applied

sciences
Article
Effect of Printing Layer Thickness on the Trueness and Margin
Quality of 3D-Printed Interim Dental Crowns
Gülce Çakmak 1 , Alfonso Rodriguez Cuellar 2 , Mustafa Borga Donmez 3 , Martin Schimmel 1,4 ,
Samir Abou-Ayash 1, * , Wei-En Lu 5 and Burak Yilmaz 1,6,7

1 Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern,
3010 Bern, Switzerland; [email protected] (G.Ç.); [email protected] (M.S.);
[email protected] (B.Y.)
2 Department of Periodontology, Clinica Dental Rodriguez Dental Clinic, Mexico City 03100, Mexico;
[email protected]
3 Department of Prosthodontics, Biruni University Faculty of Dentistry, 34010 Istanbul, Turkey;
[email protected]
4 Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine,
University of Geneva, 1205 Geneva, Switzerland
5 Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH 43210, USA;
[email protected]
6 Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern,
3010 Bern, Switzerland
7 Division of Restorative and Prosthetic Dentistry, The Ohio State University College of Dentistry,
Columbus, OH 43210, USA
* Correspondence: [email protected]; Tel.: +41-(0)31-632-8705



Abstract: The information in the literature on the effect of printing layer thickness on interim


3D-printed crowns is limited. In the present study, the effect of layer thickness on the trueness and
Citation: Çakmak, G.; Cuellar, A.R.;
margin quality of 3D-printed composite resin crowns was investigated and compared with milled
Donmez, M.B.; Schimmel, M.;
crowns. The crowns were printed in 3 different layer thicknesses (20, 50, and 100 µm) by using a
Abou-Ayash, S.; Lu, W.-E.; Yilmaz, B.
hybrid resin based on acrylic esters with inorganic microfillers or milled from polymethylmethacry-
Effect of Printing Layer Thickness on
the Trueness and Margin Quality of
late (PMMA) discs and digitized with an intraoral scanner (test scans). The compare tool of the
3D-Printed Interim Dental Crowns. 3D analysis software was used to superimpose the test scans and the computer-aided design file
Appl. Sci. 2021, 11, 9246. https:// by using the manual alignment tool and to virtually separate the surfaces. Deviations at different
doi.org/10.3390/app11199246 surfaces on crowns were calculated by using root mean square (RMS). Margin quality of crowns was
examined under a stereomicroscope and graded. The data were evaluated with one-way ANOVA
Academic Editor: Kathrin Becker and Tukey HSD tests. The layer thickness affected the trueness and margin quality of 3D-printed
interim crowns. Milled crowns had higher trueness on intaglio and intaglio occlusal surfaces than
Received: 8 September 2021 100 µm-layer thickness crowns. Milled crowns had the highest margin quality, while 20 µm and
Accepted: 2 October 2021
100 µm layer thickness printed crowns had the lowest. The quality varied depending on the location
Published: 5 October 2021
of the margin.

Publisher’s Note: MDPI stays neutral

Keywords: 3D printing; additive manufacturing; interim crowns; provisional crowns; trueness;
with regard to jurisdictional claims in
accuracy; layer thickness; margin quality
published maps and institutional affil-
iations.

1. Introduction

Copyright: © 2021 by the authors.

The introduction of digital technologies into dental practice has facilitated manufac-
Licensee MDPI, Basel, Switzerland.
turing, as computer aided design-computer aided manufacturing (CAD-CAM) enabled
This article is an open access article
the fabrication of accurate definitive restorations [1]. CAD-CAM manufacturing can be
distributed under the terms and subtractive (milling) [2] or additive, and the interest has recently shifted towards additive
conditions of the Creative Commons manufacturing technologies that are also known as rapid prototyping or 3-dimensional
Attribution (CC BY) license (https:// (3D) printing [3–5].
creativecommons.org/licenses/by/ 3D-printing manufactures an object by building up consecutive layers [5,6] and is
4.0/). used for a wide range of dental applications including diagnostic and master models,

Appl. Sci. 2021, 11, 9246. https://doi.org/10.3390/app11199246 https://www.mdpi.com/journal/applsci

