Clinical Oral Investigations (2023) 27:1577–1588

https://doi.org/10.1007/s00784-022-04779-1

RESEARCH

Three‑year clinical evaluation of zirconia and zirconia‑reinforced

lithium silicate crowns with minimally invasive vertical preparation
technique
Ammar T. Kasem1 · Mohamed Ellayeh1,2 · Mutlu Özcan3 · Amal Abdelsamad Sakrana1,4

Received: 24 June 2022 / Accepted: 6 November 2022 / Published online: 16 November 2022
© The Author(s) 2022

Abstract
Objectives Large part of the tooth is required to be removed during crown preparation. A minimally invasive method for
preparing single crowns is required to increase the durability of teeth. The aim of this study was to evaluate the clinical
performance of two ceramic systems fabricated with minimally invasive vertical preparation.
Materials and methods Forty endodontically treated maxillary premolars were prepared with vertical preparation and
received temporary crowns for a period of 21 days. Twenty zirconia-reinforced lithium silicate (Celtra Duo HT, Dentsply
Sirona, Germany) and 20 monolithic high translucency zirconia (Katana HT, Kuarary Noritake, Japan) crowns were fab-
ricated by CAD/CAM and cemented with dual-polymerizing luting resin. The crowns were evaluated clinically and radio-
graphically for 36 months following modified FDI criteria. Statistical analysis was conducted with t Student test (Cochran Q).
Results Over the follow-up period, there was no need to replace any of the study’s crowns. The overall survival rate of the
40 crowns was 100% according to the Kaplan–Meier survival method. The clinical quality of all crowns and the patient’s
satisfaction were high. No caries was detected and no adverse soft tissue reactions around the crowns were observed. Peri-
odontal probing depth was reported to be increased at mesial and distal sites more than the facial one in the 36-month follow-
up with no statistically significant difference between both materials (P = 0.186).
Conclusions Zirconia and zirconia-reinforced lithium silicate could be used as a material for restoration of teeth prepared
with vertical preparation technique. Both ceramic materials achieved good esthetic results, promotes healthy and stable soft
tissues with no mechanical complications after 3 years of clinical evaluation.
Clinical relevance Monolithic high translucency zirconia and zirconia-reinforced lithium silicate ceramics can be used for
the restorations of minimal invasive vertical preparation in premolar area with 0.5 mm margin thickness.

Keywords Vertical preparation · Biologically oriented preparation technique · Minimal invasive · Zirconia-reinforced
lithium silicate · FDI criteria

Abbreviations
FDP Fixed dental prosthesis
Y-TZP Yttria-stabilized tetragonal zirconia
polycrystal
* Ammar T. Kasem CADCAM Computer aided design-computer aided
[email protected] manufacturing
1 BOPT Biologically oriented preparation technique
Fixed Prosthodontics Department, Faculty of Dentistry,
Mansoura University, Mansoura, Egypt ZLS Zirconia-reinforced lithium silicate
2 CEJ Cemento-enamel junction
Prosthodontics Department, Faculty of Dentistry, New
Mansoura University, New Mansoura, Egypt FDI Federation Dentaire International
3 SD Standard deviation
Division of Dental Biomaterials, Center for Dental and Oral
Medicine, University of Zurich, Clinic for Reconstructive
Dentistry, Zurich, Switzerland
4
Fixed Prosthodontics Department, Faculty of Dentistry,
Horus University, New Damietta, Egypt

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1578 Clinical Oral Investigations (2023) 27:1577–1588

