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Computer Aided Designing-Computer Aided Milling in Prosthodontics: A

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 Review Article

Computer Aided Designing-Computer Aided Milling

in Prosthodontics: A Promising Technology for Future
Himanshu Aeran1, Varun Kumar2, Jyotsna Seth3, Abhishek Sharma4
1
Director Principal, Professor and Head, Department of Prosthodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India, 2Reader,
Department of Prosthodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India, 3Senior Lecture, Department of Prosthodontics,
Seema Dental College and Hospital, Rishikesh, Uttarakhand, India, 4Consultant Dental Surgeon, Dr. Garg Dental Clinic, New Delhi, India

Computer aided designing-computer aided milling (CAD-CAM) technology was introduced to dentistry way back in 1971. Over the years there
has been a constant upgradation in the quality and popularity of its application to dentistry. CAD-CAM fabricated prosthesis though initially
were considered costly and technique sensitive, nowadays they are being extensively used because of advancements in various CAD-CAM
systems that have gained popularity. The ease of work and reduced chair side time makes them a boon while providing prosthodontics
treatment. Dental CAD-CAM systems are being used not only for crowns and bridges, inlays and onlays but also for fabrication of removable
prosthesis, stents, and implant components. This article reviews the evolution of the CAD-CAM system and its applications in the field of
dentistry over the past two and a half decades.

Keywords: Computer aided designing-computer aided milling, Crowns, Inlays, Onlays, Rapid prototyping, Stereolithographic image,
Standard tessellation language format, Surgical stents

INTRODUCTION From 1971 Duret started fabrication of crowns in which

CAD refers to computer aided designing, CAM refers
to computer aided milling or machining. This process
is sometimes referred to as CAD-computer-integrated
manufacturing (CIM) process, where CIM refers to
computer integrated machining or milling. Ever since
the introduction of CAD-CAM to dentistry, there has
been a constant phase of advancement to the technology.1
CAD/CAM technology fabricates prosthesis directly from
the data obtained from the patient’s mouth. CAD CAM has
been used not only for replacement of missing or cavitated
dentition, but also for the fabrication of maxillofacial
prosthesis, for implant prosthesis and also for numerous
research studies.
HISTORICAL BACKGROUND
The CAD/CAM technology was introduced by Duret in
1971 in restorative dentistry and in 1983, the first dental
CAD/CAM restoration was manufactured. 1,2 Initially
CAD-CAM was used for large industrial projects that has
made their production easier and faster. Unlike today,
dental CAD-CAM was not very popular due to a number
of factors that included: The cost of the equipments and
the time needed, the precision needed while recording the
details of the site of preparation of the restoration, precision
in the final milling of the accurate restoration.3
occlusal surface was made using an optical impression
of the abutment tooth in the mouth, and designing was
planned using functional movements, Duret then milled
a crown with a milling machine that was coordinated
numerically. The Sopha system developed by Duret became
a landmark in the development of the current dental
CAD/CAM.1,2
In 1979, Heitlinger and Rodder milled the equivalent of the
stone model to make the crown, inlay or pontic. In 1980,
Moermann et al. took a single picture of the tooth preparation
and milled only the internal surface of the inlay.4
The CEREC 1 system was the first to be introduced for
dental purpose that marked a landmark in the mid 1980’s.
It was developed by Siemens Corporation. The ceramic
reconstruction or CEREC system stands for “Chair side
economical restoration of esthetic ceramic” and was first
introduced in 1987.4 Siemens Corporation later developed
the second generation CEREC 2 system in 1994 and Sirona,
Benheim, Germany brought the third generation CEREC 3
system in 1999. It was originally developed by Brains AG,
and the first fully operational CAD-CAM system marketed
for use in clinical dentistry.5 The CEREC 3 system (Sirona)
has several technical improvements over CEREC 2, including
the three-dimensional (3D) CEREC 3 intraoral camera,
manipulation of the picture, and the grinding unit.

