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JPOR-319; No.

of Pages 13

journal of prosthodontic research xxx (2016) xxxxxx

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Review

Advancements in CAD/CAM technology: Options


for practical implementation

Tariq F. Alghazzawi BDS, MS, MSMtE, PhDa,b,*


a
Department of Prosthetic Dental Sciences, College of Dentistry, Taibah University, Medina, Kingdom of Saudi Arabia
b
Department of Materials Science and Engineering, School of Engineering, The University of Alabama at Birmingham,
United States

article info abstract

Article history: Purpose: The purpose of this review is to present a comprehensive review of the current
Received 26 October 2015 published literature investigating the various methods and techniques for scanning, de-
Received in revised form signing, and fabrication of CAD/CAM generated restorations along with detailing the new
10 December 2015 classifications of CAD/CAM technology.
Accepted 16 January 2016 Study selection: I performed a review of a PubMed using the following search terms CAD/
Available online xxx CAM, 3D printing, scanner, digital impression, and zirconia. The articles were screened for
further relevant investigations. The search was limited to articles written in English,
Keywords: published from 2001 to 2015. In addition, a manual search was also conducted through
CAD/CAM articles and reference lists retrieved from the electronic search and peer-reviewed journals.
Milling Results: CAD/CAM technology has advantages including digital impressions and models,
3D printing and use of virtual articulators. However, the implementation of this technology is still
Scanner considered expensive and requires highly trained personnel. Currently, the design software
Digital impression has more applications including complete dentures and removable partial denture frame-
Virtual articulator works. The accuracy of restoration fabrication can be best attained with 5 axes milling units.
The 3D printing technology has been incorporated into dentistry, but does not include
ceramics and is limited to polymers. In the future, optical impressions will be replaced with
ultrasound impressions using ultrasonic waves, which have the capability to penetrate the
gingiva non-invasively without retraction cords and not be affected by fluids.
Conclusion: The coming trend for most practitioners will be the use of an acquisition camera
attached to a computer with the appropriate software and the capability of forwarding the
image to the laboratory.
# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. CAD/CAM components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. General classification of CAD/CAM systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

* Correspondence to: P.O. Box 51209, Riyadh, 11543, Saudi Arabia.


E-mail address: drtariq05@gmail.com.
http://dx.doi.org/10.1016/j.jpor.2016.01.003
1883-1958/# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont
Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.01.003
JPOR-319; No. of Pages 13

2 journal of prosthodontic research xxx (2016) xxxxxx

4. Classification of scanners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000


5. Protocol for scanning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
6. Virtual articulators and facebows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
7. Design software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
8. Digital fabrication processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
9. Limitations and future CAD/CAM technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
10. Summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

