OPTICAL IMAGING AND

MANUFACTURING IN CAD-CAM
SYSTEMS

ASSIST PROF. BURCU DIKICI

DEPARTMENT OF RESTORATIVE DENTISTRY
• Computer aiding design /computer aiding manufacturing (CAD-CAM) is a

currently developed scope of dental restorations through the use of CAD/CAM

system to create an appropriate design and fitness of different dental

restorations like zirconium crown, fixed bridges, dental veneers, inlays, onlays

and orthodontic appliances.

· create
opporte des!gn h!tmas of restorat!on
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• Milling of dental restorations from a block of base material, such as metal, ceramic

or resin, is proposed as an alternative for fabricating restorations.

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• This technology promises results of greater accuracy and structural homogeneity.
• With quality as the objective, the significant advantage in using milling technology lies in

the fact that cold working of rolled structures and ceramic materials will always yield

homogenous material structures.

• To produce milled restorations with accurate fit, digitization of the prepared tooth

surface and converting the data into control signals for computer-assisted milling is

requested.
• In
&
this regard, computer-aided design and computer-aided manufacturing
(CAD/CAM) technology in dentistry has encountered numerous problems, because
the shapes of prepared teeth and dental restorations cannot be described with
regular geometric methods because of their unlimited number of degrees of
freedom.

• Therefore, when using current CAD/CAM technology, data acquisition has to be

performed with digital mechanical scanning of the cast parts or by point-based
optical systems.
 1 Intraoral
scanning

2 Evaluation of
scanning

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3 CAD:
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CAD-CA
-
CAD: Computer Aided Design
CAM: Computer Aided
M Manufacturing
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• The CAD/CAM systems are formed basically by 3 main elements:
①
• (1) a data acquisition unit that registers all the preparation design and the surrounding

structures (the optical impression is obtained at this step and can be done direct or

opt!c
=
indirectly, sconne

②
• (2) a processing software that creates a virtual restoration and establishes all the milling
and software
parameters,-
> computer
•
②
(3) an automated milling machine that manufactures the restoration using solid blocks of
moch!ne.
the chosen restorative material. m!ll!ng
• The first Component is the scanning phase (computer surface digitization), this be divided

into two options:

1) Optical scanning .

2) Mechanical scanning.

• 1. Optical camera: This scanning device is based on the collection of 3-D structures

-
called "triangulation procedure". Here, the light source with the receptor unit presented

in a specific angle in relationship to each another. With the aid of this angle a 3-D data

calculated by computer from the image on the receptor unit.

• White light or laser beam can be used as a source of lighting,

• The following examples of optical scanners on the dental marketing

fields:

1) Lava Scan ST, 3M ESPE, scanning source= white light

Everest Scan, KaVo, scanning source= white light.

es1, etkon. scanning source= laser beam.

• Mechanical scanning devices: For this type of scanning device, the poured

-
cast is mechanically scanned (read)line-by-line by the use of a ruby ball and

the object three- dimensionally was measured and characterized by a high

quality of scanning accuracy. Then, all digital data collection would be designed

then milled.

• This technique is somewhat complicated, more expensive and time consuming

compared to other scanner

• The second component is the designing phase. After a three dimensional image is
-

captured by the use any of scanning techniques, 3-D image processing is finished and
-
the digitized data is designed within the computer followed by the construction

programs

• Finally, surface smoothing, error elimination and undesirable undercuts were blocked
- -

at this stage. Different design of restoration are done using spresific CAM which in

turn send orders to the CAM unit to fabricate restoration through a milling machine.
 -
• The Third and final component is manufacturing phase. This step transforms the
digital data of the restoration into a physical product by milling machine with the aid
of computer using a high quality diamond (disks or burs) which cut the restoration
from ingots . This process is known as "substractive method
=

cuf
-substractor
• The first 2 elements take care of the CAD phase, while the third element is responsible

for the CAM phase. The precision of these 3 elements combined will dictate the success of

the system.
• Nowadays, the CAD-CAM systems can be classified into 2 different groups according to the
ability to share CAD data: open CAD- CAM systems and closed CAD-CAM systems. The closed

-a
systems provide all the steps that are integrated, with no interchangeability between different
systems. With this closed system, the professional relies on 1 specific maker for all the
software updates. The open systems, on the other hand, allow the professional to choose be-
tween different CAD and CAM combinations.
• The main difference between a closed CAD/CAM system and an open CAD/CAM system is
that a closed CAD/CAM system does not integrate with any components manufactured by
another company. In other words, closed systems are entirely proprietary, whereas an open
CAD/CAM system can be integrated with the components.

