RESEARCH AND EDUCATION

Fit of pressed crowns fabricated from two CAD-CAM wax

pattern process plans: A comparative in vitro study
Loubna Shamseddine, DChD, MSc, DScO,a Rola Mortada, DChD, DU,b
Khaldoun Rifai, DChD, DScO, HDR,c and Jose Johann Chidiac, DChD, MScd

Lithium disilicates are considered ABSTRACT

one of the materials of choice for Statement of problem. Subtractive and additive computer-aided design and computer-aided
restorations because of their manufacturing (CAD-CAM) wax pattern processing are 2 methods of fabricating a pressed
excellent esthetics, the possibility ceramic crown. Whether a subtractive milled wax pattern or a pattern from the micro-
of adhesive cementation, and stereolithography additive process produces lithium disilicate crowns with better marginal and
their adequate marginal adapta- internal fit is unclear.
1,2
tion. A lithium disilicate resto- Materials and methods. Ten silicone impressions were made for a prepared canine tooth. Each die
ration is typically fabricated from received 2 lithium disilicate (IPS e.max) copings, 1 from milled wax blocks and 1 from additive wax.
a handmade natural wax pattern. The replica technique was used to measure the fit by scanning electron microscopy at ×80
Recently, computer-aided design magnification. Collected data were analyzed using the paired Student t test for the marginal and
and computer-aided manufac- internal fit. For the occlusal fit, the difference in scores did not follow a normal distribution, and the
Wilcoxon signed rank test was used (a=.05).
turing (CAD-CAM) systems
with advanced synthetic wax Results. The mean marginal, axial, and occlusal fit showed no significant differences when the 2
and polymers for dental pros- CAD-CAM manufacturing processes were compared (P>.05). For the marginal fit, the mean (±SD)
theses have been introduced. 3 values were 105.1 mm ±39.6 with the milled process and 126.2 mm ±25.2 for the additive
process. The mean values were 98.1 mm ±26.1 for the axial fit in the milled process and
These systems may reduce
106.8 mm ±21.2 in the additive process. For the occlusal fit, median values (interquartile interval)
the labor intensive laboratory were 199.0 mm (141.5 to 269.9) for subtractive manufacturing and 257.2 mm (171.6 to 266.0) for
procedures.3,4 micro-SLA manufacturing.
Synthetic waxes are wax/
Conclusions. No significant difference was found between the fit of the 2 techniques. The mean
polymer mixtures.5 Because values of axial and occlusal median values were 10 and 5 to 6 times greater than machine’s nominal
they are more uniform in values. (J Prosthet Dent 2016;-:---)
composition, they are preferred
to natural waxes.5,6 Polymers are products of polymeriza- crowns, fixed dental prostheses, customized implants, and
tion reactions built up by many monomer molecules complete dentures.11-14
(ethylene).7,8 However, the addition of natural wax to In CAD-CAM, 2 different systems produce physical
polymer matrices reduces their mechanical performance9 products from 3-dimensional (3D) digital models: sub-
and the thermal stability of all mixtures.10 Some are clas- tractive (computer numerical controlled [CNC] milling)
sified as commodity plastics.8 Plasticizers added to the and stereolithography additive (SLA; or inkjet 3D
polymer lower its glass-transition temperature and reduce printing).15-17 The first system is based on the removal
its rigidity.7 They are used in prosthodontics for dental of excess material until the desired form is obtained.

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

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required in CNC machining.13,41,42 Potential multiple

