Dental Materials Journal 2016; : –

Review

The marginal fit of E.max Press and E.max CAD lithium disilicate restorations:
A critical review
Radek MOUNAJJED1,2, Danielle M. LAYTON3 and Basel AZAR1

1
Department of Prosthetic Dentistry, Palacky University, Palackého 12, Olomouc 77900, Czech Republic
2
DCM, Private Dental Clinic, Topolová 340/1, 500 03 Hradec Králové, Czech Republic
3
Private Practice, 217 Wickham Terrace, Brisbane QLD 4000, Australia
Corresponding author, Basel AZAR; E-mail: baselazar1@hotmail.com

This critical review aimed to assess the vertical marginal gap that was present when E.max lithium disilicate-based restoration
(Press and CAD) are fabricated in-vitro. Published articles reporting vertical marginal gap measurements of in-vitro restorations that
had been fabricated from E.Max lithium disilicate were sought with an electronic search of MEDLINE (PubMed) and hand search of
selected dental journals. The outcomes were reviewed qualitatively. The majority of studies that compared the marginal fit of E.max
press and E.max CAD restorations, found that the E.max lithium disilicate restorations fabricated with the press technique had
significantly smaller marginal gaps than those fabricated with CAD technique. This research indicates that E.max lithium disilicate
restorations fabricated with the press technique have measurably smaller marginal gaps when compared with those fabricated
with CAD techniques within in-vitro environments. The marginal gaps achieved by the restorations across all groups were within a
clinically acceptable range.

Keywords: Marginal fit, E.max, Press, CAD, Lithium disilicate

has been argued that this results in improved dentine

INTRODUCTION
adhesion18).
Introduction of the acid etched ceramic protocol for Dental laboratories can also use the lost-wax
bonding to enamel in 19801-3) and the dentin adhesives technique to fabricate pressable lithium disilicate
in the early 1990s4,5), facilitated dental rehabilitation restorations (IPS E.max Press). Ingots of lithium
with all-ceramic prosthesis6). disilicate are heat-pressed within a porcelain furnace
Lithium disilicate is a glassy ceramic that consists to mold the ceramic material into the desired shape19,20).
of quartz, lithium dioxide, phosphor oxide, alumina, This technique reduces processing errors that may be
potassium oxide and other components7). The material associated with conventional sintering and has been
has high flexural strength up to 440 MPa7). IPS E.max shown to improve mechanical stability21,22).
lithium disilicate, introduced in 2005 by Ivoclar Vivadent Marginal fit is an important factor in the success of
(AG, Schaan, Liechtenstein), is a material where lithium restorations23,24). Marginal fit is related to both vertical
disilicate crystals (SiO2-Li2O) are embedded into a matrix and horizontal discrepancies. The marginal gap has been
of glass to minimize microcrack propagation8), thereby defined as the vertical distance from the internal surface
improving mechanical stability9). of the restoration to the finish line of the preparation25).
IPS E.max lithium disilicate restorations can be Horizontal discrepancies, such as crown overhangs, can
made using either lost-wax hot pressing techniques (IPS also occur and these result in serious misfit. Horizontal
E.max Press) or computer-aided-designed/computer- overhangs can be adjusted to some degree intraorally.
aided manufactured (CAD/CAM) milling procedures Vertical marginal gaps can only be sealed with luting
(IPS E.max CAD) either in the dental office (chairside cement. Luting cements are rough, porous, and can
CAD/CAM systems) or in the dental laboratory10). dissolve26). The larger the marginal discrepancy, the
CAD/CAM has been available for dental use since its faster will be the rate of cement dissolution26). Therefore,
development by Duret in France in the 1970s (System clinicians seek to minimize marginal gaps to decrease
Duret CAD/CAM)11). Chairside CAD/CAM systems the incidence of tooth staining, gingival irritation and
including Cerec (Sirona Dental Systems) are recognized other dental and periodontal complications accompanied
as reliable chairside CAD/CAM systems12-14) allowing with the rough surfaces present after luting cement
the fabrication of restorations from monolithic blocks of dissolution.
lithium disilicate (IPS E.max CAD)15). Following design There is no clinical or evidence-based consensus
and milling, the precrystallized restorations undergo regarding whether a specific marginal gap may be
a heat crystallization process to achieve maximum clinically acceptable for a given patient. Some studies
strength7,16). The technology allows dental practitioners indicate that a marginal fit <120 microns is clinically
to fabricate restorations in a single visit by using acceptable27), but other authors showed that a marginal
intraoral optical impressions and in-office milling17). fit ≤100 microns is more suitable28,29). Others consider
This workflow avoids use of provisional cements, and it a fit ≤75 microns clinically acceptable30). However, in

Received Jan 6, 2016: Accepted Feb 16, 2016

doi:10.4012/dmj.2016-008 JOI JST.JSTAGE/dmj/2016-008
2 Dent Mater J 2016; : –

additional studies, a marginal fit of between 25 and 40 Exclusion criteria included articles measuring the
microns for cemented restorations was considered to be marginal gap with in-vivo methods, articles in languages
a clinical goal31), but additional studies have shown that other than English.
these levels are difficult to be achieved32). The flow diagram of the search is provided in Fig. 2.
Many studies have been published on the marginal fit Out of the seventy-six articles identified, all underwent
of E.max press and CAD lithium disilicate restorations.
However, no critical review has been undertaken to
explore the collective findings of these studies.
The aim of this study was to undertake a critical
review to explore the collective findings of studies that
reported on the vertical marginal discrepancy, the
marginal gap, when restorations were fabricated from
E.max lithium disicilate.

