CAD-CAM

Introduction

• The technological changes taking place are truly revolutionizing the way dentistry
is practiced and the manner in which laboratories are fabricating restorations.

• The advent of CAD/CAM has enabled the dentists and laboratories to harness the
power of computers to design and fabricate esthetic and durable restorations.
• The concept of CAD/CAM was invented in 1970s and has already been applied in
the field of dentistry.

• In dentistry for making impressions, casts, and provisional fabrication to the

final restorations. 

• Dental CAD/CAM systems - scanner, software, and a fabrication system.

• Digital workflow records both dentitions to review and evaluate the tooth
preparation and design a restoration.

• Time efficient and eliminates the need for impression

• delivery - same day

CLINICAL APPLICATION

Primary factors to consider while treatment planning

• The type of restoration (inlay, onlay, crown)

• The choice of material to be used

• The desired occlusal relationships

• Ability to isolate the tooth preparation for delivery of the restoration       

• The restorative dentistry application of CAD/CAM technology is the fabrication
and delivery of permanent restorations for teeth

• There are three sequences involved in the CAD/CAM process.

• An intraoral scanner or camera to accurately record the hard and soft tissue
geometry (digital impression)

• A software design program to create a virtual restoration . 

• Computer-controlled device is used to produce the restoration .

INTRAORAL SCANNER EXTRAORAL SCANNER

• direct acquisition of data from • Complete arch can be scanned at a time

prepared teeth • Includes the errors introduced by

• restricted under clinical condition impression and gypsum model making

resulting in less accuracy for complete in addition to error resulting from

arch casts digitalization

Bohner et al, 2017 , JPD, Computer-aided analysis of digital dental impressions obtained from intraoral
and extraoral scanners, pg no 618
INTRAORAL SCANNER EXTRAORAL SCANNER

Trios D250

Cerec bluecam Cerec InEosX5

Production concepts of CAD CAM

• Chairside production

• Laboratory production

• Centralized fabrication in a production center 

 Laboratory production

• Dentist sends the impression to the laboratory where a master cast is fabricated
first. 
• Remaining steps are carried out completely in the laboratory. 
• With scanner, 3D data are produced on the basis of the master die and processed by
dental design software. 
• data sent to a special milling device, produces the real geometry . 
• Exact fit evaluated and, if necessary, corrected on the basis of the master cast. 
Centralized production

• satellite scanners’ in the dental laboratory to be connected with a production centre via
the Internet. 

• Data sets produced in the dental laboratory are sent to the production centre for the
restorations to be produced with a CAD/CAM device. 

• Finally, the production centre sends the prosthesis to the responsible laboratory. 

• Thus, production steps 1 and 2 take place in the dental laboratory, while the third
step takes place in the centre. 
CHAIRSIDE CAD/CAM SYSTEM

• employ all three sequences in the dental office

• record intraoral scans, a software program for designing restorations , milling

units to fabricate the restoration during a single dental appointment.

• designed to leverage the efficiency of a single appointment procedure for the

delivery of ceramic restorations
HISTORY

• Dr. Francois Duret conceptualized the first chairside CAD/CAM system in 1973.

• The first functioning chairside CAD/CAM prototype introduced - 1980s by Dr.

Werner Mörmann, and Marco Brandestini to use CAD/CAM technology to
deliver esthetic ceramic restorations
• The CEREC 1 unit marked the introduction of the CEREC system in 1985

• First color-streaming powder-free intraoral camera -2012, the CEREC Omnicam 

• The E4D Dentist System (D4D Technologies)-2008 with its DentaLogic software
offering a true three-dimensional virtual model.

• The CS 3500 - powder-free intraoral scanner 2013

 CEREC system
CEREC AC acquisition unit.

imaging camera chairside computer

(CEREC Omnicam) with the design
software

sintering and glazing

milling unit (CEREC SpeedFire
sintering furnace)
 E4D Dentist System

separate milling
Intraoral laser mobile Design
unit with a
scanner Center withD
dedicated CAM
entaLogic software
server computer

• The milling unit has two opposing electric motors that

automatically change between three different diamonds
depending on the specifics of the restoration dimensions.
 Carestream 3500 

intraoral scanner :
disposable tip and a CS Solutions Restore
CS 3000 milling unit
guiding light, indicates software
successful scan

dental laboratory via CS Connect

laboratory design programs :
3Shape (3Shape) and Exocad
(Exocad Gmbh).
Clinical application of chairside CAD CAM
systems 
 Tooth Preparation Principle for CAD/CAM Restorations

• smooth contours, rounded transitions, and uniform pulpal floor enhance the
accuracy of the CAD/ CAM restoration due to their influence on the imaging and
fabrication process : -.

• A concept unique to CAD/CAM restorations -- “undermilling” or “overmilling” 

--applied to both grinding and milling processes.

