FUNDAMENTAL

RESEARCH
Evaluating the Accuracy of Dental Restorations
Manufactured by Two CAD/CAM Milling
Systems and Their Prototypes Fabricated by
3D Printing Methods: An In Vitro Study
Ali Alenezi, BDS, MDS, PhD
Mohammed Yehya, DDS, MSc
Department of Prosthodontics, College of Dentistry, Qassim University, Buraydah, Saudi Arabia.

Purpose: This in vitro study was conducted to evaluate the marginal accuracy of all-ceramic onlay restorations
and prototypes fabricated using additive and subtractive methods. Materials and Methods: Ten typodont
first molars were prepared and scanned two times using two different scanners: ARCTICA AutoScan (KaVo
Dental) and CEREC Omnicam (Dentsply Sirona). The two groups of virtual models were used to design two
groups of virtual onlay restorations using two different CAD software (n = 10 each group) and exported in
STL files. Each group of STL files was converted to physical onlay restorations and prototypes by using three
different methods; these included two additive manufacturing techniques, stereolithography apparatus (SLA)
and digital light processing (DLP), and one subtractive technique, e.max milling using the KaVo Everest system
and the Dentsply Sirona inLab MC X5. A digital microscope was used to evaluate the marginal fit around
the onlay restorations or prototypes on the typodont teeth. Results: All evaluated groups showed mean
marginal gaps between 59 and 84 µm. No statistically significant differences were found when comparing
the marginal accuracy of onlay restorations fabricated by the subtractive method and onlay prototypes
from the two additive methods, SLA (P = .70) and DLP (P = .21). Conclusion: All the models evaluated
produced marginal gaps within the reported acceptable clinical range. Thus, these subtractive and additive
methods may be considered suitable for onlay restoration production. Int J Prosthodont 2023;36:293–300.
doi: 10.11607/ijp.7633

D
ental science has continued to explore new technologies with the aim to im-
prove the quality of treatment and minimize time and costs.1 In recent years,
researchers have extensively investigated digital methods like CAD/CAM to
enhance the restoration fabrication process.2 From a clinical perspective, CAD/CAM
technology allows scanning of the tooth surface before converting the data into signals
for computer-assisted milling, which helps produce highly accurate restorations. This
technology permits easy processing and handling in dental practice.3 Correspondence to:
CAD/CAM systems today manufacture dental restorations using either a subtractive Dr Ali Alenezi
method (SM) or an additive method (AM). These approaches are favored over the Department of Prosthodontics
Qassim University
lost-wax technique, which is used routinely to fabricate the metal supporting layer College of Dentistry
of porcelain-fused-to-metal restorations.4 For both SM and AM, the fabrication of a PO Box 6700
restoration starts by using a specific scanner to produce 3D stereoscopic images. The Buraydah Qassim 51452
Saudi Arabia
stereoscopic images are then arranged to support 3D modeling.5 Email: [email protected]
For SMs, the restoration fabrication process uses sharp rotary instruments that
cut a block of material into the desired tooth-shaped prosthesis.6 The block can be Submitted February 13, 2021;
accepted June 16, 2021.
made of different restorative materials used routinely in dentistry, such as zirconia ©2023 by Quintessence
and resin.7 Thus, the freedom to choose the material to use makes the SM the most Publishing Co Inc.

