Dental Materials Journal 2023; 42(3): 441–448

Evaluation of the trueness and adaptation of zirconia crowns fabricated with

stereolithography
Boyu LI, Qingsong JIANG and Dan MENG

Department of Prosthodontics, Beijing Stomatological Hospital, School of Stomatology, Capital Medical University, No. 4 Tiantan Xili, Dongcheng
District, Beijing 100050, China
Corresponding author, Dan MENG; E-mail: [email protected]

The aim of this study was to evaluate the accuracy and adaptation of all-ceramic zirconia crowns fabricated by stereolithography
(SLA) compared with computer-aided design/computer-aided manufacturing (CAD/CAM) milling technology. Ten all-ceramic zirconia
crowns each were fabricated with SLA (experimental group) and CAD/CAM numerical control milling technology (control group).
The accuracy (including trueness and precision), and the internal and marginal adaptation of the crowns were measured with the
optical impression and silicone rubber film method and the three-dimensional deviation analysis software Geomagic studio, and the
results were statistically analyzed. The results indicated no statistical difference in trueness and the occlusal, axial and marginal
adaptation between groups (p>0.05), and the precision in the SLA group was better than that in the milling group (p<0.05). Thus,
crowns fabricated with SLA meet clinical application requirements.

Keywords: Stereolithography, CAD/CAM, All-ceramic crown, Trueness, Adaptation

solved9-12).
INTRODUCTION
The accuracy of crowns is highly important for their
All-ceramic zirconia has become a common material accurate fitting and long-term success, and is also the
for oral fixed dental prostheses because of its excellent most important adaptation index13,14). Accuracy can be
mechanical properties and good aesthetics. Currently, defined in terms of both trueness and precision. Trueness
the main manufacturing method for all-ceramic is the deviation of a measured object or data set from the
zirconia crowns is computer-aided design/computer- reference object or reference data set, and precision is the
aided manufacturing (CAD/CAM) technology, which repeatability of measurements15). Adaptation is defined
relies on a computer numerical control (CNC) milling by the measurement of the internal and marginal gaps
system. This subtractive manufacturing (SM) method is between the crown and prepared tooth. Good internal
currently considered the most widely used technique for and marginal adaptation are necessary conditions
manufacturing all-ceramic fixed dental prostheses1,2). for crowns, and provide an objective index indicating
However, the subtractive milling of preformed ceramic whether new technology or new materials can be used in
blocks results in waste of ceramic materials and wear clinical settings. However, some studies have evaluated
to the milling burs, thus increasing the manufacturing adaptation of zirconia crowns fabricated by SLA and
costs3). Therefore, developing new manufacturing reported substantially differing results. A visible gap
technologies for all-ceramic zirconia crowns is a focus remained between the alumina all-ceramic base crown
of dental ceramic research and clinical applications. and the preparation fabricated by Dehurtevent et al.7),
Additive manufacturing (AM) technology, also known and the marginal adaptation was poor. Wang et al.16)
as three-dimensional (3D) printing, had been developed have studied the trueness of SLA all-ceramic zirconia
as a new processing method. However, compared with crowns by using a ceramic 3D SLA machine in France,
metal, resin and other materials, ceramics have a high through a process that does not significantly differ from
melting point, high sensitivity to thermal shock and milling crowns. However, the results of Revilla’s17) study
low sintering ability4). Therefore, the AM of ceramic with the same machine indicated a marginal gap of SLA
materials is a research challenge, and its applications all-ceramic zirconia crowns of 146.0±103.2 µm, which
remains in early stages5). was clinically unacceptable.
Stereolithography (SLA), an AM technology, is In this study, we applied a newly invented SLA
among the most studied and widely used AM machine and a photosensitive ceramic slurry, using a
technologies, and it greatly improves the utilization scraper system that allows the uniform laying of slurry
rate of materials6,7). The 3D printing of ceramics has with higher viscosity (owing to high loads of ceramic
long faced challenges, such as insufficient material powders) and decreases the printing layer thickness
density, poor strength, poor marginal accuracy caused to 25 µm, thus improving the density, strength and
by sintering deformation and surface roughness caused accuracy of zirconia specimens. The purpose of this
by the stacking used in AM technology and the content study was to compare the manufacturing accuracy and
of slurry ceramic particles8). In the past 10 years, the internal and marginal adaptation between SLA and
problems with this technology have been preliminarily CAD/CAM milling of all-ceramic zirconia crowns, to

