Journal of Dentistry 147 (2024) 105089

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Accuracy, adaptation and margin quality of monolithic zirconia crowns

fabricated by 3D printing versus subtractive manufacturing technique: A
systematic review and meta-analysis of in vitro studies
Sarah Emille Gomes da Silva a, Nathalia Ramos da Silva a, João Vitor do Nascimento Santos a,
Fernanda Gurgel de Gois Moreira a, Mutlu Özcan b, Rodrigo Othávio de Assunção e Souza a, *
a
Federal University of Rio Grande do Norte (UFRN), Department of Dentistry, Av. Salgado Filho, 1787, Lagoa Nova, Natal, RN, CEP 59056-000, Brazil
b
University of Zurich, Clinic for Masticatory Disorders and Dental Biomaterials, Center for Dental Medicine, Zentrum für Zahnmedizin, Plattenstrasse, 11, 8032 Zurich,
Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The purpose of this systematic review and meta-analysis was to evaluate the accuracy (trueness and
3D printing precision), marginal and internal adaptation, and margin quality of zirconia crowns made by additive
Additive manufacturing manufacturing compared to subtractive manufacturing technology.
Dental materials
Methods: The investigation adhered to the PRISMA-ScR guidelines for systematic reviews and was registered at
Milling
the Prospero database (n◦ CRD42023452927). Four electronic databases, including PubMed, Scopus, Embase,
Monolithic zirconia crowns
Prosthodontics and Web of Science and manual search was conducted to find relevant studies published until September 2023.
Systematic Review In vitro studies that assessed the trueness and precision, marginal and internal adaptation, and margin quality of
Zirconia printed crowns compared to milled ones were included. Studies on crowns over implants, pontics, temporary
restorations, laminates, or exclusively experimental materials were excluded.
Results: A total of 9 studies were included in the descriptive reporting and 7 for meta-analysis. The global meta-
analysis of the trueness (P<0.74,I2=90 %) and the margin quality (P<0.61,I2=0 %) indicated no significant
difference between the root mean square of printed and milled zirconia crowns. The subgroup analysis for the
printing system showed a significant effect (P<0.01). The meta-analysis of the crown areas indicated no sig­
nificant difference in most of the areas, except for the marginal (favoring milled crowns) and axial (favoring
printed crowns) areas. For precision and adaptation, both methods showed a clinically acceptable level.
Conclusions: Additive manufacturing technology produces crowns with trueness and margin quality comparable
to subtractive manufacturing. Both techniques have demonstrated the ability to produce crowns with precision
levels, internal discrepancy, and marginal fit within clinically acceptable limits.
Clinical significance: 3D printing emerges as a promising and potentially applicable alternative method for
manufacturing zirconia crowns, as it shows trueness and margin quality comparable to restorations produced by
the subtractive method.

1. Introduction Milling or subtractive manufacturing, despite being a widely used

method in dentistry, has limitations such as significant wastage of raw
Advances in computer-aided design (CAD) and computer-aided material [3], abrasive wear of the burs during the milling process [4]. In
manufacturing (CAM) technologies in dentistry boosted the emergence addition, the reproduction of surface geometry is limited by the size of
of new material classes and improved the digitalization and automation the burs and the number of milling machine axes [5], which hinders the
of various work processes [1]. Open systems for digital workflow have ability to reproduce smaller geometries with details [6,7]. On the other
allowed processed data to be subjected to additive or subtractive hand, additive manufacturing (AM), also known as 3D printing, is an
manufacturing methods [2]. alternative that offers advantages over milling [8], as it does not require

* Corresponding author: Federal Univesity of Rio Grande do Norte (UFRN), Department of Dentistry, Av. Salgado Filho, 1787, Lagoa Nova, Natal, RN. CEP 59056-
000, Brazil.
E-mail address: [email protected] (R.O.A. Souza).