• A closed CAD/CAM -
system has very limited flexibility. It does not allow the end user to
pick and choose different options for their design and manufacturing operations. Usually,
they have their own proprietary file systems, not allowing you to use them with other
equipment. Closed systems also often require sourcing material from one provider, versus
from the open market of providers.

• Open CAD/CAM systems are components that can design and create your dental prosthesis
using the same neutral file formats
• CAD/CAM technology was developed to solve 3 challenges.
• The first challenge was to ensure adequate strength of the restoration, especially for
posterior teeth.
• The second challenge was to create restorations with a natural appearance.
• The third challenge was to make tooth restoration easier, faster, and more accurate.
• In some cases, CAD/CAM technology provides patients with same-day restorations.
=
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of
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• Recent growth trends of CAD/CAM systems for industrial

applications in rapid prototyping have facilitated significant

improvement in software and a reduction of size and costs of

machinery.

• CAD/CAM in dentistry has been particularly useful in

permitting the fabrication of custom, patient-specific

-
restorations and prosthetics without having to use

traditional analoge dental laboratory methods.

CAD/CAM SYSTEMS
Based on their production methods these systems can be divided into the following groups.

1. In office system: Most widely and commercially used in Cerec System. This system can scan the
tooth preparation intraorally and by selecting appropriate materials, the dentist can fabricate the
restorations and seat it within a single appointment.

2. CAD/CAMS – Dental laboratory models: The indirect systems scan a stone cast or die of the prepared
tooth, in the dental lab (eg Cerec-in lab). Many of this system produce copings which require the dental
technician to add esthetic porcelain for individualization and characterization of the restoration.

3. CAD/CAM for outsourcing dental lab work using networks: since the design and fabrication of the
framework for high strength ceramics is technique sensitive, new technologies using CAD/CAM combined
with network machining center that is outsourcing the framework fabrication using an internet have been
introduced.
METHODS OF DATA ACQUISITION IN CAD CAM

There are several methods by which data can be collected for CAD.

1) Intra oral scanning

-

2) Contact and non – contact digitization

-

3) Ct scan or MRI
-
Intra Oral Scanning

• There are several intra oral scanners available in market namely CEREC® – by Sirona Dental System
GMBH (DE), Lava™ C.O.S. – by 3M ESPE (US), iTero – by CADENT LTD (IL) and E4D – by D4D

Contact & Non – Contact Digitizing

• This method involves taking an conventional impression and then after producing a model,
transferring of that data into CAD through probe digitization ( contact) or laser light ( non – Contact ).

Ct scan /MRI:

• Computed Tomography (CT & Magnetic Resonance Imaging (MRI) are newer techniques for data
acquisition for CAD Cam.By this method, individual images can be taken and then can be transferred to
CAD.
• The intraoral cameras are optical scanners and can be separated into
two types

(1) single image cameras that record individual images of the dentition.

The iTero (Align Technology), PlanScan (Plan- meca), CS 3500 (Carestream Dental LLC), and
Trios (3 shape) cameras are single image cameras which record about three teeth in a single
image.

(2) video cameras which are used by the True Definition scanner (newest version of the Lava
Chairside Oral Scanner, COS), Apollo DI (Sirona) and OmniCam (Sirona) systems.
• The information for the development of a CAD/CAM restoration may be also acquired
extraorally from the final impression or working cast. Additionally, some scanners can
record a glossy, reflective surface such as a titanium abutment while other types require an
opaquing powder.
-

• The transfer of the image from the tooth to the final fabrication of the restoration can be
divided into four methods in which Method 1 involves scanning of the teeth and implants
without any models, Method 2 involves scanning of the teeth plus fabrication of digital
models, Method 3 involves a physical impression plus scanning, and Method 4 involves a
physical impression plus scanning of its stone working casts.
• The main intraoral data acquisition systems are CEREC Bluecam System (Sirona), Lava
C.O.S. System (3M ESPE), iTero System (Cadent/Straumann), and E4D System (D4D
Technologies). The software will be described with each system for a didactic reason.
 DEVELOPMENT OF CEREC SYSTEMS

• CEREC; is the abbreviation of “Chairside Economic Reconstruction of Esthetic Ceramic”;

however, in certain literature, this acronym is just explained by the terms “Ceramic

Reconstruction”.