Overmilling where the mill Undermilling where the mill will

will over grind the spike ignore the spike causing a
area creating a marginal premature binding spot preventing
gap full seating of the restoration
 Crown
• same as for laboratory-fabricated ceramic crowns. 

• The margin design for an all-ceramic crown requires a bulk of ceramic at the margin to
avoid the risk of ceramic chipping or fracture. 

• best accomplished with a shoulder, sloped shoulder, or heavy chamfer margin.

• internal angles are rounded to facilitate internal
adaptation of the crown.
• CAD/CAM ceramic crowns :
- Axial reduction - 1 to 1.2 mm
- occlusal reduction-1.5 mm (central fissure
    area
and over nonfunctional cusps)
- 2 mm functional cusps
• Full-contour zirconia crowns : occlusal thickness 1 mm

• manufacturer of lithium disilicate blocks has recently announced that e.maxCAD

crowns now require a 1-mm occlusal reduction; requires independent validation. 

• All angles of the preparation should be rounded to facilitate accurate internal

adaptation and needless overcutting of the internal surface of the crowns during milling
 Inlay and Onlay 

• primarily adhesive-style preparations that rely on the

adhesion of the resin cement to dentin and enamel for
retention of the restoration.

• These preparations are divergent and relatively non-

mechanically retentive in design

• The internal aspect of the preparation should avoid sharp

divots or concavities, and all internal angles should be
rounded.
• Occlusal reduction should be uniform & Preparation :

-1.5 mm in central fossa and nonfunctional cusps,

- 2 mm over functional cusps.

• All cavosurface margins should placed away from the

contact position of the opposing cusps and well defined

• Beveled margins must be avoided

• Preparation isthmus : 2 mm in faciolingual width

• CAD/CAM onlay preparations do not require - ferrule
with the ceramic restoration as used with metal castings . 

• A butt-joint margin is preferred - allows for proper

thickness of the ceramic material at the margin, reducing
the incidence of marginal fracture.
• butt-joint margin causes a visible demarcation
between the tooth and the restoration.

• For esthetic concern, a modification of the facial

butt-joint margin is necessary with a football-shaped
diamond at a 45-degree angle , creating transition of
ceramic thickness over the underlying enamel while
maintaining a bulk of ceramic at the margin
Chairside Restorative Material

• Monolithic materials “blocks” are used chairside CAD/CAM restorations.

• dense, homogeneous materials

• The Vita Mark I blocks were originally created out of feldspathic porcelain and
eventually evolved into the current generation of feldspathic blocks, Vita Mark II. 
Chairside CAD/CAM materials may be divided among a number of categories based on
material composition for ease in understanding their properties and clinical applications. 
ADHESIVE CERAMIC

• Fine grained feldspathic porcelain

• Leucite reinforced porcelain

Fine grained feldspathic porcelain

• contain a significant glass component resulting in increased translucency; have -

improved “chameleon” effect.

• Flexural strength ~ 100 to 175 MPa , fine-grained particle size ~ 4um

• do not have enough inherent physical strength to be cemented with resin-modified

glass ionomer or traditional glass ionomer cements.

• Vita Mark II (Vita) and Sirona Blocks (Dentsply Sirona)

 Vita Mark II (Vita) onlay for tooth #30. A, Preoperative view of tooth #30. B,
Vita Mark II onlay delivered. C, Vita mark II onlay at the 3-year recall. D, Vita
mark II onlay at the 5-year recall

Charlton DG, Roberts HW, Tiba A: Measurement of select physical and mechanical properties of 3
machinable ceramic materials. Quintessence Int 39:573–579, 2008
Leucite reinforced porcelain

• ProCAD (Ivoclar) IPS EmpressCAD (Ivoclar) with a similar crystal structure

as IPS Empress 1 (Ivoclar). 

• EmpressCAD has a finer particle size 1 to 5 um

• two levels of translucency & multishaded blocks.

• Flexural strength -160 MPa

IPS EmpressCAD (Ivoclar) restoration. A,
Onlay preparation for tooth #19. B, IPS
EmpressCAD onlay delivered. C, IPS
EmpressCAD onlay at the 2-year recall.
Higher strength glass ceramic

• Lithium disilicate 

• Zirconia reinforced lithium silicate

• Lithium silicate
IPS e.maxCAD (lithium disilicate )

• significantly greater flexural strength and fracture toughness.

• Provided in partially crystallized state (160 MPa, 40% crystalized by volume) --

for easier and more efficient grinding . 

• After restoration fabrication, subjected to a two-stage firing cycle in a ceramic

furnace under vacuum to complete the crystallization process and achieve the
maximum flexural strength potential of the material (500 MPa). 

