RESEARCH AND EDUCATION

Marginal and internal t of pressed ceramic crowns made from

conventional and computer-aided design/computer-aided
manufacturing wax patterns: An in vitro comparison
Loubna Shamseddine, DChD, MSc, DScO,a Rola Mortada, DChD, DU,b
Khaldoun Rifai, DChD, DScO, HDR,c and Jose Johann Chidiac, DChD, MScd
The main goal of a xed restoABSTRACT
ration is the close adaptation of
Statement of problem. To our knowledge, no studies have evaluated the inuence of the wax
the crown to the prepared
fabrication technique on the internal adaptation and marginal accuracy of pressed ceramic single
tooth. A high marginal accuracy
crowns.
and an adequate internal t are
Purpose. The purpose of this in vitro study was to compare the marginal and internal fit of a lithium
the major determining factors
disilicate crown fabricated either from conventional waxing or from a subtractive milled wax
for successful clinical perforpattern.
mance.1-3 Marginal gap mean
Material and methods. Ten silicone impressions were made for a maxillary canine prepared to
values ranging from 50 mm
receive a complete crown. Two pressed lithium disilicate glass ceramic copings were made on the
to 180 mm have been dened
die poured from each impression. The rst was from a conventional wax pattern and the second
as acceptable for clinical
from milled wax blocks. The replica technique was used to measure the t by scanning electron
longevity.4,5 The fabrication of
microscope at 80 magnication. Collected data were analyzed with the paired Student t test for
the marginal and wall t. For the occlusal t, the difference in scores did not follow a normal
the wax pattern is a critical step
distribution, and the Wilcoxon signed ranks test was used (a=.05).
in the making of indirect restorations. This time consuming
Results. The mean values were 170.35 mm (SD 50.69) for the marginal t and 130.28 mm (SD
task is dependent upon the
21.64) for the internal t with the conventional technique. For the computer-aided design/
computer-aided manufacturing (CAD/CAM) technique, they were 105.14 mm (SD 39.60) and
skills of the dental laboratory
6
98.09
mm (SD 26.09). Statistical signicance was found for the marginal and internal t (P<.05).
technician. Wax has several
The occlusal t median and interval interquartile scores were 305.04 mm (269.88 to 334.38) for
inherent limitations including
conventional fabrication and 199.04 mm (141.52 to 269.88) for subtractive manufacturing. The
delicacy, thermal sensitivity,
differences were not statistically signicant (P>.05).
elastic memory, and a high coConclusions. The subtractive CAD/CAM waxing technique resulted in the improved t of a pressed
efcient of thermal expansion.7
lithium disilicate crown by decreasing the marginal gaps and internal adaptation. (J Prosthet Dent
Wax manipulation results in
2016;-:---)
a 0.4% shrinkage while
casting can produce a thermal
results have been found to be different depending on
shrinkage of 0.2%.8 It is now possible to fabricate the wax
the type of the restoration and the material used. In
patterns with different computer-aided systems, subtracmetallic single crowns, it was shown that a conventional
tive or additive, omitting several limitations of the conwaxing resulted in a better t than a computer-aided
ventional waxing technique.9 Fit and marginal adaptation

Assistant Professor, Prosthodontics Department, Lebanese University School of Dentistry, Hadath, Lebanon.
Clinical instructor, Prosthodontics Department, Lebanese University School of Dentistry, Hadath, Lebanon.
c
Professor, Prosthodontics Department, Lebanese University School of Dentistry, Hadath, Lebanon.
d
Professor, Prosthodontics Department, Lebanese University, School of Dentistry, Hadath, Lebanon.
b

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Clinical implications
An improved pressed lithium disilicate crown can
be produced from a CAD/CAM wax pattern.

design/computer-aided manufacturing (CAD/CAM)