• Different restorative materials can be used with the CEREC system including; VITA Blocs

Spinell, Zirconia, Alumina, Zirconia Mark II, YZ (VITA Zahnfabric, Bad Säckingen, Germany)
 CEREC

• The CEREC system was introduced in the market in 1985, and it was the first to use the
CAD/CAM concept chair side.
• The CEREC AC Bluecam allows the acquisition of images with much higher resolution than the
former CEREC cameras and has an image quality similar to the laboratory-scanned ones.
• This system requires a thin layer of contrast powder on top of the surface before the optical
-
impression.
• According to the manufacturer, the new CEREC Bluecam collects high-resolution images
through a blue diode with powerful LED.

• Quick and easy results are obtained with a high CAD/CAM quality, confidence, precision,
and efficiency. The high- performance diode emits a blue light with a short wavelength.
• The camera automatically detects the right moment to trigger the exposure. The

professional have to move the CEREC Bluecam gradually over the relevant area.

• This system requires a nonreflective surface for precise imaging. The contrast layer has
-

to be thin and homogeneous to avoid distortions on the final image.

-
 PROCERA ALL CERAM SYSTEM

• Introduced in 1994, it is the first system which provided outsourced fabrication using a
network connection.

• Once the master die is scanned the 3-D images is transferred through an internet link to
processing center where an enlarged die is milled by a computer controlled milling machines.
This enlargement compensates for sintering shrinkage. Aluminum oxide powder is compacted
on the die and coping is milled by a computer controlled milling machines.
CICERO SYSTEM (COMPUTER INTEGRATED
CROWN RECONSTRUCTION)
• Introduced by Denison et al in 1999,
• it includes optical scanning, metal and Ceramic sintering and computer assisted milling
to obtain restoration. Basic reconstruction includes layered life like ceramic for
natural esthetics, a precision milled occlusal surface and a machined high strength
ceramic core.
• The aim of CICERO is to mass produce ceramic restoration at one integrated site. It
includes rapid custom fabrication of high strength alumina coping and semi finished
crowns to be delivered to dental laboratories for porcelain layering / finishing.
 CERCON

• commonly referred to as a CAM system, it does not have a CAD component. The system
scans the wax pattern and mills a zirconia bridge coping from presintered zirconia
blanks, which is sintered 6- 8 hrs.

• Veneering is done with a low fusing, leucite free cercon Ceram to provide esthetic
contour. Marginal adaptation for cercon all ceramic crowns and fixed partial dentures
was reported 31.3 μm and 29.3 μm respectively.
 ITERO SYSTEM

• The optical impression iTero System (Cadent, Carlstadt, NJ) was

introduced in 2007, after 5 years of intensive research. iTero
system uses parallel confocal imaging to capture the digital impres-
sion.

• Parallel confocal imaging uses laser and optical scanning to digitally

capture the surface and contours of the tooth and gum structure.
This system includes a computer, monitor, mouse, integrated
keyboard, pedal, and scanner device. It is easily disinfected by
replacing the scanner disposable cover.
 LAVA CAD/CAM SYSTEM2

• Introduced in 2002, used for fabrication of zirconia framework for all

ceramic restorations. This system uses yttria stabilized tetragonal
zirconia poly crystals (Y-TZP) which have greater fracture resistance than
conventional ceramics.
• Lava system uses a laser optical system to digitize information.
• The Lava CAD software automatically finds the margin and suggests a
pontic. CAM produces an enlarged framework to compensate shrinkage.
• A partially sintered ziroconia block is selected for milling. Milled
framework undergoes sintering to attain final dimensions, density and
strength.
• While the iTero System does not require any powdering, the Lava C.O.S. System requires
enough powdering to allow the scanner to locate reference points. Like the Bluecam, it has to
be a thin and homogeneous layer to avoid distortions.
 E4D DENTIST SYSTEM

• Presently it is the only system besides CEREC that permits same day
in-office restorations. This system includes a laser scanner (Intraoral
digitizer), a design center and a milling unit. The scanner is placed near
the target tooth, and has 2 rubber feet that hold it to specific
distance from the area being scanned.

• As each picture is taken, the software gradually creates a 3D image.