Corresponding Author:
Dr. Himanshu Aeran, Director Principal, Professor and Head, Department of Prosthodontics, Department of Prosthodontics, Seema Dental College
and Hospital, Rishikesh, Uttarakhand, India. Mobile: +91-9837063005, E-mail: drhimanu@yahoo.com

IJSS Case Reports & Reviews | May-June 2014 | Vol 1 | Issue 1 23

 Aeran, et al.: CAD-CAM in prosthodontics
Leinfelder (1989) studied that the CAD-CAM CEREC system
was a small, complex unit developed for electronically
designing and milling ceramic restorations.
The next milestone in dental CAD-CAM systems was
crossed by Dr. Andersson in 1987 who designed the Procera
system. He a empted fabrication of titanium copings by
spark erosion. He introduced CAD/CAM technology for
processing composite veneered restorations. This system
was used around the world for the fabrication of all-ceramic
frameworks for a long time. The current Procera system
developed by Nobel Pharma, Inc., Goteborg, Sweden uses
a copying and fabrication system with a pantograph and
electric discharge machining. The pantograph stylus reads
the die and the shapes of wax pa ern and these shapes are
then feeded into a milling machine to produce electrodes in
these shapes. These electrodes are used for the production of
the final restoration using the electric discharge machining.6
The Dux system, also known as the Titan system developed
by DSC Dental, Allschwill, Switzerland, consisted of a
precision contact digitizing sensor a ached to a computer
system and a milling machine. The Dux system claims to
have an accuracy in the order of 30 (±20) μm and the milling
process takes about 10 min.7
The Celay system developed by Mikrona Technologic,
Spreitenbach, Swi erland in 1990 was a very small unit. It
consisted of a contact digitizer that records the shape of an
acrylic inlay and directly transfers the shape to a milling
machine.7,8
The Denticad system developed by BEGO, Bermen,
(Germany), and Denticad, Waltham, (USA), the Mass system
consisted of a miniature robot arm digitizer, CAD-CAM
software with an expert system for fully automated design
and a milling machine. The robot arm digitizer can be used
intra orally or on traditional models and dies. The CAD-
CAM software and expert system reside in a personal
computer. The milling machine was directly controlled by
the computer.7,9,10
The computer integrated crown reconstruction (CICERO)
system was developed by CICERO Dental System B.V.
(Hoorn, The Netherlands). The CICERO method for
production of ceramic restorations uses official scanning,
ceramic sintering, and computer assisted milling techniques
to fabricate restorations with maximal static and dynamic
occlusal contact relations. The system makes use of optical
scanning, near net-shaped metal, ceramic sintering and
computer-aided fabrication techniques.11
The Coordinate Measuring Technique System developed
by Steinbichler Optotechnik Technique GMBH, Neubeuern,
24
Germany allows the generation of a 3D data record for each
superstructure, with or without the use of a wax pa ern. The
system used a combination of strip projection methods with
triangulation, enabling measurement of the coordinates
of all measurement points recorded by a charge-coupled
device camera not only with high precision but also at a
high speed.7
Lava CAD/CAM System was introduced in 2002. It has
been used for fabrication of zirconia frameworks in all
ceramic restorations. The Lava system utilizes yttria
stabilized tetragonal zirconia poly crystals which has a
greater fracture resistance than the conventional ceramics.
Lava system uses a laser optical system to digitize
information.10,12,13
Current trends and applications of CAD-CAM systems
The Cercon Zirconia system developed by Dentsply
Ceramco, Burlington, NJ, USA is used for the production of
Zirconia - based prostheses. After preparing the abutment
teeth an impression is made and sent to the laboratory,
where it is poured into a model. A wax pa ern is made
for each coping or the crown areas of the framework of a
fixed partial denture. The pa ern is scanned and the blank
is rough-milled and fine-milled on occlusal and gingival
aspects in an enlarged size to compensate for the 20%
shrinkage that will occur during subsequent sintering at
1350°C.14,15
Now-a-days CAD-CAM is also being used for the
fabrication of complete dentures and removable
partial denture frameworks. 16 The removable partial
denture frameworks is made using rapid prototyping,
stereolithographic technique. It was developed by 3D
Systems of Valencia, CA, USA in 1986. A CAD model is
constructed by scanning the impressions of the patient
and stored in standard tessellation language (STL), which
is a stereolithographic image. The Rapid Prototyping
machine processes the STL file by creating sliced layers of
the model. The first layer of the physical model is created.
The model is then lowered by the thickness of the next
layer, and the process is repeated until completion of the
model occurs. The model and any supports are removed
after the completion of the process. The surface of the
model is then finished and cleaned.16-18
Initially the use of CAD-CAM focussed on the fabrication
of fixed restorations such as inlays, onlays, crowns and
bridges. The inability to scan and read the soft tissue and
the interocclusal relationship was a setback in fabrication
of complete and partial dentures. In the recent years,
advancements in the CAD-CAM technology has facilitated
fabrication of complete and partial removable dentures. The
fabrication of complete denture using CAD-CAM involves
IJSS Case Reports & Reviews | May-June 2014 | Vol 1 | Issue 1
 Aeran, et al.: CAD-CAM in prosthodontics

