SlideShare a Scribd company logo
Australian Dental Journal 2011; 56:(1 Suppl): 97–106
doi: 10.1111/j.1834-7819.2010.01300.x
CAD⁄CAM systems available for the fabrication of crown and
bridge restorations
T Miyazaki,* Y Hotta*
*Department of Oral Biomaterials and Technology, School of Dentistry, Showa University, Tokyo, Japan.
ABSTRACT
Dental biomaterials are widely used in all areas of routine dental practice. There are mainly two methods for their
application. Firstly, dental biomaterials are placed into living tissues, such as teeth, to fill the space. Secondly, dental devices
such as crown and bridge restorations and dentures are fabricated using various materials to restore the morphology and
function of the dentition.
Crown and bridge restorations are one of the main treatment methods used by general practitioners to achieve lifelike
restoration of form and function. The recent introduction of osseointegrated implants has expanded the application of
crown and bridge restorations for partially edentulous patients.
Mechanical durability and precision fit are mandatory requirements for crowns and bridges. The development of various
casting alloys and precise casting systems has contributed to the successful use of metal-based restorations. However, patient
requests for more aesthetic and biologically ‘safe’ materials has led to an increased demand for metal-free restorations.
There is also a growing demand to provide all-ceramic restorations more routinely. New materials such as highly sintered
glass, polycrystalline alumina, zirconia based materials and adhesive monomers, will assist dentists to meet this demand. In
addition, new fabrication systems combined with computer-assisted fabrication systems (dental CAD⁄ CAM) and various
networks are now available. Dental technology was centred on lost-wax casting technology but we now face a revolution in
crown and bridge fabrication.
This article reviews the history and recent status of dental CAD⁄ CAM, the application of CAD⁄ CAM fabricated tooth-
coloured glass ceramic crowns, and the application of all-ceramic crowns and bridges using CAD⁄ CAM fabricated zirconia
based frameworks.
Keywords: CAD ⁄ CAM, networked CAD ⁄ CAM, digitizer, glass ceramics, zirconia.
INTRODUCTION
There is a long history of dental biomaterial use in
routine dental practice. There are two main methods
for the application of dental biomaterials. Firstly, raw
dental biomaterials are transplanted into living tissue,
such as tooth and bone, to fill the space instead of living
organs or tissue transplantation. Secondly, dental
devices such as crown and bridge restorations and
dentures are fabricated from dental materials to restore
dental morphology and oral function.
Crown and bridge restorations are commonly used
by general practitioners after operative and endodontic
treatments. In addition, the recent introduction of
osseointegrated implants has expanded the application
of crown and bridge restorations to restore edentulous
spaces. Since mechanical durability and intimate fit to
abutments are mandatory for crown and bridge resto-
rations, metallic restorations and metallic frameworks
covered by glass or resin composites have become
popular. The development of both casting gold alloys
and dental precision casting systems have contributed
to the application of metallic restorations. However,
patient requests for aesthetics and biosafety has
increased the demand for metal-free restorations.
Therefore, both new materials and new processing
technology to meet patient demands are required.
We are currently in a new era of routinely providing
all-ceramic restorations because of newly available
materials such as highly sintered glass, polycrystalline
alumina and zirconia based ceramic materials, and
adhesive monomers.1
In addition, new fabrication
systems combined with a computer-assisted fabrication
system (dental CAD⁄CAM) and networks are becoming
increasingly available.2
Dental technology that used
to be centred on the standardized lost-wax casting
ª 2011 Australian Dental Association 97
Australian Dental JournalThe official journal of the Australian Dental Association
technology has been greatly improved with the intro-
duction of dental CAD ⁄CAM systems.
In this article we discuss: (1) the history and recent
status of dental CAD ⁄CAM systems; (2) the application
of CAD ⁄CAM fabricated tooth-coloured glass ceramic
crowns; and (3) the application of all-ceramic crowns
and bridges using CAD ⁄CAM fabricated zirconia based
frameworks for general practitioners.
The history and recent status of dental CAD ⁄CAM
Figure 1 shows the conventional fabrication process of
crown and bridge restorations. An impression of an
intraoral abutment is taken and a stone model is
prepared as a replica of the abutment. Creating a model
is the beginning of the laboratory work. When a
metallic restoration is fabricated, wax patterns are
manually fabricated, followed by precision casting. If
necessary, final restorations are completed by veneering
porcelain onto the metal framework.
Figure 2 shows the first generation of application of
the dental CAD ⁄CAM system by pioneers in dentistry.
Duret and colleagues pioneered the dental CAD⁄CAM
system in the early 1970s.3
They fabricated restorations
using a series of steps shown in Fig 2. The intraoral
abutment is scanned by an intraoral digitizer to obtain
an optical impression. Digitized data is reconstructed
on the monitor as a 3-D graphic and then the optimal
morphology of the crown can be ‘virtually designed’ on
the monitor. The final crown is fabricated by milling a
block using a numerically controlled machine. Duret
and colleagues later developed the commercial Sopha
system, but this system was not widely used. It is
possible that this system was designed too soon to be
applied in dentistry because of the lack of accuracy of
digitizing, computer power and materials, etc.
However, Mormann and colleagues developed the
CEREC system, and succeeded in producing a ceramic
inlay restoration using computer-assisted technology.4
Digitizing of the inlay cavity is performed directly in the
mouth using a compact intraoral camera, which is
technically less difficult compared with crown abut-
ments. Design and fabrication of the ceramic inlays are
performed using a compact machine set at the chairside
in the dental surgery. This application was innovative,
but the application was limited to inlays and occlusal
morphology and contour was initially not available. The
technical term of CAD ⁄CAM became popular in den-
tistry with the introduction of the CEREC system
throughout the world. The original idea of in-office
restoration fabrication is still currently practised. Several
reports have been published on this system, showing
satisfactory long-term results.5–7
A recent iteration of the
system can fabricate not only original inlays and onlays,
but also crowns and the cores ⁄frameworks of bridges in
both clinical and laboratory settings.
Based on the developments of Duret’s laboratory
system, many researchers worldwide, including our
own laboratory, began in the 1980s to develop a system
to fabricate a crown with an anatomical occlusal
surface. However, we found it difficult to digitize the
intraoral abutment accurately using a direct intraoral
scanner. Therefore, we decided to prepare the conven-
tional stone model to begin the CAD⁄CAM process for
the fabrication of crowns, especially for dental labora-
tory use. The second generation of the application of
dental CAD ⁄CAM systems is illustrated in Fig 3.
Different digitizers such as a contact probe,8
laser
beam with a PSD sensor, and a laser with a CCD
camera were developed. Sophisticated CAD software
and compact dental CAD ⁄CAM machines were also
developed.2
Consequently, both metallic and ceramic
restorations were able to be fabricated by the second
generation CAD ⁄CAM systems.9–16
In the early 1980s, nickel-chromium alloys were used
as a substitute for gold alloys because of the drastic
increase in gold prices at that time. However, metal
allergies became a problem, especially in northern
Europe, and a transition to allergy-free titanium was
Intraoral abutments
Impression
W ki d lWorking model
Wax up
Conventional
laboratory worksCasting (metal works)
Porcelain works
Fi l t tiFinal restorations
Luting to the abutments
Fig 1. Conventional fabrication process of crown-bridge restorations.
Intraoral abutments
Impression Intraoral digitizing
(optical impression)
Working model
CAD
Wax up Virtual model
Virtual waxup
Casting (metal works)
CAM
Porcelain works NC machining
Milling
Final restorations
Luting to the abutments
Fig 2. First generation of the dental CAD ⁄ CAM systems proposed by
Duret and colleagues.
98 ª 2011 Australian Dental Association
T Miyazaki and Y Hotta
proposed. Since the precision casting of titanium was
still difficult at that time, Andersson and colleagues
attempted to fabricate titanium copings by spark
erosion and introduced CAD⁄CAM technology to the
process of composite veneered restorations.17
This was
the first application of CAD⁄CAM in a specialized
procedure as part of a total processing system. This
system later developed as a processing centre net-
worked with satellite digitizers worldwide for the
fabrication of all-ceramic frameworks using industrial
dense sintered polycrystalline alumina known as the
Procera system.18,19
Since these high strength industrial
ceramics were not available to conventional dental
laboratories, the application of networked CAD ⁄CAM
in a processing centre was innovative in the history of
dental technology (Fig 4). Such networked production
systems are currently being introduced by a number of
companies worldwide.20–22
The production of zirconia
frameworks has become very popular in the world
market (Table 1).
The application of CAD⁄CAM is currently limited to
laboratory processing. For example, even if the zirconia
framework is fabricated using a CAD ⁄CAM process in
the machining centre, final restorations are completed
by veneering conventional porcelain using conventional
manual dental technology by dental technicians. Nev-
ertheless, there are advantages to using CAD ⁄CAM:
new materials are safe, aesthetically pleasing and
durable; increased efficiency in laboratory processing;
quick fabrication of the restoration; and quality control
of restorations such as fit, mechanical durability and
predictability. These advantages will ultimately benefit
our patients.
Because of rapid progress in new technologies,
especially optical technology, new intraoral digitizers
are now available.23–26
The application of dental
CAD ⁄CAM systems is expected to shift to the fourth
generation, as illustrated in Fig 5. At least four
commercial intraoral scanners are on the market.
Information is still limited and manipulation and
digitizing accuracy appears unclear. However, the
fourth generation is expected to be available for use
in the clinic in the near future. Besides the tools for
fabrication of restorations, computer technology is now
available for communication tools with patients, exam-
ination and diagnosis, treatment planning and guided
surgery in all fields of dentistry. Digital dentistry is
becoming a keyword for the future of dentistry.
Dental ceramics
Porcelain has been used in dentistry for 100 years.
Aesthetics is its major advantage, but brittleness for
load bearing restorations its weakest point. The
conventional powder build-up firing process was inno-
vative but is still technically sensitive. Therefore,
porcelain fused to metal restorations has been the first
choice to meet both restoration aesthetics and durabil-
ity requirements. There are two methods proposed for
shifting to all-ceramic restorations (Fig 6).27–29
The first
method is to apply reinforced glassy materials to single
crowns. CAD ⁄CAM is efficiently applied to fabricate a
single crown of reinforced glassy materials. The second
method is to fuse porcelain to high strength ceramics
instead of alloys. Dense sintered zirconia polycrystalline
material appears to be promising for the application to
the framework of bridges and even the superstructure
of implants.
The mechanical properties of brittle ceramics can be
evaluated by fracture toughness and bending strength.
Conventional porcelain is a glassy material; fracture