Appl. Sci. 2021, 11, 9246 2 of 14

surgical guides, complete dentures, occlusal splints, impression trays, implants, metal
crowns, copings, and frameworks [4,7–13]. Printing has certain advantages over milling
as less waste material is produced, multiple products with more complex geometries
can be fabricated, and less energy is consumed [14,15]. Moreover, due to an increased
accuracy and speed, of 3D-printing has increased its popularity in the dental field [16].
Several different 3D-printing technologies, namely stereolithography (SLA), digital light
processing (DLP), material jetting (MJ), material extrusion (ME), binder jetting, powder
bed fusion (PBF), sheet lamination, and direct energy deposition, are currently available for
polymers [7]. However, among these technologies, the popularity of DLP, which is based
on the UV light activation of the photosensitive resin [17], is increasing for the fabrication
of dental prosthesis [4,18].
Interim restorations are an essential component of the prosthodontic treatment as they
act as a prototype of the definitive prosthesis providing esthetics, pulp protection, tooth
positional stability, and soft tissue management [19,20]. Conventional interim restorations
are fabricated commonly by using polymethylmethacrylate (PMMA) due to its accessibility,
ease of fabrication and repair, low cost, biocompatibility, and stability in the oral environ-
ment [19–21]. Even though direct fabrication of acrylic resin interim crowns is feasible [22],
polymerization shrinkage, possible biologic reactions due to the residual monomers, and
marginal and occlusal discrepancies can be observed [20,22,23]. The indirect fabrication
of these restorations with CAD-CAM technologies led to a better internal fit [20] and
marginal integrity [24], enabling successful and long-lasting restorations [20]. Both sub-
tractive manufacturing and 3D-printing technologies are applicable for the fabrication of
interim restorations [19].
Efficiency of 3D-printing is affected by the layer thickness, laser intensity, laser
speed, build angle, the geometry of the supporting structures, and printing technol-
ogy [14,21,25–27]. Layer thickness is a controllable parameter that affects the accuracy,
which is defined by trueness and precision [28], of the final restoration [7]. Therefore,
setting the appropriate layer thickness is crucial to achieve optimum results. In addition,
layer thickness was shown to affect the printing speed and printing accuracy [16]. In
general, the layer thickness of a 3D-printer based on photopolymerization ranges between
20 to 150 µm [7].
Previous studies on 3D-printed interim materials have mainly focused on the effect
of printing orientation [14,18,25,26,29], while the effect of layer thickness was assessed
primarily when 3D-printed dental models [16], trial dentures [30], and custom trays [13]
were printed. Only one study investigated the effect of printing orientation and layer
thickness on the fit of 3-unit implant-supported fixed partial dentures [31]. To the au-
thors’ knowledge, no study has evaluated the effect of layer thickness on the accuracy of
3D-printed interim crowns. Therefore, the aim of this study was to investigate the trueness
and margin quality of interim crowns printed in 3 different layer thicknesses (20, 50, and
100 µm) comparing with that of milled PMMA crowns. The null hypotheses were that
(i) fabrication technique would not affect the trueness of the crowns and (ii) fabrication
technique and margin location would not affect the margin quality of the restorations.

2. Materials and Methods

2.1. Model and Crown Data Acquisition
A mandibular right first molar tooth in a dentate typodont model (ANA-4, Frasaco
GmbH, Tettnang, Germany) was prepared with a 1-mm-wide chamfer finish line to sim-
ulate a complete coverage crown preparation. The maxillary and mandibular typodont
models and both models when in occlusion were scanned by using an intraoral scanner
(Medit i500 v. 1.2.1, Medit, Seoul, Korea) that has a precision of 25 µm, according to the
manufacturers’ recommended scan strategy. The scans were converted to standard tes-
sellation language (STL) files (Figure 1). A complete-coverage restoration was designed
to simulate an interim crown by using a dental design software program (Exocad Dental
CAD2.2, Exocad GmbH, Darmstadt, Germany) with 30 µm cement space gap [26]. This
 Appl. Sci. 2021, 11, x FOR PEER REVIEW 3 of 14

Appl. Sci. 2021, 11, 9246 3 of 14

simulate an interim crown by using a dental design software program (Exocad Dental
CAD2.2, Exocad GmbH, Darmstadt, Germany) with 30 μm cement space gap [26]. This
design was saved as the reference scan STL file (RS-STL), which was then used to fabricate
design was saved as the reference scan STL file (RS-STL), which was then used to fabricate
3D-printed (n = 30) and milled (control) (n = 10) molar crowns.
3D-printed (n = 30) and milled (control) (n = 10) molar crowns.

Figure1.1.Mandibular
Figure Mandibularright
rightfirst
firstmolar
molarpreparation.
preparation.

2.2.
2.2.Crown
CrownFabrication
Fabrication
Three
Threedifferent
differentlayer
layerthicknesses
thicknesses(20 μm,50
(20µm, μm,and
50µm, and100
100µm)μm)were
wereused
usedtotoprint
printthethe
crowns
crowns(n(n==10 10per
perlayer
layerthickness).
thickness).First,
First,the
theRS-STL
RS-STLfilefileofofthe
thecrown
crownwas wasimported
importedtoto
DLP
DLPsoftware
software(MoonRay
(MoonRayS100, S100,SprintRay
SprintRayInc,Inc,Los
LosAngeles,
Angeles,CA, CA,USA)
USA)totoarrange
arrangethe thebuild
build
angle and support configuration. As recommended by the manufacturer
angle and support configuration. As recommended by the manufacturer of the printing of the printing
resin
resinmaterial
material(Nextdent
(NextdentCrownCrownand andBridge
BridgeMicro
MicroFilled
FilledHybrid-MFH,
Hybrid-MFH,C&B; C&B;3D 3Dsystems,
systems,
Soesterberg, ◦
Soesterberg,The TheNetherlands),
Netherlands),the theocclusal
occlusalsurface
surfaceofofthe
thecrown
crownwas wasangled
angled4545°from fromthethe
print
printareaareaforforimproved
improvedocclusal
occlusalsurface
surfacedetails.
details.The
Thesemiautomatically
semiautomaticallycreatedcreatedsupport
support
structures
structureswere werechecked
checkedand andsupports
supportsthat
thatwere
wereautomatically
automaticallycreated
createdononthe
themargin
marginarea area
and fitting surfaces of the crowns were manually eliminated. Then,
and fitting surfaces of the crowns were manually eliminated. Then, this configuration was this configuration
was duplicated
duplicated 10 times
10 times andand 10 identical
10 identical crowncrown configurations
configurations were were arranged
arranged in build
in the the build
plat-
platform of the DLP printer (MoonRay S100 Software, SprintRay
form of the DLP printer (MoonRay S100 Software, SprintRay Inc, Los Angeles, CA, USA) Inc, Los Angeles, CA,
USA)
to printto print all crowns
all crowns in theinsame
the same configuration.
configuration. ThisThis configuration
configuration was was further
further saved saved
for 3
for 3 different layer thicknesses to print the crowns in identical configuration,
different layer thicknesses to print the crowns in identical configuration, but by using dif- but by using
different
ferent layerlayerthicknesses.
thicknesses.The Thecrowns
crownswere
were printed
printed with
with the
the DLP
DLP printer
printer (MoonRay
(MoonRayS100, S100,
SprintRay Inc, Los Angeles, CA, USA) and an interim printing resin material (N1 shade,
SprintRay Inc, Los Angeles, CA, USA) and an interim printing resin material (N1 shade,
Nextdent Crown and Bridge Micro Filled Hybrid-MFH, C&B; 3D systems, Soesterberg, The
Nextdent Crown and Bridge Micro Filled Hybrid-MFH, C&B; 3D systems, Soesterberg,
Netherlands, Lot: XH312N21) by using 20 µm, 50 µm, or 100 µm (n = 10) layer thickness.
According to the manufacturer, the printing material has 100–130 MPa flexural strength,
2400–2600 MPa flexural modulus, ≤70 µg/mm3 sorption, and ≤15.5 µg/mm3 solubility.
Appl. Sci. 2021, 11, x FOR PEER REVIEW 4 of 14