1. Introduction classified into laboratory CAD/CAM in which the company


has its own scanner and milling units (e.g. Amann Girbach, 3M
With the rapid evolution of CAD/CAM (Computer Aided ESPE, Sirona Dental Systems, Zirkon Zahn, vhf camfacture AG,
Design, Computer Aided Manufacture), this has led to a Weiland Dental, Pou-Yuen and U-Best Dental, Planmeca, KaVo
dramatic impact on all disciplines of dentistry especially in the Dental, Dentsply Prosthetics) while CAD (Computer Aided
fields of prosthodontics and restorative dentistry. The inte- Design) systems in which the company has only the scanner
gration of these technological systems with advances in (e.g. D2000, 3 Shape; Dental Wings 7 series, Dental Wings; IScan
biomaterials, such as zirconia high strength ceramics, has led D104, Imetric 3D SA; Ceramill Map, AmannGirrbach; Activity
to major alterations in education and patient care. According- 850 3D, Smart Optics) and CAM (Computer Aided Manufacture)
ly, the entire dental educational landscape has been and will systems in which the company retains the milling machine unit
continue to be altered relative to economics, time efficiencies (e.g. DWX-50, Roland DGA Corporation; inLab MC X5, Sirona;
and most importantly, predicting postoperative [1,2], clinical M5, Zirkonzahn; Tizian Cut 5 Smart, Schutz Dental; S2 Model,
treatment and delivery. The advantages of CAD/CAM technol- vhf camfacture AG; Ceramill Motion 2, Amann Girrbach).
ogy will be included into three main protocols including digital The chairside CAD/CAM system is further classified into (1)
impressions [312], digital models, and virtual articulators and chairside CAD/CAM system in which the company has its own
facebow [1319] as illustrated in Fig. 1. scanner and milling units (Sirona and Planmeca); and (2)
Furthermore, prosthodontic care has become a complex image acquisition system in which the company has only a
integration of sequential techniques involving the patient, scanner without designing capabilities (e.g. True Definition
student clinician, faculty clinician, and commercial laboratories Scanner, 3M ESPE; iTero, Align Technology, Inc; Trios, 3Shape;
at multiple levels. Therefore, the purpose of this study is to Apollo DI, Sirona; CS 3500, Carestream Dental LLC). These in
review the current published literature investigating the various turn must be connected to an open laboratory scanner for
methods and techniques for scanning, designing, and fabrica- designing of the restoration.
tion of CAD/CAM generated restorations along with detailing the CAD/CAM can be further classified into open and closed
new classifications of CAD/CAM technology. It must be noted systems [21] according to data sharing. Closed systems offer
that there are significant and broad variations in acquisition all CAD/CAM procedures, including data acquisition, virtual
systems, CAD design mechanisms, and CAM fabrication design, and restoration manufacturing by the same company.
processes. Accordingly, it should be stated that every system Furthermore, all the steps are integrated into one system, and
may not be capable of developing the full range of restorations there is no interchangeability between different systems from
necessary to address individual prosthetic solutions. other companies. Open systems allow the adoption of the
original digital data by CAD software and CAM devices from
different companies.
2. CAD/CAM components The laboratory CAD systems must always be an open
system because after acquiring the data and designing the
CAD/CAM systems are composed of three major parts: (1) a data restoration, the data has to be stored in an STL file
acquisition unit, which collects the data from the area of the (STereoLithography or Standard Tessellation Language. How-
preparation, adjacent and opposing structures and then con- ever, many manufacturers use their own specific data formats,
verts them to virtual impressions [20] through intraoral scanners with the result that data for the construction programs will not
(in-office CAD/CAM or in-office CAD or image acquisition be compatible with each other [22]) and then sent to an open
systems) or indirectly by means of a stone model generated laboratory CAM system, which accepts that type of STL file
through making a conventional impression; (2) software for from that laboratory CAD system where the restoration will be
designing virtual restorations on a virtual working cast and then fabricated. Additionally, the image acquisition unit is always