Volume 36, Number 3, 2023 293

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Fundamental Research

used CAD/CAM system. However, one major limitation These CAD/CAM techniques and their progressive
of SMs is the excessive amount of material discarded development have become an important topic in den-
to produce the final prosthesis.8 In their study, Strub et tistry today. However, several studies of these techniques
al reported that around 90% of the starting material is have revealed some variations in the reported values of
wasted to fabricate the prosthesis using SM.9 The dis- marginal fit.25,26 Thus, more investigation is needed to
carded materials cannot be reused, which could present evaluate their clinical acceptability. This study aimed to
environmental and economic problems.10 evaluate in vitro the accuracy of restorations fabricated
Thus, additive manufacturing has emerged to over- using one SM (milling) and two AMs (3D printing), SLA
come some limitations of SMs. The terms “3D printing” and DLP. The null hypothesis for this study was that onlay
and “rapid prototyping technology” are routinely used to restorations fabricated from these SMs and AMs would
refer to machines that use AMs.7,10 For these methods, show equal values for marginal fit.
the material for the restoration begins as a powder or
a liquid. Then, additive manufacturing builds the object MATERIALS AND METHODS
one layer at a time until it reaches the desired shape.
These methods do not produce excess material that must In a standard working model (Frasaco) with interchange-
be discarded, since only the desired parts are produced.11 able hard resin teeth, 10 all-ceramic onlay restorations
The manufacturing techniques based on AM include were prepared on defect-free typodont mandibular left
stereolithography apparatus (SLA) and digital light pro- first molars. The all-ceramic onlay was prepared through
cessing (DLP). In SLA, a light-sensitive polymer is cured occlusal reduction of approximately 4 mm, along with
layer by layer by a scanning laser beam in a vat of liquid the removal of the mesiobuccal cusp, while preparing
polymer.12 In DLP, a liquid resin is cured layer by layer by the internal axial walls with the recommended angle of
a projector (a high-power LED source), and the object divergence (between 6 and 10 degrees). In addition,
is built upside down on an incrementally elevating plat- all internal line angles were rounded. The resin teeth
form.12 These methods require the formation of virtual were finished with a smooth carbide finishing bur and
3D models using stereoscopic images.13 Moreover, all polished with a nylon brush and a low-speed handpiece
the data from this process is saved in stereolithography polishing paste.
format, which will be used for prosthesis fabrication The 10 prepared teeth were fixed and then scanned
later.5 Researchers have found DLP to be more precise using a high-resolution optical surface blue-light scanner
than SLA after assessing dental models printed with (ARCTICA AutoScan, KaVo Everest CAD/CAM system)
these techniques, although the SLA technique yielded to generate 10 3D files of the virtual teeth. The same
higher trueness than DLP for tooth measurements and prepared teeth were scanned using an intraoral scanner
arch measurements.14 Dikova et al found that both SLA (CEREC Omnicam, Dentsply Sirona) to create another set
and DLP technologies can be used for manufacturing of 10 3D files. The scanners were calibrated according to
polymeric dental restorations.15 the manufacturer’s instructions and optimized in a fully
Regardless of the method of fabrication, accuracy is the automated fashion. Their average error was 0.006 mm
main element to consider before cementing dental res- in the sphere-spacing error test. The resolution was set
torations.16 Having said this, dental restorations with an to minimize stair stepping. Figure 1 presents a summary
accurate marginal fit are the outcome of multiple digital of all evaluated groups and the methods used for onlay
workflows.17 The marginal fit of restorations fabricated restoration fabrication.
using CAD/CAM technology is influenced by such fac- Based on the scanned files, the onlay restorations were
tors as the cutting instrument size, milling unit precision, designed using two CAD software programs with a 50-μm
digital cast rendering, and image capturing system.17 gap for the cement film: (1) KaVo MultiCAD Dental DB
Numerous reports have shown that an inadequate fit and (2) Dentsply Sirona inLab 15.1 (Fig 2). They were then
can facilitate the accumulation of plaque, which can lead exported in standard tessellation language (STL) format.
to marginal discoloration or even secondary caries.18–20 The STL files of the onlay restorations were converted
Furthermore, the gaps created from an inadequate fit into physical models using three methods: the two 3D
have a great risk of microleakage or even marginal chip- printing (additive) techniques, SLA and DLP, and the mill-
ping of the ceramic restoration.21 Some studies have ing (subtractive) technique. The two different 3D printing
claimed it would be difficult to remove excess cement technologies were used for the remaining subgroups:
when the marginal gap exceeds 100 μm, which can lead SLA using a Form 2 (Formlabs) printer and DLP using an
to late clinical failure for dental restorations.22 In one Asiga MAX UV printer. The milling (subtractive) method
review, Kosyfaki et al found a strong correlation between for the all-ceramic e.max onlay restorations was used
marginal fit and gingival inflammation.23 Thus, marginal with the KaVo Everest Engine milling machine and the
adaptation plays an important role in the long-term suc- Dentsply Sirona inLab MC X5 milling machine. The two
cess of dental restorations.24 types of 3D printing software processed the STL file by

294 The International Journal of Prosthodontics

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Alenezi/Yehya

Fig 1   Diagram show-

ing onlay restoration
fabrication process for Preparation Scanning Designing Fabrication method
all evaluated groups.

