RESEARCH AND EDUCATION

In vitro evaluation of marginal, axial, and occlusal

discrepancies in metal ceramic restorations produced
with new technologies

lu, DDS, PhD,a Halil _Ibrahim Kln, DDS, PhD,b Haydar Albayrak, DDS, PhD,c and

aog
Hasan Kocaag
Meryem Kara, MScd

One of the main goal in ABSTRACT

contemporary dentistry is to Statement of problem. Marginal and axial discrepancies of metal ceramic restorations are key to
produce an esthetic and func- their long-term success. Little information is available for metal ceramic restorations fabricated with
tional restoration, and metal soft metal milling and laser sintering technologies.
ceramic prostheses are still
Purpose. The purpose of this in vitro study was to compare the marginal, axial, and occlusal dis-
providing excellent service.1 crepancies in single-unit metal ceramic restorations fabricated with new production techniques
Various metal alloys have with those in a single-unit restoration fabricated using a conventional technique.
been used as metallic copings
Material and methods. After the articial tooth was prepared, impressions were made, and 40 dies
for the metal framework of
were obtained. Dies were randomly divided into 4 groups (n=10). Cobalt-chromium (Co-Cr) cast (C),
metal ceramic restorations.2 hard metal milled (HM), laser sintered (LS), and soft metal milled (SM) copings were fabricated.
The most commonly used Marginal, axial, and occlusal discrepancies of these copings were measured using the silicone
alloys are nickel-chromium replica technique before and after the application of veneering ceramic. Data were analyzed
(Ni-Cr) and cobalt-chromium with repeated measurements 2-way ANOVAs and Bonferroni post hoc tests (a=.05).
3,4
(Co-Cr). Beryllium (Be) has Results. Signicant differences were found in the increase of marginal discrepancy after the
been added to the Ni-Cr application of veneering ceramic in the LS group (P=.016). However, no signicant differences in
alloy in order to reduce the marginal discrepancy were found whether veneering ceramic was applied to copings before or
alloys melting temperature after in the other groups (P>.05). With regard to marginal and occlusal discrepancies, signicant
and to improve castability. 2 differences were found among the production techniques (P<.001 and P<.05, respectively). No
signicant differences in axial discrepancies were found among the groups (P>.05).
However, a Be-containing Ni
alloy releases Ni ions in Conclusion. This in vitro study showed that metal ceramic restorations produced with HM and
an acidic environment,5 and newly introduced SM techniques exhibited better marginal adaptations than those produced with
the released Ni ions may cause the LS or C technique. (J Prosthet Dent 2016;-:---)
allergic and toxic reactions.6
Co-Cr alloys have been used chiey as xed and metal frameworks or copings can be produced by casting
removable partial prosthesis frameworks, with Co providing (C),8-10 laser sintering (LS),9,11,12 hard metal milling (HM),13
hardness and Cr preventing corrosion and improving the and soft metal milling (SM).14 In dentistry, the casting
mechanical properties.2 As Co-Crebased alloys have fewer technique is still widely used to produce metal frameworks
side effects than Ni-Crebased alloys, they are an alternative or copings, and, although it has been well documented, it is
for patients with allergies to Ni-based alloys.7 Co-Cr complex and requires great technical skill.14

a
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Pamukkale University, Denizli, Turkey.
b
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Erciyes University, Kayseri, Turkey.
c
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Erciyes University, Kayseri, Turkey.
d
Specialist Dentist, Kbrs Sehitler Oral and Dental Health Center, Denizli, Turkey.