https://doi.org/10.1016/j.jdent.2024.105089
Received 3 February 2024; Received in revised form 28 April 2024; Accepted 18 May 2024
Available online 19 May 2024
0300-5712/© 2024 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

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S.E.G. Silva et al. Journal of Dentistry 147 (2024) 105089

burs or mills, reducing issues related to wear, allowing for more complex 3. Eligibility criteria
designs [9], and avoiding material waste [10].
Ceramic-based materials have only recently been considered for use Inclusion criteria in vitro and/or clinical studies that evaluated the
in additive manufacturing technology. With the growing interest in accuracy, trueness, precision, margin quality, and fit of printed zirconia.
printing ceramic restorations, the possibility of manufacturing zirconia- In vitro and/or clinical studies that compared printed zirconia with
based prostheses through additive manufacturing has emerged [11]. milled zirconia. Studies that used only one type of technique for data
The high melting point of ceramics makes them difficult to melt using acquisition (molding or scanning). Exclusion criteria included studies
normal heating methods. Thus, obtaining fully consolidated restorations with a sample size of less than 5 in the subgroups. Studies that used only
without defects is possible through the selective laser melting (SLM) implant-supported crown, pontic or temporary. Studies that investigated
technology that produces directly sintered bodies [12,13]. Another restorations other than full zirconia crowns were excluded. Reports that
widely used printing technology is stereo-lithography (SLA), where a exclusively used experimental materials, editor’s letters, comprehensive
liquid resin is mixed with a ceramic suspension and selectively solidified reviews, pilot studies, and conference abstracts were excluded.
through controlled photopolymerization. After this, post-processing
removes the photosensitive resin, fuses the ceramic particles, and thus 4. Search strategy
obtains a dense ceramic component [14-16]. In addition to these, several
technologies have been described for the production of ceramic zirconia Structured and individual search strategies were performed in four
printed parts [13], such as digital light processing (DLP) [6], electronic databases (PubMed/Medline, Embase, Scopus and ISI Web of
lithography-based ceramic LCM [7], NanoParticle Jetting (NPJ) and 3D Science) up to September 2023. Additionally, a grey literature search
gel deposition technology (3DGD) [11]. Yet, accuracy and adaptation of was performed on Google Scholar and Open Grey. No language or year
these parts compared to those manufactured by subtractive of publication limitations were applied. Furthermore, manuscripts were
manufacturing are scarcely assessed [17]. manually searched by checking the list of references and key author/co-
Adaptation and accuracy play a crucial role in clinical success, being author name of the included studies. Experts were also consulted to
intrinsically related to the manufacturing process [17]. In order to improve search findings. The database searching was performed by
determine the accuracy of printed restorations, trueness and precision previously calibrated co-authors (S.E.G.S. and J.V.N.S).
have been used as parameters. Trueness refers to the deviation of the A search strategy was applied based on keywords, MeSh terms, or
tested printing method from the original design planned in CAD [18,19], synonyms: “zirconia crown”, “zirconia crowns”, “monolithic zirconia
and precision to the capability of the method’s reproducibility [20]. crowns”, “yttria-stabilized tetragonal zirconia polycrystals ceramic”,
Regarding the restoration’s adaptation, this is a crucial factor for “zirconium dioxide”, “zirconium oxide”, “zirconium oxide”, “yttria sta­
treatment success, influencing plaque accumulation [21], risk of bilized tetragonal zirconia”, “yttria stabilized tetragonal zirconia”, “3D
microleakage, and periodontal inflammation [22], dentin hypersensi­ printing”, “3-D printing”, “3-D printings”, “3D printed resin crown”, “3
tivity [23], and cement dissolution [24]. This factor can be assessed dimensional printing”, “3-dimensional printing”, “3-dimensional print­
through the analysis of internal and marginal adaptation. It is worth ings”, “three-dimension printing”, “three-dimension printing”, “three
emphasizing the importance of the restoration margin’s quality as it dimension printing”, “CAD-CAM”, “computer-assisted image analyses”,
plays an essential role in both marginal sealing and the load-bearing “impression”, “additive manufacturing”, “digital impression”, “three-
capacity of restorations [25]. Marginal defects can become stress con­ dimensional printed crown”, “dimensional measurement accuracies”,
centration zones under functional load and are likely to develop into a “dimensional measurement accuracies”, “trueness analysis”, “internal
source of fracture [25]. discrepancies”, “marginal discrepancies”, “internal fit”, “marginal fit”
Considering the limited number of studies assessing the marginal and “marginal gap”. Using advanced option, these terms were combined
adaptation and accuracy of zirconia crowns fabricated through 3D with the Boolean operators (AND, OR), following the format from each
printing, the aim of this systematic review and meta-analysis was to database (Supplementary Table 1).
compare the precision, accuracy, and adaptation of zirconia crowns
manufactured using additive manufacturing technology versus sub­ 5. Data selection
tractive manufacturing. Therefore, this systematic review and meta-
analysis aimed to compare the precision, accuracy, and adaptation of Rayyan software (http://rayyan.qcri.org/) was used to identify and
zirconia crowns manufactured using additive manufacturing technology remove the imported studies from databases, to manage references and
versus subtractive manufacturing. The research question for the devel­ execute the process of screening and selecting studies [27]. Titles and
opment of the study was: “Does the additive manufacturing technology abstracts of identified records were independently screened by three
provide zirconia crowns with accuracy and fit similar to milled independent reviewers (S.E.G.S., F.G.G.M. and J.V.N.S). Two reviewers
crowns?”. The null hypothesis tested was that there is no difference in (S.E.G.S. and J.V.N.S) read the full texts and other reviewers (R.O.A.S.)
the accuracy, margin quality and fit of zirconia crowns manufactured settled the disagreements.
using additive manufacturing technology compared to those manufac­
tured using subtractive manufacturing technology. 6. Data extraction