computing the milling parameters; and (3) a computerized an open system, and the STL file of a certain restoration can be
milling device for manufacturing the restoration from a solid accepted by an open laboratory CAD system for the restoration
block of restorative material or additive manufacturing. to be designed and then sent to an open CAM system for the
restoration or model to be fabricated.
When complex restorations are intended to be fabricated
3. General classification of CAD/CAM systems such as an implant bar or attachments, the model can be
scanned through open laboratory CAD/CAM or laboratory
The CAD/CAM systems are classified into laboratory systems CAD systems and the STL file sent to an outsource
and chairside systems. The laboratory system is further production center (e.g., InfiniDent, Sirona; Procera, Nobel

Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont
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journal of prosthodontic research xxx (2016) xxxxxx 3

Fig. 1 Summary for the main advantages of CAD/CAM technology.

Biocare; Lava, 3M ESPE; TurboDent, Pou-Yuen and U-Best Laboratory scanners are classified into (1) optical scanners
Dental; Ceram M-center, Amann Girrbich; PlanEasyMillTM, which use the projection of a measuring light grid onto dental
Planmeca) for restoration designing and fabrication. Fur- structures under a definite angle causing a depth-dependent
thermore, when the digital model is intended to be phase shift of the grid, which the camera registers on its digital
fabricated through scanning of the teeth intraorally, the sensor. The computer calculates the 3D data of the dental
STL file of the image acquisition unit or open chairside CAD/ structure from the image of the depth modulated measuring
CAM system can be sent to an outsource production center grid; and (2) mechanical scanners, in which with the scanner
for the digital model to be fabricated through milling or (e.g., Procera Scanner from Nobel Biocare), is capable of
additive technology. reading a master cast mechanically line by line by means of a
ruby ball in order to obtain 3D measurements.

4. Classification of scanners
5. Protocol for scanning
The intraoral cameras are optical scanners and can be
separated into two types [2224] as shown in Table 1: (1) Depending on the system, the clinician has two scanning
single image cameras that record individual images of the options intraorally for developing the final restoration: (1)
dentition. The iTero (Align Technology), PlanScan (Plan- preoperative scanning which provides for incorporating the
meca), CS 3500 (Carestream Dental LLC), and Trios (3 shape) existing anatomical contour and occlusal planes into the final
cameras are single image cameras which record about restoration; and, (2) postoperative scanning of the preparation
three teeth in a single image. To record larger areas of only with the CAD design being extrapolated from selected
the dentition, a series of overlapping individual images are data points in the acquired image, and which may be
recorded such that the software program can assemble combined with an internal library of tooth anatomic designs
these into a larger three-dimensional virtual model. The contained within the computer data base.
camera is positioned in different angles to ensure accurate The patient receives a standard preparation of the
recording of data below the height of contour that would be abutment tooth according to Table 2 under clinical criteria
hidden from the camera if only an occlusal view was [25]. The preparation margins can be exposed by a cord
obtained. Those areas not visualized by the camera in the retraction technique (use of retraction cords with double or
overlapping images would then be extrapolated by the single cord techniques) or cordless retraction technique
software program to fill in the missing data areas in (Expasyl, Kerr; Racegel, Septodont; Traxodent, Premier; Gingi-
the virtual mode; and (2) video cameras which are used Trac, Centrix). Once the margin has been exposed, the
by the True Definition scanner (newest version of the Lava operator maneuvers the control to allow the scanner tip to
Chairside Oral Scanner, COS), Apollo DI (Sirona) and slide over the tooth in multiple directions depending on the
OmniCam (Sirona) systems. The difference between manufacturer sequential protocol for capturing the images
intraoral scanners is noted in Table 1. because most systems need a particular scanning path to