SLA using Form 2 printer, Formlabs

ARCTICA AutoScan, KaVo KaVo, MultiCAD DLP using Asiga MAX UV printer
Everest CAD/CAM system Dental DB software
Milling using KaVo,
Everest Engine milling machine
Onlay
restoration
design
SLA using Form 2 printer, Formlabs

CEREC Omnicam, Dentsply Sirona, DLP using Asiga MAX UV printer

Dentsply Sirona inLab 15.1 software
Milling using Dentsply Sirona
inLab MC X5 milling machine

Fig 2  (a) Virtual image of inLab software

showing the prepared area with the occlusal
view and the path of insertion of the onlay
restoration. (b) Virtual image of onlay resto-
ration including the block selection.

Volume 36, Number 3, 2023 295

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Fundamental Research

Fig 3  The selected spots for marginal fit

analysis.

Fig 4  Microscopic photograph at high

magnification showing marginal gap mea-
surement at one of the predetermined spots.
85 µm

500 µm

generating slices of the onlay restorations. The first layer measured marginal gaps between all subgroups scanned
of the physical prototype was created followed by the using the two main light scanners (KaVo and Dentsply
successive layers. This process was repeated until the Sirona). The Mann-Whitney U test was used to compare
whole onlay restoration was fabricated. the detected marginal gap values within the same group
To evaluate the marginal accuracy, the restorations fabricated using the milling (subtractive) technique and
were seated on the prepared typodont teeth using fin- the two 3D printing (additive) techniques. The signifi-
ger pressure. All of 60 specimens were evaluated at six cance level was set at P = .05. All data were plotted as
previously determined spots for marginal fit analysis mean ± standard deviation.
(Fig 3) using direct measurement without cementation
or sectioning the samples. All of the spots that were RESULTS
designated to be examined were imaged through direct
viewing at high magnification using a digital microscope Regardless of the scanning systems used in the manu-
with a micro-ruler. The margins analyses were conducted facturing methods, all of the evaluated groups showed
using ImageJ software (Fig 4). mean marginal gaps from 59 to 84 µm with no statisti-
cally significant differences when comparing all groups.
Statistical Analysis The groups scanned using the Dentsply Sirona inLab
The nonparametric Kruskal-Wallis test (SPSS Statistics showed a P value of .079 while the groups scanned using
v 22, IBM) was used to evaluate the differences in the the KaVo MultiCAD Dental DB showed a P value of .054.

296 The International Journal of Prosthodontics

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Alenezi/Yehya

Dentsply Sirona, inLab 15.1 software

KaVo, MultiCAD Dental DB software

Average marginal gap (µm)

120
Average marginal gap (µm)

Average marginal gap (µm)

100 100 100 P = .70 P = .21

80 80 80
60 60 60
40 40 40
20 20 20
0 0 0
Group 1 Group 2 Group 3 Group 1 Group 2 Group 3 Group 2 Group 3
Sirona, 3D 3D KaVo, 3D 3D 3D printing 3D printing
zirconia printing printing press printing printing Formlabs Asiga
milling Formlabs Asiga Formlabs Asiga

Fig 5  Average marginal gaps mea- Fig 6  Average marginal gaps measured Fig 7  Average marginal gaps measured
sured among the subgroups scanned us- among the subgroups scanned using KaVo within the restorations according to the 3D
ing Dentsply Sirona, inLab 15.1 software MultiCAD Dental DB software (P = .054). printing technique used.
(P = .079).