Introduction been shown that restorations manufactured from yttria-

stabilized tetragonal zirconia polycrystal (Y-TZP) may
The primary challenge of restorative dentistry is how to provide clinical longevity of 20 years [23, 24].
obtain an excellent esthetic outcome while preserving Recently, monolithic glass–ceramic materials are devel-
tooth structure through minimally invasive preparation oped to provide exceptional esthetics avoiding the draw-
techniques [1, 2]. Minimizing tooth preparation promotes backs of layered ceramics [25, 26]. Zirconia-reinforced
the preservation of the tooth structure and dento-enamel lithium silicate (ZLS) glass ceramics are now widely used
junction, which has a significant role in the redistribution as machinable ceramics for CAD/CAM techniques [27].
of stresses, resisting cracks propagation, and increasing These materials offer flexural strength varying from 370 to
the durability of teeth [3, 4]. 420 MPa which is comparable with the lithium disilicate
Two types of dental preparation are well known in the glass ceramics. Moreover, it offers an improved esthetic
literature. The first type is horizontal preparation with a outcome and bond strength compared to that of zirconia
well-defined finish line, which is then replicated in the ceramics [28].
impression and the working model. The second type is The amount of tooth preparation required for most tra-
preparation without a finish line, also known as vertical ditional all-ceramic systems varies from 1.2 to 1.5 mm
preparation or feather edge [5, 6]. For vertical preparation, axially and 1.5 to 2 mm occlusally which equal that of
the margins are determined by the laboratory technician porcelain fused to metal restorations [29, 30]. Advances in
based on gingival tissue information [7]. Vertical prepara- mechanical properties and improved optical characteristics
tions are commonly indicated for periodontally involved of current all-ceramic systems enabled the use of more
teeth that serve as abutments for fixed dental prosthesis conservative and less invasive preparation designs [3, 4].
(FDP). Periodontally involved teeth which are usually Zirconia and ZLS ceramics with minimal invasive vertical
associated with observed gingival recession require the preparation showed a comparable performance between
removal of substantial amount of tooth structure to achieve conventional and vertical preparations [18]. Based on the
a horizontal finish line that possibly compromises the results of this evaluation, this clinical study was performed
long-term prognosis of the teeth [8, 9]. Vertical prepa- to evaluate the performance of zirconia and ZLS ceram-
ration offers a conservative alternative, where the finish ics with minimal invasive vertical preparation technique
line is represented by an area rather than a horizontal line according to modified FDI criteria for 36-month follow-up
[10, 11]. period.
Recently, the utilization of vertical preparation with a
biologically oriented preparation technique (BOPT) has
been suggested [12, 13]. BOPT is a protocol in which
a new prosthetic cemento-enamel junction is created to Materials and methods
replace the anatomical crown’s emergence profile corre-
sponding to the cemento-enamel junction. A key factor Study design
for a successful BOPT protocol is fabricating an optimal
interim prosthesis that determines the new prosthetic A total of 40 crowns (n = 40) were placed for 24 patients
emergence profile which will support the gingival margin who presented for restoration of endodontically treated
and guide the healing and thickening of the gingival tissue. maxillary premolar teeth. Patients’ selection was based on
This will be reproduced when the definitive prosthesis is a set of inclusion and exclusion criteria (Table 1) [31]. The
placed [14, 15]. patients were selected from the outpatient dental clinic, Fac-
Three main factors should be considered to achieve an ulty of Dentistry, Mansoura University, Egypt. This clinical
optimal dental restoration; resistance to fracture, marginal study was performed in accordance with the guidelines of
adaptation, and esthetic value [11, 16]. Recently, two all- the Declaration of Helsinki [32]. The research protocol was
ceramic monolithic dental materials are mainly used in approved by Dental Research Ethics Committee in Mansoura
most restorative conditions for their ideal mechanical and University (05,060,218/2018), prior to patient enrollment.
esthetic characteristics; glass ceramics, and polycrystalline Treatment options were explained to the patients in terms of
zirconium dioxide [17, 18]. The noble mechanical proper- steps, benefits, and risks then a written consent was signed
ties of zirconia allow clinicians to adopt changes in the by each patient indicating his/her willingness to be part of
preparation strategies concerning the coping design [19, this study. After a screening appointment to verify patient
20]. This can allow reducing the coping thickness from eligibility, the teeth planned for crowns were randomly
0.5 to 0.3 mm and changing the chamfer finish line to assigned to the study groups according to the material used.
the more conservative feather-edge design [21, 22]. It has The information about the study participants and groups is
shown in (Table 2).

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Table 1  Inclusion and exclusion criteria of this study

Inclusion criteria Exclusion criteria

(1) Healthy patients in the age range from 20 (1) Smoking (> 10 cigarettes/day)
to 40 years (2) Any local or systemic disease
(2) Good oral hygiene or medication that might compromise
(3) Good quality of root canal treatment with no periapical lesions healing and affect the periodontium
(4) Periodontal probing depth prior to tooth preparation ≤ 2 mm and no bleeding on probing (3) Inability to give informed consent
(5) > 2 mm of keratinized tissue to participate in this study
(6) There are a minimum three remaining adjacent sound dentin walls with composite core foundation (4) History of alcohol or drug abuse
(7) The patients should be available during the follow-up schedules (5) Unfavorable crown-to-root ratio
(6) Severe clenching or bruxing habits

Table 2  Participants and groups Group ZLS Group Z

features
Restoration type Zirconia-reinforced Monolithic zirconia crowns
lithium silicate crowns
Brand name Celtra Duo Katana
Manufacturer Dentsply Sirona, Germany Kuarary Nortikate, Japan
Translucency High translucency High translucency
Flexural strength 370 MPa after glazing* 1125 MPa after sintering*
Number of crowns 20 20
Total participants 10 14
Sex (male/female) 4/6 6/8
Age 22–36 22–38
Missed during 2 1
Follow-up period Replaced with another participants
Replaced crowns 1 0
*
According to the data from the manufacturers

