PRACTICE
dental practitioner.
• This article informs the practitioner
As in many other industries, production stages are increasingly becoming automated in dental technology. As the price
of dental laboratory work has become a major factor in treatment planning and therapy, automation could enable more
competitive production in high-wage areas like Western Europe and the USA. Advances in computer technology now en
able cost-effective production of individual pieces. Dental restorations produced with computer assistance have become
more common in recent years. Most dental companies have access to CAD/CAM procedures, either in the dental practice,
the dental laboratory or in the form of production centres. The many benefits associated with CAD/CAM generated dental
restorations include: the access to new, almost defect-free, industrially prefabricated and controlled materials; an increase
in quality and reproducibility and also data storage commensurate with a standardised chain of production; an improve
ment in precision and planning, as well as an increase in efficiency. As a result of continual developments in computer
hardware and software, new methods of production and new treatment concepts are to be expected, which will enable an
additional reduction in costs. Dentists, who will be confronted with these techniques in the future, require certain basic
knowledge if they are to benefit from these new procedures. This article gives an overview of CAD/CAM-technologies and
systems available for dentistry today.
1. DEFINITION
2. Software that processes data and, situations. This saves time and offers
The term ‘CAD/CAM’ in dental technol depending on the application, the patient indirectly fabricated resto
ogy is currently used as a synonym for produces a data set for the product rations at one appointment. At present,
prostheses produced by ‘milling technol to be fabricated only the Cerec® System (Sirona) offers
ogy’. This is not entirely correct. CAD 3. A production technology that trans this possibility. Other producers also
is the abbreviation for ‘computer-aided forms the data set into the desired plan to introduce chairside CAD/CAM
design’ and CAM stands for ‘computer product. systems to the market. Since the Cerec®
aided manufacturing’. The term ‘CAD/ system functions with water-cooling, a
CAM’ does not provide any information 2. CAD/CAM PRODUCTION variety of materials can be processed,
on the method of fabrication. CONCEPTS IN DENTISTRY from glass-ceramic to high performance
All CAD/CAM systems consist of three Depending on the location of the com oxide ceramic. Clinical observations on
components: ponents of the CAD/CAM systems, in ceramic inlays are available over a period
1. A digitalisation tool/scanner that dentistry three different production of 21 years. Scientific literature reported
transforms geometry into digital concepts are available: success rates for CAD/CAM produced
data that can be processed by • chairside production inlays of 90% after ten years and 85%
the computer • laboratory production after 12 and 16 years.1-3 Historically, this
• centralised fabrication in a system was the first CAD/CAM system
production centre. in dentistry and is currently available in
its third product generation. One of the
1*
Assistant Professor, 2Head of Laboratory, 3Associate a) Chairside production benefits of this very mature system is the
Professor, Department of Prosthodontics, Ludwig-
Maximilians University, Munich, Germany All components of the CAD/CAM system software that has been supplemented by
*
Correspondence to: Dr Florian Beuer, Pacific Dental
Institute, 12750 SW 68th Avenue, Portland, Oregon,
are located in the dental surgery. Fabrica a very exact three-dimensional recon
97223, USA tion of dental restorations can thus take struction of the occlusal surface.
Email: florian.beuer@med.uni-muenchen.de
place at chairside without a laboratory
Refereed Paper procedure. The digitalisation instrument b) Laboratory production
Accepted 28 March 2008
DOI: 10.1038/sj.bdj.2008.350
is an intra-oral camera, which replaces a This variant of production is the equiva
© British Dental Journal 2008; 204: 505-511 conventional impression in most clinical lent to the traditional working sequence
c) Centralised production
The third option of computer-assisted
production of dental prostheses is cen
tralised production in a milling centre.
In this variation, it is possible for ‘sat
ellite scanners’ in the dental laboratory
to be connected with a production cen
tre via the Internet. Data sets produced
in the dental laboratory are sent to the
production centre for the restorations to
be produced with a CAD/CAM device.
Finally, the production centre sends the
prosthesis to the responsible laboratory.
