The Use of CAD/CAM in Dentistry

Gary Davidowitz,
KEYWORDS  CAD/CAM  CEREC  E4D  iTero  Lava COS  Dental laboratory
a,b, *, DDS

Philip G. Kotick,

DDS

b,c

Computer-aided design (CAD) and computer-aided manufacturing (CAM) have become an increasingly popular part of dentistry over the past 25 years.1 The technology, which is used in both the dental laboratory and the dental office, can be applied to inlays, onlays, veneers, crowns, fixed partial dentures, implant abutments, and even full-mouth reconstruction. CAD/CAM is also being used in orthodontics. CAD/CAM technology was developed to solve 3 challenges. The first challenge was to ensure adequate strength of the restoration, especially for posterior teeth. The second challenge was to create restorations with a natural appearance. The third challenge was to make tooth restoration easier, faster, and more accurate. In some cases, CAD/CAM technology provides patients with same-day restorations. Dentists and laboratories have a wide variety of ways in which they can work with the new technology. For example, dentists can take a digital impression and send it to a laboratory for fabrication of the restorations or they can do their own computeraided design and milling in-house. When laboratories receive a digital impression, they can create a stone model from the data and either continue with traditional fabrication or rescan the model for milling. Alternatively, the laboratory can do all of the design work directly on the computer based on the images received. This article discusses the history of CAD/CAM in dentistry and gives an overview of how it works. It also provides information on the advantages and disadvantages, describes the main products available, discusses how to incorporate the new technology into your practice, and addresses future applications.

International Advanced Aesthetic Dentistry Program, NYU College of Dentistry, 345 East 24th Street, New York, NY 10010, USA b Department of Cariology and Comprehensive Care, NYU College of Dentistry, 345 East 24th Street, New York, NY 10010, USA c International Comprehensive Dentistry Program, NYU College of Dentistry, 345 East 24th Street, New York, NY 10010, USA * Corresponding author. Department of Cariology and Comprehensive Care, NYU College of Dentistry, 345 East 24th Street, New York, NY 10010. E-mail address: gd33@nyu.edu Dent Clin N Am 55 (2011) 559570 doi:10.1016/j.cden.2011.02.011 dental.theclinics.com 0011-8532/11/$ see front matter 2011 Elsevier Inc. All rights reserved.

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HISTORY OF DENTAL CAD/CAM

Computer-aided design and manufacturing were developed in the 1960s for use in the aircraft and automotive industries,2 and were first applied to dentistry a decade later. Some of the most important figures in dental CAD/CAM development are Drs Francois Duret of France, Werner Mormann of Switzerland, Dianne Rekow of the United States, and Matts Andersson of Sweden. Dr Duret was the first person to develop a dental CAD/CAM device, making crowns based on an optical impression of the abutment tooth and using a numerically controlled milling machine as early as 1971.3 He produced the first dental CAD/CAM restoration in 19834 and demonstrated his system at the French Dental Associations international congress in November 1985 by creating a posterior crown restoration for his wife in less than an hour.5 Dr Duret later developed the Sopha system. Dr Mormann was the developer of the first commercial CAD/CAM system. He consulted with Dr Marco Brandestini, an electrical engineer, who came up with the idea of using optics to scan the teeth. By 1985, the team had performed the first chairside inlay using a combination of their optical scanner and milling device. They called the device CEREC, an acronym for computer-assisted ceramic reconstruction.6 Dr Rekow worked on a dental CAD/CAM system in the mid-1980s with colleagues at the University of Minnesota. This system was designed to acquire data using photographs and a high-resolution scanner, and to mill restorations using a 5-axis machine.7 Dr Andersson developed the Procera (now known as NobelProcera, Nobel Biocare, Zurich, Switzerland) method of manufacturing high-precision dental crowns in 1983.8 He was also the first person to use CAD/CAM for composite veneered restorations.9 Early technology permitted the creation of inlays, onlays, veneers, and crowns. More recently, CAD/CAM systems have been able to provide fixed partial dentures and implant abutments. Another use of CAD/CAM is in orthodontics. One example of this is Invisalign (Align Technology, Inc, Santa Clara, CA, USA), a treatment that uses multiple clear, removable appliances designed and manufactured via CAD/CAM to straighten teeth. CAD/CAM systems are becoming increasingly popular in dental offices. More than 30,000 dentists around the world own scanning and milling machines; 10,000 of these are in the United States and Canada. Worldwide, more than 15 million CEREC restorations alone have been completed.10
OVERVIEW OF CAD/CAM

