Rastogi Abhishek

i
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

ii

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,
iii

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: Signature of the Candidate
Place: Bagalkot Dr. Abhishek Rastogi

iv

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: Dr. Vikas Kamble
M.D.S
,
Place: Bagalkot Guide,
Associate Professor,
Department of Prosthodontics
P.M.N.M Dental College & Hospital,
Bagalkot 587101

v

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

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

Date:

Place: Bagalkot

vi

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

vii

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

V Va ak kr ra at tu un nd da a M Ma ah ha ak ka ay ya a S Su ur ry ya ak ko ot ti i S Sa am ma ap pr ra ab bh ha a, ,
N Ni ir rv vi ig gn na am m K Ku ur ru um me ed de ev va a S Sa ar rv va ak ka ar ry ye es sh hu u S Sa ar rv va ad da a

viii

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. I will be indebted to him for his
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.
ix

I would like to express my thanks to our Principal Dr. Shri ni vas 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. Purani k and Dr. Shi vakumar for al l owi ng me to
carry out stereomi croscopi c eval uati on 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 requi res speci al thanks for hel pi ng me out duri ng my study.
I owe sincere thanks to Mr. Abdul for his helping me to carry out my lab
procedures duri ng 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

x

LIST OF ABBREVIATIONS USED

o m Microns
o SD Standard Deviation

xi

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 custom-
fabricated 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,
xii

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.

xiii

TABLE OF CONTENTS

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

xiv

LIST OF TABLES
1. Readings of all three preparation designs using explorer. 42
2. Readings of all three preparation designs using elastomeric
disclosing media. 43
3. Readings of all three preparation designs using stereomicroscope. 44
4. Distribution of overall marginal adaptation of crowns by three
designs using explorer technique. 45
designs using elastomeric disclosing media. 46
designs using stereomicroscope. 47
7. Comparison of mean marginal openings of three designs in
Stereomicroscope by Kruskal Wallis Anova test. 48
8. Marginal accuracy findings on buccal, lingual, mesial, distal
surfaces of three preparation designs. 49
9. Percentage of 288 sites with inadequate marginal fit as detected
by explorer, elastomeric disclosing media and stereomicroscope. 50
10. Results of stereomicroscopic evaluation of 288 marginal gap sites
compared to explorer using stereomicroscope as gold standard. 51
11. Results of stereomicroscopic evaluation of 288 marginal gap sites
compared to elastomeric disclosing media using stereomicroscope as
gold standard. 51
12. Illustration 1 and 2 for calculation of sensitivity and specificity. 52

Table no. Title Page no.
xv

LIST OF GRAPHS


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

xvi

LIST OF PHOTOGRAPHS


1. Materials and armamentarium used 30
2. Armamentarium used 30
3. Stereomicroscope 31
4. Design A 32
5. Design B 32
6. Design C 32
7. Custom tray 33
8. Custom tray with wax spacer 33
9. Impression making 33
10. Final impression 33
11. Pouring of impression using vibrator 34
12. Group of Dies for design A, design B, design C 34
13. Wax coping made using dip wax technique 35
14. Carving Wax pattern 35
15. Wax pattern with margins sealed under 1.5X magnification 35
16. Fit check using explorer 36
17. Fit check using elastomeric disclosing media 36
18. Specimen under stereomicroscope 37
19. Marginal opening as seen under stereomicroscope 38
20. Marginal gap of 30m, 60 m, 90 m as seen under
stereomicroscope 38
1

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 by-
products 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. Preston
4
and Shillingburg recommended the
shoulder-bevel as the best type of finish line for the cast restoration. Rosner
5
reasoned
2

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. Pascoe
6
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
chemical
15
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

3

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
4

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.

5

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.

6

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

7

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
8

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.
9

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.
10

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 porcelain-
fused 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
11

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:
12

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.
13

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

14

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

15

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

16

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

17

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
18

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

19

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 Al
2
O
3
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
20

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

21

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

22

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 Columbia Dentoform corp.
Autopolymerizing acrylic resin DPI-RR cold cure-acrylic repair
material.
1274
Modelling wax Maarc, India 0035
Tray adhesive Dentsply International, U.S.A 050418
Medium body Addition silicone
impression material
Aquasil, Dentsply International,
U.S.A
070612
Type IV Gypsum product Pearl stone, Asian chemicals,
Gujarat, India
50589
Type II Blue Inlay waxes MDM. Corp. 0010968
Investment material Moldavest exact; Heraeus
kluzer,Germany
2653230
Non precious gold alloy FGC Copper Al l oy,
Aal baDent , Br azi l .
2000509
Elastomeric Disclosing media fit checker II; GC Tokyo, Japan 0707042

23

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
24

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)
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
25

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 water-
powder 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
26

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 phosphate-
bonded 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
-950
C, 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.
27

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.

28

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
29

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

30

31

32

33

34

35

36

37

38

39

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.

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.
significant difference on marginal adaptation using elastomeric disclosing media with
p-value 1.0000. The results were shown in the graph 2.

designs using stereomicroscope
40

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.
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.

41

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.