impression making with rubber-base impression material in This STL format is transferred to the milling system that is
a specially designed double impression tray.17 These trays a ached to the computer. The STL data is used for milling
are adjusted at a certain vertical dimension in the patient’s the required prosthesis that has been designed using a
mouth and are then retrieved and transferred to the 3D CAD-CAM software (Table 1).
laser scanning system. The impressions are scanned and
a 3D digital model is obtained. This data can be used for The conventional technique for fabrication of prosthesis
arrangement of teeth after selection of the shade. The 3D involves preparation of abutments, impression making
image is used for development of a 3D model of the denture followed by model production, wax up, and then casting,
to be fabricated and then it is milled using a milling unit.17,19 but the CAD-CAM technology involves direct digitization
of abutment teeth inside the oral cavity instead of taking
INTEGRATED IMPLANTOLOGY conventional impressions. The restorations are designed
on a computer using CAD software based on the digitized
Nowadays there is a greater interest in the CAD-CAM data that acts as a virtual wax-up. The restorations are
systems for implant-supported prosthesis, as they have processed using a computer assisted milling machine. In the
been used for the manufacture of implant abutments more recent times to counteract the difficulty of accurately
and surgical stents in implant dentistry.20 Ideally, the scanning the abutments and the adjacent teeth, stone models
abutment head should resemble a prepared tooth with are poured after impressions and these stone models are
good form, morphology and emergence profile. Proper scanned using the scanning system and the STL image
implant positioning and appropriate preparation of hard thus obtained is used for milling the prosthesis. The entire
and soft tissue is critical to create optimal emergence process of electronic designing and subsequent milling of a
profile, function, esthetics, and periodontal health.21,22 ceramic restoration requires approximately 25 to 30 min.3,27
A custom design, perfect fit and higher resistance are the
main characteristics of CAD-CAM implant abutments. ADVANTAGES OF CAD-CAM SYSTEMS
CAD-CAM surgical templates allow transferring the
software planning to the surgical field.23-26 CAD-CAM technology has brought about a revolution in
the modern dental practice. Use of CAD-CAM serves the
The various types of implant abutments can be classified following advantages.
into three categories:
1. Stock (prefabricated) abutments: They are milled Application of new materials
Advancement and development in the material science
in different materials (titanium, zirconium) using
has constantly motivated to develop newer manipulation
CAD-CAM technology. These are available either
techniques also. Introduction of high-strength ceramics
straight or preangled.
brought into consideration of processing FPD frameworks
2. UCLA (laboratory wax and cast) abutments: They are
but it was difficult to process them using conventional dental
manufactured from a gold platform and a castable sleeve
laboratory technologies. Such high strength dental ceramics
that allows individualizing the shape and height.
could be be er used with the CAD/CAM technology for
3. Computer-milled solid abutment abutments: A solid
processing fixed prosthesis.3,10
block of titanium is milled using a computerized milling
machine to the operator’s specifications.
Table 1: The various CAD-CAM systems, the type of
In the more recent times, CAD-CAM has also been used production unit and the method of scanning used by the
for fabrication of maxillofacial prosthesis using rapid system
CAD-CAM system Type of production Method of scanning
prototyping procedure. Use of CAD-CAM for fabrication
CEREC 1/2/3 Direct in-office Laser
of maxillofacial prosthesis has helped in more accurate
Denticad Direct in-office Contact probe
shade matching and providing precise anatomic features. Sopha Direct in-office Holography and laser
The process involves scanning of the site and the donor Celay Indirect in-office Contact probe
ear using a scanner and transmi ing the STL format into a Procera Industrial outsourcing Contact probe
prototyping machine.20,21 using networks
CEREC in-Lab Dental laboratory Contact probe
CAD-CAM components and procedure 3,27 CICERO Dental laboratory Laser
The CAD-CAM system is composed of a scanning unit Dux Dental laboratory Contact probe
Lava Dental laboratory Laser
that is composed of a high resolution camera that reads
Denti CAD Dental laboratory Contact probe
the finest details of the surface to be scanned. The scanned
Everest Dental laboratory Optical scanner
data is converted into STL format. The STL format is the CAD: Computer aided designing, CAM: Computer aided milling, CICERO: Computer
format that is readable by most of the CAD-CAM software. integrated crown reconstruction