In brief, in-office dental CAD/CAM systems consist of a handheld scanner, a cart that houses a personal computer together with a monitor, and a milling machine. The scanner head is placed intraorally above the tooth preparation and the resulting data appear on the monitor as 2-dimensional (2-D) or 3-dimensional (3-D) images. Design work is done on the monitor and the instructions are sent to a computerassisted processing machine for milling. Restorations are milled from prefabricated blocks of porcelain. Options include feldspathic, leucite, or lithium disilicate materials as well as blocks of composite.11 After the restoration is examined and approved, it is polished and inserted using conventional bonding techniques. Results with in-office milling machines appear to be as good as those from laboratory milling machines. A systematic review of 16 articles that comprised 1957 restorations found no significant differences in 5-year survival rates between chairside CEREC restorations (90.2% to 93.8%) and Celay laboratory restorations (82.1%).12

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ADVANTAGES AND DISADVANTAGES OF CAD/CAM

The use of CAD/CAM technology for dental restorations has numerous advantages over traditional techniques. These advantages include speed, ease of use, and quality. Digital scans have the potential to be faster and easier than conventional impressions because casts, wax-ups, investing, casting, and firing are eliminated.13 According to Sirona, half-arch impressions with the most recent version of CEREC take 40 seconds and full-arch impressions take 2 minutes.14 CAD/CAM also makes design and fabrication faster; a full-contour crown takes just 6 minutes to mill.15 Having a milling machine on site means that patients can receive their permanent restoration the same day they come in, without making a second appointment. Patients no longer need to have provisional restorations, which take time to fabricate and fit.13 If anesthetics are needed, they only need to be administered once. The quality of CAD/CAM restorations is extremely high because measurements and fabrication are so precise. In a study of 117 subjects by Henkel,16 each subject had 2 crowns made. One crown was made based on physical impressions using standard trays and impression material and another was made based on electronic impressions. Without knowing which one was which, dentists chose the crown based on the electronic impression 68% of the time. Perhaps this difference in the finished product should not be surprising, given the wide variation in quality of traditional impressions. Writing in a 2005 article, Christensen17 stated that he had seen impressions sent to laboratories in which more than 50% of the preparation margins were not discernible. Traditional impressions suffer from problems, such as bubbles and tears in the impression material, cords or other debris embedded in the impression material, and missing teeth.17 CAD/CAM restorations have a natural appearance because the ceramic blocks have a translucent quality that emulates enamel, and they are available in a wide range of shades.13 Ceramic wears well in the mouth, even when used for posterior teeth; because it is no more abrasive than conventional and hybrid posterior composite resins, it causes minimal wear to the opposing teeth.13 Finally, quality is consistent because prefabricated ceramic blocks are free from internal defects and the computer program is designed to produce shapes that will stand up to wear. Savings in time and labor have the potential to reduce costs, and the promise of faster, high-quality restorations should appeal to patients and patients are also happy to avoid the need for gag-inducing impressions. Another benefit is that all the scans can be stored on the computer; whereas, standard stone models take up space and can chip or break if stored improperly.18 Still, CAD/CAM systems have disadvantages. The initial cost of the equipment and software is high, and the practitioner needs to spend time and money on training.13 Dentists without a large enough volume of restorations will have a difficult time making their investment pay off. Just as with conventional impressions, in taking an optical scan the dentist needs to obtain an accurate recording of the tooth in need of restoration. The scan needs to emphasize the finish line and precisely duplicate the surrounding and occlusive teeth. Digital scanning requires the same type of soft-tissue management, retraction, moisture control, and hemostasis that is so important for conventional impressions. Digital impression systems may not save time as they are currently used because of the need for multiple steps. For example, dentists who use certain scanners must first send the images for a cleanup process, which is followed by setting of the margins by a dental technician. The images next go to the clinicians dental laboratory for review

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and then back for model milling. Finally, the models and dies are then sent to the clinicians dental laboratory for fabrication of the restoration.16
OFFICE-BASED DEVICES