Figures 5 and 6 outline the results of the marginal gap for cement film. Some reports claimed that a cement
assessment of the examined onlay restorations accord- space greater than 30 µm improves the marginal fit.30
ing to the manufacturing methods, which showed no In addition, finger pressure without cementation was
significant differences between all groups. In addition, used to obtain good adaptation of onlays during the
no significant differences were found in the comparison evaluation of marginal fit. Cementation can influence
between marginal gaps measured in the subgroups with the accuracy of the adaptation due to variations in ce-
the same 3D technology used (Fig 7). mentation techniques.30
The onlays from all of the scanners evaluated had the
DISCUSSION same degree of marginal gaps. Overall, the measured
gaps, as measured with these scanners and 3D printers,
Recent applications of digital technology in the dental ranged from 59 to 84 µm, which is in accordance with
field have produced dramatic changes that have taken the values reported in the literature.17,31 Nevertheless, a
the clinical process to a different level. One of the main comparison of onlay gap measurements obtained from
developments combines 3D printing and CAD/CAM the usage of different scanning and fabrication meth-
technology, which are thought to improve productiv- ods must be done carefully. In the literature, there is no
ity and allow the fabrication of complex restorations.12 agreement about the amount of marginal discrepancy
Numerous reports have revealed good outcomes when that is acceptable in clinical settings. Many studies have
fabricating dental restorations using these technolo- suggested that the marginal gap should not exceed
gies.27–29 However, even when proper procedures are 120 µm to be clinically acceptable for a long-term fixed
followed during the preparation and cementation stages, dental prosthesis.25,31 Thus, the gaps produced by all
the potential for leaving small gaps between the surface the tested subgroups were within this acceptable range.
of the tooth and the restoration remains a challenge. Evaluation of the gaps was based on six reference
In this study, the authors evaluated the marginal fit points selected at different angles. Gaps around the
and precision of dental onlay models fabricated by dif- onlay margins were measured by viewing them directly
ferent types of CAD/CAM and 3D printers. The null at high magnification using a digital microscope. Di-
hypothesis of the study, which stated that the evalu- rect viewing is believed to be an easy and nondestruc-
ated subtractive and additive methods used for onlay tive method of measurement, since it does not require
fabrication would exhibit similar degrees of marginal fit, special instruments or software.19,31 Thus, it could be
was accepted, since there were no statistical differences considered an applicable method for use in clinical set-
among the marginal fit values of the methods evaluated. tings. One potential limitation of this method is that
This study involved the analysis of samples of actual the spots selected for gap measurements might not
dental onlays, since they have a more complex geometry be truly representative of the entire marginal fit of the
than full crowns. The CAD/CAM software used to design restoration.31 In addition, it was not possible to examine
the onlay restoration features a gap of about 50 µm the internal fit using this method, so internal fit was not