Received Jun 28, 2022: Accepted Dec 22, 2022

doi:10.4012/dmj.2022-146 JOI JST.JSTAGE/dmj/2022-146
442 Dent Mater J 2023; 42(3): 441–448

evaluate whether SLA of all-ceramic zirconia crowns All-ceramic crown design

can meet clinical needs. The die was scanned with a 3shape trios-3 intraoral
scanner (3shape, Copenhagen, Denmark), and the die
MATERIALS AND METHODS with full crown wax pattern was scanned simultaneously.
Through the supporting design software 3shape dental
Generation preparation system, the all-ceramic zirconia crowns corresponding to
A standard all-ceramic crown preparation of a resin the wax pattern were designed with the “deformation
maxillary right first molar (16) abutment tooth (500A, according to prefabricated spare parts” tool (parameter
Nissin, Kyoto, Japan) was selected as the abutment, design: the thickness of marginal adhesive, 30 µm;
and 15, 16 (abutment) and 17 were fixed on the self- thickness of internal adhesive, 75 µm; minimum crown
setting resin base (Fig.1). The impression was fabricated thickness, 1 mm). The STLdesign files of all-ceramic
through a one-step method with additive silicone rubber zirconia crowns were exported.
impression material (DMG, Hamburg, Germany). The
silicone rubber impression was required to have material Fabrication of all-ceramic zirconia crowns
at least 3 mm thick around the preparation body without The STLdesign files of both groups were used to fabricate
defects. Then, the die stone (Dentona, Dortmund, all-ceramic crowns. The milling group used zirconia
Germany) was cast, and the die was checked for the ceramic blocks (Wieland, Munich, Germany) and a CAD/
absence of bubbles and defects. The above process was CAM milling machine (inlab MC ×5, Sirona, Berlin,
repeated to prepare 21 dies meeting the requirements. Germany). The SLA group used an SLA printer (csl-100,
One die was used for fabricating a wax pattern for a full Porimy 3D Printing Technology, Kunshan, China) and
contour crown on 16 preparations (Fig. 2) for subsequent a photosensitive ceramic slurry (Porimy 3D Printing
prosthesis design. The other 20 dies were randomly Technology) composed of 47 vol% ceramic powders and
divided into SLA group and milling group (n=10). 53 vol% photosensitive resin premix containing resin
monomer, photoinitiator, dispersant and additives.
The specifications of the SLA manufacturing are
shown in Table 1. After printing, the green bodies were
ultrasonically cleaned and proceed to the de-binding
and sintering steps (Fig. 3). No post-treatment, such as
polishing or glazing, was performed in both groups.

Fig. 1 Representative images of the resin model of a

standard all-ceramic crown preparation for the
maxillary right first molar (16).
(a) Occlusal view, (b) palatal view

Fig. 3 Heat treatment schedule for stereolithographic

Fig. 2 Representative images of a full crown wax pattern fabrication of zirconia all-ceramic crowns.
of the maxillary right first molar (16). 350°C to 550°C=de-binding stage; 550°C to
(a) Occlusal view, (b) palatal view 1,500°C=sintering stage

Table 1 Specifications of the SLA manufacturing

Items Parameters

Layer thickness 25 µm

Laser scan spacing 50 µm

Laser scan speed 2,000 mm/s

Laser power 0.45 W

Scan frequency 30 kHz

 Dent Mater J 2023; 42(3): 441–448 443

Determination of the accuracy of all-ceramic crowns

The inner and outer areas of each all-ceramic crowns
were scanned with a 3shape intraoral scanner, and the
STLscan files were exported, and the best fit alignment
was determined with STLdesign files in Geomagic studio
2013 software (n=10). The STLdesign and STLscan files were
cut with dedicated tools to isolate and select only the
external occlusal surface and the marginal area (Figs.
4a, b). The 3D deviation spectrum was set at 13 color
segments, the maximum/minimum critical was set at
±50 mm, and the maximum/minimum nominal was set
at ±10 mm. Then 3D deviation analysis was performed.
The results of trueness evaluation are presented as a
color-difference map and the root mean square (RMS)
value for each area (Figs. 4c–f). For analysis of the
precision, RMS values were assessed by superimposition
of STLdesign within the group (n=10C2=45) (Fig. 5).