2. Materials and methods Two authors (N.R.S. and J.V.N.S.) used a standardized collection
form to extract the most relevant methodological data from selected
This systematic review was conducted in accordance with the studies. The data extracted were author names, publication year, group
Preferred Reporting Items for Systematic Reviews and Meta-Analysis number, test groups, sample, measured points, measured variables,
(PRISMA) guidelines [26]. The study protocol was registered at the evaluation method, and results. If the manuscript presented data in
Prospero database under the DOI number CRD42023452927. The graphic format, numeric values were requested from the corresponding
question of this systematic review was formulated using the acronym authors via e-mail.
PICO: (P) posterior tooth that required full crown rehabilitation; (I)
zirconia crown fabricated by 3D printed technique; (C) milled zirconia 7. Quality assessment
crowns fabrication technique; (O) accuracy (trueness and precision) and
internal and marginal fit. In order to assess the risk of bias of the primary studies included in
this review, an in vitro evaluation scale was adapted from the previous
systematic reviews [28,29], but organized based on domains and

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including relevant sources of bias for dental materials studies. Sources of The margin quality was assessed by the mean score of the Schriwer
bias were grouped in 4 different domains: 1- bias in planning and allo­ et al. [25] scale (degree 1 to 5), which was classified according to the
cation; 2- bias in specimen preparation; 3- bias in outcome assessment number and severity of defects. The mean score for margin quality,
and 4- bias in data treatment and reporting. The risk of bias was indi­ standard deviations, and number of specimens per group were extracted
vidually measured by two reviewers (J.V.N.S and F.G.G.M) and from the studies selected. Based on the sensitivity analysis and due to the
confirmed by a third member of the team (R.O.A.S.). Once again, dis­ low methodological heterogeneity, the fixed-effect model was used to
agreements were resolved by reaching consensus among the three as­ calculate the mean difference (MD) (95 % CI). For all meta-analysis,
sessors. A supplementary table summarizing the risk of bias results was P-values less than 0.05 were considered as statistically significant. The
made and the RobVis web visualization tool (www.riskofbias.info/welc I2 statistic was used to measure the heterogeneity and classify it as low
ome/robvis-visualization-tool) and was used to build output figures. (I2<25 %, moderate I2≤50 %, and high (I2>75 %). The meta-analysis
was performed using the software RStudio statistical program (Version
8. Data analysis 2023.09.1+494© 2023 RStudio, PBC).