crown.10 For a Co-Cr 3-unit partial xed dental prostheses,
CAD/CAM demonstrated a better t compared with the
conventional method.11 The vertical discrepancy of the wax
pattern/digitized partial xed dental prostheses was
signicantly higher than the computer designed frameworks for a 3-unit zirconia prosthesis,12 while no difference
has been found for a titanium crown.13
Lithium disilicate ceramic was developed as a glass
ceramic with improved strength.14 It can be processed
either with a lost-wax hot pressing technique or a CAD/
CAM milling procedure.15 The marginal and internal gap
have been well documented for complete coverage single
restorations in pressed glass ceramic from manually
fabricated wax patterns (Table 1).16-37 The popularity of
heat-pressed ceramics relies on the ability to use the lostwax technique to produce dental ceramic restorations. In
this method, the restoration is waxed, sprued, invested,
and eliminated. The ceramic ingot is then melted and
pressed into the investment.38 This ceramic can be used
for inlays, onlays, crowns, or anterior 3-unit partial xed
dental prostheses and can be used for both the monolithic anatomic contour or as a core.39-41
Despite the progress in technologies that led to the
introduction of new systems claiming to produce accurately adjusted restorations,9 controversies still exist about
the effect of the milling procedure on the t of the prosthesis. Results vary from a better t of the milled restorations,19,35 to no difference,31,42 or even to more mist
when compared with the pressed ones.10,13,20,25,32,43
The mist measurements at various points between
the cast surface and the tooth are the best denition of the
casting t.44 This mist includes the internal gap, marginal
gap, and vertical marginal discrepancy and the horizontal
marginal discrepancy, overextended margin, absolute
marginal discrepancy, and seating discrepancy44 (Fig. 1).
Different techniques have been used to measure the mean
values of accuracy for the marginal t of crowns. The most
common clinical instrument used to detect marginal
adaptation is the dental explorer. It helps to detect vertical
mists (under and over contour) and horizontal defects.
Clinical evaluation techniques using an explorer appear to
be inadequate for the assessment of marginal accuracy.45
The diameter of the explorer tip inuences the clinical
evaluation of horizontal gaps.46 When margins are evaluated with an explorer, this evaluation is more likely to be
based on the size and character of overhangs and ledges
rather than on the actual dimension of the opening of

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margins.46,47 Sometimes adjustment of the restoration is

used to improve the results of the explorer evaluation.
According to Karlsson,48 the adjustment of the copings
between the dies and the preparations is a mandatory step,
with the discrepancies between the denitive die and the
intaglio of crowns being signicantly lower than those
between the prepared tooth and the intaglio of crowns.
The adjustment procedure affects the cement thickness
and so has limitations. Optimal cement properties occur
between 50 and 100 mm values.49 Higher values might
fracture the ceramic.49
Several in vitro techniques have been suggested for
measuring the marginal t alone or in combination with
the internal t of crowns. Among the destructive
methods used, the specimens are sectioned then studied
under an optical microscope or a scanning electron microscope (SEM).50 Alternatively, nondestructive methods
have been used, including the stereomicroscope and
image analysis, restricted to the marginal evaluation.51
These methods are sensitive because a slight deviation
of the photographic angle will distort the measurement.
For the stereomicroscope, the microscope is set perpendicular to the margin of the restoration, making the
evaluation of the marginal gap of an overhanging
restoration (vertical overextension) impossible.13 The
prolometer device that measures a surfaces prole to
quantify its roughness is subjected to false interpretation
in repositioning the specimens.34 Other nondestructive
methods are able to evaluate both internal and marginal
discrepancies, with different accuracy values. In
computerized x-ray microtomography, artifacts from
refraction of the images due to radiation and the difculty
of dening the materials (having different coefcients of
absorption) could be possible.52 In the triple scan
method, the accuracy and capability to capture the
different surfaces/materials is directly related to the material surface. Usually highly reective or translucent
surfaces (such as ceramic restorations) need to be coated
with a contrast agent, which might introduce errors.53
The replica technique is a nondestructive evaluation
technique of cement lm thickness.54 It is an accurate
and reliable method that has been used in vivo and
in vitro.55,56 A light-body elastomeric impression material
is used to measure the thickness of the t, using the
optical microscope, stereomicroscope, SEM, or the
microtomography analysis (micro-CT). The optical
scanning of the replica shows high accuracy measurements below a thicknesses of 15 mm; above 100 mm the
accuracy decreases.57 The micro-CT is capable of
resolving thickness to approximately 10 mm but can be
expensive and time-consuming.57 SEM provides more
appropriate and realistic observations than a light microscope, especially with complex margin morphologies.58 For the same measurement, the SEM gives
higher values than for the stereomicroscope.59 The main
Shamseddine et al

2016

Table 1. Peer-reviewed studies on single crown marginal and internal fit of pressed glass ceramics Empress, Empress2, and IPS e.max
Authors (year)
Measuring Method
Marginal Gap (SD), mm
Internal gap (SD), mm
Anadioti et al. (2015)16

Triple scan

Pimenta et al. (2015)17

X-ray micro-CT

Demir et al. (2015)18

Micro-CT

Ng et al. (2014)19

Stereomicroscope

Anadioti et al. (2014)20

3D-2D

Beyari et al. (2014)21

Stereomicroscope

Mously et al. (2014)22

Neves et al. (2014)23
Asavapanumas et al. (2013)24

Stereomicroscope

Martinez-Rus et al. (2013)25

SEM

Yucel et al. (2013)26

Cho et al. (2012)27

Not mentioned

111 (47)

