SYSTEMATIC REVIEW

Marginal and internal adaptation of single crowns and fixed

dental prostheses by using digital and conventional workflows:
A systematic review and meta-analysis
Mahya Hasanzade, DDS, MSc,a Mahdi Aminikhah, DDS, MSc,b Kelvin I. Afrashtehfar, DDS, MSc, Dr med dent,c
and Marzieh Alikhasi, DDS, MScd

ABSTRACT
Statement of problem. Digital and conventional options for definitive impressions and for the fabrication of fixed dental prostheses (FDPs)
have been compared in previous studies. However, a comprehensive review with concluding data that determined which method provided
the minimal internal and marginal adaptation is lacking.
Purpose. The purpose of this systematic review and meta-analysis of in vivo and in vitro studies was to compare the marginal and internal
adaptation of complete-coverage single-unit crowns and multiunit FDPs resulting from digital and conventional impression and fabrication methods.
Material and methods. The review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) and
followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, Cochrane Trials, Scopus,
and Open Grey databases were used to identify relevant articles. Based on fixed prostheses impression and fabrication methods, groups
from each study were categorized into 4 groups: conventional impression and fabrication (CC), conventional impression and digital
fabrication (CD), digital scanning and conventional fabrication (DC), and digital scanning and fabrication (DD). The risk of bias was
assessed by using the Cochrane Collaboration tool for clinical trials and the modified Methodological Index for Non-Randomized Studies
(MINORS) for in vitro studies. Heterogeneity was evaluated among studies, and meta-analysis was performed with random-effect models
(a=.05). Subgroup analysis was conducted when possible.
Results. Eight clinical trials and 21 in vitro studies were eligible for analysis. There was no significant difference between the CD and DD
clinical groups for marginal adaptation (P=.149); However, the DD group had significantly less internal discrepancy than the CD group
(P=.009). The in vitro studies found no significant difference in marginal adaptation among the CC-CD, CC-DC, and CC-DD pairs (P=.437,
P=.387, P=.587), but in the comparison CD versus DD group, a significantly better marginal adaptation was observed for the DD group
(P=.001). All the compared in vitro groups were similar in terms of internal adaptation.
Conclusions. Impression and fabrication techniques may affect the accuracy of fit of complete-coverage fixed restorations. A completely
digital workflow yielded restorations with comparable or better marginal adaptation than the other methods. (J Prosthet Dent
2021;126:360-8)

Computer-aided design and computer-aided manufacturing processing.1 Precision in these 2 steps results in the final
(CAD-CAM) systems include 2 steps, data acquisition by adaptation of the restorations.1-4 Data acquisition could be
intraoral scanners, impression scanning, or definitive cast made either by direct digitizing from the abutment with an
scanning followed by the fabrication of restorations after data intraoral scanner, which allows the clinician to acquire data
Supported by the 2019 AAED Grant for Research in Esthetic Dentistry from the American Academy of Esthetic Dentistry (AAED).
a
Assistant Professor, Department of Prosthodontics, Dental Research Center, Dentistry Research Institute, School of Dentistry, Tehran University of Medical Sciences,
Tehran, Iran.
b
PhD Candidate, Department of Ecology and Genetics, Faculty of Science, University of Oulu, Oulu, Finland.
c
Visiting Research Associate, Department of Oral Surgery & Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland; and Implant Fellow, Department
of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland; and Assistant Professor, Division of Restorative Dental
Sciences, College of Dentistry, Ajman University, Ajman City, United Arab Emirates.
d
Professor, Department of Prosthodontics, Dental Research Center, Dental Implant Research Center, Dentistry Research Institute, Tehran University of Medical Sciences,
Tehran, Iran.