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4 journal of prosthodontic research xxx (2016) xxxxxx

Table 1 Comparisons of different in-Office CAD/CAM systems. All the cameras can get full arch scan and they can scan
implants intraorally except PlanScan. The Trios, iTero, and True Definition Scanners can perform orthodontic analysis.
Open/close Color Portable Type of CAD/CAM Acquisition Powder Color Imaging type
system matching technology required image
CEREC Omnicom Closed No No Digital imaging and White light No Yes Filming (Video)
(Sirona) in-office
manufacturing
PlanScan Open No Yes Digital imaging and Blue Laser No No Filming (Video)
(Planmeca) in-office
manufacturing
Trios Color (3 Shape) Open Yes Yes Image acquisition unit Blue LED No Yes Photographing
(multiple images)
iTero (Align Open No No Image acquisition unit Red Laser No Yes Photographing
Technology) (multiple images)
True Definition Open No No Image acquisition unit Blue LED Yes No Filming (Video)
Scanner (3M ESPE)
CS 3500 (Carestream Open No Yes Image acquisition unit White LED No Yes Photographing
Dental LLC) (multiple images)
Apollo DI (Sirona) Closed No No Image acquisition unit NAa Yes No Filming (Video)
a
NA = information not available.

Table 2 Guidelines of tooth preparation for CAD/CAM generated restoration.


Criteria Recommendation Reasons
1. Incisal/occlusal reduction It depends on material typea and Not enough preparation will result in fracture of the
restoration designb (it ranges from restoration
0.5 mm to 1.5 mm)
2. Axial reduction It depends on material typea and Not enough preparation will result in fracture of the
restoration designb (it ranges from restoration
0.5 mm to 1.5 mm)
3. Total convergence angle It should be between 48 and 68 Parallel axial walls will confuse most scanners and may
prevent accurate scanning of the preparation
4. Morphology of internal It should be rounded Sharp line angles on the occluso-axial surface should be
line angle avoided because the milling bur, which has a specific
diameter, will remove excessive material in trying to
reproduce detailed design configuration and a sharp line
angle, thereby causing an over-milled restoration which
can result in structurally compromised areas and
improperly fitting restoration.
5. Morphology of gingival It should be either a rounded The 908 internal angle (sharp internal angle) is
margin shoulder or a deep chamfer contraindicated because of the same reason previously
mentioned about the sharp line angle at the occluso-axial
line angle.
Trough or gutter margins should be avoided because they
may prevent accurate scanning of the preparation.
Knife-edge or feather margins are not acceptable because
they do not allow for adequate areas for porcelain build-up
or enough thickness of the margin of the milled ceramic
restoration.
a
Zirconia, glass-ceramics, metal, composite resin.
b
Restoration design: monolithic (full contour restoration), reduced restorations, copings/frameworks.

achieve accurate scanning results. After the scan of the of the teeth and implants without any models, Method 2
prepared tooth is completed, the antagonists of the opposing involves scanning of the teeth plus fabrication of digital
arch are scanned in the same exact manner. models, Method 3 involves a physical impression plus
The information for the development of a CAD/CAM scanning, and Method 4 involves a physical impression plus
restoration may be also acquired extraorally from the final scanning of its stone working casts.
impression or working cast. Additionally, some scanners can In Method 1 [2729], the maxillary and mandibular arches,
record a glossy, reflective surface such as a titanium abutment including teeth and implants, are scanned using an intraoral
while other types require an opaquing powder [26]. scanner or image acquisition unit. The virtual interocclusal
The transfer of the image from the tooth to the final record is attained through a buccal scan in which the patient is
fabrication of the restoration can be divided into four methods instructed to close into maximum intercuspation and the
as illustrated in Table 3, in which Method 1 involves scanning facial aspect of the opposing quadrants in this static position is

Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont
Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.01.003
JPOR-319; No. of Pages 13
Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.01.003
Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont

Table 3 Methods for scanning physical casts, physical impressions and teeth intraorally.

