23

Esthetics and Computer-Aided

Design and Computer-Aided
Manufacturing (CAD/CAM)
Systems
Masly Harsono and Gerard Kugel

In the mid-1980s, the earliest generation of computer-aided 3. Restoration design

design/computer-aided manufacturing (CAD/CAM) technol- 4. Milling of the restoration
ogy was designed to fabricate immediate chairside inlay and onlay 5. Finishing of the restoration (coloring, glaze, polish) and ad-
ceramic restorations.1 This initial technology required an exces- hesive luting
sive amount of fabrication time. The first generation of computer
software and hardware that accompanied this technology offered
only a limited, two-dimensional view of the scanned images be- Advantages
cause the system’s hard drive was incapable of storing the volume The CAD/CAM system eliminates the need for traditional im-
of data required for a three-dimensional view. CAD/CAM tech- pression making because systems can make direct impressions.
nology has evolved to become a practical and useful resource for By enhancing tooth preparations the new technologies allow
dental professionals to perform chairside restorations.2 dentists to make better observations and assessments of the
In CAD/CAM technology, a digital impression is substitut- tooth preparation based on the enlarged 3D images. Most mod-
ed for the traditional elastomeric impression using an intraoral ern CAD system software can also check for undercuts. Other
digital scanner.3 Alternatively a digital scan of a cast made from advantages of the CAD/CAM system include the following:
a traditional elastomeric impression also can be performed. An 1. Manufacturing of the restoration (not all systems). An in-
intraoral digital impression that “captures” the data of the teeth office portable milling is capable of immediate milling of the
and their supporting soft-tissue structures is recorded by a scan- restoration, generally in less than an hour, eliminating the use
ning wand using an optic laser, digital imaging, and/or video of an off-site dental laboratory.
technology. A specialized three-dimensional (3D) rendering 2. Alternative materials. All CAD/CAM systems use milling
program allows the images of the intraorally scanned impres- technology meaning that the dentist is not limited to restora-
sions to be actualized in three dimensions and in real time on a tions fabricated from by casting and pressing procedures.
computer monitor. The software allows the dental professional 3. Open architecture system (not all systems). Digital
to mark margins, digitally design wax-up proposals of the resto- impressions made with devices that feature an open architec-
ration, place accurate occlusal contacts, and refine the proximal ture system are compatible with any milling machine, as
contact areas with adjacent teeth. The clinician can perform any opposed to a closed architecture system in which the digital
or all of these procedures at the chairside “design center” before impression and the restoration milling machine must be
sending the definitive data to the computer-controlled milling from the same manufacturer. An open system, therefore,
unit. The workflow is summarized by the following steps: provides more freedom of choice when it comes to the selec-
1. Tooth preparation tion of materials and a restoration fabrication partner (either
2. Intraoral scan a dental laboratory of the manufacturer of the CAD/CAM

479
480 PART 4 | E s t h e t i c s a n d O t h e r C l i n i ca l A p p l i ca t i o n s