Among the variables investigated in the included studies, "trueness" 9. Results

and "margin quality" were the most frequently reported and that utilized
more similar measurement parameters. Consequently, they were 9.1. Selection of sources of evidence
selected for meta-analysis to compare the data from the printed and
milled zirconia crowns. After screening of the database and removal of duplicates, 252
For trueness, the meta-analysis was performed by surface crown area studies were identified (Fig. 1). During the screening process, 242 re­
(entire crown, external, internal, internal occlusal, axial, and occlusal). ports were excluded after reading the title and abstract. Seven studies
Trueness was measured by the Root Mean Square (RMS) where the mean were included as complementary database search filtered the reference
RMS, standard deviations, and number of specimens per group were lists. Thus, 17 studies were read in detail, and 8 of those were excluded
extracted from the studies selected. From the studies that presented according to the criteria presented in Fig. 1. Hence, 9 studies were
more than one printing (experimental) or milling (control) group, each considered eligible for the descriptive reporting and 7 for meta-analysis
group was included and considered independently and identified ac­ of this systematic review.
cording to the different characteristics of the groups. Based on the
sensitivity analysis and due to the high methodological heterogeneity, a
9.2. Characteristics of sources of evidence
random-effect model was used to calculate the standardized mean dif­
ference (SMD) with 95 % confidence interval (CI). The subgroup anal­
The characteristics of the 9 studies selected are listed in Supple­
ysis was performed for each crown area to assess the effect of the
mentary Table 2. The type of sample most frequently evaluated was
printing system. The "external" area was excluded from subgroup anal­
molars (n = 7) [2,6,22,30-33]. Among the reported 3D-printer systems,
ysis because all studies in this analysis used the SLA printing system.
the stereolithography (SLA) system was the most commonly used one (n

Fig. 1. PRISMA 2020 flow diagram summarizing identification and selection process.