76.19 (52.71 -99.66)

73.26 (54.69-92.03)

230-290 (80)

Not mentioned

74 (47)

Not mentioned

40-48 (9)
89-5 (2)

Not mentioned

36.091 (38.470)/33.465 (38.766)-62.023

(49.962)/45.221 (41.871)

178.895 (77.203)/183.949 (43.162)-117.508

(50.132)/150.515 (57.963)

Micro-CT

30.8 (8.97)

74.03 (6.81)-128.11 (18.96)

Micro-CT

36.8 (13.9)

Not mentioned

52.22 (10.66)-81.79 (16.20)-106.44 (18.480)

Not mentioned

52.1 (17)-69.7 (8)

Not mentioned

Stereomicroscope

29.3 (5)

Not mentioned

Optical Microscope

27.5 (19.4)-30.2 (18.6)-35.1 (20.0)-27.2 (13.7)

Not mentioned

Farid et al. (2012)28

Stereomicroscope

13.5 (1.4)-40.5 (1.7)

Not mentioned

Subasi et al. (2012)29

Stereomicroscope

105.2 (21.33)
98.5 (26.04)

Not mentioned

Borges et al. (2012)30

Optical Microscope

95.65 (19.54)-137.97 (40.69)

Not mentioned

Yksel et al. (2011)31

Stereomicroscope

92.6 (4)

Not mentioned

Baig et al. (2010)32

Computerized image analysis

36.6 (32.1)

Not mentioned

Holden et al. (2009)33

Optical Microscope

55.8 (5.9)

Not mentioned

Good et al. (2009)34

Prolometry

103.7 (68.99)
85.8 (42.66)
91.1 (49.61)

Not mentioned

Al-Rababah et al. (2008)35

Stereomicroscope

85.3 (17.6)

117.9 (22.5)

Bindl et al. (2005)36

SEM

44 (23)

105 (53)

Goldin et al. (2005)37

Optical Microscope

81 (25)

Not mentioned

SEM, scanning electron microscope; SD, standard deviation.

Over contour
a
f

c
d

b
Under
contour

e
Figure 1. Schematic representation of possible marginal discrepancies
and internal t measurements. Absolute discrepancy in overextended
margin (a); absolute discrepancy in underextended margin (b); marginal
gap (c); internal t (d); occlusal t (e); curvature nish line (f).

limitation of this method is the distortion or even damage

of the silicone during manipulation, such as defects of the
material in the area of measurement.60 A recent study of
the replica technique evaluation suggested a digital
computer-based method providing 3D quantitative and
qualitative results without data loss over the complete
Shamseddine et al

surface that occurs during the cutting process. The results

provide many point measurements instead of having
them on the sectioned line only.61 No published investigations have evaluated the inuence of the wax
fabrication technique on the internal adaptation and
marginal accuracy of pressed ceramic single crowns.
The purpose of this study was to compare the marginal and internal fit of a single lithium disilicate crown
manufactured from conventional waxing fabrication
versus milled wax fabrication. The hypothesis was that
the CAD/CAM wax fabrication technique improved internal adaptation and marginal accuracy when compared
with the conventional technique.
MATERIAL AND METHODS
A maxillary right canine on a dental Typodont model
(Frasaco; Practicon, Inc) was prepared to receive a single
crown. The tooth preparation had a marginal round internal angle shoulder with an axial reduction of about 1.5
mm and an occlusal reduction of 2 mm. The prepared
tooth was then duplicated by single-step polyvinyl
siloxane dual-viscosity impressions (putty and light body
Express STD; 3M ESPE), using a stock perforated coated
metal tray (GC Corp). Ten impressions of the preparation
were made at room temperature by one of the authors

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Issue

Acrylic model: complete coverage

preparation (maxillary canine)

One step impression

n=10

Wax manufacturing
n=20

G1: Manual
n=10

G2: CAD/CAM
n=10

Replicas (G1)
n2=20

Replicas (G2)
n2=20

Sections
(G1)
10 M-D
10 B-L

Sections
(G2)
10 M-D
10 B-L

Figure 3. Scanning electron microscope of replica specimen showing

marginal gap locations and some points of internal t measurements
(80 magnication).

Figure 2. Summary of protocol steps.