toughness is approximately 1.0 MPa m1 ⁄ 2
and bending
Intraoral abutments
Impression
Working model
Wax up Digitizing model
Digitizing
CAD/CAM
Conventional laboratory works
Final restorations
Luting to the abutments
Casting (metal works)
Fig 3. Second generation of the dental CAD ⁄ CAM systems as a part
of dental laboratory works.
Intraoral abutments
Impression
Working model
Wax up Digitizing model
Digitizing
Casting (metal works)
Machining center
CAD/CAM
Conventional laboratory works
Final restorations
Luting to the abutments
Fig 4. Third generation of the dental CAD ⁄ CAM systems using a
machining centre.
ª 2011 Australian Dental Association 99
CAD ⁄CAM systems
strength is approximately 100 MPa. This material is
not strong enough for load bearing molar restorations.
New dental ceramics have improved the mechanical
properties of conventional porcelain (Fig 7).30–32
Initially, porcelain was reinforced by dispersing
crystals. Aluminous porcelain is widely available. Since
conventional powder build-up and the firing procedure
is technique-sensitive, new, more easily manipulated
ceramic materials have been developed. In response to
this demand, castable and pressable ceramics were
developed and are available for single aesthetic resto-
rations. In addition, prefabricated reinforced glass
ceramic blocks are available for milling using a
CAD ⁄CAM device. The fracture toughness of these
materials range from 1.5 to 3.0 MPa m1 ⁄ 2
. However,
these are still available only for single restorations.
Another type of ceramic includes alumina and other
fine ceramic powders that are porously sintered and
glass is infiltrated among the pores. These materials are
called glass infiltrated ceramics and include the well-
known brand In-Ceram. Their fracture toughness
ranges from 3 to 5 MPa m1 ⁄ 2
. These materials have
been applied to bridge restorations but the prognosis
has not been satisfactory.
Finally, industrial dense polycrystalline ceramics such
as alumina, zirconia and alumina-zirconia composites
are currently available with the application of CAD ⁄
CAM technology using a networked machining centre.
In particular, yttrium partially stabilized tetragonal
zirconia polycrystalline (YTZP) has a very high fracture
toughness from 5 to 10 MPa m1 ⁄ 2
. When a crack
initiates on the YTZP, the concentration of stress at the
top of the crack causes the tetragonal crystal to
transform into a monoclinic crystal with volumetric
expansion. This prevents further crack propagation.33
Table 1. Popular CAD⁄CAM systems available for the fabrication of zirconia frameworks
CAD ⁄ CAM system
(Manufacture)
Dizitizing
Method
Restoration type Material Central
machining
centreIn Veneer Cr Br Resin Titanium Gold Ceramic Alumina Zirconia
Etkon (Etkon AG) PSD ⁄ Laser s s s s s s s s
Everest (KaVo
electrotechnical
work GmbH)
CCD ⁄ White light s s s s s s s Available
Lava (3M ESPE Dental AG) CCD ⁄ White light s s s s s Available
Pro 50, WaxPro (SYNOVAD) CCD ⁄ Color light s s s s s s s
Procera (Nobel Biocare
Germany GmbH)
Touch Probe s s s s s s s s
Hint ELs DentaCAD systeme
(Hint-ELs GmbH)
CCD ⁄ White light s s s s s Available
KATANA system (Noritake
dental supply co., LTD)
CCD ⁄ Laser s s s Available
Cercon smart ceramics
(DeguDent GmbH)
CCD ⁄ Laser s s s Available
CEREC3 ⁄ inLab (Sirona
Dental of system GmbH)
CCD ⁄ Laser s s s s s s Available
DCS Dental (DSC Dental AG) PSD ⁄ Laser s s s s s s s s Available
ZENOÒ
Tec System (Wieland
Dental & Technik GmbH)
CCD ⁄ Laser s s s s s s Available
Intraoral abutment
Intraoral digitizing
(optical impression)
Network to CAD
the machining center Virtual model
Virtual wax up
CAD
CAM
CAM NC machining
Milling
Conventional
laboratory works In office restorations
In labo restorations
Luting to the abutments
Fig 5. Fourth generation of the dental CAD ⁄ CAM systems using an
intraoral digitizer.
Alloys
High strength ceramics
Porcelain fused to
metal frameworks
Porcelain fused to
high strength ceramic
frameworks
Reinforced glass
ceramics (porcelain)
Fig 6. Two directions of all-ceramic restorations replacing conven-
tional porcelain fused to metal frameworks.
100 ª 2011 Australian Dental Association
T Miyazaki and Y Hotta
In addition, alumina-zirconia nano-composites devel-
oped in Japan are very tough with a fracture tough-
ness of 19 MPa m1 ⁄ 2
and a bending strength of
1400 MPa.34
Application of CAD⁄CAM fabricated tooth-coloured
glass ceramic crowns
Currently, prefabricated reinforced glass ceramic
blocks are available for milling using a CAD⁄CAM
device. Table 2 illustrates the mechanical properties of
a typical leucite-reinforced glass ceramic compared
with those of tooth enamel. Mechanical properties of
leucite-reinforced glass ceramics are equal or superior
to those of tooth enamel. However, materials with
these properties were conventionally not available to
replace enamel, even for a single crown.
Glass ceramic crowns can be automatically fabricated
without any sensitive manual labour using a CAD⁄CAM
process (Fig 8).35
In addition, conventional finishing
procedures such as add-ons, staining, and glazing are
available because of the same porcelain base materials as
a glass ceramic block for milling. Figure 9 shows a hemi-
sectioned surface after cementing. There is no porosity
inside because of the prefabricated block used at the
factory. The fit of the crown is excellent with a cement
thickness at the margin of less than 20 lm.
Figure 10 illustrates the result of a fracture test of a
CAD ⁄CAM fabricated crown luted to an abutment
with and without luting cement.36
When a crown was
fractured on the abutment without luting cement, the
fracture force was only 700 N. The fracture load
increased to 2000 N when the crown was luted with
a luting cement but without adhesive. Interestingly, the
fracture load increased to 4000 N when the crown was
luted using luting cement with silane-coupling agents
and adhesive monomers. Therefore, glass ceramic
crowns are reinforced by adhesive treatment.
CAD⁄CAM glass ceramic (porcelain) crowns are
clinically useful because of their easy manipulation
without technically sensitive build-up processes. They
are user-friendly because finishing work such as con-
ventional staining, add-ons and glazing techniques are
available. They are also promising because of their
excellent fit and aesthetics, strong durability with
adhesive resin cements and quick fabrication. However,
they are only available for a single crown.
Application of all-ceramic crowns and bridges using
CAD⁄CAM fabricated zirconia based frameworks
Zirconia is available for fabricating frameworks of
bridge restorations instead of metal bonded restorations
because of its higher fracture toughness. There are two
types of zirconia blocks currently available for distinct
CAD ⁄CAM applications. The first application is the use
of fully sintered dense blocks for direct machining using
a dental CAD⁄CAM system with a grinding machine.
The second application is the use of partially sintered
blocks and green blocks for CAD⁄CAM fabrication
followed by post-sintering to obtain a final product
with sufficient strength. The former application has a
superior fit because no shrinkage is involved in the
process, but is disadvantaged by inferior machinability
associated with heavier wear on the milling tool. In
addition, microcrack formation on the material during
PorcelainPorcelain
16
18 Glass ceramics
Glass infiltrated ceramics
NANOZR
Alumina/Zirconia
Polycrystalline Zirconia
(YTZP)
16
12
14
nano-composites
Lava
Polycrystalline
8
10
I C Zi i
Cercon
Lava
ZENO Zr Discs
Katana Zr
4
6
OCC
Cryscera IPS e.max CAD
In-Ceram Alumina
In-ceram spinell
In-Ceram Zirconia IPS e.max ZirCAD
Procera Almina
MK II
Omega
Fracturetoughness(MPa/m1/2)
16001400120010008006004000 200
0
2 IPS Empress2
Dicor MGC
Bending strength (MPa)
Alumina
Fig 7. Mechanical properties of new dental ceramics.
Table 2. Mechanical properties of leucite-reinforced
glass ceramics and tooth enamel
Glass ceramics Tooth enamel
Bending strength (MPa) 100120 85
Fracture toughness (MPaÆm1 ⁄ 2
) 1.21.5 1.2
Elastic modulus (GPa) 6872 65
Hardness (Hv) 500650 350
ª 2011 Australian Dental Association 101
CAD ⁄CAM systems
the milling procedure might deteriorate the mechanical
durability of the restoration.20,37
The latter application
has the advantage of easy machinability without as
much wear on the tools or chipping of the material.
However, because of extensive shrinkage during the
post-sintering process, the fit of the frameworks must
be compensated for by the dimensional adjustment of
CAD procedures involving the frameworks.37,38
We conducted a fitting test of zirconia frameworks
fabricated by the CAD ⁄CAM process.39
Zirconia
frameworks were fabricated using a standardized metal
abutment. After luting frameworks to the abutment
with luting cement, the thickness of the cement layer
was measured. In this study, the cement space was
designed beforehand on the abutments by the CAD
process. The red dotted line shows the designed cement
thickness. Figure 11 shows that the fit of a single crown
coping was perfect. When the number of pontics
increases, the cement thickness of the margin of the
crown of the pontic side tends to increase, but this is
still within clinically acceptable levels.40–42
On the other hand, according to the results of a
fitting test using the angled type bridge model,36
even if
the fit of the margin of the crowns was excellent, similar
to the straight type models, there was slight distortion
of the framework. Therefore, there is a need to be
aware of the difference between zirconia frameworks
and metal frameworks, especially the implant super-
structure. When there is a discrepancy in metal
frameworks at a trial insertion, they can be adjusted
by separation and soldering, but this cannot be done
with zirconia frameworks.
Digitizing Automatic CAD DecsyTM PRO CADTM Automatic tool
at Decsy ScanTM blocks exchange
Milled crownilled crown Stainig Add-on Grazing
Fig 8. Fabrication of glass ceramic crowns using the CAD ⁄ CAM system of Angel crownsTM
(Media, Japan).
Porosity free Excellent fit:
Cement thickness
was 20 µm at the margin
Fig 9. Sectioned surface of a CAD ⁄ CAM fabricated ceramic crown
after cementing.
4500
3000
3500
4000
2000
2500
500
1000
1500
Fractureload(N)
Control: without luting cements
0
Control L A
Control: without luting cements
L: luting cements without adhesive monomers
A: luting cements with silane-coupling agents
and adhesive monomers
Fig 10. Result of a fracture test of a CAD ⁄ CAM fabricated crown
luted to an abutment.
102 ª 2011 Australian Dental Association
T Miyazaki and Y Hotta
The final restoration is completed by veneering
conventional porcelain on the zirconia frameworks by
conventional dental technological manual work. Even
though zirconia is tougher than conventional dental
ceramics, veneering porcelain is as brittle as conven-
tional porcelain. Debonding and chipping of veneering
porcelain sometimes occurs. Therefore, the properties
of porcelain and processing of veneering materials are
still very important for the prognosis of the final
zirconia restorations. Each manufacturer recommends
surface treatment of zirconia frameworks prior to
porcelain fusing, such as sandblasting and heat treat-
ments. However, the effect of surface treatments on the
bonding strength of porcelain to zirconia is still
controversial.43
Table 3 shows the list of commercial
Originally designed cement spaceOriginally designed cement space
Fig 11. Result of a fitting test of zirconia frameworks fabricated by the CAD ⁄ CAM system of KATANATM
(Noritake, Japan).
Table 3. Commercial veneering porcelain products available for zirconia frameworks
Thermal expansion
coefficiency
(10)6
⁄ °C) (25–500°C)
Firing
temp. (°C)
Compatible
Zirconia
Cerabien ZR (NORITAKE) 9.1 930–940 KATANA, Procera Zirconia
Vintage ZR (SHOFU) 9.3–9.4 900–940 NANOZR
Initial Zr (GC Europe) 9.4 810 All products
CerconÒ
Ceram S (Dentsply DeguDent) 9.5 810–850 Cercon
CeramcoÒ
PFZ (Dentsply Ceramco) – 890–930 Cercon
LavaTM
Ceram (3M ESPE) 10.0 810 Lava Zirconia
Vita VMÒ
9 (Vita) 8.8–9.2 900–940 In-Ceram YZ Cubes
NobelRondoTM
Zirconia (Nobel Biocare) 9.3 890–980 Procera Zirconia
IPS e. maxÒ
Ceram (Ivoclar vivadent) 9.5 (100–400°C) 800 IPS e. max ZirCAD
IPS e. maxÒ
ZirLiner (Ivoclar vivadent) 9.8 (100–400°C) 960 IPS e. max ZirCAD
