RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

COMPARISON OF THE CLINICAL EVALUATION OF THE MARGINAL

ACCURACY OF THE CAST RESTORATION WITH STEREOMICROSCOPY

Dissertation submitted in partial fulfillment of the requirement for the degree of

MASTER OF DENTAL SURGERY IN
PROSTHODONTICS, CROWN & BRIDGE

APRIL 2009

Dr. ABHISHEK RASTOGI

DEPARTMENT OF PROSTHODONTICS, CROWN & BRIDGE P.M. NADAGOUDA MEMORIAL DENTAL COLLEGE & HOSPITAL, BAGALKOT 587 101, KARNATAKA.

COMPARISON OF THE CLINICAL EVALUATION OF THE MARGINAL

ACCURACY OF THE CAST RESTORATION WITH STEREOMICROSCOPY

By DR. ABHISHEK RASTOGI Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfillment of the requirements for the degree of

MASTER OF DENTAL SURGERY In

PROSTHODONTICS Under the Guidance of Dr. VIKAS KAMBLE

DEPARTMENT Of PROSTHODONTICS, CROWN & BRIDGE P. M. N. M. DENTAL COLLEGE AND HOSPITAL

Year: 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

ii

BANGALORE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE DECLARATION BY THE CANDIDATE

I here by declare that this dissertation entitled Comparison of the clinical evaluation of the marginal accuracy of the cast restoration with

stereomicroscopy is a bonafide and genuine research work carried out by me under the guidance of Dr Vikas Kamble
M.D.S,

Associate Professor, Department of

Prosthodontics, P.M.N.M Dental College & Hospital, Bagalkot.

Date: Place: Bagalkot

Signature of the Candidate Dr. Abhishek Rastogi

iii

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled Comparison of the clinical evaluation of the marginal accuracy of the cast restoration with stereomicroscopy is a bonafide research work done by Dr. Abhishek Rastogi in partial fulfillment of the requirement for the degree of Master of Dental Surgery.

Date: Place: Bagalkot

Dr. Vikas Kamble Guide, Associate Professor,

M.D.S,

Department of Prosthodontics P.M.N.M Dental College & Hospital, Bagalkot 587101

iv

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT, PRINCIPAL/ HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled Comparison of the clinical evaluation of the marginal accuracy of the cast restoration with stereomicroscopy is a bonafide research work done by Dr. Abhishek Rastogi under the guidance of Dr.Vikas Kamble
M.D.S,

Associate Professor, Department of Prosthodontics, P.M.N.M Dental

College & Hospital, Bagalkot.

Dr. VIKAS KAMBLE

M.D.S

Dr. SHRINIVAS S VANAKI M.D.S Principal, P.M.N.M Dental College & Hospital,Bagalkot-587101

Associate Professor and Head, Department of Prosthodontics, P.M.N.M Dental College & Hospital, Bagalkot-587101 Date: Place: Bagalkot

COPY RIGHT Declaration by the Candidate

I here by declare that Rajiv Gandhi University of Health Sciences, Karnataka shall have rights to preserve, use and disseminate this dissertation in print or electronic format for academic / research purpose.

Date: Place: Bagalkot Dr. Abhishek Rastogi

Rajiv Gandhi University of Health Sciences, Karnataka

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Dedicated To My Beloved Parents Whose Countless Sacrifices Made My Dreams A Reality

Vakratunda Mahakaya Suryakoti Samaprabha, Nirvignam Kurumedeva Sarvakaryeshu Sarvada

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ACKNOWLEDGEMENT

This thesis represents the assistance and efforts of many individuals, the contributions of whom I acknowledge and to whom I give my thanks. The individual most responsible for the completion of this study is my guide Dr.Vikas Kamble, Associate Professor and Head, Department of Prosthodontics, P.M.N.M Dental College, Bagalkot. His tireless pursuit for academic excellence and professional insight were a source of constant encouragement and inspiration. A mere word of thanks is not sufficient to express his unflinching support, keen surveillance, inestimable aid and continued inspiration during the preparation of this dissertation. He is a person who has a rare combination of being a dedicated professional and a caring human being. overwhelming help and kindness. It is with supreme sincerity and deep sense of appreciation that I thank my esteemed teacher Dr. Raviraj G.Desai Associate Professor, Department of Prosthodontics, P.M.N.M Dental college, Bagalkot. He has always given me excellent guidance, encouragement and friendly help during the course of my entire post graduation and under whose shade I comfortably grew up in department. His inspiration and encouragement have molded me to present. My heartfelt gratitude to Dr. (Mrs) Veena K. Subbarao former Professor, and Head, Department of Prosthodontics, P.M.N.M Dental college, Bagalkot, a teacher of inspiring genius and unstinting generosity for her overall guidance, encouragement, and suggestions during the course of this study. I would also like to thank Dr. Chandu G.S., former Associate Professor for his valuable suggestions and assistance throughout my postgraduate course. I would like to thank our staff members Dr. Kashinath Arabbi, Dr Reshma Kulkarni and Dr Nagraj for their support and kindly help. I will be indebted to him for his

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I would like to express my thanks to our Principal Dr. Shrinivas S. Vanaki, for his support and providing me with adequate facilities for my study. Expressions are inadequate to convey my immense gratitude to Dr. S.S. Vanaki, Dr. R. S. Puranik and Dr. Shivakumar for allowing me to carry out stereomicroscopic evaluation as a part of my research work. I also thank our honorable chairman Shri. V. C. Charantimath for providing all the necessary facilities and an opportunity to carry out this study. My ever encouraging and helping colleagues Dr. D R V Kumar, Dr. Sumit Deshpande, Dr. Dayanand Huddar, Dr Piyush Tandon, Dr. Alok Sharma, Dr. Nishant Rajwadha, Dr Suresh Nagral, Dr Amandeep Bhullar, Dr Pavan Kulkarni, Dr Hitendra Yadav and Dr Suchitra S.R for their support, valuable criticism, suggestions and unfailing companionship. Among my friends Dr. Lakhmikant, Dr. Sudhakara and Dr Mangesh Shenoy requires special thanks for helping me out during my study. I owe sincere thanks to Mr. Abdul for his helping me to carry out my lab procedures during my study. I owe sincere thanks to Mr. S. B. Javali for his statistical help. I would like to thank our librarian for his immense support and providing me books and journals during my study. I convey my deepest gratitude to all other staff members, my post graduate colleagues for their help throughout this study. My special thanks to my parents and all my family members for their unseen sacrifices, constant advice, support and encouragement in every moment of my study. Their cheerful encouragement, timely support and cooperation made me to do my work better with my maximum enthusiasm. Lastly I wish to thank all those who have directly or indirectly contributed to the successful completion of this dissertation. Dr. Abhishek

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LIST OF ABBREVIATIONS USED o m Microns o SD Standard Deviation

ABSTRACT

Background and Objectives: One of the most important criteria for the clinical success and longevity of cast restorations is its marginal adaptation. Marginal discrepancies adversely affect local periodontal tissue condition. There are several commonly used techniques to evaluate the accuracy of marginal fit of cast restoration prior to clinical acceptance. These include the use of dental explorer and Elastomeric disclosing materials. Studies have reported 30 microns to be a clinically acceptable gap discrepancy. However, there is limited information on sensitivity and specificity of commonly practiced clinical evaluations in detecting a marginal discrepancy of this magnitude. The indications for the use of die spacers in fabrication of cast restorations are well documented in the literature. In this in vitro study, die spacer was intentionally not used to create variations in casting fit for the purpose of the study. The aim of this study was to assess the effect of preparation design on marginal adaptation, as well as to assess sensitivity and specificity of clinical evaluation (i.e. explorer and elastomeric disclosing material) of cast restoration marginal adaptation when compared to stereomicroscopy. Materials and method: Three Ivorine molar teeth of different designs were prepared Design A-A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B -A complete crown preparation with a chamfer finish line. Design C-A three-quarter crown preparation with proximal boxes and beveled finish line. Elastomeric impressions of each tooth were made using individual customfabricated trays. Eight individual dies were fabricated of each design. A total of 24 dies were prepared. Wax patterns were fabricated on the dies using type II inlay wax and casted using a non precious gold alloy. The casting procedures were standardized by investing immediately after waxing. Each casting underwent examination with an explorer, disclosing media, and a stereomicroscope. Twelve circumferential recordings were made of each casting, xi

 three on each buccal, lingual, mesial and distal surface, marked with a groove on original ivorine teeth and highlighted using a fine indelible marker, for a total of 288 examination sites. A ranking of fit or misfit was given to each examination site after assessment with explorer and disclosing media. Stereomicroscopy at a value less than or equal to 30 microns measurements was used as a gold standard to evaluate the significance of different designs on marginal adaptation. Three sites for each buccal, lingual, mesial, and distal surface were given an overall evaluation of fit or misfit. A surface was raked fit where all 3 measurement points on a surface were less than or equal to 30 microns using stereomicroscopy. If any of three measurement points of a surface had a value of greater than 30 microns, that surface was ranked as misfit. Chi-square tests of independence and Kruskal-Wallis were used to evaluate the effect of preparation design and compare the agreement between examination methods for detection of marginal gap size of greater than or equal to 30 microns. Sensitivity and specificity for explorer and disclosing media as compared to stereomicroscope was calculated using statistical formula given by Park.

