U

GRINDING PRECISION AND ACCURACY OF FIT

OF CEREC 2 CAD-CIM INLAYS

WERNER H.

MORMANN, D.M.D., D.D.S., PH.D.; JENS SCHUG, D.D.S.

Ohe CEREC (Siemens AG) computer-assisted design/computer-inThe authors conducted research

to determine the grinding preci-

sion and accuracy of fit of ceramic inlays generated with the

completely redesigned CEREC 2 computer-assisted design/com-

puter-integrated manufacturing,
or CAD-CIM, unit. They found

that the grinding precision of the

CEREC 2 unit was 2.4 times

greater than that of CEREC 1.
With CEREC 2, the mean (+ standard deviation) luting interfaces
were 56 + 27 micrometers,

which is a 30 percent improvement in the accuracy of fit com-

pared with that of CEREC 1.

tegrated manufacturing, or CAD-CIM, method has been used in clinical dentistry for more than 10 years.' More than 3,000 practitioners worldwide are using the four versions of this system to generate restorations in their practices. The advances of CAD-CIM technology have been reported extensively in the dental literature.'-3 In vitro4 and in vivo studies5 have examined the accuracy of fit and dimensions of luting interfaces of the CAD-CIM restorations. The first clinical investigation of computer-generated ceramic restorations was begun in 1986.5 The inlays were fabricated using the original CEREC 1 (a) hardware (BRAINS AG) and software (CEREC Operating System, or COS, version 1.0; BRAINS AG).67 Examination by scanning electron microscopy, or SEM, showed occlusal luting interfacial widths to be 140 to 265 micrometers.5 Using the second-generation CEREC 1 (b) unit developed in 1988 (Siemens AG) and COS 2.0 software developed in 1991 (Siemens AG), researchers clinically measured interfacial widths, which were a mean ( standard deviation) of 169 48 pm.8 In an in vitro study, Inokoshi and colleagues9 measured the marginal interfaces in Class II CEREC restorations using second-generation CEREC 1 (b) hardware and COS 2.1 software; they found that widths ranged between 50 and 99 pm. The third-generation CEREC 1 (c) unit was introduced in 1992.10 An electric motor significantly increased the engine power as well as the service life of the grinding disks." The higher rigidity of the system and a smaller diamond grain diameter (64 pm) of the grinding wheel considerably improved the marginal integrity of the machined restorations." The precision of the margins was reported to be in the 80- to 120-pm range.'2 The completely redesigned CEREC system, called CEREC 2, is able to produce inlays, overlays, veneers and full crowns. Through improvements in the grinding process and optimized three-dimensional, or 3-D, scanning, it aims to achieve an even higher accuracy of fit than previous systems achieved.'3 The further development of the intraoral 3-D camera was done in accordance with the original CEREC process.6
JADA, Vol. 128, January 1997 47

R ESEARCH-

Figure 1. The monitor of the CEREC 2 computer-assisted design/computer-integrated manufacturing unit (Siemens AG) shows an intraoral optical impression of a mesio-occlusodistal cavity in a lower left first molar.

Figure 2. Geometric illustration of a sample representing a mesio-occlusodistal inlay. a. The occlusal view is shown; the arrow indicates grinding direction. b. The proximal transverse cross section, as indicated by the single asterisk in a, is shown. c. The mesiodistal central cut, as indicated by the double asterisk in a, is shown. B: midproximal; H: central-occlusal; E: gingival/axial line angles; and F: central floor.