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Clinical Implications
Soft metal milling and laser sintering techniques
can serve as alternatives to the conventional cast
technique in the fabrication of metal ceramic
restorations.
The development of computer-aided design (CAD)
and computer-aided manufacturing (CAM) methods
have revolutionized the dental laboratory industry and
led to breakthroughs in restoration production.15-17 Kim
et al14 evaluated subtractive and additive techniques for
dental CAD/CAM. Subtractive techniques deal with the
milling of restorations from block-shaped materials,
whereas additive techniques rely on 3-dimensional
printing or sintering materials.11,12 Advantages of these
techniques are that the predesigned restorations can be
produced in a short time18 and that the fabrication of the
restorations can be standardized.19
Improvements have also been made in metal frame-
work production technologies.20 The milling process for
Co-Crebased alloys is difcult because of their hardness.2
Recently, presintered soft Co-Crebased metal alloy
blocks have been introduced to produce metal ceramic
restorations for metallic copings.2,14 This production
method has several advantages over HM techniques,
including the fact that less stress is applied to the milling
machine. Therefore, the lifetimes of the milling machine
and of the rotary cutting instruments are extended.14
Also, the milling time is reduced. The processing steps
in the fabrication of metal alloy blocks are comparable
with those in the production of zirconia blocks. After
milling, the milled metallic framework is sintered in an
argon gas atmosphere at high temperature, resulting in
approximately 11% shrinkage.2
LS is a new additive production technique in
dentistry14 and may replace casting for base metal al-
loys.21,22 It is based on a rapid prototyping method and
uses a high-temperature laser to produce 3-dimensional
metallic frameworks for CAD restoration software.21
When the laser is applied to the metal particles, they
melt, and the framework is gradually formed in layers by
repeating this process.23
Marginal adaptation is one of the factors that
determines the longevity of xed prostheses.24-26
McLean and von Fraunhofer27 reported that the
maximum clinically acceptable marginal discrepancy
value was 120 mm. Insufcient marginal adaptation can
cause periodontal diseases because of plaque accumula-
tion, increasing the risk of caries lesions and micro-
leakage.1,28 Studies have suggested that marginal
discrepancy is the most important factor in the success
and longevity of metal ceramic restorations.24,29 A study
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of 142 failed xed partial dentures reported that improper
marginal adaptation was the most important factor in the
failure.30
The t of metal ceramic frameworks may change after
the application of veneering ceramic because of frame-
work design, type of alloy, shrinkage of the ceramic
during ring, and different coefcients of thermal
expansion for ceramic and alloy.31-35
The purpose of this study was to evaluate the
marginal, internal, and occlusal adaptations of metal
ceramic restorations fabricated using different production
techniques before and after the application of veneering
ceramic. The rst null hypothesis was that no differences
would be found in the marginal adaptation of metal
copings produced using different techniques. The second
null hypothesis was that the application of veneering
ceramic would not affect the marginal adaptation of the
restorations.
MATERIAL AND METHODS
An articial maxillary right molar tooth (ANKA-4 Z;
Frasaco GmbH) with a circumferential deep chamfer
margin (approximately 1.2 mm in width) and occlusal
reduction of 1.5 to 2 mm was prepared according to the
preparation guidelines for metal ceramic restorations
(Fig. 1).36 Forty impressions were made with a polyvinyl
siloxane impression material (Variotime; Heraeus Kulzer
GmbH) in a custom-made tray to ensure uniform
thickness of the impression material and poured with a
Type IV dental stone (Fujirock EP; GC Corp).
Casts were numbered randomly using an electronic
research randomizer (www.randomizer.org). Using
the block randomization method, we assigned casts to
1 of 4 groups (n=10) according to the metal coping
production techniques (C, HM, LS, or SM). All metal
copings were designed and produced by an experienced
dental technician. The metal 0.5-mm coping thickness
and 30-mm cement space (0.5 mm from the margin) were
designed using CAD. Table 1 shows the coping materials
and their composition used in this study.
To produce the metal copings using the C technique,
10 specimens were scanned (3D Scanner; Dental Wings),
and digital images were transferred to a computer. The
metal copings were designed with software (DWOS-
CNB; Dental Wings). A wax coping was produced
(Alliance wax; Turkuaz Dental) using a CAM system
(DC40-series; Yenadent Ltd Co). Copings were seated on
the stone die, and margins were controlled under
magnication. Wax patterns were coated with surfactant
(Aurolm; Bego), allowed to dry for 3 minutes, and
invested (Bellavest SH; Bego). For wax elimination, the
specimens were placed in an oven (Midtherm 200 MP;
Bego). Temperature was increased from room tempera-
ture to 250 C at 5 C/min. After 50 minutes, the rate was

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Kocaag
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Figure 1. Prepared articial tooth.
increased by 7 C/min until a temperature of 900 C was
reached. The temperature was held for 60 minutes. After
the wax elimination, the Co-Cr alloy (Kera C; Eisen-
bacher Dentalwaren ED GmbH) was cast in an electric
induction furnace (INF-2010; Mikrotek Dental). The in-
vestment and sprues were removed with airborne-
particle abrasion with 125-mm aluminum oxide under
0.2 MPa pressure (MKK-975; Mikrotek Dental) and
carbide disks at low speed. Copings were steam cleaned
(Vap 6; Zhermack), dried with air, and adjusted to seat on
the dies.
To produce the metal copings with the HM technique,
10-specimens were scanned (3D Scanner; Dental Wings),
and the digital images were transferred to a computer.
The metal copings were designed using computer soft-
ware (DWOS-CNB; Dental Wings), and they were milled
from Co-Cr blocks (Kera Disc; Eisenbacher Dentalwaren
ED GmbH) using a CAM technique (DC40-series;
Yenadent Ltd Co). The copings produced were adjusted
and seated on the dies.
To produce the metal copings with the LS technique,
10 specimens were scanned (3D Scanner; EOS GmbH
Optical Systems), and the digital images were transferred
to a computer. The designed metal frameworks (CAM-
bridge; EOS GmbH) were produced using the EOSINT
M270 technique. They were fabricated using rapid pro-
totyping technology in which a high-precision, high-
energy laser (Yb ber laser of approximately 200 W with
compressed air of 7000 hPa) was used to melt a
controlled deposition of 20-mm-thick Co-Cr powder
(SP2; EOS GmbH).
To produce metal copings with the SM technique, 10
specimens were scanned, and digital images were
designed using CAD (Ceramill match 2; Amann Girr-
bach). The presintered Co-Cr blocks (Ceramill Sintron;

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Kocaag
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3
Table 1. Brand, manufacturer, lot number, and composition of coping
materials used in this study
Production Brand,
Technique Manufacturer Lot No Composition (wt%)
C Kera C, ED GmbH P14-81 Co, 58-62; Cr, 25; W, 9; V, 2; Nb, 2;
Fe, 1; Mo, 1; Si, <1; Al, <1; C, <1
HM Kera Disc, B 15-869 Co, 62; Cr, 28; W, 8.71; Si, 1.57;
ED GmbH Fe, <1.0; C,<1.0; Mn, <1.0
LS SP2, EOS GmbH H371501 Co, 62-66; Cr, 24-26; Mo, 5-7;
W, 4-6; Si, 1; Fe, <1.0
SM Ceramill sintron, 1301005 Co, 66; Cr, 28; Mo, 5; Si, <1.0;
Amann Girrbach Fe, <1.0; Mn, <1.0
C, cast; HM, hard metal milling; LS, laser sintering; SM, soft metal milling.
Amann Girrbach) were milled in a milling machine
(Ceramill Motion2; Amann Girrbach) to produce the
metal copings. The specimens obtained were sintered
with argon gas at 1 300 C in a sintering furnace accord-
ing to manufacturers instructions (Ceramill Agotherm;
Amann Girrbach). After the production process, all
copings were evaluated and placed on the dies for
measurement.
After the metal copings had been fabricated, the
marginal, axial, and occlusal adaptations were measured
using silicone replicas.37 Light viscosity silicone material
(Variotime Light Flow; Heraeus Kulzer GmbH) was
mixed according to the manufacturers instructions and
applied inside the metal copings. The copings were then
placed on the master model using nger pressure38 for 2
minutes to simulate clinical conditions. Excess material
was removed from the restoration with a surgical blade.
The marginal discrepancy was measured with a stereo-
microscope (Nikon SMZ 1500; Nikon Corp) at 100
magnication when the copings were on the master
model. The buccal, mesial, distal, and palatal marginal
areas of the model were photographed (Clemex L 1.3M
CL-13-213; Clemex Technologies Inc). The digital images
were transferred to a computer and analyzed with image
analysis software (Clemex Vision Lite; Clemex Technol-
ogies Inc), which was calibrated before each measure-
ment. Two marginal discrepancy measurements were
made from each side of each coping. The average values
of these measurements were then calculated to dene
the marginal discrepancy of the copings (Fig. 2). In total,
320 measurements were made for 40 copings.
Internal discrepancy measurements were made of the
light-body silicone material supported by a heavy-body
silicone material (Variotime Easy Putty; Heraeus Kulzer
GmbH).37 Each silicone replica was sectioned into 4 pieces
mesiodistally and buccolingually. The sections were
photographed from mesial, distal, buccal, and palatal
aspects under the microscope (Nikon SMZ 1500; Nikon
Corp) at 100 magnication. The images were then
transferred to the computer. Measurements of 2 axial
(Fig. 3) and 1 occlusal discrepancies were made on each
image. Thus, 8 axial and 4 occlusal measurements were
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Figure 2. Occlusal view of articial tooth. (a) and (b) are marginal
discrepancy measurement points; (x) and (y) are mesiodistal and
buccolingual section lines; 1, 2, 3, and 4 are occlusal discrepancy
measurement points.
Figure 4. View of silicone mold.
made for each coping. The average discrepancy values
were calculated, and data were recorded. In total,
320 measurements were made for axial discrepancy values
and 160 measurements for occlusal discrepancy values.
After these measurements were made, the copings
were veneered with feldspathic ceramic (VITA VM13;
VITA Zahnfabrik). Veneering ceramic was rst applied to
only 1 of the metal copings. A 2-piece silicone mold was
then prepared from the obtained metal ceramic restora-
tion to standardize the other ceramic veneers (Fig. 4).
Silicone replicas were obtained with the same procedures
and measurements were repeated (Fig. 5). The recorded
measurements of the marginal, axial, and occlusal dis-
crepancies were subjected to the Kolmogorov-Smirnov
test to examine the normality of the distribution
(a=.05). Data were then analyzed with repeated mea-
surement 2-way analysis of variances (ANOVAs) and the
Bonferroni post hoc tests to evaluate the marginal, axial,
and occlusal t of metal ceramic restorations fabricated
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Figure 3. Axial view of articial tooth. 1 and 2 are axial measurement
points.
Figure 5. Digital photograph shows marginal discrepancy after appli-
cation of veneering ceramic.
using different framework fabrication methods (a=.05),
using a statistical software program (IBM SPSS Statistics
v20; IBM Corp).
RESULTS
According to the results of repeated measurements
2-way ANOVAs, there was no interaction between
ceramic ring and production technique for all evalua-
tions (marginal, axial, occlusal) (Table 2). With regard to
the marginal discrepancy, statistically signicant differ-
ences were found among the production techniques
(P<.001). According to the Bonferroni post hoc test
results, statistically signicant differences were also found
among the groups both before and after the application
of veneering ceramic (P=.004 and P=.001, respectively).
After the application of veneering ceramic, statistically
signicant differences were found in the increase of
marginal discrepancy in the LS group (P=.016) (Table 3).

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Table 2. Repeated measurements 2-way ANOVAs for each discrepancy Table 3. Mean (SD) marginal discrepancy (mm) in 4 groups (n=10)
evaluation Production Before Application of After Application of
Type III Sum Mean Technique Veneering Ceramic Veneering Ceramic P
Factor of Squares df Square F P C 102.1 (26.3)a 98.8 (14.6)a .706
Marginal discrepancy evaluation HM 71.8 (28.2)b 72.5 (14.3)b .937
Ceramic ring a
966.067 1 966.067 2.576 .117 LS 72.7 (14.5) b
94.7 (13.7)a .016
Production techniqueb 10713.995 3 3571.332 11.031 <.001 SM 68.0 (12.2)b 76.7 (17.3)b .337
Ceramic ringProduction 1858.195 3 619.398 1.651 .195 C, cast; HM, hard metal milling; LS, laser sintering; SM, soft metal milling.
techniquea Different superscript letters in column represent statistically signicant differences (P<.05).
Axial Discrepancy Evaluation
Ceramic ringa 7.366 1 7.366 .024 .879
Production techniqueb 587.483 3 195.828 .889 .456
Table 4. Mean (SD) axial discrepancy (mm) in 4 groups (n=10)
Ceramic ringProduction 991.069 3 330.356 1.054 .381
techniquea Production Before Application of After Application of
Technique Veneering Ceramic Veneering Ceramic P
Occlusal Discrepancy Evaluation
C 100.4 (12.9)a 100.2 (14.0)a .981
Ceramic ring a
1547.304 1 1547.304 2.710 .108
HM 100.7 (10.4)a 91.0 (32.4)a .232
Production techniqueb 24380.926 3 8126.975 5.022 .005
LS 89.8 (13.6)a 99.8 (13.1)a .214
Ceramic ringProduction 2658.146 3 886.049 1.552 .218
techniquea SM 94.2 (11.6)a 91.6 (10.6)a .743
a C, cast; HM, hard metal milling; LS, laser sintering; SM, soft metal milling.
Test within-subjects contrasts.
b Different superscript letters in column represent a statistically signicant difference (P<.05).
Test between-subjects effects.

However, the Bonferroni test result revealed no signi- Table 5. Mean (SD) occlusal discrepancy (mm) in 4 groups (n=10)
cant differences among the other groups before and after Production Before Application of After Application of
Technique Veneering Ceramic Veneering Ceramic P
the application of veneering ceramic (P>.05) (Table 3). C 161.5 (32.6)a 169.2 (26.4)a .477
With regard to axial discrepancy, no statistically signi- HM 217.8 (34.7)b 196.6 (31.0)a .104
cant differences were found in any of the groups before LS 208.3 (40.4) b
204.4 (31.2)a .723
and after the application of veneering ceramic (P>.05) SM 191.8 (40.1)b 174.0 (24.5)a .055
(Table 4). The application of veneering ceramic had no C, cast; HM, hard metal milling; LS, laser sintering; SM, soft metal milling.
effect on the axial discrepancy in any of the groups Different superscript letters in column represent a statistically signicant difference (P<.05).

(P>.05) (Table 4). There was a statistically signicant

difference in occlusal discrepancy of the groups (P<.05),
with the lowest occlusal discrepancy recorded in the
C group. Although statistically signicant differences
were found in the occlusal discrepancy among the groups
before the application of veneering ceramic (P=.005), no
statistically signicant difference was found among the
groups after the application of veneering ceramic (P>.05)
(Table 5).
DISCUSSION
In light of the data obtained, the rst null hypothesis was
rejected. The C group displayed the highest marginal
discrepancy. The second null hypothesis was also rejec-
ted because the application of veneering ceramic affected
the marginal discrepancy of the restorations, especially in
the LS group where the application of veneering ceramic
increased the marginal discrepancy. This nding is in
accordance with the study by Kim et al.20 Although the
marginal discrepancies in the other groups differed
before and after the application of veneering ceramic, the
changes were not statistically signicant.
According to the results of this study, although
the lowest marginal discrepancy values before the
application of veneering ceramic were in the SM group
(68 12.2 mm), after the ceramic application, the lowest
marginal discrepancy values were in the HM group
(72.5 14.3 mm). Before the application of veneering
ceramic, the marginal discrepancy was the smallest in the
SM group, followed by the HM, LS, and C groups. This
nding is in accordance with the results of an earlier
study.14
Although the application of veneering ceramic at a
high temperature affected the marginal discrepancy, the
marginal discrepancy values of all the groups were
clinically acceptable.27
Xu et al9 reported that the marginal discrepancy of
Co-Cr copings produced with LS (102.86 mm) were better
than those of Co-Cr copings produced with C (170.19
mm). The results of that study are in accordance with the
current ndings. However, the marginal discrepancy in
the C group was greater than that in the current study
(102.1 mm). This situation may be explained with the
technicians skill, deformation of the wax pattern, and
shrinkage of the impression material or expansion of the
gypsum that can all affect marginal discrepancy of a cast
restoration.4,11,26
Regarding the axial and occlusal discrepancies, no
differences between before and after the application of
veneering ceramic were found in any of the groups.
In this study, the same type of veneering ceramic powder

