INTRODUCTION : Everything is perfect in the universe, even our desire to improve it.

Such quest towards perfection in our field, has opened up several new range of systems. One such system is CAD CA!. Computer Aided Design and Computer Aided !anufacture "CAD#CA!$ systems have %een used for many years in various industries, nota%ly the automotive industry, %ut are now finding applications development in dentistry. CAD : CAD is the use of computer systems in the design and development of a product. &he computer is used as an e'tended drawing %oard, allowing three dimensional modeling and design. !athematical modeling of the structure allows some aspects of its performance to %e assessed %efore it ever leaves the drawing %oard. CAM : CA! is the use of a computer system to operate machine tools. &his allows the shaping of materials to form structures and devices. &he computers controlling the machine tools can operate from instructions set up %y the computer aided design system. (n this way a complete integrated system is set up. &he o%)ect to %e made is designed on a computer screen and then the design is implemented %y the computer.

BASIC ARCHITECTURE OF CAD-CAM : *estorative dentistry has %een restricted %y the range of fa%rication technologies availa%le. Direct placement restorations are limited to the alloying of dental amalgam, acid %ase reactions or the polymeri+ation of resins. ,a%oratory fa%ricated restorations are limited to lost wa' casing, porcelain sintering or resin polymeri+ation. &his restricts the range of materials which can %e used. CAD#CA! systems open up a range of new material systems %y providing a new method for the control of shape. &he ma)or limiting factor in applying CAD#CA! technology to dental restorations is that the preparation of the tooth is the prime factor which determines the shape of the final restoration. &his means that some method of scanning the tooth preparation accurately needs to %e employed. -arious methods of achieving this are %eing tried. &he first system which %ecame availa%le commercially was developed in .urich %y /erner !ormann and mar0eted %y Siemens of 1ermany. &his is the 2C3*3C system. At the time of writing this system is the only commercially availa%le chair side dental ACD#CA! system on the many scientific studies and over 4555 machines are in clinical use. &he 2C3*3C6 concept is the ingenious result of a sophisticated analysis of the requirements of a dental restorative system and the application of logical pro%lem reduction. &his is com%ined with an elegant and effective engineering solution, matched to the pro%lem reduction model. &he tooth preparation is rationali+ed to e'clude the need for internal machining of the ceramic %lan0. &his allows speedy production of the final restoration %y a tur%ine driven diamond milling dis0 in a single pass along the ceramic %lan0. &he topography of the tooth preparation is recorded optically in a fraction of a second and a digital model created in the computer.

PROCEDURE : (also see CD) The optical i p!essio" : (n order to ma0e the surface of the tooth visi%le to the infra red illuminator in the active camera, it is necessary to coat the tooth with titanium o'ide power. &his highly reflective powder is sprayed on as a dry dust. &he tooth is first coated with a polysor%ate film, the imaging liquid. &his holds the powder in place. A light emitting diode pro)ects the image of a grid onto the tooth surface. &he camera o%serves this grid from a slight angle. -ertical contour of the cavity is o%served as a lateral shift in the lines of the grid %rought a%out %y a paralla' effect. &his shift is used to determine the physical measurement of height. So#t$a!e a"% the !esto!atio" %esi&" : Once a three dimensional model of the tooth preparation is recorded the restoration must %e designed on top of it. &he first generation software required some level of design intervention %y the operator %ut as the software has %ecome more sophisticated less s0ill is needed. &he operator maps out the %ase of the restoration %y placing plotting points on the photograph of the cavity which appears on a computer monitor. &he machine e'trapolates across this area and determines the true topography of the cavity floor. &he operator ne't outlines the appro'imal surface and the machine suggests the placement of the marginal ridge. &hese features may %e edited easily. &he points are )oined up %y the computer which then locates the occlusal margin of the cavity using a wall finding algorithm which loo0s progressively up the wall of the cavity until a hori+on is located. (t identifies this as the cavity edge. &hese data are used to construct a wire frame model of the restoration. 3dition of the data is possi%le to alter the e'ternal profile of the final restoration. &he wire frame model is stored to dis0 and the data