The objective of this study

was to examine the grinding precision and accuracy of fit of inlays in mesio-occlusodistal preparations produced by a CEREC 2 CAD-CIM unit.
MATERIALS AND
M ETHODS

To study grinding precision, we used a CEREC 1 (c) unit equipped with an electric drive and a CEREC 2 unit (Figure 1). For the CEREC 1 unit, we used the COS 2.1 software. The CEREC 2 unit ran on specially developed software (COS 4.01 13;
48 JADA, Vol. 128, January 1997

Siemens AG). We also used grinding disks with 64-,um-diameter diamonds in the coating and ceramic blocks, size I 10 (10 x 9 x 15 millimeters), of the following materials: - Vita CEREC Mark II (Vita Zahnfabrik); - Dicor MGC glass ceramic light (Dentsply Int.). The software used in both CEREC units contained the special design of a geometrically stylized mesio-occlusodistal inlay of known dimensions (Figure 2). However, because software engineering time was

unavailable, the programs used for the samples machined by the CEREC 1 and CEREC 2 units could not be modified to produce samples of identical dimensions. Since direct comparison was not possible, we chose dimensional variation as an independent parameter for the examination of grinding precision. Production of geometric samples. Before starting, we mounted new grinding disks and recalibrated the grinding units by activating the automatic calibration mode that is included in every software ver-

RESEARCH
sion. The grinding disks were changed in both units after the same number of grinding operations and after the message "please replace the wheel" was displayed on the screen of the CEREC 1 unit. After three samples were milled, we replaced the cooling water with new tap water, to which 14 milliliters of cooling lubricant (CEREC Cimplus D14-A) was added. For the grinding process, the geometric samples were divided into four groups: - Vita Mark II with CEREC 1 (n = 40); - Dicor MGC with CEREC 1 (n = 40); - Vita Mark II with CEREC 2 (n = 40); - Dicor MGC with CEREC 2 (n = 40). Thus, 40 samples of each of the two materials were produced by the test unit (CEREC 2) and the control unit (CEREC 1) for a total of 160 samples. Assessing grinding precision. To evaluate grinding precision, we measured four linear dimensions on each of the standardized geometric samples, as shown in Figure 2. The locations of the linear measurements were selected and defined according to the action ofthe grinding wheel. Measurements B (midproximal) and H (central-occlusal) related to the grinding action of the radial cut. Measurements E (gingival/axial line angles) and F (central floor) related to the grinding action that was oriented to the long axis of the sample. The samples were fixed on standard SEM holders and mounted in the 3-D scanning measuring device on a threecoordinate table.14 We used a microscope with an internal reticle14 to position the samples in such a way that the starting

and end points of the respective linear measurement on the sample had the same focal distance as each other in the microscope and coincided with the X-axis of the coordinate table. Beginning with the starting point centered under the reticle, we then moved the three-coordinate table straight toward the end point, using computer-controlled 100-jim steps first and 1-pm steps for the final 10-jim approach. The overall distance (in micrometers) was then recorded on the screen.14 Statistical analysis of grinding precision. Differences in the amount of variation in dimensional data between CEREC 1 and CEREC 2, as assessed by measurements B, H, E and F, were examined using the F test, including correction for multiple test situations according to Bonferroni."5 Standard deviation was used to express variation of the data, and P-values for statistical dif-

ferences are presented in Table 1. In addition, all B, H, E and F data for VITA Mark II and Dicor MGC were pooled for CEREC 1 (n = 320) and CEREC 2 (n = 320), and standard deviations were compared. Accuracy of fit of inlays in mesio-occlusodistal preparations. Twelve extracted human caries-free molar teeth were prepared with a mesio-occlusodistal Class II cavity. We prepared one gingival margin to approximately 1.5 mm above the cementoenamel junction and called this the "deep" preparation. We prepared the other gingival margin to include the cementoenamel junction and called this the "very deep" preparation.16"7 Six teeth were restored with individual inlays generated by the CEREC 2 unit, and the other six teeth were restored with individual inlays generated by the CEREC 1

unit.7"18
For the CEREC 2-generated inlays, we selected the extrapolaJADA, Vol. 128, January 1997 49

IESEAR CH

Figure 4. Manufacturing a mesio-occlusodistal test inlay is a fully automatic process. Synchronous actions of the grinding wheel (floor, walls, occlusion) and bur (occlusion) are shown.