360 THE JOURNAL OF PROSTHETIC DENTISTRY

September 2021 361

impression technique (C)?”. Second, “In complete-

Clinical Implications coverage restorations of natural dentition (P), does the
Fully digital workflows for dental restoration digital fabrication method (I) provide better marginal and
internal adaptation (O) compared with the conventional
fabrication could result in slightly better or
fabrication method (C)?”. There was no specification of
comparable marginal and internal adaptation when
time or setting.
compared with partially digital or fully conventional
An electronic search up to April 2018 was developed
workflows.
to identify relevant articles for the following databases:
Medline through PubMed, Elsevier Scopus, Cochrane
Controlled Register of Trials (CENTRAL), and Open
directly, or by indirect digitization of a conventional definitive
Grey (www.opengrey.eu). In addition, a hand search was
cast with a laboratory scanner.5-9 The indirect method has the
completed on the reference list of included studies. The
disadvantage of requiring a conventional impression, which
PubMed search strategy is presented in Supplemental
includes potential improper tray selection, the need to
Table 1 (available online), and the selection criteria in
disinfect the impression, distortion of impressions before
the Supplemental Material section Methodology.
pouring, and the dimensional changes of the stone cast.2,3
The methodological quality and risk of bias of the
However, conclusive evidence for the superiority of accu-
included in vivo studies were analyzed by 2 independent
racy of these methods is lacking.10-14 Moreover, in spite of the
reviewers (M.H., M.A.), by using the Cochrane Collab-
advances in restoration fabrication methods and the evolu-
oration tool for analysis of the risk of bias. Discrepancies
tion of new milling systems, controversies about whether
were solved by consensus, and a third review author
these systems are better than conventional techniques are
(K.I.A.) was consulted. Four items among the 6 items of
also lacking.4
this tool were considered key domains. Two domains
Marginal and internal adaptation are critical factors in
assessing randomization were not regarded as key do-
the long-term success of a restoration. Ill-fitting resto-
mains as both methods were performed during a single
rations may lead to plaque accumulation, cement disso-
operation. The modified Methodological Index for Non-
lution, microleakage, and secondary caries.15 In addition
Randomized Studies (MINORS) scale was used to
to the impression and fabrication techniques, other var-
assess the risk of bias.21 Each item of modified MINORS
iables affecting restoration fit include the type of resto-
tool was scored 2 if data were available and sufficient.
ration,2 restoration material,16,17 amount of spacer,18
The items were scored as 1 when data were insufficient
finish line design,14,19 cementation, and adjustment of
and 0 when not available.
the restoration.15 In spite of the lack of consensus, the
According to the impression and fabrication method,
maximum acceptable clinical marginal discrepancy has
each group of studies was categorized to one of the
been reported to be 120 mm.2,3 The purpose of this sys-
following groups: conventional impression and conven-
tematic review and meta-analysis was to determine
tional fabrication method (CC), conventional impression
whether the use of digital scanning and fabrication
and digital fabrication method (CD), digital scanning and
methods can improve the marginal and internal adap-
digital fabrication method (DD), and digital scanning and
tation of complete-coverage restorations compared with
conventional method of fabrication (DC). The main
conventional methods. The null hypothesis was that
outcomes measured were the mean differences in the
conventional and digital scanning and fabrication
marginal and internal gap among the following sub-
methods resulted in restorations with similar marginal
groups: CC-CD, CC-DC, CC-DD, CD-DD, DC-DD, and
and internal discrepancies.
CD-DC. The effect sizes of each study were computed as
the standard mean difference (SMD). Quantitative ana-
MATERIAL AND METHODS
lyses were accomplished for the in vivo and in vitro
The review protocol was registered and allocated the studies distinctly based on the SMD. In all meta-analysis,
identification number CRD42018093040 in the Interna- only studies with available data for each defined group
tional Prospective Register of Systematic Reviews were included so that meta-analysis with a different
(PROSPERO). This study followed the guidelines of the number of studies are presented.
Preferred Reporting Items for Systematic reviews and For each effect size of each subgroup, a 95% confi-
Meta-Analyses (PRISMA).20 dence interval (CI) was calculated. The inverse variance
The MeSH terms and keywords were defined based method in the random-effects model (a=.05) was
on 2 PICO (population [P], intervention [I], comparison selected to combine the effect sizes. The effect of the
[C], and outcome [O]) questions: first, “In complete- combination of impression and fabrication method on
coverage restorations of natural dentition (P), does the the marginal and internal gap was estimated distinctly for
digital scanning technique (I) provide better marginal and the designs of both studies. All subgroup analyses
internal adaptation (O) compared with the conventional calculated I2 to determine heterogeneity, as well as the