Results: The preparation design did not significantly affect overall marginal adaptation. Examination by explorer at 30m revealed 39% sensitivity and 91% specificity. The disclosing media had 10.06% sensitivity and 82% specificity at 30m. Conclusion: Preparation designs examined in this study did not significantly affect the marginal adaptation and accuracy of the castings. Commonly used clinical evaluation techniques i.e explorer and elastomeric disclosing media may be inadequate for assessments of marginal accuracy. Explorer technique proved to be better aid in detection of marginal accuracy as compared to elastomeric disclosing media. For better evaluation of marginal accuracy of the cast restorations, the routine use of a stereomicroscope in the laboratory is indicated which provides a superior quality control prior to examination of restorations intraorally.

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TABLE OF CONTENTS

Page No. 1. Introduction 2. Objective 3. Review of literature 4. Materials and method 5. Results 6. Discussion 7. Conclusion 8. Summary 9. Bibliography 10. Annexure 1 5 6 22 39 54 58 59 61 66

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 LIST OF TABLES Table no. Title Page no. 42

1. Readings of all three preparation designs using explorer. 2. Readings of all three preparation designs using elastomeric disclosing media. 3. Readings of all three preparation designs using stereomicroscope. 4. Distribution of overall marginal adaptation of crowns by three designs using explorer technique. 5. Distribution of overall marginal adaptation of crowns by three designs using elastomeric disclosing media. 6. Distribution of overall marginal adaptation of crowns by three designs using stereomicroscope. 7. Comparison of mean marginal openings of three designs in Stereomicroscope by Kruskal Wallis Anova test. 8. Marginal accuracy findings on buccal, lingual, mesial, distal surfaces of three preparation designs. 9. Percentage of 288 sites with inadequate marginal fit as detected by explorer, elastomeric disclosing media and stereomicroscope. 10. Results of stereomicroscopic evaluation of 288 marginal gap sites compared to explorer using stereomicroscope as gold standard. 11. Results of stereomicroscopic evaluation of 288 marginal gap sites compared to elastomeric disclosing media using stereomicroscope as gold standard. 12. Illustration 1 and 2 for calculation of sensitivity and specificity.

43 44

45

46

47

48

49

50

51

51 52

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 LIST OF GRAPHS

Table no.

Title

Page no.

1. Distribution of overall marginal adaptation of crowns by three designs using explorer technique. 2. Distribution of overall marginal adaptation of crowns by three designs using elastomeric disclosing media. 3. Distribution of overall marginal adaptation of crowns by three designs using stereomicroscope. 4. Comparison of mean marginal openings of three designs in Stereomicroscope by Kruskal Wallis Anova test. 5. Percentage of fit and misfit sites in explorer technique. 6. Percentage of fit and misfit sites in elastomeric disclosing media 7. Percentage of fit and misfit sites in stereomicroscope. 48 50 50 50 47 46 45

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 LIST OF PHOTOGRAPHS

Table no.

Title

Page no.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Materials and armamentarium used Armamentarium used Stereomicroscope Design A Design B Design C Custom tray Custom tray with wax spacer Impression making Final impression Pouring of impression using vibrator Group of Dies for design A, design B, design C Wax coping made using dip wax technique Carving Wax pattern Wax pattern with margins sealed under 1.5X magnification Fit check using explorer Fit check using elastomeric disclosing media Specimen under stereomicroscope Marginal opening as seen under stereomicroscope Marginal gap of 30m, 60 m, 90 m as seen under stereomicroscope xvi

30 30 31 32 32 32 33 33 33 33 34 34 35 35 35 36 36 37 38

38

INTRODUCTION
The adaptation of cast restoration to the prepared tooth has been capriciously defined as the fit of the restoration, although precise definition is lacking. Investigators have described casting fit by mean marginal openings between the prepared tooth and casting margins,1 by adaptation of multiple points inside the castings,2 by vertical seating of the casting on prepared tooth or die, or by the distance from the cavosuface angle of the preparation to the margin of the casting. If a marginal misfit is viewed as a combination of gap error and extension error, a finite number of possible types of misfit exist. Ideally there are no marginal discrepancies between the tooth and restoration and the emergence profile of the restoration is coincident with sub marginal surfaces of the prepared tooth. Because of deficiencies inherent in the dental casting technique, a gap of varying width is likely to occur between a casting and a tooth, both on the internal surface and at the margins. A luting agent is used to fill this space and provides both a marginal seal and friction retention for the casting. Cement dissolution can occur along the casting tooth interface with concomitant risk of caries. Open marginal configurations encourage micro leakage of bacteria and their byproducts during dissolution of the luting agents. This can cause severe effects on the health of pulpal tissues.3 There is a continuing quest to determine the best way to minimize the width of the cement line within accepted technique constraints. Different finish-line designs have been advocated for several reasons. Preston4 and Shillingburg recommended the shoulder-bevel as the best type of finish line for the cast restoration. Rosner5 reasoned 1

 that a beveled finish line would fit better than a shoulder and trigonometric analysis to support his assertion. He recommended beveled margin parallel to the axial wall for smallest possible cement line. Pascoe6 concluded that, with an oversized casting, a shoulder finish line minimizes marginal opening whereas a beveled shoulder does not. Others advocated use of shoulder finish lines in metal ceramic technique for periodontal and esthetic reasons. In view of the limited and contradictory theoretical, laboratory, and clinical evidence available, it is not clear which finish line design, if any, may offer the greatest advantage.7 Clinical acceptability and longevity of cast restoration is related to marginal fit. The result of dental lost wax casting techniques are greatly influenced by the expansion and contraction of all of the materials used, including impression materials, waxes, gypsum products, plastics, and metals. In practice, many cast crowns do not precisely fit on the dies on which they are made. Distortions in the casting results in non-uniform cementation space and surfaces of actual binding between tooth and metal. Much of distortion occurs during casting process. Approaches toward correcting casting-induced errors have involved additive and subtractive techniques. Additive methods include the use of die spacers,8, 9 a technique that currently enjoys wide acceptance. Subtractive methods include the bulk etching of internal surfaces by chemical15 and electrochemical processes. Disclosing materials such as chloroform with rouge or soft waxes have been advocated for more selective removal of metal, often at the time of delivery. Elastomeric materials have been recently advocated for use as a guide during selective internal finishing and visualization of the precementation space.10, 11

 Controlled production of a uniform and properly sized precementation space would seem to be important for (1) initial seating of casting on its dies, (2) appropriate fluid flow during cementation, and (3) optimized post cementation marginal seal and occlusal fit of restoration.12 The production of cast restorations with perfect margins is not yet possible. McLean and Von Fraunhofer found that in vivo marginal discrepancies ranged from 10 to 160 m. There are several commonly used techniques to evaluate the marginal accuracy of cast restorations prior to clinical acceptance. These include use of dental explorer, and elastomeric materials.11, 12, 13 McLean and Von Fraunhofer suggested that a dental explorer could not detect marginal gaps less than 80 m. Others have found even greater discrepancies.14 Many disclosing agents, including chloroform and rouge, disclosing waxes, wax aerosols, and zinc oxide-eugenol have been used as aids in fitting crowns.15 McLean and Von Fraunhofer used polyether elastomeric impression material to evaluate the potential cement film thickness beneath clinical restorations they suggested a further application of this technique for the placement of cast restorations. This technique was further described by several authors using a light bodied- condensation reaction silicone impression material.10, 11, 12 Several studies have reported 30m to be clinically acceptable gap discrepancy.8 However, there is limited information on sensitivity and specificity of commonly practiced clinical evaluations (i.e. explorer and elastomeric disclosing material) in detecting a marginal discrepancy of this magnitude. Sensitivity of a technique is the probability that there will be a positive result i.e. marginal gap is present between the casting and prepared tooth. Higher the values of sensitivity lower will be the false 3

 negative rate i.e. the tendency of the technique to locate the closely adapted margins even when marginal gaps are present will be less. The specificity of the technique is the probability that there will be a negative result i.e. the casting margins are closely adapted to the prepared tooth. Higher the values of specificity, lower will be the false positive rate i.e. the tendency of the technique to locate the marginal gap even when the margins are closely adapted to the prepared tooth will be less. The indications for the use of die spacers in fabrication of cast restorations are well documented in the literature.7,
16, 17

In this in vitro study, die spacer was

intentionally not used to create variations in casting fit for the purpose of the study. The aim of this study was to assess the effect of preparation design on marginal adaptation, as well as to assess sensitivity and specificity of clinical evaluation of cast restoration marginal accuracy when compared to stereomicroscopy.