system. Once the restoration is digitally designed by the multiple units, fixed partial dentures, implant abutments, and
dentist or technician, it is electronically sent to the facility zirconium or metal crowns. Cerec can also be integrated with
with the milling machine center for fabrication. the Galileos System to construct surgical guides for implant
placement. The Cerec’s Biogeneric software can analyze indi-
vidual patient occlusion and the anatomy of adjacent teeth so
Disadvantages that the restoration is patient-specific. Preparation evaluation
Following are some of the disadvantages of using CAD/CAM software (prepCheck) is included. This is a learning tool that
technologies: provides an analysis of either a computer-simulated tooth prep-
1. Expense. CAD/CAM technologies are expensive. Most are aration or a scan of an actual tooth preparation.
leased and the cost of the actual restorations sometimes rival Cerec AC Bluecam CAD System was released in 2009 and
laboratory fees. used a short wavelength blue-diode LED laser light that the
2. Learning curve. To use this new technology properly, the manufacturer claimed produces increased illumination to aid in
dentist or technician must be well-acquainted with computer scanning difficult access areas. It acquired single quadrant high-
design, implying an inherent learning curve for the system. resolution 3D images in less than a minute and occlusion regis-
3. Multiple unit limitations. Currently only some systems are trations in a few seconds and has electronic image stabilization.
able to manufacture multiple-unit restoration. The 3D data obtained from the system could be exported into a
4. Inability to image in a wet environment. Optically based standard STL (stereolithography) file format for use with any in-
imaging systems are incapable of obtaining accurate images dustry standard 3D software. In 2013, CEREC Omnicam system
in the presence of excess fluids. Impression-based systems was introduced which the manufacture claims does not require
have similar limitations. Nevertheless hydrophilic impres- titanium oxide application for scanning. However, the company
sion material is better equipped to overcome this limitation. still offers the CEREC Optispray to cover the reflective tooth sur-
5. Incompatibility with other imaging and CAD/CAM sys- face for more precise imaging in difficult scanning situations.
tems. Because of the 3D file format used by CAD/CAM
systems, they are not compatible with the 2-D IIS (intraoral
imaging) system. Although stereolithography (STL) is a The E4D Dentist
standard file format employed by 3D CAD software, some Unlike the earlier models of the Cerec system, the E4D system
CAD/CAM systems use their own 3D file formats. (made by D4D Technologies, Richardson, TX, and distrib-
6. Bulky scanning wand. Current commercial CAD systems uted by Henry Schein, Melville, NY) does not require the use
use a bulky, corded scanning wand. The slightly inconvenient of titanium oxide. The system wand contains a digital micro-
design of this wand may prove to be an awkward limitation mirror device and uses red diode laser to acquire a grayscale
in some intraoral situations. 3D image. The E4D system contains a chairside portable mill-
ing unit. E4D’s Compass software allows the pairing of the
CLINICAL PRODUCTS E4D CAD/CAM technology with i-CAT (Gendex Dental
Systems, Hatfield, PA) cone beam Technology for the coordi-
nation surgical implant planning. Like the Cerec, E4D Version
CLINICAL TIP 2.0 software allows the E4D to export digital files in an open-
Proper tissue management and cord retraction must be per- architecture stereolithography CAD data format widely used
formed during the digital impression the scanning procedure. by other 3D software packages. This will allow rapid prototyp-
Hardware systems and software versions are regularly updated ing and CAM on a wide array of devices. The E4D software
by the manufacturer, making it crucial to verify the current product named Compare serves as an evaluation tool for tooth
status with the manufacturer before making a purchase. preparation.8

The Cerec 4.0 The Lava COS

The Cerec system (made by Sirona Germany and distributed by The Lava COS system, originally developed by Brontes Tech-
Paterson Dental Co., St Paul, MN) was first introduced in the nologies (Cambridge, MA) and now made by 3M ESPE, is a
United States in 1996.4-6 It requires the use of a white, glare-free scanner-only system (it does not contain a portable milling ma-
powder containing titanium oxide to enhance the contrast of chine). It uses Brontes’ 3D-in-motion technology to capture con-
the tooth. A CCD sensor wand makes a 3D infrared scan of the tinuous 3D video images for digital impressioning. The scanner/
preparation in roughly 0.1 seconds at a resolution of 25 mm.5,7 software combination is capable of capturing approximately
The digital image is displayed on the self-contained micropro- 20 3D datasets per second, each with more than 10,000 data
cessor display where the dentist designs the restoration. The points. At its highest capture rate, more than 2400 3D datasets
Cerec is capable of fabricating porcelain inlays, onlays, crowns, and more than 24 million data points per arch can be acquired
and veneers, and allows immediate, single visit esthetic restora- within 2 minutes. The scanner is claimed to have an accuracy of
tions. Version 4 can mill a single-unit definitive or provisional between 6 and 11 mm.9 Similar to early model Cerec CAD/
restoration and a provisional three-unit fixed partial denture CAM systems, Lava COS requires the use of a powder for scan-
from an acrylic block. The system also contains a block that ning. The scan data are electronically sent to the dental labora-
functions as a wax casting (burnout block) for a cast metal tory, which in turn electronically sends the information to a
crown. The system also contains a portable, six-axis micromill- centralized cast manufacturing facility where the cast is fabri-
ing machine that can be used in the dental office. The clinician cated from an epoxy resin using stereolithography. The cast is
can electronically send a design and the digital impression with then returned to the dental laboratory for conventional restora-
Cerec Connect to the off-site laboratory for fabrication of casts, tion fabrication.
 CHAPTER 23 | Esthetics and CAD/CAM Systems 481