ZiroxÒ
(WIELAND) 10.0 900 ZENOTM
Zr
Creation ZI (Creation Willi Geller
International AG)
9.5 810 YTZP
25
30
15
20
5
10
0
5
CerabienZR
(Noritake)
e-max
(IPSe.max®Ceram,
Zirox
(ZIROX®,
Bondingstrength(MPa)
Ivoclar vivadent) WIELAND)
Fig 12. Result of a bonding test of three porcelain products conven-
tionally fused to zirconia plates (IPS e-max ZirCAD, Ivoclar
Vivadent) under the ISO 9693.
ª 2011 Australian Dental Association 103
CAD ⁄CAM systems
veneering porcelain products for zirconia frameworks.
There are differences in the thermal coefficients of
expansion and firing temperatures among the products,
indicating a different composition of powder.
We tested the bonding strength of porcelain fused to
zirconia frameworks (Fig 12).36
Three commercial
porcelain powders were fused to the zirconia plate for
a bending test (in accordance with ISO 9693) for the
porcelain fused to the metal crowns. We determined the
differences of the products based on the bending
strength. Compared with the recommended strength
of porcelain fused to metal system (25 MPa), the
bonding strength of porcelain fused to zirconia frame-
works appeared to be inferior to that of metal ceramics.
Improvement needs to be made to the compatibility of
the thermal expansion coefficient based on the powder
composition.
On the other hand, adhesive treatment of zirconia
using alumina sandblasting and adhesive monomers is
available and appears to be positive.44,45
Bending
specimens of the same ISO standard were prepared
using a milled porcelain plate adhered to the zirconia
plate with three adhesive monomers and resin cements.
As shown in Fig 13, even the bonding strength is
decreased after thermal cycling, and the bonding
strength of adhered specimens is higher than that of
fused specimens.36
Therefore, a new hybrid structure of CAD⁄CAM
porcelain crowns adhered to the CAD ⁄CAM zirconia
framework (PAZ) has been proposed (Fig 14).36
In this
system, zirconia frameworks are digitized and porcelain
crowns are also fabricated by the CAD ⁄CAM process.
Milled porcelain crowns are adhered to zirconia
frameworks using adhesive resin cements and the final
restoration is completed. Manipulation of the structure
is reproducible and reliable without conventional
manual porcelain work. Adhesive treatments reinforce
the durability of porcelain. Even if porcelain chips,
repairing it is easy using the preserved data. (Figure 15
shows a clinical case of the PAZ bridge.)
CONCLUSIONS
This article reviews the current state and future
perspectives of the application of dental CAD⁄CAM
systems, particularly in the field of fabrication of crown
and bridge restorations. CAD ⁄CAM is a panacea for
fabricating glass ceramic (porcelain) single crowns.
However, adhesive treatments are mandatory for
durability. Porcelain fused to CAD ⁄CAM zirconia
frameworks appears to be a favourable option in the
35
40
45
25
30
35
*
*
*
10
15
20
0
5
10
Bondingstrength(MPa)
AZ primer
 resicem
(Shofu)
Epricode
 panavia®F2.0
(Kuraray)
Metal/zirconia primer
 multilink
(Ivoclar vivadent)
Fig 13. Result of a bonding test of the milled porcelain plate (IPS
Empress CAD, Ivoclar Vivadent) adhered to the zirconia plate (IPS e-
max ZirCAD, Ivoclar Vivadent) using three adhesive monomers under
the ISO 9693. * indicates the bonding strength after thermal cycles of
10 000 times at 560 °C.
[PAZ]
[PFZ]
Zirconia frameworks
(CAD/CAM, firing)
Digitizing
Porcelain crowns Porcelain fusing
Adhesion to frameworks
Final crowns
Final crowns
Manipulation is reproducible and reliable,
without conventional manual porcelain works.
CAD/CAM is applied partially.
Porcelain work is still technically
sensitive.Adhesive treatments reinforce the durability
of porcelain.
Repair of porcelain is easy.
Repair of porcelain is difficult.
(CAD/CAM) (Conventional firing)
Fig 14. Schematic illustration of a novel fabrication system of a hybrid structure of CAD ⁄ CAM porcelain crowns adhered to the CAD ⁄ CAM
zirconia frameworks (PAZ) and conventional porcelain fused to the CAD ⁄ CAM zirconia frameworks (PFZ).
104 ª 2011 Australian Dental Association
T Miyazaki and Y Hotta
clinic. However, the challenge still remains to fix
standardized surface treatments of frameworks and
develop more compatible porcelain powders. Pressing
porcelain is a potential candidate for conventional
porcelain work but is still technically sensitive. There
should be a shift to digital dentistry in the future. A
hybrid structure of CAD ⁄CAM porcelain crowns
adhered to CAD ⁄CAM zirconia frameworks is a
promising option because manual porcelain work is
not technically sensitive and porcelain is easy to repair.
The application of CAD⁄CAM technology in den-
tistry provides an innovative, state-of-the-art dental
service to patients and is also beneficial for general
practitioners. Conventional laboratory technology and
dental technician skills remain important because
dental restoration and prostheses are not just industrial
products but medical devices that need to function in
the body. Therefore, we must combine new technology
and conventional technology to meet patient demand.
REFERENCES
1. Anusavice KJ. Dental ceramics. In: Anusavice KJ, ed. Phillips’
Science of Dental Materials. 12th edn. Saunders, 2003:655–
719.
2. Miyazaki T, Hotta Y, Kunii J, Tamaki Y. A review of dental
CAD ⁄ CAM: current status and future perspectives from 20 years
of experience. Dent Mater 2009;28:44–56.
3. Duret F, Preston JD. CAD ⁄ CAM imaging in dentistry. Curr Opin
Dent 1991;1:150–154.
4. Mormann WH, Brandestini M, Lutz F, Barbakow F. Chairside
computer-aided direct ceramic inlays. Quintessence Int
1989;20:329–339.
5. Reiss B, Walther W. Clinical long-term results and 10-year
Kaplan-Meier analysis of Cerec restorations. Int J Comput Dent
2000;3:9–23.
6. Nakamura T, Dei N, Kojima T, Wakabayashi K. Marginal and
internal fit of Cerec 3 CAD ⁄ CAM all-ceramic crowns. Int J
Prosthodont 2003;16:244–248.
7. Effrosyni A, Tsitrou E, Northeast S, van Noort R. Evaluation of
the marginal fit of three margin designs of resin composite crowns
using CAD ⁄ CAM. J Dent 2007;35:68–73.
8. Persson M, Andersson M, Bergman B. The accuracy of a high-
precision digitizer for CAD ⁄ CAM crowns. J Prosthet Dent
1995;74:223–229.
9. Hotta Y. Fabrication of titanium copings using the CAD ⁄ CAM
process. Japan J Dent Mat Dev 1992;11:169–178.
10. Hotta Y, Miyazaki T, Lee G, Kobayashi Y. Accuracy of
the ceramic crown fabricated by the newly developed
CAD ⁄ CAM system. J Showa Univ Dent Soc 1996;16:230–
234.
11. Hotta Y, Miyazaki T, Warita K, Kawawa T. Automatic
fabrication of ceramic crowns using a newly developed
dental CAD ⁄ CAM system. J Esthet Dent 1998;10:
69–75.
12. Kobayashi Y. The effect of digitizing conditions on the accuracy
of ceramic crowns fabricated by using the second version of the
experimentally developed dental CAD ⁄ CAM machine. J Showa
Univ Dent Soc 2000;20:165–172.
13. Miyazaki T, Hotta Y, Kobayashi Y, Lee G, Furuya A, Kawawa T.
Characteristics of dental CAD ⁄ CAM system ‘Decsy’ and clinical
application. QDT 2000;25:34–41.
14. Hotta Y, Ozawa A, Kobayashi Y, Miyazaki T. Development of a
dental CAD ⁄ CAM system fabricating dental prostheses. J Showa
Univ Dent Soc 2001;21:86–91.
15. Hotta Y, Miyazaki T, Fujiwara T, et al. Durability of tungsten
carbide burs for the fabrication of titanium crowns using dental
CAD ⁄ CAM. Dent Mater 2004;23:190–196.
16. Tomita S, Shinya A, Gomi H, et al. Machining accuracy of
CAD ⁄ CAM ceramic crowns fabricated with repeated machin-
ing using the same diamond bur. Dent Mater 2005;24:123–
133.
17. Andersson M, Carlsson L, Persson M, Bergmann B. Accuracy of
machine milling and spark erosion with a CAD ⁄ CAM system. J
Prosthet Dent 1996;76:187–193.
18. Andersson M, Oden A. A new all-ceramic crown: a dense-sin-
tered, high purity alumina coping with porcelain. Acta Odontol
Scand 1993;51:59–64.
19. Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five-
year clinical evaluation of Procera All Ceram crowns. J Prosthet
Dent 1998;80:450–456.
20. Suttor D, Bunke K, Hoescheler S, Hauptmann H, Hertlein G.
LAVA–the system for all-ceramic ZrO2 crowns and bridge
frameworks. Int J Comput Dent 2001;4:195–206.
21. Sorensen JA. The Lava system for CAD ⁄ CAM production of
high-strength precision fixed prosthodontics. QDT 2003;26:57–
67.
Fig 15. Clinical application of PAZ restorations to the maxillary
implant prostheses (Courtesy of Dr Higuchi, Showa University Dental
Hospital).
ª 2011 Australian Dental Association 105
CAD ⁄CAM systems
22. Piwowarczyk A, Ottl P, Lauer H-C, Kuretzky T. A clinical
report and overview of scientific studies and clinical procedures
conducted on the 3M ESPE LavaTM
. J Prosthodont 2005;14:
39–45.
23. Cadent. URL: http://www.cadentinc.com. Accessed May 2010.
24. 3M ESPE. URL: http://solutions.3m.com/wps/portal/3M/en_US/
LavaCOS/3MESPE-LavaCOS/. Accessed May 2010.
25. Sirona. URL: http://www.cereconline.com/cerec/. Accessed May
2010.
26. D4D Technologies LLC. URL: http://www.e4d.com/. Accessed
May 2010.
27. Raigrodski AJ, Chiche GL. The safety and efficiency of anterior
ceramic fixed partial dentures: a review of the literature. J Pros-
thet Dent 2001;86:520–525.
28. Raigrodski AJ. Contemporary materials and technologies for all-
ceramic fixed partial dentures: a review of the literature. J Pros-
thet Dent 2004;92:557–562.
29. Heather JC, Wook-jin S, Igor JP. Current ceramic materials and
systems with clinical recommendations: a systematic review. J
Prosthet Dent 2007;98:389–404.
30. Ban S. Dental materials science of all ceramics. J Dent Technol-
ogy (Extra issue: All ceramics restoration) 2005;32–43.
31. Ban S, Sato H, Yamashita D. Microstructure and mechanical
properties of recent dental porcelains. Arch Bioceramics Res
2006;6:58–61.
32. Ban S. Material science of zirconia and future prospects. Practice
In Prosthodontics 2008;41:385–397.
33. Nawa M, Nakamoto S, Seino T, Niihara K. Tough and strong
Ce-TZP ⁄ alumina nanocomposites doped with titania. Ceramics
Int 1998;24:497–506.
34. Miyazaki T, Hotta Y, Kunii J, Fujiwara T. Current status and
future prospects of a dental CAD ⁄ CAM system used in crown-
bridge restorations. Dentistry in Japan 2007;43:189–194.
35. Tamaki Y, Hotta Y, Kunii J, Kuriyama S, Higuchi D, Miyazaki
T. CAD ⁄ CAM all ceramic dental restorations on implants: a
panacea or a challenge? Dental Medicine Research 2010;30:42–
49.
36. Besimo CE, Spielmann HP, Rohner HP. Computer-assisted gen-
eration of all-ceramic crowns and fixed partial dentures. Int J
Comput Dent 2001;4:43–62.
37. Luthardt RG, Rieger W, Musil R. Grinding of ziroconia-TZP in
dentistry–CAD ⁄ CAM-technology for the manufacturing of fixed
dentures. In: Sedel L, Rey C, eds. 10th International Symposium
on Ceramics in Medicine Bioceramics 10, Paris, France.
Amsterdam: Elsevier, 1997:437–440.
38. Kunii J, Hotta Y, Tamaki Y, et al. Effect of sintering on the
marginal and internal fit of CAD ⁄ CAM fabricated zirconia
frameworks. Dent Mater 2007;26:820–826.
39. Tinschert J, Natt G, Mautsch W, Spiekermann H, Anusavice KJ.
Marginal fit of alumina and zirconia-based produced by a
CAD ⁄ CAM system. Oper Dent 2001;26:367–374.
40. Reich S, Wichmann M, Nkenke E, Proeschel P. Clinical fit of all-
ceramic three-unit fixed partial dentures, generated with three
different CAD ⁄ CAM systems. Eur J Oral Sci 2005;113:174–179.
41. Gonzalo E, Sua´rez MJ, Serrano B, Lozano JF. Marginal fit of
zirconia posterior fixed partial dentures. Int J Prosthodont
2008;21:398–399.
42. Fischer J, Grohman P, Stawarczyk B. Effect of zirconia surface
treatments on the shear strength of zirconia ⁄ veneering ceramic
composites. Dent Mater J 2008;27:448–454.
43. Tanaka R, Fujishima A, Shibata Y, Manabe A, Miyazaki T.
Cooperation of phosphate monomer and silica modification on
zirconia. J Dent Res 2008;87:666–670.
44. Takeuchi K, Fujishima A, Manabe A, et al. Combination treat-
ment of tribochemical treatment and phosphoric acid ester
monomer of zirconia ceramics enhances the bonding durability of
resinbased luting cements. Dent Mater J 2010;29:316–323.
Address for correspondence:
Dr Takashi Miyazaki
Department of Oral Biomaterials and Technology
School of Dentistry
Showa University
1-5-8 Hatanodai
Shinagawa-ku
Tokyo 142-8555
Japan
Email: miyazaki@dent.showa-u.ac.jp
106 ª 2011 Australian Dental Association
T Miyazaki and Y Hotta