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= 5) [2,6,22,31-32] followed by Digital Light Processing (DLP) [6,17], overview of the overall risk of bias outcome, considering all sources of
NanoParticle Jetting (NPJ) [33], Lithography-based Ceramic (LCM) [7], bias across all studies, can be seen in Fig. 2. Overall, the studies included
and 3D gel deposition (3 DGD) [30]. The studies reported the evaluation in this systematic review were classified as having a moderate to low risk
of several outcomes as the trueness, margin quality [30], internal and of bias. Bias sources such as the justification and reporting of sample
marginal adaptation and precision. For all these variables, the higher the size, randomization of samples (D1) and blinding of the test operator
value, the lower the quality of the analyzed parameter. Among the (D3) were not reported in many studies.
measured points analyzed in the included studies, all of them employed
point subdivision of the entire crown surface in the intaglio area, margin 9.4. Summary of results
area, external occlusal area, and external axial area, as well as for
interproximal contacts and marginal adaptation. The results of the descriptive reporting from the nine included
studies indicate that the crowns exhibited high accuracy, rendering
9.2.1. Trueness them suitable for clinical use.
The trueness, the most reported outcome, was evaluated by the su­
perimposition of the scanned crown on the reference CAD crown and 9.4.1. Trueness
was calculated by the root mean square (RMS) (n = 7) in most of the Trueness was measured in seven studies [2,6,7,22,30,32,33]. The
studies [2,6,7,22,30,32,33]. authors reported varying results, depending on the specific area of the
crown.
9.2.2. Precision
Precision was evaluated in Lerner et al. [7] by inspection (visual and 9.4.2. Overall crown
tactile) of the interproximal contact and the marginal adaptation of the For overall crown, Lerner et al. [7] reported superior trueness for
crowns. In the study of Abualsaud & Alalawi [22], the precision was milled crowns but Zhu et al. [33] showed that the trueness of the printed
assessed by the superimposition of the scanned crowns to the first crowns (NPJ) was better than the two subtractive manufactures tested
manufactured crown file of each group. This data was used to calculate (VITA YZ HT; VITA Zahnfabrik and UPCERA MT; UPCERA). Abualsaud
the RMS. and Alalawi [22] reported no significant difference between milled and
printed crowns.
9.2.3. Margin quality
Margin quality was assessed using the Schriwer et al. [25] scale, 9.4.3. External
which classifies the degree 1 to 5, according to the number and severity The studies [2,32] that investigated this area showed that the RMS of
of defects: 1, Smooth edge with no defects; 2, Smooth edge with few, the milled and printed crowns was comparable. To assess trueness,
small separate defects; 3, Several small defects; 4, Rough edge with Wang et al., (2019) [2] used a non-inferior test which evaluated statis­
continuous defects; 5, Large defects [30,32,33]. tically significant differences between the two methods (printed and
milled). Accordingly, RMS of the 3D-printed crown group was not
9.2.4. Adaptation greater than that of the CAD-CAM milled crown. In this case, the true­
Internal and marginal adaptation was measured by the silicone ness of the 3D-printing group was considered not worse than the
replica technique in most of the studies [31,17]. These replicas allow for CAD-CAM milling group.
a visual estimation of cement space thickness creating a
three-dimensional model of the precementation space and offers a visual 9.4.4. Internal
aid to a research tool for the three-dimensional recording of crown fit. Most of the studies [2,6,22,30,32,33] reported no significant differ­
The silicone replica is a nondestructive technique and offers guidance ence in the trueness of the milled and printed crowns. However, Li et al.
for precise grinding to enhance the fitting and sealing of fixed prostheses [30] showed that the trueness of the milled crows was better than the
[17]. printed (3DGD). On the other hand, Zhu et al. [33] showed that the
trueness of the printed crowns (NPJ) was better than milled crowns
fabricated by UPCERA system and was similar to that of the milled
9.3. Quality assessment crowns fabricated by VITA system.

The result of the risk of bias for the 9 studies included in this sys­
tematic review is presented in Supplementary Table 3. An illustrative

Fig. 2. Distribution of risk of bias analysis showing among the studies included.

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9.4.5. Marginal 10. Meta-analysis