Figure 3. The completed design of a mesio-occlusodistal test inlay on the CEREC 2 mon itor displays the computer-generated occlusal sui rface, including the central main fissure and cusp sicipes.

we seated the inlays using ultrasonic insertion21 with the help of an ultrasonic scaler topped with a spherical plastic plug. The replica technique used for

tion design mode that automatically generates an individualized

occlusal-surface morphology. " Figure 3 illustrates a typical finished extrapolation design of a test inlay, and Figure 4 shows how the inlay is machined. Because of similar results regarding grinding precision for the two materials, we chose to use only one material (Vita Mark II porcelain) for the machining of individual inlays in the accuracy-of-fit evaluation. We used Brilliant Lux microfine hybrid (Coltene/Whaledent) as the luting material and A.R.T. Bond (Coltene/Whaledent) as the adhesive for the inlays. Working without waterspray,
50

identical reproduction of the restored teeth, as needed for the SEM examination, was carried out as described above. Under a scanning electron microscope, we measured the widths of the marginal interfaces of all inlays in 36 locations: 12 occlusal, four shoulder, four proximal-lateral (deep), four proximal-lateral (very deep), four line angles (deep), four line angles (very deep), two gingival (deep) and two gingival (very deep).922 Statistical analysis of interfacial width of inlay margins. The mean widths of the marginal luting material interface between the tooth and the restoration of eight margin sectors (that is, occlusal; shoulder;

proximal-lateral of deep and very deep proximal preparations; line angles of deep and very deep proximal preparations; and gingival margins of deep and very deep proximal preparations) were calculated by pooling the data for the above-mentioned margin locations. We used the t-test to discover any significant differences between CEREC 1 and CEREC 2, correcting for multiple test situations according to Bonferroni. Photographic and SEM documentation of inlays. We photographed all restored teeth from the occlusal, mesial and distal aspects using a camera equipped with a 200-mm lens with x2 magnification. To document luting interfaces, SEM pictures were taken at xlO0 magnification (Figure 5).
RESULTS

Grinding precision. For both the Vita Mark II and Dicor MGC restoration materials, standard deviations in the B dimension (midproximal) were significantly lower (P < .05) with CEREC 2 than with CEREC 1 (Table 1). In the H di-

JADA, Vol. 128, Januar-y 1997

RESEARECI

._.Fi.r

A.; cIaI~ Th

ta

m'

_.'.g.n.-

..'.,,.',v.r,.1.n,X,t_w782-

Framm 4-Inly: la hewit. 5 OESRC I (fptos AM margin (a~autnlhg electrorn_ ny X100), witha (aE" kting Intal wit C.l ONEC margin (SEM~ XIQO), with a qonstant _mafl Interlal widh.

mension (central-occlusal), significant differences between CEREC 1 and CEREC 2 samples were also found with Vita Mark II (P < .001) and Dicor MGC (P < .01). In addition, standard deviations for dimensions E (gingivalaxial line angles) and.F (central floor) showed significt differences between the CEREC 1 and CEREC 2 units for both restoration materials exami'ned. Standard deviations of pooled CEREC 2 measurements were smaUler than those of CEREC 1 measurements by a;factor of 2.4. Accuracy of it. The interfacial width of the CEREG 1 and CEREC 2 inlays differed significantly in margin sections at the deep and very deep line angles of proximal preparations as well as at the gingival margins of deep proximal preparations (P < .05) (Table 2). There was a strong and constant tendency of the CEREC 2 inlays to have smaller interfacial widths than those of the CEREC 1 inlays. When data for all 36 margin locations were pooled, the mean interfacial widths were 56 - 27 pm for CEREC 2

CEREC 1 inlays, a statistically insignificant difference (P > .05). Typical SEM findings of occlusal margn sections are shown in Figure 5.
DISCUSSION

~inlays and 84t 38 pm for

Grinding precision of CADCIM-machined restorations is a crucial prerequisite to high accuracy of flt.'2 In this study, we used the standard deviation

d, I _e '

amM-.t.

.-

of defined linear measurements

on geometric inlay samples ma-

chined from Vita CEREC Mark II and Dicor MGC ceramics to

eaiegrinin

preciLsion.