Clinical Implications errors are related to the 3D scanning technique,43,44 for
Processing lithium disilicate crowns from milled or example, accuracy of segmentation (most arbitrary
parameter),23,45 insufficient triangulation, and accuracy of
micro-SLA wax patterns produced similar marginal
details in the reproduction from the STL file.46 In the SLA
discrepancy and influenced the internal fit. Refining
technique, horizontal x-, y-, and vertical z-axes would
the settings of CAD-CAM machines should improve
affect the results.47 The z-axis is the dominant error factor
clinical results.
leading to shrinkage and production of stair steps.48,49 All
these issues reduce the resolution seen in the z direction
in particular or in directions oblique to x, y, and z.48
The second process builds up material in multiple
Another error related to the polymerization process is
layered sections.18 Computer numerical controlled
in relation to depth, as parts might bend if exposed to too
milling machines are composed of multiaxis milling
much heat (stitching or over-polymerized).32,50 More-
(3 to 6) devices and burs. The fifth and sixth axes
over, shrinkage of the material during polymerization
improve milling time and quality precision as burs will
accumulates residual stresses, and porosities between
access more zones and angles for cutting materials.19,20
successive layers affect the finished product.51 Thus, the
In the additive process, the virtual prototype will be
adhesion between successive layers is weaker than the
numerically segmented into thin layers (5 to 20 layers
one in the same layer.52 Using an UV apparatus for 10
per mm) generated from algorithms of CAD files.21 This
minutes to finalize the polymerization leads to a more
thickness varies from 10 to 700 mm depending on the
uniform wax pattern.53
technique used.22 The segmented object is approxi-
Minor details could be created with a range of preci-
mated by a triangular mesh and exported for
sion between 150 and 300 mm for SLA and 5 and 35 mm
manufacturing in a stereolithography (STL) file
in micro-SLA for polymers,54 whereas CNC machines
format.22,23 The construction is made by layers from the
have precision of 75 to 150 mm (mainly for metals).54
bottom up, bonding one on top of another to produce
Milled wax patterns may not result in a better marginal
the application.17 The SLA machine consists of a
and internal fit of metal coping crowns compared with
container (vat) with a photopolymerized resin. A laser
manual fabrication,55 whereas lithium disilicate copings
(or ultraviolet [UV] radiation)17 mounted on top moves
do.56 In prosthodontics, dental casts produced from SLA
in 2 horizontal axes (x and y)16,24-26 and polymerizes
technology seem to be more accurate than milled ones.57
the resin surface layer on contact. Once a slice is
Metal cast copings resulting from wax patterns manu-
completed, a build platform mounted below the surface
factured by micro-SLA give a better marginal fit than
moves down the vertical (z) axis by a distance equal to
those from milled waxes.11
the layer thickness (50 to 200 mm),16,24-27 carrying with
As far as the authors are aware, the precision and
it the previously polymerized resin layer. This procedure
accuracy of a wax pattern made with the subtractive or
is repeated until the product is completed. Once
additive technique for a pressed crown has not been
completed, the part is elevated above the vat and
reported. Therefore the purpose of this study was to
drained.28 It is rinsed in alcohol and polymerized in a
compare the marginal and internal fit of a single lithium
UV chamber to polymerize the 20% remaining unpo-
disilicate crown made from milled wax versus a micro-
lymerized resin.29-31 Afterward, the support pillars are
SLA fabrication. The null hypothesis was that the 2
separated from the product by hand, and the surfaces
systems would have similar internal adaptation and
are polished and finished.
marginal accuracy.
Micro-SLA is based on the same principle as SLA and
produces high-resolution small objects with the most
MATERIAL AND METHODS
complicated shapes and intricate details.32
In the subtractive technique, various parameters Twenty pressed lithium disilicate glass ceramic copings
propagate through the digital workflow process: soft- issued from milled (n=10) and micro-SLA (n=10) wax
ware,33 scanner,34 and milling errors.35 The accuracy of patterns were made (Table 1). This sample size provided
the restoration is affected by the complexity of the object, at least 80% power to detect at least a 10-mm difference
material properties,36 and size of tooling.36-38 Production between the 2 techniques (a=.05; standard deviation of
of fine details by milling is largely dependent on the the difference equal to 10).
diameter of the smallest milling bur (normally approxi- A maxillary right canine was prepared by a prostho-
mately 1 mm),3 as smaller burs do not produce fine details dontist (R.M.) for a ceramic crown with a marginal round
for accuracy39 (approximately 10 mm).40 internal angle shoulder, an axial reduction of approxi-
Additive manufacturing is not constrained by draft mately 1.5 mm, and an occlusal reduction of 2.0 mm in a
angle, internal geometries, axis, or fixture designs dental typodont model (Frasaco; Practicon, Inc). As the

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Table 1. Composition of waxes used according to manufacturer

Wax Manufacturer Available Data Composition
VisiJet FTX 3D Systems, Inc Organic mixture:
1. Triethylene glycol diacrylate C12H18O6: 40-50% (crosslinking polymeric material)
2. Tricyclodecane dimethanol diacrylate: 15-25% (high refractive index monomer which exhibits
low volume shrinkage in polymerization)
3. Phenylbis (2,4,6-trimethyl benzoyl); phosphine oxide: 1-2% (UV photo initiator)
Zenotec Bleu Ivoclar Vivadent AG Synthetic wax
No further relevant information available.