Prosthetic procedures Germany). A minimal invasive preparation for all-ceramic

crown was carried out, with an initial depth of 0.8 mm to a
The time sequence of all procedures is shown in (Fig. 1). final depth of 1 mm axially and 0.5 mm at the marginal area.
One week before preparation, all patients underwent scaling The occlusal surface was reduced by 1.5 mm with a 1-mm
and prophylaxis to enhance the gingival condition. Then, minimal thickness in the thinnest portion of the crown.
the periodontal probing depth (PPD) was registered at three A rotary curettage of the gingival sulcus (gingitage) was
facial and palatal sites (mesial, midpoint, distal) and also performed simultaneously with vertical tooth preparation
proximally using a periodontal probe rounding the measure- [33]. To avoid any violation of the biologic width, the prepa-
ments to the nearest millimeter. ration extended sub-gingivally not deeper than 1 mm from
The shade selection procedure was done for all selected the gingival margin using a 4 × magnification loupe (Wen-
patients before preparation using both visual and instru- zhou Amtech Medical Technology Co., China) regardless of
mental methods to complement each other for the accurate the probing depth recorded at baseline. Teeth were prepared
esthetic outcomes. The conventional visual method for shade with a vertical margin (Fig. 2), so there was a finishing area
selection was performed using the IVOCLAR VIVADENT rather than a finish line. The reduction was started by reduc-
A-D shade guide (Ivoclar Vivadent, Liechtenstein). Then, ing the occlusal surface by 1.5 mm using a football stone.
a portable clinical spectrophotometer (Vita Easyshade V, Fine-tapered stone was then used to separate the interproxi-
Vita Zahnfabrik, Germany) was used to identify digitally mal contact area. The axial reduction was started using a
and precisely the patient teeth shade required for the shade tapered diamond with rounded end to create a supra-gingival
selection of the crowns. chamfer finishing line. Using the batt bur (857–314-014,
All teeth preparations were carried out by one prostho- Komet, Germany), the preparation was extended sub-gingi-
dontist under local anesthesia (articaine with 1:100.000 val removing the formerly prepared finish line. The prepa-
epinephrine). The standardized technical procedures were ration was extended 0.5–1 mm apical to the free gingiva
performed using a kit for vertical preparation (0197, Komet, with a 6 to10° convergence angle. The preparation was then

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Fig. 1  Diagram showing the time sequence of interventions and examinations

Fig. 3  Illustration showing the difference between A conventional

and B vertical preparations

Fig. 2  Steps of vertical preparation. A 1.5-mm occlusal reduction. part of the preparation, while the external one was thicker
B 0.8-mm initial axial reduction of supra-gingival part with cham-
which follows the external portion of marginal gingiva. The
fer preparation using tapered diamond stone with round end. C
0.5–1 mm sub-gingival preparation. D Checking the preparation by space between both margins represents the negative image
putty index of the gingiva (Fig. 4). After that, a light-polymerized flow-
able composite was used to fill the space between the two
margins to make the coronal margin thicker and create the
checked by putty index to make standardization of prepa- crown contour. In this way, a new CEJ was obtained in the
ration. The difference between vertical and conventional sulcus not deeper than 0.5 to 1 mm, respecting the tooth
preparation is shown in (Fig. 3). biologic width. After an accurate finishing with flexible alu-
The direct temporization technique followed by relining minum oxide discs (3 M™ Sof-Lex™ Discs) and polishing
was used. After fit verification, all crowns were relined using with diamond wheels (3 M™ Sof-Lex™ Diamond Spirals),
auto-polymerizing resin (VISALYS TEMP, Kettenbach the crown was cemented using provisional cement (Provilat,
GmbH & Co.kg, Germany) [7]. Two distinct margins for the Promedica, Germany).
crown were shown after the setting of temporary material; Patients were instructed to use Chlorhexidine gluco-
a thin internal margin, which replicates the intra-sulcular nate solution (0.2%) for 7 days until they could practice