MATERIALS AND METHODS

An electronic search of MEDLINE (PubMed) was
conducted by two independent reviewers. All terms were
entered as keywords. The search strategy is outlined in
Fig. 1. In addition, a hand search of Journal of Prosthetic
Dentistry, Journal of Dental Materials, International
Journal of Prosthodontics, European Journal of
Dentistry, Journal of Operative Dentistry, Journal of
Brazilian Oral Research, and Journal of Dentistry from
January 2005 until December 2014 was completed.
The search commenced from the year 2005, as this was
the year when E.max lithium disilicate material was
introduced by the manufacturing company, Ivoclar
Vivadent. Unpublished manuscripts and grey literature
were not sought. Duplicate studies were excluded (n=6).
Eligibility criteria included in-vitro studies,
published after 2005 in English, regarding the vertical
marginal fit of E.max lithium disilicate restorations. Fig. 1 Example search for MEDLINE (PubMed) database.

Fig. 2 Flow chart of search strategy.

 Dent Mater J 2016; : – 3

Table 1 Summary of study characteristics of articles retained for qualitative analysis

Type of Size of Year of

Authors Material and technique Mean Marginal gap (Microns)
restoration sample publication

E.max CAD+conventional 3D measurement: 88±24

15
impression (PVS) 2D measurement: 76±23

E.max CAD+Digital 3D measurement: 84±21

15
impression (LavaTM C.O.S.) 2D measurement: 74±26
Anadioti et al. 10)
Crown 2014
E.max Press+conventional 3D measurement: 48±9
15
impression (PVS) 2D measurement: 40±9

E.max Press+Digital 3D measurement: 89±20

15
impression (LavaTM C.O.S.) 2D measurement: 75±15

Before cementation: 83.13

E.max press+Resin (Standard deviation 25.04)
15
modified GIC After cementation: 137.82
(Standard deviation 44.44)
Borges et al.35) Crown 2012
Before cementation: 101.50
(Standard deviation 21.20)
E.max press+Resin cement 15
After cementation: 138.10
(Standard deviation 38.13)

Before cementation: 80–130

E.max press+Chamfer 135º 10
After cementation: 190–310
Demir et al. 9)
Crown 2014
Before cementation: 70–160
E.max press+Shoulder 90º 10
After cementation: 140–220

Before cementation:
45.51 (42.04–48.98)
After cementation:
E.max press 24
62.86 (57.42–68.31)
After fatigue:
58.59 (51.78–65.41)
Guess et al.33) Onlay 2014
Before cementation:
50.09 (47.18–52.99)
E.max CAD After cementation:
24
(CEREC 3D inlab) 54.05 (52.26–55.84)
After fatigue:
50.54 (48.63–52.46)

E.max CAD CEREC in lab 40.2±6.7 10

Hamza et al.15) Crown 2013
E.max CAD Everest 28.1±7.9 10

E.max CAD (E4D) with

55.18 (50.70–76.25) 10
spacer 30 microns

E.max CAD (E4D) with

49.35 (32.30–56.10) 10
Mously et al.37) spacer 60 microns Crown 2014
E.max CAD (E4D) with
46.65 (30.55–58.15) 10
spacer 100 microns

E.max press 30.80 (24.35–41.75) 10

E.max CAD (CEREC 3D) 39.2±8.7 5

Neves et al. 38)
E.max CAD (E4D) 66.9±31.9 Crown 5 2014

E.max press 36.8±13.9 5

4 Dent Mater J 2016; : –

Table 1 continued

E.max CAD (LavaTM C.O.S.) 48±25 15

Ng et al.34) Crown 2014
E.max press 74±47 15

E.max CAD (E4D)+Ideal

38.5 (Standard deviation 9) 25
preparation

E.max CAD (E4D)+Fair

Renne et al.17) 58.3 (Standard deviation 12) Crown 34 2012
preparation

E.max CAD (E4D)+Poor

90.1 (Standard deviation 23) 15
preparation

Partial-
Schaefer et al.19) E.max press 78 (Standard deviation 23) coverage 5 2012
crowns

E.max press+One step

70 (Standard deviation 11) 5
impression/Single viscosity
Partial-
E.max press+One step
Schaefer et al.39) 78 (Standard deviation 15) coverage 5 2013
impression/Dual viscosity
crown
E.max press+Two step
107 (Standard deviation 12) 5
impression/Dual viscosity

E.max press+Chamfer 105.2±21.33 10

Subasi et al.20) Coping 2012
E.max press+Shoulder 98.5±26.04 10

Yuksel and
E.max press 92.6±4 Crown 12 2011
Zaimoglu36)

full text screening (Kappa=0.81, indicating excellent of thermomechanical fatigue in a computer-controlled