The trueness of the milled crowns was better than printed crowns in
the studies of Li et al. [30] (3DGD), Lerner et al. [7] (LCM), and Kim The meta-analysis of the trueness included seven studies [2,6,7,22,
et al. [6] (DLP and SLA). Only Zhu et al. [33] found that the trueness of 30,32,33]. Refaie et al. [17] were excluded because the trueness was not
the printed (NPJ) crowns was better than milled ones using the UPCERA measured in these studies. Wang and Sun, [31] was excluded because
system. Wang et al. [2], Abualsaud and Alalawi [22], and Zhu et al. [33] the RMS for the trueness was not calculated. Li et al. [30] presented the
(VITA group) found no difference in the trueness between both fabri­ RMS of the crown and a fixed dental prosthesis with 4 elements, with the
cation methods. data on trueness from the crown group being included in the
meta-analysis. The meta-analysis of the margin quality included the 3
9.4.6. Axial studies that performed this analysis [30,32,33]. Among the studies that
While Abualsaud and Alalawi [22] (SLA) and Zhu et al. [33] (NPJ) presented more than one experimental or control group, Zhu et al. [33]
showed that printed crowns presented better trueness than milled reported the fabrication of zirconia crown with one printer system, the
crowns, Li et al., reported no significant difference between both fabri­ NPJ, and 2 different brands of zirconia for milling (VITA YZ HT; VITA
cation methods. Zahnfabrik and UPCERA MT; UPCERA). Li et al. [32] reported groups
with different finish line designs (chamfer, rounded shoulder, and knife
9.4.7. Internal occlusal edge). In the study of Kim et al. [6], the control groups of 4Y-PSZ and
Wang et al. [2] showed that the trueness was comparable but the 5Y-PSZ were combined using appropriate formulas for merging means
study of Kim et al. [6] indicated results different for SLA and DLP and SD [34].
printing systems. DLP showed better trueness than SLA and one of the The global meta-analysis of the trueness indicated no significant
milled crown groups (4YZ) and showed no significant difference to the difference between the RMS of printed and milled zirconia crown (SMD:
other milled crown group (5YZ). 0.12; 95 % CI: -0.58, 0.82; P = 0.74, I2 = 90 %) (Fig. 3). The subgroup
analysis showed that the printing system was significant (P < 0.01). The
9.4.8. Occlusal 3DGD and LCM printing system showed a significant difference, favor­
Abualsaud and Alalawi [22] (SLA) showed that the trueness of the ing milled crowns. However, NPJ printing system showed a significant
printed crowns was better than milled ones. Zhu et al. [33] (NPJ) re­ difference, favoring printed crowns. In the meta-analysis performed for
ported similar results in the comparison to the milled UPCERA system, each crown area (Figs. 4-10), there was no significant difference be­
but there was no significant difference to the milled VITA system. tween printed and milled zirconia crown in most of the areas, except for
However, Lerner et al. [7] (LCM) reported better results for the milled the marginal (SMD: 1.60; 95 % CI: 0.01, 3.20; P = 0.05, I2 = 93 %)
crowns. (Fig. 7), favoring milled crown, and axial area (SMD: 2.81; 95 % CI:
-5.31, -0.30; P = 0.03, I2 = 93 %) (Fig. 8), favoring the printed crowns.
9.4.9. Precision The subgroup analysis showed that the printing system was significant
Concerning to the precision, Lerner et al. [7] and Abualsaud et al. for the overall crown (P < 0.01), marginal (P < 0.01), axial (P < 0.01),
[22] assessed this outcome using different parameters, as mentioned and occlusal (P < 0.01) areas of the crown. The global meta-analysis of
previously. Lerner et al. [7] found no significant difference in precision the margin quality showed no significant difference between printed
between the interproximal contacts and marginal adaptation of printed and milled zirconia crown (SMD: -0.02; 95 % CI: -0.10, 0.06; P = 0.61, I2
and milled zirconia crowns. However, Abualsaud and Alalawi [22] re­ = 0 %) (Fig. 11).
ported significantly higher RMS values for milled crowns than for
printed crowns in all tested areas (occlusal, axial, marginal, internal, and 11. Discussion
overall crown), indicating better precision for printed zirconia crowns.
This study systematically reviewed articles which investigated the
9.4.10. Margin Quality accuracy, evaluating the trueness and precision parameters, internal and
The selected studies demonstrated a satisfactory margin quality for marginal fit of monolithic 3D-printed and milled zirconia crowns.
both printed and milled zirconia crowns [7,30,32] where Li et al. [30] Additionally, the study evaluated the margin quality of the produced
noted that crowns with a knife-edge finish design, whether printed or crowns. Thus, only two secondary outcomes (trueness and margin
milled, exhibited more defects than those with chamfer and rounded quality) were subjected to meta-analysis due to the high heterogeneity
chamfer finish lines. The number of defects was slightly higher in milled of studies. The findings of this meta-analysis showed that 3D printing
than in printed crowns. technology produces zirconia crowns with comparable trueness and
margin quality compared to those of the ones manufactured by sub­
9.4.11. Adaptation tractive methods.
Internal and marginal adaptation were evaluated in three studies. In order to assess the trueness of the crowns, it was considered that
Wang and Sun [31] and Refaie [17] measured these outcomes using this parameter relates to the agreement between the measured regions
silicone replicas. Wang and Sun [31] reported that the adaptation in the on the manufactured crown and the reference CAD file used to fabricate
marginal, corner, and occlusal areas was superior for milled zirconia it [35,36]. For most studies, this correspondence was evaluated by
crowns but lower in the axial area compared to printed zirconia crowns scanning the crowns after printing/milling and overlaying the obtained
from various printers. Refaie et al. [17] also demonstrated that the STL files onto the original reference CAD file and the root mean square
adaptation in the marginal, cervical, and occlusal areas of milled crowns (RMS) is often used, where a low RMS value indicates good accuracy
was better than that of printed crowns, with no significant difference in (ISO–12836) [37]. Obtaining high trueness of the final crown compared
the axial area. Abualsaud and Alalawi [22] assessed internal and mar­ to the designed restoration is not only important for proper fitting of the
ginal adaptation using a different method, involving digital scanning of crown on the prepared tooth but also for minimizing adjustments and
the master die with and without a fit checker, followed by image su­ modifications of the restoration in the office [22]. Based on the findings
perimposition. The authors reported better adaptation in the occlusal of this study, the null hypothesis was accepted. The trueness of 3D
and axial areas for printed crowns and better in the internal area for printed crowns was similar to those manufactured by milling technique
milled crowns. There was no significant difference between the with both techniques resulting in clinically acceptable trueness.
manufacturing methods in the marginal area and the overall crown. In most analyzed areas, the trueness of both manufacturing methods
was similar. However, in the axial region (internal and external), con­
sisting mainly vertical surfaces, better trueness results were observed for