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Fig. 4  Photographs showing relining of the temporary crown. A Fig. 5  Photographs showing removable die after preparation and
Relined temporary crown was inserted in patient mouth. B The space ditching. A Bucco-lingually and B mesio-distally
between the two margins was filled by flowable composite. C The
internal margin was evidenced by red marker. D The excess resin was
trimmed by discs and the emergence profile was shaped to support The crowns of ZLS group were etched using 9.5% hydro-
the gingival margin fluoric acid for 20 s according to the manufacturer’s instruc-
tions. Then, acid residues were removed from the crowns
intaglio surface by rinsing under running water. Crowns
were dried using air syringe till the appearance of chalky
regular oral hygiene. The temporary crowns were left in white surface. Finally, one coat of porcelain primer was
place for a period of 14–21 days [7, 12] to promote the applied to the intaglio surface, and then air-dried for 3–5 s
healing process and allow for the thickening of gingival following the manufacturer’s instructions. For group Z, the
tissue. After the period of temporization, the gingival tis- intaglio surface was air borne particle abraded using A ­ l2O 3
sue became stabilized and final impressions were taken particles (50 µm; 4 bar (0.4 MPa) air pressure for 14 se).
using two-step polyvinyl siloxane impression material The tip of the sandblaster device was adjusted 10 mm away
(Elite HD + putty soft, Zhermack, Italy). Double retrac- from the crowns [34]. Then crowns’ intaglio surfaces were
tion cords were applied for 5 min before recording the covered by one coat of zirconia primer, then air-dried for
impression using two different cord sizes #00 and #1 cord 3–5 s following the manufacturer’s instructions. Since the
(Gingicord, Denu, Korea) impregnated with a hemostatic margins were placed inside the intra-sulcular compartment,
agent (aluminum chloride). The impression was poured alternative methods rather than rubber dam were used to
twice, the first cast was used for ditching and scanning and isolate the environment from moisture, such as retractors
the other one was used for checking and verification of the for the lips, cotton rolls, and retraction cords to control the
crowns before insertion. The gingival part around the abut- sulcular fluids and to remove excess cement sub-gingivally
ment was removed showing the sub-gingival area of the [35]. Dual-polymerizing self-adhesive universal luting resin
preparation reproduced on the model as shown in (Fig. 5). (G-CEM Capsules, GC Co., Japan) was used for the cemen-
The casts were scanned using a 3D optical scanner (Cer- tation of all crowns of both groups.
amill Map400, AmannGirrbach, Germany) and designed
with compatible software (Ceramill Mind CAD, version Clinical follow‑up protocol
3.5.6.1408, AmannGirrbach GmbH, Germany). Twenty
high translucency ZLS crowns were wet milled and 20 Clinical follow-up was stated 48 h after cementation (base-
monolithic high translucency zirconia crowns were dry line) then 6, 12, 18, 24, and finally after 36 months [36].
milled using a CAM system (Ceramill motion II, Amann- At each recall appointment, both clinical examinations and
Girrbach, Germany). For ZLS, the crowns were subjected periapical radiographs were performed using modified FDI
to a first glaze firing process at 820 C, then additional criteria [37]. Clinical examinations were performed using a
glaze firing was performed at 770 C (heating rate 55 C / mirror, sharp explorer, and digital photographs then the final
min, hold time 1:30 min). The sintering of zirconia crowns score was taken based on a 3-examiner evaluation. The new
was performed by raising the temperature of the ceramic FDI criteria set a different background for the evaluation
furnace from room temperature to 1450 C for 2.5 h and of dental restorations by introducing 3 groups of criteria;
holding this temperature for 2 h, and then decreasing it to esthetic, functional, and biological. Each of these groups has
room temperature again for 2.5 h. subgroups with the final score in each group being dictated

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by the most severe score among all the sub-scores. The All crowns were evaluated clinically and radiographi-
selected FDI criteria and the methods of evaluation for each cally at baseline (48 h after cementation), 6, 12, 18, 24,
criterion are described in (Table 3). and finally at 36 months. Clinical evaluation was done
using diagnostic tools and digital photographs (Figs. 6
Statistical analysis and 7). All scores were drawn after observation by the
same clinicians. Scores 3, 4, and 5 were not observed
The data were tabulated, coded, then analyzed in the envi- through the evaluation period for all the tested criteria so,
ronment of IBM SPSS (Statistical package for social sci- they were excluded from the results. Over the follow-up
ences) computer software, version 23.0. Descriptive statis- period, there was no need to replace any of the study’s
tics were expressed as mean (SD) and valid percentages for
continuous and categorical data. The baseline comparisons
and continuous variables between groups were performed
using t Student test (Cochran Q).