Determination of the internal and marginal adaptation

of all-ceramic crowns
Preparation of silicone rubber film: A layer of glycerol
was applied on the tissue areas of SLA all-ceramic
Fig. 4 Selected areas of all-ceramic crowns [(a) external zirconia crowns (n=10) and CAD/CAM milling all-ceramic
occlusal surface, (b) marginal surface] and color zirconia crowns (n=10) and blown into a thin uniform
maps representing RMS values (mm) in crowns layer with high-pressure gas. A scanning silicone rubber
fabricated by SLA. (c) Color map of external light body was injected into the inner area and placed
occlusal surface, (d) color map of marginal surface, on the corresponding stone die. The crown was loaded
(e) color map of all crown —external surface, (f) vertically with a pressure of 20 N (2 kg weight) for 5 min.
color map of all crown —internal surface.

Fig. 5 (a) All crown trueness, (b) external occlusal surface trueness, (c) marginal surface trueness, (d) all crown
precision.
444 Dent Mater J 2023; 42(3): 441–448

To ensure uniform stress on each tooth cusp, a base was test combined with Levene test for equal variance
made of silicone rubber in advance and placed between analysis and independent sample t-test.
the weight and the all-ceramic crown (Fig. 6). After the
light body was completely hardened, the spilled light RESULTS
body was gently removed with a sharp surgical blade,
and then the all-ceramic crown was removed to obtain The all-ceramic zirconia crowns fabricated by SLA and
20 stone dies with silicone rubber film (Fig. 7). CAD/CAM milling technology were located on the die, as
Measurement of silicone rubber film thickness: The shown in Fig. 9. No visible marginal gaps or morphological
stone die with silicone rubber film was scanned with a differences were observed between groups.
3shape intraoral scanner to obtain STLfilm files, and the Regarding the trueness evaluation, Table 2 shows
film was then removed. The stone die was scanned with the RMS median±IQR (interquartile range) values and
the same method, and STLdie files were exported. The upper and lower quartiles of the two groups and p values
best-fit alignment was performed by using adjacent teeth of the Mann-Whitney U test. Although the median values
(15 and 17) as a reference, followed by a 3D deviation were larger in the SLA group than the milling group, no
analysis of the occlusal, axial and marginal areas (Fig. significant difference was found between groups in terms
8). The average distance was recorded as the thickness of all crown area (p=0.597), the external occlusal surface
of the silicone rubber film. (p=0.580) and the marginal surface (p=0.977). Regarding
the precision of all crown area, Table 3 shows the RMS
Statistical analysis
Statistical analyses were performed in a statistical
software program (IBM SPSS Statistics, v26.0; IBM,
Armonk, NY, USA). First, the normality of the trueness,
precision and adaptation values was analyzed with
the Shapiro-Wilk test. The normality of trueness
and precision was not satisfied (p<0.05). Therefore,
significant differences in trueness data were analyzed
with the Kruskal-Wallis test, and post hoc analysis was
performed with the Mann-Whitney U test. Statistical
analysis of adaptation was performed with the normality

Fig. 8 3D deviation analysis of the cement space. Area

chosen for superimposing two scans (red).
(a) Marginal area, (c) occlusal area, (e) axial area.
3D deviation analysis results of different areas. (b)
Fig. 6 Representative images of the preparation of Marginal area, (d) occlusal area, (f) axial area.
silicone rubber films.

Fig. 9 Representative images of all-ceramic zirconia

Fig. 7 Representative images of silicone rubber film. crowns fabricated by different technologies.
(a) Occlusal view, (b) palatal view (a) SLA, (b) milling
 Dent Mater J 2023; 42(3): 441–448 445

Table 2 Trueness of crowns fabricated by SLA and milling

Part Group Median±IQR (µm) Percentile 25 (µm) Percentile 75 (µm) p

SLA 40.8±12.0 32.3 44.3

All crown 0.796
Milling 35.4±25.3 32.2 57.6

External occlusal SLA 37.8±11.9 31.3 43.2

0.684
surface Milling 32.2±32.9 28.2 61.1

SLA 42.6±9.8 37.9 47.8

Marginal surface 0.353
Milling 36.0±22.6 33.0 55.6

SLA, stereolithography; SD, standard deviation; IQR, interquartile range; CI, confidence interval

Table 3 All crown precision of crowns fabricated by SLA and milling

Group Median±IQR (µm) Percentile 25 (µm) Percentile 75 (µm) p

SLA 37.8±15.5 32.5 48.0

0.000
Milling 49.0±20.9 39.8 60.7

IQR, interquartile range

Table 4 Occlusal, axial and marginal adaption of crowns fabricated by SLA and milling