• As soon as the restoration is approved, the data are transmitted to

either the in-house milling machine or a dental laboratory.
• ADVANTAGES AND DISADVANTAGES OF DIGITAL IMPRESSIONS
• The disadvantages of the method include the lack of familiarity among dentists. It is not a
known concept and mastered by all. The equipment is sophisticated, although lately it has
been greatly simplified, and it takes training and practice to acquire the technique.
•
6-
• The cost of equipment is high, but after depreciation it becomes cheaper than the
conventional technique. Comparative studies between conventional and digital impression in
terms of accuracy suggest that there is a small similarity. However, it requires long-term
clinical studies to highlight that these systems are superior in terms of accuracy for the
restorations.
+
Ot
• The advantages of digital impression include simplicity, the elimination of the “dirty” cabinet
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and patient discomfort. The method has no issues of incorporating air bubbles. However, a
t
close attention should be directed towards not acquiring artifacts due to saliva, gum margins,
and the sites in the oral cavity. There is no -
need for storage space or the purchase of spoons
and impression materials. The risk of contamination is reduced, and disinfection needed by
the classical impressions is not a must for the digital impression technique.
• It is necessary to make very precise preparations (for both techniques), and digital
impressions do not support approximations. Gingival sulcus preparation is as important as for
conventional impressions.
• Data-capturing systems differ considerably among the currently available systems.
 ADVANTAGES AND DISADVANTAGES OF
CAD/CAM TECHNOLOGY
+ + t
• These advantages include speed, ease of use, and quality.
- -

• Having a milling machine on site means that patients can receive their permanent restoration on the
+ same day they come in, without making a second appointment.
• If anesthetics are needed, they only need to be administered once.
• The quality of CAD/CAM restorations is extremely high because measurements and fabrication are
extremely precise. +
-
-

• Traditional impressions suffer from problems, such as bubbles and tears in the impression material,
cords or other debris embedded in the impression material, and missing teet.
-
• CAD/CAM restorations have a natural appearance because the ceramic blocks have a translucent+
quality that emulates enamel, and they are available in a wide range of shades.
• The quality is consistent due to the prefabricated ceramic blocks which are free from internal defects,
and the computer program is designed to produce shapes that will stand up to wear.
 ADVANTAGES AND DISADVANTAGES OF
CAD/CAM TECHNOLOGY

+ ↓
• Savings in time and labor have the potential to reduce costs, and the promise of faster, high-quality
restorations should appeal to patients..

• Another benefit is that all the scans can be stored on the computer whereas standard stone models
take up space and can chip or break if stored improperly.

• The digital systems are not free from drawbacks. The initial cost of the equipment and software is
high, and the practitioner needs to spend time and money on training.

• Just as with conventional impressions, in taking an optical scan, the dentist requires to achieve an
accurate recording of the tooth to obtain a precise restoration.
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 CAD/CAM BLOCKS
1) PORCELAIN 3) COMPOSITE 4)
BASED BASED ZIRCONIA
2) HYBRID
CERAMIC

Feldspatik
Resin nano-ceramic
Zirconia
Polimer
infiltrated
ceramic
leucite-reinforced
porcelains

Composite

Dr. Sameer Puri. (2018). Material Choices for CAD/CAM Dentistry. Dentistry
Lithium Silicate Glass Ceramics Today.
• Two main types of materials are currently available for esthetic CAD/CAM-processed indirect
dental restorations: glass-ceramics/ceramics and resin-composites.

• Ceramics are defined as crystalline, non-metallic materials, containing metallic and non-metallic
elements bonded by ionic and/or covalent bonds, while glasses share the same definition but are
amorphous.

• Glass-ceramics are composite-type materials in which the glassy phase acts as the matrix and the
ceramic as the reinforcing filler .

• Resin composites consist of a polymeric matrix reinforced by fillers that could be inorganic
(ceramics or glass-ceramics or glasses), organic, or composite
• Glass-ceramics/ceramics are strong, stiff, brittle materials, with low fracture toughness and high
susceptibility to failure in the presence of flaws.

• The optical properties (translucency, fluorescence, opalescence, etc.) of glass-ceramics/ceramics are

superior to those of resin-based materials .

• While glass-ceramics/ceramics (depending on their composition) might be adversely affected by the pH

of the oral environment and/or of the diet, water sorption/desorption could lead to the degradation of
the polymer matrix and/or of the coupling-agent-mediated polymer-filler bond.
Leucite-Reinforced Glass Ceramics

• Leucite-reinforced ceramics are not recommended for crowns in the posterior segment due
to their lower mechanical properties compared to other glass ceramics.

• However, their aesthetic qualities are sufficient, and the wear resistance of the enamel
antagonist is similar to other glass ceramic materials.