OBJECTIVE OF THE STUDY

The aim of this study was to assess the effect of preparation design on marginal adaptation, as well as to assess sensitivity and specificity of clinical evaluation of cast restoration marginal accuracy when compared to stereomicroscopy.

REVIEW OF LITERATURE
A study investigated four representative casting techniques to determine if a number of castings made by these techniques would be dimensionally same. The conclusions derived from this study were: The variations in the size between a number of castings made by a present day dental casting techniques may be of order of 1.0 per cent. The inherent surface roughness or texture of the casting will appreciably affect the subsequent fit. A problem of obtaining uniform expansion exists when making full crowns and probably mesioocclusal distal inlays by hygroscopic compensating techniques.18

An article described a clinical procedure for making precision casting restorations. The procedure follows the conditions specified in previous experimental research. Consistent success has been obtained by this technique, with minimal amount of time, labour, and materials.19

An article discussed the function, placement, and reproduction of bevels for gold castings. Castings have inherent errors of a significant character. The preparation of teeth should be modified to cancel errors as much as possible, and to make use of certain specific properties of gold castings.5

 A study investigated the factors governing the resistance of the cementing medium in the placement of full crowns by measurement of the thickness of the cement on cervical shoulders of the preparations of various types. Techniques to relieve the resistance of the cement within the crowns were developed. Conclusions derived from this study were: The Excessive amount of pressure during cementation produced no significant difference in the thickness of the cement on the shoulders of the preparations. An increase in taper of the walls of the preparation resulted in marked decrease in the thickness of the cement on the shoulders. A decrease in the height of the preparation slightly decreased the thickness of cement on the shoulders. Relief spaces made on the inside surfaces of the crowns to reduce the resistance of cement markedly reduced the cement thickness on the shoulders. No significant difference was found between two types of application of a relief material in the seating of crowns. However, the buccolingual application of tinfoil was the most simple to use clinically. Cement exposure was greatest on the shoulder type of preparations, much less on the chamfered type, and very little on the shoulder less type. 20

A study was done to evaluate microscopically the marginal opening, termed clinically acceptable by ten experienced dentist, who also evaluated the marginal adaptation of visually accessible and inaccessible gold inlay margins by explorer. The study also 7

 determined if gold inlay margins may be closed past the film thickness of zinc phosphate cement by proper finishing and polishing. The conclusions of the study were: The least acceptable, visually accessible margin was computed from a linear regression prediction formula to be open 39m. The range of opening of 40 barely clinically acceptable margins was from 2 to 51 m. There is direct relationship between the microscopic opening of visually accessible occlusal and proximal gold inlay margins and the experienced restorative dentists ability to evaluate this opening clinically by sight and explorer. The dentists were not able to evaluate consistently the marginal opening of gingival areas by explorer or roentgenogram. Margins closed past the reported film thickness of zinc phosphate cements if proper finishing techniques are used. Explorer examination of visually accessible gold inlay margins is superior to and more reliable than, explorer or roentgenographic examination of visually inaccessible margins.14

A study compared the fit of certain casting alloys, investments and techniques. Alloys and combinations used were- (1) Micro-bond Platinum series alloy and investment, (2) Ney G 3 Gold and Cristoballite investment, (3) Ney G 3 Gold and Whip-mix Hydrotrol investment, (4) Ceramo no.1 alloy and whip-mix cermigold investment, (5) Ceramo no.1 alloy And ransom-Randolph H.F.G investment. Conclusions drawn from this study were: All castings evaluated in this study failed to seat precisely.

 The most superior castings from the standpoint of overall adaptation to the dies were those made with Ceramco No.1alloy and Whip-Mix Ceramigold investment. Results achieved with the cristobalite and H.F.G. investment alloy were comparable. The results produced by the Micro-bond investment-alloy combinations were felt to unsuitable for general use. The Hydrotrol investment-alloy combination produced the worst results in this study. The use of this investment without water bath provided insufficient expansion. Binding occurred towards the occlusal end of nearly all castings. The MOD castings showed a definite pattern of distortion. Phosphate and ethyl silicate bonded investments produced 1.0 % more expansion than gypsum bonded. Proximal lengths of the MOD castings were all shorter than corresponding length of dies. The definition of casting accuracy should take into consideration a degree of fit rather than absolute adaptation.21

An article described methods for achieving a better fitting restoration with more closely adapted margins. They were: Silver-plated dies are used for better marginal detail. Water swaged patterns are used for closer adaptation; then the margins are overwaxed.

 The internal surface of the casting is relieved, except for the margins. This will allow cement to flow more easily for better seating. Vise-seat the inlay on the silver-plated die, trim the margins, burnish-fit the margins, then polish the casting on the silver die. Use an exacting cementation procedure.22

A study was done to determine relationship between preparation finish line configurations and marginal stability of porcelain-fused-to-metal restorations during firing cycle. The study concluded that shoulder finish lines, with or without bevel, were found to produce significantly less distortion in labial margins of porcelainfused to-metal restorations than do chamfer finish lines with and without a bevel. 23

A study determined the influence of crown-margin location on the gingival tissue for cast complete crowns. A comparison of the two margin locations using four different methods of evaluation revealed no difference (1) in health of the gingival tissues, (2) in change in sulcus depth, (3) in gingival contour, and (4) in plaque accumulation. This study suggested that the fit and finish of full crown restorations may be more significant to gingival health than location of the finish line. 24

An article discussed the factors that determine an adequate preparation for ceramometal restorations. The factors include margin design, margin placement and technique and instrumentation during tooth preparation. When all physical and biologic requirements of tooth preparations are considered, and the preparation is approached as a concept rather than simply a technique, it is possible to provide

10

 foundation for desirable esthetic form, to develop strength compatible with function, and to preserve the attachment apparatus of the supporting tooth.4

A study analyzed the geometry of finish lines for full crown restorations. And concluded that the geometry exhibiting least marginal discrepancy was shoulder of slightly oversized casting. This was significantly better than oversize bevel, the control shoulder, or the control bevel.6

A study describes methods for eliminating the effect of internal discrepancies which cause a rebound effect, requiring occlusal reduction and adjustments of faulty margins. And concluded that a die relief method was found to be most suitable of the three casting compensation techniques.8

A study examined the influence of the marginal design on occlusal seat and marginal seal of a cemented full crown restoration. Featheredge and parallel bevel preparations demonstrated the best marginal seal, followed in order by the full shoulder, 45-degree shoulder, and finally the 90-degree shoulders with 30-degree and 45-degree bevels. With regard to seating of the restoration, the 90-degree full shoulder demonstrated the best seat, followed in order by 45-degree shoulder, 90-degree shoulder with 45-degree bevel featheredge, 90-degree shoulder with 30-degree bevel, chamfer with parallel bevel, and finally 90-degree shoulder with parallel bevel.25

An investigation was done to determine which metal and coping design combination consistently provided optimum marginal accuracy and esthetics. The study concluded that: 11

 Hollow grinding provides an adequate preparation for anterior ceramometal restorations. Nonprecious (ni-cr) alloys can cast accurate as semiprecious or precious ceramoalloys. Metal distortion is not significant in a collarless or a collar coping design, if 0.4 mm metal thickness is used. Collarless, facially butted porcelain ceramometal crowns are clinically unacceptable.