agreement) and thirteen were included in the study. Of chewing simulator, Willytec, Munich, Germany,
the 63 exclusions, 2 used in-vivo methods to assess the under clinically relevant conditions) was studied.
marginal gap, 6 were duplicates, 9 were published prior Measurements were undertaken with a stereomicroscope
to 2005, 22 did not report the marginal gaps of lithium at 200× magnification (Zeiss Axioskop Zeiss, Oberkochen,
disicilate, and 24 did not report the vertical marginal Germany), a 3 CCD-colour videocamera (Sony 3CCD,
gap. Sony, Koln, Germany), and image analysis program (cell
Full texts of the articles matching the inclusion Imaging Software for Life Sciences Microscopy, Olympus
criteria were read carefully by the same reviewers. Soft Imaging Solutions, Munster, Germany). The mean
Data extracted included the material, technique, mean marginal gap for the E.max press group was 45.51 (95%
marginal gap (microns), type of restoration, sample size, CI 42.04–48.98) microns before cementation, 62.86 (95%
year of publication (Table 1). CI 57.42–68.31) microns after cementation, and 58.59
Reported outcomes and methodological heterogeneity (95% CI 51.78–65.41) microns after thermomechanical
were explored qualitatively. cycling. The mean marginal gap for the E.max CAD
group was 50.09 (95% CI 47.18–52.99) microns before
RESULTS cementation, 54.05 (95% CI 52.26–55.84) microns after
cementation, and 50.54 (95% CI 48.63–52.46) microns
The search identified 13 studies that matched the after thermomechanical cycling. The difference in the
inclusion criteria, with 11 studies reporting on E.max mean marginal gap was not statistically significant
press, 7 reporting on E.max CAD, 5 reporting marginal between the two groups before cementation (p-value 0.29)
gaps of both E.max press and E.max CAD. The studies and after thermomechanical cycling (p-value>0.05). In
assessed the marginal fit of complete crowns (n=9), contrast to the outcomes reported before cementation, or
partial veneer crowns (n=2), onlays (n=1) and copings after thermomechanical cycling, Guess and colleagues
(n=1). found that onlays fabricated with the press technique
Guess and colleagues33) studied the marginal fit of had significantly higher marginal gaps than those
E.max press and E.max CAD (CEREC 3D InLab) onlays. fabricated with the CAD technique after cementation
The marginal gap before cementation, after cementation, (p-value 0.024). The authors concluded that cementation
and after exposure to thermomechanical cycling (cycles increased the marginal gap significantly, while the
 Dent Mater J 2016; : – 5

thermomechanical fatigue had no significant effect33). The authors did not express the difference in the
Ng and colleagues34) compared the marginal gap of marginal gap after cementation of specimens with
E.max press and E.max CAD (LAVA C.O.S. scanning different marginal designs clearly. However, across
unit) crowns. The marginal gap was measured using both marginal designs, the authors concluded that the
a stereomicroscope at 40× magnification with a digital marginal gap increased significantly after cementation,
camera (5D Mark II 21-mp, Canon) mounted on the p-value<0.05 (The exact p-value was not reported), which
stereomicroscope (Edmund E-Zoom, Edmund Optics) agrees with the results of Borges and colleagues, and
and a software for photos calibration and measurements Guess and colleagues, except in the shoulder preparation
(Image J 1.32, U.S. National Institutes of Health). The (sagittal buccal region), where no significant increase
mean marginal gap was 48±25 SD (standard deviation) was noticed9).
microns for the E.max CAD group, and 74±47 SD Subasi and colleagues20) studied the marginal fit of
microns for the E.max Press group. Similarly to the E.max press copings after cementation in combination
outcomes of the cemented CAD Cerec 3D onlays studied with two types of finishing lines (shoulder and chamfer).
by Guess and Colleagues, the mean marginal gap of the The measurements of the marginal gap were achieved
uncemented crowns were significantly higher for the using stereomicroscope at 46× magnification and a
E.max press group compared to the E.max CAD LAVA computer software (Leica StereoExplorer software, Leica
group34). Microsystems). The mean marginal gap was 105.2±21.33
Borges and colleagues35) studied the marginal fit microns for the chamfer group, and 98.5±26.04 microns
of E.max press crowns in combination with two types for the shoulder group, with no significant differences
of luting cements (Resin cement, resin-modified glass between the two groups (p-value 0.36). These variances
ionomer cement). The marginal gap was measured using were unclear from the original article, if they are
an optical microscope at 50× magnification. The mean standard errors or standard deviations20).
marginal gap was 83.13±25.04 SD microns for the resin- Mously and colleagues37) compared the marginal fit
modified glass ionomer group before cementation and of E.max press and E.max CAD crowns (E4D scanner).
137.82±44.44 SD microns after cementation. The mean Four groups were assessed: Group 1: E.max CAD with a
marginal gap was 101.50±21.20 SD microns for the resin 30 micron spacer, group 2: E.max CAD with a 60 micron
cement group before cementation and 138.10±38.13 spacer, group 3: E.max CAD with a 100 micron spacer,
SD microns after cementation. The authors concluded group 4: E.max press. The marginal gap was measured
that no significant differences were found between the using microcomputed tomography, micro-XCT (mCT 40,
cements (p-value<0.05), but the mean marginal gap Scanco Medical) and a program for analyzing images
increased significantly after cementation35), which agrees (Image J software, National Institutes of Health). The
with the results of Guess and colleagues. results for the median marginal gap were: Group 1: 55.18
Yuksel and colleagues36) studied the marginal (50.70–76.25) microns, group 2: 49.35 (32.30–56.10)
fit of E.max press crowns (n=12 crowns) with two microns, group 3: 46.65 (30.55–58.15) microns, group
types of luting cements (Glass ionomer cement (n=6), 4: 30.80 (24.35–41.75) microns. The marginal gap was
Self-adhesive resin cement (n=6). Measurements of significantly lower in the E.max press group than the
the marginal gap were achieved after sectioning the E.max CAD groups (p-value=0.005)37). In contrast with
specimens and digital photography under a the results reported by Ng and colleagues regarding
stereomicroscope at 50× magnification. The mean marginal gaps before cementation, and the results of
marginal gap was 92.6±4 microns with slightly higher Guess and colleagues regarding marginal gaps after
values for the glass ionomer cement group, but with no cementation, this study concluded that the marginal
significant differences36). The variance in this study is not gaps of the E.max press specimens were significantly
clear from the original article, if it is a standard deviation lower than the E.max CAD specimens. This may be
or a standard error. These results are in agreement with attributed to the differences in the CAD systems used
those reported by Borges and colleagues. in these studies, CEREC-Inlab 3D system in the study
Demir and colleagues9) studied the marginal fit of Guess and colleagues, DMG/Mori Seiki system in the
of E.max press crowns in combination with 2 types of study of Ng and colleagues, and E4D system in the study
finishing lines (Shoulder 90° and chamfer 135°) across 10 of Mously and colleagues.
specimens per group. The marginal gap was measured Neves and colleagues38) compared the marginal fit of
with micro-CT and (CTan) software before cementation E.max press and E.max CAD crowns. Three groups were
and after cementation and thermal cycling. The results assessed: Group 1 (E.max CAD CEREC 3D bluecam
were shown in tables: scanner), group 2 (E.max CAD E4D laser scanner),
E.max press crowns with shoulder finish line before group 3 (E.max Press). The marginal gap was measured
cementation: 70–160 microns by processing software (v1.12.0.0, Sky-Scan) after micro
E.max press crowns with chamfer finish line before CT scanning. The mean marginal gap was 39.2±8.7 SD
cementation: 80–130 microns microns for group 1, 66.9±31.9 SD microns for group 2,
E.max press crowns with shoulder finish line after and 36.8±13.9 SD microns for group 3. E.max Lithium
cementation: 140–220 microns disilicate crowns fabricated with either the —Cerec 3D
E.max press crowns with chamfer finish line after Bluecam scanner CAD/CAM or heat-press technique—
cementation: 190–310 microns achieved significantly smaller marginal gaps than crowns
6 Dent Mater J 2016; : –