42

Table 1: Readings of all three preparation designs using Explorer

Design C- A three-quarter crown preparation with proximal boxes and beveled finish
line.
SPECIMEN NO.

DESIGN

SURFACE

SITES
1 2 3 4 5 6 7 8
1 F F F F MF MF MF MF
2 F F F F MF MF MF MF
BUCCAL
3 F MF F F MF F MF MF
1 F MF MF F F F F F
2 F MF MF F F F F F
LINGUAL
3 F MF MF F F F MF F
1 F F MF MF F F MF MF
2 F F F F F F MF F
MESIAL
3 F MF F F MF F F F
1 F F F MF F F F F
2 F F MF F F F F F
Design
A
DISTAL
3 F F MF F MF MF F F
1 MF F F MF F F F F
2 MF MF F F F F F F
BUCCAL
3 MF F F F F F F F
1 MF MF F MF F MF F MF
2 MF F F MF F F F MF
LINGUAL
3 MF F F MF F F F MF
1 MF F F F F MF F F
2 MF MF F F F MF F F
MESIAL
3 MF F F F F MF F MF
1 F F F F F F F MF
2 F F F F F F F MF
Design
B
DISTAL
3 F F F F F F F MF
1 F F F F F F MF F
2 F F F MF MF F F F
BUCCAL
3 F F F MF F F F F
1 MF F MF MF MF MF F F
2 MF MF MF MF MF MF F MF
LINGUAL
3 MF F F F MF MF MF MF
1 MF MF F MF MF F F MF
2 F F F F MF F F F
MESIAL
3 MF F MF F MF F MF MF
1 F F F F F MF MF MF
2 F F F F F F F MF
Design
C
DISTAL
3 MF F MF F F F F F
43

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

line.

SPECIMEN NO.

DESIGN

SURFACE

SITES
1 2 3 4 5 6 7 8
1 F F F F MF F MF MF
2 F F F F MF F MF F
BUCCAL
3 F F F F MF F F F
1 F F F F F F F F
2 F F F F F F F F
LINGUAL
3 F F F F F F F F
1 F F F F F F MF F
2 F F F F F MF F F
MESIAL
3 F F F F F F F F
1 F F F MF F F F F
2 F F F F F F F F
Design
A
DISTAL
3 F F F F F F F F
1 MF F F F F F F F
2 MF F F F F F F F
BUCCAL
3 MF F F F F F F F
1 MF MF F F F F F F
2 F F F F F F F MF
LINGUAL
3 F F F F F F F F
1 F F F F F F F F
2 F F F F F F F F
MESIAL
3 F F F F F F F MF
1 F F F F F F F MF
2 F F F F F F F MF
Design
B
DISTAL
3 F F F F F F F MF
1 F F F F F F F F
2 F F F F F F F F
BUCCAL
3 F F F F F F F F
1 F F MF MF F F F F
2 MF F MF MF F MF F F
LINGUAL
3 MF F MF F F F F F
1 MF MF F F F F F F
2 F F F F F F F F
MESIAL
3 F F F F F F F F
1 F F F F F F F F
2 F F F F F F F F
Design
C
DISTAL
3 F F F F F F F F
44

Table 3: Readings of all three preparation designs using Stereomicroscope

line.
SPECIMEN NO.

DESIGN

SURFACE

SITE
1 2 3 4 5 6 7 8
1 60 39 30 63 119 130 130 126
2 32 60 30 60 128 120 128 140
BUCCAL
3 18 125 30 30 120 84 124 128
1 58 128 118 30 68 44 30 60
2 62 115 120 30 63 21 48 30
LINGUAL
3 75 120 128 48 30 51 124 62
1 58 45 120 124 52 48 120 123
2 42 45 12 60 48 112 128 28
MESIAL
3 60 118 30 63 124 58 68 30
1 28 120 15 119 56 73 30 83
2 9 45 120 15 48 92 28 98
Design
A
DISTAL
3 15 124 130 66 124 130 30 21
1 153 27 35 45 28 60 33 63
2 123 75 75 30 51 28 38 48
BUCCAL
3 120 26 63 32 42 75 76 75
1 141 123 36 87 12 125 26 125
2 124 54 45 60 12 48 18 122
LINGUAL
3 123 39 30 42 45 30 26 128
1 125 15 42 51 72 128 70 90
2 129 125 36 88 57 131 53 51
MESIAL
3 38 33 36 84 48 124 60 132
1 30 57 81 93 93 27 60 128
2 54 58 60 69 54 35 62 124
Design
B
DISTAL
3 30 76 57 90 58 27 60 124
1 60 30 48 39 33 39 125 35
2 72 58 81 126 123 35 72 30
BUCCAL
3 21 24 36 124 27 8 34 22
1 123 72 123 141 125 127 77 88
2 141 128 183 144 129 201 87 120
LINGUAL
3 123 48 102 66 124 124 125 130
1 123 118 45 148 126 77 93 78
2 45 21 31 10 124 74 94 99
MESIAL
3 79 30 128 45 128 54 104 137
1 57 15 63 16 96 128 87 125
2 51 48 36 27 45 30 15 134
Design
C
DISTAL
3 123 39 128 63 87 28 30 48
45