A hairline metal-collar coping design is recommended for hollow-ground preparations where a nonprecious alloy is used.26

An article described a technique for mounting and refining multiple restorations (castings) to a high degree of accuracy. The remounting procedure is used to correct dimensional changes of the impression material, die stone, wax, investment, and alloy shrinkage that occur in making the castings. The technique offers a solution to many problems encountered when making final adjustments in the mouth.15

A study evaluated the phosphate-bonded investment and a calcium-bonded investment for surface smoothness and marginal fit they impart to type III gold castings. The conclusions of the study were: The marginal fit with the phosphate-bonded investment method was superior to that obtained with the calcium sulphate-bonded investment. Surface roughness was greater for the castings with the phosphate-bonded investment when measured with SEM photographs and visual observation.

12

 The phosphate-bonded investment increased the incidence of nodules on the surface of the castings. No correlation was demonstrated between marginal fit and surface roughness or the incidence of nodules on the castings.27

A study was done to evaluate the agreement within and between experienced dentists when using an explorer to identify the maximum size of acceptable openings of nonvisible margins. The study concluded that there was significant inconsistency within and among members of the faculty as to the maximum opening acceptable and more reliable methods are needed for evaluating nonvisible margins of castings before cementation.1

An article describes the use of an elastic material of room-temperature vulcanizing (RTV) silicone type as a displaying medium, an aid in fitting the castings. The primary advantage of this technique is that it enables the practitioner to accurately visualize the final cement displacement and thereby improve the physical fit of the restoration. Margins are rarely altered, but inferior modifications are a beneficial adjunct to complete seating and marginal integrity.10

An article described that a full veneer preparation with a beveled gingival margins combined with a differentially oversized casting has shown to offer theoretic potential for: Minimizing marginal discrepancies Decreasing the incidence of overhangs Minimizing the effects of variations in casting size.28 13

An article describes a clinical method for efficient and accurate assessment of the marginal integrity of cast restorations using light-bodied elastomeric material. An acceptable cast restoration fabricated with die relief should express all elastomeric material along the bevel. This is evident with this technique.11 A study compared the adaptation of the margins of gold crowns produced from three impression-die combinations. The study concluded that crowns produced on silver dies from polysulfide impressions had a smaller marginal opening than the crowns made on dies of improved stone.2

A study was done to determine the influence of the die relief agent on the retention of cast restorations using three cementing mediums. The study concluded that die relief agents resulted in a 32% reduction in the forces required to dislodge castings cemented with zinc phosphate. Other cements did not differ statistically.9

A study examined the comparative fit in vivo of three types of PFM crown margins. Marginal openings were measured with SEM on replicas derived from elastomeric impressions. And concluded that there was no significant difference among beveled metal margins, metal butt margins, or porcelain butt margins either before or after cementation at 95% confidence level. It is possible under clinical conditions to consistently produce porcelain butt margins with less than 50m marginal opening in PFM restoration.16

14

 A study was done to correlate the marginal fit of full cast crowns made by commercial dental laboratories with the design of the margin. The conclusions of the study were:

Margins prepared with unbeveled heavy chamfers and shoulders were most
likely to have openings that exceeded 39m on the dies. They were also most likely to have metal flash left on the margins.

Knife edged and beveled margins were least likely to have metal flash or openings that exceeded 39m on the dies.29

A study determined whether internal relief compensated for the restrictive effects of grooves on seating of complete cast crowns. The study concluded that:

Die relief significantly improved the seating of complete cast-gold crowns

with or without grooves.

Omitting die spacer from grooves did not reduce the benefits of
relieving the remainder of the die.

The grooves did not disrupt seating when die spacer application was complete or specifically omitted from the grooves alone.17

A study on method to improve the fit of castings by use of elastomeric impression materials was done, and it was found that condensation polysilicone impression material is well suited to meet the requirements of an ideal disclosing material. A two fold improvement in marginal seal and occlusal seat was achieved in the experimental castings compared with the control castings.12

15

 A study was done to determine whether the use of a silicone fit-indicator leaves a residual film in a metal casting and to measure the potential effect of this residual film on the retention of a cemented core. The study concluded that these indicators seem to leave a residual film that significantly reduces crown retention. Gross mechanical removal and use of an organic cleaning solution proved ineffective in removing the residual silicone.30

A study examined relationship between marginal adaptation of dental casting and periodontal tissue health. And concluded that an increase in marginal discrepancy between dental casting and prepared tooth resulted in an increase of gingival inflammation measured by a gingival index and crevicular fluid volume.3

A study measured and compared the marginal accuracy of complete crowns made from low-gold and base metal alloy systems with that of cowns from traditional type III high gold alloy. The findings of the study indicated that Ag-Pd alloy crowns exhibited the best marginal accuracy among the alternative alloys tested. However, their marginal discrepancy value was still slightly higher than that of the crowns made of type III high-gold-alloy. Conversely, Ni-Cr-Mo alloy crowns exhibited the poorest marginal accuracy.31

A study was conducted to determine the effectiveness of a silicone disclosing medium, G-C fit-checker, as an aid in improvement of marginal integrity. The preadjustment mean marginal opening was 92 microns and the post adjustment measurement 55 microns, yielding a mean reduction of 37 microns (SEM 3 microns) or 39%. 13

16

 A study evaluated axial and marginal fit of crowns made for three tooth preparations that had different labial finish lines configuration: shoulder, shoulder-bevel, and chamfer. There were no significant differences (p< or =.05) among groups for marginal and axial gaps. The study concluded that crown fit was not influenced by any of the three finish lines tested, and castings with well fitted margins exhibited measurable axial wall space.7 A study was done to determine the effect of two impression materials used in three different techniques for the accuracy of the marginal fit of metal castings. The following method was used(1) putty in a metal stock tray with simultaneous elastomeric impression wash, (2) copper band relined with Autopolymerizing acrylic resin and subsequent light-body elastomeric impression material, and(3) copper bands with modeling compound. There were no statistically significant differences between various impression materials, techniques, and facial and lingual surfaces.32

A study was done to evaluate the marginal discrepancy and surface roughness of complete crowns made with an accelerated casting technique, that uses four phosphate bonded investments and a high noble metal ceramic alloy. Comparisons between the conventional and accelerated casting techniques were made for each investment and among investment. The following conclusions were drawn: There was no statistical difference in the marginal discrepancy of cast crowns made by using accelerated technique as compared with conventionally made crowns. Differences in the average surface roughness of cast crowns were not detected between the accelerated and the conventional techniques

17

 Clinically acceptable complete castings can be obtained with the accelerated technique if optimum heating conditions are selected for each investment.33

A study done to measure the marginal gaps and to determine clinical acceptability of single-unit castings invested in a phosphate bonded investment by using conventional and accelerated methods. Marginal gaps for castings made with an accelerated technique showed no statistical difference when compared with a conventional casting group. The accelerated casting technique offers a cost-effective and time-saving method by which single-unit castings for metal/ceramic crowns can be fabricated. The methods used for accelerating the casting process are technique sensitive. Minor variations in the procedures can cause casting defects such as nodules, fins, and porosity.34

A study compared, in vitro, the marginal fit of 4 types of complete crowns on human premolar teeth with the use of nondestructive profilometry. This method determined whether fit was influenced by type of crown or surface morphology of the tooth, namely, grooved or ungrooved surfaces. The study concluded that: For each specimen, there was considerable variation from profile to profile in marginal fit of crown-to-tooth preparation, with rapid changes between underextension and overextension. Very few crown profiles achieved a perfect vertical or horizontal overlap. Effect of surface type, grooved or ungrooved, was not significant.35

18

 A study investigated the compositional stability of a commercial type III gold alloy with different casting protocols and to examine the influence of casting protocol on the marginal accuracy of complete cast crowns. The study concluded that recasting type III gold alloy may adversely affect the marginal accuracy of complete cast crowns. However, in this study, such effects were not clinically significant.36

A study was done to verify the influence of casting techniques on the internal and cervical fitting of the complete cast crowns, applying die-spacer material to the die prior to the fabrication of the wax pattern, or removing metal from the interior of the casting before cementation by abrading with aluminium oxide particles or chemical etching with nitric acid. The study concluded that the best marginal and inner fits were obtained with gas-oxygen torch source. The 45-degree chamfered shoulder showed the best marginal and inner fit, and better internal relief was obtained in the crowns abraded with 50m Al2O3 particles.37

