The Evolution and Revolution in

Prosthodontics Continues
John A. Sorensen, DMD, PhD, FACP
The rate of innovations in prosthodontics has been picking up considerable
momentum and products have emerged, demonstrating superb strength and high
esthetics. Trends indicate a preference for metal-free restorations, as the offerings
of zirconia products have become more nuanced. Also, innovative scanning
systems provide dental teams a greater flexibility and enhanced productivity.
The integration of materials and digital technologies has facilitated enormous
advancements in fixed and removable prosthodontics in the last 4 years. This
synergistic combination has helped the specialty evolve to provide both the
clinician and dental laboratory technician with enhanced prostheses possessing an
increased clinical reliability while enabling fabrication with increased efficiency,
reduced fabrication times, and better economy. This is all while providing greater
precision and a superior restoration for the patient.
At no other time in dentistry has there been such a rapid rate of development in
prosthodontic materials, digital technology, software, and the integration of
systems. The products that have benefited the most from the convergence of these
elements are single-tooth implant surgical/prosthodontics and posterior
conventional crowns. Dentistry has witnessed an ease of fabrication of posterior
restorations using high-strength ceramics that are highly esthetic, possess a
monolithic structure, and have excellent occlusal anatomy.

Zirconia and Lithium Disilicate

New trends have begun to emerge. In November 2010, Glidewell
Laboratories1 reported that the fabrications of BruxZirTM (Glidewell
Laboratories, http://glidewelldental.com) were surpassing porcelain-fused-to-metal
restorations as the most-common material fabricated in the companys laboratory.
Then, Lab Management Today2 published a 2014 survey of dental laboratories,
which revealed more metal-free restorations were fabricated than metal-based
restorations.
The unprecedented rise in popularity of the full-contour zirconia ceramic crown
has been indisputable. Perhaps demonstrating the extent to which clinicians have
embraced monolithic zirconia crowns is the commercial success of the BruxZir
crown with production of more than 100,000 units per month for at least the last 3
years. BruxZir crowns are even now made for CEREC (Dentsply
Sirona, www.dentsplysirona.com) and inLab (Dentsply Sirona). A number of
other dental laboratories have considerable sales numbers for their versions of
monolithic zirconia ceramic restorations. Dentists prefer these types of monolithic
restorations because they are virtually indestructible, are reasonably esthetic, do
not chip, and are gentle on opposing dentition. 3,4
To overcome the inherent opacity of high-strength zirconia ceramics,
manufacturers have directed their research efforts toward developing hightranslucency zirconia for anterior restorations (cubeX2 cubic zirconia, DAL DT

Technologies, http://daltechsystems.ca; Katana Ultra Translucent Multi-Layered,

Kuraray Noritake Dental, www.kuraraynoritake.com; Prettau Anterior,
Zirkonzahn, www.zirkonzahn.com; Zenostar MT, Wieland Dental, www.wielanddental.de). Their work has concentrated on increasing the cubic zirconia phase,
which has led to a higher translucency. An increase in the Yttrium concentration is
then required to help stabilize the metastable zirconia ceramic. The tradeoff for
greater translucency conferred by increased cubic zirconia is reduced strength.
However, at 550 MPa to 700 MPa, the product has ample strength for anterior or
posterior single crowns. Using a different zirconia formulation, Sagemax
Bioceramics (www.sagemax-dental.com) has produced the NexxZr Plus zirconia
with greater translucency but a strength of 1000 MPa.
Another innovation making zirconia more esthetic is the presintering
staining/coloring/ characterization of full-contour zirconia prostheses in the green
state. This provides a predictable, simple, and effective natural shading that
routinely produces highly esthetic results. A significant advantage of the
presintering approach is that the coloring and effects are distributed throughout the
body of the ceramic and are not just a surface phenomenon. The Colour Liquid
Prettau Anterior Aquarell (Zirkonzahn) is a coloring system facilitating rapid
characterization of the monolithic crowns or fixed dental prostheses. LavaTM Plus
High Translucency Zirconia Dyeing Liquid (3M ESPE, www.3mespe.com),
NexxZr Color (Sagemax), and Zenostar Color Zr (Wieland) are also effective
coloring systems. Other manufacturers have developed multilayered-gradient
shaded milling disks (Katana Zirconia [ML], Kuraray Noritake Dental).
With a clinically validated track record of more than a decade of widespread use,
the lithium disilicate ceramic (e.max, Ivoclar Vivadent) has been extraordinarily
successful. This ubiquitous system is the gold standard for the creation of tooth
structure-preserving, highly esthetic, adhesive ceramic restorations. Clinicians trust
the system for applications in the prosthodontic spectrum from minimally invasive
veneers, to partial coverage posterior restorations, to full molar crowns.
Throughout the years, the lithium disilicate system has evolved from a
predominately lost-wax pressed format to being fabricated with CAD/CAM
applications.
Sirona just introduced a rapid-sintering induction oven that purportedly transforms
the milling of zirconia crowns into a chairside procedure. Sirona says the CEREC
SpeedFire furnace can sinter a single zirconia crown in just 15 minutes, and with
its milling system, the entire crown can be completed in well under an hour.
Recent research tested a novel zirconia surface-modification technology called
femtosecond laser that can systematically create 50-m holes on the bonding
surface of zirconia to create mechanical retention for adhesive cements. The results
demonstrated a twofold increase in shear bond strength to MDP-containing
cements compared to airborne particle abrasion alone. 5,6