Volume 36, Number 3, 2023 297

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Fundamental Research

evaluated.32 Several studies have evaluated the use of available for printing. These differences make it difficult
silicone replicas to evaluate marginal and internal fit.33,34 to equitably compare the results of published studies.
The replica technique has been used widely because it However, some reports have claimed that AM technol-
allows evaluation of the internal marginal gaps within ogy applied in 3D printers shows better outcomes for
different regions of the restoration.35 complex geometry compared to subtractive methods.47
Numerous studies have applied 3D analysis to assess In this study, two 3D printer systems were evaluated:
marginal fit.36,37 It is believed that 3D analysis can mea- the Form 2 by Formlabs and the Asiga MAX UV. The
sure a large number of spots, which increases reliability Formlabs 3D printer is based on SLA technology, while
and provides more representative measurements. A com- the Asiga system uses DLP technology. These two tech-
mon 3D method used to assess marginal fit is the triple- niques have been investigated extensively in the litera-
scan protocol. This protocol includes the measurement ture, and they are believed to be the most common
of many spots, although some studies showed lower 3D technologies used for dental applications. In the
data dispersion using this method.38,39 Some other 3D SLA technique, a UV laser creates complex shapes by
methods used to assess marginal fit are digital calipers localized polymerization with high feature resolution.
and American Board of Orthodontics cast-radiograph Among SLA models, Formlabs printers were clinically
analysis tools.40 examined numerous times, and they yielded acceptable
The two methods of manufacturing evaluated in this outcomes.46 Other SLA printers were associated with
study (additive and subtractive) are based on a sophisti- errors that affected their accuracy.40,48 The risk of er-
cated digital workflow.17 Thus, the marginal fit of onlays rors with repeated printing is believed to be lower with
is an outcome of several digital processes. Meanwhile, the DLP technique since it cures the restoration material
the authors did not compare fabrication methods using layer by layer. Some reports also claimed that the DLP
the same technology or resolution. The methods that technique is faster and more precise than the SLA tech-
were evaluated in this study (CAD/CAM and two 3D nique. In the end, it is known that different factors can
printers) are commonly used in the field of digital dental influence the accuracy of printed restorations, including
technology for diagnostic and manufacturing purposes. laser speed, building angulation and direction, and the
For 3D printers, the manufacturers’ instructions indicate number of layers used in the fabrication process.
that about 3 hours of printing time is required for a pair The evaluation in this study was a comparison of the
of dental models, depending on the type of 3D printing.1 marginal fit of onlay restorations and prototypes scanned
With CAD/CAM technology, the precision of the mill- with two scanning systems, the CEREC Omnicam and the
ing unit is believed to have an important role in the KaVo Everest, before the fabrication process. According
accuracy of the marginal fit.41 In general, most of the to the present evaluation, the scanning systems did not
other factors that determine the accuracy of restorations appear to affect the accuracy of the fabricated samples.
are also associated with CAD/CAM machines, such as Amin et al49 compared the accuracy of digital impression
the type of image capturing system and the size of the obtained by the CEREC Omnicam with conventional im-
cutting instrument.41,42 The two methods of subtractive pressions. They found that the CEREC Omnicam yielded
manufacturing used in this study—Everest (KaVo) and impressions that were significantly more accurate when
MC X5 inLab (Dentsply Sirona)—are both well known compared to conventional impressions. As for the KaVo
in the dental market and have been in clinical use for scanner, one study reported a relatively low rate of ac-
years. Of the similarities between these systems, the curacy and some degree of distortion compared to other
most important is the five-axis milling unit. This type of laboratory scanners.50
milling unit has better cutting characteristics than the In summary, this study found no scientific differences
three-axis unit.30 The additional axes enhance milling in accuracy among CAD/CAM and 3D printer systems
efficiency and precision.43 The five-axis units use the commonly used for fabricating dental onlay prototypes.
additional axes to access complex parts of restorations Only some of the commonly used fabrication meth-
that would be difficult to reach with three-axis units. ods were evaluated in this study. Future studies should
Five-axis milling has also been reported to improve sur- evaluate additional digital technologies that have fewer
face texture and finish.24 differences in characteristics and processing methods,
As with CAD/CAM machines, the characteristics of allowing for a fairer comparison.
3D printers play a crucial role in determining restoration
accuracy.44 Each manufacturer equips their 3D printers CONCLUSIONS
with specific characteristics and resolution levels. Most
3D printers designed for dental applications are associ- Within the limitation of this study, no statistically sig-
ated with various laser speeds, building directions, and nificant differences were found when comparing the
numbers of layers.45,46 Additional variations between marginal accuracy of onlay restorations fabricated by
printers include the technology used and the materials the subtractive (milling) method and onlay prototypes