Area Group Mean±SD (µm) 95%CI (µm) p

SLA 144.2±40.37 115.35~173.11

Occlusal 0.959
Milling 143.4±32.06 110.49~152.71

SLA 80.8±18.26 67.71~93.83

Axial 0.129
Milling 66.2±22.36 49.42~80.94

SLA 109.5±31.64 86.83~132.10

Marginal 0.287
Milling 93.9±31.92 66.62~101.08

SD, standard deviation; CI, confidence interval

median±IQR (interquartile range) values and upper and its standardized, repeatable and efficient manufacturing
lower quartiles of the two groups and p values of the process19); however, it has high manufacturing costs,
Mann-Whitney U test. The SLA group had significantly owing to the waste of large amounts of materials and
better precision than the milling group (p=0.000). the need to change milling burs frequently. Moreover,
The occlusal, axial and marginal adaptation in the microcracks are easily introduced in milling ceramics,
SLA and milling group is shown in Table 4. Although thus resulting in the failure of prostheses3). Compared
the axial and marginal adaptation in the SLA group with SM, material addition manufacturing (AM)
(80.8±18.26 µm and 109.5±31.64 µm) was larger than technology, also known as 3D printing, involves 3D
that in the milling group (66.2±22.36 µm and 93.9±31.92 construction through layer-by-layer superposition based
µm), the difference was not statistically significant on digital die files20). In the forming process, no tools or
(p>0.05). molds are needed, and the utilization rate of raw materials
is nearly 100%, thus greatly decreasing production
DISCUSSION costs, simplifying the production process, shortening the
production cycle and enabling manufacturing of high-
Zirconia ceramics have high strength, high hardness, precision complex structures that are difficult to produce
wear resistance and corrosion resistance in terms with traditional forming processes4). Compared with SM
of mechanical properties, and the highest fracture technology, AM can save materials and is not limited by
toughness among commonly used dental ceramic milling tools. It also has the advantages of being able
materials18). Therefore, all-ceramic zirconia materials to manufacture more complex and fine structures and
are widely used in fixation and repair. As an alternative enable mass customization21).
to traditional casting methods, CAD/CAM milling is a The AM technologies used for processing ceramic
mature technology that has been widely used because of materials mainly include powder bed fusion, binder
446 Dent Mater J 2023; 42(3): 441–448