Appl. Sci. 2021, 11, 9246 4 of 14

The Netherlands, Lot: XH312N21) by using 20 μm, 50 μm, or 100 μm (n = 10) layer thick-
ness. According to the manufacturer, the printing material has 100–130 MPa flexural
strength, 2400–2600 MPa flexural modulus, ≤70 μg/mm3 sorption, and ≤15.5 μg/mm3 sol-
The DLP
ubility. printer
The has UVhas
DLP printer DLP UVprojector, LED-based
DLP projector, light source,
LED-based and 405
light source, andnm405blue-violet
nm blue-
light resin
violet lightcuring unit. After
resin curing unit.printing, the printed
After printing, crowns were
the printed crownsremoved from the from
were removed platform
the
by using a putty knife, ultrasonically rinsed for 5 min (first 3 min then 2 min) in 96%
platform by using a putty knife, ultrasonically rinsed for 5 min (first 3 min then 2 min) in clean
alcohol
96% solution
clean alcohol(Alcohol
solutionisopropilico, Quimi Klean,
(Alcohol isopropilico, Mexico
Quimi Klean,City, Mexico)
Mexico City,according
Mexico) ac-to
the manufacturers’ recommendations. After ensuring that the crowns were
cording to the manufacturers’ recommendations. After ensuring that the crowns were dry dry and free
of alcohol
and free ofresidue,
alcohol they were
residue, postpolymerized
they by using by
were postpolymerized an using
ultraviolet polymerizing
an ultraviolet unit
polymer-
(SprintRay
izing Procure Model
unit (SprintRay SRP1811A,
Procure Model SprintRay
SRP1811A,Inc, Los Angeles,
SprintRay CA,Angeles,
Inc, Los USA) (405 nmUSA)
CA, LED
arrays)
(405 nmforLED 30 arrays)
min (Figure
for 302).
min (Figure 2).

Figure
Figure 2.
2. 3D-printed
3D-printed interim
interim crowns
crowns ((A):
((A): 20
20 μm
µm crowns;
crowns; (B):
(B): 50
50 μm
µm crowns; (C): 100
crowns; (C): 100 µm
μm crowns).
crowns).

The
The support structures were
support structures were cut
cutand
andtrimmed
trimmedafter
aftercooling
coolingand
andthe
thesurface
surfacewas
wasgently
gen-
tly smoothened to prevent errors during the alignment
smoothened to prevent errors during the alignment procedure. procedure.
In
In the milling
milling technique,
technique,crowns
crownswere
weremilled
milled (Wieland
(Wieland Zenotec
Zenotec mini,
mini, V6.12.04,
V6.12.04, Wie-
Wieland
land Dental + Technik GmbH & Co.KG, Pforzheim, Germany) from
Dental + Technik GmbH & Co.KG, Pforzheim, Germany) from a polymethyl methacry- a polymethyl meth-
acrylate
late (PMMA)(PMMA) blockblock (A2 shade,
(A2 shade, Lot number:
Lot number: HL201104,
HL201104, Upcera,
Upcera, ShenzhenShenzhen
UpceraUpcera
Dental
Dental Technology
Technology Co. Ltd.,Co. Ltd., Shenzen,
Shenzen, Guandong,Guandong,
China). China). The designed
The designed STL fileSTL
wasfile was in-
inserted in
serted
the blockin to
themill
block to mill 10
10 identical identical
crowns. Thecrowns.
support The support
structures structures
were were cut after
cut and trimmed and
trimmed
milling, andafter milling,
the supportand the support
surfaces surfaces
were gently were gently
smoothened. Allsmoothened. All crown
crown fabrication fab-
processes
rication processes were performed by one operator (G. Ç).
were performed by one operator (G. Ç).
Appl. Sci. 2021, 11, x FOR PEER REVIEW 5 of 14
Appl. Sci. 2021, 11, 9246 5 of 14