• resulting restoration : grain size ~1.5um with a 70% crystal volume

 IPS emaxCAD (Ivoclar) crown for tooth #30. A, Preoperative view of tooth
#30. B, IPS emaxCAD crown delivered. C, IPS emaxCAD crown at 2-year recall.
D, IPS emaxCAD crown at 4-year recall.

Albakry et al: Biaxial flexural strength, elastic moduli, and x-ray difraction characterization of three pressable all-
ceramic materials. J Prosthet Dent 89(4):374–380, 2003

Belli R et al: Mechanical fatigue degradation of ceramics versus resin composites for dental restorations. Dent
Mater 30(4):424–432, 2014
Celtra Duo (zirconia-reinforced lithium silicate )

• high content of ultrafine glass ceramic crystals (1 um) & 10% zirconia content. 

• provided by the manufacturer in a fully crystallized state that may be either hand
polished or glaze fired in a ceramic furnace prior to delivery. 

• Hand polishing the restoration results in flexural strength ~ 210 MPa, while
glazing it in a porcelain oven results in flexural strength of 370 MPa. 

• NICE! (Straumann) recently introduced

Glazed Celtra Duo (Dentsply Sirona) crown for teeth #4 and #5. A, All-ceramic
crown preparations for teeth #4 and #5. B, Facial view of all-ceramic crown
preparations from the facial. C, Delivered glazed Celtra Duo crowns for teeth #4
and #5. D, Facial view of delivered Celtra Duo glazed crowns.
Resilient Ceramic

• Cerasmart (GC America)

• Enamic (Vita) 

• Lava Ultimate (3M) 

• Includes materials that have a resin matrix (instead of a glass matrix) 

• Allows greater force absorption capability without fracture

• No additional firing is required allowing for a very efficient delivery process

following fabrication of the restoration

• Flexural strength properties similar to human dentin

• Indicated for single-unit restorations

• Disadvantage - low stiffness . Therefore treating the intaglio surface of the

restoration with sandblasting technique & selecting a totaletch approach combined
with adhesive cementation is considered to be imperative

• Resilient ceramics are less dense, So they mill faster, with a smaller incidence of
margin chipping during milling compared to glass-containing materials
Lava Ultimate (3M) 

• Nanoceramic material  

• Contains silica particles(size 20nm), zirconia particles(4 to 11 nm) agglomerated nanosize

particles of silica and zirconia 

• All embedded in a highly cross-linked polymer matrix with 80% ceramic load. 

• Flexural strength of 170 MPa 

• Indicated for inlays and onlays but not for crowns

Cerasmart (GC America)

• Flexible nanoceramic with a resin matrix containing homogeneously distributed

nanoceramic filler particles.

• The material is a high-density composite resin with 71% silica and barium glass
nanoparticles filler by weight.

• Flexural strength of 230 Mpa

• Indicated for inlays, onlays, and crowns

Enamic (Vita) 

• Resin-based hybrid ceramic 

• dual interpenetrating structure of a leucite-based and zirconia-reinforced ceramic network 

• Mechanical properties in between glass ceramics and highly filled composites.

• Advantage- ceramic network provides wear resistance; polymer network improves the fracture

resistance

• Disadvantage- ceramic network makes the material more brittle and susceptible to fracture.

• Flexural strength of 150 Mpa

• Indicated for inlays, onlays, and crowns.

Composite resin block materials

PARADIGM MZ100(3M)
BRILLIANT CRIOS(coltene)
Based on Z100 composite chemistry
Recently introduced reinforced composite
Relies on proprietary processing technique to block
maximize the degree of cross-linking in the bis-
GMA polymer-based composite material Contains amorphous silica and glass ceramic
particles in a cross-linked methacrylate
It has zirconia-silica filler, which is radiopaque
matrix
Filler content 85% by weight with an average
particle size of 0.6micron Flexural strength ~ 198MPa
Flexural strength ~ 150 MPa

Sulaiman et al 2020, JERD, Materials in digital dentistry—A review

Minimally Invasive CAD/CAM
Restorations
• Scientific data on minimally invasive restorations such as CAD/CAM veneers are still scarce. 
• Minimally invasive anterior veneers can be fabricated from LDS and leucite-reinforced glass-
ceramics at a thickness of 0.5 mm. 
• ultrathin veneers (0.3 mm) - LDS (Maunula et al. 2017).  
• Nonretentive preparation designs ranging from 0.4 to 0.6 mm at the fissure and 1.0 to 1.3
mm at the cups tip are suggested (Schlichting et al. 2016). 
• no preparation is needed—with significant loss of the vertical dimension of occlusion due to
erosive wear (Schlichting et al. 2016). 
• High fracture loads surpassing physiologic chewing forces were described for these minimally
invasive restorations when fabricated from LDS, LSP, and PICN, irrespective of the application
of fatigue (Al-Akhali et al. 2017; Yazigi et al. 2017). 
• Conservative monolithic zirconia molar crowns (0.5-mm occlusal thickness) and posterior 3-unit
FDPs (0.6- mm occlusal thickness) also showed high fracture resistance.
F.A. Spitznagel et al, 2018, Journal of Dental Researchs, CAD/CAM Ceramic Restorative Material for
Natural Teeth
Chairside CAD/CAM Clinical Workflow
Chairside CAD/CAM worklow using the CEREC system has been described

Preoperative view of tooth #19.