iTero CLINICAL TIP

The iTero System (Align Technology, Inc.) uses parallel/ The outcome of the CAD/CAM restoration is dependent
confocal technology to capture the digital images and gener- upon the experience of the dentist or operator. There is a
ate a 3D model. The scanner wand is capable of capturing a learning curve involved with operation of the scanner and/or
digital impression of 100,000 data points with a resolution software.
of 0.5 mm. A powder coating of the teeth is not required.
The preparation is scanned and the dentist sends the data to
iTero for conversion into a file format that is compatible with CAD/CAM RESTORATION MATERIALS
an in-office milling system. The data are then returned to the Advances in CAD/CAM CAM technology occurred simultane-
dentist for in-office milling. Alternatively the data can be ously with innovations in esthetic restorative materials. Modern
sent to iTero for refinement of the digital impression and monoblock ceramic materials have been engineered to resist mas-
delineation of margins and then sent to a local dental labora- ticatory stress and milling induced damage. Feldspathic ceramic
tory for a quality check. The dental laboratory can then mill materials have been mostly replaced by reinforced ceramic with
the restoration using an in-laboratory milling machine or silica (feldspar, leucite, and lithium disilicate), nonsilica (alumina
fabricate a conventional cast on a 3D printer and create the and zirconia), and a combination of resin-ceramic based materi-
restoration using traditional methods. A final alternative is als, resulting in a three- to 11-fold increase in flexural strength.15,16
to send the data to iTero for data refinement, have the local Computer modeling simulation shows that a single, thick, mono-
dental laboratory perform the definitive quality check and lithic all-ceramic crown materials performed better under stress
then returned the data to iTero for fabrication of a polyure- when compared with ceramic core material with veneering porce-
thane milled cast. The cast is then shipped to the local dental lain.17,18 Furthermore the coefficient of thermal expansion mis-
laboratory for creation of a restoration using traditional match between core and veneer materials may initiate the internal
methods. stress that causes delaminating or internal cracking of porcelain.