journal of prosthodontic research xxx (2016) xxxxxx


Digital Impression Physical Impression

Method 1 Method 2 Method 3 Method 4


1. Type of impression Scan of the teeth and Scan of the teeth and Scan of the full arch impression tray including Impression of teeth and
implants using chairside implants using chairside teeth only using laboratory scanner implants
scanner or image acquisition scanner or image acquisition
unit and then sending the unit and then sending the
STL file to a laboratory STL file to a laboratory
scanner or outsource scanner or outsource
production center production center
2. Type of interocclusal Virtual record which is used Physical record which is Physical record which Physical record which is Physical record which is
record on virtual articulator used on physical articulator is scanned for virtual used on physical used on physical articulator
articulator articulator for Option 1 only
3. Type of working casts Virtual casts Polyurethane casts using Virtual casts Polyurethane casts using Stone casts using vacuum
milling or 3D printing milling or 3D printing mixing of gypsum products
4. Mounting of maxillary Virtual mounting with Option 1 Virtual mounting with Option 1 Option 1
and mandibular virtual articulator virtual articulator Option 2
casts + transfer of the
maxillary and
mandibular casts to
the laboratory scanner
5. Indications Full contour restorations Full contour restorations, Full contour Full contour Full contour restorations,
and copings/frameworks restorations restorations, and and copings/frameworks
copings/frameworks (Option 1 only)
Option 1: The maxillary cast is mounted to The physical articulator using a physical facebow, and the mandibular cast is mounted to the upper cast using a standard physical inter-occlusal record.
Depending on the type of laboratory scanner used, the physical articulator is then inserted with mounted maxillary and mandibular casts into the laboratory scanner or the mounted maxillary and
mandibular casts are transferred from the physical articulator via a transfer kit or plate which is then inserted into the laboratory scanner. Option 2: The maxillary and mandibular casts are inserted
without an interocclusal record into the laboratory scanner, and then scanned with virtual mounting of the casts on the virtual articulator.

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6 journal of prosthodontic research xxx (2016) xxxxxx

scanned. This method is mainly indicated for monolithic prove that the restoration margin accuracy from scanning the
restorations only. impression is enhanced, and may be decreased if there is an
For implant crowns, the healing abutments with optical undercut in the preparation.
markers can be directly scanned or the dentist can digitally In Method 4 [34,36,37], the physical impressions are poured
capture a scan body seated on the implant. A scan body is a with gypsum products including teeth and implants. The
plastic or metal coping with markers that provide 3D maxillary and mandibular casts can be managed with two
registration of the implant location [30,31]. All intraoral different protocols: (A) the maxillary cast is mounted to the
scanners are able to scan implant scan bodies, but the physical articulator using a physical facebow, and the
difference is the compatibility of the intraoral scanner with mandibular cast is mounted to the upper cast using a physical
the different implant manufacturers. For example, the Sirona interocclusal record. Once again, depending on the type of
CAD/CAM system has the ability to scan for implant abutment scanner used, the physical articulator is inserted with
fabrication with the chairside scanner CEREC Omnicam such mounted maxillary and mandibular casts into the laboratory
as Certain1 (external connection), Astra Tech OsseoSpeed, scanner or the mounted maxillary and mandibular casts are
and Frialit/Xive. Once the scan body, indicating the implant transferred from the physical articulator via a transfer kit or
level position in the jaw, is recorded, the 3D data file can be plate which is then inserted into the laboratory scanner. (B)
used to design and mill the crown. Either this can be done The maxillary and mandibular casts are inserted without an
chairside, in the office by an assistant or dental technician or interocclusal record into the laboratory scanner, and then
the file can be sent to a CAD/CAM equipped laboratory or scanned with virtual mounting of the casts on the virtual
production center for abutment and crown fabrication which articulator. This method is the most common used and is
may include fabrication of a monolithic abutment crown. indicated for monolithic and coping/framework restorations.
Alternatively, healing abutments with optical markers can be Flugge et al. [38] reported that scanning with the intra-oral
scanned with an intraoral scanner and generate implant scanner (iTero) is less accurate than scanning with the
abutments and cement-retained restorations without the use laboratory scanner (D250) because of the presence of saliva,
of impression materials, dental stone, or implant impression blood, movable gingiva, and translucency of the teeth.
copings and analogs [32]. A study reported that the implant Intraoral scanning with the iTero is less accurate than model
definitive casts fabricated from the encoded healing abutment scanning with the iTero. For treatment planning and
impressions were found to be less accurate than those manufacturing of tooth-supported appliances, virtual models
fabricated from an open tray with the splinted impression created with the iTero can be used. An extended scanning
copings technique for restoring 2 paired (108 or 308) convergent protocol can improve the scanning results in some regions
internal connection implants with non-engaging screw- [38]. Data acquired by intraoral scanning, computed tomogra-
retained splinted 2-unit implant restorations. Accuracy of fit phy, cone-beam computed tomography, and extraoral surface
was not influenced by the implant angulation or position for scanning can be combined for implant treatment planning [39]
either impression technique or by the encoded healing to ensure the effective positioning of implants relative to
abutment height for the encode impression technique [33]. anatomic structures such as mandibular canal and maxillary
In Method 2 [34,35], as noted in Table 3, this construction sinus.
method allows the fabrication of polyurethane working casts.
Following an intraoral scan of the maxillary and mandibular
arches including teeth and implants using an image acquisi- 6. Virtual articulators and facebows
tion unit or CAD/CAM system, the images are electronically
transmitted using an STL file to the laboratory CAD system or The facebow is used in conjunction with an articulator to
outsource production center. Polyurethane working casts are relate the maxillary arch to the axes of the condylar hinge axis
then fabricated either by milling or additive manufacturing. in the three planes of space. A facebow is a mechanical device
Once, the working casts are developed, the maxillary cast is that uses a tripod location for the two posterior references by
mounted to the physical articulator using a physical facebow, approximating each of the TMJs and an anterior reference
and the mandibular cast is mounted to the upper cast using a point to relate the maxillary cast vertically to the selected
standard physical interocclusal record. Depending on the type horizontal reference plane. This transfer is critical for
of laboratory scanner used, the physical articulator is then extensive oral rehabilitation [13] and can be done by two
inserted with mounted maxillary and mandibular casts into methods. The CAD/CAM virtual articulator replicates a fully
the laboratory scanner or the mounted maxillary and adjustable mechanical articulator.
mandibular casts are transferred from the physical articulator The first method requires that the mechanical facebow be
via a transfer kit or plate which is then inserted into the adapted to the patient and then transferred to the mechanical
laboratory scanner. This method is considered the best articulator to mount the maxillary cast. Subsequently, the
because of the advantages of polyurethane casts. mechanical articulator is transferred to the virtual articulator
In Method 3 [34], the physical impressions including teeth by inserting the mechanical articulator with the mounted
only are scanned with a laboratory scanner. A standard maxillary and mandibular casts (e.g., inEos X5, Sirona) or the
interocclusal record is also obtained. This method offers a dual maxillary and mandibular cast are fixed with a transfer
option. The first option is that the physical record is scanned assembly (Ceramill map400, Amann Girrbach) or plate (e.g.,
with the impression to generate 3D virtual casts; and the D2000, 3 Shape) individually depending on the type of
second option follows the same protocol as Method 2. This laboratory scanner. This method cannot be used for complete
method is not recommended because there is no literature to dentures. Several companies have customized a virtual

Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont
Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.01.003
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journal of prosthodontic research xxx (2016) xxxxxx 7

articulator for their CAD/CAM system. Examples of companies general forms of tooth morphology provided by these CAD/
using this practice are Amann Girrbach, Smart Optics, and CAM systems can provide only basic shapes. There is always
Zirkonzahn. Therefore, the selection of the mechanical some manual alterations and modifications required because
articulators should be based on the type of laboratory scanner every patient is unique, and every tooth has its own
in which the corresponding transfer assembly or plate specific morphological features that are unique for the patients
to the articulator which will match the same type of virtual system [40,41]. The alternative method is to use the database
articulator for minor post-operative adjustment after fabrica- of the biogeneric tooth morphology to identify and imitate the
tion of the restorations. This method is indicated for copings/ individual occlusal morphology of a patient. With the digital
frameworks, layered restorations, or when additive technolo- CAD model being visible on the computer monitor, it can be
gy is intended to be used. rotated in three dimensions as well as magnified to evaluate
The second method is implementing a virtual facebow critical areas of the model prior to transmitting the file to the
using optical scanning and novel methodology based on manufacturing process. Furthermore, the recommended die
reverse engineering by scanning six points with a reference spacer thickness can be selected [42] thereby eliminating the
head plus transverse horizontal axes to transfer the exact use of manual application of die spacer with different colors.
position of the maxillary cast to the virtual articulator. The
maxillary and mandibular arch are scanned with an optical
scanner (intraoral scanner) connected to a personal computer 8. Digital fabrication processes
with specific software. Three extraoral points are determined
on the patient head (two points on the temporomandibular This is the last phase of the dental CAD/CAM process. It
joints and one at the infraorbital point just below the left eye) involves developing a restoration from a CAD model into a
in order to generate the horizontal plane. Then, articulating physical part that undergoes processing, finishing, and
paper is placed on the flat metal facebow fork, which is placed polishing before being inserted into the patients mouth
on the maxillary teeth, and three intraoral points (most [40]. The two primary methods used to fabricate these
prominent cusps) are determined to generate the occlusal restorations may be subtractive (milling and grinding) or
plane. The total of six points can create a cranial coordinate additive manufacturing (Rapid Prototype, RP or 3D printing) as
system with different reverse engineering software in which illustrated in Table 4.
the cranial coordinate system of the patient is in coincidence Milling/machining technology is a type of restoration
to the cranial coordinate system of the virtual articulator. fabrication that utilizes subtraction manufacturing technolo-
Therefore, the maxillary digital cast is transferred to the gy from large solid blocks. The technology dentists and
virtual articulator software (virtual mounting of maxillary cast technicians are familiar with is computer numerically
into virtual articulator in centric occlusion). Finally, the controlled machining (CNC), which is based on processes in
patient is instructed to close his/her mouth in centric which power-driven machine tools are used with a sharp
occlusion and the buccal scan (digital occlusal record) is cutting tool to mechanically cut the material to achieve the
performed from three different directions (right, left, front) desired geometry with all the steps controlled by a computer
using intraoral scan to orient the mandibular digital cast to the program. The selection of milling materials is based on
maxillary digital cast on the virtual articulator in centric application as illustrated in Table 5.
occlusion (virtual mounting of mandibular cast to maxillary The milling units are categorized into two classifications
cast) [1417]. This method is indicated for full contour according to Fig. 2: (A) dry/wet/milling and grinding in which
restorations to be fabricated with milling only. some milling materials need dry milling and others need wet
milling (according to Table 5) or (B) number of axes (3 axes or 4
axes or 5 axes) in which both the 4 axes and 5 axes move
7. Design software linearly up and down through different axes (X, Y, Z). The main
difference is the number of rotations, the block/disc can rotate
Special software is provided by the manufacturers for the design around X axes only (A rotation), but in the 5 axes, the block/
of various kinds of dental restorations. With different software disc rotates around X axes (A rotation) and the spindle rotates
from different manufacturers, various designs can be imple- around Y axes (B rotation). The main difference between 4 axes
mented such as copings and fixed partial denture (FPD) and 5 axes milling units is illustrated in Table 6. Furthermore,
frameworks, full anatomical crowns and FPD, inlays, onlays, restorations milled with a 5-axial milling unit have a greater
veneers, table-tops and non-prepared veneers, temporaries accuracy than those milled with a 4-axial milling unit because
including FPD and pontics, diagnostic wax-up including physical 5-axial milling unit can mill undercuts in all directions [43].
models, post and core, telescopes, customized abutments with Not all 5 axes milling units are the same because of differences
positioning guides, implants FPD and bars, implant planning in the amount of A and B rotations.
with surgical guides, removable partials, denture design A rotary cutting instrument with a smaller diameter results
including impression trays, splints, model builder (crown and in a more accurate milling process [44]. The main disadvan-
FPD/Implants), orthodontics and appliances can be designed. tage of milling technology is the milling procedure accuracy is
The final anterior restorations can be fabricated through a copy dictated by the diameter of the smallest bur [45]. Therefore,
scan of the models of temporary restorations to compensate for any surface details less than the diameter of the milling bur
the anterior guidance table and silicone matrices. will be overmilled, and it will contribute to low retention of the
In these systems, multiple tooth morphologies are avail- restoration. There is a difference between in-office and
able in their own internal digital libraries. However, the laboratory milling units in terms of the number and the types

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Table 4 Comparison between milling and 3D printing.


Subtractive technology Additive technology 3D printing
milling and grinding
Chromium Cobalt Removable Partial Framework No Yes through Direct Metal Laser Sinteringa
(DMLS)
Chromium Cobalt Copings, Crowns, Bridges Yes Yes through DMLS
Complete Dentures Yes (Weiland, AvaDent) Yes (Pala, Dentca)
Digital Models Yes Preferred through StereoLithogrAphya (SLA),
Scan, Spin and Selectively Photocuringa
(3SP), PolyJeta, Direct Light Projectiona (DLP)
Burnout Pattern for Copings/Frameworks, Yes by wax or resin Yes by photopolymeric resin through DLP
Crowns, FPD, Inlays, Onlays, Veneers,
Removable Partial Framework
Zirconia Restoration Yes No
Glass-Ceramic Restoration Yes No
Titanium Abutments Yes No
Titanium Bars Yes No
Wax-up Yes Yes through DLP
Provisional Restorations Yes Yes through DLP
Splint Yes No
Custom Trays No Yes through PolyJet
Surgical Drill Guide Yes Preferred through PolyJet, DLP
Advantages It is available for all types of (1) Finer detail reproduction (undercuts,
materials better anatomy), (2) more economical than
milling, (3) more mass production (greater
numbers of units), (4) larger objects produced
(facial prosthesis), (5) better passive
production (no force application), (6) can
reproduce complex shapes without requiring
special cutting tool, (7) unlimited geometry
options, (8) faster than milling, and (9) print
exactly as designed without waste.
Disadvantages (1) The thinnest part of the It is not available for ceramics and titanium
restoration is limited by the size of metals
the bur; if the thinnest part is
smaller than the smallest bur, it
will result in over-milling and
cause loose fit restoration, (2)
expensive for using glass-ceramic
blocks, and (3) require expensive
CAM unit.
a
Different techniques of additive technology.