Figure 2. Representation of 5 axes (A, B, X, Y, Z) in milled wax process

horizontal and vertical directions in layering building wax by micro-SLA
Figure 1. Standardized parameters setting by Dental Wings Ivoclar
process. SLA, stereolithography additive. Subtractive: A, lateral rotation;
software: (1) Cement discrepancy=0.01 mm; (2) extra vertical
B, antero-posterior rotation; X, antero-posterior translational movement;
discrepancy=0.04 mm; (3) extra horizontal discrepancy=0.01 mm;
Y, lateral translational movement; Z, vertical movement. Micro-SLA: X,
(4) collar position=0.8 mm; (5) minimum thickness=0.5 mm; (6) margin
horizontal antero-posterior translational movement; Y, horizontal lateral
thickness=0.15 mm; (7) emergence angle=67 degrees; (8) emergence
translational movement; Z, vertical movement.
offset=0.1.

quality of crown preparation in CAD-CAM systems has a format was carried out and sent to prototype machines
significant impact on marginal discrepancy,58 the tooth for manufacturing.
was carefully prepared. The prepared tooth was then Two wax pattern copings were made on the die issued
duplicated with a single step dual-viscosity impression from each impression. The first coping was from milling a
with a polyvinyl siloxane (putty and light-body Express prefabricated wax disk (Zenotec Blue; Ivoclar Vivadent
STD; 3M ESPE). Ten impressions of the tooth prepara- AG) using milling burs consecutively 2.5 mm, 1, and 0.7
tion were made at room temperature by a single inves- mm on a 5-axis dry machine (Wieland Zenotec Select;
tigator (R.M.). Once polymerized, the impressions were Ivoclar Vivadent AG). The second coping was from micro-
poured with Type IV gypsum (Excalibur; Siladent SLA (Project 1200; 3d Systems, Inc) using an UV poly-
Dr. Böhme & Schöps GmbH). merizable plastic (VisiJet FTX Green; 3d Systems, Inc)
Each cast was digitized using the Wieland Dental (Fig. 2). After manufacturing, the copings were soaked in
Wings scanner (model S107; Ivoclar Vivadent AG). From isopropanol for 20 minutes, and any excess resin was
the virtual cast, wax copings were designed by Dental scrubbed off. Dry, compressed air was used to eliminate
Wings Ivoclar software (Zenotec CAD; 4.3.2.2.23248 excess solvent. The wax copings were placed in a post-
Powered by dwos) according to standardized parame- polymerization apparatus for 60 minutes after cleaning.
ters: extra vertical discrepancy of 0.04 mm (40 mm), extra The layer thickness was 0.03 mm. A sprue was attached,
horizontal discrepancy of 0.01 mm (10 mm), collar posi- and the wax copings were invested in a phosphate-
tion of 0.8 mm, maximum thickness of 0.5 mm, marginal bonded carbon-free investment (Bellavest SH; Bego)
thickness of 0.15, and cement discrepancy at the margin poured from a vacuum mixer (Multivac 4; Degussa AG).
of 0.1 mm (100 mm) (Fig. 1). This marginal setting Once the investment had set, the wax was eliminated, and
discrepancy is considered to be in the clinically accept- the ceramic ingot (IPS e.max; Ivoclar Vivadent AG) was
able range59 and could optimize physical and clinical pressed. After devestment and cleaning, the copings were
properties of the resin-based luting agent.60 A divided into 2 groups of 10 specimens according to their
compensation step for the cutter tool diameter to ensure wax pattern manufacturing type.
that the milling bur reached the desired surface in a The restorations were fitted to their corresponding
CAM software was not used in the protocol as it might dies. When interference existed on the internal aspects,
have increased the internal space and might have pro- they were marked and removed with water-cooled
duced negative fit errors.61 The transformation to STL diamond rotary instruments. The restorations were

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Table 2. Statistical results

Margin Axial Occlusal
Paired t test Paired t test Wilcoxon Signed Rank Test
Wax n Mean, mm SD P Mean SD P Median, mm Interquartile Interval P
Milled 10 105.1 39.6 .055 98.1 26.0 .48 199.0 141.5-269.9 .88
Micro-SLA 10 126.2 25.2 106.8 21.2 257.2 171.6-266.0