TRIOS Advantages
Like the iTero, the TRIOS system (3Shape A/S) is a scan- 1. Immediate crown fabrication. The crowns are able to be
ner-only system that does not require the use of titanium immediately fabricated eliminating traditional laboratory
oxide powder and the wand does not need to be held at any fabrication procedures.
specific distance or angle. The scanning wand is capable of 2. Monolithic crowns. Single layer ceramic materials exhibit
capturing more than 3000 2D images per second and the better strength than dual layer core and veneer porcelain.
autoclavable tip can be rotated for alternation between the 3. Marginal integrity. CAD/CAM milling crowns exhibit the
maxillary and mandibular jaws. The system uses a touch same marginal integrity as those made with conventional
screen monitor to display live 3D images and its motion- laboratory-made crown restorations.19-21
sensor interface and hand-held scanner allows the dentist to
virtually rotate and turn the 3D digital impression without
touching the screen. The TRIOS software contains tools Disadvantages
for instant clinical validation of the impression and tooth 1. Limited color shades. The blocks are only available in a few
preparation at chairside such as the Occlusal Clearance selected shades and frequently require staining before glazing.
tool ensures adequate tooth reduction and the Insertion 2. Monochromatic color/appearance. The monochromatic
Direction tool verifies convergence/divergence issues. Scan- appearance can only be overcome by staining or by using a
ning information is sent to the dental laboratory that accepts polychromatic block.
STL file format using 3 Shape’s Communicate solution soft- The monoblock ceramic can be rectangular, tubular, or in the
ware system shape of the dental arch depending on the type of milling ma-
chine used. Most frequently in-office/portable milling machines
use the rectangular or tubular shapes. Porcelain restoration
NobelProcera materials can be categorized into the following categories: rein-
The NobelProcera system (Noble Biocare) was originally de- forced ceramic with nonsilica (alumina and zirconia), silica
signed to fabricate a titanium substructure core beneath a low- (feldspar, leucite, and lithium disilicate), and a combination of
fusing ceramic for use as a fixed partial denture.10 It has since resin-ceramic based materials. Only some of these materials are
been modified to include a sintered high-purity alumina coping currently used in office based CAD/CAM milling systems
combined with compatible veneering porcelain to create all-
ceramic crown restorations.11-14
Unlike office-based CAD/CAM CAM systems, the Nobel- NON–SILICA-BASED CERAMICS
Procera system is designed for dental laboratory use only. The
laboratory scans the stone cast poured from a conventional im- Zirconia
pression sent by the dentist. After the stone replicated cast is Millable zirconia is generally the strongest ceramic material.
properly ditched, it is placed into the cast holder platform of Zirconia is difficult to mill; therefore the blocks are usually
the scanner. The optical impression scanner uses conoscopic presintered and less dense. The material will only be fully sinter-
holography technology, which the manufacturer claims offers ing after the milling procedure is completed. Fabrication of zirco-
more accuracy and shorter scanning time compared with stylus nia restorations require a higher degree of skill than that required
scanner technology. for other ceramic materials because of its density and hardness.
482 PART 4 | E s t h e t i c s a n d O t h er C l i ni c a l A p p li c a t i o n s

The restorations are, therefore, usually fabricated by laboratory IPS Empress CAD (Ivoclar Vivadent). Early chairside ceramic
technicians. Glass particles are included in the composition of this milling blocks were available in limited shades and therefore re-
material to enhance esthetics. quired external staining. Recently a greater selection of incremen-
tally chroma and value gradated polychromatic ceramic blocks
(IPS Empress CAD) for both the PlanScan CAD/CAM Resto-
Alumina ration System (E4D Technologies) and CEREC CAD/CAM
Alumina-based systems typically use an alumina substrate System (Sirona Dental Inc. USA) have become available. These
over which a conventional layer of feldspathic porcelain is tri-shaded blocks contain different cervical, body, and incisal seg-
placed. Currently there are only limited alumina blocks avail- ments in an attempt to mimic the polychromaticity of natural
able for office based CAD/CAM systems such as VITA In- teeth. Blocks are also available with high and low translucency.
Ceram Alumina block (Vident) and inCoris Al (Sirona Dental
Inc. USA).
Lithium Disilicate
Glass ceramics are characterized based on their crystalline struc-
SILICA ture and/or application with lithium disilicate ranking among the
best known and most widely used types of glass ceramics. Lithium
Feldspathic Porcelains disilicate is an esthetic, high-strength material that can be conven-
Feldspathic porcelains are typically available in sintered, pressed tionally cemented or adhesively bonded. For example, IPS e.max
and milled block form. Examples are fine particle ceramic (Ivoclar Vivadent) composed of lithium dioxide, quartz, phosphor
blocks: Vitablocs Triluxe Forte and Vitablocs RealLife (Vident). dioxide, alumina, potassium oxide, and other components is a
Both have a graded variation in chroma. The incisal/occlusal composition that yields a highly thermal shock-resistant glass ce-
third exhibits a low, less intense chroma with high translu- ramic because of its low thermal expansion during processing. It
cency, the body layer exhibits regular chroma and the cervical can be processed using either well-known, lost-wax hot pressing
layer exhibits the highest chroma and the lowest translucency techniques or state-of-the-art CAD/CAM milling procedures.
(Fig. 23-1A,B). The pressable lithium disilicate (IPS e.max Press, Ivo-
The Vitablocs RealLife (Fig. 23-1C) blocks better mimic clar Vivadent) is produced according to a unique bulk casting
the enamel-layered-over-dentin design of the natural tooth and production process in order to create the ingots. This process
reproduce translucency, chroma, and value by positioning the involves a continuous manufacturing process based on glass
restoration to be milled within a spherical dome of dentin that is technology (melting, cooling, simultaneous nucleation of two
surrounded by more translucent enamel. different crystals, and growth of crystals) that is constantly op-
timized in order to prevent the formation of defects. The micro-
structure of the pressable lithium disilicate material consists of
Leucite-Reinforced Ceramics approximately 70% lithium disilicate crystals, which are needle-
Leucite-reinforced ceramics are available in sintered pressed and shaped and measure 3 to 6 mm in length, embedded in a glassy
milled block CAD/CAM forms. Examples are IPS Empress and matrix.