IJSS Case Reports & Reviews | May-June 2014 | Vol 1 | Issue 1 25

 Aeran, et al.: CAD-CAM in prosthodontics
Reduced labor
The application of CAD/CAM technology reduces the
labour cost and the chair side time. The total processing time
is much shorter than that of conventional powder build-up
and baking of porcelain. With regard to particular esthetic
requirements, milled crowns could be completed merely
by staining, using a conventional and simple method. The
esthetic requirements can be more accurately met when
compared to the conventional techniques.3,10
Cost effectiveness
Production of all-ceramic FPDs using a zirconia framework
fabricated by a CAD/CAM process could provide even more
financial benefits to owners of dental laboratories because
they can invest in small measuring machines and not in
large expensive facilities; thus they could concentrate on
conventional porcelain processing.3,10
Quality control
Clinical and in vitro studies using finite element and
fractographic analyses show that the primary causes of
failure reported for all-ceramic FPDs differed from those
reported for the metal-ceramic FPDs. Fractures of ceramic
FPDs tended to occur in the connector areas because of the
concentrated stress. Therefore, the design of the connector,
particularly the dimensions, must be made independently
depending on the type of ceramic material used for the
framework. CAD better guarantees the durability and
reduces the risk of fracture.28,29
DISCUSSION
Over the years there have been significant advancements
in the field of dentistry and dental material sciences.
Dentistry has evolved from crude restorations made of
wires, ivory and wood to the current esthetic dentistry
which involves use of high strength ceramics, dental
implants and medical grade silicones for restoration of
missing teeth and maxillofacial organs.3 Each advancement
has marked a scope for newer and more esthetic restorative
procedure. The current CAD-CAM technology being
expensive is still making its place in the dental market.
In the years to come the current CAD-CAM systems are
expected to completely eliminate or markedly decrease
the conventional all ceramic and porcelain fused to metal
restoration fabrication techniques. CAD-CAM technology
is expected to show more development and help in the
fabrication of even more precise and esthetic restorations
in future. CAD-CAM technology will contribute more
efficiently in the fields of dental implantology and
maxillofacial prosthodontics in the years to come.
Enhancing a patient’s quality of life through dental service
has become the most important factor. We have to offer
more comfortable and higher quality dental services to
26
all patients to maintain their oral function. A positive
application of new materials and advanced technology
is essential for dental service in the future. CAD/CAM
technology will contribute greatly to the health of aging
of patients in future.
CONCLUSION
The advancements in the CAD-CAM systems have
developed not only from the structural level but, also at the
level of precision and applications. During the initial years
when CAD-CAM was introduced in dentistry, their use was
restricted to inlays, onlays and single unit crowns. Over the
past few years CAD-CAM have shown and proved their
utility in restorative, prosthetic, and pre-surgical dentistry.
CAD-CAM technology is being constantly worked upon
and it seems to have a more innovative and advanced future
in the years to come.
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How to cite this article: Aeran H, Kumar V, Seth J, Sharma A. Computer Aided
Designing-Computer Aided Milling in Prosthodontics: A Promising Technology
for Future. IJSS Case Report & Reviews 2014;1(1):23-27.
Source of Support: Nil, Conflict of Interest: None declared.
27