Scanning Systems
Since the introduction of intraoral scanning (IOS) systems and other digital
prosthodontics systems at the 2013 International Dental Show in Cologne,

Germany, dentistry has seen an unprecedented rate of development of IOS, design

software, and milling systems. In just the last 2 years, great improvement has
occurred in the integration of software and digital devices so that workflow
progresses seamlessly throughout the steps of acquisition, ie, CAD and CAM.
Laboratory scanners such as the D2000 lab scanner (3Shape, www.3shape.com)
boast improved accuracy, a significant increase in scanning speed, and an ability to
scan two casts simultaneously. Additional innovations include calibrated transfer
plates enabling capture of the occlusion and model position in the articulator, allin-one scanning of bite-impression tray, and improved scanning of impressions.
Studies have established the high accuracy of intraoral scanners for single-tooth
preparation scanning7,8 and now full-arch scanning.9 Improved technology and
software facilitate extremely rapid intraoral scanning with new systems being more
intuitive and easier to stay on track.

Milling
Many improvements have occurred with milling machines such as high-capacity
systems holding eight milling disks (Wieland Zenotec select hybrid, Ivoclar
Vivadent) and high-capacity wet-milling machines for lithium disilicate restoration
fabrication (IPS e.matrix, Wieland, Ivoclar Vivadent). Another high-capacity
system is the M4 Milling Unit (Zirkonzahn, www.zirkonzahn.com), which has an
extra-large milling area (15 inches by 7 inches) suitable for production of up to 20
full arches at once. The tool-changer function holds up to 32 milling tools, and a
large variety of materials can be processed in one milling process.
In addition to the developments for large milling centers, even more exciting was
the introduction at the 2015 International Dental Show of 4-axis wet-milling
machine systems in the mid $20,000 range (Biodenta DS 1300,
Biodenta, www.biodenta.net). Also, a similarly affordable system was introduced
at the recent Chicago Lab Management Today meeting (DWX-4W, Roland
DGA, www.rolanddga.com). This affordability greatly expands the use of
CAD/CAM systems to smaller dental laboratories and to dental practices for
chairside applications to mill ceramics, PMMA, composite, and titanium.
A masters degree thesis project measured the accuracy of chairside milling of
custom titanium abutments to within 25 m to 30 m for precision. 10 With the
economical wet-milling machines, IOS, and available software, the concept of a
desktop dental lab was introduced in December 2015 in which a clinic could use
software to integrate the cone-beam computed tomography and IOS scans,
treatment plan implants, mill out a surgical guide, design and mill a provisional
crown, and design and mill an abutment and crown from a variety of materials. 11

Digital Workflows
Digital technologies have also touched removable prosthodontics. To varying
degrees, the Avadent (www.avadent.com), DENTCA (www.dentca.com), and
Digital Denture (Ivoclar Vivadent) systems have incorporated digital workflows.
The Ivoclar Vivadent system is cleverly designed in that the dentist can work at a
traditional level of analog border-molded impressions and, through the process,
merely make a few numeric settings that allow the dental laboratory to work in a

nearly completely digital workflow. With all these systems, the denture base is
milled from a factory-fabricated pink PMMA disk that is dense and free of voids
and flaws. The fit of the intaglio surface of the milled base is perfect, unlike
traditional heat-processed PMMA in which the 8% to 9% polymerization shrinkage
pulls away from the palatal aspect creating poor adaptation. DENTCA introduced a
3D-printable denture base system.
Other exciting developments in removable prosthodontics include a system in
which the doctor could perform an intraoral scan of the prepared teeth and soft
tissues, and then send STL files to the laboratory. The laboratory would then 3D
print the resin model, use software to design the RPD framework, and then print
the CrCo metal framework. Finally, the powder alloy is laser sintered to produce a
precise-fitting metal framework (3DRPD USA, www.3drpd.com).

Conclusion
Recent innovations in modern materials, digital technology, software, and
integration of systems make the future appear bright for prosthodontics. With the
control, reduced capital investment, added capabilities, increased flexibility, and
the precision available, never has there been a more exciting time in fixed and
removable prosthodontics.

References
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9, 2016.
2. LMT Research Department. The Answers Issue. Lab Management Today. March
2016.
3. Sorensen JA. Three-body wear of enamel against full crown ceramics. J Dent
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10. An H. Accuracy of milled custom abutments fabricated from a semiprefabricated abutment blank. MSD Thesis, Graduate Prosthodontics, University of
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11. Sorensen JA. The desktop dental lab. Inside Dentistry. 2015;11:54-61.
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