This approach corresponded-to a previous evaluation ofthe grinding precision of a CEREC unit.4. A small standard deviation implies high grinding precision in the machining of the samples. Irrespective of the material used, the grinding precision of the -CEREC 2 unit was 2. 4 times higher than that ofthe CEREC 1 unit, as determined by the ratio of the standard deviation for CEREC 1 pooled linear measurements to the standard deviation- for CEREC 2 pooled linear measurements. Grinding precision generally is limited by the size and shape ofthe grinding tools and tool control.13 Feed rate, depth of cut, grain size of the abrasive material (diamonds) on the tools, water cooling system and chemical additives to the coolant water are factors influencing surface quality and dimensions of machined ceramic workpieces.711,225 The improved grnding precision of CEREC 2 vs. CEREC 1 as observed in this study can be attributed to the general improvement in electronics and engineering know-how accumulated during the developmental stages of CEREC 1.1' Variations in mesiodistal
JADA, Vol. 128, January 1997 51

HESEARCHinterfacial width of CEREC 2 inlays (56 27 pm) was smaller than that of CEREC 1 inlays (84 38 gm); it also was smaller than the interfacial widths of CEREC 1 inlays reported in other studies.58912 Differences in our study were statistically significant (P < .05) at line angles in deep and very deep proximal preparations as well as at deep gingival margins. In a recent study, the mean occlusal interfacial width of CEREC 2 inlays was 48 34 pm, representing a 35 percent improvement over CEREC 1 inlays.27 The CEREC 2 interfacial widths reported in this study tended to be smaller than those achieved with other
machining systems. 12,28-33

Lime angle___0s-;_ r0

(deep)
(verydeep)

124 + 44
10955

59 30
6727
31

<.05

<.05
.05

Gingival

(deep)
(very

32

18 c

er:tep) 0 ; 0 50 ;7 i W4f02

All margin sections

84 38

56 + 27

NS

Bonfer

sample dimensions E and F obviously were influenced by wear and deformation of the grinding wheels. Loss of cutting ability during the service life of a grinding wheel causes increased load buildup between the tool and ceramic blank, resulting in deformation of the tool.11 CEREC 2 was less affected by this phenomenon. The loss of contour fidelity, as observed in CEREC 1 samples, as well as the higher standard deviation of the overall interfacial width of margins in CEREC 1 inlays can also be attributed in part to this effect. Automatic calibration of the tools before each restoration is ground has been optimized with CEREC 2 and has contributed to the improved grinding precision and accuracy of fit of the restorations.
52 JADA, Vol. 128, January 1997

The results of this study support laboratory13 and clinical26 experience showing that the first-fit rate of CEREC 2 restorations is high. Improvements in the 3-D camera contributed considerably to the increased accuracy of fit of CEREC 2 inlays. The CEREC 2 camera displays the tooth preparation with x12 magnification on the high-resolution color monitor, which shows more detail than both the CEREC 1 monitor (x8 magnification) and magnifying glasses (x2 to x4 magnification).'9 The computer-aided design of CEREC 2 restorations has been simplified by clear program steps for the user to follow as well as automatic design steps that prevent operating errors to a large extent. In our study, the overall mean

Despite favorable clinical long-term results of CEREC restorations,5'34 38 researchers have assumed that interfacial width is the limiting factor with regard to long-term clinical success of adhesively placed ceramic restorations, thus requiring a higher accuracy of fit.4'39 A clinical investigation of aesthetic inlays measured the wear rate of luting agents and found that most of the wear occurred during the first 12 months of clinical service; it then tended to level out.8 A recent analysis of clinical studies of CEREC restorations supported these findings.40 Holmes found that excellent full-coverage castings typically have a gap of about 40 to 60 pm beween the margin of the preparation and the margin of the restoration.41 The accuracy of fit of CEREC 2 restorations in our study (mean interfacial width, 56 27 ,m) and in a recent study (48 34 pm)27 is close to this standard of good precision. In addition, the SEM survey in our study showed highly constant interfacial width and con-