2.3. Crown Analysis

2.3. Crown
All crownsAnalysis
were examined under optical magnification loupe (3.5×) to ensure that
All crowns
they were free fromwere anyexamined
defects andunder nooptical magnification
adjustments were made loupe the ×
on (3.5 ) to ensure
inner surfaces that
of
theycrowns
the were free from
[26]. any defects
Crowns and no
were then adjustments
kept in dry andwere made on
lightproof the inner
boxes to scan surfaces
withinof48theh
crowns
after the[26]. Crowns First,
fabrication. were then kept in dry
the scanner wasand lightproof
calibrated andboxes
then tothescan within
printed 48 milled
and h after
the fabrication.
crowns were scannedFirst, the scanner
by using an was calibrated
intraoral scannerand then the
(Medit i500printed
v. 1.2.1,and milled
Medit, crowns
Seoul, Ko-
were scanned by using an intraoral scanner (Medit i500 v. 1.2.1, Medit,
rea) by the same operator (G. Ç) and the scan files were converted to STL files (test-scan Seoul, Korea) by the
same operator
STL). During the (G. scan,
Ç) and thecrowns
the scan files were
were converted
hold to STL
with small files (test-scan
tweezers and as STL). During
the intraoral
the scan,utilized
scanner the crownshas awere
filter hold with small
for colors, tweezers
the parts and with
in contact as thetheintraoral
tweezers scanner utilized
were scanned
has a filter
afterwards. for colors, the parts in contact with the tweezers were scanned afterwards.
For the
For thedeviation
deviationanalysis,
analysis,root rootmean
mean square
square (RMS)
(RMS) waswasusedused to indicate
to indicate howhow far
far the
the deviations were from zero between the 2 different datasets
deviations were from zero between the 2 different datasets [32]. A low RMS value indi- [32]. A low RMS value
indicated
cated a higha high degree
degree of 3D of 3D matching
matching of of
thethe superimposeddata,
superimposed data,which
whichtranslated
translatedto to high
high
trueness [33]. First, test-scan STL files and designed crown STL file
trueness [33]. First, test-scan STL files and designed crown STL file (RS-STL) were im- (RS-STL) were imported
into a software
ported (Medit Link,
into a software (Medit Medit,
Link,Seoul,
Medit,Korea).
Seoul, Compare tool (Medit
Korea). Compare toolCompare v1.1.1.61,
(Medit Compare
Medit, Seoul,
v1.1.1.61, Medit, Korea)
Seoul, ofKorea)
the software, which has
of the software, an automatic
which alignment
has an automatic tool was tool
alignment usedwasfor
the superimposition, virtually separation of the surfaces, and RMS calculation. For the
used for the superimposition, virtually separation of the surfaces, and RMS calculation.
superimposition, RS-STL was moved to the reference data and test-scan STL was moved to
For the superimposition, RS-STL was moved to the reference data and test-scan STL was
the target data by using the alignment tool of the software. Then, manual alignment tool of
moved to the target data by using the alignment tool of the software. Then, manual align-
the software was selected and 3 reference points; central fossa, mesial and distal triangular
ment tool of the software was selected and 3 reference points; central fossa, mesial and
fossae were selected both in the reference and target data. Test-scan STL files were then
distal triangular fossae were selected both in the reference and target data. Test-scan STL
superimposed over the RS-STL file (Figure 3).
files were then superimposed over the RS-STL file (Figure 3).

Figure
Figure 3.
3. (A):
(A): Reference
Reference points
points determined
determined for
for the
the superimposition
superimposition of
of STL
STL files
files (1:
(1: Central
Central fossa;
fossa; 2:
2: Distal
Distaltriangular
triangular fossa;
fossa;
3: Mesial triangular fossa), (B): Superimposition of the Test-scan STL over the RS-STL by using these points.
3: Mesial triangular fossa), (B): Superimposition of the Test-scan STL over the RS-STL by using these points.

To
To generate
generatecolorcolormaps
mapstotorepresent
represent the 3D3D
the deviation,
deviation, deviation
deviation display
displaymode of the
mode of
software was used. The maximum/minimum critical (nominal)
the software was used. The maximum/minimum critical (nominal) values were set at values were set at +50/−50
μm
+50/with
−50 aµm tolerance range ofrange
with a tolerance +10/−10 μm,−respectively
of +10/ [34]. After
10 µm, respectively [34].the superimposition,
After the superimpo-
color-difference
sition, color-difference maps were created to compare the test scan STL file and RS-STL
maps were created to compare the test scan STL file and the for
the RS-STL
the overall RMS, which includes all surfaces of the crowns. The software
for the overall RMS, which includes all surfaces of the crowns. The software automatically automatically
calculated
calculated the
the RMSRMS from
from the
the color-difference
color-difference maps, maps, without
without the the need
need for
for an
an additional
additional
formula.
formula.For ForthetheRMS
RMSofofexternal,
external,intaglio,
intaglio,marginal
marginal area,
area, and
andintaglio
intaglio occlusal
occlusalsurfaces of
surfaces
the crowns,
of the crowns, thethe
test-scan STL
test-scan STLfiles and
files andthetheRS-STL
RS-STLfilefilewere
wereimported
importedagain,
again, and
and these
surfaces
surfaces were
were virtually
virtually separated
separated both
both in
in test-scan
test-scan STL
STL files
files and
and RS-STL
RS-STL file
file [34] dividing
crowns
crowns into
into 44 different
different parts by using the edit mode of the software. After After separation,
separation, the
superimposition
superimposition was done once again for each surface (external, intaglio, marginal
was done once again for each surface (external, intaglio, marginal area,
area,
and
and intaglio
intaglio occlusal
occlusal surfaces)
surfaces) ofof each
each crown
crown by by using
using automatic
automatic alignment
alignment modemode ofof the
software, and the color-difference maps were generated for those surfaces and the RMS
Appl. Sci. 2021, 11, x FOR PEER REVIEW 6 of 14
Appl. Sci. 2021, 11, 9246 6 of 14

software, and the color-difference maps were generated for those surfaces and the RMS
values were
values were automatically
automatically calculated
calculated (Figure
(Figure 4). The
The areas
areas with deviations exceeding the
scale utilized were presented as gray by the software.However,
scale utilized were presented as gray by the software. However,allallareas were
areas included
were in
included
the RMS calculation.
in the RMS calculation.