Results

Twenty-four patients (10 males and 14 females, aged

22–38 years, mean age 30 years) received 40 crowns of
which 20 were included in group ZLS and 10 in group Z.
All participants completed the 36-month follow-up period
except for 2 patients related to group ZLS and 1 patient
related to group Z were missed and replaced by other par-
ticipants. Only one crown in group ZLS was fractured dur-
ing insertion and before cementation due to extra load from
the patient, and the fractured crown was replaced with a
Fig. 6  Intra oral photographs: showing A Celtra Duo and B
new one. Regarding group Z, one crown was debonded after KATANA crowns 48 ho after cementation. C Celtra Duo and D
30 months and re-cemented. KATANA crowns at 36-month follow-up appointment

Table 3  FDI criteria and the method of evaluation for each selected criterion
Criteria Method of evaluation

Surface luster - A qualitative inspection in relation to neighboring enamel with thoroughly cleaned and dried restored tooth
and switched off operator light at a distance of 60–100 cm
Staining - Clinical inspection using mirror and illumination
Color match and translucency - Comparison to that of the surrounding tooth tissue and adjacent teeth using visual and instrumental (Vita
Easyshade V) methods
- A standard set of digital photographs were also provided for stability comparison
Esthetic anatomical form - Visual comparison to the normal form with switched off operator light at a distance of 60–100 cm
Fracture of material and retention - Clinical inspection using mirror/probe, loupe magnification, and proper illumination after thorough clean-
ing and dryness
Occlusal contour and wear - Qualitatively through photo-documentation of the occlusal surface (contact areas) of crowns, antagonist,
and adjacent teeth (reference enamel) at baseline and recall appointments
Approximal anatomical form - Approximal contact points were evaluated with metal blades/strips (25, 50, and 100) (TOR VM Ltd, Mos-
cow, Russia). Waxed dental floss was used for calibration at baseline and at all recalls
- Approximal contour was evaluated through visual assessment with regard to the normal
Radiographic examination - X-rays for the involved teeth at each recall appointment
Patient view - Structured interview with the patient on his/her satisfaction/dissatisfaction with the crown
Tooth integrity - Clinical inspection using mirror/probe, loupe magnification, and proper illumination after dryness
- A set of blunt probes, straight, and double angled for proximal sites, with different blunt tips of 50, 150, and
250 μm were used (DENTSPLY Maillefer Instruments, Ballaigues, Switzerland)
Periodontal response - Clinical inspection of the involved tooth using mirror, periodontal probe, and papillary bleeding index (PBI
scale 0–4) with comparison to a control reference tooth
Oral and general health - Broad clinical inspection of the oral cavity and the medical status and history of the patient

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Fig. 7  Radiographic images:

showing Celtra Duo (above) and
KATANA (below) crowns dur-
ing follow-up period. No pathol-
ogy, no pockets, and there was a
harmonious transition between
crowns and neighboring teeth

crowns. The overall survival rate of the 40 crowns was Esthetic properties (Tables 4)
100% according to the Kaplan–Meier survival method
[38]. All patients were satisfied with esthetic and func- Regarding group ZLS, the surface luster was not changed for
tional outcomes at all examinations. all crowns over the evaluation period and was scored as 1;
however, four crowns belonging to group Z were scored as 2

Table 4  Esthetic properties among studied groups with difference between follow-up scores
Esthetic properties Group FDI score Baseline 12 months 24 months 36 months Test of significance
(1–5) ∗ N (%) N (%) N (%) N (%) (Cochran Q)

Surface luster ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …

Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 16 (80.0) 16 (80.0) P = 0.007*
Score 2 0 (0.0) 0 (0.0) 4 (20.0) 4 (20.0)
Test of significance … … P = 0.106 P = 0.106
Surface staining ZLS Score 1 20 (100.0) 20 (100.0) 18 (90.0) 16 (80.0) P = 0.047*
Score 2 0 (0.0) 0 (0.0) 2 (10.0) 4 (20.0)
Z Score 1 20 (100.0) 20 (100.0) 10 (50.0) 6 (30.0) P < 0.001*
Score 2 0 (0.0) 0 (0.0) 10 (50.0) 14 (70.0)
Test of significance … … P = 0.661 P = 0.333
Color match and translucency ZLS Score 1 14 (70.0) 14 (70.0) 14 (70.0) 14 (70.0) P = 1.0
Score 2 6 (30.0) 6 (30.0) 6 (30.0) 6 (30.0)
Z Score 1 18 (90.0) 18 (90.0) 18 (90.0) 18 (90.0) P = 1.0
Score 2 2 (10.0) 2 (10.0) 2 (10.0) 2 (10.0)
Test of significance P = 0.114 P = 0.114 P = 0.114 P = 0.114
Esthetic anatomical form ZLS Score 1 18 (90.0) 18 (90.0) 18 (90.0) 18 (90.0) P = 1.0
Score 2 2 (10.0) 2 (10.0) 2 (10.0) 2 (10.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) P = 1.0
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance P = 0.487 P = 0.487 P = 0.487 P = 0.487