ES EAR C H

tinuous adhesion of the inlays,

thus fulfilling an important clinical requirement.4 High-vscosity cementation using light-cured, microfine, hybrid composite20 and ultrasonic insertion2' proved to be very practical in this study and is a standard procedure in our clinic.
CONCLUSION

The improvements in CAD-CIM technology, as represented by the CEREC 2 unit, provide dental practitioners and dental laboratory technicians with a fast and easy production method for ceramic restorations using industrially prefabricated Vita Mark II and Dicor MGC machinable ceramic materials. As a result of high machining precision, we found an excellent accuracy of fit (56 + 27 gm) in this study. The small standard deviation indicates the very high reliability of CAD-CIM production. Experience in our clinic shows that the same degree of accuracy of fit is true for other CEREC 2 restorations, such as onlays, veneer laminates and single full crowns.
Dr. Mormann is one of the original developof the CEREC system. He is president of the board of the Foundation for ComputerAssisted Dentistry in Z Zurich, Switzerland, a nonprofit organizaers
tion tha

Effect of gap dimension on composite cement Quintessence Int 1994;25:53-8. 5. Mormann W, Krejci I. Computer-designed inlays after 5 years in situ: clinical performance and scanning electron microscopic evaluation. Quintessence Int 1992;23(2):109-115. 6. Williams AG, Rekow D. The Switzerland and Minnesota developments in CAD/CAM. J Dent Pract Admin 1987;4(2):50-5. 7. Mormann W, Brandestini M. Die Cerec computer reconstruction, inlays, onlays und veneers. Berlin: Quintessenz; 1989:18-30. 8. O'Neal SJ, Miracle RL, Leinfelder KF. Evaluating interfacial gaps for esthetic inlays. JADA 1993;124(12):48-54. 9. Inokoshi S, Van Meerbeek B, Willems G, Lambrechts P, Bream M, Vanherle G. Marginal accuracy of CAD/CAM inlays made with the original and the updated software. J Dent
wear.

1. Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:12-6. 2. Mormann W, ed. International symposium on computer restorations. Chicago: Quintessence; 1991:13-7. 3. Calamia JR. Advances in computer-aided design and computer-aided manufacture technology. In: Golub-Evans J, ed. Current opinion in cosmetic dentistry. 2nd ed. Philadelphia: Current Science; 1994:67-73. 4. Kawai K, Isenberg BP, Leinfelder KF.

receives roy-

alties on the sale of

the CEREC system.

Dr. Mormann Is a professor and director, Division of Aesthetic and Computer Restorations, Clinic of Preventive Dentistry, Perlodontology and

Dr. Schug is

lectur-

or, Division of Aes-

Carlology, University of Zurich, Dental School, Plat-

thetic and Computer

Restorations, Clinic
of Preventive Den-

tenstrasse 11, CH-8028 Zurich, Switzerland. Address reprint requests to Dr. Mormann.

tistry, Peruodontology and

Cariology,

Dental School, University of Zurich, Switzerland.

10. Mormann W. Chairside computer-generated ceramic restorations: the Cerec third generation improvements. Pract Periodontics Aesthet Dent 1992;4(7):9-16. 11. Furrer 0, Mormann W. Effizienz und Kantenqualitat beim computertechnischen Formschleifen von Keramikinlays. Schweiz Monatsschr Zahnmed 1993;103:17-25. 12. Duret F. The practical dental CAD/CAM in 1993. J Can Dent Assoc 1993;59:445-53. 13. Pfeiffer J. The character of Cerec 2. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:255-65. 14. Roulet J. Degradation of dental polymers. Basel: Karger; 1987:93-8. 15. Sachs L. Angewandte Statistik. Berlin: Springer; 1992:347-9. 16. Fett HP, Mormann WH, Krejci I, Lutz F. The effects of short bevels and silanization on marginal adaptation of computer-machined mesio-occluso-distal inlays. Quintessence Int 1991;22:823-9. 17. LoPresti JT, David S, Calamia JR. Microleakage of CAD-CAM porcelain restorations. Am J Dent 1996;9:37-9. 18. Mormann W, Brandestini M. The fundamental inventive principles of Cerec CAD/CIM and other CAD/CAM methods. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:81-96. 19. Mormann W, Mattiola A. Computer-generated occlusion of Cerec 2 inlays and overlays. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:391-407. 20. Besek MJ, Mormann W, Lutz F. Curing of composites under Cerec inlays. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:347-60. 21. Roulet J-F, Noack MJ. Tooth colored conventional and Cerec restorations-claim and reality. In: Mormann W, ed. International symposium on computer restorations. Chicago: Quintessence; 1991:233-43. 22. Schug J. Schleifprazision und Passgenauigkeit bei der Herstellung von computertechnisch formgeschliffenen Restaurationen