(R.M.). Light-bodied impression material was injected on

and around the prepared tooth and dispersed with syringe air for approximately 3 seconds. A custom tray with
putty was seated without applying any additional force.
To ensure adequate polymerization at room temperature,
the impressions were allowed to polymerize according to
the manufacturers recommendations.
The casts were poured with Type IV gypsum (Excalibur; Siladent Dr. Bhme & Schps GmbH). Two lithium
disilicate glass ceramic copings were made on the die
from each impression with the lost wax pressed technique. The rst was from a conventional waxing (Renfert
GmbH), the second was from the Wieland dry machine
using a wax disk (Zenotec blue; Ivoclar Vivadent AG).
Each wax coping was poured in a phosphate bonded
carbon-free investment (Bellavest SH; Bego) using a
vacuum mixing device (Multivac 4; Degussa) according to
the manufacturers instructions. The lithium disilicate
copings (IPS e.max; Ivoclar Vivadent AG) were made
with the pressed technique (CeramPress Qex; Dentsply
NeyTech). Two groups of copings were obtained: G1 for
the manual waxing and G2 for the CAD/CAM. In the rst
group, copings were produced using conventional
waxing (Renfert GmbH) with a silver die spacer (Pico-Fit;
Renfert GmbH). A new bottle was used to limit the
evaporation liquid, a factor that might inuence the nal
consistency.62 In the second group, each gypsum model
was scanned with Wieland Dental Wings (S107; Ivoclar
Vivadent AG). From the virtual model wax, copings were
then designed by Dental Wings software (Zenotec CAD,
4.3.2.2.23248 Powered by dwos) and milled with a 5-axes
machine (Wieland Zenotec Select; Ivoclar Vivadent AG).

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Figure 4. Scanning electron microscope of replica specimen showing

occlusal t measurements (80 magnication).

The software was set according to standardized parameters: extra vertical gap set to 0.04 mm, extra horizontal
gap set to 0.01 mm, collar position 0.8 mm, maximum
thickness 0.5 mm, marginal thickness 0.15 mm, and
cement gap at the margin 0.1 mm. The same dental
technician fabricated all restorations at a commercial
laboratory. The distortion of wax crown patterns is unavoidable. Regardless of the method of manipulation,
wax develops a degree of internal strain during preparation. This strain tends to be relieved over time, which
leads to distortion. The distortion of wax is both time and
temperature dependent, and ideally wax patterns must
be invested immediately after removal from the preparation.63,64 In the present investigation, this rule was
respected. Each die received 2 copings, one issued from
the wax made from the manual technique and the other
from CAD/CAM (Fig. 2).
After the pressing process, minor adjustments were
necessary to seat the castings on their dies. When interferences existed on the internal aspects, they were
Shamseddine et al

2016

Table 2. Summary of results comparing manual and CAD/CAM wax patterns

Margin
Student t test

Walls
Student t test

Occlusal
Wilcoxon Signed Ranks Test

Wax

Mean mm

SD

Mean mm

SD

Median mm

Interval Interquartile

Manual

10

170.35

50.69

.003*

130.28

21.64

.005*

305.04

269.88 to 334.38

.17

CAD/CAM

10

105.14

39.60

98.09

26.09

199.04

141.52 to 269.88

CAD/CAM, computer-aided design/computer-aided manufacturing; SD, standard deviation.

*Statistically signicant.

marked and systematically removed with water-cooled

diamond rotary instruments. Restorations were seated
on the prepared tooth, and their marginal t was evaluated with a silicone indicator paste (Fit Checker; GC
Corp) and an explorer. Adjustments were done as
necessary. The coping was accepted when the indicator
paste showed a thin and homogeneous thickness and the
explorer did not penetrate a crevice between the restoration and the plastic tooth. This criterion was chosen in
relation to the clinically acceptable conditions.
The second step was to measure the t of these restorations using the silicone replica technique. Copings
were lled with a polyether light-body (Impregum Soft;
3M ESPE) and placed on the abutment teeth, applying
nger pressure on the occlusal surface to mimic the
insertion step of a crown. Once the light-body silicone
has polymerized, the whole was removed from the
model. The remaining empty space of the intaglio of the
restoration was injected with a polyether medium-body
(Impregum Soft; 3M ESPE). Two replicas were made
from each coping. The replicas were sectioned with a
razor blade. One replica was sectioned mesiodistally
(M-D) and the other buccolingually (B-L). These sections
were used to measure the internal and marginal t. All
sections were coated with copper in order to be
conductive and so become visible on the SEM. The lightbodied thickness was measured from the beginning to
the end of the section at several points. The mean value
of each measurement was taken as the nal result in each
specimen. The SEM was used at 80 magnication
(Figs. 3, 4).
Data were analyzed using statistical software (IBM
SPSS Statistics v20; IBM Corp). Marginal and internal
gap mean values and their standard deviations (SD) were
calculated. The paired Student t test was conducted for
equality of means for margin and wall t because of the
normal distribution. The Wilcoxon signed ranks test was
used to assess differences on occlusal t as the difference
scores did not follow a normal distribution (a=.05).
RESULTS
Several adjustments for the same copings were needed.
Each adjustment was done on several intaglios in the rst
group, or on selected points in the second. Surfaces
needed more adjustments than for the selected points.
The results are summarized in Table 2. A more signicant
Shamseddine et al