298 The International Journal of Prosthodontics

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Alenezi/Yehya

fabricated using two additive methods (3D printing): SLA 18. Syrek A, Reich G, Ranftl D, Klein C, Cerny B, Brodesser J. Clinical evalu-
and DLP. All of the models evaluated produced marginal ation of all-ceramic crowns fabricated from intraoral digital impres-
sions based on the principle of active wavefront sampling. J Dent
gaps within the reported acceptable clinical range. Thus, 2010;38:553–559.
these subtractive and additive methods should be con- 19. Contrepois M, Soenen A, Bartala M, Laviole O. Marginal adaptation of
sidered suitable for onlay restoration production. ceramic crowns: A systematic review. J Prosthet Dent 2013;110:447–
454.e10.
20. Kim DY, Kim JH, Kim HY, Kim WC. Comparison and evaluation of
ACKNOWLEDGMENTS marginal and internal gaps in cobalt-chromium alloy copings fabri-
cated using subtractive and additive manufacturing. J Prosthodont Res
2018;62:56–64.
The authors thank Dr Walaa Babeer and Dr Abdulaziz Algifari for their 21. Stappert CF, Chitmongkolsuk S, Silva NR, Att W, Strub JR. Effect of
effort in producing the 3D models. The authors declared that there mouth-motion fatigue and thermal cycling on the marginal accuracy
are no conflicts of interest. of partial coverage restorations made of various dental materials. Dent
Mater 2008;24:1248–1257.
22. Witkowski S, Komine F, Gerds T. Marginal accuracy of titanium cop-
REFERENCES ings fabricated by casting and CAD/CAM techniques. J Prosthet Dent
2006;96:47–52.
1. Beuer F, Schweiger J, Edelhoff D. Digital dentistry: An overview of 23. Kosyfaki P, del Pilar Pinilla Martín M, Strub JR. Relationship between
recent developments for CAD/CAM generated restorations. Br Dent J crowns and the periodontium: A literature update. Quintessence Int
2008;204:505–511. 2010;41:109–126.
2. Sousa MV, Vasconcelos EC, Janson G, Garib D, Pinzan A. Accuracy and 24. Goujat A, Abouelleil H, Colon P, et al. Marginal and internal fit of CAD-
reproducibility of 3-dimensional digital model measurements. Am J CAM inlay/onlay restorations: A systematic review of in vitro studies. J
Orthod Dentofacial Orthop 2012;142:269–273. Prosthet Dent 2019;121:590–597.e3.
3. Ritzberger C, Apel E, Höland W, Peschke A, Rheinberger VM. Properties 25. Neves FD, Prado CJ, Prudente MS, et al. Micro-computed tomography
and clinical application of three types of dental glass-ceramics and ce- evaluation of marginal fit of lithium disilicate crowns fabricated by using
ramics for CAD-CAM technologies. Materials (Basel) 2010;3:3700–3713. chairside CAD/CAM systems or the heat-pressing technique. J Prosthet
4. Willer J, Rossbach A, Weber HP. Computer-assisted milling of dental Dent 2014;112:1134–1140.
restorations using a new CAD/CAM data acquisition system. J Prosthet 26. Boitelle P, Mawussi B, Tapie L, Fromentin O. A systematic review of CAD/
Dent 1998;80:346–353. CAM fit restoration evaluations. J Oral Rehabil 2014;41:853–874.
5. Al Mortadi N, Eggbeer D, Lewis J, Williams RJ. CAD/CAM/AM applica- 27. Zaharia C, Gabor AG, Gavrilovici A, et al. Digital dentistry–3D printing
tions in the manufacture of dental appliances. Am J Orthod Dentofacial applications. J Int Med 2017;2:50–53.
Orthop 2012;142:727–733. 28. Joo HS, Park SW, Yun KD, Lim HP. Complete-mouth rehabilitation using
6. Tapie L, Lebon N, Mawussi B, Fron-Chabouis H, Duret F, Attal JP. Under- a 3D printing technique and the CAD/CAM double scanning method: A
standing dental CAD/CAM for restorations—Accuracy from a mechani- clinical report. J Prosthet Dent 2016;116:3–7.
cal engineering viewpoint. Int J Comput Dent 2015;18:343–367. 29. Kale E, Seker E, Yilmaz B, Özcelik TB. Effect of cement space on the mar-
7. Bidra AS, Taylor TD, Agar JR. Computer-aided technology for fabricating ginal fit of CAD-CAM-fabricated monolithic zirconia crowns. J Prosthet