Figure 4. Color maps generated by the superimposition of the milled (1), 20 μm (2), 50 μm (3), and 100 μm (4) crown
Figure 4. Color maps generated by the superimposition of the milled (1), 20 µm (2), 50 µm (3), and 100 µm (4) crown meshes
meshes over reference data ((A): Overall RMS; (B): External RMS; (C): Internal RMS; (D): Marginal RMS; (E): Intaglio
over reference data ((A): Overall RMS; (B): External RMS; (C): Internal RMS; (D): Marginal RMS; (E): Intaglio Occlusal RMS).
Occlusal RMS).
For margin quality comparison, each crown was randomly numbered by an indepen-
For margin quality comparison, each crown was randomly numbered by an inde-
dent individual, and then visually examined with an optical microscope (Zeiss) under
pendent individual, and then visually examined with an optical microscope (Zeiss) under
×60 magnification by a single operator (G.Ç.) who was blinded about the numbering, and
×60 magnification by a single operator (G.Ç.) who was blinded about the numbering, and
a grading system from 1 to 3 was used as performed in a previous study [29]. Grade 1
acrown
grading system
margins from 1 rough
indicated to 3 was used
edges as performed
similar to layers.in a previous
Grade 2 crownstudy [29].indicated
margins Grade 1
crown margins indicated rough edges similar to layers. Grade 2 crown margins
slightly rough edges similar to waves. Grade 3 crown margins indicated smooth edges indicated
slightly rough
(Figure 5). edges
Margin similar
quality wasto examined
waves. Grade 3 crown
at each marginmargins
locationindicated smoothmesial,
(buccal, lingual, edges
(Figure 5). Margin quality was examined at each margin location (buccal, lingual,
and distal) of each crown, and the average was calculated for each printed or milled crown.mesial,
and distal) of each crown, and the average was calculated for each printed or milled
crown.
Appl. Sci. 2021, 11, 9246 7 of 14
Appl. Sci. 2021, 11, x FOR PEER REVIEW 7 of 14

Figure5.5.Margins
Figure Marginsaccording
accordingtotothe
thegrading
gradingsystem
system((A):
((A):Grade
Grade3;3;(B):
(B):Grade
Grade2;2;(C):
(C):Grade
Grade1).1).

2.4.
2.4.Statistical
StatisticalAnalysis
Analysis
The
The statisticalevaluation
statistical evaluationofofthe
thedata
datawas
wasperformed
performedby byusing
usingthe
thestatistical
statisticalsoftware
software
R.R.Normality
Normality assumption was verified using the Shapiro Wilks test. DifferenceininRMS
assumption was verified using the Shapiro Wilks test. Difference RMS
values
valuesbetween
betweenfabrication
fabrication technique within
within each
eacharea
areaofofmeasurement,
measurement,difference
difference in in
av-
average qualityrating
erage quality ratingbetween
betweenfabrication
fabricationtechnique,
technique, and
and difference
difference in in quality
quality rating
rating be-
between marginlocation
tween margin location for
for each
each fabrication
fabrication technique
technique waswasanalyzed
analyzedbybyusing
usingthetheone-way
one-way
analysis
analysisofofvariance
variance(ANOVA).
(ANOVA). Additionally, pairwise
Additionally, comparisons
pairwise withinwithin
comparisons the groups were
the groups
analyzed with Tukey HSD Post-Hoc analysis (α =
were analyzed with Tukey HSD Post-Hoc analysis (α = 0.05).0.05).

3. Results
3. Results
One-way ANOVA results of the RMS values of each surface are presented in Table 1,
One-way ANOVA results of the RMS values of each surface are presented in Table
and Figure 6 illustrates the RMS at each measured surface for control and different layer-
1, and Figure 6 illustrates the RMS at each measured surface for control and different
thickness groups.
layer-thickness groups.
Appl. Sci. 2021, 11, 9246 8 of 14

Table 1. Mean RMS (µm) values ± standard deviations for milled and 3D-printed interim crowns. Different superscript
lowercase letters in same column indicate significant differences among groups (p < 0.05).

Intaglio Occlusal
Layer Thickness Overall RMS (µm) External RMS (µm) Intaglio RMS (µm) Marginal RMS (µm)
RMS (µm)
Control (Milled) 64.5 ±10.94 a 54 ±21.29 a 32.6 ±15.01 a 11.3 ±14.36 a 31.5 ±6.92 a
20 µm 56.1 ±10.7 a 59.4 ±10.7 a 49.9 ±12.13 ab 14.9 ±9.57 a 33.4 ± 2.22 ab
50 µm 53.3 ±9.3 a 48.5 ±13.67 a 45.4 ±15.75 ab 9.1 ±8.02 a 34.7 ±1.83 ab
100 µm 61.3 ±15.31 a 62.4 ±18.21 a 52.8 ±17.32 b 14.6 ±9.94 a 41.5 ±12.55 b

Appl. Sci.p2021,
values 0.145
11, x FOR PEER REVIEW 0.263 0.026 0.576 0.024 8 of 14

Figure
Figure6.6.Box-plot
Box-plotgraph
graphof
ofthe
theRMS
RMSvalues
valuesof
ofmilled
milledand
and3D-printed
3D-printedinterim
interimcrowns
crownsaccording
according to
to different
different surfaces.
surfaces.