of burs, number of axis (4 or 5 milling axis), wet/dry, milling/ because of shrinkage during building, postcuring, and mini-
grinding. mal thickness of the layers.
Anadioti et al. [34] reported that the internal gap obtained There are several techniques that can be involved in the
from the lava digital impression/pressed crowns group additive technology including Direct Metal Laser Sintering
(0.211 mm  SD 0.041) was significantly greater than that (DMLS), StereoLithogrAphy (SLA), Scan, Spin and Selectively
obtained from the other groups (P < .001), while no significant Photocuring (3SP), PolyJet, and Direct Light Projection (DLP).
differences were found among silicone impression/pressed The primary difference is related to developing the z-plane,
crowns (0.111 mm  SD 0.047), silicone impression/CAD/CAM which represents the vertical components of the restorations
fabricated crowns (0.116 mm  SD 0.02), and lava digital [46]. Printing a digital model is more accurate than milling [35]
impression/CAD/CAM fabricated crowns (0.145 mm  SD 0.024). and more accurate than conventional plaster models [47].
Additive manufacturing is defined as the process of joining However, the fabrication of an implant surgical template is
materials to make objects from 3D model data, usually layer fabricated more accurately using five-axis milling than rapid
upon layer [46]. Once the CAD design is finalized, it is prototyping [48]. Printing can be used for soft tissue models for
segmented into multislice images. For each millimeter of implant cases, and the socket can be prepared for the implant
material, there are 520 layers in which the machine lays analog to be inserted. Furthermore, the patient name and the
down successive layers of liquid or powder material that are record number can be inscribed on the virtual model. Based on
fused to create the final shape. This is followed by further the final crown design, a preparation guide can be easily
refinement to remove the excess material and supporting created to help the dentist to validate the shape and size of the
frame. The main problem with this type of manufacturing is preparation. The abutment design can be improved by
that it can cause differences in the final model production visualizing the osseous structure.

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journal of prosthodontic research xxx (2016) xxxxxx 9

Table 5 The milling materials can be classified according to application, cutting tool, dry/wet/milling/grinding with hard
or soft protocol.
Main applications Cutting Milling/ Milling/grinding (wet/dry)
tool grinding
(hard/soft)
Presintered zirconia1,2,3 Copings/frameworks, crowns, Diamond or Soft milling Dry because wet milling will
inlays, onlays, FPD, abutments carbide bur cause softening
Fully sintered zirconia 1 Copings/frameworks, crowns, Diamond bur Hard milling Wet because dry milling will
inlays, onlays, FPD cause cracks and fracture
Chromium cobalt1,2 Copings/frameworks, crowns, Carbide bur Soft or Hard Dry or wet milling which
FPD milling depends on milling type (hard
or soft)
Titanium2,4 Implant abutments and bars Carbide bur Hard milling Wet milling to keep the tools
from overheating/breaking
Polymethylmethacrylate Provisional restorations, Carbide bur Hard milling It can be both but preferred dry
(PMMA)1,2 burnout pattern (casting, because wet milling will cause
pressing, overpressing), splint, undesired residue
complete dentures, verification
of the final prosthesis
intraorally
Polyurethane (PU) 2 Digital models Carbide bur Hard milling It can be both but preferred dry
because wet milling will cause
undesired residue
Wax1,2 Burnout pattern or diagnostic Diamond or Soft milling Dry because wet milling will
wax-up carbide bur cause undesired residue
Composite resin1,2 Crowns, inlays, onlays, veneers Carbide bur Hard milling It can be both but preferred dry
(e.g., Paradigm MZ 100, because wet milling will cause
Ceramill Comp) undesired residue
Zirconia reinforced lithium Crowns, inlays, onlays, veneers Diamond burs Hard grinding Wet because dry milling will
silicate, ZLS1 (e.g., Celtra cause cracks and fracture from
DUO) heat
Zirconia reinforced lithium Crowns, inlays, onlays, veneers Diamond burs Hard grinding Wet because dry milling will
disilicate1 (e.g., Vita cause cracks and fracture from
Suprinity) heat
Lithium disilicate based Copings/frameworks, crowns, Diamond burs Hard grinding Wet because dry milling will
glass-ceramic1 (e.g., e. inlays, onlays, anterior FPD, cause cracks and fracture from
max CAD) veneers heat
Lithium silicate based Crowns, inlays, onlays, veneers Diamond burs Hard grinding Wet because dry milling will
glass-ceramic1 (e.g., cause cracks and fracture from
Obsidian) heat
Leucite based glass- Crowns, inlays, onlays, veneers Diamond burs Hard grinding Wet because dry milling will
ceramic1 (e.g., IPS cause cracks and fracture from
Empress CAD) heat
Resin reinforced feldspathic Crowns, inlays, onlays, veneers Diamond burs Hard grinding Wet because dry milling will
ceramic1 (e.g., Vita cause cracks and fracture from
Enemic, Lava Ultimate) heat
Processing materials can be fabricated in block (1), disc (2). As the strength of zirconia increases, the translucency drops so there are 3 forms of
zirconia (3): very translucent (anterior copings/frameworks, crowns, FPD), translucent (posterior copings/frameworks, crowns, FPD),
traditional (bruxer patients, conceal dark dentin). Titanium (4) can be present as pure for implant abutments and alloy for bars.