More Related Content

What's hot

CAD/CAM CEREC course
CAD/CAM CEREC courseCAD/CAM CEREC course
CAD/CAM CEREC course
Christis Isseyegh
 
Cadcam in Dentistry
Cadcam in DentistryCadcam in Dentistry
Cadcam in Dentistry
Popopo12345
 
CAD/CAM in prosthetic dentistry
CAD/CAM in prosthetic dentistryCAD/CAM in prosthetic dentistry
CAD/CAM in prosthetic dentistry
Tanta University, Faculty of Dentistry
 
عرض تقديمي1
عرض تقديمي1عرض تقديمي1
عرض تقديمي1
Duha Alobaidi
 
Cad cam and cad-cim in restorative dentistry
Cad cam and cad-cim in restorative dentistryCad cam and cad-cim in restorative dentistry
Cad cam and cad-cim in restorative dentistry
drnids_modern
 
Cad cam technology seminar presentation using microsoft word.
Cad cam technology seminar presentation using microsoft word. Cad cam technology seminar presentation using microsoft word.
Cad cam technology seminar presentation using microsoft word.
Mohd Faiz
 
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Indian dental academy
 
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Indian dental academy
 
CAD/CAM in dentistry
CAD/CAM in dentistryCAD/CAM in dentistry
CAD/CAM in dentistry
Mick Muianga
 
Evaluation of removable partial denture frameworks fabricated
Evaluation of removable partial denture frameworks fabricatedEvaluation of removable partial denture frameworks fabricated
Evaluation of removable partial denture frameworks fabricated
NAMITHA ANAND
 
Cad cam /orthodontic courses by Indian dental academy
Cad cam /orthodontic courses by Indian dental academy Cad cam /orthodontic courses by Indian dental academy
Cad cam /orthodontic courses by Indian dental academy
Indian dental academy
 
Digital impressions
Digital impressions Digital impressions
Digital impressions
Navreet Bajwa
 
Journal club PROSTHODONTICS
Journal club PROSTHODONTICSJournal club PROSTHODONTICS
Journal club PROSTHODONTICS
NAMITHA ANAND
 
Cad cam in prosthodontics
Cad cam in prosthodonticsCad cam in prosthodontics
Cad cam in prosthodontics
Priyam Javed
 
Dental Ceramics PART 3
Dental Ceramics PART 3Dental Ceramics PART 3
Dental Ceramics PART 3
NAMITHA ANAND
 
Recent Advances in Implant Surface Science
Recent Advances in Implant Surface ScienceRecent Advances in Implant Surface Science
Recent Advances in Implant Surface Science
www.ffofr.org - Foundation for Oral Facial Rehabilitiation
 
3D impressions in prosthodontics
3D impressions in prosthodontics3D impressions in prosthodontics
3D impressions in prosthodontics
Siripurapu Sravani
 
Digital dentistry (2)
Digital dentistry (2)Digital dentistry (2)
Digital dentistry (2)
Abbasi Begum
 
Recent advances in diagnosis and treatment planning1
Recent advances in diagnosis and treatment  planning1Recent advances in diagnosis and treatment  planning1
Recent advances in diagnosis and treatment planning1
Indian dental academy
 

What's hot (19)

CAD/CAM CEREC course
CAD/CAM CEREC courseCAD/CAM CEREC course
CAD/CAM CEREC course
 
Cadcam in Dentistry
Cadcam in DentistryCadcam in Dentistry
Cadcam in Dentistry
 
CAD/CAM in prosthetic dentistry
CAD/CAM in prosthetic dentistryCAD/CAM in prosthetic dentistry
CAD/CAM in prosthetic dentistry
 
عرض تقديمي1
عرض تقديمي1عرض تقديمي1
عرض تقديمي1
 
Cad cam and cad-cim in restorative dentistry
Cad cam and cad-cim in restorative dentistryCad cam and cad-cim in restorative dentistry
Cad cam and cad-cim in restorative dentistry
 
Cad cam technology seminar presentation using microsoft word.
Cad cam technology seminar presentation using microsoft word. Cad cam technology seminar presentation using microsoft word.
Cad cam technology seminar presentation using microsoft word.
 
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy
 
Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy Advance ortho /certified fixed orthodontic courses by Indian dental academy
Advance ortho /certified fixed orthodontic courses by Indian dental academy
 
CAD/CAM in dentistry
CAD/CAM in dentistryCAD/CAM in dentistry
CAD/CAM in dentistry
 
Evaluation of removable partial denture frameworks fabricated
Evaluation of removable partial denture frameworks fabricatedEvaluation of removable partial denture frameworks fabricated
Evaluation of removable partial denture frameworks fabricated
 
Cad cam /orthodontic courses by Indian dental academy
Cad cam /orthodontic courses by Indian dental academy Cad cam /orthodontic courses by Indian dental academy
Cad cam /orthodontic courses by Indian dental academy
 
Digital impressions
Digital impressions Digital impressions
Digital impressions
 
Journal club PROSTHODONTICS
Journal club PROSTHODONTICSJournal club PROSTHODONTICS
Journal club PROSTHODONTICS
 
Cad cam in prosthodontics
Cad cam in prosthodonticsCad cam in prosthodontics
Cad cam in prosthodontics
 
Dental Ceramics PART 3
Dental Ceramics PART 3Dental Ceramics PART 3
Dental Ceramics PART 3
 
Recent Advances in Implant Surface Science
Recent Advances in Implant Surface ScienceRecent Advances in Implant Surface Science
Recent Advances in Implant Surface Science
 
3D impressions in prosthodontics
3D impressions in prosthodontics3D impressions in prosthodontics
3D impressions in prosthodontics
 
Digital dentistry (2)
Digital dentistry (2)Digital dentistry (2)
Digital dentistry (2)
 
Recent advances in diagnosis and treatment planning1
Recent advances in diagnosis and treatment  planning1Recent advances in diagnosis and treatment  planning1
Recent advances in diagnosis and treatment planning1
 

Similar to J.1834 7819.2010.01300.x.pdf;jsessionid=a9841 ec321b08731bb84527bae4b186c.f02t02

Miyazaki a review of dental cad-cam current status and future perspectives ...
Miyazaki   a review of dental cad-cam current status and future perspectives ...Miyazaki   a review of dental cad-cam current status and future perspectives ...
Miyazaki a review of dental cad-cam current status and future perspectives ...
Catalina Arredondo Nercasseau
 
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp011 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
hieusach-kimnhung
 
Tooth preparation for full veneer crowns /certified fixed orthodontic course...
Tooth preparation for full veneer crowns  /certified fixed orthodontic course...Tooth preparation for full veneer crowns  /certified fixed orthodontic course...
Tooth preparation for full veneer crowns /certified fixed orthodontic course...
Indian dental academy
 
hybrid abutments.pptx
hybrid abutments.pptxhybrid abutments.pptx
hybrid abutments.pptx
Nishu Priya
 
Advanced tools in restoring compound cavities
Advanced tools in restoring compound cavitiesAdvanced tools in restoring compound cavities
Advanced tools in restoring compound cavities
Rajaasamarji
 
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
iosrjce
 
Removable Partial Denture Equation
Removable Partial Denture  EquationRemovable Partial Denture  Equation
Removable Partial Denture Equation
Naveed AnJum
 
Implants in dentistry/prosthodontic courses
Implants in dentistry/prosthodontic coursesImplants in dentistry/prosthodontic courses
Implants in dentistry/prosthodontic courses
Indian dental academy
 
Article on Zirconia 2
Article on Zirconia 2Article on Zirconia 2
Article on Zirconia 2
DrHimanshu Joshi
 
17 implant abutment 1
17  implant abutment 117  implant abutment 1
17 implant abutment 1
Rehman Atiq
 
3 implant systems
3 implant systems3 implant systems
3 implant systems
Lama K Banna
 
ACRYLIC PARTIAL DENTURES................
ACRYLIC PARTIAL DENTURES................ACRYLIC PARTIAL DENTURES................
ACRYLIC PARTIAL DENTURES................
paulveenaADC
 
PowerPoint Slides from NanoMarkets Report on Medical Ceramics
PowerPoint Slides from NanoMarkets Report on Medical CeramicsPowerPoint Slides from NanoMarkets Report on Medical Ceramics
PowerPoint Slides from NanoMarkets Report on Medical Ceramics
n-tech Research
 
customized brackets.pptx
customized brackets.pptxcustomized brackets.pptx
customized brackets.pptx
Kalaiselvi674620
 
Cad lt canine article
Cad lt canine articleCad lt canine article
Cad lt canine article
phident
 
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
Indian dental academy
 
Publishid Simplyfinig direct post pattern technique using fiber post
Publishid Simplyfinig direct post pattern technique using fiber postPublishid Simplyfinig direct post pattern technique using fiber post
Publishid Simplyfinig direct post pattern technique using fiber post
Reda Dimashkieh
 
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
Indian dental academy
 
Digital Removable Complete Denture—an Overview.pptx
Digital Removable Complete Denture—an Overview.pptxDigital Removable Complete Denture—an Overview.pptx
Digital Removable Complete Denture—an Overview.pptx
Nishu Priya
 
Recent advances in ceramics for dentistry/ dental implant courses
Recent advances in ceramics for dentistry/ dental implant coursesRecent advances in ceramics for dentistry/ dental implant courses
Recent advances in ceramics for dentistry/ dental implant courses
Indian dental academy
 

Similar to J.1834 7819.2010.01300.x.pdf;jsessionid=a9841 ec321b08731bb84527bae4b186c.f02t02 (20)

Miyazaki a review of dental cad-cam current status and future perspectives ...
Miyazaki   a review of dental cad-cam current status and future perspectives ...Miyazaki   a review of dental cad-cam current status and future perspectives ...
Miyazaki a review of dental cad-cam current status and future perspectives ...
 