fabricated with the —CAD/CAM E4D Laser scanner— (Qualify 12, Geomagic, Stuttgart, Germany) after
(p-value 0.046)38). These results compare favourably with digitizing the prepared tooth and the partial coverage
the CAD E4D results of Mously and colleagues. They crown by a white-light scanner. The mean marginal gap
indicate that the E.max press technique is superior to was:
the E4D, and that different CAD techniques such as the Group 1: 70±11 SD microns , group 2: 78±15 SD
CEREC 3D bluecam scanner or alternative technologies microns , group 3 : 107±12 SD microns.
studied by other authors may produce superior outcomes The authors concluded that the one step impression
for CAD/CAM fabricated prostheses. technique resulted in significantly less marginal gap than
Hamza and colleagues15) measured the marginal gap the two step impression technique (p-value 0.006)39).
of E.max CAD crowns using two different CAD/CAM In a different study, Schaefer and colleagues19)
systems (CEREC InLab, Kavo Everest). Digital images studied the marginal fit of E.max press partial coverage
were taken at a 100× magnification and the marginal crowns. Measurements were completed using computer
gap was measured with computer software (Optimas 6.5, software (Qualify 12, Geomagic) after digitizing
Media Cybernetics, Rockville, MD, USA). The Everest the prepared tooth and the partial coverage crown
CAD/CAM system specimens showed significantly lower by a structured light scanner (Flex 3A, Otto Vision
marginal gap (28.1±7.9 SD microns) than those of the Technology, Jena, Germany). The mean marginal gap
Cerec InLab system specimens (40.2±6.7 SD microns) was 78±23 SD microns19). The results achieved in this
(p-value<0.05)15). The authors attributed this difference study agrees with all the other studies included in this
to the 3-axis milling unit of the Cerec InLab, compared review, in terms of having a mean marginal gap below
to the 5-axis unit of the Everest system. However, in 120 microns.
the study of Neves and colleagues, both the Cerec 3D Renne and colleagues17) studied the marginal gap of
system and the E4D system had a 3-axis milling unit, E.max CAD (E4D scanning unit) crowns in combination
and the results were significantly different between the with three categories of preparation: Ideal (n=25), fair
2 systems. (n=34), and poor (n=15). The authors considered both
Anadioti and colleagues10) compared the marginal fit heavy chamfer and modified shoulder preparations
of E.max press and E.max CAD crowns in combination as acceptable. The marginal fit was measured using
with conventional (PVS) and optical impressions the replica technique, where a green light body VPS
(LavaTM C.O.S). The study was divided into 4 groups: impression material (Genie, Sultan Healthcare,
Group 1 (PVS+Press), group 2 (PVS+CAD), group 3 Englewood, NJ, USA) was injected into the crowns
(Optical+Press), group 4 (Optical+CAD). The marginal before placing them on the corresponding die with
fit was measured in 3 dimensions and 2 dimensions finger pressure to replicate the marginal gap. Thus, no
computer software (Geomagic Qualify 2012, Research cementation was applied in this study. The authors used
Triangle Park, NC, USA) after digitizing the sample a microscope at 100× magnification, a digital camera
using a laser scanner (Laser Design, GKS, Minneapolis, and a digital software (Omnimet 8.8.1, Buehler). The
MN, USA). The mean marginal gap was: mean marginal gap was 38.5 microns with a standard
Group 1: 3D measurement (48±9 SD microns), 2D deviation 9 microns for the ideal preparation group, 58.3
measurement (40±9 SD microns), microns with a standard deviation 12 microns for the
Group 2: 3D measurement (88±24 SD microns), 2D fair preparation group, and 90.1 microns with a standard
measurement (76±23 SD microns), deviation 23 microns for the poor preparation group.
Group 3: 3D measurement (89±20 SD microns), 2D The authors concluded that the category of preparation
measurement (75±15 SD microns), affected significantly the marginal fit of E.max CAD
Group 4: 3D measurement (84±21 SD microns), 2D crowns (p-value<0.001)17)
measurement (74±26 SD microns).
The smallest marginal gap was measured in the first DISCUSSION
group (Conventional impression +E.max press) 3D (48
microns) and 2D (40 microns), which was significantly This critical review collated information from the
smaller than in the other groups (p-value<0.0001)10). published literature regarding the marginal fit of E.max
These results are in agreement with Mously and lithium disilicate restorations (Press and CAD). These
colleague, which also showed that the E.max press techniques are becoming more common for fabrication of
restorations achieved by silicon impressions had minimal dental restorations in clinical practice40), but advances
marginal gaps. in technology and laboratory techniques mean that
Schaefer and colleagues39) studied the marginal fit the techniques are regularly evolving. Marginal gaps
of E.max press partial coverage crowns fabricated from will always be present when indirect restorations
master casts when different impression techniques are fabricated, and the presence of such gaps can be
were used. Group 1: One step single viscosity, vinyl related to ongoing cement dissolution, dental caries and
siloxanether material (Identium, Kettenbach), group periodontal complications40).
2: One step dual viscosity, vinyl siloxanether material The search identified 13 studies that met the
(Identium, Kettenbach), group 3: Two step dual viscosity, inclusion criteria. Out of the 5 studies that compared
vinyl polysiloxane material (Panasil, Kettenbach). the marginal fit of E.max press and E.max CAD
Measurements were undertaken with computer software restorations, the majority (n=3) found that the E.max
 Dent Mater J 2016; : – 7