Table 1. Mean RMS (μm) values Significant

± standard deviations
differencesforwere
milled and 3D-printed
observed amonginterim crowns.
fabrication Different for
techniques superscript
intaglio and
lowercase letters in same column indicate significant differences among groups (p < 0.05).
intaglio occlusal surface RMS values (p ≤ 0.026). Milled crowns presented significantly
Overalllower
RMSRMSExternal
values than
RMS100 µm crowns
Intaglio RMSat bothMarginal
intaglio (p = 0.025,
RMS estimated
Intaglio difference
Occlusal RMSin
Layer Thickness means: −20.2 µm) and intaglio occlusal (p = 0.021, estimated difference in means: −10 µm)
(µm) (µm) (µm) (µm) (µm)
surfaces. Every other apairwise comparison for intaglio (p ≥ 0.251) and intaglio aocclusal
Control (Milled) 64.5 ±10.94 a 54 ±21.29 32.6 ±15.01 a 11.3 ±14.36 a 31.5 ±6.92
(p ≥ 0.178) surfaces were nonsignificant.
20 μm 56.1 ±10.7 aAverage59.4 ±10.7 a 49.9 ±12.13 ab 14.9 ±9.57 a 33.4
margin quality of the crowns showed significant differences (Figure ± 2.22 ab
7); based on
50 μm 53.3 ±9.3 a 48.5 ±13.67
the 3-point scale, milled crowns45.4
a ±15.75 abhigher quality
presented 9.1 ±8.02 a 34.7
than the others (p ±1.83vs.
< 0.001
ab
20 µm,
100 μm 61.3 ±15.31 a 62.4 ±18.21
estimated difference in means: 52.8
a ±17.32 p = 0.00114.6
1.25 points;
b
vs. ±9.94
50 µm, estimated 41.5
a ±12.55inb means:
difference
p values 0.145
0.68 points; and 0.263 0.026
p < 0.001 vs. 100 µm, 0.576in means: 1.53 points).
estimated difference 0.024

Significant differences were observed among fabrication techniques for intaglio and
intaglio occlusal surface RMS values (p ≤ 0.026). Milled crowns presented significantly
lower RMS values than 100 μm crowns at both intaglio (p = 0.025, estimated difference in
means: −20.2 μm) and intaglio occlusal (p = 0.021, estimated difference in means: −10 μm)
surfaces. Every other pairwise comparison for intaglio (p ≥ 0.251) and intaglio occlusal (p
≥ 0.178) surfaces were nonsignificant.
Average margin quality of the crowns showed significant differences (Figure 7);
based on the 3-point scale, milled crowns presented higher quality than the others (p <
0.001 vs. 20 μm, estimated difference in means: 1.25 points; p = 0.001 vs. 50 μm, estimated
difference in means: 0.68 points; and p < 0.001 vs. 100 μm, estimated difference in means:
1.53 points).
Appl. Sci.
Appl. Sci. 2021, 11, x9246
2021, 11, FOR PEER REVIEW 9 9of
of 14
14

Figure 7.7. Average

Average margin
margin quality
quality of
of all
all groups,
groups, evaluated
evaluated by
by using
using aa3-point
3-pointscale,
scale,ranging
rangingfrom
from11(worst
(worstmarginal
marginalquality)
quality)
to
to 33 (best
(best marginal
marginal quality).
quality).

The margin quality

The qualityofof5050µm
μmcrowns
crowns was higher
was higherthan thatthat
than of 20ofµm
20 (p
μm= 0.006, estimated
(p = 0.006, esti-
difference
mated in means:
difference 0.58 points)
in means: and 100and
0.58 points) (p <μm
µm100 0.001,
(p <estimated difference
0.001, estimated in means:
difference in
0.85 points)
means: crowns.crowns.
0.85 points) The difference between
The difference 20 µm20crowns
between and 100
μm crowns andµm100 crowns was
μm crowns
nonsignificant
was (p =(p0.348).
nonsignificant = 0.348).Table
Table2 summarizes
2 summarizesthethep pvalues
valueswhen
whenthe the Tukey
Tukey HSD test
was applied
was applied to
to analyze
analyze the
the effect
effect of
of margin location
location on the margin quality within each
fabrication technique.
fabrication technique.

2. ppvalues
Table 2.
Table valuesfor
forthe pairwise
the comparison
pairwise comparisonbetween different
between margin
different locations
margin for milled
locations and 3D-printed
for milled interim interim
and 3D-printed crowns.
p < 0.05 indicate
crowns. significant
p < 0.05 indicate differences
significant betweenbetween
differences locations.
locations.

Locations
Locations
Layer Thickness Buccal-Lingual
Layer Thickness Buccal-Lingual Buccal-Mesial
Buccal-Mesial Buccal-Distal
Buccal-Distal Lingual-Mesial
Lingual-Mesial Lingual-Distal
Lingual-Distal Mesial-Distal
Mesial-Distal
Control (Milled)
Control (Milled) 0.005
0.005 0.03
0.03 0.005
0.005 0.885
0.885 >0.05
>0.05 0.885
0.885
20 µm 0.121 0.762 0.988 0.566 0.223 0.914
20
50 µm
μm 0.121
0.765
0.762
0.765
0.988
0.988
0.566
>0.05
0.223
0.915
0.914
0.915
50 µm
100 μm 0.765
<0.001 0.765
0.831 0.988
0.831 >0.05
<0.001 0.915
<0.001 0.915
>0.05
100 μm <0.001 0.831 0.831 <0.001 <0.001 >0.05
No significant differences were found between the quality of the margins at different
No significant
locations for 20 µmdifferences
(p ≥ 0.121) were
and 50found
µm (pbetween
≥ 0.765)the qualityHowever,
crowns. of the margins
marginatquality
different
of
locations for 20 μm (p ≥ 0.121) and 50 μm (p ≥ 0.765) crowns. However, margin
milled (p = 0.002) and 100 µm (p < 0.001) crowns were significantly affected by the margin quality of
milled
location.(p =The
0.002) and distal,
mesial, 100 μmand(p <lingual
0.001) crowns
margin were significantly
quality affected
of the milled crownsby was
the margin
similar
location. The mesial, distal, and lingual margin quality of the milled crowns was
(p ≥ 0.885), while buccal margin quality was inferior to that at other locations (p ≤ 0.03). similar
(p
For≥ the
0.885),
100 while buccallingual
µm crowns, marginmargin
qualityquality
was inferior to that
was higher at other with
compared locations
other(plocations
≤ 0.03).
For the 100 μm crowns, lingual margin quality was higher compared with
(p < 0.001); the differences among other locations were nonsignificant (p ≥ 0.831). Theother locations
(p < 0.001);
margin the differences
quality in control andamong
eachother
layerlocations
thicknesswere nonsignificant
groups according to(pthe
≥ 0.831).
marginThe mar-
location
gin quality inincontrol
is presented Figureand8. each layer thickness groups according to the margin location is
presented in Figure 8.
Appl. Sci. 2021, 11, 9246 10 of 14
Appl. Sci. 2021, 11, x FOR PEER REVIEW 10 of 14