Four products are presently available for digital impressions in the dental office: CEREC AC (Sirona, Charlotte, NC, USA), E4D Dentist (D4D Technologies, Richardson, TX, USA), iTero (Cadent, Carlstadt, NJ, USA), and Lava COS (3M ESPE, St Paul, MN, USA). Taking digital impressions allows dentists to do away with selecting trays, mixing materials and waiting for them to set, cleaning up the mess from the impressions, disinfecting the impressions, and shipping the impressions to a laboratory. The CEREC and E4D devices can be combined with in-office design and milling; whereas, the iTero and Lava COS devices are reserved for image acquisition only. In-office milling allows same-day restorations.
The CEREC System

CEREC, introduced in 1987, was the first dental system to combine digital scanning with a milling unit. The system allows dentists to provide restorations made from commercially available ceramic blocks in a single visit. The earliest models produced inlays and onlays only.6 The newest model, known as CEREC AC powered by BlueCam (Sirona, Charlotte, NC, USA) and introduced in 2009,19 also has the ability to take half-arch or full-arch impressions and create crowns, veneers, and bridges. The current acquisition system employs intense blue light from blue light-emitting diodes (LEDs). The camera projects blue light onto the teeth, which reflects it back at a slightly different angle. This method of visualization is referred to as active triangulation. To use the system, the entire tooth preparation to be scanned is coated with a layer of special titanium dioxide powder, which makes translucent areas of the teeth opaque and permits the camera to register all of the tissues. Several optical impressions are then taken from an occlusal orientation, being sure to obtain images of the tooth to be restored as well as the adjacent and opposing teeth. The scanner is able to focus automatically. After the impression is complete, a 3-D rendering of the tooth to be restored appears on the monitor. The dentist is able to mark where the die should begin and end based on this image. The software program then generates a proposed restoration based on comparisons to the surrounding teeth, which can then be altered or fine tuned as needed. After the design is approved, the milling process can begin. A block of ceramic or composite material in the correct color is simply inserted into the milling unit.15 Alternatively, the dentist can obtain a digital impression and send the data to a dental laboratory. The laboratory can then design and mill the restoration using CAD/CAM technology. They can also use the digital image to fabricate a hard resin model based on the data and proceed to fabricate the restoration in the conventional manner.
The E4D Dentist System

The E4D Dentist system, which made its debut in 2008, is presently the only other system besides CEREC that permits same-day in-office restorations.18 Dentists can purchase the design center and laser scanner alone, or also purchase the milling unit. This system includes a laser scanner, called the IntraOral Digitizer, along with a design center and milling unit. The scanner is small, so patients do not need to open their mouth as wide (Fig. 1).

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Fig. 1. E4D. (Courtesy of D4D Technologies.)

The E4D system requires the use of powder in some but not all cases. To use the system, the restoration site is prepared as it is for a traditional impression. The scanner is placed near the target tooth, and has 2 rubber feet that hold it a specific distance from the area being scanned. Looking at a computer monitor, the image of the target tooth is centered on the screen. A foot pedal is then released, which activates the image capture using software called ICEverything (D4D Technologies, Richardson, TX, USA). The software on the screen then prompts the dentist to adjust the scanner for the next image. As each picture is taken, the software gradually creates a 3-D image. The image can then be viewed from any angle to confirm that the scan is complete. Instead of scanning the opposing arch, an occlusal registration is created with an impression material and is placed atop the target tooth. The scanner captures the combination of registration material and uncovered teeth, using this information to design restorations of the correct heights. The design system automatically detects the finish lines and marks them on the screen. After the dentist approves these markings, the computer proposes a restoration model for the target tooth. Currently, one advantage of E4D is that the designer can work on up to 16 restorations at once.

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As soon as the restoration is approved, the data are transmitted to either the in-house milling machine or a dental laboratory. The office milling machine will then manufacture the restoration from the chosen blocks of ceramic or composite.
The Cadent iTero

Cadent introduced iTero in 2007 as the first digital impression system for conventionally manufactured crowns and bridges. Unlike the other 3 digital impression systems, which acquire images using triangulation, iTero employs parallel confocal imaging.20 Specifically, the device projects 100,000 parallel beams of red laser light at the teeth and transforms the reflected light into digital data through the use of analog-to-digital converters.21 This technology allows scans to be taken without coating the teeth in powder. The absence of powder means that the scanner can be rested directly on the teeth during scanning. One disadvantage is that the scanner head is larger than those of the other 3 scanners discussed here.18 To start, information about the patient, including the type of restoration and the tooth color, is entered into the computer. The system provides voice and visual commands to guide the dentist through each scan; a typical series ranges from 15 to 30. The monitor combines these scans to provide a 3-D color model of both arches. The complete scanning process takes about 3 to 5 minutes for a full mouth. During the review phase, the dentist is able to review the scan from any angle. A digital articulator permits the dentist to review the occlusal clearance and make any needed modifications to the prepared teeth or opposing arch. After the scan is approved, a dedicated wireless connection transmits the scan to Cadent for cleanup and initial design. The file then gets transmitted to the dental laboratory.
The Lava Chairside Oral Scanner