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp011 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
1 7 pdf-toothpreparationforfullveneercrownssuchi-140305001933-phpapp01
 
Tooth preparation for full veneer crowns /certified fixed orthodontic course...
Tooth preparation for full veneer crowns  /certified fixed orthodontic course...Tooth preparation for full veneer crowns  /certified fixed orthodontic course...
Tooth preparation for full veneer crowns /certified fixed orthodontic course...
 
hybrid abutments.pptx
hybrid abutments.pptxhybrid abutments.pptx
hybrid abutments.pptx
 
Advanced tools in restoring compound cavities
Advanced tools in restoring compound cavitiesAdvanced tools in restoring compound cavities
Advanced tools in restoring compound cavities
 
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
Resin bonded bridge: A forgotten first frontier for an aesthetically critical...
 
Removable Partial Denture Equation
Removable Partial Denture  EquationRemovable Partial Denture  Equation
Removable Partial Denture Equation
 
Implants in dentistry/prosthodontic courses
Implants in dentistry/prosthodontic coursesImplants in dentistry/prosthodontic courses
Implants in dentistry/prosthodontic courses
 
Article on Zirconia 2
Article on Zirconia 2Article on Zirconia 2
Article on Zirconia 2
 
17 implant abutment 1
17  implant abutment 117  implant abutment 1
17 implant abutment 1
 
3 implant systems
3 implant systems3 implant systems
3 implant systems
 
ACRYLIC PARTIAL DENTURES................
ACRYLIC PARTIAL DENTURES................ACRYLIC PARTIAL DENTURES................
ACRYLIC PARTIAL DENTURES................
 
PowerPoint Slides from NanoMarkets Report on Medical Ceramics
PowerPoint Slides from NanoMarkets Report on Medical CeramicsPowerPoint Slides from NanoMarkets Report on Medical Ceramics
PowerPoint Slides from NanoMarkets Report on Medical Ceramics
 
customized brackets.pptx
customized brackets.pptxcustomized brackets.pptx
customized brackets.pptx
 
Cad lt canine article
Cad lt canine articleCad lt canine article
Cad lt canine article
 
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
Acid etches bridges and its scope/certified fixed orthodontic courses by Indi...
 
Publishid Simplyfinig direct post pattern technique using fiber post
Publishid Simplyfinig direct post pattern technique using fiber postPublishid Simplyfinig direct post pattern technique using fiber post
Publishid Simplyfinig direct post pattern technique using fiber post
 
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
Micro implant anchorage in orthodontics /certified fixed orthodontic courses ...
 
Digital Removable Complete Denture—an Overview.pptx
Digital Removable Complete Denture—an Overview.pptxDigital Removable Complete Denture—an Overview.pptx
Digital Removable Complete Denture—an Overview.pptx
 
Recent advances in ceramics for dentistry/ dental implant courses
Recent advances in ceramics for dentistry/ dental implant coursesRecent advances in ceramics for dentistry/ dental implant courses
Recent advances in ceramics for dentistry/ dental implant courses
 

Recently uploaded

Epcon is One of the World's leading Manufacturing Companies.
Epcon is One of the World's leading Manufacturing Companies.Epcon is One of the World's leading Manufacturing Companies.
Epcon is One of the World's leading Manufacturing Companies.
EpconLP
 
Global Peatlands Map and Hotspot Explanation Atlas
Global Peatlands Map and Hotspot Explanation AtlasGlobal Peatlands Map and Hotspot Explanation Atlas
Global Peatlands Map and Hotspot Explanation Atlas
Global Landscapes Forum (GLF)
 
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
Joshua Orris
 
Improving the Management of Peatlands and the Capacities of Stakeholders in I...
Improving the Management of Peatlands and the Capacities of Stakeholders in I...Improving the Management of Peatlands and the Capacities of Stakeholders in I...
Improving the Management of Peatlands and the Capacities of Stakeholders in I...
Global Landscapes Forum (GLF)
 
world-environment-day-2024-240601103559-14f4c0b4.pptx
world-environment-day-2024-240601103559-14f4c0b4.pptxworld-environment-day-2024-240601103559-14f4c0b4.pptx
world-environment-day-2024-240601103559-14f4c0b4.pptx
mfasna35
 
Peatlands of Latin America and the Caribbean
Peatlands of Latin America and the CaribbeanPeatlands of Latin America and the Caribbean
Peatlands of Latin America and the Caribbean
Global Landscapes Forum (GLF)
 
Overview of the Global Peatlands Assessment
Overview of the Global Peatlands AssessmentOverview of the Global Peatlands Assessment
Overview of the Global Peatlands Assessment
Global Landscapes Forum (GLF)
 
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
Joshua Orris
 
Peatland Management in Indonesia, Science to Policy and Knowledge Education
Peatland Management in Indonesia, Science to Policy and Knowledge EducationPeatland Management in Indonesia, Science to Policy and Knowledge Education
Peatland Management in Indonesia, Science to Policy and Knowledge Education
Global Landscapes Forum (GLF)
 
Improving the viability of probiotics by encapsulation methods for developmen...
Improving the viability of probiotics by encapsulation methods for developmen...Improving the viability of probiotics by encapsulation methods for developmen...
Improving the viability of probiotics by encapsulation methods for developmen...
Open Access Research Paper
 
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
pjq9n1lk
 
Enhanced action and stakeholder engagement for sustainable peatland management
Enhanced action and stakeholder engagement for sustainable peatland managementEnhanced action and stakeholder engagement for sustainable peatland management
Enhanced action and stakeholder engagement for sustainable peatland management
Global Landscapes Forum (GLF)
 
Promoting Multilateral Cooperation for Sustainable Peatland management
Promoting Multilateral Cooperation for Sustainable Peatland managementPromoting Multilateral Cooperation for Sustainable Peatland management
Promoting Multilateral Cooperation for Sustainable Peatland management
Global Landscapes Forum (GLF)
 
Environment Conservation Rules 2023 (ECR)-2023.pptx
Environment Conservation Rules 2023 (ECR)-2023.pptxEnvironment Conservation Rules 2023 (ECR)-2023.pptx
Environment Conservation Rules 2023 (ECR)-2023.pptx
neilsencassidy
 
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
p2npnqp
 
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
Open Access Research Paper
 
Wildlife-AnIntroduction.pdf so that you know more about our environment
Wildlife-AnIntroduction.pdf so that you know more about our environmentWildlife-AnIntroduction.pdf so that you know more about our environment
Wildlife-AnIntroduction.pdf so that you know more about our environment
amishajha2407
 
Lessons from operationalizing integrated landscape approaches
Lessons from operationalizing integrated landscape approachesLessons from operationalizing integrated landscape approaches
Lessons from operationalizing integrated landscape approaches
CIFOR-ICRAF
 
Microbial characterisation and identification, and potability of River Kuywa ...
Microbial characterisation and identification, and potability of River Kuywa ...Microbial characterisation and identification, and potability of River Kuywa ...
Microbial characterisation and identification, and potability of River Kuywa ...
Open Access Research Paper
 
RoHS stands for Restriction of Hazardous Substances, which is also known as t...
RoHS stands for Restriction of Hazardous Substances, which is also known as t...RoHS stands for Restriction of Hazardous Substances, which is also known as t...
RoHS stands for Restriction of Hazardous Substances, which is also known as t...
vijaykumar292010
 

Recently uploaded (20)

Epcon is One of the World's leading Manufacturing Companies.
Epcon is One of the World's leading Manufacturing Companies.Epcon is One of the World's leading Manufacturing Companies.
Epcon is One of the World's leading Manufacturing Companies.
 
Global Peatlands Map and Hotspot Explanation Atlas
Global Peatlands Map and Hotspot Explanation AtlasGlobal Peatlands Map and Hotspot Explanation Atlas
Global Peatlands Map and Hotspot Explanation Atlas
 
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
Optimizing Post Remediation Groundwater Performance with Enhanced Microbiolog...
 
Improving the Management of Peatlands and the Capacities of Stakeholders in I...
Improving the Management of Peatlands and the Capacities of Stakeholders in I...Improving the Management of Peatlands and the Capacities of Stakeholders in I...
Improving the Management of Peatlands and the Capacities of Stakeholders in I...
 
world-environment-day-2024-240601103559-14f4c0b4.pptx
world-environment-day-2024-240601103559-14f4c0b4.pptxworld-environment-day-2024-240601103559-14f4c0b4.pptx
world-environment-day-2024-240601103559-14f4c0b4.pptx
 
Peatlands of Latin America and the Caribbean
Peatlands of Latin America and the CaribbeanPeatlands of Latin America and the Caribbean
Peatlands of Latin America and the Caribbean
 
Overview of the Global Peatlands Assessment
Overview of the Global Peatlands AssessmentOverview of the Global Peatlands Assessment
Overview of the Global Peatlands Assessment
 
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
Evolving Lifecycles with High Resolution Site Characterization (HRSC) and 3-D...
 
Peatland Management in Indonesia, Science to Policy and Knowledge Education
Peatland Management in Indonesia, Science to Policy and Knowledge EducationPeatland Management in Indonesia, Science to Policy and Knowledge Education
Peatland Management in Indonesia, Science to Policy and Knowledge Education
 
Improving the viability of probiotics by encapsulation methods for developmen...
Improving the viability of probiotics by encapsulation methods for developmen...Improving the viability of probiotics by encapsulation methods for developmen...
Improving the viability of probiotics by encapsulation methods for developmen...
 
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
在线办理(lboro毕业证书)拉夫堡大学毕业证学历证书一模一样
 
Enhanced action and stakeholder engagement for sustainable peatland management
Enhanced action and stakeholder engagement for sustainable peatland managementEnhanced action and stakeholder engagement for sustainable peatland management
Enhanced action and stakeholder engagement for sustainable peatland management
 
Promoting Multilateral Cooperation for Sustainable Peatland management
Promoting Multilateral Cooperation for Sustainable Peatland managementPromoting Multilateral Cooperation for Sustainable Peatland management
Promoting Multilateral Cooperation for Sustainable Peatland management
 
Environment Conservation Rules 2023 (ECR)-2023.pptx
Environment Conservation Rules 2023 (ECR)-2023.pptxEnvironment Conservation Rules 2023 (ECR)-2023.pptx
Environment Conservation Rules 2023 (ECR)-2023.pptx
 
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
原版制作(Newcastle毕业证书)纽卡斯尔大学毕业证在读证明一模一样
 
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
Kinetic studies on malachite green dye adsorption from aqueous solutions by A...
 
Wildlife-AnIntroduction.pdf so that you know more about our environment
Wildlife-AnIntroduction.pdf so that you know more about our environmentWildlife-AnIntroduction.pdf so that you know more about our environment
Wildlife-AnIntroduction.pdf so that you know more about our environment
 
Lessons from operationalizing integrated landscape approaches
Lessons from operationalizing integrated landscape approachesLessons from operationalizing integrated landscape approaches
Lessons from operationalizing integrated landscape approaches
 
Microbial characterisation and identification, and potability of River Kuywa ...
Microbial characterisation and identification, and potability of River Kuywa ...Microbial characterisation and identification, and potability of River Kuywa ...
Microbial characterisation and identification, and potability of River Kuywa ...
 
RoHS stands for Restriction of Hazardous Substances, which is also known as t...
RoHS stands for Restriction of Hazardous Substances, which is also known as t...RoHS stands for Restriction of Hazardous Substances, which is also known as t...
RoHS stands for Restriction of Hazardous Substances, which is also known as t...
 