Figure 8. Margin
Margin quality
qualityof ofgroups
groupsaccording
accordingtotomargin
marginlocation,
location,evaluated
evaluatedbybyusing
usinga a3-point
3-pointscale
scalethat
thatranged from
ranged 1
from
(worst marginal
1 (worst marginalquality)
quality)toto3 3(best
(bestmarginal
marginalquality).
quality).

4.
4. Discussion
Discussion
Significant
Significant differences
differences in in terms
termsof oftrueness
truenesswere werefoundfoundcomparing
comparing the
the 100100µm μm print-
printing
ing layer thickness to other groups. Therefore, the first null hypothesis
layer thickness to other groups. Therefore, the first null hypothesis was rejected. The best was rejected. The
best margin quality was found in milled crowns, followed
margin quality was found in milled crowns, followed by the 50 µm layer thickness group. by the 50 μm layer thickness
group. Accordingly,
Accordingly, the second the second null hypothesis
null hypothesis was rejected.
was rejected.
In terms of trueness, the present study
In terms of trueness, the present study showed that 3D-printedshowed that 3D-printed interiminterim
crowns,crowns,
printed
printed withthickness
with a layer a layer thickness
of 20 or 50 of µm,
20 orare50similar
μm, are to similar
the milled to the milled
interim interim
crowns, crowns,
which are
which are used
currently currently used routinely.
routinely. Similar
Similar results results
have beenhave been reported
reported also for 3D-printed
also for 3D-printed ceramic
ceramic
crowns crowns
[15,35]. [15,35].
The effect Theofeffect of thethickness
the layer layer thickness
on theon the trueness
trueness of 3Dofprinted
3D printed castscasts
and
and
complete dentures has been demonstrated in previous studies [30,36]. Those studies
complete dentures has been demonstrated in previous studies [30,36]. Those
demonstrated
demonstrated the the highest
highest trueness
trueness whenwhen aa layer
layer thickness
thickness of of 100
100 μmµm was used, whereas
the
the 100
100 μm
µm layer
layer thickness
thickness resulted
resulted in in the
the lowest
lowest trueness
trueness in in the
the present
present study. The main
difference
difference between
between those those andand thethe present
present study
study maymay be be due
due to to the nature of the objects
printed.
printed. Neither
Neithercasts castsnor nordentures
dentures have have as as thin
thin andand tapered
tapered margins
margins as as crowns
crowns have,
have,
instead, they have
instead, they havelarge largeplain
plainandand round
round surfaces
surfaces [36].[36].
When When the layer
the layer thickness
thickness is too is too
small,
small, discrepancies
discrepancies can occur, can occur, especially
especially with thin
with such suchmargins
thin margins [30].combination
[30]. The The combination of
of thin
thin
layerlayer thickness
thickness and thinandmargins
thin margins
could could
also bealso be an explanation
an explanation for the factfor that
the fact that the
the trueness
seems toseems
trueness be slightly
to behigher
slightlyinhigher
the 50 in µmthe group
50 μm compared to the 20 µm
group compared group,
to the 20 μm although
group,
this difference
although was not statistically
this difference significant.
was not statistically It should be
significant. noted that
It should the aforementioned
be noted that the afore-
scoping review
mentioned scoping on review
complete denture fabrication
on complete includedincluded
denture fabrication various various
studies studies
[36], which
[36],
applied varying settings for the 3D-printing, and therefore, the
which applied varying settings for the 3D-printing, and therefore, the deviations in true- deviations in trueness may
not be attributed to the layer thickness alone. A study, which
ness may not be attributed to the layer thickness alone. A study, which showed that layer showed that layer thickness
did not affect
thickness did the
nottrueness
affect the of trueness
printed models
of printedwhenmodels
100 µmwhen was applied,
100 μm stillwasrecommended
applied, still
the use of 100 µm
recommended the layer
use ofthicknesses
100 μm layer duethicknesses
to the economic due toadvantages
the economic as the printing time
advantages as theis
shortened
printing [37].is However,
time shortenedthe time
[37]. factor may
However, thebe lessfactor
time importantmay be when lesssmall restorations
important when
such as
small crowns aresuch
restorations fabricated.
as crowns Considering the effect
are fabricated. of the layer
Considering the thickness
effect of the onlayer
trueness at
thick-
thin surfaces such as crown margins [30], high layer thickness
ness on trueness at thin surfaces such as crown margins [30], high layer thickness may be may be expected to result in
low trueness,
expected which
to result wastrueness,
in low confirmed by lower
which trueness and
was confirmed by marginal
lower trueness quality andfound with
marginal
Appl. Sci. 2021, 11, 9246 11 of 14