lithium disilicate restorations fabricated with the press of the stone cast, as well as disinfection may cause
technique had significantly smaller marginal gaps an additional distortion49,50). The application of a die
than those fabricated with CAD technique10,37,38). This hardener and die spacer, the fabrication of a wax pattern
finding may be related to the scanning device accuracy, of the restoration, and the investment and pressing
software design, spacer settings, and milling machine process may also be source of errors51,52). However, the
accuracy41-43). measurements conducted by Ng and colleagues34) were
Most of the included studies had some possible made at only 8 locations per specimen, which might be
drawbacks, which might have affected the outcomes. inadequate. Groten et al. suggested that, ideally, 50 or
Mously and colleagues 37) were among the authors at least 20–25 measurements are required to obtain
that found that the E.max lithium disilicate restorations clinically relevant information about the gap size53).
fabricated with the press technique had significantly The Cerec 3D system (Sirona, Bensheim, Germany)
smaller marginal gaps than those fabricated with CAD and the Everest system (Kavo, Bismarckring, Germany)
technique. The authors used Micro-CT to measure the use different software and milling systems to fabricate
marginal gap. The disadvantages of this method include ceramic restorations15). Hamza et al. concluded that the
the low capacity of discrimination of CT microtomography Everest CAD system crowns showed significantly lower
compared to the optical or electron microscope44). A marginal gap than those of the Cerec InLab system15).
major drawback of this technique is radiation artifacts, However, the measurements were also made at only 8
which are caused by the differences in the coefficient locations per specimen, which might be inadequate to
of radiation absorption among the different materials give accurate results.
used45). This technique was also used in the study of Schaefer and colleagues concluded that the one step
Demir and colleagues which showed that marginal gap impression technique resulted in a significantly lower
of E.max press crowns increased significantly after marginal gap of the E.max press partial-coverage crowns
cementation9). The use of this method of measurement than the two step impression technique39). However,
in these two studies may have affected the reliability of impressions were made on an acrylic resin model, which
the results. differs from dentine and enamel. In addition, soft tissue,
Anadioti and colleagues44) measured the marginal saliva, crevicular fluid, humidity and temperature
gap using a new scanner, and its reliable use would have would differ between the intraoral and the laboratory
been subject to a learning curve by the researchers. In environments.
addition, errors might take place during the multiple The quality of preparation (ideal, fair, poor) had
scanning phases: 1) The prepared dentoform tooth a significant effect on the marginal fit of E.max CAD
(master die), 2) the intaglio of each all-ceramic crown crowns before cementation as shown by Renne et al.17).
and 3) each crown on the dentoform tooth in a final Despite the fact that the evaluators in the study of
position. These errors are likely to occur and may affect Renne and colleagues used magnifying loupes 2.5× for
the final result significantly. evaluating the quality of preparations, the preparation
Neves and colleagues38) showed a significantly quality was assessed with a subjective method,
smaller marginal gap of E.max Lithium disilicate using visual inspection to determine the extent that
crowns fabricated with (Cerec 3D Bluecam scanner preparations differed from the ideal. This method could
CAD/CAM system) or the heat-press technique than contribute to allocation bias in this study.
E.max Lithium disilicate crowns fabricated with (CAD/ In additional research relating to preparation design,
CAM E4D Laser scanner)38). However, the sample size the mean marginal gap of E.max press crowns was not
of this study was very small (5 specimens per group) affected by the design of the finishing line (Shoulder vs
compared to other studies like Guess and colleagues chamfer) as shown by Subasi et al. after cementation20)
(24 specimens per group), which could be inadequate to and Demir et al. before and after cementation9).
give a significant result. In addition, a silicon material The major drawback of the study made by Subasi
was used to fix the crowns on the die model, which could and colleagues is that the measurements were only made
affect the accuracy of the marginal gap measurement. after cementation, with no measurements achieved
Conversely, one study showed no significant before cementation as done by Guess and colleagues.
difference in the mean marginal gap between the E.max Regarding the measurements after cementation, it does
CAD and E.max press restorations33), while another not show the fit of the restorative material without
study showed that the E.max CAD restorations had the cement layer. The cement layer may increase the
significantly smaller marginal gap than the E.max press marginal gap uncontrollably and unequally depending
restorations34). on the cement type and viscosity. Therefore, it is better
The findings of the latter study could be explained to measure the marginal fit either before cementation,
by the following: E.max press restorations require or before and after cementation. It has been reported
an accurate negative replica of the dentition with an that the marginal gap increased by 13 to 22 µm when
elastomeric impression material46,47). Transporting the crown was luted with cement54,55). In our review,
the impression to the dental laboratory subjects the all the studies that tested the effect of cementation on
impression to a large variation in temperature, which the marginal gap of E.max restorations, had similar
could result in dimensional changes48). In addition, the conclusion, that the cementation increased the marginal
length of time between impression making and pouring gap significantly9,33,35).
8 Dent Mater J 2016; : –