∗Score: 1 = clinically excellent/very good, 2 = clinically good, 3 = clinically sufficient/satisfactory, 4 = clinically unsatisfactory (but repairable),
5 = clinically poor (replacement necessary)

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1584 Clinical Oral Investigations (2023) 27:1577–1588

in the 24- and 36-month control appointments. Surface stain- during the follow-up period. Regarding group Z, approximal
ing did not change over 6 months and was scored as 1 for anatomical form was scored as 1 for all crowns during the
both groups; however, two crowns in group ZLS was scored first year and only two crowns were scored 2 in the 24- and
as 2 at 12 months and four crowns were scored as 2 at 24- 36-month follow-up appointments.
and 36-month control appointments. For group Z, ten crowns
were scored as 2 at the 12-month control appointment and Biologic properties (Tables 6)
14 crowns were scored as 2 at the 24- and 36-month control
visits. Color match and translucency was scored as 1 for all None of the 40 crowns exhibited fracture of restored teeth
crowns of both groups during the 36-month follow-up period during the complete observation period and tooth integrity
except for six crowns in group ZLS and two crowns in group Z was scored as 1. Oral and general health was scored as 1
were scored 2 from the baseline. The esthetic anatomical form for all crowns in both groups during the 36-month follow-
did not change during the evaluation period and was scored as up period. Regarding periodontal response, all crowns
1 for all crowns of both groups except for two crowns belong- of group ZLS were scored as 1 at baseline and 12-month
ing to group ZLS was scored as 2 from the baseline. follow-up visit. At the 24-month recall visit, eight crowns
were scored as 2, and ten crowns were scored as 2 at the
Functional properties (Tables 5) 36-month follow-up appointment. For group Z, the peri-
odontal response was scored as 1 for all crowns at baseline
Fracture of material and retention, radiographic examina- and four crowns were scored as 2 in the 12-month follow-
tion, and patient’s view were scored as 1 during the clinical up appointment. After 2 years, ten crowns scored as 2 at
evaluation period for all crowns in both groups. Approximal 24 months, and 14 crowns scored as 2 at the 36-month
anatomical form also was scored as 1 for all ZLS crowns follow-up appointments.

Table 5  Functional properties among studied groups with difference between follow-up scores
Functional properties Group FDI score Baseline 12 months 24 months 36 months Test of significance
(1–5) ∗ N (%) N (%) N (%) N (%) (Cochran Q)

Fracture of material and retention ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance … … … … …
Occlusal wear ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 16 (80.0) P = 0.005*
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 4 (20.0)
Test of significance … … … P = 0.106
Approximal ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
anatomical form Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 18 (90.0) P = 0.104
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 2 (10.0)
Test of significance … … … P = 1.0
Radiographic examination ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance … … … …
Patient view ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance … … … …

∗Score: 1 = clinically excellent/very good, 2 = clinically good, 3 = clinically sufficient/satisfactory, 4 = clinically unsatisfactory (but repairable),
5 = clinically poor (replacement necessary)

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Table 6  Biological properties among studied groups with difference between follow-up scores
Biological properties Group FDI score Baseline 12 months 24 months 36 months Test of significance
(1–5) ∗ N (%) N (%) N (%) N (%) (Cochran Q)

Tooth integrity ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …

Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance … … … … …
Periodontal response ZLS Score 1 20 (100.0) 20 (100.0) 12 (60.0) 10 (50.0) P < 0.001*
Score 2 0 (0.0) 0 (0.0) 8 (40.0) 10 (50.0)
Z Score 1 20 (100.0) 16 (80.0) 10 (50.0) 6 (30.0) P < 0.001*
Score 2 0 (0.0) 4 (20.0) 10 (50.0) 14 (70.0)
Test of significance … P = 0.106 P = 0.525 P = 0.196
Oral and general health ZLS Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Z Score 1 20 (100.0) 20 (100.0) 20 (100.0) 20 (100.0) …
Score 2 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Test of significance … … … …
∗
Score: 1 = clinically excellent/very good, 2 = clinically good, 3 = clinically sufficient/satisfactory, 4 = clinically unsatisfactory (but repairable),
5 = clinically poor (replacement necessary)