are used to drive a milling machine which shapes a %loc0 of ceramic to the required form. After the volume model has %een created, a ceramic %loc0 is inserted into the milling machine and the device renders the final restoration. &his is the original hydraulic tur%ine version. An electric drive is now availa%le and provides a finer surface finish on the ceramic restoration and a much improved cutting efficiency. !illing with a rotary dis0 is simple and effective %ut there are certain limitations of cut which are implicit in the system. &he preparations cut in the tooth must %e designed to ta0e these limitations into account. Possi'le : A : 3'ternal curves in the plane of the cutting dis0 on any surface. B : 3'ternal curves perpendicular to the plane of the cutting dis0 on any surface. C : Straight steps across the whole of a surface in the plane of the cutting dis0. Not possi'le : ( : Steps with risers at angles to the plane of the cutting dis0. ) : (nternal curves with a radius smaller than that of the cutting dis0. * : 7ndercut surfaces. Steps in the same plane as the dis0 are not possi%le nor are any areas of internal milling such as would %e needed to fa%ricate a crown. &his limitation affects the design of cavity which can prepared. 8owever, most cavity surfaces can %e restored with modifications to the traditional cavity design. !achining such a small item as a dental crown, %ridge or inlay requires high levels of precision, especially when creating an internal fitting surface such as that of crown. A capstan head milling machine is needed to fa%ricate the inner surfaces of crowns as a num%er of cutting instruments

will %e needed to create the shape. Such machines ta0e much greater time in manufacturing are li0ely to %e limited to la%oratory use and will not allow single visit crown placement. Cost appears to %e the greatest o%stacle to commercial reali+ation of wor0ing systems. ,a%oratory %ased CAD#CA! systems are availa%le and mostly rely on digiti+ing data from dental models which are cast from conventional impressions. &he digiti+ing systems are %ased on mechanical stylus tracing and this ta0es a considera%le time to do. (t is more than reasona%le to loo0 at the direction in which technology is moving and predict that the ne't stage of tooth reconstruction which will come to the attention of the computer technologist is the cutting of the tooth preparations. (n this way the machine could optimi+e all stages of re%uilding or replacing a tooth. Structural analysis can %e integrated into computer aided design. &his is 0nown as finite element analysis or 93A. 93A allows the distri%ution of stresses in a structural design to %e analysed. 9rom this information the design of the structure can %e modified in order to optimi+e the stress distri%ution %oth in the structure itself and in the structures which support it. (ntegrating such a design system into a dental CAD#CA! system is a formida%le %ut achieva%le tas0 which would allow the development of restorations far superior to any of today.

RESTORATI+E MATERIA,S FOR CAD-CAM : CAD#CA! systems %ased on machining of presintered alumina or +irconia %loc0s in com%ination with specially designed veneer ceramics satisfy the demand for all ceramic posterior crowns and fi'ed partial dentures. !any ceramic materials are availa%le for use as CAD#CA! restorations. Common ceramic materials used in earlier dental CAD#CA! restorations have %een machina%le glass ceramics such as Dicor or -ita !ar0 ((. Although monochromatic, these ceramic materials offer e'cellent esthetics, %iocompati%ility, great color sta%ility, low thermal conductivity, and e'cellent wear resistance. &hey have %een successfully used as inlays, onlays, veneers, and crowns. 8owever, Dicor and -ita !ar0 (( are not strong enough to sustain occlusal loading when used for posterior crowns. 9or this reason, alumina and +irconia materials are now %eing widely used as dental restorative materials. &hese ceramic agents may not %e cost effective without the aid of CAD#CA! technology. 9or instance, (n Ceram, first descri%ed %y Degrange and Sadoun, has %een shown to have good fle'ural strength and good clinical performance. 8owever, the manufacture of conventional (n Ceram restoration ta0es up to 4: hours. ;y milling copings from presintered alumina or +irconia %loc0s within a <5 minute period and reducing the glass infiltration time from : hours to :5 minutes, C3*3C in,a% decreases fa%rication time %y =5>. .irconia is strong and has high %iocompati%ility. 9ully sintered +irconia materials can %e difficult to mill, ta0ing ? hours for a single unit. Compared with fully sintered +irconia, milling, restorations from presintered or partially sintered solid %loc0s is easier and less time consuming, creates less tool loading and wear, and provides higher precision. After milling, (n Ceram spinell, alumina, and +irconia %loc0s are glass infiltrated to fill fine

porosities. Other machina%le presintered ceramic materials are sintered to full density, eliminating the need for e'tensive use of diamond tools. 7nder stress the sta%le tetragonal phase may %e transformed to the monoclinic phase with a ?> to :> volume increase. &his dimensional change creates compressive stresses that inhi%it crac0 propagation. &his phenomenon, called transformation toughening, actively opposes crac0ing and gives +irconia its reputation as the smart ceramic. &he quality of transformation toughness and its affect on other properties is un0nown. .irconia copings are laminated with low fusing porcelain to provide esthetics and to reduce wear of the opposing dentition. (f the a%utment lac0s adequate reduction the restoration may loo0 opaque. ;ecause they normally are not etcha%le or %onda%le, a%utments require good retention and resistance form. Alumina and +irconia restorations may %e cemented with either conventional methods or adhesive %onding techniques. Conventional conditioning required %y leucite ceramics "eg, hydrofluoric acid etch$ is not needed. !icroetching with Al<O? particles on cementation surfaces removes contamination and promotes retention for pure aluminum o'ide ceramic. &wo in vitro studies recommended that a resin composite containing an adhesive phosphate monomer in com%ination with a silane coupling#%onding agent can achieve superior long term shear %ond strength to the intaglio surface of @rocera AllCeram and @rocera All.ir0on restorations. CAD#CA! systems also can %e applied to restorations requiring metal and are used to fa%ricate implant a%utments and implant retained overdenture %ars. &he DCS system can fa%ricate crown copings from titanium alloy with e'cellent precision. Several articles have reported the e'tension of CAD#CA! technology to the fa%rication of ma'illofacial prostheses such as the artificial ear.