A B

F I G U R E 2 3 - 1 A, Vitablocs Triluxe Forte with grade

variation in color saturation (block view). B, Vitablocs
Triluxe Forte with grade variation in color saturation
(tooth view). C, Vitablocs RealLife block with spherical
dome dentin surrounded by more translucent enamel.
C (Courtesy Vident, Brea, CA.)
 CHAPTER 23 | Esthetics and CAD/CAM Systems 483

data on material wear properties are not yet available and cur-
rently, there is only limited clinical data in the literature. The
most significant advantage of this product is that post-milling
oven firing is unnecessary.

CLINICAL TIP
It is essential for clinicians to have knowledge of what type
of ceramic are needed in every situation.

CLINICAL TECHNIQUE
FIGURE 23-2 IPS e.max CAD impulse blocks in different Case Study
brightness and shades. (Courtesy Ivoclar Vivadent, Amherst, NY.)
A healthy 85-year-old woman presented to the dental office on
an emergency basis with a coronal fracture of the maxillary right
The machinable lithium disilicate blocks (IPS e.max CAD lateral incisor. The medical history was noncontributory. It was
blocks) (Fig. 23-2) are produced by bulk casting but are only determined that the tooth required endodontic therapy, a post
formed to a softer intermediate blue translucent state, to en- and core and a crown. The tooth was endodontically treated
sure that the blocks can be milled efficiently. The intermediate followed by the placement of a prefabricated post (RelyX fiber
crystallization process yields lithium metasilicate crystals that post, 3M ESPE) and a core build-up of composite resin (Filtek
have properties that include ease of machinability and good Z250, 3M ESPE) (Fig. 23-3A,B).
edge stability. After milling, the restorations are fired to their A shade was selected with Vita shade guide and a digital
definitive higher strength crystallized state. The microstructure photograph (Canon D50 with macro lens, Canon Inc.) was
of the intermediate crystallized lithium disilicate consists of made to aid the laboratory technician in fabricating proper tooth
40% platelet-shaped lithium metasilicate crystals embedded in a color and morphology. A digitally designed virtual wax-up of the
glassy phase. These crystals range in length from 0.2 to 1.0 mm. tooth was constructed following margin marking (Fig. 23-3C).
Post-crystallization microstructure of IPS e.max CAD lithium After the sprue location was determined digitally, the data
disilicate material consists of 70% fine-grain lithium disilicate for the designed crown were sent to the computer-controlled
crystals embedded in a glassy matrix.22-25 milling machine. A provisional crown was made with bis-acrylic
Ivoclar Impulse lithium disilicate blocks are available in material (Tuff-Temp, Pulpdent Corp.) and delivered to the pa-
different brightness values and opalescence shades. The opales- tient due to the lengthy procedure in the initial unscheduled
cence blocks are mainly designed to create thin veneers and other emergency visit and scheduling requirements that precluded
partial coverage restorations and single crowns (see Fig. 23-2). completing the restoration during the initial visit. The final res-
toration was completed using a D3-V1 Impulse mono-ceramic
block (Ivoclar Vivadent). Following milling, the crown was cus-
REINFORCED RESIN-CERAMIC tomized using laboratory burs (Fig. 23-3D).
A reinforced resin-ceramic block (Lava Ultimate CAD/CAM, The crown was then stained and glazed using the IPS e.max
3M ESPE). is a unique resin nano-ceramic material. The manu- ceram shade kit (Ivoclar Vivadent) on a white dental stone
facturer claims long-lasting esthetics and performance, however, working model (Fig. 23-3E).