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362 Volume 126 Issue 3

358 records 121 records 124 records retrieved

Identification
35 records retrieved
retrieved from retrieved from from gray literature
from cochrane
PubMed scopus and hand searching

106 records after duplicates removed and title selection

Screening

11 articles excluded with reason:

- Lack of related type of data (n=3)22-24

47 records were eligible
Eligibility

for full text level - Type of study (n=2)25-26

- Type of restoration (n=3)27-29

- Lack of related intervention group (n=3)30-32

36 records* were included in quantitative analysis

Included

8 clinical studies 29 in vitro studies

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of search strategy and study selection. *One study33
included both in vivo and in vitro data

c2 test. If the number of studies in each subgroup was quality because of unclear risk for reporting bias, or other
limited, the same s2 was assumed within each subgroup. sources of bias.7,33,34 Two clinical trials lacked randomi-
Accordingly, the other subgroups were considered for zation and blinding.35,37 These authors stated that no
estimating the s2. All statistical tests were performed by randomization was needed because both methods were
using a statistical software program (Stata, v14.0; Stata- performed in a single operation.35,37 Supplemental
Corp LLC). Table 2 (available online) presents the risk of bias sum-
mary for the included in vitro studies. All studies had a
low risk of bias in terms of 5 items of the quality
RESULTS
assessment tool: clearly stated aim, contemporary
Among 514 potentially relevant articles from electronic groups, control groups with other impression materials,
and hand searching, 106 articles were selected after and statistical analysis. In contrast, a high risk of bias was
removing duplicates and title selection. Among the 48 found for 3 items: preparation method, adequate number
full-text eligible studies, 11 were excluded,22-32 and 37 of observations, and power analysis.
articles, which consisted of 8 prospective clinical trials7,33-39 Extracted data for in vivo and in vitro studies are
and 29 in vitro studies,6,8,9,13,14,16-19,40-58 remained for presented in Table 1 and Supplemental Table 3 (available
quantitative analysis (Fig. 1). The interexaminer Cohen online). Most of the studies (62.5% of in vivo and 72.4%
kappa values were 0.83 for the abstract and 0.87 full-text of in vitro studies) used a chamfer finish line.
screenings, indicating almost perfect agreement. For the marginal discrepancy evaluation, data from
A summary of the reviewers’ judgments about each in vivo studies were sufficient for quantitative analysis
risk of bias item for each included clinical trial is pre- only for the CD-DD group. In this comparison, no sig-
sented in Figure 2. Three articles met all criteria and were nificant difference existed between both groups (P=.149;
judged as high quality.36,38,39 Three articles had fair Fig. 3). Analysis for in vitro studies was feasible for 4

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restoration, and restoration material) that could affect the

Incomplete outcome data addressed

main outcomes. In the first subgroup analysis, pair

Blinding of outcome assessment

Adequate sequence generation
comparison groups were categorized into 2 strata based