An in vitro study evaluated the marginal adaptation and fracture strength of ceramic optimized polymer (ceromer)/ fiber reinforced composite ( FRC) crowns with respect to the various types of finish lines. The study concluded that marginal gaps were greater for the chamfer finish line specimens than in the shoulder finish line specimens. However, the fracture strength of the chamfer finish line specimens was greater than that of the shoulder finish line specimens.38

A study compared the marginal accuracy of posterior metal ceramic(MC), all-ceramic IPS Empress2, and experimental pressed ceramic(EPC-VP 1989/4)three unit fixed partial dentures(FPD), before and after luting and after thermo-mechanical fatigue in a 19

 dual-axis chewing simulator. The study concluded that marginal gap values of these all-ceramic materials and conventional MC techniques are on a similar level. In particular, almost all marginal gap values observed in this study were within the limits of clinical acceptance.39

A study was done to analyze the influence of marginal design on maginal accuracy of a casting in a clinical set up of patients. Three different types of finish lines-chamfer, 135 shoulders, and 90 shoulder were employed. The difference between the three different preparation types was significant. The lowest median values were obtained for the chamfer preparations, while the 90 shoulders always produced the highest median values. The study concluded that marginal designs had much less influence on the marginal fit of high non precious alloy castings than expected. There is considerable reason to assume that technical but clinical parameters influence the quality of fixed prosthodontics much more than has been believed in the past.40

A study assessed the effect of preparation design on marginal adaptation. In addition, sensivity and specificity of clinical evaluations of marginal adaptations of cast restorations were assessed and compared to stereomicroscopy. The study concluded that the preparation design does not significantly affect the marginal adaptation. Clinical detection, with similar sensivity and specificity as the stereomicroscope, occurred at marginal openings greater than or equal to 124 m. Therefore, commonly used clinical evaluation techniques using an explorer and disclosing media may be inadequate for assessments of marginal accuracy.41

20

 A study was done to evaluate the influence of investment type and number of sprues on accuracy of crown castings made with commercially pure titanium. The study concluded that: The magnesium oxide-bonded investment (Rematitan Ultra) provided significantly better casting accuracy for CP titanium crowns compared to the monoammonium dihydrogenphosphate-bonded investment (Rematitan plus). The marginal accuracy of crowns cast with CP titanium was significantly better when 2 sprues were used rather than one. The monoammonium dihydrogenphosphate-bonded investment (Rematitan plus) provided casting accuracy similar to that obtained with the magnesium oxide-bonded investment (Rematitan Ultra) when 2 sprues were used in casting CP titanium crowns.42

21

MATERIALS AND METHOD

This invitro study was carried out in Department of Prosthodontics, P.M.N.M. Dental College and hospital, Bagalkot.

MATERIALS USED: Following materials were used:

MATERIALS

MANUFACTURER

BATCH NO.

Ivorine molar teeth Autopolymerizing acrylic resin

Columbia Dentoform corp. DPI-RR cold cure-acrylic repair 1274 material.

Modelling wax Tray adhesive

Maarc, India Dentsply International, U.S.A Dentsply

0035 050418

Medium body Addition silicone Aquasil, impression material Type IV Gypsum product U.S.A Pearl

International, 070612

stone,

Asian

chemicals, 50589

Gujarat, India Type II Blue Inlay waxes Investment material MDM. Corp. Moldavest kluzer,Germany Non precious gold alloy FGC Copper A l l o y , 2000509 exact; 0010968 Heraeus 2653230

AalbaDent, Brazil. Elastomeric Disclosing media fit checker II; GC Tokyo, Japan 0707042

22

 ARMAMENTARIUM USED: 1. Air rotor hand piece (NSK, Japan) 2. Diamond burs (shofu crown and bridge preparation kit) 3. Rubber bowls, plaster spatula, lacrons carver, BP blade and scalpel 4. Vaccum mixer (V-Mix, yoshida) 5. Vibrator (J- Morita corp.) 6. Waxing heater (SW-50 SPM) 7. Electric waxing up instruments (Renfert, Germany) 8. Casting machine (Ducatron serie 3) 9. Burnout Oven (VULCAN 3-550 Ney) 10. Explorer (Explorer AMP No. 5 Dentsply) 11. Glass slab and metal spatula 12. Stereomicroscope (Lawerence & Mayo, India)

METHOD FOLLOWED: The method involved the evaluation of the marginal fit of cast restorations. Eight specimens of three different preparation designs were made, and castings were examined using an explorer, disclosing media, and a stereomicroscope for marginal adaptation.

1) PREPARATION OF TEETH Three Ivorine maxillary first molar teeth were selected for study and were mounted by securing roots with wax. The roots were then invested in dental stone (Kalstone, Kalabhai India). A flat base was made in dental stone, 15 mm below the cervical portion of the invested ivorine tooth which acts as stopper during the placement of 23

 impression tray. These three ivorine teeth were then prepared with three different designs: Design A- A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B - A complete crown preparation with a chamfer finish line. Design C- A three-quarter crown preparation with proximal boxes and beveled finish line. Standardized tooth preparations were performed using a air turbine dental hand piece using diamond points with the aid of paralleling device. A cone angle of 6 degrees and a preparation height of 4mm, (measured at the midfacial surface of the tooth), were used. Tooth preparations were done by one operator to eliminate operating variables in multiple tooth preparations.

2) FABRICATION OF CUSTOM TRAY To fabricate a custom tray, initially two layers of modeling wax (Maarc, India) was adapted over the prepared ivorine teeth for each design as a spacer. The custom tray was made with autopolymerizing acrylic resin (DPI-RR cold cure-acrylic repair material). The custom tray was bench cured for 24 hours. Eight custom trays were made for each preparation design, thus total of 24 custom trays were fabricated. All custom trays were finished and kept ready for making impressions.

3) IMPRESSIONS OF TEETH The ivorine teeth were thoroughly cleaned using damp cotton cloth before making impressions. The custom trays were then coated with tray adhesive (Dentsply International, U.S.A) after removal of wax spacer. Medium body addition silicone 24

 impression material (Aquasil, Dentsply International, U.S.A) was mixed according to manufacturers instructions. The custom tray was filled with impression material and was seated on the prepared ivorine teeth with adequate finger pressure till the resistance of the stopper is felt and the tray surface comes in even contact with dental stone block. The custom tray was held in position until the impression material sets. After setting impression was removed and inspected for any defects under 1.5X magnification. Thus total of 24 impressions were made with 8 in each of preparation design.

4) DIE PREPARATION The type IV die stone (Pearl stone, Asian chemicals, Gujarat, India), with a waterpowder ratio of 25cc/100 gms was mechanically mixed using vaccum mixer, and poured into the impression using vibrator. After final set, dies were recovered. The dies were inspected for any discrepancies under 1.5X magnification. They dies were numbered and three groups were formed according to preparation designs, with eight dies in each group. Thus a total of 24 dies were prepared.

5) FABRICATION OF WAX PATTERN AND INVESTMENT An even application of die lubricant (Die Lube Wax Sep. Dentecon, U.S.A) was done on each die. Wax patterns were fabricated on the dies using type II blue inlay wax (MDM. Corp.). Dip wax technique was used to form wax copings. The copings were continued to be dipped until there was sufficient bulk from which final pattern was carved. The patterns were contoured parallel to the emergence profile and margins were manually sealed under 1.5X magnification as accurate wax pattern

25

 which showed no marginal discrepancy was mandatory. Wax patterns were carefully removed from the dies so as to minimize distortion of patterns. Sprue wax of diameter 2.5 mm was attached to the occlusal surface of each pattern on the non functional cusps and was angled so that it was obtuse to the adjacent axial walls and occlusal surface. Each Wax pattern was invested immediately in phosphatebonded investment with the powder liquid ratio was 60g of powder to 12 ml of liquid, after cleaning it using wax pattern cleaner (Jelenko), this reduces the surface tension of wax and permits better wetting. The investment material was mechanically spatulated under vaccum spatulation time for 90 seconds. The wax patterns were carefully painted with the investment mixture by means of fine sable hair brush. The casting ring lined with cellulose acetate ring liner was then filled with the investment material under mechanical vibration and allowed to set on the bench for 1 hour. All procedures were carried out by one operator.

