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Materials for chairside CAD/CAM

restorations

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 Practical Applications

Materials for Chairside

CAD/CAM Restorations
Dennis J. Fasbinder, DDS*

Abstract: Chairside computer-aided design/computer-aided
manufacturing (CAD/CAM) systems have become consider-
ably more accurate, efficient, and prevalent as the technology
has evolved in the past 25 years. The initial restorative mate-
rial option for chairside CAD/CAM restorations was limited to
ceramic blocks. Restorative material options have multiplied
and now include esthetic ceramics, high-strength ceramics,
and composite materials for both definitive and temporary
restoration applications. This article will review current mate-
rials available for chairside CAD/CAM restorations.
System (D4D Technologies, www.e4dsky.com) were both
introduced as CAD/CAM systems capable of imaging, de-
signing, and fabricating ceramic restorations chairside.''^
Restorative materials for chairside CAD/CAM systems have
several unique features. Manufacturers fabricate the material in a
solid block form ready for the milling process. Both commercial
systems employ a wet grinding process for shaping or milling
the restoration from the preformed blocks. The material mtist
be capable of being milled efficiently, generally in less than 20
minutes. This enables the final restoration to be delivered at
the same appointment the tooth is prepared. To avoid early

T
he delivery of ceramic restorations in a single ap-
pointment became a treatment option in 1985 with
the introduction of the first chairside computer-
aided design/computer-aided manufacturing (CAD/CAM)
system.' In today's dental marketplace, two chairside CAD/
CAM systems are available. The CEREC* acquisition cen-
ter (AC) (Sirona, www.sirona.com) and the E4D Dentist
Table 1:
Categories of Materials for Chairside CAD/CAM Restorations
failure, the restoration must be capable of being milled with-
out damage to the material. Optimally, the final restoration
should require minimal time for the post-milling processing
to complement the chairside delivery. A lengthy post-milling
processing would be expected to detract from the usefulness
of the material chairside. For this reason, zirconia restorations
are not considered chairside restorations even though they can
be milled in a CAD/CAM system. The
required post-milling processing time of
6 to 8 hours is unreasonable for a single
appointment procedure.

Category Brand Name (Manufacturer) CEREC AC E4D In the past 25 years, materials have
been introduced as chairside CAD/CAM
Esthetic ceramics Vitabloc Mark II (Vident) systems have evolved. This article reviews
(feldspathic) CEREC Blocs (Sirona Dental)
current materials available for chairside
Esthetic ceramics IPS Empress CAD (Ivoclar) CAD/CAM restorations.
(leucite-reinforced) Paradigm C (3M ESPE)

High-strength ceramics IPS e.max CAD (Ivoclar) CAD/CAM RESTORATIVE

(lithium disilicate)
MATERIALS
Composite resin Paradigm MZ100(3M ESPE) Several categories of restorative materi-
(final restorations)
als are available for chairside CAD/CAM
Composite resin Vita CAD-Temp (Vident)
restorations (Table 1). Esthetic ceram-
(temporary restorations) Telio (Ivoclar)
ics contain a glass phase that allows the

*Clinical Professor of Dentistry and Director, Advanced Education In General Dentistry Program, Department of Cariology,
Restorative Sciences, and Endodontics, The University of Michigan School of Dentistry, Ann Arbor, Michigan