Free of other sources of bias

on spacer thickness (spacer thickness 30 mm and spacer

Free of selective reporting

thickness >30 mm). The results of the subgroup analysis

Allocation concealment
of the CC-DD group for internal discrepancy reported a
significant difference among the groups when spacer
thickness was >30m with better adaptation for CC tech-
nique (P=.008; Supplemental Fig. 5, available online).
However, the difference was not significant for marginal
adaptation in either stratum of spacer thickness (P>.05;
Rödiger et al. 2017 – – – + ? ? Supplemental Fig. 6, available online). Spacer thickness
analysis for the CD-DD group resulted in better marginal
Yun et al. 2017 – – – + + + adaptation with spacer thickness  30 mm for the DD
method (P=.002, SMD=1.549, 95% CI=0.566-2.532;
Ahrberg et al. 2016 + + + + ? ?
Supplemental Fig. 7, available online).
Berrendero et al. 2016 + + + + + ? In the second subgroup analysis, the effect of type of
restoration was assessed for the CD-DD pair. The DD
Pradíes et al. 2015 + + + + + ? group reported better marginal adaptation than the CD
group, both in single-unit restoration (P=.013,
Sakornwimon & Leevailoj 2017 + + + + + +
SMD=0.659, 95% CI=0.136-1.181) and FDPs (P=.046,
Zarauz et al. 2016 + + + + + + SMD=0.864, 95% CI=0.014-1.714; Supplemental Fig. 8,
available online). Moreover, the DD group significantly
Zeltner et al. 2016 + + + + + + outperformed the CD group in FDPs in terms of internal
adaptation (P=.026; SMD=0.630, 95% CI=0.074-1.187).
The third subgroup analysis was regarding restoration
– High risk ? Unclear risk + Low risk material for CC-DD and CD-DD pairs. The results found
no significant difference for marginal and internal dis-
Figure 2. Risk of bias summary: reviewers’ judgments about each risk of
crepancies for the CC-DD pair considering different
bias item for each included in vivo study.
restorative materials. When analyzing CD-DD, cobalt-
chromium (Co-Cr) restorations fabricated with a fully
pairs; however, insufficient data were available for the digital method had a smaller internal gap (P=.028;
CD-DC and DC-DD group. No significant difference was Supplemental Fig. 9, available online). In addition, the
found in the comparison of the CC group with CD manufacture of zirconia restorations with the DD method
(P=.437; Supplemental Fig. 1, available online), CC group resulted in less marginal discrepancy compared with the
with DC (P=.387; Supplemental Fig. 2, available online), CD method (P=.001, SMD=0.994, 95% CI=0.383-1.604).
and CC group with DD (P=.587; Supplemental Fig. 3, There was no significant difference between both groups
available online). The DD group reported better marginal in lithium disilicate (P=.494) and Co-Cr restorations
adaptation compared with the CD group (P=.001; (P=.057).
Supplemental Fig. 4, available online). The mean mar-
ginal discrepancies of the subgroups from in vitro and
DISCUSSION
in vivo studies are presented in Table 2.
For the internal discrepancy evaluation, data were Conflicting results among past systematic reviews
sufficient for performing a meta-analysis for the CD-DD regarding the marginal and internal adaptation of res-
subgroup from in vivo studies. The DD method displayed torations fabricated with different methods encouraged
significantly better outcomes compared with the CD this updated review with meta-analyses.2-4 The results of
method (P=.009; Fig. 4). The analysis was done for all this study indicate that a completely digital workflow
subgroups of in vitro studies except the CD-DC group resulted in restorations with comparable or better inter-
because of insufficient data. No significant difference was nal and marginal adaptation in comparison with partially
found between the following in vitro studies groups: CC- digital or completely conventional methods.
CD, CC-DC, CC-DD, CD-DD, and DC-DD. The mean A previous review regarding the marginal adaptation
internal discrepancies of in vitro and in vivo studies for of restorations fabricated with CAD-CAM milling tech-
pair groups are presented in Table 2. nology, conventional casting, and direct metal laser sin-
The CC-DD and CD-DD groups had sufficient data to tering process concluded that the techniques resulted in
evaluate the potential factors (spacer thickness, type of restorations with similar adaption.4 Additionally, a