6) FABRICATION OF CASTINGS The rings were then, placed in an oven (VULCAN 3-550 Ney). A standardized burn out and preheat procedure of 30 minutes at 23-270 C, 30 minutes at 270-580 C, and 30 minutes at 580-950C, was followed. Casting was accomplished in an induction centrifugal casting machine (Ducatron serie 3) using non precious gold alloy with a composition of 80.07% copper, 7.80% Al, 3% Fe, 2.70% Zn, 1.70%Mn, 4.30% Ni. Castings were devested, cleaned, and air abraded with 50 microns aluminium oxide at 0.6 Mpa, (fine grit, jelenko quartz abrasive; Armonk, NY). Sprues were removed using silicon carbide disks, and the castings were finished externally using blue, green, and brown rubber wheels. Internal positive defects were removed using a round bur under 1.5X magnification. 26

 Castings were ultrasonically cleaned in distilled water and stored until further evaluation

7) MEASUREMENT OF MARGINAL FIT Each casting underwent examination with an explorer, elastomeric disclosing media (fitcheckerII), and a stereomicroscope. One examiner performed the clinical evaluations with an explorer and disclosing media. The examiner made a list of 20 sites without prior observation or examination of specimens to select 20 random sites for initial examination. These sites were then used to determine intraoperator reliability, which is established to be 95%. The reliability of stereomicroscope approximated 100%. Twelve circumferential recordings were made of each casting, three on each buccal, lingual, mesial and distal surface, marked with a groove on original ivorine teeth and highlighted using a fine indelible marker, for a total of 288 examination sites.

Evaluation of marginal adaptation using Explorer Margins were evaluated by examiner relying on his tactile sense with great concentration. Examiner evaluated the margins by feeling it with explorer. Same explorer was used to evaluate all castings for the purpose of standardization. Explorer misfit was defined as any of the following: clinically unacceptable vertical marginal discrepancy, horizontal marginal discrepancy, under extended margins, and seating discrepancy examined at original magnification 1.5.

27

 Evaluation of marginal adaptation using Elastomeric Disclosing Media Material (fit checker II; GC Tokyo, Japan) was manipulated according to manufacturers instructions. Each experimental casting was filled with disclosing material then seated on the respective ivorine teeth with finger pressure appropriate to seat the casting on prepared tooth. An area was interpreted as fit if the seal of the casting is observed to be apparent by clearly identifiable thin translucent film. Areas where the film is very thin or thick indicate misfit.

Evaluation of marginal adaptation using Stereomicroscope A stereomicroscope (Lawerence & Mayo, India) was used to examine these twelve circumferential sites at 30X magnification. The recordings were made and interpreted using software (ImageJ 1.40g U.S.A). Stereomicroscopy at a value less than or equal to 30 microns measurements was used as a gold standard to evaluate the significance of different designs on marginal adaptation. Three sites for each buccal, lingual, mesial, and distal surface were given an overall evaluation of acceptable or unacceptable. Since in a clinical situation adequacy of marginal accuracy at each point is desired, these values were not averaged; instead a surface was ranked as fit where all 3 measurements were less than or equal to 30 microns using stereomicroscopy. If any of the 3 measurement points had a value of greater than 30 microns that surface was ranked as misfit. Chi-square tests of independence and kruskal-Wallis were performed at a priority level of significance of =0.05 to determine the significance of each surface (buccal, lingual, mesial, and distal) and overall design with respect to marginal adaptation. Further Chi-square tests of independence were used to compare agreement between

28

 stereomicroscope, explorer, and disclosing media detection of marginal gaps less than or equal to 30 microns. Sensitivity and specificity for explorer and disclosing media as compared to stereomicroscope was calculated using statistical formula given by Park.43

29

30

31

32

33

34

35

36

37

38

RESULTS

Table1, 2, 3 shows the readings of all three preparation designs using Explorer, elastomeric disclosing media and stereomicroscope respectively.

Table 4 shows the distribution of overall marginal adaptation of crowns by three designs using explorer technique. For Design A 12.50% were misfit and 87.50% fit. For Design B 25.00% were misfit and 75% fit. For Design C 37.50% were misfit and 62.50% fit. On comparison using chi-square test of independence, the three designs showed no significant difference on marginal adaptation using explorer technique with p-value 0.5134. The results were shown in the graph 1.

Table 5 shows the distribution of overall marginal adaptation of crowns by three designs using elastomeric disclosing media For Design A 0% was misfit and 100% fit. For Design B 0% was misfit and 100% fit. For Design C 0% was misfit and 100% fit. On comparison using chi-square test of independence, the three designs showed no significant difference on marginal adaptation using elastomeric disclosing media with p-value 1.0000. The results were shown in the graph 2.

Table 6 shows the distribution of overall marginal adaptation of crowns by three designs using stereomicroscope 39

 For Design A 100% were misfit and 0% fit. For Design B 87.5% were misfit and 12.5% fit. For Design C 100% were misfit and 0% fit. On comparison using chi-square test of independence, the three designs showed no significant difference on marginal adaptation using stereomicroscope with p-value 0.352. The results were shown in the graph 3.

In table 7 the mean marginal openings of three designs in Stereomicroscope is compared for statistical analysis using kruskal wallis Anova test. The three designs showed no significant difference in the mean marginal opening with p-value 0.1197. The results were shown in the graph 4. Thus the preparation design did not significantly affect overall marginal adaptation.

Table 8 shows the marginal accuracy findings on buccal, lingual, mesial, distal surfaces of three preparation designs. Analysis of different surfaces revealed no significant difference in marginal adaptation for the three designs examined.

Table 9 shows the percentage of 288 sites with inadequate marginal fit as detected by explorer, elastomeric disclosing media, and stereomicroscope. Explorer detected 33.33% of misfit sites. Elastomeric disclosing media detected 10.06% of misfit sites. Stereomicroscope detected 79.16% of misfit sites. Graph 5, 6, 7 shows the percentage of fit and misfit sites for each of the three techniques.

40

 Table10 shows the overall agreement between the stereomicroscope and explorer was 50.69%, with a 19.09% correct acceptance rate (19.09% of the time the explorer ranked fit and the stereomicroscope showed a gap size of less than or equal to 30m) and 31.59% correct rejection rate (31.59% of the time the explorer ranked misfit and the stereomicroscope showed a gap size of greater than 30m).

Table11 shows the overall agreement between the stereomicroscope and elastomeric disclosing media was 29.16%, with a 19.09% correct acceptance rate (19.09% of the time the elastomeric disclosing media ranked fit and the stereomicroscope showed a gap size of less than or equal to 30m) and 10.06 % correct rejection rate (10.06 of the time the elastomeric disclosing media ranked misfit and the stereomicroscope showed a gap size of greater than 30m).

Illustrations 1 & 2 shows that the explorer at 30m had 39% sensitivity and 91% specificity and elastomeric disclosing media had 10% sensitivity and 82% specificity respectively.

41

 Table 1: Readings of all three preparation designs using Explorer

SPECIMEN NO.
1 2 3 4 5 6 7 8

DESIGN

SURFACE

SITES

BUCCAL

LINGUAL

Design A
MESIAL

DISTAL

BUCCAL

LINGUAL

Design B
MESIAL

DISTAL

BUCCAL

LINGUAL

Design C
MESIAL

DISTAL

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

F F F F F F F F F F F F MF MF MF MF MF MF MF MF MF F F F F F F MF MF MF MF F MF F F MF

F F MF MF MF MF F F MF F F F F MF F MF F F F MF F F F F F F F F MF F MF F F F F F

F F F MF MF MF MF F F F MF MF F F F F F F F F F F F F F F F MF MF F F F MF F F MF

F F F F F F MF F F MF F F MF F F MF MF MF F F F F F F F MF MF MF MF F MF F F F F F

MF MF MF F F F F F MF F F MF F F F F F F F F F F F F F MF F MF MF MF MF MF MF F F F

MF MF F F F F F F F F F MF F F F MF F F MF MF MF F F F F F F MF MF MF F F F MF F F

MF MF MF F F MF MF MF F F F F F F F F F F F F F F F F MF F F F F MF F F MF MF F F

MF MF MF F F F MF F F F F F F F F MF MF MF F F MF MF MF MF F F F F MF MF MF F MF MF MF F

Design A-A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B - A complete crown preparation with a chamfer finish line. Design C- A three-quarter crown preparation with proximal boxes and beveled finish line. 42

 Table 2: Readings of all three preparation designs using Elastomeric disclosing media

SPECIMEN NO.
1 2 3 4 5 6 7 8

DESIGN

SURFACE BUCCAL

SITES

LINGUAL

Design A
MESIAL

DISTAL

BUCCAL

LINGUAL

Design B
MESIAL

DISTAL

BUCCAL

LINGUAL

Design C
MESIAL

DISTAL

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

F F F F F F F F F F F F MF MF MF MF F F F F F F F F F F F F MF MF MF F F F F F

F F F F F F F F F F F F F F F MF F F F F F F F F F F F F F F MF F F F F F

F F F F F F F F F F F F F F F F F F F F F F F F F F F MF MF MF F F F F F F

F F F F F F F F F MF F F F F F F F F F F F F F F F F F MF MF F F F F F F F

MF MF MF F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

F F F F F F F MF F F F F F F F F F F F F F F F F F F F F MF F F F F F F F

MF MF F F F F MF F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

MF F F F F F F F F F F F F F F F MF F F F MF MF MF MF F F F F F F F F F F F F

Design A-A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B - A complete crown preparation with a chamfer finish line. Design C- A three-quarter crown preparation with proximal boxes and beveled finish line.