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Fig. 3. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown and the subgroup analysis for the printing system. CI: confidence
interval; SMD: standardized mean difference; E: external; I: internal; M: marginal; O: occlusal; A: axial; OC: overall crown; IO: internal occlusal; IA: internal axial.

printed crowns. On the other hand, in the marginal region, trueness was Additionally, printing parameters such as layer thickness and angulation
better for milled crowns. According to Zhu et al. [33], large curved can influence the trueness of the printed piece. One way to minimize this
surfaces are more prone to errors than vertical surfaces in 3D printing disadvantage of additive manufacturing is by printing with a reduced
due to layer deposition during the process, leading to a surface-stepping layer thickness to provide better trueness for curved regions [33].
phenomenon. This can negatively impact trueness in convex areas of Despite quantitative results did not reveal statistically significant
printed crowns, such as the marginal and cusp regions [3,6,38]. differences in trueness in the occlusal region of crowns, some studies

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Fig. 4. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the overall crown area and the subgroup analysis for the
printing system. CI: confidence interval; SMD: standardized mean difference.

Fig. 5. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the external crown area and the subgroup analysis for the
printing system. CI: confidence interval; SMD: standardized mean difference.

Fig. 6. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the internal crown area and the subgroup analysis for the
printing system. CI: confidence interval; SMD: standardized mean difference.

indicate [7,32,39] that occlusal surfaces are also more prone to errors in analysis, Zhu et al. [33] showed that crowns printed by the NPJ system
3D printing, where the precise reproduction of cusps may be affected by showed superior or similar accuracy to milled crowns in most areas. The
the presence of printing supports, which need to be positioned at the SLA system showed similar accuracy to milling in most areas of the
occlusal level, unlike in milled crowns. After printing, the removal of crown. On the other hand, DLP [6], LCM [7], and 3DGP [30] systems
these supports is necessary, and this process may affect the trueness of yielded more controversial results, with accuracy being similar or infe­
this region [7]. In contrast, for milled crowns, these supports are rior to milled crowns depending on the area of the crown.
attached to the axial region, which clinically has less influence on the Regarding the margin quality, it is known that this factor directly
physiological contact of the crown. influences the clinical performance of restorations, with better margin
One aspect that can also affect the accuracy of printed crowns is the quality associated with a lower risk of biological and technical compli­
printing system. The printing system can influence the level of detail in cations [25,30,40]. The type of margin preparation, contour, and
printing an object [33]. The most commonly used system in the included emergence profile of fixed prostheses can primarily influence the peri­
studies was SLA [2,6,22,31,32], although other technologies were odontal response to the prosthesis [41]. In the articles included in this
mentioned in isolated studies [6,7,17,30,33]. In subgroup analysis, the review, margin quality was classified on a scale of 1-5, based on the
accuracy of some areas of the crown was affected by the printing system. presence of flaws and a smooth or rough edge [25]. The findings of this
However, due to the limited number of studies using systems other than study demonstrated that margin quality was similar between printed
SLA, caution is warranted in interpreting the results. In qualitative and milled crowns.