Regarding the removable partial denture, the framework After the coping and framework are fabricated through
design is drawn on the working cast and then scanned using a additive technology (printing of the resin copings and
laboratory scanner. The framework is always fabricated by frameworks, and then pressed later with glass-ceramic) or
printing a photopolymeric framework and then cast with milling/grinding, the veneering porcelain can be fabricated by
chromium cobalt, or the framework can be printed directly three different methods (Fig. 3) to include traditional layering
from chromium cobalt through Direct Metal Laser Sintering. of porcelain, pressing technique (manual wax-up of the
Complete dentures can be fabricated digitally; as certain pattern or printing/milling of the resin pattern to be pressed),
clinical procedures are performed according to the manufac- and the CAD-on veneering technique (the computer will
turers of the digital dentures, then the complete dentures are calculate the interocclusal distance between the prepared
fabricated [4955]. Some companies can mill the denture base tooth and opposing tooth/prepared tooth), then the computer
and then bond the prefabricated denture teeth to the recesses will design both the coping/framework and veneer porcelain
of the milled denture base (Weiland and AvaDent), or both the at the same time. The copings/framework will be milled from a
denture base and teeth are milled as one unit (AvaDent). An zirconia disc and the veneer porcelain (CAD-on veneer) will be
alternative method is 3D printing of the base and the teeth as milled from a lithium disilicate block. The two parts will be
one unit (Pala and Dentica). attached to each other using fusion glass or luting cement. The

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10 journal of prosthodontic research xxx (2016) xxxxxx

Fig. 2 Classifications of subtractive technology. The soft and dry milling, and grinding strategy is dictated by the material
type, while the number of milling axes is dictated by the design of the dental restoration.

Table 6 Classification and comparison of milling units according to the number of axes.
Four axes milling unit Five axes milling unit
Dry/wet It can be wet (chairside) or dry (laboratory) Always dry and wet
Maintenance Low High
Weight Lighter Heavier
Applications General dentistry: veneers, inlays, onlays, In addition to general dentistry, it can mill
copings/frameworks, crowns, fixed partial attachments, implant abutments,
dentures telescope crowns, splints, models, bars,
screw retained implant crown and FPD,
surgical drill guide
Linear movement and rotations Three spatial directions X, Y, Z and Three spatial directions X, Y, Z, tension
tension bridge A (rotation around X axes) bridge A (rotation around X axes) and
milling spindle B (rotation around Y axes)
Cost Cheaper More expensive
Milling of sharp angles and Yes (one direction which is less accurate) Yes (different directions which are more
undercuts accurate)
Number of cutting tools Less More
Milling time Short Long
Milling accuracy Low High
Chairside milling unit Yes No
Laboratory milling unit Yes Yes
Processing material: block Yes (chairside and laboratory) Yes
Processing material: disc Yes (laboratory only) Yes

CAD-on veneering technique is becoming more popular


because of (1) absence of voids or defects [56], (2) ensures 9. Limitations and future CAD/CAM
an even thickness of the veneer porcelain (veneer to core technology
thickness ratio), (3) no effect of cooling rate, (4) less number of
firings, (5) no need for liner, (6) lower coefficient of thermal The cameras are line of sight, which means that the camera
expansion, CTE (closer to the CTE of zirconia) than pressed and can only record what is visible to the camera lens. Therefore,
layered porcelain, (7) resistant to aging, and higher bond those structures or margins obscured by saliva, blood, or soft
strength between the veering ceramic and zirconia as tissue are not visible to the camera and will not be accurately
compared to layering and pressing techniques [57,58]. recorded [23,59,60]. The absence of glass-ceramics in a disc

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journal of prosthodontic research xxx (2016) xxxxxx 11

Fig. 3 Methods for veneering copings and frameworks.

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Please cite this article in press as: Alghazzawi TF. Advancements in CAD/CAM technology: Options for practical implementation. J Prosthodont
Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.01.003