• In recent years, they have been replaced by lithium silicate ceramics, which have better
physical properties and sufficient optical properties.
Lithium Silicate Ceramics
• Some sources claim that lithium silicate ceramics (e.g., IPS e.max CAD by Ivoclar Vivadent, Schaan,
Liechtenstein, VITA Suprinity PC by VITA Zahnfabrik and Celtra Duo by Dentsply Sirona) are the
strongest of all the available silicate ceramics with a flexural strength of around 407 Mpa.
• First, lithium disilicate ceramic was introduced to the market in 1998 (IPS Empress 2).
• Its chemical composition—a crystalline phase consisting of lithium disilicate and lithium
orthophosphate—indicates higher fracture resistance without a negative influence on the
translucency of the material.
• It shows good clinical results in follow-ups with a failure-free rate at the level of 93% .
Composites
• With the development of CAD/CAM materials, and increasing doctor and patient
expectations, hybrid structures, such as composite resins, hybrid ceramics or
conventional materials with additives altering their physical properties, have been
introduced to the market.
• Composites are known to be materials made of at least two substances, exhibiting
properties from each of them. It is no surprise that regarding CAD/CAM, an
additive for polymeric or ceramic materials is used in order to enhance the
tribological or mechanical properties or simply the aesthetics of the prostheses.
• We can outline polymer-infiltrated ceramic networks (PICN) and resin composite
blocks (RCB). The former consists of two phases: a ceramic scaffold and an
interpenetrating polymeric network. The latter are formed by transferring the filler
into a monomer mixture.
Hybrid Materials
• In fact, VITA Enamic (VITA Zahnfabrik) seems to be an adequate material not only for crowns in the posterior
segment but also in aesthetic segment or restorations with reduced wall thickness.
• The structure of VITA Enamic is based on two interpenetrating networks—dominant ceramic mesh (86%) is
reinforced by a polymer (14%). As mentioned, the structure of the hybrid material allows us to combine the
beneficial properties of ceramics and composites.
• VITA Enamic has optimal flexibility, stress resistance and light conductivity, which provide better visual
adaptation.
• After designing, as an effect of milling, we can obtain anatomically precise restorations. It is worth mentioning
that milling, which in our case was performed by the CEREC System, is faster (about 6.5 min for molar crown) for
this material compared to others.
Nanoceramics (Resin nanoceramics)

• Recently, silica based ceramics are frequently used with CAD/CAM systems in consequence of their unique
aesthetic properties. Feldspathic ceramics and leucite reinforced glass ceramics has not only high esthetical
properties but also low fatigue resistance.

• Due to the poor mechanical characteristics of glass ceramics, composite-based restorative materials are
preferred instead.

• Composite- based restorative materials’ elastic modulus value is close to tooth and they both have similar
occlusal force absorption capacity. However, composite material undergoes more surface wear due to the
inadequate hardness, for this reason the surface polish has not last longer.

• Therefore, favorable properties of composites and ceramics were integrated using nanotechnology and
developments in the production of new dental restorative materials shows remarkable progress
• Nanoceramics are composed of 80% ceramics and 20% resin materials. It is stated that, a high proportion of
nanoparticles embedded in resin matrix enables the material abrasion and fracture resistant.

• Nano-sized structure of the ceramics also strengthens chemical bonds formed between inorganic ceramics
and organic resin matrix. The dimensions of nanoparticles are ranged between 0.6-1 micrometers.

• The modulus of elasticity is defined as the measure of elastic deformation of the material under stress. The
elastic moduli of restorative materials used in dentistry have to be compatible with elastic modulus of tooth.
This compatibility has a positive impact on the long-term success of the restorations.
MARGINAL INTEGRITY OF CAD/CAM
RESTORATIONS

• One of the most important criteria in evaluating fixed restorations is marginal integrity.
• .The wear of the gap increased dramatically in the first year, becoming stable after the second
year.
• McLean and Von Fraunhofer proposed that an acceptable marginal discrepancy for full coverage
restorations should be less than 120 μm.
• Christensen suggested a clinical goal of 25 μm to 40 μm for the marginal adaptation of
cemented restorations.
• However, most clinicians agree that the marginal gap should be no greater than 50 μm to 100 μm
 CONCLUSIONS

• CAD/CAM systems have enhanced dentistry by providing high-quality restorations. The evolution of
current systems and the introduction of new systems demonstrate increasing user friendliness,
expanded capabilities, and improved quality, and range in complexity and application.

• New materials also are more esthetic, wear more nearly like enamel, and are strong enough for full
crowns and bridges.

• Emerging technologies may expand the capabilities of future systems, but they also may require a
different type of training to use them to their full capacity.
• Recently, several aspects of CAD/CAM systems have had significant technological improvements.
These include the development and application of new materials, the introduc- tion of virtual
articulator software, and development of scanners, the availability of more efficient milling and
3D printing machines, and transfer of digitized casts to the virtual articulator.
• The coming trend for most practitioners will be the use of an acquisition camera attached to a
laptop computer with the appropriate software and the capability of forwarding the image to the
commercial laboratory.