J.1834 7819.2010.01300.x.pdf;jsessionid=a9841 ec321b08731bb84527bae4b186c.f02t02

  • 1. Australian Dental Journal 2011; 56:(1 Suppl): 97–106 doi: 10.1111/j.1834-7819.2010.01300.x CAD⁄CAM systems available for the fabrication of crown and bridge restorations T Miyazaki,* Y Hotta* *Department of Oral Biomaterials and Technology, School of Dentistry, Showa University, Tokyo, Japan. ABSTRACT Dental biomaterials are widely used in all areas of routine dental practice. There are mainly two methods for their application. Firstly, dental biomaterials are placed into living tissues, such as teeth, to fill the space. Secondly, dental devices such as crown and bridge restorations and dentures are fabricated using various materials to restore the morphology and function of the dentition. Crown and bridge restorations are one of the main treatment methods used by general practitioners to achieve lifelike restoration of form and function. The recent introduction of osseointegrated implants has expanded the application of crown and bridge restorations for partially edentulous patients. Mechanical durability and precision fit are mandatory requirements for crowns and bridges. The development of various casting alloys and precise casting systems has contributed to the successful use of metal-based restorations. However, patient requests for more aesthetic and biologically ‘safe’ materials has led to an increased demand for metal-free restorations. There is also a growing demand to provide all-ceramic restorations more routinely. New materials such as highly sintered glass, polycrystalline alumina, zirconia based materials and adhesive monomers, will assist dentists to meet this demand. In addition, new fabrication systems combined with computer-assisted fabrication systems (dental CAD⁄ CAM) and various networks are now available. Dental technology was centred on lost-wax casting technology but we now face a revolution in crown and bridge fabrication. This article reviews the history and recent status of dental CAD⁄ CAM, the application of CAD⁄ CAM fabricated tooth- coloured glass ceramic crowns, and the application of all-ceramic crowns and bridges using CAD⁄ CAM fabricated zirconia based frameworks. Keywords: CAD ⁄ CAM, networked CAD ⁄ CAM, digitizer, glass ceramics, zirconia. INTRODUCTION There is a long history of dental biomaterial use in routine dental practice. There are two main methods for the application of dental biomaterials. Firstly, raw dental biomaterials are transplanted into living tissue, such as tooth and bone, to fill the space instead of living organs or tissue transplantation. Secondly, dental devices such as crown and bridge restorations and dentures are fabricated from dental materials to restore dental morphology and oral function. Crown and bridge restorations are commonly used by general practitioners after operative and endodontic treatments. In addition, the recent introduction of osseointegrated implants has expanded the application of crown and bridge restorations to restore edentulous spaces. Since mechanical durability and intimate fit to abutments are mandatory for crown and bridge resto- rations, metallic restorations and metallic frameworks covered by glass or resin composites have become popular. The development of both casting gold alloys and dental precision casting systems have contributed to the application of metallic restorations. However, patient requests for aesthetics and biosafety has increased the demand for metal-free restorations. Therefore, both new materials and new processing technology to meet patient demands are required. We are currently in a new era of routinely providing all-ceramic restorations because of newly available materials such as highly sintered glass, polycrystalline alumina and zirconia based ceramic materials, and adhesive monomers.1 In addition, new fabrication systems combined with a computer-assisted fabrication system (dental CAD⁄CAM) and networks are becoming increasingly available.2 Dental technology that used to be centred on the standardized lost-wax casting ª 2011 Australian Dental Association 97 Australian Dental JournalThe official journal of the Australian Dental Association
  • 2. technology has been greatly improved with the intro- duction of dental CAD ⁄CAM systems. In this article we discuss: (1) the history and recent status of dental CAD ⁄CAM systems; (2) the application of CAD ⁄CAM fabricated tooth-coloured glass ceramic crowns; and (3) the application of all-ceramic crowns and bridges using CAD ⁄CAM fabricated zirconia based frameworks for general practitioners. The history and recent status of dental CAD ⁄CAM Figure 1 shows the conventional fabrication process of crown and bridge restorations. An impression of an intraoral abutment is taken and a stone model is prepared as a replica of the abutment. Creating a model is the beginning of the laboratory work. When a metallic restoration is fabricated, wax patterns are manually fabricated, followed by precision casting. If necessary, final restorations are completed by veneering porcelain onto the metal framework. Figure 2 shows the first generation of application of the dental CAD ⁄CAM system by pioneers in dentistry. Duret and colleagues pioneered the dental CAD⁄CAM system in the early 1970s.3 They fabricated restorations using a series of steps shown in Fig 2. The intraoral abutment is scanned by an intraoral digitizer to obtain an optical impression. Digitized data is reconstructed on the monitor as a 3-D graphic and then the optimal morphology of the crown can be ‘virtually designed’ on the monitor. The final crown is fabricated by milling a block using a numerically controlled machine. Duret and colleagues later developed the commercial Sopha system, but this system was not widely used. It is possible that this system was designed too soon to be applied in dentistry because of the lack of accuracy of digitizing, computer power and materials, etc. However, Mormann and colleagues developed the CEREC system, and succeeded in producing a ceramic inlay restoration using computer-assisted technology.4 Digitizing of the inlay cavity is performed directly in the mouth using a compact intraoral camera, which is technically less difficult compared with crown abut- ments. Design and fabrication of the ceramic inlays are performed using a compact machine set at the chairside in the dental surgery. This application was innovative, but the application was limited to inlays and occlusal morphology and contour was initially not available. The technical term of CAD ⁄CAM became popular in den- tistry with the introduction of the CEREC system throughout the world. The original idea of in-office restoration fabrication is still currently practised. Several reports have been published on this system, showing satisfactory long-term results.5–7 A recent iteration of the system can fabricate not only original inlays and onlays, but also crowns and the cores ⁄frameworks of bridges in both clinical and laboratory settings. Based on the developments of Duret’s laboratory system, many researchers worldwide, including our own laboratory, began in the 1980s to develop a system to fabricate a crown with an anatomical occlusal surface. However, we found it difficult to digitize the intraoral abutment accurately using a direct intraoral scanner. Therefore, we decided to prepare the conven- tional stone model to begin the CAD⁄CAM process for the fabrication of crowns, especially for dental labora- tory use. The second generation of the application of dental CAD ⁄CAM systems is illustrated in Fig 3. Different digitizers such as a contact probe,8 laser beam with a PSD sensor, and a laser with a CCD camera were developed. Sophisticated CAD software and compact dental CAD ⁄CAM machines were also developed.2 Consequently, both metallic and ceramic restorations were able to be fabricated by the second generation CAD ⁄CAM systems.9–16 In the early 1980s, nickel-chromium alloys were used as a substitute for gold alloys because of the drastic increase in gold prices at that time. However, metal allergies became a problem, especially in northern Europe, and a transition to allergy-free titanium was Intraoral abutments Impression W ki d lWorking model Wax up Conventional laboratory worksCasting (metal works) Porcelain works Fi l t tiFinal restorations Luting to the abutments Fig 1. Conventional fabrication process of crown-bridge restorations. Intraoral abutments Impression Intraoral digitizing (optical impression) Working model CAD Wax up Virtual model Virtual waxup Casting (metal works) CAM Porcelain works NC machining Milling Final restorations Luting to the abutments Fig 2. First generation of the dental CAD ⁄ CAM systems proposed by Duret and colleagues. 98 ª 2011 Australian Dental Association T Miyazaki and Y Hotta
  • 3. proposed. Since the precision casting of titanium was still difficult at that time, Andersson and colleagues attempted to fabricate titanium copings by spark erosion and introduced CAD⁄CAM technology to the process of composite veneered restorations.17 This was the first application of CAD⁄CAM in a specialized procedure as part of a total processing system. This system later developed as a processing centre net- worked with satellite digitizers worldwide for the fabrication of all-ceramic frameworks using industrial dense sintered polycrystalline alumina known as the Procera system.18,19 Since these high strength industrial ceramics were not available to conventional dental laboratories, the application of networked CAD ⁄CAM in a processing centre was innovative in the history of dental technology (Fig 4). Such networked production systems are currently being introduced by a number of companies worldwide.20–22 The production of zirconia frameworks has become very popular in the world market (Table 1). The application of CAD⁄CAM is currently limited to laboratory processing. For example, even if the zirconia framework is fabricated using a CAD ⁄CAM process in the machining centre, final restorations are completed by veneering conventional porcelain using conventional manual dental technology by dental technicians. Nev- ertheless, there are advantages to using CAD ⁄CAM: new materials are safe, aesthetically pleasing and durable; increased efficiency in laboratory processing; quick fabrication of the restoration; and quality control of restorations such as fit, mechanical durability and predictability. These advantages will ultimately benefit our patients. Because of rapid progress in new technologies, especially optical technology, new intraoral digitizers are now available.23–26 The application of dental CAD ⁄CAM systems is expected to shift to the fourth generation, as illustrated in Fig 5. At least four commercial intraoral scanners are on the market. Information is still limited and manipulation and digitizing accuracy appears unclear. However, the fourth generation is expected to be available for use in the clinic in the near future. Besides the tools for fabrication of restorations, computer technology is now available for communication tools with patients, exam- ination and diagnosis, treatment planning and guided surgery in all fields of dentistry. Digital dentistry is becoming a keyword for the future of dentistry. Dental ceramics Porcelain has been used in dentistry for 100 years. Aesthetics is its major advantage, but brittleness for load bearing restorations its weakest point. The conventional powder build-up firing process was inno- vative but is still technically sensitive. Therefore, porcelain fused to metal restorations has been the first choice to meet both restoration aesthetics and durabil- ity requirements. There are two methods proposed for shifting to all-ceramic restorations (Fig 6).27–29 The first method is to apply reinforced glassy materials to single crowns. CAD ⁄CAM is efficiently applied to fabricate a single crown of reinforced glassy materials. The second method is to fuse porcelain to high strength ceramics instead of alloys. Dense sintered zirconia polycrystalline material appears to be promising for the application to the framework of bridges and even the superstructure of implants. The mechanical properties of brittle ceramics can be evaluated by fracture toughness and bending strength. Conventional porcelain is a glassy material; fracture toughness is approximately 1.0 MPa m1 ⁄ 2 and bending Intraoral abutments Impression Working model Wax up Digitizing model Digitizing CAD/CAM Conventional laboratory works Final restorations Luting to the abutments Casting (metal works) Fig 3. Second generation of the dental CAD ⁄ CAM systems as a part of dental laboratory works. Intraoral abutments Impression Working model Wax up Digitizing model Digitizing Casting (metal works) Machining center CAD/CAM Conventional laboratory works Final restorations Luting to the abutments Fig 4. Third generation of the dental CAD ⁄ CAM systems using a machining centre. ª 2011 Australian Dental Association 99 CAD ⁄CAM systems
