoration and the tooth should improve
the longevity of the restoration. Many factors can affect
marginal accuracy including the type of material used,
the nish line conguration, and the fabrication tech-
nique. This study evaluated the vertical marginal t of 5
monolithic zirconia ceramic crowns using 5 different
CAD-CAM manufacturing systems.
Different CAD-CAM systems were selected for this
study in order to eliminate any human error during
fabrication. Also, a comparison of these different CAD-
CAM systems may help clinicians to select the system
capable of producing the best marginal t.26 The CAD-
CAM systems used in this study differ in their milling
condition, scanning technique, and number of milling
axes.
For standardization, a stainless steel die was
machined to simulate the shape of a maxillary rst pre-
molar prepared to receive a ceramic restoration. Natural

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Table 3. Multiple comparisons Bonferroni be lost when restorations are cemented because of
Mean
95% CI variations in cement type, viscosity, and cementation
Group Group Difference Lower Upper techniques.22
I J (I-J) SE P Bound Bound
The results of this study showed that monolithic
TZ1 PZ 19.9* 2.35 <.001 13.15 26.62
CZ 14.1* 2.35 <.001 7.41 20.89
restorations fabricated from TZI using the Cerac MXCL
BZ 16.4* 2.35 <.001 9.70 23.18
milling machine had a signicantly higher marginal
ZZ 12.0* 2.35 <.001 5.28 18.75 discrepancy than those of the other systems tested. This
PZ TZ1 -19.8* 2.35 <.001 -26.62 -13.15 agreed with Hamza et al,21 who stated that the difference
CZ -5.7 2.35 .164 -12.47 1.00 in marginal accuracy might have resulted from the
BZ -3.4 2.35 1.000 -10.18 330 number of milling axes of the machine. The TZI mono-
ZZ -7.9* 2.35 .011 -14.60 -1.13 lithic restoration was milled with the MXCL milling
CZ TZ1 -14.2* 2.35 <.001 -20.89 -7.41 machine, which has a 4-axis motion and mills under wet
PZ 5.7 2.35 .164 -1.00 12.47 conditions. However, group CZ used Ceramill zolid
BZ 2.3 2.35 1.000 -4.44 9.03 translucent zirconia (CER, Amann Girbach AG) milled
ZZ -2.1 2.35 1.000 -8.87 4.60 with the Ceramill motion milling machine (Aman Gir-
BZ TZ1 -16.4* 2.35 <.001 -23.18 -9.71
bach AG); group ZZ used Zenostar zirconia (ZEN,
PZ 3.4 2.35 1.000 -3.30 10.18
Wieland) milled with the Wieland dental milling unit
CZ -2.3 2.35 1.000 -9.03 4.44
(Wieland); group PZ used Prettau zirconia translucent
ZZ -4.43 2.35 .623 -11.17 2.31
zirconia (PZ Zirkonzahn) milled with the Zirkonzan
ZZ TZ1 -12.1* 2.35 <.001 -18.75 -5.28
PZ 7.9* 2.35 .011 1.13 14.61
milling unit (Zirkonzan); and group BZ specimens used
CZ 2.1 2.35 1.000 -4.60 8.87
Bruxzir solid zirconia (BRX, Glidewell) were milled with
BZ 4.4 2.35 .623 -2.31 11.17 the S1 VHF milling machine (vhf group). All of them
have a 5-axis milling motion, and this explains the
Bz, Bruxzir solid zirconia; CI, condence interval; Cz, Ceramill Zolid translucent zirconia;
Pz, Prettau zirconia translucent zirconia; TZ1, Incoris TZI; Zz, Zenostar zirconia. *Mean nonsignicant differences between them in terms of
differences were signicant (P<.05). marginal t values These results indicate that, although a
CAD-CAM milling machine with 5 axes may take more
teeth were not used as they vary in age, individual time to mill a restoration than a 4-axis milling machine, it
structure, and time of storage. In contrast, with milled produces more accurate restorations.
metallic dies, uniform measurements could be obtained Another explanation for the higher marginal
for any preparation. discrepancy of the TZI group may be due to a phenom-
The die was designed to have 12 degrees of total enon called point clouds in the scanning process. This
convergence angle. This convergence angle has been occurs during the scanning of small areas and leads to
recommended by many authors16,17,22 as it allows proper imperfection in the restoration.34,35 However, light
seating of the denitive restoration. The occlusal surface scanners with blue light use a short wavelength light
was milled to a at rather than an anatomic surface, thus source which reduces scanning and improves t.36
ensuring an even thickness of the restoration, which McLean and von Fraunhofer37 stated that a restora-
results in better marginal adaptation than an anatomic tion is considered clinically successful when the marginal
one.25 discrepancy and the luting space is less than 120 mm. The
A U-shaped groove, 3-mm long and 0.5-mm deep, current study showed that the marginal accuracy of all
was prepared parallel to the long axis of the stainless tested groups was within this range and can be consid-
steel die for repeatable seating of the crown specimens ered clinically acceptable.
and to prevent their rotation.26 A shoulder nish line was In contrast with in vivo studies, in vitro results should
chosen in the present investigation as it provided suf- be interpreted cautiously because testing conditions
cient thickness for the zirconia at the margin, thus pre- cannot exactly reect the clinical situation. Nevertheless,
venting a marginal defect during the milling process.7 such results might provide valuable information and
Also Re et al,28 Gomes-Azevedo et al,29 and Souza guidelines for clinical applications. In the present in vitro
et al30 revealed that a better marginal seal for zirconia investigation, every effort was made to standardize
restorations was achieved when the preparation ended conditions and to simulate the clinical situation.26
with a shoulder nish line rather than a chamfer nish Another important limitation of this study was that
line. the authors used different materials with different CAD-
In the current study, the CAD-CAM software for the CAM systems. Although standardizing the material type
cement space was set to 50 mm, whereas 30 to 50 mm and scanning unit can be benecial in detecting the
was found to deliver the best marginal t.31 The mar- differences between milling units, the authors were
ginal t was measured without cementation in this concerned about testing the compatibility of the system
study to ensure precise primary adaptation, which can as a whole because dental laboratories normally do so.

THE JOURNAL OF PROSTHETIC DENTISTRY Hamza and Sherif

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Therefore, future studies should evaluate components
individually.
CONCLUSIONS
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. All tested CAD-CAM systems produced monolithic
zirconia restorations with clinically acceptable mar-
ginal t.
2. The CAD-CAM system with 5 axes and dry milling
produces better marginal accuracy.
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Corresponding author:
Dr Tamer A. Hamza
Professor of Fixed Prosthodontics
Faculty of Oral and Dental Medicine
Misr International University
Cairo
EGYPT
Email: drtamerhamza@hotmail.com
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY