Microleakage of ceramic inlays luted with different resin cements and dentin adhesives

Bulent Uludag, DDS, PhD,a Ozge Ozturk, DDS, PhD,b and A. Nilgun Ozturk, DDS, PhDc Faculty of Dentistry, University of Ankara, Ankara, Turkey; Faculty of Dentistry, University of Selcuk, Konya, Turkey
Statement of problem. Despite recent advances in adhesive dentistry, resin cement/dentin adhesive combinations are not able to prevent microleakage in ceramic inlays. Marginal quality of tooth-colored restorations in large Class II cavities is satisfactory in enamel margins, but microleakage in dentin margins remains a concern. Purpose. The purpose of this study was to evaluate the microleakage of all-ceramic inlays luted with 2 dual-polymerizing resin cements or 1 autopolymerizing resin cement in combination with different dentin adhesives. Material and methods. One hundred and twenty extracted human mandibular third molars were used in this study. Teeth were prepared to receive Class II MOD inlays with enamel gingival margins on 1 proximal surface and dentin gingival margins on the other surface. One hundred and twenty prepared teeth were divided into 3 groups of 40; 1 group for each resin cement: RelyX ARC, Variolink II, or Panavia 21. Each of the 3 groups were further divided into 4 dentin adhesive groups; Single Bond, ExciTE DSC, ED Primer, or Admira Bond. Each of the resin cements were used in combination with the 4 dentin adhesives, and IPS Empress ceramic inlays were placed with 12 different cement/adhesive combinations. After 1000 thermal cycles in a 5-55C water bath with a dwell time of 30 seconds, all specimens were subjected to cyclic axial mechanical loading. Then the restored teeth were stored in 0.5% basic fuchsin solution for 24 hours. The extent of dye penetration along the margins was measured with a stereomicroscope at x40 magnification. The data were evaluated statistically using repeated-measures ANOVA and Duncan tests (=.05). Results. Microleakage at dentin margins was greater than that at enamel margins (P<.05) for all groups. Variolink II and RelyX ARC resin cements showed significantly lower microleakage results than Panavia 21 with all dentin adhesives in enamel margins. For dentin margins, Variolink II/Admira Bond combination showed the lowest microleakage value in dentin (P<.05). Conclusions. The overall microleakage at the enamel margins was significantly less than at the dentin margins (P<.05). Panavia 21 showed higher microleakage values than Variolink II and RelyX ARC in enamel margins. (J Prosthet Dent 2009;102:235-241)

Clinical Implications

The results of this study suggest that there are no significant differences in microleakage at dentin margins between dual-polymerizing resin cements and autopolymerizing resin cements with the different cement/adhesive combinations evaluated.
Efficient adhesion between cavity walls and restorative materials is important for long-lasting restorations.1,2 Microleakage of cariogenic bacteria along the cavity walls of restorations is reported to be a siga

nificant cause of pulpal inflammation, pulp necrosis,3-7 and secondary caries4-8 in restored teeth. The signs of microleakage include immediate postoperative sensitivity, chronic sensitivity, and marginal discoloration.9-11

Microleakage at the enamel-restoration interface has been minimized since the introduction of acid etching by Buonocore in 1955,12 but sealing dentin margins remains a challenge.2,7,13,14

Professor, Department of Prosthodontics, University of Ankara, Faculty of Dentistry. Private practice, Istanbul, Turkey. c Associate Professor, Department of Prosthodontics, University of Selcuk, Faculty of Dentistry.
b

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Composite resin restorative materials undergo significant volumetric shrinkage when polymerized. It has been suggested that this property results in poor margin quality in composite resin restorations.1 Different composite resin restorative systems and techniques have been developed, and direct composite resin placement is one of these techniques.15 However, clinicians have difficulty establishing proper anatomic form, proximal contour, and contact in large, direct placement composite resin restorations. Indirect inlay systems have been developed to overcome this limitation of direct placement restorations.16 One of the advantages attributed to the ceramic inlay technique is a thermal expansion coefficient of the ceramic which is similar to that of the tooth hard substance, as well as the reduced volume of shrinking composite resin (limited to the luting resins), both of which are known to have positive effects on marginal adaptation.17-20 Clinical success with ceramic inlays/onlays has been assisted by the development of a reliable bond between composite resin and dental tissues.21,22 Generally, an adhesive resin cement is recommended for luting ceramic inlays,23 particularly because of the excellent esthetic and mechanical properties (flexural strength, compressive strength) of adhesive resin cements.20,24,25 Light-polymerized, dual-polymerized, and autopolymerized luting composite resins have all been used with ceramic inlays.26-28 Etched enamel12 provides an ideal surface for reliable bonding performance using adhesive resins.29,30 Success with bonding to dentin, however, has been less reliable due to the unique characteristics of the dentin substrates, including high organic content, tubular structure variations, and the presence of outward fluid movement.31-37 In an attempt to improve the bond between dentin and composite resin, a number of dentin adhesives have been introduced. These react to form chemical or micromechanical bonds between the tooth structure and the restoration.38 There are 2 types of tooth surface treatments. The total-etch technique involves conditioning enamel and dentin with phosphoric acid in a single step. To avoid overetching the dentin, the phosphoric acid gel is usually applied first to the enamel margins and then to the dentin surface.39 Self-etching adhesives, however, contain acidic monomers which are copolymerized with adhesive monomers after surface conditioning.39-41 An intrinsic problem of selfetching systems is the acid-base reaction of the acidic monomers with the amines used in the initiator systems,39,42,43 such as the camphorquinone/amine system in light-polymerizing adhesives. Many techniques involving dyes have been used to assess microleakage both in vivo and in vitro. Dye penetration is a technique to determine the loss of adhesion. Other methods, such as the silver nitrate staining technique, or penetration of radioactive substances, are not commonly used because they are time-consuming and the handling of these materials is difficult.44 Digital image analysis allows quantitative measurement of the length of dye penetration. This method can assess the condition and amount of microleakage of restorations more accurately than the traditional scoring system that made microleakage studies more subjective.45 The purpose of this study was to evaluate the microleakage of all-ceramic inlays luted with 2 dual-polymerizing resin cements and 1 autopolymerizing resin cement in combination with different dentin adhesives. The null hypothesis was that the adhesive/ cement combinations have no effect on microleakage.

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stored in 0.5% thymol (Merck KGaA, Darmstadt, Germany) at room temperature from the day of extraction. The teeth were cleaned using scalers and rotating brushes to completely remove soft tissue remnants. Teeth were embedded up to 2 mm apical to the cemento-enamel junction in autopolymerizing resin (Palavit G; Heraeus Kulzer GmbH, Wehrheim, Germany). The teeth were prepared for Class II MOD inlays. All preparations were made according to the following criteria using inlay diamond rotary cutting instruments (Inlay Prep Kit 4261; Komet Dental, London, UK): 10 degrees of axial wall convergence; flat floor; 3-mm depth and 4-mm width of the isthmus; 1 proximal box limited to enamel (1 mm coronal to the cemento-enamel junction), and the other extending 1 mm apical to the cemento-enamel junction. Impressions were then made with polyether impression material (Impregum F; 3M ESPE, Seefeld, Germany) of all specimens, and refractory dies were prepared (Cergo Fit; Dentsply DeguDent GmbH, Hanau, Germany). To fabricate the IPS Empress inlays, restoration patterns were waxed (Yeti Dentalprodukte GmbH, Engen, Germany), sprued, and invested with refractory material (AlphaDie MF; Schtz-Dental GmbH, Rosbach, Germany). The paper ring and sprue former were removed after 1 hour. The molds were then transferred to a burn-out furnace (Vulcan 3-550, Dentsply Ceramco, York, Pa), heated from room temperature to 250C at a rate of 5C/min, held at 250C for 30 minutes, then further heated from 250 to 850C at a rate of 5C/min, and finally held at 850C for 60 minutes. After completion of the heating cycles, the investment ring was immediately removed from the heating furnace, and the cold ingot was placed in the investment ring. The investment ring with the ingot and the alumina plunger were transferred to the 700C preheated pressing furnace (EP 600; Ivoclar Vivadent, Schaan, Lichtenstein). For the IPS Empress ceramics,

MATERIAL AND METHODS

One hundred and twenty extracted caries- and restoration-free human mandibular third molars were used in this study. The teeth were

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the furnace was heated from 700 to 1180C. The ingot was subjected to a plunger pressure of 5 bar, as recommended by the manufacturer. After pressing, the ceramic inlays were divested, finished with diamond rotary cutting instruments (ND.0136.006; Komet Gebr Brasseler GmbH, Lemgo, Germany), and glazed. One hundred and twenty prepared teeth were divided into 3 groups of 40, 1 group for each of 3 resin cements: RelyX ARC, Variolink II, and Panavia 21. Each of the 3 groups was further divided into 4 dentin adhesive groups: Single Bond, ExciTE DSC, ED Primer, and Admira Bond. Each of the resin cements was used in combination with the 4 dentin adhesives. The resin cements and dentin adhesives used in this study are described in Table I. All of the ceramic inlays were etched with 9.6% hydrofluoric acid (Porcelain Etch Gel; Pulpdent Corp, Watertown, Mass) for 2 minutes. For Panavia 21 resin cement, a layer of a silane coupling agent mixture (Clearfil Porcelain Bond Activator and Clearfil SE Bond Primer; Kuraray Co Ltd, Osaka, Japan) was applied to the ceramic bonding (intaglio) surfaces for 5 seconds, then air dried. For Variolink II and RelyX ARC, a layer of silane coupling agent (Silane Bond Enhancer; Pulpdent Corp) was applied to the ceramic bonding surfaces for 1 minute, then air dried. For the RelyX/Single Bond group, 35% phosphoric acid gel (Scotchbond Etchant; 3M EPSE, St. Paul, Minn) was applied to the enamel surface for 30 seconds and the dentin surface for 15 seconds, water rinsed for 10 seconds, and then gently air dried for 5 seconds. Single Bond was applied to the cavity surface, gently air dried for 5 seconds, and polymerized for 10 seconds with the light-polymerizing unit (Hilux 200 Light Curing Unit; Benlioglu Dental, Ankara, Turkey). RelyX ARC was mixed for 10 seconds and applied to both prepared teeth and the bonding surface of the ceramic restorations. A static load (1 kg) was used to stabilize the inlays during the bonding procedure. Excessive cement was removed with an explorer, and the cement was polymerized for 40 seconds with the lightpolymerizing unit at 350 mW/cm2 with a light tip-to-specimen distance of 2 mm. For the RelyX/ExciTE DSC group, 35% phosphoric acid gel (Scotchbond Etchant; 3M ESPE) was applied to the enamel surface for 30 seconds and the dentin surface for 15 seconds, water rinsed for 10 seconds,

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Table I. Resin cements and dentin adhesives used in this study

Resin Cement
RelyX ARC Variolink II

Manufacturer
3M ESPE, St. Paul, Minn Ivoclar Vivadent, Schaan, Liechtenstein

Batch Number
20050524 G13371

Composition
Bis-GMA, TEGDMA, silica-zirconia glass Bis-GMA, UDMA, TEGDMA silicon dioxide, autopolymerizing initiators, light-polymerizing initiators, stabilizer, pigments Bis-GMA, MDP, quartz, benzoyl peroxide, initiators, phosphate, monomer, amine, sulfine, stabilizer

Panavia 21

Kuraray Co Ltd, Osaka, Japan

41235

Dentin Adhesive
Single Bond

Manufacturer
3M ESPE

Batch Number
7MH

Composition
Bis-GMA, polyalkenoic acid co-polymer, dimethacrylate, HEMA, photoinitiators, ethanol, water HEMA, dimethacrylate, phosphonic acid acrylate, silicon dioxide, initiators, stabilizer, alcohol HEMA, 5-MASA, MDP, water, catalyst Ormocer (organically modifed ceramic), bis-GMA, HEMA, organic acid, acetone

ExciTE DSC

Ivoclar Vivadent

G11590

ED Primer Admira Bond

Kuraray Co Ltd VOCO GmbH, Cuxhaven, Germany

41154 779921

Bis-GMA: bisphenol-A glycidyl dimethacrylate; TEGDMA: tetraethyleneglycol dimethacrylate; UDMA: urethane dimethacrylate; MDP: 10-methacryloyloxy-decyl dihydrogen phosphate; HEMA: 2-hydroxyethyl methacrylate; 5-MASA: methacryloyl-5-aminosalicylic acid

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and gently air dried for 5 seconds. ExciTE DSC was applied to the cavity surface, gently air dried for 3 seconds, and polymerized for 10 seconds with the light-polymerizing unit. RelyX ARC was applied in the same manner. For the RelyX/ED Primer group, ED Primer was applied to the cavity surface for 60 seconds and gently air dried. RelyX ARC was applied as previously described. For the RelyX/Admira Bond group, 35% phosphoric acid gel (Scotchbond Etchant; 3M ESPE) was applied to the enamel surface for 30 seconds and the dentin surface for 15 seconds, water rinsed for 10 seconds, and gently air dried for 5 seconds. Admira Bond was applied to the cavity surface for 30 seconds, gently air dried, and polymerized for 10 seconds with the light-polymerizing unit. RelyX ARC was applied. Variolink II and Panavia 21 resin cements were used in combination with the 4 dentin adhesives in the same manner. After 24 hours of storage in water at 37C, all teeth were subjected to 1000 thermal cycles (Thermal Cycle; Nve, Ankara, Turkey) between 5and 55C using a dwell time of 30 seconds. All specimens were subjected to cyclic axial mechanical loading (100,000 cycles, 1.6 Hz, constant occlusal load of 50 N) using a 5-mm steel ball. Specimens were coated with nail polish (Del Laboratories, Inc, Uniondale, NY) 1 mm short of the restoration margins and immersed in 0.5% basic fuchsin dye (SPI Supplies Division, Structure Probe, Inc, West Chester, Pa) for 24 hours. Following removal from the solution, the teeth were rinsed under tap water and embedded in autopolymerizing orthodontic acrylic resin (Orthocryl EQ; Dentaurum, Ispringen, Germany). Each tooth was vertically sectioned twice mesial-distally, through the restorations along the long axis, into 0.5-mm-wide sections, with a watercooled diamond disc (Mikrocut; Metkom, Bursa, Turkey). Four specimens (0.5 x 10 x 15 mm) were made from each tooth. For each specimen, dye penetration along the cavity walls in dentin and enamel on each of the 4 sectioned surfaces was digitally photographed at x40 under a stereomicro-

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scope (Carl Zeiss AG, Oberkochen, Germany), and the data were transferred to a personal computer. For each specimen, staining along the cavity walls was measured using image analysis software (KS 400 Image for Windows; Carl Zeiss AG) and the percentage of dye penetration was calculated in relation to the entire cavity length. The differences in the amount of dye penetration along the cavity walls were evaluated statistically using repeated-measures analysis of variance (ANOVA) and Duncan tests (=.05).

RESULTS
Table II illustrates the mean percentage and SD for the microleakage results obtained with the 2 resin cements in combination with the 4 dentin adhesives. The results of repeatedmeasures ANOVA are summarized in Table III and indicate that microleakage values vary according to the resin cements and dentin adhesives (P<.05) used. There were significant differences in microleakage between the enamel and dentin margins (P<.05).

Table II. Percent mean values and SD for microleakage (n=10)

Enamel Variolink II Mean
ExciTE DSC Single Bond ED Primer Admira Bond
Ab 0.58

Dentin Panavia 21 Mean

b A2.69

RelyX ARC Mean

Aa A1.38

Variolink II Mean
A a 2.21

RelyX ARC Mean

a 2.91

Panavia 21 Mean
Aa A9.08

SD
0.81

SD
1.95

SD
2.77

SD
1.57

SD
2.45

SD
2.29

Ab 0.56

1.1

Ab 0.23

0.32

Ab A5.58

2.87

Aa 3.52

2.21

A a 3.53

2.97

Aa A10.93

2.50

Aa 1.01

1.22

Ab 0.54

0.90

A a A3.99

2.76

A a A1.90

1.98

Aa A5.00

3.59

a A5.44

2.83

Aa 0.75

1.22

Ab 1.39

1.59

A b A3.81

1.63

a 0.93

1.28

A a A4.74

2.70

a A6.66

1.73

Superscripted lowercase letters (a, b) indicate differences in cement/bonding agent combination (with respect to orientation); right superscript characters (A, A, and ) indicate differences in orientation/cement combination (with respect to bonding agent); left subscript characters (, A, and A) indicate differences in orientation/bonding agent combination (with respect to cement). Same characters on same sides (left or right) of values indicate no significant difference in results (P<.05).

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Table III. Results of repeated-measures ANOVA

Source
Between Groups Cement Bonding agent Cement x bonding agent 928.0 46.0 132.8 464.0 15.3 22.1 2 3 6 77.9 2.57 3.72 <.001 .050 .002

Sum of Squares

Mean Square

df

Within groups Orientation Orientation x cement Orientation x bonding agent Orientation x cement x bonding agent 491.0 69.9 30.1 89.5 491.0 35.0 10.0 15.0 1 2 3 6 138.1 9.83 2.82 4.19 <.001 <.001 .042 <.001

Microleakage at the dentin margins was greater than that at the enamel margins (P<.05) for all groups. Variolink II and RelyX ARC resin cements showed the lowest microleakage results with all dentin adhesives in enamel margins. Panavia 21 showed higher microleakage values than Variolink II and RelyX ARC. The lowest microleakage value was obtained with RelyX/Single Bond in enamel for all resin cements (P<.05). With dentin margins, there were no significant differences between RelyX ARC and Variolink II combinations with Single Bond and ExciTE DSC dentin adhesives. However, the Variolink II/Admira Bond combination showed the lowest microleakage value in dentin (P<.05). Panavia 21 combined with ED Primer showed the lowest microleakage compared to the other Panavia 21/dentin adhesive combinations.

DISCUSSION
With regard to the influence of the adhesive/cement combinations on the dentin margins, the results of this study do not support rejection of the null hypothesis. This study is in agreement with other studies35-37 in which enamel margins demon-

strated a good seal, in contrast to the dentin margins, because the smallest degree of microleakage was observed in enamel. It is also known that the composition and other special characteristics of luting agents, such as the setting properties and the dentin adhesives used, determine the degree of leakage.7 Universal dentin adhesives have been recommended for bonding porcelain, composite resin, and alloy to both dentin and enamel. One reported benefit of these agents is the ability to seal dentin, which results in a reduction of interfacial microleakage and pulpal sensitivity.29,30 For all-ceramic inlays, microleakage is an important consideration for preserving the marginal seal due to less than ideal marginal adaptation of the porcelain material.29 The total-etch technique involves conditioning enamel and dentin with phosphoric acid in a single step. Selfetching adhesives, however, contain acidic monomers which are copolymerized with adhesive monomers after surface conditioning.39,40 Therefore, self-etching cementation systems require no rinsing step and are therefore generally less technique sensitive.40 Variolink II and RelyX ARC resin cements showed the lowest mi-

croleakage results with all dentin adhesives in enamel margins. Panavia 21 combined with the self-etching adhesive, ED Primer, showed significantly higher microleakage values than Variolink II and RelyX ARC in enamel margins. This can be explained by the 2 different enamel bonding mechanisms of the total-etch and the selfetching techniques. The slow polymerization rate of Panavia 21 may allow more water to diffuse from the vital dentin into the hydrophilic interface between the Panavia 21 primer and dentin, due to its more hydrophibic nature.39,41 The 2 phases seem to weaken the interface. With dentin margins, there were no significant differences between dual-polymerizing resin cements and the autopolymerizing resin cement. In a recent study in which ceramic inlays cemented with a dual-polymerized or autopolymerized composite resin luting agent were clinically evaluated, Sjgren et al28 reported no significant differences between the 2 luting agents. These findings were confirmed by van Dijken et al,27 who investigated the use of a dual-polymerized and an autopolymerized composite resin luting agent in restorations with extensive dentin/enamel-bonded ceramic

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coverage. An in vitro study of microleakage found significantly worse results in dentin compared to enamel margins for Variolink II/Excite and Panavia F/ED Primer. However, there were no significant differences between Variolink II/Excite and Panavia F/ED Primer.26 These differences in study results can be explained by the differences in cavity widths and tooth types. The smallest degree of microleakage was achieved in enamel. Dentinal adhesion has been shown to be less predictable. Much of the difficulty in bonding to dentin is the result of the complex histological structure and the variable composition of dentin.34 The results from the current study compare favorably with other studies in which enamel margins demonstrated a good seal, in contrast to the dentin margins.35-37 Although lower microleakage values were obtained by using the manufacturers recommended adhesive/composite resin luting cement, similar microleakage results were obtained by using different adhesive system/composite resin luting cement combinations. Significant differences in microleakage values were specific to the proprietary brand of the bonding agent. The limitations of this study include that there was no evaluation of the effect of nonaxial loading and lateral movement. In vitro tests have been used to study some properties of materials to provide information about their potential clinical performance. However, in vitro tests cannot adequately simulate clinical conditions. Thus, the results of in vitro tests should be applied with caution to the clinical situation. The final evaluation of a material, including resin cements, should be performed in long-term clinical studies. 1. Microleakage at enamel margins was significantly less than at dentin margins (P<.05). 2. The autopolymerizing resin cement Panavia 21 showed signficantly higher microleakage values than Variolink II and RelyX ARC in enamel margins, but no significant differences were found in dentin margins for the all-ceramic material evaluated.