complete dentures: Systematic review of historical background, current Dent 2016;116:890–895.
status, and future perspectives. J Prosthet Dent 2013;109:361–366. 30. Hamza TA, Ezzat HA, El-Hossary MM, Katamish HA, Shokry TE, Rosen-
8. Kim KB, Kim JH, Kim WC, Kim JH. Three-dimensional evaluation of gaps stiel SF. Accuracy of ceramic restorations made with two CAD/CAM
associated with fixed dental prostheses fabricated with new technolo- systems. J Prosthet Dent 2013;109:83–87.
gies. J Prosthet Dent 2014;112:1432–1436. 31. Dolev E, Bitterman Y, Meirowitz A. Comparison of marginal fit between
9. Strub JR, Rekow ED, Witkowski S. Computer-aided design and fabrica- CAD-CAM and hot-press lithium disilicate crowns. J Prosthet Dent
tion of dental restorations: Current systems and future possibilities. J Am 2019;121:124–128.
Dent Assoc 2006;137:1289–1296. 32. Balkaya MC, Cinar A, Pamuk S. Influence of firing cycles on the
10. Ford S, Despeisse M. Additive manufacturing and sustainability: An ex- margin distortion of 3 all-ceramic crown systems. J Prosthet Dent
ploratory study of the advantages and challenges. J Cleaner Production 2005;93:346–355.
2016;137:1573–1587. 33. Kohorst P, Brinkmann H, Dittmer MP, Borchers L, Stiesch M. Influence
11. Khan M, Dickens P. Selective laser melting (SLM) of pure gold for manu- of the veneering process on the marginal fit of zirconia fixed dental
facturing dental crowns. Rapid Prototyping J 2014;20:471–479. prostheses. J Oral Rehabil 2010;37:283–291.
12. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in 34. Torabi K, Vojdani M, Giti R, Taghva M, Pardis S. The effect of various
dentistry. Br Dent J 2015;219:521–529. veneering techniques on the marginal fit of zirconia copings. J Adv
13. Palazzo G, Ronsivalle V, Oteri G, et al. Comparison between additive Prosthodont 2015;7:233–239.
and subtractive CAD-CAM technique to produce orthognathic surgical 35. Colpani JT, Borba M, Della Bona Á. Evaluation of marginal and internal fit
splints: A personalized approach. J Pers Med 2020;10:273. of ceramic crown copings. Dent Mater 2013;29:174–180.
14. Kim SY, Shin YS, Jung HD, Hwang CJ, Baik HS, Cha JY. Precision and 36. Matta RE, Schmitt J, Wichmann M, Holst S. Circumferential fit assess-
trueness of dental models manufactured with different 3-dimensional ment of CAD/CAM single crowns—A pilot investigation on a new virtual
printing techniques. Am J Orthod Dentofacial Orthop 2018;153:144–153. analytical protocol. Quintessence Int 2012;43:801–819.
15. Dikova TD, Dzhendov DA, Ivanov D, Bliznakova K. Dimensional accuracy 37. Boitelle P, Tapie L, Mawussi B, Fromentin O. Evaluation of the marginal fit
and surface roughness of polymeric dental bridges produced by different of CAD-CAM zirconia copings: Comparison of 2D and 3D measurement
3D printing processes. Arch Mater Sci Eng 2018;2:65–75. methods. J Prosthet Dent 2018;119:75–81.
16. Mously HA, Finkelman M, Zandparsa R, Hirayama H. Marginal and 38. Schaefer O, Decker M, Wittstock F, Kuepper H, Guentsch A. Impact of
internal adaptation of ceramic crown restorations fabricated with digital impression techniques on the adaption of ceramic partial crowns
CAD/CAM technology and the heat-press technique. J Prosthet Dent in vitro. J Dent 2014;42:677–683.
2014;112:249–256. 39. Park JM, Hämmerle CHF, Benic GI. Digital technique for in vivo assess-
17. Duqum IS, Brenes C, Mendonca G, Carneiro TAPN, Cooper LF. Marginal ment of internal and marginal fit of fixed dental prostheses. J Prosthet
fit evaluation of CAD/CAM all ceramic crowns obtained by two digital Dent 2017;118:452–454.
workflows: An in vitro study using micro-CT technology. J Prosthodont 40. Loflin WA, English JD, Borders C, et al. Effect of print layer height on
2019;28:1037–1043. the assessment of 3D-printed models. Am J Orthod Dentofacial Orthop
2019;156:283–289.
41. Bosch G, Ender A, Mehl A. A 3-dimensional accuracy analysis of chair-
side CAD/CAM milling processes. J Prosthet Dent 2014;112:1425–1431.