1992;20:171-7.

(Medical Thesis). Zurich: University of Zurich; 1995:13-5. 23. Kunzelmann K, Hickel R. Zur Prazision des Cerec-Systems: Die Schleifeinheit. Dtsch Zahnarztl Z 1990;45:277-80. 24. Rekow ED, Zhang GM, Thompson V. Machining ceramic materials for dental restorations. In: Jahanmir S, ed. Machining of advanced materials. Washington, D.C, 1993: U.S. Department of Commerce Technology Administration, National Institute of Standards and Technology; Special publication 847:425-35. 25. Feher A, Mormann W, Lutz F. Die Standzeit von Cerec-Schleifscheiben. Schweiz Monatsschr Zahnmed 1991;101:857-63. 26. Reiss B. Cerec practice integration. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:267-76. 27. Benz C, Benz B, El Mahdy K, Hickel R. Clinical evaluation of the Cerec II system in comparison to Cerec 1. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:516-24. 28. Siervo S, Pampalone A, Siervo P, Siervo R. Prazision und Vielseitigkeit des CelaySystems. Quintessenz 1994;45:379-96. 29. Schlegl A, Besimo C, Guggenheim R, Dueggelin M. In-Vitro-Untersuchung zur marginalen Passgenauigkeit von computergefrasten Titankronen. Schweiz Monatsschr Zahnmed 1991;101:1273-8. 30. Russell MM, Andersson M, Dahlmo K, Razzoog ME, Lang BR. A new computer-assisted method for fabrication of crowns and fixed partial dentures. Quintessence Int 1995;26:757-63. 31. Uchiyama Y. Production of metal crowns by CAD/CAM. Quintessence 1991;10:111-7. 32. Sohmura T, Takahashi J. Use of CAD/CAM system to fabricate dental prostheses. Part 1: CAD for a clinical crown restoration. Int J Prosthodont 1995;8:252-8. 33. Miyasaki T, Hotta Y, Lee WS, et al. Automatic fabrication of dental restorations by a CAD/CAM process. Quintessence Dent Technol 1996;20(11):1-4. 34. Isenberg B, Essig M, Leinfelder K. Three-year clinical evaluation of CAD/CAM restorations. J Esthet Dent 1992;4(5):173-6. 35. Otto T. Experience with Cerec in a Swiss practice. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:601-7. 36. Walther W, Reiss B. Six year survival analysis of Cerec restorations in a private practice. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:199-204. 37. Brauner AW, Bieniek KW. Seven years of clinical experience with the Cerec inlay system. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:217-28. 38. Pallesen U. Clinical evaluation of CAD/CAM ceramic restorations: 6-year report. In: Mormann W, ed. CAD/CIM in aesthetic dentistry. Chicago: Quintessence; 1996:241-53. 39. Krejci I. Zahnfarbene Restaurationen, Qualitat, Potential und Indikationen. Munich: Hanser; 1992:232-37. 40. Kerschbaum T. Quality assurance in Cerec restorations. In: Mormann W, ed. CAD/ CIM in aesthetic dentistry. Chicago: Quintessence.

1996:321-33.

41. Rekow ED. Dental CAD-CAM systems: what is the state of the art? JADA 1991;

122(13):43-8.

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