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16.Soares CJ, Martins LR, Fernandes Neto AJ, Giannini M. Marginal adaptation of indirect composites and ceramic inlay systems. Oper Dent 2003;28:689-94. 17.Bott B, Hannig M. Optimizing class II composite resin esthetic restorations by use of ceramic inserts. J Esthet Dent 1995;7:1107. 18.Bullard RH, Leinfelder KF, Russell CM. Effect of coefficient of thermal expansion on microleakage. J Am Dent Assoc 1988;116:871-4. 19.Donly KJ, Wild TW, Bowen RL, Jensen ME. An in vitro investigation of the effects of glass inserts on the effective composite resin polymerization shrinkage. J Dent Res 1989;68:1234-7. 20.Bott B, Hannig M. Effect of different luting materials on the marginal adaptation of Class I ceramic inlay restorations in vitro. Dent Mater 2003;19:264-9. 21.Inokoshi S, Wllems G, Van Meerbeek B, Lambrechts P, Braem M, Vanherle G. Dualcure luting composites: Part I: Filler particle distribution. J Oral Rehabil 1993;20:13346. 22.Sjgren G, Molin M, Van Dijken J, Bergman M. Ceramic inlays (Cerec) cemented with either a dual-cured or a chemically cured composite resin luting agent. A 2-year clinical study. Acta Odontol Scand 1995;53:325-30. 23.Dietschi D, Magne P, Holz J. Recent trends in esthetic restorations for posterior teeth. Quintessence Int 1994;25:659-77. 24.Mitchell CA, Douglas WH, Cheng YS. Fracture toughness of conventional, resin-modified glass-ionomer and composite luting cements. Dent Mater 1999;15:7-13. 25.Li ZC, White SN. Mechanical properties of dental luting cements. J Prosthet Dent 1999;81:597-609. 26.Federlin M, Schmidt S, Hiller KA, Thonemann B, Schmalz G. Partial ceramic crowns: influence of preparation design and luting material on internal adaptation. Oper Dent 2004;29:560-70. 27.van Dijken JW, Hasselrot L, Ormin A, Olofsson AL. Restorations with extensive dentin/ enamel-bonded ceramic coverage. A 5-year follow-up. Eur J Oral Sci 2001;109:222-9. 28.Sjgren G, Molin M, van Dijken JW. A 5-year clinical evaluation of ceramic inlays (Cerec) cemented with a dual-cured or chemically cured resin composite luting agent. Acta Odontol Scand 1998;56:263-7. 29.Neme AL, Evans DB, Maxson BB. Evaluation of dental adhesive systems with amalgam and resin composite restorations: comparison of microleakage and bond strength results. Oper Dent 2000;25:512-9. 30.Duke ES. Adhesion and its application with restorative materials. Dent Clin North Am 1993;37:329-40. 31.Eliades G. Clinical relevance of the formulation and testing of dentine bonding systems. J Dent 1994;22:73-81. 32.Frankenberger R, Krmer N, Petschelt A. Technique sensitivity of dentin bonding: effect of application mistakes on bond strength and marginal adaptation. Oper Dent 2000;25:324-30.

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CONCLUSIONS
Within the limitations of this in vitro investigation, the following conclusions were drawn:

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Noteworthy Abstracts of the Current Literature Marginal and internal fits of fixed dental prostheses zirconia retainers
Beuer F, Aggstaller H, Edelhoff D, Gernet W, Sorensen J. Dent Mater 2009;25:94-102. Epub 2008 Jul 11.
Objectives: CAM (computer-aided manufacturing) and CAD (computer-aided design)/CAM systems facilitate the use of zirconia substructure materials for all-ceramic fixed partial dentures. This in vitro study compared the precision of fit of frameworks milled from semi-sintered zirconia blocks that were designed and machined with two CAD/CAM and one CAM system. Methods: Three-unit posterior fixed dental prostheses (FDP) (n=10) were fabricated for standardized dies by: a milling center CAD/CAM system (Etkon), a laboratory CAD/CAM system (Cerec InLab), and a laboratory CAM system (Cercon). After adaptation by a dental technician, the FDP were cemented on definitive dies, embedded and sectioned. The marginal and internal fits were measured under an optical microscope at 50x magnification. A one-way analysis of variance (ANOVA) was used to compare data (=0.05). Results: The mean (S.D.) for the marginal fit and internal fit adaptation were: 29.1 m (14.0) and 62.7 m (18.9) for the milling center system, 56.6 m (19.6) and 73.5 m (20.6) for the laboratory CAD/CAM system, and 81.4 m (20.3) and 119.2 m (37.5) for the laboratory CAM system. One-way ANOVA showed significant differences between systems for marginal fit (P<0.001) and internal fit (P<0.001). Significance: All systems showed marginal gaps below 120 m and were therefore considered clinically acceptable. The CAD/CAM systems were more precise than the CAM system. Reprinted with permission of the Academy of Dental Materials.

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