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364 Volume 126 Issue 3

Table 1. Characteristics of in vivo studies included

Spacer Marginal Internal
Authors, Impression Fabrication Sample Restoration Finish Thickness Gap (mm), Gap (mm),
Year Group Group (n) Material Restoration Type Line (mm) Mean (SD) Mean (SD)
Ahrberg et al, Con Dig 25 ZrO2 Single crowns and Chamfer 50 70.4 (28.87) 139.75 (55.72)
20167 Dig/Lava COS Dig 25 FDPs 61.08 (24.77) 129.54 (45.98)
Berrendero et al, Con Dig 30 ZrO2 Single crowns Chamfer 50 119.9 (59.9) 185.4 (112.1)
201633 Dig (Ultrafast) Dig 30 106.6 (69.6) 170.9 (119.4)
Pradíes et al, Con Dig 34 ZrO2 Single crowns NR NR 91.46 (72.17) 190.55 (68.84)
201534 Dig/Lava COS Dig 34 76.33 (65.32) d
Rödiger et al, Con Dig 20 ZrO2 Single crowns Chamfer 40 82.17 (75.17) 153.07 (61.12)
201735 Dig/TRIOS Dig 20 87.40 (91.21) 131.39 (68.27)
Sakornwimon Con Dig 16 ZrO2 Single crowns NR NR 56.29 (38.08) NR
et al, 201736 Dig/TRIOS Dig 16 61.52(32.16) NR
Yun et al, 201737 Con Con 10 Au Single crowns Chamfer NR 83.48 (11.35) 156.36 (39.81)
Con Con 10 73.65 (16.71) 228.48 (47.91)
Zarauz et al, Con Dig 26 ZrO2 Single crowns Chamfer NR 133.51 (48.78) 173 (92.65)
201638 Dig/iTero Dig 26 80.29 (26.24) 111.40 (54.04)
Zeltner et al, Con Con 10 LS2 Single crowns NR NR 90.4 (66.1) 96.65 (59.49)
201639 Dig/iTero Dig 10 60 127.8 (58.3) 159.95 (72.54)
Dig/Lava COS Dig 10 60 94.3 (58.3) 140.25 (57.27)
Dig/CEREC Dig 10 70 141.5 (106.2) 191.05 (111.37)
Dig/CEREC Dig 10 70 83.6 (51.1) 168.85 (63.02)

Au, gold; Co-Cr, cobalt-chromium alloy; Con, conventional; Dig, digital; FDP, fixed dental prosthesis; iOS, intraoral scan; KAlSi2O6, leucite; LS2, lithium disilicate; NR, not reported;
Pd-Ag, palladiumesilver; ZrO2, Zirconia.

quantitative analysis was not possible with the informa- digital workflow was significantly better than indirect
tion available until June 2016. To date, there have been 4 digitizing (CD) in marginal adaptation. These findings
published reviews comparing digital and conventional suggest that digital technology in both the impression
impressions regarding marginal and internal adapta- and fabrication steps is comparable with the conventional
tion.2,3,59,60 In a review of 10 clinical trials, a similar method. In a fully digital workflow, most errors derived
performance of digital scanning compared with from the inherent deficiency of material, including
conventional impressions was reported.59 The 2 other dimensional stability, deformation of impression mate-
meta-analyses of in vitro studies reported no significant rial, expansion and contraction of the cast, and human
difference between the 2 impression methods.2,3 How- errors.2,3 Moreover, in systems where the scanners,
ever, the study population was limited to a specific type design software program, and milling machines are
of treatment and material.3 The last meta-analysis, optimally matched, the error tolerance of each step can
including both in vitro and in vivo studies, favored be compensated.
marginal adaptation of digital scanning when compared The results from studies that evaluated the marginal
with conventional impression.60 However, these reviews fit of different impression and fabrication methods show
only compared different impression methods without great heterogeneity, which might be explained by
considering the fabrication method. Both data capturing discrepancy in fabrication materials,4 precision of the
and fabrication procedures could affect the overall mar- scanner and milling system, preparation design,61
ginal and internal discrepancy. measuring method,15 adjusting restoration, amount of
In the present review, the evaluation of clinical data spacer, and measurement of cemented or noncemented
was only possible for the CD-DD group (Table 2; Figs. 3, restorations.15,18 A recent review reported that the mar-
4). The clinical fully digital group (DD) had a similar ginal adaptation of CAD-CAM restorations is influenced
marginal adaptation compared with the CD group by the material of the block.4 Most heat-pressed lithium
(Fig. 3), whereas it had a significantly better internal disilicate single crowns displayed equal or better marginal
adaptation than the CD group (Fig. 4). fit than did those that were milled.4,62 However, there
Results of in vitro studies were available to compare have been an insufficient number of clinical trials to
different combinations of fully digital (DD), fully con- confirm it.63,64 In the current review, the marginal
ventional (CC), and partially digital workflows (CD or adaptation of entirely digital and partial digital (CD)
DC). There was no significant difference between CC- workflows concerning lithium disilicate had in vitro re-
DC, CD-DD, CC-CD, and DC-DD groups regarding sults ranging from better adaptation when milled,6,9,43 to
marginal and internal adaptation. However, the fully showing better adaptation when pressed.17,18