The Lava Chairside Oral Scanner (COS) was launched in February 2008.18 The system includes a mobile cart, a touch screen display, and a scanner with a camera at the end (Fig. 2). The camera, which contains 192 LEDs and 22 lens systems, employs active wavefront sampling to capture images at video rate. After preparing the tooth and retracting the gingival tissue, the dentist dries the arch and gives it a light dusting of titanium dioxide powder. Just enough powder is used to permit the scanner to identify reference points. The scan is obtained by moving the wand first over the occlusal surfaces, then over the buccal surfaces, and finally over the lingual sufaces. An additional scan is taken of the occlusal surfaces. The monitor image, which appears instantly, can be rotated and magnified to ensure that all areas have been scanned properly and no holes appear. The dentist also has the ability to switch between 3-D and 2-D images. Finally, the system is compatible with 3-D glasses for a true 3-D experience. After signing off on the scans, the data is sent wirelessly to the laboratory, where the die is cut and the margin marked digitally. Then the data go to 3M, where a technician reviews and synthesizes the images before creating a stone model. This stone model is then sent to the laboratory. The Lava COS can be used to make any type of crown or bridge, not just Lava crowns and bridges.

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Fig. 2. Lava COS. (Courtesy of 3M ESPE.)

LABORATORIES

Laboratories are increasingly using CAD/CAM to create restorations. CAD/CAM technology is the only way to create zirconia copings because the design program is able to adjust precisely for the shrinkage caused by sintering. A common way for laboratories to use CAD/CAM is for the laboratory to scan the stone model with a digital scanner. After waxing up the model, a second scan is done. The design program combines the 2 images digitally to determine the form of the restoration. The best known of these systems is InLab, CERECs laboratory-based designing and milling system. This system is able to fabricate 3-unit bridge frames and automatic virtual occlusal adjustments. The system is able to mill zirconia cores or full-ceramic restorations using materials, such as IPS Empress or IPS e.max (both from Ivoclar Vivadent, Amherst, NY, USA).

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A major advantage of using CAD/CAM systems in the laboratory is that the final restoration can look exactly like the provisional. CAD/CAM systems also shorten the learning curve for new dental technicians, although a dental technician still finishes each restoration by hand. CAD/CAM technology does not replace the need for skilled dental laboratory technicians.
INCORPORATING CAD/CAM INTO YOUR PRACTICE

The age of CAD/CAM in dentistry has clearly arrived. Now it is up to individual dentists to decide how much of the new technology they want in their office and how quickly. Some dentists wish to have the latest technology and are willing to spend the money to have it. However, another point to consider is patient population. Dentists with younger, more affluent patients may be able to charge a premium for the convenience of same-day restorations. On the other hand, those whose practices consist primarily of direct restorations, removable prosthodontics, and periodontal treatments may not be able to recoup their investment. Dentists who wish to begin providing same-day restorations can purchase a complete CEREC AC or E4D system at a cost of approximately $90,000 to $112,000.22 A lower-cost option is to purchase a digital scanner only; prices for these range from about $24,000 to $41,000.22 Each scan costs between $16 and $35.22 Dentists who choose a CEREC AC or E4D scanner have the ability to add a milling unit at a later date. Using a digital scanner improves patient comfort because impressions can be uncomfortable. Using a complete system has the potential to reduce costs related to impression material, provisional crowns, time in the office, and laboratory bills. Dr Parag Kachalia estimated that dentists who switch to office CAD/CAM systems can reduce their laboratory bill by 60% to 70%.22 Dentists who do advanced aesthetic treatment know how important provisional veneers and crowns are to the overall treatment success. Provisionals are used to not only protect the exposed tooth tissues and to give a more cosmetic appearance during the time the permanent restorations are being fabricated but also to allow for a trial run of the size, shape, and contour of the restorations. Once these parameters are accepted, the ceramist needs to duplicate them as best as possible in the final restorations. The use of CAD/CAM allows for the laboratory to do just that in an exact way. The laboratory technician makes 2 virtual models; one of the provisionals and one of the final impression of the prepared teeth. They virtually superimpose the provisionals over the prepared teeth. The veneers are then milled in that precise shape, with the ceramist cutting back a small portion to allow for layering and detail work (Figs. 37). Using CAD/CAM technology in this way allows the ceramist to duplicate the emergence profile, incisal edge position, contours, and exact dimensions of the provisional veneers.
THE FUTURE OF CAD/CAM