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Fig. 7. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the marginal crown area and the subgroup analysis for the
printing system. CI: confidence interval; SMD: standardized mean difference.

Fig. 8. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the axial crown area and the subgroup analysis for the printing
system. CI: confidence interval; SMD: standardized mean difference.

Despite these results, some authors have demonstrated that certain Another parameter that was descriptively evaluated was the preci­
milled crowns exhibited more defects at the margin compared to printed sion of the crowns. To assess the precision of the restorations, mea­
crowns, especially in thin margins [30,33], revealing an advantage of surements were made from the manufactured crowns and compared
this technology, as such preparations still pose a challenge for subtrac­ with other crowns within each manufacturing technique. Only two
tive manufacturing [25,32]. However, due to the small difference, no studies included evaluated this parameter. The precision of additively
statistical significance was observed in this study. Li et al. [32] reported manufactured crowns was better in all evaluated areas compared to
excellent margin quality in both printed and milled crowns with chamfer milled crowns. This reflects the limitation of the milling process, where
and rounded chamfer finishes. However, they observed a higher number in most cases, milled crowns are consecutively manufactured using the
of defects in crowns with a knife-edge finish, with these defects being same zirconia disc, and the subtractive manufacturing process itself
more prominent in milled crowns. The increased number of defects at induces changes and progressive wear of the drills used, starting after
the margin of milled crowns may be caused by the marks left by the the first milling [43], which can affect the precision of the produced
milling tools during the milling process [30], potentially introducing pieces. Additionally, the position of the crowns within the disc and their
stresses and flaws in the restoration [42], especially in thin-margin relationship with the drill and milling axis is not consistent for all
areas. crowns. Hence, the crowns produced from the same block may exhibit

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S.E.G. Silva et al. Journal of Dentistry 147 (2024) 105089

Fig. 9. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the internal occlusal crown area and the subgroup analysis for
the printing system. CI: confidence interval; SMD: standardized mean difference.

Fig. 10. Forest plot summarizing comparison of the trueness of “printed” vs “milled” zirconia crown for the occlusal crown area and the subgroup analysis for the
printing system. CI: confidence interval; SMD: standardized mean difference.

Fig. 11. Forest plot summarizing Margin quality and comparing “printed” vs “milled” manufacturing methods. CI: confidence interval; MD: mean difference.

different deviations from the CAD file, resulting in dimensional differ­ is no consensus in the literature regarding clinically acceptable values of
ences when compared to one another [22]. However, considering the misfit, with studies suggesting a range of 50 to 120 μm [44,45], while
limited number of studies that evaluated this parameter, the interpre­ others propose 100 to 150 μm [46,47]. In this review, better adaptation
tation of the results should be approached with caution. values for printed restorations were found in the axial region by Wang
Internal and marginal adaptation can be evaluated based on their and Sun, [31] and Refaie [17] and in the occlusal and axial regions by
discrepancies, where the marginal discrepancy is the distance from the Abualsaud and Alalawi [22]. On the other hand, milled crowns exhibi­
outer edge of the crown to the outer face of the preparation finish, while ted better values for marginal and internal adaptation in all other re­
internal discrepancy considers the space of the cement layer [44]. There gions. It is important to note that misfit is a crucial factor in the longevity

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S.E.G. Silva et al. Journal of Dentistry 147 (2024) 105089

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