Thus, production steps 1 and 2 take place
in the dental laboratory, while the third
step takes place in the centre.5,8 As a
result, the configuration of the prosthe Fig. 2 Screen-shot of CAD-construction of 14 single crown copings
sis remains in the hands of the dental
technician. The benefit of outsourcing
CAM production is to be found in the
small investment requirement, since
only the digitalisation tool and soft
ware have to be purchased, still having
access to a high quality production pro
cess. In addition, this procedure results
in greater independence, since there is
no relation to a particular production
technology (such as, eg milling tech
nology). It must, however, be noted that
presently almost all CAD/CAM systems
are only available as closed systems. In
other words, if one acquires a scanner
from one manufacturer, this implies, in
the case of a closed system, that there is
only access to that manufacturer’s pro Fig. 3 Different possibilities of the working axis: 3 spatial directions X, Y and Z (3 axis
cesses and line of products. In addition, milling devices); 3 spatial directions X, Y, Z and tension bridge A (4 axis milling devices); 3
spatial directions X, Y, Z, tension bridge A and milling spindle B (5 axis milling devices)
the dental laboratory loses the income
from producing the framework, since it • Everest Scan (KaVo, white light 3.3 Processing devices
is fabricated in the production centre. projections) The construction data produced with the
Many production centres also offer • es1 (etkon, laser beam). CAD software are converted into mill
laboratories without a scanner the pos ing strips for the CAM-processing and
sibility of sending the master cast to the b) Mechanical scanner finally loaded into the milling device.
centre for scanning, designing and fab In this scanner variant, the master cast is Processing devices are distinguished by
rication. The additional veneering of the read mechanically line-by-line by means means of the number of milling axes:
frameworks for prosthetic restorations is of a ruby ball and the three-dimensional • 3-axis devices
carried out in the dental laboratory. structure measured. The Procera Scan • 4-axis devices
Recently, dentists have been offered ner from Nobel Biocare (Göteborg) is • 5-axis devices.
the possibility of sending the impres the only example for mechanical scan
sion directly to the production centre ners in dentistry. This type of scanner is a) 3-axis milling devices
(biodentis). This application is presently distinguished by a high scanning accu This type of milling device has degrees
limited to ceramic inlays only. racy, whereby the diameter of the ruby of movement in the three spatial direc
An additional simplification in CAD/ ball is set to the smallest grinder in the tions. Thus, the mill path points are
CAM production consists of intraoral milling system, with the result that all uniquely defined by the X -, Y -, and Z
data collection (optical impression). This data collected by the system can also – values (Fig. 3). The calculation invest
means a digitalisation of what is now be milled.5,10 The drawbacks of this data ment is therefore minimal. A milling
only an ‘analogue’ step in the production measurement technique are to be seen in of subsections, axis divergences and
process. This could lead to additional the inordinately complicated mechanics, convergences, however, is not possible.
improvement in quality and cost reduc which make the apparatus very expen This demands a virtual blocking in such
tion. New software developments will sive with long processing times com areas. All 3-axis devices used in the
make it possible to directly judge the pared to optical systems. dental area can also turn the component
quality of the preparation intraorally, by 180° in the course of processing the
before data are finally sent to the dental 3.2 Design software inside and the outside. The advantages of
laboratory or production centre. Special software is provided by the these milling devices are short milling
manufacturers for the design of vari times and simplified control by means of
3. CAD/CAM COMPONENTS ous kinds of dental restorations. With the three axes. As a result, such mill
3.1 Scanner such software, crown and fi xed partial ing devices are usually less costly than
dentures (FPD) frameworks can be con those with a higher number of axes.
Under the term ‘scanner’ one under structed on the one hand (Fig. 2); on Examples of 3-axis devices: inLab
stands, in the area of dentistry, data the other hand, some systems also offer (Sirona), Lava (3M ESPE), Cercon brain
collection tools that measure three the opportunity to design full anatomi (DeguDent).
dimensional jaw and tooth structures cal crowns, partial crowns, inlays, inlay
and transform them into digital data retained FPDs, as well as adhesive FPDs b) 4-axis milling devices
sets. Basically there are two different and telescopic primary crowns.11 The In addition to the three spatial axes, the
scanning possibilities: software of CAD/CAM systems presently tension bridge for the component can
• optical scanners available on the market is being continu also be turned infinitely variably (Fig.