702 Compendium November | December 2010—Volume 31, Number 9

 Fasbinder

restoration to be etched and adhesively bonded for retention

to the tooth. High-strength ceramics offer a substantial in-
crease in flexural strength compared with esthetic ceramics
but not at the level of polycrystalline ceramics, such as zirco-
nia. Two types of composite resin blocks are available. One
brand is used for final restorations, and the other marketed
composite resin blocks are recommended for long-term tem-
porization. Although composite resin materials have desirable
properties for chairside applications, ceramic blocks are the
primary material used for chairside CAD/CAM restorations.
Figure 1 Preoperative clinical condition of tootb No. 3 with
ESTHETIC CERAMICS recurrent caries under the mesiofacial cusp.
The principle features of esthetic ceramics are that they con-
tain a glass phase and have excellent translucency and moder-
ate strength. The glass component allows them to be etched
and adhesively bonded to the tooth, which is critical to the
restoration's long-term retention and durability. The two feld-
spathic glass-ceramic materials are Vitablocs Mark II (Vident,
www.vident.com) and CEREG" Blocs (Sirona). Both mate-
rials are fine-grained, homogeneous feldspathic porcelain
with an average particle size of 4 jim.' Introduced in 1991,
Vitablocs Mark II are available in the 10 most common Vita
3D-Master shades. GEREC Blocs entered the marketplace
in 2007 and are manufactured by Vita Zahnfabrik (www. Figure 2 Adhesive preparation for a chairside CAD/CAM
vita-zahnfabrik.com)."* The blocks are available in six shades ceramic onlay.
and three degrees of color saturation (chroma): translucent
(T), medium (M), and opaque (O)."*
Vitablocs Mark II is also offered in several types of multi-
colored hlocks. TriLuxe blocks (Vident) contain three different
shade layers to re-create the shade and translucency of the tooth
from cervical to incisai. TriLuxe^ríe blocks (Vident) feature a
gradient of color and translucency from cervical to incisai with
increased fluorescence and chroma in the cervical area. Ihe
newly introduced RealLife block (Vident) has an innovative
3-D radial gradient of color and translucency from the internal
to external of the block to simulate the natural transition from
dentin core to enamel veneer. GEREG Blocs are also produced Figure 3 Paradigm C chairside CAD/CAM ceramic onlay at
in a multicolored block form. The GEREG Bloc PG has a 2 years post treatment.
three-layered structure with the bottom (cervical) layer having
the highest pigmentation and lowest translucency and the top Vitablocs Mark II restorations have the most clinical stud-
(incisai) layer possessing the highest translucency and lowest ies published relative to chairside GAD/GAM materials as this
color intensity. It is available in three gradient shades. Multicolor product is the oldest-marketed chairside GAD/GAM mate-
blocks offer an enhanced esthetic result compared with con- rial.' A clinical study conducted on 2328 inlays and onlays
ventional monochromatic blocks. Further customization of for 794 patients in a private practice reported 35 failures over
either type can he accomplished hy shade characterization and 9 years.''The Kaplan-Meier survival prohahility was 97.4%
glazing using the Vita Shading Paste As.sortment Kit. The kit at 5 years and 95.5% at 9 years. Another study reported a
is compatible with both Vitablocs Mark II and GEREG Blocs. Kaplan-Meier survival probability of 90.4% afi:er 10 years