Re.ie$ o# Co

o" CAD-CAM S/ste s :

CAD#CA! systems may %e categori+ed as either in office or la%oratory systems. Among all dental CAD#CA! systems, C3*3C is the only manufacturer that provides %oth in office and la%oratory modalities. Similar to CAD#CA! systems have increased significantly during the last 45 years and include DCS @recident, @rocera, C3*3C in,a%, and ,ava. CA! capa%ilities without the design stage. Several of the more common dental CAD#CA! systems are descri%ed %elow. CEREC : /ith C3*3C 4 AAD C3*3C <, an optical scan of the prepared tooth is made with a couple charged device "CCD$ camera, and a ? dimensional digital image is generated on the monitor. &he restoration is then designed and milled. /ith the newer C3*3C ?D, the operator records multiple images within seconds, ena%ling clinicians to prepare multiple teeth in the same quadrant and create a virtual cast for the entire quadrant. &he restoration is then designed and transmitted to a remote milling unit for fa%rication. /hile the system is milling the first restoration, the software can virtually seat the restoration %ac0 into the virtual cast to provide the ad)acent contact while designing the ne't restoration. C3*3C in,a% is a la%oratory system in which wor0ing dies are laser scanned and a digital image of the virtual model is displayed on a laptop screen. After designing the coping or framewor0, the la%oratory technician inserts the appropriate -(&A (n Ceram %loc0 into the C3*3C in,a% machine for milling. &he technician then verifies the fit of the milled coping or framewor0. &he coping or framewor0 is glass infiltrated and veneering porcelain is added. One recent in vitro evaluation of CAD#CA! ceramic crowns that compared the marginal adaptation of C3*3C < with C3*3C ?D concluded

that crown adaptation for C3*3C ?D ":B.C 4=.C m$ was significantly %etter compared with C3*3C < "=B.5 ??.D m$. DCS P!eci%e"t : &he DCS @recident system is comprised of a @reciscan laser scanner and @recimill CA! multi tool milling centre. &he DCS Dentform software automatically suggests connector si+es and pontic forms for %ridges. (t can scan 4: dies in 4 fully automated operation. !aterials used with DCS include porcelain, glass ceramic, (n Ceram, dense +irconia, metals and fi%er reinforced composites. &his system is one of the few CAD#CA! systems that can mill titanium and fully dense sintered +irconia. An in vitro study was conducted evaluating the marginal fit of alumina E and +irconia %ased ? , : and C unit posterior fi'ed partial dentures machined %y the DCS @resident system. &hey concluded that the system easily met the requirement of less discrepancy than 455 m. Another study evaluated that DCS system for fa%ricating titanium copings. &he mean values of marginal fit for the individual crowns ranged from <4.< 4:.F m to D4.F <C.4 m. &he mean value for all crowns was :B.5 ?4.C m. P!oce!a : @rocera # AllCeram was introduced in 4==: and according to company data, has produced ? million units as of !ay <55:. @rocera uses an inhnovative concept for generating its alumina and +irconia copings. 9irst, a scanning stylus acquires ?D images of the master dies that are sent to the processing center via modem. &he processing center then generates enlarged dies designed to compensate for the shrin0age of the ceramic material. Copings are manufactured %y dry pressing high purity alumina powder "G==.=>$ against the enlarged dies. &hese densely pac0ed copings. &he complete produce for @rocera coping fa%rication is very technique