• mechanical scanners. ously improved. The latest construction 3). As a result it is possible to adjust
possibilities are continuously available to bridge constructions with a large verti
a) Optical scanners the user by means of updates. The data cal height displacement into the usual
The basis of this type of scanner is the of the construction can be stored in vari mould dimensions and thus save mate
collection of three-dimensional struc ous data formats. The basis therefore is rial and milling time.
tures in a so-called ‘triangulation proce often standard transformation language Example: Zeno (Wieland-Imes).
dure’. Here, the source of light (eg laser) (STL) data.9 Many manufacturers, how
and the receptor unit are in a definite ever, use their own data formats, spe c) 5-axis milling devices
angle in their relationship to one another. cific to that particular manufacturer, With a 5-axis milling device there is
Through this angle the computer can with the result that data of the construc also, in addition to the three spatial
calculate a three-dimensional data set tion programs are not compatible with dimensions and the rotatable tension
from the image on the receptor unit.9 each other. bridge (4th axis), the possibility of rotat
Either white light projections or a laser The systems available on the market ing the milling spindle (5th axis) (Fig.
beam can serve as a source of illumina are differentiated mostly in their con 3). This enables the milling of complex
tion (Fig. 1). The following can be named struction software. While many systems geometries with subsections, as for
as examples of optical scanners on the emphasise an indication spectrum that example, lower jaw FPDs on converg
dental market: is as broad as possible, other manufac ing abutment teeth (end molar tipped
• Lava Scan ST (3M ESPE, white light turers place emphasis on intuitive use towards the medial plane) (Fig. 4), or
projections) and user-friendliness. also crown and FPD substructures that,
4. MILLING VARIANTS
a) Dry processing
Dry processing is applied mainly with Fig. 4 Pinned master cast of converging abutment teeth for a fixed partial denture in the
mandible. At least a 4 milling axis is required for the milling unit to fabricate a substructure
respect to zirconium oxide blanks with for this situation
a low degree of pre-sintering. This offers
several benefits:
• Minimal investment costs for the Table 1 Selection of resin materials for CAD/CAM systems
milling device
CAD/CAM
• No moisture absorption by the die Name Manufacturer
system
Description
ZrO2 mould, as a result of which there
Filler-free acrylic polymer for lost
are no initial drying times for the CAD-Waxx Vita inLab
wax technique
ZrO2 frame prior to sintering. Residue-free cauterisable resin for lost
Cercon base cast DeguDent Cercon
wax technique
Disadvantages: Residue-free cauterisable resin for lost
Everest C-Cast KaVo Everest
wax technique
• The lower degree of pre-sintering
results in higher shrinkage values for Fibre-free acrylic polymer with micro-filler
CAD-Temp Block Vita Cerec 3, inLab for long-term temporary full and partial
the frameworks. crowns and FPDs up to two pontics
Some manufacturers also offer the
Fibre reinforced polymer for long-term
option of milling resin material in a dry Everest C-Temp KaVo Everest temporary crowns and FPD frameworks,
milling process [Zeno 4030 (Wieland- requiring an additional veneering
Imes), Lava Form and Cercon brain]. Artegral
Merz Cerec 3, inLab
Semi individual blanks for anterior long-term
imCrown provisional single crowns
b) Wet milling
In this process the milling diamond or the respective production system. Some b) Resin materials
carbide cutter is protected by a spray of milling devices are specifically designed On the one hand, resin materials can be
cool liquid against overheating of the for the production ZrO2 frames, others used for the milling of lost wax frames for
milled material. This kind of process cover the complete palette of materials casting technology; on the other hand, it is
ing is necessary for all metals and glass from resins to glass ceramics and high possible to use resin materials directly as
ceramic material in order to avoid dam performance ceramics. The following crown and FPD frameworks for long-term
age through heat development. ‘Wet’ materials can normally be processed on provisional or for full anatomical long
processing is recommended, if zirconium dental CAD/CAM devices: term temporary prostheses (Table 1). Pre
oxide ceramic with a higher degree of fabricated semi-individual polymer blanks
pre-sintering is employed for the milling a) Metals (semi-finished) with a dentine enamel
process. A higher degree of pre-sintering At present, titanium, titanium alloys layer are provided by one manufacturer
results in a reduction of shrinkage factor and chrome cobalt alloys are processed (artegral imCrown, Merz Dental). The
and enables less sinter distortion. using dental milling devices. The mill exterior contour conforms to an anatomi
Examples: Everest (KaVo), Zeno 8060 ing of precious metal alloys has been cally complete anterior tooth crown, while
(Wieland-Imes), inLab (Sirona). shown to be of no economic interest, due the internal aspect of the crown is milled
to the high metal attrition and the high out of the internal volume of the blank.
5. MATERIALS FOR material costs.
CAD/CAM PROCESSING Examples: coron (etkon: non-precious c) Silica based ceramics
The list of various materials for process metal alloy), Everest Bio T-Blank (KaVo, Grindable silica based ceramic blocks are
ing by CAD/CAM devices depends on pure titanium). offered by several CAD/CAM systems
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