www.compendiumlive.com Compendium 7031

 Practical Applications
Figure 4 Preoperative clinical condition of a gold crown
witb a perforation in the occlusal surface.
Figure 5 Cemented IPS e.max CAD crown at the baseline
evaluation.
Figure 6 IPS e.max CAD crown at tbe 3-year recall evaluation.
for 200 Vitabloc Mark I restorations placed in 108 patients
in private practice." In a follow-up report for that study, the
authors reported an 88.7% success rate at 17 years." From
1991 to 2006, a series of papers reported the clinical status
of 1011 CEREC restorations for up to 18 years.'' " After
5 years, the survival probability was 95%, and after 7 years,
it was 91.6%. At 10 years, the survival probability was 90%
and declined to 84.9% at 16.7 years. A systematic review of
29 clinical studies, which included 2862 inlays, reported a
1704 Compendium
survival rate of 97.4% after 4.2 years.'- The primary mode
of failure was fracture of the ceramic restoration. Less com-
mon failures included tooth fracture, wear of the cement,
and postoperative sensitivity.
The two leucite-reinforced glass-ceramic materials are
IPS Empress CAD (Ivoclar, www.ivoclarvivadent.us) and
Paradigm™ C (3M ESPE, www.3mespe.com). Introduced in
1998, the first leucite-reinforced glass-ceramic CAD/CAM
block was ProCAD (Ivoclar). It evolved to the current IPS
Empress CAD and is a 35% to 4 5 % leucite-reinforced glass-
ceramic similar to IPS Empress I but with a finer particle size
of 1 \im to 5 pm. The blocks are available in tiine popular
shades in either a high translucency (HT) or low translucency
(LT) version. The H T version has an increased translucency
while the LT type has a brighter value and is available in four
bleach shades. IPS Empress CAD is offered in a multicolor
block form. Offered in five colors, the block has a color gradi-
ent and translucency from cervical to incisai to simulate the
transition of color and translucency in the natural dentition.
Individual shade customization of either the monochromatic
or multicolor blocks can be accomplished with the use of IPS
Empress Universal Stains."
Introduced in 2006, Paradigm C (3M ESPE) is a 30% leu-
cite-reinforced glass-ceramic. Available in six shades. Paradigm
C is a radiopaque ceramic that exhibits a chameleon effect
once seated in the tooth due to its enhanced translucency and
fluorescence''' (Figttre 1 throtigh Figure 3). This product is not
available in a polychromatic block at this time. The shade of
Paradigm C restorations can be customized using the Lava™
Ceram (3M ESPE) stains and glaze.
Studies involving IPS Empress CAD are limited; however,
this product is similar to Empress I in physical structure,
so a similar clinical performance may be anticipated. A lit-
erature review of lotigevity and clinical performance of IPS
Empress restorations was reported in 2002.''' Six clinical
trials on the performance of IPS Empress inlays and onlays
and three clinical trials on the performance of IPS Empress
crowns were identified in the literature. Survival rates for
IPS Empress inlays and onlays ranged from 96% at 4.5 years
to 9 1 % at 7 years with most failures due to bulk fracture
of the restorations. IPS Empress crowns had survival rates
from 92% to 99% at 3 to 3.5 years, with failure also mainly
due to crown fracture.
HIGH-STRENGTH CERAMICS
IPS e.max CAD (Ivoclar) was introduced in 2006 as a lithi-
um-disilicate CAD/CAM material with a flexural strength of
November | December 2010—Volume 31, Number 9
Practical Applications
Figure 7 Baseline evaluation of tooth No. 3 with a Paradigm
MZ100 composite chairside CAD/CAM inlay.
Figure 8 Three year evaluation of the Paradigm MZ100
inlay on tooth No. 3.
Figure 9 Six year evaluation of the Paradigm MZ100 inlay
on tooth No. 3.
360 MPa to 400 MPa, which is two to three times the flexural
strength of the esthetic ceramics."*''' The increased strength
affords the opportunity to either etch and adhesively bond
the material to the tooth or use a conventional cementation
technique.'" Lithium disilicate was initially developed as a sub-
structure material that offered greater translucency compared
with other high-strength ceramic core materials. However, it
has gained popularity for use as a monolithic restoration in
1706 Compendium
chairside CAD/CAM systems due to the enhanced strength.
The CAD/CAM block form is available in nine A-D shades,
two translucencies, and four bleach shades.
IPS e.max CAD blocks consist of 0.2-|jm to l-|.im lithium
meta-silicate crystals with approximately 40% crystals by vol-
ume. The block is blue violet, accounting for the commonly
used "Blue Block" description. This partially crystallized "soft"
state allows the block to be easily milled without excessive
diamond bur wear or damage to the material. After milling,
the restoration must undergo a two-stage firing process in a
porcelain oven under vacuum (20 to 25 minutes) to complete
the crystallization of the lithium disilicate. This also converts
the blue shade of the precrystallized block to the selected tooth
color and results in a glass-ceramic with a fine grain size of