SLA, stereolithography additive.

seated on the master model, and their marginal fit was DISCUSSION

evaluated with a silicone indicator paste (Fit Checker;
The null hypothesis was accepted, as additive and milled
GC Corp) and an explorer. Adjustments were done
wax patterns had a similar fit. The sample size of 10
when necessary. Marginal fit was considered acceptable
specimens was adequate for a statistical power set at
when the explorer did not penetrate between the
80%. The marginal fit mean values were found near the
restoration and the tooth to mimic clinically acceptable
nominal machine values (100 mm) 98.1 mm (subtractive)
conditions.
and 106.8 mm (micro-SLA) without any significant dif-
The fit of the restorations was measured with a
ference and were in the clinically acceptable range.59
nondestructive replica technique,62 an accurate and reli-
Setting different CAD-CAM systems at 30-mm cement
able method used in vivo and in vitro studies.63,64 The
thickness, a mean marginal discrepancy was found
copings were filled with a polyether light-body impres-
ranging between 64.8 mm and 83.4 mm for micro-SLA
sion material (Impregum Soft; 3M ESPE) and placed on
and 65.9 mm and 93.4 mm for milled wax. However,
the abutment tooth, applying finger pressure on the
this was done for metal casting crowns.11 The difference
incisal surface. Once the light-body polyether had poly-
found may be attributed to the manufacturing types, with
merized, it was removed with the crown and the intaglio
no mention of the marginal discrepancy nominal values.
filled with a polyether medium-body impression material
The axial fit mean values obtained in this study were
(Impregum Soft; 3M ESPE). Two replicas were made
98.1 (CAD-milling) and 106.8 mm (micro-SLA) with no
from each abutment. They were sectioned with a razor
significant difference. They were 10 times greater than
blade, one mesiodistally, the other buccolingually. All
the programmed values of the die spacer thickness (10
sections were coated with copper to become conductive
mm). This might be due to the accumulation of several
and be visible with a scanning electron microscope
error sources during processing (subtractive and additive)
(SEM). The SEM (ASC-2100; Seron technology) was
and during postprocessing (fitting and post polymer-
used at ×80 magnification. Perpendicular to the medium-
izing). Occlusal fit mean values were 5 to 6 times greater
body polyether line, the light-bodied material thickness
than the programmed values (40 mm) as 199.0 mm (CAD-
was measured every 400 mm along the interface. The
milling) and 257.2 mm (micro-SLA) was found with no
marginal discrepancy was defined at the end of the
significant difference. Even more, the lowest and highest
medium-body curvature for each section. A total of 65
values in both groups were greater than the parameters
measurement points with 0.01-mm accuracy were made
set. These values affected the ceramic strength.60
per specimen (650 per group). The replica technique
The high values found in both groups (occlusal and
needs 50 measurements for marginal discrepancy values
axial areas) could be the result of the manual adjustment
to become clinically relevant.65 This study, using only 40
needed to fit the copings. Another source of the differ-
measurements per group, cannot therefore be extrapo-
ence between the nominal machine values and the
lated. Data were analyzed using statistical software (IBM
measured values was the inaccuracy in the
SPSS Statistics v20; IBM Corp). The mean values and
manufacturing technique added to the manual adjust-
standard deviations (SD) of the marginal and internal
ment of the copings. Nevertheless, using a 5-axis milling
discrepancies were calculated. A t test was conducted for
system for the subtractive group allowed the production
equality of means for margin and axial fit (normal dis-
of convergence, divergence, and complex shapes of mil-
tribution). The Wilcoxon signed rank test was used for
led surfaces,3,18,20 minimizing the error. The cutting tools
median and interquartile interval values and for occlusal
are incapable of cutting sharp internal angles,51 and the
fit (a=.05).
size discrepancy between the cutting tools and tooth
geometry could explain the reduction of internal fit
RESULTS
precision.37,38
Statistical results are summarized in Table 2. No signifi- In the additive processing, parameters that might
cant differences were found for the marginal, axial, or have the greatest effect on the results are the axes of
occlusal fittings (P>.05) between the 2 wax pattern build directions. The stair-stepping effects may have
manufacturing methods. affected the dimensional accuracy of the pattern26 but

THE JOURNAL OF PROSTHETIC DENTISTRY Shamseddine et al

- 2016 5

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