sensitive %ecause the degree of die enlargement must precisely match the shrin0age produced %y sintering the alumina or +irconia. According to recent research data, the average marginal gap for @rocera#AllCeram restorations ranges from C:m to F:m. ,iterature also confirms that @rocera restorations have e'cellent clinical longevity and strength. &he fle'ural strength for @rocera alumina is FDB !@a and for +ircoina is 4<55 !@a. @rocera also is capa%le of generating AllCeram %ridge copings. 8owever, the occlusal ECervical height of the a%utment should %e at least ? mm and the pontic space should %e less than 44 mm. &he recommended preparation marginal design for @rocea is a deep chamfer finish line with a recommended coping thic0ness of 5.: mm to 5.F mm. ,a.a : (ntroduced in <55<, ,ava uses a laser optical system to digiti+e information from multiple a%utment margins and the edentulous ridge. &he ,ava CAD software automatically finds the margin and suggests a pontic. &he framewor0 is designed to %e <5> larger to compensate for sintering shrin0age. After the design is complete, a properly si+ed semisintered +irconia %loc0 is selected for milling. &he %loc0 is %ar coded to register the special design of the %loc0. &he computer controlled precision milling unit can mill out <4 copings or %ridge framewor0s without supervision or manual intervention. !illed framewor0s then undergo sintering to attain their final dimensions, density, and strength. &he system also has D different shades to color the framewor0 for ma'imum esthetics. 8ertlein and colleagues tested the marginal adaptation of yttria +irconia %ridges processed with the ,ava system for < milling time "BC minutes vs CF minutes$. &hey concluded that the milling time does not affected the marginal adaptation "F4 <Cm vs C= <4 m$ for ? unit +irconia %ridge framewor0s.

E.e!est : !ar0eted in <55<, the 3verest system consists of scan, engine, and therm components. (n the scanning unit, a reflection free gypsum cast is fi'ed to the turnta%le and scanned %y a CCD camera in a 4H4 ratio with an accuracy of measurement of <5 m. A digital ?D model is generated %y computing 4C point photographs. &he restoration is then designed on the virtual ?D model with /indows %ased software. (ts machining unit has C a'is movement that is capa%le of producing detailed morphology and precise margins from a variety of materials including leucite reinforced glass ceramics, titanium. @artially sintered +irconia framewor0s require additional heat processing in its furnace. Ce!co" : &he Cercon System is commonly referred to as a CA! system %ecause it does not have a CAD component. (n this system scans the wa' pattern and mills a +irconia %ridge coping from presintered +irconia %lan0s. &he coping is then sintered in the Cercon heat furnace "4,?C5 5 C$ for F to D hours. A low fusing, leucite free Cercon Ceram S veneering porcelain in vitro study the marginal adaptation for Cercon all ceramic crowns and fi'ed partial dentures was reported as ?4.? m and <=.? m, respectively. One of the most important criteria in evaluating fi'ed restorations is marginal intergrity. 3valuating inlay restorations, ,einfelder and colleagues reported that marginal discrepancies larger than 455m resulted in e'tensive loss of the luting agent. O6Aeal and colleagues reported the possi%ility of wear gap dimension e'ceeded 455 m. 3ssig and colleagues conducted a C year evaluation of gap wear and reported that vertical wear is half of the hori+ontal gap. &he wear of the gap increased dramatically in the first year, %ecoming sta%le after the second year.

!c,ean and -on 9raunhofer proposed that an accepta%le marginal discrepancy for full coverage restorations should %e less than 4<5 m. Christensen suggested a clinical goal of <Cm to :5m for the marginal adaptation of cemented restorations. 8owever, most clinicians agree that the marginal gap should %e no greater than C5m to 455m. Current research data indicate that most dental CAD#CA! systems are now a%le to produce restorations with accepta%le marginal adaptation of less than 455 m.

CONC,USION : CAD#CA! systems have dramatically enhanced dentistry %y providing high quality restorations. &he evolution of current systems and the introduction of new systems demonstrate increasing user friendliness, e'panded capa%ilities, and improved quality, and range in comple'ity and application. Aew materials also are more esthetic, wear more nearly li0e enamel, and are strong enough for full crowns and %ridges. Dental CAD#CA! technology is successful today %ecause of the vision of many great pioneers. As Duret, concluded in his article in 4==4, &he systems will continue to improve in versatility, accuracy, and cost effectiveness, and will %e a part of routine dental practice %y the %eginning of the <4st century. The true work of art is but a shadow of the divine perfection Michelengelo.

CAD-CAM
O0tli"e

12 INTRODUCTION 32 CAD 42 CAM 52 BASIC ARCHITECTURE OF CAD-CAM 62 PROCEDURE 72 RESTORATI+E MATERIA,S FOR CAD-CAM 82 RE+IE9 OF COMMON CAD-CAM S)STEM :2 CONC,USION ;2 PO9ERPOINT FORMAT OF SEMINAR

CO,,E<E OF DENTA, SCIENCES

DEPARTMENT OF CONSER+ATI+E DENTISTR) AND ENDODONTICS

SEMINAR ON

CAD CAM IN RESTORATIVE DENTISTRY

PRESENTED B) :
D!2 Si%%hes$a!a" +2