Volume 36, Number 3, 2023 299

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Fundamental Research

42. Alghazzawi TF. Advancements in CAD/CAM technology: Options for 47. Galante R, Figueiredo-Pina CG, Serro AP. Additive manufacturing of ce-
practical implementation. J Prosthodont Res 2016;60:72–84. ramics for dental applications: A review. Dent Mater 2019;35:825–846.
43. Alajaji NK, Bardwell D, Finkelman M, Ali A. Micro-CT evaluation of 48. Zhang ZC, Li PL, Chu FT, Shen G. Influence of the three-dimensional
ceramic inlays: Comparison of the marginal and internal fit of five and printing technique and printing layer thickness on model accuracy. J
three axis CAM systems with a heat press technique. J Esthet Restor Orofac Orthop 2019;80:194–204.
Dent 2017;29:49–58. 49. Amin S, Weber HP, Finkelman M, El Rafie K, Kudara Y, Papaspyridakos
44. Rungrojwittayakul O, Kan JY, Shiozaki K, et al. Accuracy of 3D printed P. Digital vs. conventional full-arch implant impressions: A comparative
models created by two technologies of printers with different designs of study. Clin Oral Implants Res 2017;28:1360–1367.
model base. J Prosthodont 2020;29:124–128. 50. Pan Y, Tam JM, Tsoi JK, et al. Evaluation of laboratory scanner accuracy
45. Ishida Y, Miyasaka T. Dimensional accuracy of dental casting patterns by a novel calibration block for complete-arch implant rehabilitation. J
created by 3D printers. Dent Mater J 2016;35:250–256. Dent 2020;102:103476.
46. Favero CS, English JD, Cozad BE, Wirthlin JO, Short MM, Kasper FK. Ef-
fect of print layer height and printer type on the accuracy of 3-dimen-
sional printed orthodontic models. Am J Orthod Dentofacial Orthop
2017;152:557–565.

Literature Abstract

Single and Partial Tooth Replacement With Fixed Dental Prostheses Supported by Dental Implants: A Systematic Review of
Outcomes and Outcome Measures Used in Clinical Trials in the Last 10 Years
To evaluate outcome measures, methods of assessment, and analysis in clinical studies on fixed single- and multiple-unit implant
restorations. Three independent electronic database searches (MEDLINE, EMBASE, and Cochrane) were done to identify prospective and
retrospective clinical studies published from January 2011 up to June 2021 with ≥20 patients and minimum 1-year follow-up period on
technical and clinical outcomes of implant-supported single crowns (SCs) and partial fixed dental prostheses (P-FDPs). An entire data
extraction was performed to identify primarily the most reported outcome measures and later to define the choice of assessment methods
of those outcome measures. The outcomes were analysed descriptively, and the strength of association was evaluated using the Pearson
chi-square test (p ≤ .05). In a total 531 studies, 368 on SCs (69.3%), 70 on P-FDPs (13.1%), and 93 on both restoration types (17.5%)
were included; 56.3% of all studies did not clearly define a primary outcome. The most frequent primary outcome was marginal bone
level (MBL) (55.2%) followed by implant survival (5.3%), professional aesthetic evaluation (3.4%), and technical complications (2.1%).
Peri-implant indices were the most reported secondary outcome (55.1%), followed by implant survival (39.9%), MBL (36%), and implant
success (26.4%). Prosthetic failure (seven studies [3.9%]) was one of the least reported outcome measures. Outcome measures and their
assessment methods showed high heterogeneity among studies. Primary outcomes were not often defined clearly, and the most frequently
selected primary outcome was marginal bone loss. Prosthetic outcomes, implant survival, and patient-related outcomes were only
infrequently reported.
Sailer I, Barbato L , Mojon P, Pagliaro U, Serni L, Karasan D, Cairo F. Clin Oral Implants Res 2023;34 Suppl 25:22-37. References: 26. Reprints: F Cairo:
[email protected]—Carlo Poggio, Italy

300 The International Journal of Prosthodontics

© 2023 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Copyright of International Journal of Prosthodontics is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.