the 100 µm group in the present study. Although a previous study has shown that the
marginal fit of 3D-printed crowns is within a clinically acceptable range, and that there is no
difference between 3D-printed and milled crowns [38], significant differences in the margin
quality were found in the present study. The marginal quality in the present study was
evaluated by a 3-point scale instead of absolute values, indicating worse margin quality of
the 3D-printed crowns irrespective of the layer thickness. Interestingly, the margin quality
was not influenced by margin location in 20 µm and 50 µm groups, but in milled and
100 µm groups. The significantly worse margin quality at the buccal aspect of the milled
group may be due to the slightly narrower preparation margin on the distobuccal side.
During the milling process, defects may occur at thin crown margins [39]. Hypothetically,
the preparation margin could also be the reason for the better marginal quality at the lingual
crown margin in the 100 µm group. The lingual aspect of the margin preparation was the
most uniform, which might have allowed the crown to be fabricated accurately even with
the largest layer thickness of 100 µm. A large layer thickness might have a negative effect
on the margin quality, especially with varying crown margin thicknesses. The fact that the
margins of the prepared tooth were not uniform at all aspects is a limitation of the present
study. Future studies are necessary to determine the effect of layer thickness on trueness
and margin quality.
The reference data set can be recorded with a laboratory scanner, or more precisely
with a high-precision optical or tactile industrial scanner [40]. However, because such
scanners cannot be used intraorally, the reference data set was taken with an intraoral
scanner. The intraoral scanner used has a software that enables immediate scanning of
the fabricated restoration and the analysis of the trueness of the restoration comparing
with the design STL. Adequate scan accuracy with the intraoral scanner used has been
demonstrated in previous studies on single crowns [41]. Generally, intraoral scanners have
demonstrated sufficient accuracy especially when scanning partial arches, as executed in the
present study [41]. Since the reference data set was used to fabricate all crowns, potential
errors during scanning would be expected to affect all groups similarly and therefore,
can be considered negligible for its effect on the comparisons aimed. The trueness was
analyzed by the calculation of RMS differences between the test and reference datasets.
Calculating RMS differences is the most commonly applied trueness analysis in digital
dentistry [42]. However, the effect of different software programs to calculate RMS values
between corresponding datasets is not clear [43–45]. The influence of the build angle on
the fabrication of 3D-printed crowns has been shown in various studies [14,18,25,26,29].
The build angle of 45◦ was used to print the crowns based on the recommendation by the
manufacturer. A 45◦ build angle is similar to 135◦ build angle in terms of crown orientation
during the fabrication, except that the 45◦ angle assumes a buccal crown orientation while
135◦ angle assumes a lingual crown orientation. The effect of build angle on crown accuracy
when DLP technology is used was previously investigated and the highest accuracy was
achieved when 135◦ angle was used [18].
Due to the pilot nature of the present study, no sample size calculation could be
performed. The sample size was based on earlier studies, focusing on the 3D-printing
accuracy [14,46] and enabled the detection of statistically significant differences in terms of
trueness and marginal quality. One of the main limitations of the present study is that only
one material was used for the fabrication of milled and 3D-printed crowns. Since previous
studies have shown that the material has a significant influence on crown accuracy [47],
the present study findings are not directly applicable to other materials. Nevertheless,
the present study is the first of its kind indicating the influence of layer thickness on the
accuracy of 3D printed resin crowns. The quantification of the marginal gap size was
not performed in the present study. Since there was no difference between the milled
and 3D-printed crowns when a layer thickness of 20 µm or 50 µm was used, a major
difference in terms of marginal gap size would not be expected between these groups,
however, marginal gap measurements can be performed in future studies to see how
milling/printing trueness translates to marginal quality. The fact that the margin quality
Appl. Sci. 2021, 11, 9246 12 of 14

was only assessed by one observer is another weak point. Since the observer was blinded
during the evaluation, it can at least be assumed that the risk of bias (e.g., by personal
preferences) was minimized [48].

5. Conclusions
Considering limitations of the present study, it can be concluded that the trueness and
marginal quality of 3D-printed interim crowns was influenced by the printing layer thickness.
For improved trueness and margin quality for interim crowns using the applied materials
and settings, a printing layer thickness of 20 or 50 µm may be preferable over 100 µm.

Author Contributions: Conceptualization, G.Ç., A.R.C. and B.Y.; methodology, G.Ç. and A.R.C.;
software, G.Ç. and M.B.D.; validation, G.Ç., M.B.D. and B.Y.; formal analysis, G.Ç. and W.-E.L.;
investigation, G.Ç.; resources, A.R.C.; data curation, W.-E.L., M.B.D. and S.A.-A.; writing—original
draft preparation, M.B.D. and S.A.-A.; writing—review and editing, M.B.D., S.A.-A., M.S. and
B.Y.; visualization, G.Ç.; supervision, M.S. and B.Y.; project administration, G.Ç. and B.Y., funding
acquisition, none. All authors have read and agreed to the published version of the manuscript.
Funding: The authors would like to thank Laboratorio Innovando (Mexico City, Mexico) for their
support in milling crowns and 3D Sequence Digital Laboratorio (Mexico City, Mexico) for their
support in printing machine. The materials used in the present study were self-funded.
Data Availability Statement: Data available on request. The data presented in this study are
available on request from the corresponding author. The data are not publicly available due to
ongoing research using the data.
Acknowledgments: The authors would like to thank Laboratorio Innovando (Mexico City, Mexico)
for their support in milling crowns and 3D Sequence Digital Laboratorio (Mexico City, Mexico) for
their support in printing machine. The materials used in the present study were self-funded.
Conflicts of Interest: The authors declare no conflict of interest.

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