The tooth preparation, including the margins,
must be visible by retraction of soft tissues and
isolated from moisture contamination so that
the camera may accurately capture a digital
image of the preparation.

All-ceramic crown preparation for tooth #19.

Case identification in the Administrative Phase.
• The opposing arch is also recorded, as well as a scan
of the dentition in maximum intercuspation from the
facial aspect.

• The computer software virtually articulates the

opposing models using the scan of the facial surfaces
so the appropriate occlusal relationships for the
restoration may be designed.
• The restoration design is initiated by identifying the
margins of the planned restoration to identify the
limits of the restoration design.

• The software utilizes data from adjacent and

opposing teeth to generate a proposed (virtual)
restoration

Top- The Model Axis is set for the model.

Bottom- The crown margin is identiied
Biogeneric proposal of the crown
Visualization of the occlusal contacts for refinement
Visualization of the proximal contact for refinement
Crown proposal in the proposed mill block (Celtra Duo)
• The design software enables control of the emergence profile of the restoration,
occlusal anatomy, planned occlusal contacts, and size and intensity of proximal
contacts.
• Once the design of the restoration is complete, it is transmitted to the milling unit so
the fabrication process may create the volumetric shape of the restoration out of an
industrially produced block of ceramic material.
• subtractive grinding or milling processes of ceramic blocks are accomplished based
on the volumetric design created with the software design program.
• Most restorations may be designed and milled within 10 to 15 minutes.
• Extended machining times may be required for more complex geometries of fixed
partial dentures or implant restorations.
• Slower machining may be preferred for thin margins, such as for porcelain
veneers, in order to prevent chipping during fabrication
• Final glaze firing and/or external surface polishing follows clinical
confirmation of the anatomy and marginal adaptation of the resultant
restoration. 
• The final restoration is adhesively cemented with resin cement.
Delivered Celtra Duo ceramic crown for tooth #19. (C–
K, Courtesy Dentsply Sirona.)
 Accuracy of Digital Impression

• Accuracy of the final restoration depends on the accuracy of the recorded dimensions of the tooth
preparation for both conventional and digital impressions.
• The accuracy of the margin and internal adaptation of any restoration is limited by the geometry of
the tooth preparation and the limitations of the recording medium. 
• The tooth preparation must be well isolated from moisture contamination and adjacent soft tissues.
• Digital impressions provide excellent immediate feedback relative to the recorded tooth preparation. 
• Digital magnification of the image, in many cases up to 20 times lifesize, facilitates critical evaluation
of the tooth preparation while the patient is still in the chair. 
• Preparation corrections may be accomplished immediately. Additionally, inadequately captured areas
may be immediately reimaged without the need to redo the entire impression, as is the case with
conventional impression materials
Clinical Longevity of CAD/CAM
Restoration 
• Long-term randomized clinical trials are considered the most robust study design
for the purpose of proper assessment of clinical longevity.
• Wittneben et al evaluated the clinical performance of CAD/CAM restorations in a
systematic review
• The included publications(between 1985 and 2007) comprised 14 prospective and
2 retrospective studies on the chairside CEREC System (CEREC 1 and 2) as well
as the laboratory system Celay, providing follow-up data from 2 to 10 years.
• The restorations included mostly posterior crowns, but some studies evaluated
inlays, onlays, endocrowns, and anterior crowns
• The estimated survival rate for CEREC single-tooth restorations was 91.6%.
• Restorations fabricated with feldspathic porcelain had the highest 5-year survival
rate, which contrasted with the lowest 5-year survival rate for glass ceramic. 
• At 5 years, ceramic onlays performed equally as successful as crowns
• Posselt and Kerschbaum conducted a retrospective study on the clinical
performance of 2328 inlays and onlays for 794 patients in a private practice
setting. A total of 35 failures were reported over 9 years.
• Kaplan-Meier survival probability reported was 97.4% at 5 years and 95.5% at
9 years for CEREC inlays and onlays
Conclusion

• The use of CAD / CAM technology significantly shortens the time of

creating prosthetic work, and CAD /CAM systems are easy to use
• But as the future approaches, the systems and materials available to
us will continue to evolve, improve, and enhance dentistry.
• precision of restorations made by CAD / CAM technology in the
function of all the individual errors of procedures and equipment, and
that scanning is the initial source of possible inaccuracies, the higher
resolution scanner will most significantly contribute to the quality of
the entire system.
• Thank you