approximately 1.5 \im and a 70% crystal volume incorpo-
rated in a glass matrix."
Eew clinical studies involve IPS e.max CAD or its press-fit
counterpart IPS e.max Press due to its limited time in the
marketplace. A prospective clinical study on molar onlay
restorations used a split-mouth design in 25 patients to
compare the clinical longevity of IPS e.max Press onlays with
ProCAD onlays.™ One ProCAD onlay fractured at 9 months
and was considered a failure. The Kaplan-Meier survivability
at 3 years was 97% for the ProCAD onlays and 100% for
the IPS e.max Press onlays. An ongoing longitudinal clinical
study is evaluating the clinical performance of 62 IPS e.max
CAD crowns in 43 patients. Each crown was placed in a
single treatment appointment with the CEREC AC system
(Figure 4 through Figure 6). At the end of 2 years, there were
no reported crown failures and no clinically visible chipping
or cracking of the crowns.^'
COMPOSITE RESIN-
PERMANENT RESTORATIONS
Paradigm MZlOO (3M ESPE) was introduced in 2000. It
is a polymer composite block based on the ZIOO composite
chemistry using a processing technique to maximize the de-
gree of cross-linking.-'"' Paradigm MZlOO has zirconia-silica
filler particles and is 85% filled by weight with an average
particle size of 0.6 pm. It is radiopaque and available in six
shades, as well as a more translucent enamel color.
Paradigm MZlOO represents a departure from the more
popular ceramic materials. Composite can be more easily
adjusted and polished intraorally compared to ceramic materi-
als. This is an important feature of the chairside clinical tech-
nique because there is generally no working die and occlusal
refinement occurs intraorally. Repair of porcelain restorations
November | December 2010—Volume 31, Number 9
Practical Applications
intraorally has not proven to be more than a moderately effec-
tive temporary technique.^'"'^'' With Paradigm, the restoration
surface is air-abraded with 50-pm silicon dioxide, and a hybrid
composite can be bonded to the abraded surface. Although
untested for clinical longevity, this affords an easy and efficient
intraoral repair procedure for Paradigm MZlOO restorations.
An ongoing clinical study reported the 3-year and 6-year
results of a randomized clinical trial of 40 Paradigm MZlOO
inlays and 40 Vitabloc Mark II inlays''''^^ (Eigure 7 through
Eigure 9). All restorations were evaluated at baseline, 6 months,
and annually for 6 years using modified USPHS criteria. One
Vitabloc Mark II inlay had postoperative sensitivity that re-
solved in 2 weeks. Throughout the 6-year recall, all other
restorations had no sensitivity. The CAD/CAM composite
The principle features of
esthetic ceramics are that they
contain a glass phase and have
excellent translucency and moderate
strength. The glass component
allows them to be etched and adhe-
sively bonded to the tooth, which is
critical to the restoration's long-term
retention and durability.
inlays performed similarly to the CAD/CAM ceramic inlays
at the 6-year recall with greater than 90% alpha ratings for
all categories evaluated.
COMPOSITE R E S I N -
TEMPORARY MATERIALS
The most recent material addition for CAD/CAM chairside
restorations is acrylic temporary materials. With the continued
development of laboratory CAD/CAM systems and digital
impression systems, CAD/CAM temporary crowns and fixed
partial dentures (EPDs) are available, as well. The CAD/CAM
process avoids an air-inhibited surface layer on conventional
self-cure or VLC acrylics, as well as polymerization shrinkage.
Vita CAD-Temp* (Vident) is a highly crosslinked micro-
filled polymer that is available in extended block sizes, includ-
ing lengths of 40 mm and 55 mm, to accommodate multiple-
unit EPDs.^' It is offered as a monocolor block that comes
I 708 Compendium
in four shades or a multicolor form with four shade layers
for more esthetic cases. Telio® CAD (Ivoclar) was recently
introduced as a millable cross-linked polymethyl methacry-
late block for temporary crowns and EPDs. The block is part
of the Telio system, which includes a self-curing composite,
desensitizes and cement. It is available in five shades.^'
Both temporary materials are recommended by the man-
ufacturers for up to 1 year of clinical service.
CONCLUSION
The term chairside CAD/CAM restoration is more descriptive
of the fabrication technique than the actual final restoration
as demonstrated by the various types of materials available
for restorative treatment. All of the available ceramic and
composite materials demonstrate the desirable quahties of
machinable materials. They can be milled efficiently for chair-
side use without damage to the restoration. The materials
are esthetically acceptable as milled yet provide the ability to
customize the final shade of the restoration if desired. All are
recommended for use with an adhesive cementation tech-
nique. To date, clinical studies have documented the predict-
ability and longevity of chairside CAD/CAM restorations.
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Fasbinder
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