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September 2021 365

%
Study ID SMD (95% CI) Weight

Ahrberg et al. (2016) 0.34 (−0.22, 0.90) 13.88

Berrendero et al. (2016) 0.20 (−0.31, 0.71) 14.86

Boeddinghaus et al. (2015) −0.06 (−0.38, 0.26) 18.51

Pradies et al. (2015) 0.22 (−0.26, 0.69) 15.46

Rodiger et al. (2017) −0.06 (−0.68, 0.56) 12.77

Sakornwimon & Leevailoj (2017) −0.14 (−0.84, 0.55) 11.52

Zarauz et al. (2016) 1.34 (0.73, 1.94) 13.01

Overall (I-squared=66.5%, P=.006) 0.25 (−0.09, 0.59) 100.00

NOTE: Weights are from random effects analysis

−1.94 0 1.94
Favors CD group Favors DD group

Figure 3. Conventional impression and digital fabrication versus digital scanning and digital fabrication: marginal gap for in vivo studies (standardized
mean difference [SMD] and confidence intervals [CIs]; CD versus DD group). CD, conventional impression and digital fabrication; DD, digital
scanning and fabrication.

Nonetheless, the results of the subgroup meta-analysis Table 2. Mean of internal and marginal gaps in pair groups according to
found no significant difference between these 2 tech- subgroup meta-analyses
niques. Moreover, the efficiency of the fabrication Pair Groups Mean of Internal Mean of Marginal
Compared Studies Type Gap (mm) Gap (mm)
method is influenced by the restoration material. Twelve
Group A Group B In Vitro In Vivo Group A Group B Group A Group B
articles with zirconia restorations compared CD groups CC CD U d 108.2 108.8 87.8 89.2
with DD groups and reported better marginal adaptation CC DC U d 133.3 168.1 53.9 66.5
in the DD groups (Supplemental Fig. 10, available CC DD U d 122.5 112.9 74.1 68.4
online).8,13,14,19,44,45,47-49,52,57 CD DD U d 117.1 106.5 87.8 74.1*
Subgroup analyses of spacer thickness reported better DC DD U d 161.7 133.8 64.5 53.6
marginal adaptation of fully digital workflow compared CD DD d U 171.1 146.8* 100.1 98.1
with conventional impression and digital fabrication when C, conventional; D, digital. In each cell of pair group columns, first letter represents
the spacer was <30 mm (Supplemental Fig. 7, available impression, whereas second letter represents fabrication method for prosthesis.
*Significant difference between groups.
online). This result is consistent with that of a previous
meta-analysis that reported better marginal adaptation for reported statistically significant differences among the 3
digital scanning with reduced cement spacer settings.60 margin types.19
When analyzing the type of restorations, the fully The measurement instruments used for the marginal
digital workflow was better than indirect digitizing in discrepancy can affect the results.15 The included studies
FDPs both for marginal and internal adaptation. The used diverse methods to evaluate marginal discrepancies,
distortion of indirect digitation may occur when trans- including direct visualization with an optical comparator
ferring the abutment position of FDPs with a conven- or optical microscope,18,49 digital
6,14,17,18,45,46,49,56,57
tional impression. The role of finish line design in photography, the silicone replica
marginal adaptation is unclear.15,65,66 However, the finish technique,7,8,13,16,33-39,42,44,45,47,51-53,59 microcomputed
line design should be considered a confounding factor tomography,41,43,54 scanning electron microscopy,19 and
that could influence the heterogeneity of results. An the triple scan protocol.9,41,50,55 These methods have
in vitro study compared chamfer, shoulder, and knife- different specificity and reliability in determining the
edge design in terms of marginal adaptation and amount of misfit. Hence, the variations in measurement