  • 4. strength is approximately 100 MPa. This material is not strong enough for load bearing molar restorations. New dental ceramics have improved the mechanical properties of conventional porcelain (Fig 7).30–32 Initially, porcelain was reinforced by dispersing crystals. Aluminous porcelain is widely available. Since conventional powder build-up and the firing procedure is technique-sensitive, new, more easily manipulated ceramic materials have been developed. In response to this demand, castable and pressable ceramics were developed and are available for single aesthetic resto- rations. In addition, prefabricated reinforced glass ceramic blocks are available for milling using a CAD ⁄CAM device. The fracture toughness of these materials range from 1.5 to 3.0 MPa m1 ⁄ 2 . However, these are still available only for single restorations. Another type of ceramic includes alumina and other fine ceramic powders that are porously sintered and glass is infiltrated among the pores. These materials are called glass infiltrated ceramics and include the well- known brand In-Ceram. Their fracture toughness ranges from 3 to 5 MPa m1 ⁄ 2 . These materials have been applied to bridge restorations but the prognosis has not been satisfactory. Finally, industrial dense polycrystalline ceramics such as alumina, zirconia and alumina-zirconia composites are currently available with the application of CAD ⁄ CAM technology using a networked machining centre. In particular, yttrium partially stabilized tetragonal zirconia polycrystalline (YTZP) has a very high fracture toughness from 5 to 10 MPa m1 ⁄ 2 . When a crack initiates on the YTZP, the concentration of stress at the top of the crack causes the tetragonal crystal to transform into a monoclinic crystal with volumetric expansion. This prevents further crack propagation.33 Table 1. Popular CAD⁄CAM systems available for the fabrication of zirconia frameworks CAD ⁄ CAM system (Manufacture) Dizitizing Method Restoration type Material Central machining centreIn Veneer Cr Br Resin Titanium Gold Ceramic Alumina Zirconia Etkon (Etkon AG) PSD ⁄ Laser s s s s s s s s Everest (KaVo electrotechnical work GmbH) CCD ⁄ White light s s s s s s s Available Lava (3M ESPE Dental AG) CCD ⁄ White light s s s s s Available Pro 50, WaxPro (SYNOVAD) CCD ⁄ Color light s s s s s s s Procera (Nobel Biocare Germany GmbH) Touch Probe s s s s s s s s Hint ELs DentaCAD systeme (Hint-ELs GmbH) CCD ⁄ White light s s s s s Available KATANA system (Noritake dental supply co., LTD) CCD ⁄ Laser s s s Available Cercon smart ceramics (DeguDent GmbH) CCD ⁄ Laser s s s Available CEREC3 ⁄ inLab (Sirona Dental of system GmbH) CCD ⁄ Laser s s s s s s Available DCS Dental (DSC Dental AG) PSD ⁄ Laser s s s s s s s s Available ZENOÒ Tec System (Wieland Dental & Technik GmbH) CCD ⁄ Laser s s s s s s Available Intraoral abutment Intraoral digitizing (optical impression) Network to CAD the machining center Virtual model Virtual wax up CAD CAM CAM NC machining Milling Conventional laboratory works In office restorations In labo restorations Luting to the abutments Fig 5. Fourth generation of the dental CAD ⁄ CAM systems using an intraoral digitizer. Alloys High strength ceramics Porcelain fused to metal frameworks Porcelain fused to high strength ceramic frameworks Reinforced glass ceramics (porcelain) Fig 6. Two directions of all-ceramic restorations replacing conven- tional porcelain fused to metal frameworks. 100 ª 2011 Australian Dental Association T Miyazaki and Y Hotta
  • 5. In addition, alumina-zirconia nano-composites devel- oped in Japan are very tough with a fracture tough- ness of 19 MPa m1 ⁄ 2 and a bending strength of 1400 MPa.34 Application of CAD⁄CAM fabricated tooth-coloured glass ceramic crowns Currently, prefabricated reinforced glass ceramic blocks are available for milling using a CAD⁄CAM device. Table 2 illustrates the mechanical properties of a typical leucite-reinforced glass ceramic compared with those of tooth enamel. Mechanical properties of leucite-reinforced glass ceramics are equal or superior to those of tooth enamel. However, materials with these properties were conventionally not available to replace enamel, even for a single crown. Glass ceramic crowns can be automatically fabricated without any sensitive manual labour using a CAD⁄CAM process (Fig 8).35 In addition, conventional finishing procedures such as add-ons, staining, and glazing are available because of the same porcelain base materials as a glass ceramic block for milling. Figure 9 shows a hemi- sectioned surface after cementing. There is no porosity inside because of the prefabricated block used at the factory. The fit of the crown is excellent with a cement thickness at the margin of less than 20 lm. Figure 10 illustrates the result of a fracture test of a CAD ⁄CAM fabricated crown luted to an abutment with and without luting cement.36 When a crown was fractured on the abutment without luting cement, the fracture force was only 700 N. The fracture load increased to 2000 N when the crown was luted with a luting cement but without adhesive. Interestingly, the fracture load increased to 4000 N when the crown was luted using luting cement with silane-coupling agents and adhesive monomers. Therefore, glass ceramic crowns are reinforced by adhesive treatment. CAD⁄CAM glass ceramic (porcelain) crowns are clinically useful because of their easy manipulation without technically sensitive build-up processes. They are user-friendly because finishing work such as con- ventional staining, add-ons and glazing techniques are available. They are also promising because of their excellent fit and aesthetics, strong durability with adhesive resin cements and quick fabrication. However, they are only available for a single crown. Application of all-ceramic crowns and bridges using CAD⁄CAM fabricated zirconia based frameworks Zirconia is available for fabricating frameworks of bridge restorations instead of metal bonded restorations because of its higher fracture toughness. There are two types of zirconia blocks currently available for distinct CAD ⁄CAM applications. The first application is the use of fully sintered dense blocks for direct machining using a dental CAD⁄CAM system with a grinding machine. The second application is the use of partially sintered blocks and green blocks for CAD⁄CAM fabrication followed by post-sintering to obtain a final product with sufficient strength. The former application has a superior fit because no shrinkage is involved in the process, but is disadvantaged by inferior machinability associated with heavier wear on the milling tool. In addition, microcrack formation on the material during PorcelainPorcelain 16 18 Glass ceramics Glass infiltrated ceramics NANOZR Alumina/Zirconia Polycrystalline Zirconia (YTZP) 16 12 14 nano-composites Lava Polycrystalline 8 10 I C Zi i Cercon Lava ZENO Zr Discs Katana Zr 4 6 OCC Cryscera IPS e.max CAD In-Ceram Alumina In-ceram spinell In-Ceram Zirconia IPS e.max ZirCAD Procera Almina MK II Omega Fracturetoughness(MPa/m1/2) 16001400120010008006004000 200 0 2 IPS Empress2 Dicor MGC Bending strength (MPa) Alumina Fig 7. Mechanical properties of new dental ceramics. Table 2. Mechanical properties of leucite-reinforced glass ceramics and tooth enamel Glass ceramics Tooth enamel Bending strength (MPa) 100120 85 Fracture toughness (MPaÆm1 ⁄ 2 ) 1.21.5 1.2 Elastic modulus (GPa) 6872 65 Hardness (Hv) 500650 350 ª 2011 Australian Dental Association 101 CAD ⁄CAM systems
  • 6. the milling procedure might deteriorate the mechanical durability of the restoration.20,37 The latter application has the advantage of easy machinability without as much wear on the tools or chipping of the material. However, because of extensive shrinkage during the post-sintering process, the fit of the frameworks must be compensated for by the dimensional adjustment of CAD procedures involving the frameworks.37,38 We conducted a fitting test of zirconia frameworks fabricated by the CAD ⁄CAM process.39 Zirconia frameworks were fabricated using a standardized metal abutment. After luting frameworks to the abutment with luting cement, the thickness of the cement layer was measured. In this study, the cement space was designed beforehand on the abutments by the CAD process. The red dotted line shows the designed cement thickness. Figure 11 shows that the fit of a single crown coping was perfect. When the number of pontics increases, the cement thickness of the margin of the crown of the pontic side tends to increase, but this is still within clinically acceptable levels.40–42 On the other hand, according to the results of a fitting test using the angled type bridge model,36 even if the fit of the margin of the crowns was excellent, similar to the straight type models, there was slight distortion of the framework. Therefore, there is a need to be aware of the difference between zirconia frameworks and metal frameworks, especially the implant super- structure. When there is a discrepancy in metal frameworks at a trial insertion, they can be adjusted by separation and soldering, but this cannot be done with zirconia frameworks. Digitizing Automatic CAD DecsyTM PRO CADTM Automatic tool at Decsy ScanTM blocks exchange Milled crownilled crown Stainig Add-on Grazing Fig 8. Fabrication of glass ceramic crowns using the CAD ⁄ CAM system of Angel crownsTM (Media, Japan). Porosity free Excellent fit: Cement thickness was 20 µm at the margin Fig 9. Sectioned surface of a CAD ⁄ CAM fabricated ceramic crown after cementing. 4500 3000 3500 4000 2000 2500 500 1000 1500 Fractureload(N) Control: without luting cements 0 Control L A Control: without luting cements L: luting cements without adhesive monomers A: luting cements with silane-coupling agents and adhesive monomers Fig 10. Result of a fracture test of a CAD ⁄ CAM fabricated crown luted to an abutment. 102 ª 2011 Australian Dental Association T Miyazaki and Y Hotta
  • 7. The final restoration is completed by veneering conventional porcelain on the zirconia frameworks by conventional dental technological manual work. Even though zirconia is tougher than conventional dental ceramics, veneering porcelain is as brittle as conven- tional porcelain. Debonding and chipping of veneering porcelain sometimes occurs. Therefore, the properties of porcelain and processing of veneering materials are still very important for the prognosis of the final zirconia restorations. Each manufacturer recommends surface treatment of zirconia frameworks prior to porcelain fusing, such as sandblasting and heat treat- ments. However, the effect of surface treatments on the bonding strength of porcelain to zirconia is still controversial.43 Table 3 shows the list of commercial Originally designed cement spaceOriginally designed cement space Fig 11. Result of a fitting test of zirconia frameworks fabricated by the CAD ⁄ CAM system of KATANATM (Noritake, Japan). Table 3. Commercial veneering porcelain products available for zirconia frameworks Thermal expansion coefficiency (10)6 ⁄ °C) (25–500°C) Firing temp. (°C) Compatible Zirconia Cerabien ZR (NORITAKE) 9.1 930–940 KATANA, Procera Zirconia Vintage ZR (SHOFU) 9.3–9.4 900–940 NANOZR Initial Zr (GC Europe) 9.4 810 All products CerconÒ Ceram S (Dentsply DeguDent) 9.5 810–850 Cercon CeramcoÒ PFZ (Dentsply Ceramco) – 890–930 Cercon LavaTM Ceram (3M ESPE) 10.0 810 Lava Zirconia Vita VMÒ 9 (Vita) 8.8–9.2 900–940 In-Ceram YZ Cubes NobelRondoTM Zirconia (Nobel Biocare) 9.3 890–980 Procera Zirconia IPS e. maxÒ Ceram (Ivoclar vivadent) 9.5 (100–400°C) 800 IPS e. max ZirCAD IPS e. maxÒ ZirLiner (Ivoclar vivadent) 9.8 (100–400°C) 960 IPS e. max ZirCAD ZiroxÒ (WIELAND) 10.0 900 ZENOTM Zr Creation ZI (Creation Willi Geller International AG) 9.5 810 YTZP 25 30 15 20 5 10 0 5 CerabienZR (Noritake) e-max (IPSe.max®Ceram, Zirox (ZIROX®, Bondingstrength(MPa) Ivoclar vivadent) WIELAND) Fig 12. Result of a bonding test of three porcelain products conven- tionally fused to zirconia plates (IPS e-max ZirCAD, Ivoclar Vivadent) under the ISO 9693. ª 2011 Australian Dental Association 103 CAD ⁄CAM systems