Borges and colleagues found no significant effect to the knowledge base in this growing field.
of the cement type (resin cement,Variolink II or resin- This critical review provides information about
modified glass ionomer cement, Rely X), on the marginal the dimensions of vertical marginal gaps that can be
fit of E.max press crowns35). However, the study was achieved under experimental conditions in the in-vitro
conducted on extracted bovine teeth, which could have environment with E.max lithium disilicate. However,
different characteristics and reaction with the fixating these in-vitro measurements do not necessarily reflect
cements from those of vital human teeth, which in turn clinical reality. The studies have been designed to
could have affected the results of the study. maximize internal consistency, allowing the data to be
Despite the drawbacks found in the studies collated in a repeatable manner and understood within
included in our critical review, there were also positive the context of each study. However, each in-vitro study
methodological decisions which contributed to strong environment differs considerably from everyday clinical
findings of individual studies. The sample size was practice. Differences may include (the existence of saliva
sufficiently large to avoid type II errors, and allow and soft tissues make intraoral tooth preparation and
confidence in the significant results reported by Borges impression making much more complicated than in-
and colleagues, Renne and colleagues, and Guess and vitro ones, the prepared teeth in in-vitro studies might
colleagues. The studies of Yuksel and colleagues, Demir be fabricated from different materials that might have
and colleagues, and Guess and colleagues were achieved different characteristics than natural teeth, and other
on extracted human teeth and this allowed the behavior factors), which means that the results have reduced
of the teeth under experimental investigations to be as external validity. Despite this limitation, the information
similar as possible to the intraoral environment. One reported provides researchers with a “proof of concept”,
out of the thirteen studies measured the marginal gap and an important starting point to guide hypotheses for
at 50 or more locations for each restoration in the study, future clinical studies. Further research is required in
Neves and colleagues, minimizing measurement error three separate domains: (1) to determine whether these
and allowing the circumferential fit of the restoration to marginal gap dimensions can be routinely achieved in
be estimated with the highest accuracy. a clinical environment; (2) the clinical consequences
The results from studies evaluating the marginal that such marginal gaps have on the longevity and
fit of different all-ceramic restorations, show great complication burden of restorations; and (3) to review
variations within the same restorative material and such outcomes across different restorative materials.
technique56-59). This might be explained by the following
factors: Measurement of cemented or non-cemented CONCLUSIONS
restorations, the material from which the die model is
fabricated from (acrylic, metal, zircon, human teeth and Within the scope of this critical review, the following
bovine teeth), the type of scanner and milling device, the conclusions were drawn:
thickness of the die spacer used, the type of microscope, 1. The majority of studies showed that E.max lithium
the amount of magnification used for the measurement, disilicate restorations fabricated with the press
and the number of measurements. Despite these technique have measurably smaller marginal
differences, the mean marginal gap of all E.max lithium gaps when compared with those fabricated with
disilicate restorations in the studies appraised in this CAD techniques.
critical review, regardless of technique, was within the 2. The marginal gaps achieved by the restorations
clinically acceptable range. across all groups were within a clinically
The results of this critical review are limited acceptable range.
by aspects of its methodology. Studies published in
languages other than English were excluded, grey CONFLICTS OF INTEREST
literature was not sought, the electronic search strategy
excluded indexing terms, and multiple bibliographic None of the authors report any conflict of interests.
databases were not consulted. Therefore, it is likely that
relevant articles were excluded from this critical review. FUNDING
The authors aimed to collate articles from the published
literature at large. It is known that the exclusions listed This research was carried out without funding.
above increase the chance that small studies, especially
those with non-significant results, are not identified REFERENCES
as part of the appraisal. However, the authors did
not seek to complete a systematic review, and did not 1) Horn HR. A new lamination: porcelain bonded to enamel. N Y
State Dent J 1983; 49: 401-403.
seek to combine the results quantitatively with meta-
2) Calamia JR. Etched porcelain facial veneers: a new treatment
analytic techniques. The critical appraisal of the collated modality based on scientific and clinical evidence. N Y J Dent
material completed in this review provides clinicians 1983; 53: 255-259.
and researchers with an important resource to guide 3) Simonsen RJ, Kanca J. Tensile bond strengths of etched
clinical decisions and to assist in the design of ongoing porcelain. J Dent Res 1983.
research. The authors acknowledge the limitations, but 4) Nakabayashi N, Nakamura M, Yasuda N. Hybrid layer as a
dentin-bonding mechanism. J Esthet Dent 1991; 3: 133-138.
also espouse the contribution that this review has made
 Dent Mater J 2016; : – 9