lower marginal gap was found in the CAD/CAM group

than with manual manufacturing (P=.003). The internal
gap at the walls was found to be signicantly lower in the
CAD/CAM group than in the manual group (P=.005).
However, no signicant difference was found for the
occlusal t between the 2 groups (P=.17).
DISCUSSION
The clinical evaluation was made by the same operator
using the same explorer to reduce the measurement
discrepancies. The difference in adjustment interventions
between the 2 groups could be the result of the difference
in the wax distortion pattern between the manual and
the milled wax. These differences are mainly related to
the ow properties, shrinkage, and expansion after the
unequal heating and cooling of the manually fabricated
wax, while the wax used for CAD/CAM is a solid synthetic wax produced from polymerization reaction and is
less sensitive to temperature conditions.65
A limitation of this study was that the measurement
area is restricted to the sectioned line. The replica technique cannot be extrapolated to a clinical test value as for
this clinical test, Groten et al66 suggests 50 measurements
are needed.
The marginal gap of the crown made from wax CAD/
CAM manufacturing (105.14 39.60 mm) was signicantly lower than that of the conventionally waxed crown
(170.35 50.69 mm). This result may be because small
defects in the manual waxing caused by the wax patterns
color and glossy surface can be difcult to identify.67 The
act of removing a wax pattern from a die causes an
average 35-mm opening of the shoulder margin before
investing,68 which also contributes to such results. The
marginal gap values obtained seem better than the values
found in other published papers,17,19,20-28 perhaps
because the preparation form has a signicant impact on
the marginal gap of lithium disilicate crowns fabricated
with a CAD/CAM system.69 The preparation at the
gingival margin with a curved nish line on a Typodont
model seems to increase the values.24,29 This may explain
our results as we used a similar preparation design
(Fig. 1).
Regarding the thickness of the light body in the
replica technique compared with the cement thickness
after cementation in other studies, the values were
similar.30,34 Furthermore, the representation of cement

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thickness at the walls was less than 100 mm in the CAD/

CAM group (98.09 26.09 mm) as opposed to the manual
process (130.28 21.64 mm) (P=.005). For the occlusal t,
no signicant difference was found between the 2
groups. All values representing cement thickness found
in the CAD/CAM manufacturing were in the range of
clinical acceptance, while for the conventionally processed technique, the marginal values were higher than
the accepted value of 120 mm.70 The differences in the
internal t between CAD/CAM and manual groups could
be explained by the accurate setting of the digital die
spacer in the CAD/CAM technique (the standard setting
of the Dental Wings Ivoclar software die spacer was 40
mm occlusal and 10 mm at wall surfaces), while in the
manual fabrication the die spacer is variable. This difference is accounted for by the evaporation of the
liquid.62 As for the occlusal t, results could be explained
by the diameter of the milling tool of the CAM machine.
The tool has a diameter that cannot precisely access the
sharp internal angles of the canine preparation and
therefore the results become similar to a manually produced wax.
CONCLUSION
Within the limitations of this in vitro study comparing
wax manufacturing methods between manual and CAD/
CAM fabrication, the t of a pressed lithium disilicate
crown is affected as follows:
1. CAD/CAM wax manufacturing signicantly decreased
the marginal gap when compared with conventional
waxing.
2. CAD/CAM wax manufacturing signicantly improved
the adaptation at the axial walls when compared with
conventional waxing.
3. No signicant difference was found between CAD/
CAM and conventional wax manufacturing regarding
the adaptation of the occlusal surface.
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Corresponding author:
Dr Loubna Shamseddine
Lebanese University
Prosthodontics Department
Mazraa, Daybess St
El Ferdaouss Building, 1st oor
Beirut
LEBANON
Email: drloubna1@hotmail.com
Acknowledgment
The authors thank Roland Habchi, Physicist Researcher at the platform of
nanoscience and nanotechnology - Lebanese University, for his assistance with
the SEM analysis; and Mr Naoum Merhej, Dental Laboratory Technician at the
School of Dentistry - Lebanese University, for his contribution in the copings
fabrication.
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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