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366 Volume 126 Issue 3

%
Study ID SMD (95% CI) Weight

Ahrberg et al. (2016) 0.20 (−0.36, 0.75) 18.81

Berrendero et al. (2016) 0.12 (−0.38, 0.63) 22.65

Pradies et al. (2015) 0.24 (−0.24, 0.71) 25.53

Rodiger et al. (2017) 0.33 (−0.30, 0.95) 14.91

Zarauz et al. (2016) 0.80 (0.23, 1.37) 18.10

Overall (I-squared=0.0%, P=.457) 0.32 (0.08, 0.56) 100.00

NOTE: Weights are from random effects analysis

−1.37 0 1.37
Favors CD group Favors DD group

Figure 4. Conventional impression and digital scanning versus digital scanning and digital fabrication: internal gap data from in vivo studies
(standardized mean difference [SMD] and confidence intervals [CIs]; CD versus DD group). CD, conventional impression and digital fabrication;
DD, digital scanning and fabrication.

tools among the studies could hamper the generaliz- 3. According to the in vitro studies, there were no
ability and transferability across studies.15 Moreover, significant differences between the internal gaps of
wide variations in acquisition systems, CAD design all the compared groups.
mechanisms, and CAM milling processes could result in 4. Cement spacer settings of less than 30 mm pro-
heterogeneous data. For instance, restorations milled duced a better marginal fit of the fully digital
with a 5-axis milling unit have greater accuracy than workflow compared with indirect digitizing of the
those milled with a 4-axis milling unit, because the 5-axis cast (P=.002). However, this difference dissipated
milling unit can virtually mill all undercuts in every di- when the spacer thickness was more than 30 mm
rection.67 More information about the limitations of the (P=.018).
review can be found at Supplemental Material section 5. Regarding restoration type, the analyses reported
Discussion. that the DD group was better than the CD group
both in marginal (P=.046) and internal adaptation
CONCLUSIONS (P=.036) in FDPs. Similarly, the DD group reported
better marginal adaptation of single crowns in
Based on the findings of the present systematic review comparison with the CD group (P=.013).
with meta-analysis of in vivo and in vitro studies, the
following conclusions were drawn:
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digital impression with Lava™ COS and conventional impression technique. 67. Alghazzawi TF. Advancements in CAD/CAM technology: options for prac-
BMC Oral Health 2016;16:129. tical implementation. J Prosthodont Res 2016;60:72-84.
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J Prosthet Dent 2016;116:362-7. Corresponding author:
59. Nagarkar SR, Perdigao J, Seong W-J, Theis-Mahon N. Digital versus con- Dr Kelvin I. Afrashtehfar
ventional impressions for full-coverage restorations: a systematic review and School of Dental Medicine e zmk bern, Faculty of Medicine
meta-analysis. J Am Dent Assoc 2018;149:139-47. University of Bern
60. Hasanzade M, Shirani M, Afrashtehfar KI, Naseri P, Alikhasi M. In vivo Freiburgstrasse 7, Bern 3010
and in vitro comparison of internal and marginal fit of digital and SWITZERLAND
conventional impressions for full-coverage fixed restorations: a sys- Email: [email protected]
tematic review and meta-analysis. J Evid Based Dent Pract 2019;19:
236-54. Author contribution
61. Cho L, Choi J, Yi YJ, Park CJ. Effect of finish line variants on marginal ac- Conceptualization was done by M.Al.; Data curation was carried out by M.Al.,
curacy and fracture strength of ceramic optimized polymer/fiber-reinforced M.H., M.Am.; Formal analysis was done by M.Am.; Funding acquisition was done
composite crowns. J Prosthet Dent 2004;91:554-60. by K.I.A.; Investigation was carried out by M.Al., M.H., and K.I.A.; Methodology
62. Mounajjed R, Layton DM, Azar B. The marginal fit of e.max Press and e.max was carried out by M.Al. and K.I.A.; Project administration was carried out by
CAD lithium disilicate restorations: a critical review. Dent Mater J 2016;35: M.Al. and K.I.A.; Resources were contributed by M.Al.; Software was taken care
835-44. by M.Am.; Supervision was carried out by K.I.A.; Validation was carried out by
63. Cooper LF, Stanford C, Feine J, McGuire M. Prospective assessment of CAD/ K.I.A.; Visualization was carried out by M.Al., M.H., and K.I.A.; Writingdoriginal
CAM zirconia abutment and lithium disilicate crown restorations: 2.4-year draft was carried out by M.Al., M.H., and K.I.A.; Writingdreview & editing was
results. J Prosthet Dent 2016;116:33-9. carried out by M.Al., K.I.A.
64. Afrashtehfar KI, Brägger U, Treviño-Santos A, de Souza RF. Letters to the
editor. Evid Based Dent 2017;18:2. Acknowledgments
65. Ates SM, Yesil Duymus Z. Influence of tooth preparation design on fitting The third author, K.I.A., was generously supported by the 2019 AAED Grant for
accuracy of CAD-CAM based restorations. J Esthet Restor Dent 2016;28: Research in Esthetic Dentistry from the American Academy of Esthetic Dentistry
238-46. (AAED).
66. Vojdani M, Safari A, Mohaghegh M, Pardis S, Mahdavi F. The effect of
porcelain firing and type of finish line on the marginal fit of zirconia copings. Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
J Dent 2015;16:113-20. https://doi.org/10.1016/j.prosdent.2020.07.007