5) Pospiech P. All-ceramic crowns: bonding or cementing? Clin 26) Jacobs MS, Windeler AS. An investigation of dental luting
Oral Investig 2002; 6: 189-197. cement solubility as a function of the marginal gap. J Prosthet
6) Spear F, Holloway J. Which all-ceramic system is optimal Dent 1991; 65: 436-442.
for anterior esthetics? J Am Dent Assoc 2008; 139 Suppl: 27) McLean JW, von Fraunhofer JA. The estimation of cement
19S-24S. film thickness by an in vivo technique. Br Dent J 1971; 131:
7) Tysowsky, GW. The science behind lithium disilicate: a metal- 107-111.
free alternative. Dent Today 2009; 28: 112-113. 28) Reich S, Gozdowski S, Trentzsch L, Frankenberger R,
8) Ohyama T, Yoshinari M, Oda Y. Effects of cyclic loading on Lohbauer U. Marginal fit of heat-pressed vs. CAD/CAM
the strength of all-ceramic materials. Int J Prosthodont 1999; processed all-ceramic onlays using a milling unit prototype.
12: 28-37. Oper Dent 2008; 33: 644-650.
9) Demir N, Ozturk AN, Malkoc MA. Evaluation of the marginal 29) Davis DR. Comparison of fit of two types of all-ceramic
fit of full ceramic crowns by the microcomputed tomography crowns. J Prosthet Dent 1988; 59: 12-16.
(micro-CT) technique. Eur J Dent 2014; 8: 437-444. 30) Hung SH, Hung KS, Eick JD, Chappell RP. Marginal fit of
10) Anadioti E, Aquilino S, Gratton D, Holloway J, Denry I, porcelain-fused-to-metal and two types of ceramic crown. J
Thomas G, Qian F. 3D and 2D marginal fit of pressed and Prosthet Dent 1990; 63: 26-31.
CAD/CAM lithium disilicate crowns made from digital and 31) Council adopts American Dental Association Specification
conventional impressions. J Prosthodont 2014; 23: 610-617. No. 8 (dental zinc phosphate cement) and 11 (agar impression
11) Heymann HO, Bayne SC, Sturdevant JR, Wilder AD Jr, material). Council on Dental Materials and Devices. J Am
Roberson TM. The clinical performance of CAD/CAM- Dent Assoc 1967; 74: 1565-1573.
generated ceramics inlays. A four year study. J Am Dent 32) May KB, Russell MM, Razzoog ME, Lang BR. Precision of fit:
Assoc 1996; 127: 1171-1181. the Procera AllCeram crown. J Prosthet Dent 1998; 80: 394-
12) Bindl A, Mormann WH. Clinical and SEM evaluation of all- 404.
ceramic chair-side CAD/CAM-generated partial crowns. Eur 33) Guess PC, Vagkopoulou T, Zhang Y, Wolkewitz M, Strub
J Oral Sci 2003; 111: 163-169. JR. Marginal and internal fit of heat pressed versus CAD/
13) Reiss B, Walther W. Clinical long-term results and 10-year CAM fabricated all-ceramic onlays after exposure to thermo-
Kaplan-Meier analysis of Cerec restorations. Int J Comput mechanical fatigue. J Dent 2014; 42: 199-209.
Dent 2000; 3: 9-23. 34) Ng J, Ruse D, Wyatt C. A comparison of the marginal fit of
14) Reiss B. Clinical results of Cerec inlays in a dental practice crowns fabricated with digital and conventional methods. J
over a period of 18 years. Int J Comput Dent 2006; 9: 11-22. Prosthet Dent 2014; 112: 555-560.
15) Hamza TA, Ezzat HA, El-Hossary MM, Katamish HA, Shokry 35) Borges GA, Faria JS, Agarwal P, Spohr AM, Correr-Sobrinho
TE, Rosenstiel SF. Accuracy of ceramic restorations made L, Miranzi BA. In vitro marginal fit of three all-ceramic crown
with two CAD/CAM systems. J Prosthet Dent 2013; 109: 83- systems before and after cementation. Oper Dent 2012; 37:
87. 641-649.
16) Borba M, Cesar PF, Griggs JA, Della Bona Á. Adaptation 36) Yuksel E, Zaimoglu A. Influence of marginal fit and cement
of all-ceramic fixed partial dentures. Dent Mater 2011; 27: types on microleakage of all-ceramic crown systems. Braz
1119-1126. Oral Res 2011; 25: 261-266.
17) Renne W, McGill ST, Forshee KV, DeFee MR, Mennito AS. 37) Mously HA, Finkelman M, Zandparsa R, Hirayama
Predicting marginal fit of CAD/CAM crowns based on the H. Marginal and internal adaptation of ceramic crown
presence or absence of common preparation errors. J Prosthet restorations fabricated with CAD/CAM technology and the
Dent 2012; 108: 310-315. heat-press technique. J Prosthet Dent 2014; 112: 249-256.
18) Frankenberger R, Lohbauer U, Taschner M, Petschelt 38) Neves FD, Prado CJ, Prudente MS, Carneiro TA, Zancopé K,
A, Nikolaenko SA. Adhesive luting revisited: influence of Davi LR, Mendonça G, Cooper LF, Soares CJ. Micro-computed
adhesive, temporary cement, cavity cleaning, and curing tomography evaluation of marginal fit of lithium disilicate
mode on internal dentin bond strength. J Adhes Dent 2007; 9 crowns fabricated by using chairside CAD/CAM systems
Suppl 2: 269-273. or the heat-pressing technique. J Prosthet Dent 2014; 112:
19) Schaefer O, Watts DC, Sigusch BW, Kuepper H, Guentsch A. 1134-1140.
Marginal and internal fit of pressed lithium disilicate partial 39) Schaefer O, Kuepper H, Sigusch BW, Thompson GA, Hefti
crowns in vitro: a three-dimensional analysis of accuracy and AF, Guentsch A. Three-dimensional fit of lithium disilicate
reproducibility. Dent Mater 2012; 28: 320-326. partial crowns in vitro. J Dent 2013; 41: 271-277.
20) Subasi G, Ozturk N, Inan O, Bozogullari N. Evaluation of 40) Felton DA, Kanoy BE, Bayne SC, Wirthman GP. Effect of
marginal fit of two all-ceramic copings with two finish lines. in vivo crown margin discrepancies on periodontal health. J
Eur J Dent 2012; 6: 163-168. Prosthet Dent 1991; 65: 357-364.
21) Stappert CF, Att W, Gerds T, Strub JR. Fracture resistance 41) Alghazzawi TF, Liu PR, Essig ME. The effect of different
of different partial-coverage ceramic molar restorations: An fabrication steps on the marginal adaptation of two types of
in vitro investigation. J Am Dent Assoc 2006; 137: 514-522. glass-infiltrated ceramic crown copings fabricated by CAD/
22) Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, CAM technology. J Prosthodont 2012; 21: 167-172.
fracture toughness and microstructure of a selection of all- 42) Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an
ceramic materials. Part I. Pressable and alumina glass- overview of recent developments for CAD/CAM generated
infiltrated ceramics. Dent Mater 2004; 20: 441-448. restorations. Br Dent J 2008; 204: 505-511.
23) Baig MR, Tan KB, Nicholls JI. Evaluation of the marginal fit 43) Fahmy AM. Comparison of marginal fit between collarless
of a zirconia ceramic computer-aided machined (CAM) crown metal ceramic and two all ceramic restorations. J Am Sci
system. J Prosthet Dent 2010; 104: 216-227. 2012; 8: 528-534.
24) Pak HS, Han JS, Lee JB, Kim SH, Yang JH. Influence of 44) Anadioti E. Internal and marginal fit of pressed and cad
porcelain veneering on the marginal fit of Digident and Lava lithium disilicate crowns made from digital and conventional
CAD/CAM zirconia ceramic crowns. J Adv Prosthodont 2010; impressions. 2013, University of Iowa. p. 153.
2: 33-38. 45) Pelekanos S, Koumanou M, Koutayas SO, Zinelis S, Eliades
25) Holmes JR, Bayne SC, Holland GA, Sulik WD. Considerations G. Micro-CT evaluation of the marginal fit of different In-
in measurement of marginal fit. J Prosthet Dent 1989; 62: Ceram alumina copings. Eur J Esthet Dent 2009; 4: 278-292.
405-408. 46) Dixon DL, Breeding LC, Brown JS. The effect of custom tray
10 Dent Mater J 2016; : –