43

 Table 3: Readings of all three preparation designs using Stereomicroscope

SPECIMEN NO.

1
DESIGN SURFACE BUCCAL SITE

LINGUAL

Design A
MESIAL

DISTAL

BUCCAL

LINGUAL

Design B
MESIAL

DISTAL

BUCCAL

LINGUAL

Design C
MESIAL

DISTAL

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

60 32 18 58 62 75 58 42 60 28 9 15 153 123 120 141 124 123 125 129 38 30 54 30 60 72 21 123 141 123 123 45 79 57 51 123

39 60 125 128 115 120 45 45 118 120 45 124 27 75 26 123 54 39 15 125 33 57 58 76 30 58 24 72 128 48 118 21 30 15 48 39

30 30 30 118 120 128 120 12 30 15 120 130 35 75 63 36 45 30 42 36 36 81 60 57 48 81 36 123 183 102 45 31 128 63 36 128

63 60 30 30 30 48 124 60 63 119 15 66 45 30 32 87 60 42 51 88 84 93 69 90 39 126 124 141 144 66 148 10 45 16 27 63

119 128 120 68 63 30 52 48 124 56 48 124 28 51 42 12 12 45 72 57 48 93 54 58 33 123 27 125 129 124 126 124 128 96 45 87

130 120 84 44 21 51 48 112 58 73 92 130 60 28 75 125 48 30 128 131 124 27 35 27 39 35 8 127 201 124 77 74 54 128 30 28

130 128 124 30 48 124 120 128 68 30 28 30 33 38 76 26 18 26 70 53 60 60 62 60 125 72 34 77 87 125 93 94 104 87 15 30

126 140 128 60 30 62 123 28 30 83 98 21 63 48 75 125 122 128 90 51 132 128 124 124 35 30 22 88 120 130 78 99 137 125 134 48

Design A-A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B - A complete crown preparation with a chamfer finish line. Design C- A three-quarter crown preparation with proximal boxes and beveled finish line. 44

Table 4: Distribution of overall marginal adaptation of crowns by three designs using explorer technique Designs Design A Design B Design C Total Misfit 1 2 3 6 % 12.50 25.00 37.50 25.00 df=2 Fit 7 6 5 18 % 87.50 75.00 62.50 75.00 Total 8 8 8 24

Chi-square= 1.3330

p=0.5134, NS

Graph1:Distribution of over all marginal adaptation of crowns by

three designs using explorer technique

9.00 8.00 7.00 No of subjects 6.00 5.00 4.00 3.00 2.00 1.00 0.00
DESIGN A DESIGN B DESIGN C

7 6 5

3 2 1

Misfit

Fit

45

Table 5: Distribution of overall marginal adaptation of crowns by three designs using elastomeric disclosing media Designs Design A Design B DesignC Total Misfit 0.00 0.00 0.00 0.00 % 0.00 0.00 0.00 0.00 df=2 Fit 8 8 8 24 % 100.00 100.00 100.00 100.00 Total 8 8 8 24

Chi-square= 0.0000

p=1.0000, NS

Graph2 :Distribution of overall 9.00 8.00 7.00 No of subjects 6.00 5.00 4.00 3.00 2.00 1.00 0.00 0
DESIGN A

marginal adaptation of crowns by three designs using elastomeric disclosing media

8 8

0
DESIGN B

0
DESIGN C

Misfit

Fit

46

Table 6: Distribution of overall marginal adaptation of crowns by three designs using Stereo Microscope Designs Design A Design B Design C Total Misfit 8 7 8 23 % 100 87.5 100 96 df=2 Fit 0 1 0 1 p=0.352, NS % 0 12.5 0 4 Total 8 8 8 24

Chi-square= 0.0000

Graph3 :Distribution of overall marginal adaptation of crowns by three 9.00 8.00 7.00 No of subjects 6.00 5.00 4.00 3.00 2.00 1.00 0.00
DESIGN A

designs in stereomicroscope
8 7 8

1 0
DESIGN B DESIGN C

Misfit

Fit

47

Table7: Comparison of mean marginal openings of three designs in Stereomicroscope by Kruskal Wallis Anova test KruskalWallis test: H value 4.2450 Significance p-value 0.1197

Designs Design A

Means 63.92

Std.Dev. 29.60

Sum of Ranks 93.00

NS

Design B

64.45

17.68

75.00

Design C

81.75

14.67

132.00

Total

70.04

22.33

Graph4:Comparison of mean marginal openings of three designs in

100.00 90.00 80.00 Mean value 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
DESIGN A DESIGN B DESIGN C

Stereomicroscope
81.75 63.92 64.45

29.6 17.68 14.67

Means

Std.Dev.

48

 Table 8: Marginal accuracy findings on buccal, lingual, mesial, distal surfaces of three preparation designs. EXPLORER Design FIT Design A Design B Design C 5 3 5 Buccal MISFIT 3 5 3 Lingual FIT 3 5 0 MISFIT 5 3 8 FIT 4 2 1 Mesial MISFIT 4 6 7 FIT 7 4 6 Distal MISFIT 1 4 2

p=0.511, NS

p=0.028, NS

p=0.244, NS

p=0.244, NS

ELASTOMERIC DISCLOSING MEDIA Buccal Lingual Design FIT Design A Design B Design C 7 5 8 MISFIT 1 3 0 FIT 5 8 4 MISFIT 3 0 4 FIT 7 6 6

Mesial MISFIT 1 2 2 FIT 7 7 8

Distal MISFIT 1 1 0

P=0.122, NS

p=0.073, NS

p=0.777, NS

p=0.580, NS

STEREOMICROSCOPE Buccal Design FIT Design A Design B Design C 0 1 0 MISFIT 8 7 8

Lingual FIT 1 0 0 MISFIT 7 8 8 FIT 0 0 0

Mesial MISFIT 8 8 8 FIT 0 1 0

Distal MISFIT 8 7 8

P=0.352, NS

p=0.352, NS

p=1.0000, NS

p=0.352, NS

49

 Table 9: Percentage of 288 sites with inadequate marginal fit as detected by , explorer, elastomeric disclosing media, and stereomicroscope Technique Explorer Disclosing media Stereomicroscope N
96/288 29/288

Percentage 33.33% 10.06% 79.16%

228/288

Graph 5: Percentage of Fit and Misfit sites in Explorer

33.33% 66.67%
MISFIT FIT

Graph 6: Percentage of Fit and Misfit sites in Elastomeric disclosing media

10.06%

89.94%
MISFIT FIT

Graph 7: Percentage of Fit and Misfit sites in Stereomicroscope

20.84%

79.16%
MISFIT FIT

50

 Table10: Results of stereomicroscopic evaluation of 288 marginal gap sites compared to explorer using stereomicroscope as gold standard Stereomicroscopic findings +(MISFIT) -( FIT) Total Explorer findings

+(MISFIT)

91

96

-( FIT) Total

137 228

55 60

192 288

Table 11: Results of stereomicroscopic evaluation of 288 marginal gap sites compared to elastomeric disclosing media using stereomicroscope as gold standard Stereomicroscopic findings +(MISFIT) Elastomeric disclosing media -( FIT) Total

+(MISFIT)

24

29

-( FIT) Total

204 228

55 60

259 288

51

Illustration 1: SENSITIVITY can be calculated using statistical formula given by park43 Sensitivity = TP/TP+FN Where, TP = True positive, FN = False negative. For explorer, Sensitivity = 91/91+137 = 0.39 = 39% For elastomeric disclosing media, Sensitivity = 24/24+204 = 0.10 =10%