Periodontal probing depth (PPD) was reported to be evident with recorded wear of opposing dentition which was
increased at mesial and distal sites more than the facial one in apparent at the 36-month follow-up.
the 36-month follow-up appointment with no statistically sig- The incidence of complications, whether biological or
nificant difference between both materials. A two-way ANOVA mechanical, in the present study was not statistically signifi-
test was performed to analyze the effect of site and material on cant [39]. One study [15] evaluated the clinical behavior of
PPD separately and illustrated statistically no significant effect complete-coverage crowns and FDPs on teeth with vertical
of changing the material (P = 0.186) while there was a statisti- preparation without finish line. The sample included a total
cally significant effect of changing the site (P = 0.001). of 149 teeth that were prepared vertically without finish line
with 0.5 mm prosthetic margin of zirconia. Two years after
treatment, vertical preparation without finish line produced
gingival thickening, margin stability, and optimal esthetics.
Discussion Neither crowns nor FPDs presented any mechanical compli-
cations which coincided with the current study.
For the restoration to be successful, principles of tooth prepa- Although there was some controversy in the literature, as
ration; esthetic, function, and biological should be applied to whether or not, sub-gingivally placed restoration’s mar-
and respected [9]. In this study, FDI criteria were used to gin may or may not adversely affect the periodontal clinical
evaluate these principles. The vertical preparation was per- parameters, it may reveal a detrimental effect on periodontal
formed to test whether zirconia and ZLS ceramics could health if not managed well [40]. Gingival recession is associ-
be used as esthetic crowns in very thin thickness [18]. The ated with several factors, including gingival biotype (qual-
esthetic principles depend mainly on selecting the appropri- ity and quantity of keratinized gingival tissue), iatrogenesis
ate material, color selection, and the emergence profile of during the dental preparation phase, chronic inflammation,
the restoration [36]. and inadequate prosthetic marginal fit. Several studies have
In this study, two high translucency ceramic materials indicated that sub-gingival restorations with a conventional
were selected to mimic translucency and shade of natural finish line are associated with periodontal inflammation and
teeth. Placing the margin sub-gingivally allowed achieving possible gingival recession [9, 12]. In a study to evaluate
an optimal emergence profile. Regarding surface luster and the influence of supra-gingival and sub-gingival margins on
staining, results showed that ZLS has higher surface luster periodontal health, Dhanraj et al. reported that both margins
and less staining than zirconia at 24- and 36-month follow- similarly influence the periodontal health regarding plaque
up. This could be attributed to the loss of zirconia surface accumulation and gingival health status but an increase in
glaze with subsequent surface roughness and also this was pocket depth was observed with sub-gingival margins [41].

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1586 Clinical Oral Investigations (2023) 27:1577–1588

The present study obtained good gingival health out- this protocol is a viable procedure; however, it was recom-
comes in terms of pocket depth, inflammation, and bleed- mended to advocate longer follow-up studies.
ing on probing for both materials throughout the evalua- Vertical preparation technique is complex and clinically
tion period. As already mentioned in the results, PPD was more time-consuming. Moreover, situating the line of the
reported to be increased at mesial and distal sites more than prosthetic margin adequately is difficult because there
the facial one in the 36-month follow-up appointment with is no definitive finish line exists. Also, there is a risk of
no statistically significant difference between both materials. uncontrolled invasion of the sulcus if performed by little
This finding could be related to patient’s difficulty to clean experience dentist or technician. Excess cement was also
effectively the interproximal surfaces, as compared to the difficult to be removed. The technique has not been backed
facial one. Furthermore, the restorative procedures—i.e., by scientific evidence, and not enough research is avail-
preparation, impression, and removal of luting agent’s excess able [46–48]. The relationship between the gingival bio-
are more difficult in these areas. It has been demonstrated type and the clinical outcome could not be established by
that restorations with sub-gingival margins can contribute to the present study. The results of the present study may be
plaque accumulation, especially in areas that are hard to be considered preliminary, as bigger sample size and longer
efficiently treated with scaling instruments [12]. observational periods are probably needed to establish
Agustín-Panadero et al. [42] evaluated the clinical, possible unidentified correlations between the examined
mechanical, and biological behavior of posterior 3-unit parameters.
FPDs placed on teeth prepared with BOPT. Forty partici-
pants received a 3-unit zirconia FPD in the posterior region
of the mandible or maxilla. Twenty FPDs were placed on
teeth prepared with BOPT (study group) and 20 on teeth Conclusions
with a horizontal chamfer finishing line (control group).
After the 5-year follow-up, in the analysis of PPD, 26.3% of Under the conditions of this study, the following conclusions
teeth in the control group had pockets of more than 3 mm were drawn:
in depth, whereas the BOPT group had only 10%. It was
reported that posterior FPDs prepared by using BOPT had (1) Zirconia and ZLS could be used as a material for resto-
a good clinical response over a 5-year follow-up, with a low ration of teeth prepared with vertical preparation tech-
gingival index, a small increase in pocket depth, and a 100% nique.
marginal stability of the surrounding tissues. High survival (2) Both ceramic materials achieved good esthetic results,
rates after 5 years indicated that the technique produced pre- promotes healthy and stable soft tissues with no
dictable outcomes. mechanical complications after three years clinical
According to the technique used in this study, the bio- evaluation.
logical width violation is practically not possible as the non-
working tip of the special bur is calibrated so that not touch-
ing the first millimeter of the root where the connective
tissue enters the cementum. Furthermore, the usage of a
Author contribution Study design: AK, ME, AS. Experiments and
smaller tip permits a rotary curettage of the sulcus epithe- data analyses: AK, ME, AS. Drafted the manuscript: AK. Reviewed
lium with little or no bleeding and a quicker healing [43, the manuscript: ME, AS, MO. All authors have read and approved the
44]. The interim crowns were used to direct the remodeling final manuscript.
of gingiva through over-contouring or under-contouring to
Funding Open access funding provided by The Science, Technology &
increase the gingival thickness [45]. The margins of res- Innovation Funding Authority (STDF) in cooperation with The Egyp-
torations were designed to be with minimal thickness and tian Knowledge Bank (EKB).
extended only 0.5 to 1 mm sub-gingival to prevent violation
of biological width and recession of gingiva. Data availability The datasets used and/or analyzed during the current
study available from the corresponding author on reasonable request.
The clinical success and survival of zirconia crowns fab-
ricated with vertical margins were evaluated previously [8]. Declarations
Results suggested that for zirconia crowns, vertical margins
allowed clinical performance similar to that reported with Competing interests The authors declare no competing interests.
other margin designs but with less invasive preparations
Ethics approval All procedures performed in studies involving human
which coincided with the current study. The periodon- participants were in accordance with the ethical standards of the insti-
tal response of periodontally healthy teeth restored using tutional and/or national research committee and with the Helsinki Dec-
vertical preparation combined with a light rotary curet- laration and its later amendments or comparable ethical standards. The
tage (gingitage) was evaluated [33]. Results suggested that