material type and adhesive drying time on the tensile bond of the minimum number of marginal gap measurements
strength of an impression material/adhesive system. Int J required for practical in-vitro testing. J Prosthet Dent 2000;
Prosthodont 1994; 7: 129-133. 83: 40-49.
47) Mandikos MN. Polyvinyl siloxane impression materials: an 54) Wolfart S, Wegner SM, Al-Halabi A, Kern M. Clinical
update on clinical use. Aust Dent J 1998; 43: 428-434. evaluation of marginal fit of a new experimental all-ceramic
48) Corso M, Abanomy A, Di Canzio J, Zurakowski D, Morgano system before and after cementation. Int J Prosthodont 2003;
SM. The effect of temperature changes on the dimensional 16: 587-592.
stability of polyvinyl siloxane and polyether impression 55) Beschnidt SM, Strub JR. Evaluation of the marginal accuracy
materials. J Prosthet Dent 1998; 79: 626-631. of different all-ceramic crown systems after simulation in the
49) Rodriguez JM, Bartlett DW. The dimensional stability of artificial mouth. J Oral Rehabil 1999; 26: 582-593.
impression materials and its effect on in vitro tooth wear 56) Groten M, Girthofer S, Probster L. Marginal fit consistency
studies. Dent Mater 2011; 27: 253-258. of copy-milled all-ceramic crowns during fabrication by light
50) Thongthammachat S, Moore BK, Barco MT, Hovijitra S, and scanning electron microscopic analysis in vitro. J Oral
Brown DT, Andres CJ. Dimensional accuracy of dental casts: Rehabil 1997; 24: 871-881.
influence of tray material, impression material, and time. J 57) Rinke S, Huls A, Jahn L. Marginal accuracy and fracture
Prosthodont 2002; 11: 98-108. strength of conventional and copy-milled all-ceramic crowns.
51) Campagni WV, Preston JD, Reisbick MH. Measurement of Int J Prosthodont 1995; 8: 303-310.
paint-on die spacers used for casting relief. J Prosthet Dent 58) Yeo IS, Yang JH, Lee JB. In vitro marginal fit of three all-
1982; 47: 606-611. ceramic crown systems. J Prosthet Dent 2003; 90: 459-464.
52) Gorman CM, McDevitt WE, Hill RG. Comparison of two heat- 59) Sulaiman F, Chai J, Jameson LM, Wozniak WT. A comparison
pressed all-ceramic dental materials. Dent Mater 2000; 16: of the marginal fit of In-Ceram, IPS Empress, and Procera
389-395. crowns. Int J Prosthodont 1997; 10: 478-484.
53) Groten M, Axmann D, Pröbster L, Weber H. Determination