Illustration 2: SPECIFICITY can be calculated using statistical formula given by park43 Specificity = TN/TN+FP Where, TN = True negative, FP = False positive. For explorer, Specificity = 55/55+5 = 0.91 = 91%

52

 For elastomeric disclosing media, Sensitivity = 24/24+5 = 0.82 = 82%

53

DISCUSSION
Several authors have emphasized that marginal accuracy and internal adaptations are critical factors for clinical success of cast restoration. The relationship between rate of failure and size of opening of margins for dental castings has not been established by definitive, longitudinal, and clinical studies. However, there is general agreement that it is desirable to have margins closed as much as possible to reduce width of cement line. A recent study showed that thickness of cement layer may interact with other factors to affect the speed of disintegration of dental cement. The relationship between margin adaptation and periodontal health has been confirmed in experimental animals and humans. This study was designed to evaluate the relationship of marginal accuracy of cast restorations to various tooth preparations. The three preparation designs evaluated in this study are most commonly used in the clinical practice. Previous studies could not come to an agreement as to which is the best finish line in terms of marginal adaptation. Some studies concluded that feather edge and bevel finish lines provide the best marginal seal19 while others suggested shoulder with oversized casting as best finish line in terms of marginal adaptation.6 Therefore this study was undertaken to determine the effect of these finish lines on the marginal adaptation of cast restorations. In the current study it was determined that preparation designs assessed had no statistically significant effects on the marginal accuracy of cast restorations. This observation is consistent with that of the few recent studies.7, 16 A non precious copper based alloy NPG and phosphate bonded investment was used in this study for the fabrication of castings. These materials have reported to provide better marginal fit as per previous studies. 54

 Christensen (1966) reported that when visible and invisible margins were evaluated with an explorer the barely acceptable range was 2-51 m with a mean of 21 m and 34-119 m with a mean of 74 m respectively. However the results of present study indicate that the most commonly used method i.e. explorer, for evaluating the fit of castings may be even less reliable than reported. When margins are evaluated with an explorer acceptance is more likely to be based on the size and character of overhangs and ledges than on the actual size of opening of the margins. The advantages of using an elastomeric disclosing media to aid in clinical assessment of castings are well documented.8,
11

In this invitro study, it appears that these

materials did not significantly aid in detection of marginal gaps as compared to the explorer. However the use of elastomeric disclosing media, in the assessment of the internal fit of castings remains valuable.11 In clinical practice, where assessment of an inter-proximal area may be more difficult with an explorer, the use of these materials may further assist in marginal discrepancy detection. So, an elastomeric disclosing media was used as one of the technique of clinical evaluation of marginal adaptation. One of the disadvantage of using an elastomeric disclosing media was that it reduces cement bond strength due to the presence of residual silicone film. This film can be removed from the internal aspect of the casting using an organic solvent or by air abrading using aluminium oxide. Likewise, the film can be removed from the tooth with a gentle prophylaxis, prior to cementation to enhance the cement bond strength.30 In current study, the sensitivity of explorer and elastomeric disclosing media as compared to stereomicroscope at 30 m was 39% and 10% respectively. Higher values of sensitivity for explorer technique as compared to elastomeric disclosing media indicate that explore technique is more reliable as compared to elastomeric 55

 disclosing media in detecting marginal gaps. However values of sensitivity for both the techniques evaluated is considerably low, indicating that these techniques may not be adequate to determine presence of marginal gaps of or less than 30 m. The specificity of the explorer and elastomeric disclosing media as compared to stereomicroscope at 30 m was 91% and 82% respectively. Higher values of specificity for explorer technique as compared to elastomeric disclosing media indicates that explorer technique is more reliable as compared elastomeric disclosing media in detecting margins that are closely adapted to prepared tooth. Similar results were found in previous study done by Jahangiri.41 The limitations of this study are that the assessments of marginal accuracies were not performed intraorally and that the errors in fabrication and handling of dies and castings are assumed to be minimal. Within these limitations, it appears that clinical examination based on an explorer and the use of elastomeric materials may not provide satisfactory accuracy needed for detection of marginal gap sizes of less than or equal to 30 m. A recent study has reported that clinical detection of marginal gap size with similar sensitivity and specificity as stereomicroscope occurs at greater than or equal to 124 m.41 Although the stereomicroscope cannot be used to assess restorations intraorally, the future development of an intraoral apparatus may be of value. However, the use of a stereomicroscope as a supplement method for assessing castings on dies may provide a higher degree of marginal gap detection prior to examination of these castings intraorally. This instrument is easy to use and is not considered costly.

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 The software program used in this study was purpose of multiple measurements and storage of images, and future image analysis. This software program is not necessary for quality.

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CONCLUSION
1. The preparation designs examined in this study did not significantly affect the marginal adaptation and accuracy of the castings. 2. Commonly used clinical evaluation techniques i.e. explorer and elastomeric disclosing media may be inadequate for assessments of marginal accuracy. 3. Explorer technique proved to be better aid in detection of marginal accuracy as compared to elastomeric disclosing media. 4. At 30 m explorer revealed 39% sensitivity and 91% specificity and elastomeric disclosing media revealed 10.06% sensitivity and 82% specificity. 5. For better evaluation of marginal accuracy of the cast restorations, the routine use of a stereomicroscope in the laboratory is indicated which provides a superior quality control prior to examination of restorations intraorally. Above mentioned conclusions are within the limitations of this study. The assessments of marginal accuracies were not performed intraorally, so further research is required to obtain a better insight of the methods to assess the marginal adaptation of the cast restorations that can be used intraorally.

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SUMMARY
The aim of this study was to assess the effect of preparation design on marginal adaptation, as well as to assess sensitivity and specificity of clinical evaluation of cast restoration marginal accuracy when compared to stereomicroscopy. Three Ivorine molar teeth of different designs were prepared: Design A- A complete crown preparation with a buccal shoulder (1mm wide) and bevel as remaining finish line. Design B - A complete crown preparation with a chamfer finish line. Design C- A three-quarter crown preparation with proximal boxes and beveled finish line. Elastomeric impressions of each tooth were made using individual customfabricated trays. Eight individual dies were fabricated of each design. A total of 24 dies were prepared. Wax patterns were fabricated on the dies using type II inlay wax and casted using a non precious gold alloy. The casting procedures were standardized by investing immediately after waxing. Each casting underwent examination with an explorer, elastomeric disclosing media, and a stereomicroscope. Twelve circumferential recordings were made of each casting, three on each buccal, lingual, mesial and distal surface, marked with a groove on original ivorine teeth and highlighted using a fine indelible marker, for a total of 288 examination sites. A ranking of fit or misfit was given to each examination site after assessment with explorer and elastomeric disclosing media. Stereomicroscopy at a value less than or equal to 30 m measurements was used as a gold standard to evaluate the significance of different designs on marginal adaptation. Three sites for each buccal, lingual, mesial, and distal surface were given an overall evaluation of 59

 acceptable or unacceptable. A surface was raked fit where all 3 measurement points on a surface were less than or equal to 30 m using stereomicroscopy. If any of three measurement points of a surface had a value of greater than 30 m, that surface was ranked as misfit. The data obtained was subjected to statistical analysis using Chi-square tests of independence and Kruskal-Wallis test. It was found that the preparation design examined in this study did not significantly affect the marginal adaptation and accuracy of the castings. Examination by explorer at 30 m revealed 39% sensitivity and 91% specificity. The elastomeric disclosing media had 10.06% sensitivity and 82% specificity at 30m. Thus the commonly used clinical evaluation techniques like explorer and elastomeric disclosing media were inadequate for assessments of marginal accuracy. For better evaluation of marginal adaptation of the cast restorations, the routine use of a stereomicroscope in the laboratory is indicated which provides a superior quality control prior to examination of restorations intraorally.

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STATISTICAL FORMULA
1) Mean: sum of all the observation and divided by total no of observations X = Xi / n Xi = value of each of each observation, n= No of observation.

2) Standard Deviation: root mean square SD= (x x) 2 / n-1

X = Variable, x = Mean of x, n = No of observation.

3) Chi-Square Test (2- test) 2 = (Observed frequencies - Expected frequencies)2/ Expected frequencies = (O - E) 2/ E O = Observed frequencies, E= Expected frequencies.

4) Sensitivity: (by Parks formula) Sn = TP / (TP + FN) Where TP and FN are the number of true positive and false negative results, respectively.

5) Specificity: (by Parks formula) Sp = TN / (TN + FP) Where TN and FP and the number of true negative and false positive results, respectively.

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