Table 4: Distribution of overall marginal adaptation of crowns by three designs using
explorer technique
Designs Misfit % Fit % Total
Design A 1 12.50 7 87.50 8
Design B 2 25.00 6 75.00 8
Design C 3 37.50 5 62.50 8
Total 6 25.00 18 75.00 24
Chi-square= 1.3330 df=2 p=0.5134, NS

1
7
2
6
3
5
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
N
o

o
f

s
u
b
j
e
c
t
s
DESIGN A DESIGN B DESIGN C
Graph1:Distribution of over all marginal adaptation of crowns by
three designs using explorer technique
Misfit Fit

46

elastomeric disclosing media
Design A 0.00 0.00 8 100.00 8
Design B 0.00 0.00 8 100.00 8
DesignC 0.00 0.00 8 100.00 8
Total 0.00 0.00 24 100.00 24
Chi-square= 0.0000 df=2 p=1.0000, NS

0
8
0
8
0
8
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
N
o

o
f

s
u
b
j
e
c
t
s
Graph2:Distribution of overall marginal adaptation of crowns by three
designs using elastomeric disclosing media
Misfit Fit
47

Stereo Microscope
Design A 8 100 0 0 8
Design B 7 87.5 1 12.5 8
Design C 8 100 0 0 8
Total 23 96 1 4 24
Chi-square= 0.0000 df=2 p=0.352, NS

8
0
7
1
8
0
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
N
o

o
f

s
u
b
j
e
c
t
s
Graph3:Distribution of overall marginal adaptation of crowns by three
designs in stereomicroscope
Misfit Fit
48

Table7: Comparison of mean marginal openings of three designs in Stereomicroscope
by Kruskal Wallis Anova test

Designs Means Std.Dev.
Sum of
Ranks
Kruskal-
Wallis
test: H -
value p-value
Significance
Design A 63.92 29.60 93.00
Design B 64.45 17.68 75.00
Design C 81.75 14.67 132.00
Total 70.04 22.33
4.2450 0.1197 NS

63.92
29.6
64.45
17.68
81.75
14.67
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
M
e
a
n

v
a
l
u
e
Graph4:Comparison of mean marginal openings of three designs in
Stereomicroscope
Means Std.Dev.

49

Table 8: Marginal accuracy findings on buccal, lingual, mesial, distal surfaces of
three preparation designs.
EXPLORER
Buccal Lingual Mesial Distal Design
FIT MISFIT FIT MISFIT FIT MISFIT FIT MISFIT
Design A 5 3 3 5 4 4 7 1
Design B 3 5 5 3 2 6 4 4
Design C 5 3 0 8 1 7 6 2
p=0.511, NS p=0.028, NS p=0.244, NS p=0.244, NS

ELASTOMERIC DISCLOSING MEDIA
Design A 7 1 5 3 7 1 7 1
Design B 5 3 8 0 6 2 7 1
Design C 8 0 4 4 6 2 8 0
P=0.122, NS p=0.073, NS p=0.777, NS p=0.580, NS

STEREOMICROSCOPE
Design A 0 8 1 7 0 8 0 8
Design B 1 7 0 8 0 8 1 7
Design C 0 8 0 8 0 8 0 8
P=0.352, NS p=0.352, NS p=1.0000, NS p=0.352, NS

50

Table 9: Percentage of 288 sites with inadequate marginal fit as detected by ,
explorer, elastomeric disclosing media, and stereomicroscope
Technique N Percentage
Explorer 96/288 33.33%
Disclosing media 29/288 10.06%
Stereomicroscope 228/288 79.16%

MISFIT FIT
33.33%
66.67%
Graph 5: Percentage of Fit and Misfit sites in Explorer

MISFIT FIT
20.84%
79.16%
Graph 7: Percentage of Fit and Misfit sites in Stereomicroscope

MISFIT FIT
10.06%
89.94%
Graph 6: Percentage of Fit and Misfit sites in Elastomeric disclosing media
51

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)

-( FIT)

91

137

5

55

96

192
Total 228 60 288

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

+(MISFIT)

-( FIT)

24

204

5

55

29

259
Total 228 60 288
52

Illustration 1:
SENSITIVITY can be calculated using statistical formula given by park
43
Sensitivity = TP/TP+FN
Where, TP = True positive,
FN = False negative.
For explorer,
Sensitivity = 91/91+137
= 0.39
= 39%
For elastomeric disclosing media,
= 0.10
=10%

Illustration 2:
SPECIFICITY can be calculated using statistical formula given by park
43
Specificity = TN/TN+FP
Where, TN = True negative,
FP = False positive.
For explorer,
Specificity = 55/55+5
= 0.91
= 91%

53

For elastomeric disclosing media,
= 0.82
= 82%

54

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 seal
19
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.
55

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
56

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.
57

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.

58

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.

59

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)
Design C- A three-quarter crown preparation with proximal boxes and beveled
finish line.
Elastomeric impressions of each tooth were made using individual custom-
fabricated 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
60

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.

61

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66

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

S D = (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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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

A hairline metal-collar coping design is recommended for hollow-ground

C, was followed. Casting was accomplished in an

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