Over the next decade, as prices come down and dentists become more comfortable with the new technology, we can expect to see increased use of CAD/CAM in dentistry. Same-day restorations will become more popular and will likely expand to fixed partial and removable dentures. One area for improvement would be representation of jaw movement using CAD/CAM; current design software only captures shapes.

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Fig. 3. Virtual cutting of the dies. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

Fig. 4. Overlay of provisional virtual model over final virtual model. Note that the teeth were being lengthened by about 2 to 3 mm. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

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Fig. 5. Labial overlay of models. Note how emergence profile can exactly mimic the provisionals. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

Scanning, designing, and milling devices are expected to become increasingly simple and convenient to use. In anticipation of future advances, the CEREC AC is prepared for voice control and voice output.15 Improvements in technology should avoid some of the back-and-forth data information between the dentist, the manufacturer, and the dental laboratory. Another potential use of dental CAD/CAM could be in third-world countries where laboratories and skilled ceramists might not be readily available.5 CAD/CAM technology could allow technicians to do much of the work and restorations could be created on the spot.

Fig. 6. Wax-up for provisionals. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

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Fig. 7. Final restorations on model. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

SUMMARY

Using CAD/CAM technology in the dental office and laboratory may have seemed like science fiction 20 years ago, but today it is reality. We now have the ability to create inlays, onlays, veneers, crowns, fixed partial dentures, implant abutments, and full-mouth reconstruction using CAD/CAM. CAD/CAM units are still expensive to purchase and use. But as prices come down and more health care providers embrace the technology, we can expect digital scanners and computer-assisted design and manufacturing to become standard in dentistry.
ACKNOWLEDGMENTS

Devon Schuyler, MA, ELS assisted in the preparation of this manuscript.

REFERENCES

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10. FAQS. Answers you need for the results you desire. Sirona; 2008. Available at: http://www.Cereconline.Com/Cerec/Faqs.Html. Accessed February 15, 2011. 11. Materialsoptions and partners. Available at: http://www.Cereconlin.Com/Cerec/ Materials.Html. Sirona; 2008. Accessed August 6, 2010. 12. Wittneben JG, Wright RF, Weber HP, Gallucci GO. A systematic review of the clinical performance of CAD/CAM single-tooth restorations. Int J Prosthodont 2009; 22(5):46671. 13. Mormann WH, Brandestini M, Lutz F, Barbakow F. Chairside computer-aided direct ceramic inlays. Quintessence Int 1989;20(5):32939. 14. The CEREC Acquisition Center powered by Bluecam. Available at: http://www. cereconlin.com/cerec/acquisition-center.html. Sirona; 2008. Accessed August 6, 2010. 15. CEREC AC: CAD/CAM for everyone [pamphlet]. Charlotte (NC): Sirona. 16. Henkel GL. A comparison of fixed prostheses generated from conventional vs digitally scanned dental impressions. Compend Contin Educ Dent 2007;28(8): 4224, 4268, 4301. 17. Christensen GJ. The state of fixed prosthodontic impressions: room for improvement. J Am Dent Assoc 2005;136(3):3436. 18. Birnbaum N, Aaronson HB, Stevens C, et al. 3D digital scanners: a high-tech approach to more accurate dental impressions. Inside Dentistry 2009;5(4). 19. Sirona introduces CEREC AC powered By Bluecam [press release]. Charlotte (NC): Sirona; 2009. 20. Cadent Itero. Creating the perfect byte [pamphlet]. Carlstadt (NJ): Cadent; 2008. 21. Lava Chairside Oral Scanner C.O.S [pamphlet]. St Paul (MN): 3M ESPE; 2009. 70-2009-3999-2. 22. Kachalia PR, Geissberger MJ. Dentistry a la carte: in-office CAD/CAM technology. J Calif Dent Assoc 2010;38(5):32330.