A B
F I G U R E 2 3 - 3 A, Endodontically treated teeth with fiber post placement. B, Composite resin
core build-up.
Continued
484 PART 4 | E s t h e t i c s a n d O t he r C l in i c a l A p p l i c a t i o n s

F
E
FI G U R E 2 3 - 3 , c o n t ’ d C, Virtual digital wax up (E4D Technologies) on the maxillary right
lateral incisor. D, IPS e.max CAD impulse blocks after milling and customization with laboratory
burs. E, IPS e.max CAD impulse esthetic stain and glaze on stone die. F, Postoperative images
following crown cementation.

The crown was tried in and adjusted and, after the patient 6. Mormann J et al: Marginal adaptation von adhasiven Porzellaninlays in vitro,
approved the esthetics, the restoration was cemented using a Schwizerische Monatsshrift fur Zahnmedizin 85:1118-1129, 1985.
7. Mormann J: Method for the manufacture of dental reconstructions and blank for
definitive composite resin luting cement (Multilink Automix, carrying out this method.
Ivoclar Vivadent) (Fig. 23-3F). 8. Renne WG, McGill ST, Mennito AS, Wolf BJ, Marlow NM, Shaftman S, et al: E4D
compare software: an alternative to faculty grading in dental education, J Dent Educ
77(2):168-175, 2013.
CONCLUSION 9. Balakrishnama S, Wenzell K, Bergeron J, Ruest C, Reusch B, Kugel G: Dimensional
repeatability from the LAVA COS 3D Intra-oral Scanning System, Boston, 2009, Boston
Center For Oral Health.
The success of CAD/CAM technology depends on the clini- 10. Smedberg JI, Ekenbäck J, Lothigius E, Arvidson K: Two-year follow-up study of
cal skills of the dentist and the ability to properly employ Procera-ceramic fixed partial dentures, Int J Prosthodont 11(2):145-149, 1998.
technology. This begins with proper diagnosis and tooth 11. Awliya W, Odén A, Yaman P, Dennison JB, Razzoog ME: Shear bond strength of a
resin cement to densely sintered high-purity alumina with various surface conditions,
preparation followed by proper use of the CAD/CAM tech- Acta Odontol Scand 56(1):9-13, 1998.
nology. Many of the procedures involved with the fabrication 12. Andersson M, Razzoog ME, Odén A, Hegenbarth EA, Lang BR: Procera: a new way
CAD/CAM restorations are major departures from tradi- to achieve an all-ceramic crown, Quintessence Int 29(5):285-296, 1998.
13. Wagner WC, Chu TM: Biaxial flexural strength and indentation fracture toughness of
tional techniques. A distinct learning curve is involved with three new dental core ceramics, J Prosthet Dent 76(2):140-144, 1996.
attaining the skills necessary to become clinically facile with 14. Persson M, Andersson M, Bergman B: The accuracy of a high-precision digitizer for
CAD/CAM of crowns, J Prosthet Dent 74(3):223-229, 1995.
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Prosthodont 8(3):239-246, 1995.
16. McLaren EA, Giordano RA: Zirconia-based ceramics: material properties, esthetics,
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