Noteworthy Abstracts of the Current Literature

Early loading of titanium dental implants with an intraoperatively conditioned

hydrophilic implant surface: 3-year results of a prospective case series study
Stefan Paul Hicklin, Simone Fm Janner, Nicole Schnider, Vivianne Chappuis, Daniel Buser, Urs Brägger
Int J Oral Maxillofac Implants Sep/Oct 2020;35:1013-20

Purpose. The hydrophilic implant surface (INICELL) is a chemical alteration of a sandblasted and thermally acid-
etched surface that should lead to long-term osseointegration. This study investigated 3-year results after early loading
of implants with a hydrophilic, moderately rough surface in occlusal contact.

Material and methods. This prospective case series study was conducted in subjects with partially edentulous
mandibles. Implants were placed on day 21 and loaded with a provisional reconstruction after at least 21 days of
healing (baseline, day 0) if their implant stability quotient (ISQ) was 70 (mean of three measurements) and were
replaced by definitive porcelain-fused-to-metal prostheses at the 6-month follow-up visit. Follow-up examinations
were planned 1, 3, 6, 12, and 36 months after baseline.

Results. A total of 20 implants were placed in 15 patients (mean age: 51 years, range: 32 to 67 years). After 36 months,
all implants were osseointegrated, and no suppuration was recorded. Small changes of bone level were observed
between 3 months and 36 months. At 36 months, the median values of the 20 implants were 0.25 (range: 0 to 0.5, SD:
0.17), 0.25 (range: 0 to 1, SD: 0.27), and 4 (range: 2 to 7.25, SD: 1.17) for the mean modified Plaque Index (mPI), mean
modified Sulcus Bleeding Index (mSBI), and mean probing pocket depth, respectively. The pairwise analysis between 3
and 36 months showed an improvement in the mean mPI (P=.0126) and mean mSBI (P=.0059). After 36 months, all
patients (n=15) were fully satisfied with a mean of 9.43 (range: 8 to 10, SD: 0.678) at the visual analog scale.

Conclusions. Early functional loading of implants with a hydrophilic, moderately rough outer surface in occlusal
contact 21 days after healing appears to be a safe and feasible treatment option when placed in the posterior mandible
of partially edentulous patients.
Reprinted with permission of Quintessence Publishing.

THE JOURNAL OF PROSTHETIC DENTISTRY Hasanzade et al