  • 8. veneering porcelain products for zirconia frameworks. There are differences in the thermal coefficients of expansion and firing temperatures among the products, indicating a different composition of powder. We tested the bonding strength of porcelain fused to zirconia frameworks (Fig 12).36 Three commercial porcelain powders were fused to the zirconia plate for a bending test (in accordance with ISO 9693) for the porcelain fused to the metal crowns. We determined the differences of the products based on the bending strength. Compared with the recommended strength of porcelain fused to metal system (25 MPa), the bonding strength of porcelain fused to zirconia frame- works appeared to be inferior to that of metal ceramics. Improvement needs to be made to the compatibility of the thermal expansion coefficient based on the powder composition. On the other hand, adhesive treatment of zirconia using alumina sandblasting and adhesive monomers is available and appears to be positive.44,45 Bending specimens of the same ISO standard were prepared using a milled porcelain plate adhered to the zirconia plate with three adhesive monomers and resin cements. As shown in Fig 13, even the bonding strength is decreased after thermal cycling, and the bonding strength of adhered specimens is higher than that of fused specimens.36 Therefore, a new hybrid structure of CAD⁄CAM porcelain crowns adhered to the CAD ⁄CAM zirconia framework (PAZ) has been proposed (Fig 14).36 In this system, zirconia frameworks are digitized and porcelain crowns are also fabricated by the CAD ⁄CAM process. Milled porcelain crowns are adhered to zirconia frameworks using adhesive resin cements and the final restoration is completed. Manipulation of the structure is reproducible and reliable without conventional manual porcelain work. Adhesive treatments reinforce the durability of porcelain. Even if porcelain chips, repairing it is easy using the preserved data. (Figure 15 shows a clinical case of the PAZ bridge.) CONCLUSIONS This article reviews the current state and future perspectives of the application of dental CAD⁄CAM systems, particularly in the field of fabrication of crown and bridge restorations. CAD ⁄CAM is a panacea for fabricating glass ceramic (porcelain) single crowns. However, adhesive treatments are mandatory for durability. Porcelain fused to CAD ⁄CAM zirconia frameworks appears to be a favourable option in the 35 40 45 25 30 35 * * * 10 15 20 0 5 10 Bondingstrength(MPa) AZ primer resicem (Shofu) Epricode panavia®F2.0 (Kuraray) Metal/zirconia primer multilink (Ivoclar vivadent) Fig 13. Result of a bonding test of the milled porcelain plate (IPS Empress CAD, Ivoclar Vivadent) adhered to the zirconia plate (IPS e- max ZirCAD, Ivoclar Vivadent) using three adhesive monomers under the ISO 9693. * indicates the bonding strength after thermal cycles of 10 000 times at 560 °C. [PAZ] [PFZ] Zirconia frameworks (CAD/CAM, firing) Digitizing Porcelain crowns Porcelain fusing Adhesion to frameworks Final crowns Final crowns Manipulation is reproducible and reliable, without conventional manual porcelain works. CAD/CAM is applied partially. Porcelain work is still technically sensitive.Adhesive treatments reinforce the durability of porcelain. Repair of porcelain is easy. Repair of porcelain is difficult. (CAD/CAM) (Conventional firing) Fig 14. Schematic illustration of a novel fabrication system of a hybrid structure of CAD ⁄ CAM porcelain crowns adhered to the CAD ⁄ CAM zirconia frameworks (PAZ) and conventional porcelain fused to the CAD ⁄ CAM zirconia frameworks (PFZ). 104 ª 2011 Australian Dental Association T Miyazaki and Y Hotta
  • 9. clinic. However, the challenge still remains to fix standardized surface treatments of frameworks and develop more compatible porcelain powders. Pressing porcelain is a potential candidate for conventional porcelain work but is still technically sensitive. There should be a shift to digital dentistry in the future. A hybrid structure of CAD ⁄CAM porcelain crowns adhered to CAD ⁄CAM zirconia frameworks is a promising option because manual porcelain work is not technically sensitive and porcelain is easy to repair. The application of CAD⁄CAM technology in den- tistry provides an innovative, state-of-the-art dental service to patients and is also beneficial for general practitioners. Conventional laboratory technology and dental technician skills remain important because dental restoration and prostheses are not just industrial products but medical devices that need to function in the body. Therefore, we must combine new technology and conventional technology to meet patient demand. REFERENCES 1. Anusavice KJ. Dental ceramics. In: Anusavice KJ, ed. Phillips’ Science of Dental Materials. 12th edn. Saunders, 2003:655– 719. 2. Miyazaki T, Hotta Y, Kunii J, Tamaki Y. A review of dental CAD ⁄ CAM: current status and future perspectives from 20 years of experience. Dent Mater 2009;28:44–56. 3. Duret F, Preston JD. CAD ⁄ CAM imaging in dentistry. Curr Opin Dent 1991;1:150–154. 4. Mormann WH, Brandestini M, Lutz F, Barbakow F. Chairside computer-aided direct ceramic inlays. Quintessence Int 1989;20:329–339. 5. Reiss B, Walther W. Clinical long-term results and 10-year Kaplan-Meier analysis of Cerec restorations. Int J Comput Dent 2000;3:9–23. 6. Nakamura T, Dei N, Kojima T, Wakabayashi K. Marginal and internal fit of Cerec 3 CAD ⁄ CAM all-ceramic crowns. Int J Prosthodont 2003;16:244–248. 7. Effrosyni A, Tsitrou E, Northeast S, van Noort R. Evaluation of the marginal fit of three margin designs of resin composite crowns using CAD ⁄ CAM. J Dent 2007;35:68–73. 8. Persson M, Andersson M, Bergman B. The accuracy of a high- precision digitizer for CAD ⁄ CAM crowns. J Prosthet Dent 1995;74:223–229. 9. Hotta Y. Fabrication of titanium copings using the CAD ⁄ CAM process. Japan J Dent Mat Dev 1992;11:169–178. 10. Hotta Y, Miyazaki T, Lee G, Kobayashi Y. Accuracy of the ceramic crown fabricated by the newly developed CAD ⁄ CAM system. J Showa Univ Dent Soc 1996;16:230– 234. 11. Hotta Y, Miyazaki T, Warita K, Kawawa T. Automatic fabrication of ceramic crowns using a newly developed dental CAD ⁄ CAM system. J Esthet Dent 1998;10: 69–75. 12. Kobayashi Y. The effect of digitizing conditions on the accuracy of ceramic crowns fabricated by using the second version of the experimentally developed dental CAD ⁄ CAM machine. J Showa Univ Dent Soc 2000;20:165–172. 13. Miyazaki T, Hotta Y, Kobayashi Y, Lee G, Furuya A, Kawawa T. Characteristics of dental CAD ⁄ CAM system ‘Decsy’ and clinical application. QDT 2000;25:34–41. 14. Hotta Y, Ozawa A, Kobayashi Y, Miyazaki T. Development of a dental CAD ⁄ CAM system fabricating dental prostheses. J Showa Univ Dent Soc 2001;21:86–91. 15. Hotta Y, Miyazaki T, Fujiwara T, et al. Durability of tungsten carbide burs for the fabrication of titanium crowns using dental CAD ⁄ CAM. Dent Mater 2004;23:190–196. 16. Tomita S, Shinya A, Gomi H, et al. Machining accuracy of CAD ⁄ CAM ceramic crowns fabricated with repeated machin- ing using the same diamond bur. Dent Mater 2005;24:123– 133. 17. Andersson M, Carlsson L, Persson M, Bergmann B. Accuracy of machine milling and spark erosion with a CAD ⁄ CAM system. J Prosthet Dent 1996;76:187–193. 18. Andersson M, Oden A. A new all-ceramic crown: a dense-sin- tered, high purity alumina coping with porcelain. Acta Odontol Scand 1993;51:59–64. 19. Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five- year clinical evaluation of Procera All Ceram crowns. J Prosthet Dent 1998;80:450–456. 20. Suttor D, Bunke K, Hoescheler S, Hauptmann H, Hertlein G. LAVA–the system for all-ceramic ZrO2 crowns and bridge frameworks. Int J Comput Dent 2001;4:195–206. 21. Sorensen JA. The Lava system for CAD ⁄ CAM production of high-strength precision fixed prosthodontics. QDT 2003;26:57– 67. Fig 15. Clinical application of PAZ restorations to the maxillary implant prostheses (Courtesy of Dr Higuchi, Showa University Dental Hospital). ª 2011 Australian Dental Association 105 CAD ⁄CAM systems
  • 10. 22. Piwowarczyk A, Ottl P, Lauer H-C, Kuretzky T. A clinical report and overview of scientific studies and clinical procedures conducted on the 3M ESPE LavaTM . J Prosthodont 2005;14: 39–45. 23. Cadent. URL: http://www.cadentinc.com. Accessed May 2010. 24. 3M ESPE. URL: http://solutions.3m.com/wps/portal/3M/en_US/ LavaCOS/3MESPE-LavaCOS/. Accessed May 2010. 25. Sirona. URL: http://www.cereconline.com/cerec/. Accessed May 2010. 26. D4D Technologies LLC. URL: http://www.e4d.com/. Accessed May 2010. 27. Raigrodski AJ, Chiche GL. The safety and efficiency of anterior ceramic fixed partial dentures: a review of the literature. J Pros- thet Dent 2001;86:520–525. 28. Raigrodski AJ. Contemporary materials and technologies for all- ceramic fixed partial dentures: a review of the literature. J Pros- thet Dent 2004;92:557–562. 29. Heather JC, Wook-jin S, Igor JP. Current ceramic materials and systems with clinical recommendations: a systematic review. J Prosthet Dent 2007;98:389–404. 30. Ban S. Dental materials science of all ceramics. J Dent Technol- ogy (Extra issue: All ceramics restoration) 2005;32–43. 31. Ban S, Sato H, Yamashita D. Microstructure and mechanical properties of recent dental porcelains. Arch Bioceramics Res 2006;6:58–61. 32. Ban S. Material science of zirconia and future prospects. Practice In Prosthodontics 2008;41:385–397. 33. Nawa M, Nakamoto S, Seino T, Niihara K. Tough and strong Ce-TZP ⁄ alumina nanocomposites doped with titania. Ceramics Int 1998;24:497–506. 34. Miyazaki T, Hotta Y, Kunii J, Fujiwara T. Current status and future prospects of a dental CAD ⁄ CAM system used in crown- bridge restorations. Dentistry in Japan 2007;43:189–194. 35. Tamaki Y, Hotta Y, Kunii J, Kuriyama S, Higuchi D, Miyazaki T. CAD ⁄ CAM all ceramic dental restorations on implants: a panacea or a challenge? Dental Medicine Research 2010;30:42– 49. 36. Besimo CE, Spielmann HP, Rohner HP. Computer-assisted gen- eration of all-ceramic crowns and fixed partial dentures. Int J Comput Dent 2001;4:43–62. 37. Luthardt RG, Rieger W, Musil R. Grinding of ziroconia-TZP in dentistry–CAD ⁄ CAM-technology for the manufacturing of fixed dentures. In: Sedel L, Rey C, eds. 10th International Symposium on Ceramics in Medicine Bioceramics 10, Paris, France. Amsterdam: Elsevier, 1997:437–440. 38. Kunii J, Hotta Y, Tamaki Y, et al. Effect of sintering on the marginal and internal fit of CAD ⁄ CAM fabricated zirconia frameworks. Dent Mater 2007;26:820–826. 39. Tinschert J, Natt G, Mautsch W, Spiekermann H, Anusavice KJ. Marginal fit of alumina and zirconia-based produced by a CAD ⁄ CAM system. Oper Dent 2001;26:367–374. 40. Reich S, Wichmann M, Nkenke E, Proeschel P. Clinical fit of all- ceramic three-unit fixed partial dentures, generated with three different CAD ⁄ CAM systems. Eur J Oral Sci 2005;113:174–179. 41. Gonzalo E, Sua´rez MJ, Serrano B, Lozano JF. Marginal fit of zirconia posterior fixed partial dentures. Int J Prosthodont 2008;21:398–399. 42. Fischer J, Grohman P, Stawarczyk B. Effect of zirconia surface treatments on the shear strength of zirconia ⁄ veneering ceramic composites. Dent Mater J 2008;27:448–454. 43. Tanaka R, Fujishima A, Shibata Y, Manabe A, Miyazaki T. Cooperation of phosphate monomer and silica modification on zirconia. J Dent Res 2008;87:666–670. 44. Takeuchi K, Fujishima A, Manabe A, et al. Combination treat- ment of tribochemical treatment and phosphoric acid ester monomer of zirconia ceramics enhances the bonding durability of resinbased luting cements. Dent Mater J 2010;29:316–323. Address for correspondence: Dr Takashi Miyazaki Department of Oral Biomaterials and Technology School of Dentistry Showa University 1-5-8 Hatanodai Shinagawa-ku Tokyo 142-8555 Japan Email: miyazaki@dent.showa-u.ac.jp 106 ª 2011 Australian Dental Association T Miyazaki and Y Hotta