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Clinical Oral Investigations (2023) 27:1577–1588 1587

research protocol was approved by Dental Research Ethics Committee preparation design in the posterior region. J Prosthet Dent
in Mansoura University (05060218/2018), prior to patient enrollment. 115:678–683. https://​doi.​org/​10.​1016/j.​prosd​ent.​2015.​10.​007
11. Hasanzade M, Sahebi M, Zarrati S, Payaminia L, Alikhasi M
Informed consent Informed consent was obtained from all individual (2021) Comparative evaluation of the internal and marginal adap-
participants included in the study. tations of CAD/CAM endocrowns and crowns fabricated from
three different materials. Int J Prosthodont 34:341–347. https://​
doi.​org/​10.​11607/​ijp.​6389
Conflict of interest The authors declare no competing interests.
12 Paniz G, Nart J, Gobbato L, Chierico A, Lops D, Michalakis
K (2016) Periodontal response to two different subgingival
Open Access This article is licensed under a Creative Commons Attri-
restorative margin designs: a 12-month randomized clinical
bution 4.0 International License, which permits use, sharing, adapta-
trial. Clin Oral Investig 20:1243–1252. https://​doi.​org/​10.​1007/​
tion, distribution and reproduction in any medium or format, as long
s00784-​015-​1616-z
as you give appropriate credit to the original author(s) and the source,
13. Agustín-Panadero R, Loi I, Fernández-Estevan L, Chust C, Rech-
provide a link to the Creative Commons licence, and indicate if changes
Ortega C, Pérez-Barquero JA (2020) Digital protocol for creating
were made. The images or other third party material in this article are
a virtual gingiva adjacent to teeth with subgingival dental prepa-
included in the article's Creative Commons licence, unless indicated
rations. J Prosthodont Res 64:506–514. https://​doi.​org/​10.​1016/j.​
otherwise in a credit line to the material. If material is not included in
jpor.​2019.​10.​006
the article's Creative Commons licence and your intended use is not
14 Solá-Ruiz M, Del Rio HJ, Labaig-Rueda C, Agustín-Panadero R
permitted by statutory regulation or exceeds the permitted use, you will
(2017) Biologically oriented preparation technique (BOPT) for
need to obtain permission directly from the copyright holder. To view a
implant-supported fixed prostheses. J Clin Exp Dent 9:603–607.
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
https://​doi.​org/​10.​4317/​jced.​53703
15 Agustín-Panadero R, Serra-Pastor B, Fons-Font A, Sola-Ruiz M
(2018) Prospective clinical study of zirconia full-coverage resto-
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