jetting, material extrusion jet and SLA22). Powder bed was 18.1% in length (x axial), 20% in width (y axial), and
fusion is a direct technology, whereas the other three 24.3% in height (z axial)29). Three-point flexural strength
are indirect technologies, in which the green body after sintering was 963.3±85.75 MPa in the 0° direction
containing organic adhesive or resin and ceramic powder and 816.6±88.06 MPa in the 90°direction, thus meeting
is constructed with an AM process, and the organic the clinical strength standard for fabricating all-ceramic
components are removed by further degreasing and crowns.
sintering9). SLA technology is a relatively well studied The manufacturing accuracy of prostheses is the
and mature technique, and thus it enables excellent most basic and important requirement. With the broad
accuracy, resolution and surface smoothness20). In SLA application of computer-aided design and manufacturing,
technology, the slices of a 3D model are established the manufacturing accuracy of prostheses depends on the
by computer software, and other parameters, such manufacturing technology itself. However, no standards
as the printing height, are set. The ceramic slurry have been established for the 3D measurement of
composed of ceramic powders and photosensitive resin, full crown accuracy. In this experiment, a CAD/CAM
photoinitiator, dispersant and plasticizer is evenly laid milling system with high trueness was used as the
on the working platform, and a UV laser beam with a control group. The internal and marginal adaptation of
specific wavelength and intensity is used to light cure the prosthesis are key to clinical success. The internal
the slurry point by point according to the software adhesive must have a certain thickness to maintain
design. After completion of the printing of one layer, the strength30). However, excessive thickness can easily
working platform is lowered by the height of one layer, lead to excessive stress and damage to prostheses. The
and the printing of the next layer continues6,23). The marginal discrepancy should be as small as possible. Poor
green body was subjected to debinding for removal of marginal adaptation can easily lead to greater plaque
the resin components, which was followed by sintering accumulation, secondary caries at the marginal area,
of the ceramic24). This technology combines the excellent marginal discoloration and greater risk of microcracks,
molding performance of polymeric materials and the high- thus, damaging the tooth body and periodontal tissue13).
temperature stability of ceramic materials. Therefore, The American Dental Association has recommended
this method is highly promising for processing zirconia a marginal gap standard of 25–40 µm for full crown
ceramic materials25). prostheses30). However, researchers have found that this
In the past, the problems of insufficient density, standard is usually difficult to achieve. A commonly used
accuracy and strength of 3D light curing ceramics reference standard is a marginal adaptation for a full
hindered research progress in prosthodontic treatment23). crown less than 120 µm, which is acceptable in clinical
Lian et al.26) printed zirconia ceramic dental bridges with prosthodontics, and an internal adaptation between 30
the SLA technique and slurry containing 40 vol% solid and 300 µm, which is clinically acceptable31). Wang et
powder. The bridges attained good surface hardness al.32) compared the internal and marginal adaptation of
and surface roughness. The apparent solid density was all-ceramic zirconia crowns fabricated by two different
6.03±0.10 g•cm3, and the shrinkage rate was 20–30% in SLA systems, CeraFab7500 (CF) alumina and CSL150
each direction. However, the flexural strength was only (CL) zirconia, and a conventional milling system,
200 MPa. In alumina ceramic crowns fabricated with X-MILL500 zirconia. The mean±SD value of the marginal
SLA, Dehurtevent et al.7) achieved a flexure strength of adaptation of CL group was 109±27 μm, which is within
300 MPa; however, a visible gap was observed between the clinically acceptable range. Revilla et al.17) compared
the bridge retainer and abutment preparation, thus the internal and marginal discrepancies of all-ceramic
indicating poor marginal adaptation. However, in recent zirconia crowns fabricated by a CNC milling system
years, with continual improvements in material ratios (CARES, Straumann, Basel, Switzerland) and SLA
and equipment parameters, these problems have been system (CERAMAKER 900, 3DCeram, Limoges,
preliminarily solved. Doreau et al.27) first formulated a France). The median±IQR for the SLA group was
reactive medium containing a photosensitive resin, very 146.0±103.2 μm, and manufacturing defects were
high loads of ceramic powders (approximately 70 vol%), encountered mostly on the intaglio marginal area, and
dispersants and a thickener. The high load of ceramic showed the highest marginal discrepancy and were
powder increased the flexural strength of components. deemed clinically unacceptable. These results suggested
Ji et al.28) optimized the sintering temperature and that the SLA technique is still in a pre-clinical stage and
sintering time to 1,450°C and 150 min, respectively, to the discrepancies in these results might have been due
achieve high strength. In this study, the slurry that we to poor control of the dimensional shrinkage during the
used contained 84 wt% solid powder (47 vol%) with main de-binding and sintering stage of green bodies.
components of ZrO2 and 4.5–6.4% Y2O3. The ceramic 3D Although the measurement results in this study
printer was equipped with a scraper that spread the showed that the median values of trueness were larger
slurry with viscosity <3,000 mPa•s uniformly on the in the SLA group than the milling group, we observed
platform, and the printed part was built up in layers. no significant difference between groups (p>0.05).
Debinding of green bodies occurred at a temperature of Simultaneously, the SLA group had better precision than
50–550°C after printing and the sintering temperature the milling group and the difference was statistically
was 1,500–1,550°C. The porosity was 0.88%, and the significant (p<0.05), possibly because the layer-by-
buckling deformation was 0.065 mm. The shrinkage rate layer principle of SLA resulted in a slightly higher
 Dent Mater J 2023; 42(3): 441–448 447

shrinkage rate in height (z axial) and consequently crowns fabricated by SLA technology reached that of
a deviation between the SLA crown and the original CAD/CAM milling technology of all-ceramic zirconia
design. However, the SLA technique has outstanding crowns, and its internal and marginal adaptation can
repeatability, and therefore shows excellent precision. meet clinical needs and obtain a good surface finish.
The adaptation of the occlusal and axial area was However, SLA technology still has drawbacks of
between 30 and 300 µm, and no significant difference problems such as a single color option, high costs and
was observed between groups (p>0.05). The marginal time-consuming procedures. Nevertheless, this method
adaptation mean value in the SLA group was slightly has good application prospects and is expected to become
higher than that in the milling group, but both were less an alternative technology for fabricating all-ceramic
than 120 µm, and no significant difference was observed zirconia restorations.
between groups (p>0.05). The results indicated that SLA
technology meets the accuracy and adaptation needs for ACKNOWLEDGMENTS
clinical applications. Notably, in crown design, owing
to the bur turning limitation of milling technology, the This work was supported by the Beijing Municipal
adhesive gap at the line angle of the occlusal surface Administration of Hospitals Incubating Program [grant
must be increased through a process called bur turning numbers PX2022061]; and the National Key R&D
compensation. This process is necessary because when Program of China [grant number 2018YFB1106900].
the axial area angle of the preparation body is sharp,
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