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6 Volume
was used for all metal copings. The use of different
veneering ceramic powders might have affected this
nding.
As shown in several studies of marginal and axial
discrepancy, the chamfer nish line as used in this study
was preferred4,8,17 and resulted in reduced marginal
discrepancy than a feather-edge nish line.39
Kim et al20 reported that the application of a
veneering ceramic affected the marginal and axial dis-
crepancies of the metal ceramic restorations. In the
current study, the axial discrepancies of the all groups
were similar before and after the application of veneering
ceramic. Lakhani et al34 reported that, because of
different thermal expansion coefcients, any remaining
stress would be released, possibly affecting the marginal
discrepancies. However, the ndings of this study are in
contrast with those of Lakhani et al.34
Other studies have also used a microscope and
silicone replicas to measure marginal, axial, and occlusal
discrepancies.8,12 This technique provides in vitro mea-
surements before and after the application of veneering
ceramic, and its accuracy and reliability have been
conrmed.37 Marginal and axial discrepancies can also be
measured by rst cementing the specimens and then
sectioning them buccolingually and mesiodistally.1,25
This technique was not used in this study because it is
destructive and would have prevented the evaluation of
the effect of the veneering ceramic. In addition, it cannot
be used in clinical conditions.14
With developments in CAD/CAM technology, the
production of various restorations has been standardized
and simplied. More studies are needed of the clinical
acceptability of metal ceramic restorations produced with
new technologies. Although the marginal discrepancies
of the metal copings produced by using the C and HM
techniques have been well documented, only a few
studies have evaluated the marginal discrepancy of Co-
Cr metal copings produced with the LS10,22 and SM
techniques.14 In addition, little information is available
for the effect of temperature on the marginal and axial
discrepancies of the restorations produced using LS
production technique.20 Furthermore, no studies of the
marginal or axial discrepancies of ceramic restorations
produced with SM technique after the application of
veneering ceramic and no studies of the effect of the
veneering ceramic on the marginal and axial gap of metal
ceramic restorations produced with SM technique are
available.
The current study, which evaluated the marginal,
axial, and occlusal discrepancies of Co-Cr copings fabri-
cated with different techniques and the effect of
veneering ceramic applications on the marginal, axial,
and occlusal discrepancies, has some limitations. These
include the discrepancy measurement technique and the
lack of a standardized method for making the
THE JOURNAL OF PROSTHETIC DENTISTRY
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impressions. In this study, a 3-dimensional discrepancy
evaluation technique, which could have provided many
more measurements, was not used. During the impres-
sion stages, only nger pressure was used. Although this
technique has been used in the literature,38 it may
produce silicone layers of different thickness and thereby
affect the data.
CONCLUSIONS
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. Compared with the C technique, the LS, SM, and
HM techniques had better marginal t in metal
copings.
2. There were no signicant differences in axial
discrepancies among the groups, either before or
after the application of veneering ceramic.
3. The application of veneering ceramic had no
effect on the marginal discrepancy except in the LS
group.
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Corresponding author:
Dr Hasan Kocaa
g ao

g lu
Pamukkale University
Department of Prosthodontics
Denizli
TURKEY
Email: hasankocaagaoglu@hotmail.com
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY