Daniel Edelhoff

Digital dentistry: an overview of recent developments for CAD/CAM generated restorations

As in many other industries, production stages are increasingly becoming automated in dental technology. As the price of dental laboratory work has become a major factor in treatment planning and therapy, automation could enable more competitive production in high-wage areas like Western Europe and the USA. Advances in computer technology now enable cost-effective production of individual pieces. Dental restorations produced with computer assistance have become more common in recent years. Most dental companies have access to CAD/CAM procedures, either in the dental practice, the dental laboratory or in the form of production centres. The many benefits associated with CAD/CAM generated dental restorations include: the access to new, almost defect-free, industrially prefabricated and controlled materials; an increase in quality and reproducibility and also data storage commensurate with a standardised chain of production; an improvement in precision and planning, as well as an increase in efficiency. As a result of continual developments in computer hardware and software, new methods of production and new treatment concepts are to be expected, which will enable an additional reduction in costs. Dentists, who will be confronted with these techniques in the future, require certain basic knowledge if they are to benefit from these new procedures. This article gives an overview of CAD/CAM-technologies and systems available for dentistry today.

High-strength CAD/CAM-fabricated veneering material sintered to zirconia copings — A new fabrication mode for all-ceramic restorations

OBJECTIVES With this in vitro study the fracture strength of zirconia-based crown copings being veneered with a CAD/CAM generated high-strength ceramic cap by sintering is compared with anatomically identical zirconia-based crowns, which were either overpressed or veneered by the layering technique for completion. METHODS A 1.2mm, 360 degrees chamfer preparation was performed on a second maxillary molar and was dublicated 15 times in a cobalt-chromium-alloy. A sample of 45 zirconia copings was produced and divided into three groups. In the first group (VT) zirconia copings received conventional veneering in layering technique, in the second group the veneering porcelain was pressed over the zirconia coping (PT), and for the third group (ST) a CAD/CAM-fabricated high-strength anatomically shaped veneering cap was sintered onto the zirconia coping. All crowns were cemented conventionally onto their dies and tested in the universal testing machine until clinical failure. The fracture load data were compared by a one-way analysis of variance and a multiple comparison posthoc test (alpha<0.05). RESULTS Specimens from group VT showed a mean (S.D.) fracture load of 3700.39 (1238.72) N, group OT 3523.73 (1181.11) N and group ST 6262.67 (2257.42) N. The difference between groups VT/OT and ST were statistically significant (P<0.001). SIGNIFICANCE The new CAD/CAM-fabricated bilayered restorations (ST) were superior to the present techniques (VT and OT) in terms of fracture load and offer the possibility to produce cost-effective crowns and fixed partial dentures with a potential lower risk of chippings.

In vivo fracture resistance of implant-supported all-ceramic restorations

STATEMENT OF PROBLEM Because of their specific mechanical properties, all-ceramic restorations demonstrate a lower fracture resistance than ceramic restorations supported by metal substructures. However, advances have been made in the fabrication of high-strength all-ceramic abutments for anterior implants. No previous study has compared the fracture loads between 2 different all-ceramic abutments restored by glass-ceramic crowns. PURPOSE The purpose of this in vitro investigation was to quantify the fracture load of implanted-supported Al(2)O(3) and ZrO(2) abutments restored with glass-ceramic crowns. MATERIALS AND METHODS Two ceramic abutments were tested: an Al(2)O(3) abutment (CerAdapt) and a ZrO(2) abutment (Wohlwend Innovative). The abutments (n = 10) were placed on Brånemark dental implants and prepared for restoration with glass-ceramic crowns (IPS Empress). After fabrication, in accordance with the manufacturers guidelines, the crowns were bonded to the all-ceramic abutments with a dual-polymerizing resin luting agent. The fracture loads (N) were determined by force application at an angle of 30 degrees by use of a computer-controlled universal testing device. The data were analyzed with the unpaired t test (alpha=.05). RESULTS Statistical analysis showed significant differences between both groups (P=.001) of all-ceramic abutments, with mean fracture load values of 280.1 N (+/- 103.1) for the Al(2)O(3) abutments and 737.6 N (+/- 245.0) for the ZrO(2) abutments. CONCLUSION Within the limitations of this study, both all-ceramic abutments exceeded the established values for maximum incisal forces reported in the literature (90 to 370 N). The ZrO(2) abutments were more than twice as resistant to fracture as the Al(2)O(3)-abutments.

Marginal and internal fits of fixed dental prostheses zirconia retainers

OBJECTIVES CAM (computer-aided manufacturing) and CAD (computer-aided design)/CAM systems facilitate the use of zirconia substructure materials for all-ceramic fixed partial dentures. This in vitro study compared the precision of fit of frameworks milled from semi-sintered zirconia blocks that were designed and machined with two CAD/CAM and one CAM system. METHODS Three-unit posterior fixed dental prostheses (FDP) (n=10) were fabricated for standardized dies by: a milling center CAD/CAM system (Etkon), a laboratory CAD/CAM system (Cerec InLab), and a laboratory CAM system (Cercon). After adaptation by a dental technician, the FDP were cemented on definitive dies, embedded and sectioned. The marginal and internal fits were measured under an optical microscope at 50x magnification. A one-way analysis of variance (ANOVA) was used to compare data (alpha=0.05). RESULTS The mean (S.D.) for the marginal fit and internal fit adaptation were: 29.1 microm (14.0) and 62.7 microm (18.9) for the milling center system, 56.6 microm (19.6) and 73.5 microm (20.6) for the laboratory CAD/CAM system, and 81.4 microm (20.3) and 119.2 microm (37.5) for the laboratory CAM system. One-way ANOVA showed significant differences between systems for marginal fit (P<0.001) and internal fit (P<0.001). SIGNIFICANCE All systems showed marginal gaps below 120 microm and were therefore considered clinically acceptable. The CAD/CAM systems were more precise than the CAM system.

In vitro performance of full-contour zirconia single crowns

OBJECTIVES Zirconia based restorations exhibited high failure rates due to veneering-porcelain fractures. Milling to full-contour might be an alternative approach for zirconia restorations. The aim of this study was to evaluate full-contour zirconia crowns in terms of light-transmission, contact wear (restoration and antagonist) and load-bearing capacity. Powder build-up veneered zirconia substructures and CAD/CAM-veneered zirconia substructures served as controls. METHODS Four different kinds of crowns were fabricated on 12 metal dies: zirconia substructure with powder build-up porcelain (veneering technique), zirconia substructure with CAD/CAM generated veneering (sintering technique), full-contour zirconia glazed (glazed full-contour) and full-contour zirconia polished (polished full-contour). All crowns had the same dimensions. After light-transmission was measured the crowns were cemented on the corresponding metal dies. The specimens were loaded according to a special wear method in the chewing simulator (120,000 mechanical cycles, 5 kg load, 0.7 mm sliding movement, 320 thermocycles). Wear of the restoration and the antagonist were measured. All specimens were loaded until failure. One-way ANOVA and a LSD post-hoc test were used to compare data at a level of 5%. RESULTS Polished full-contour showed significantly higher light transmission than the other groups (p=0.003; ANOVA). Polished full-contour exhibited significantly less contact wear at the restoration (p=0.01; ANOVA) and higher contact wear at the antagonist (p=0.016; ANOVA) compared to the other groups. Glazed full-contour zirconia showed similar contact wear at the antagonist compared to veneering technique (p=0.513, post-hoc LSD). Crowns with conventional veneering showed significantly lower load-bearing capacity (p<0.001; ANOVA). SIGNIFICANCE Milling zirconia to full-contour with glazed surface might be an alternative to traditionally veneered restorations.

Wear at the titanium–titanium and the titanium–zirconia implant–abutment interface: A comparative in vitro study

OBJECTIVE The purpose of this study was to determine and measure the wear of the interface between titanium implants and one-piece zirconia abutments in comparison to titanium abutments. METHODS 6 implants were secured into epoxy resin blocks. The implant interface of these implants and 6 corresponding abutments (group Zr: three one-piece zirconia abutments; group Ti: three titanium abutments) were examined by a microscope and scanning electron micrograph (SEM). Also the implants and the abutments were scanned by 3D-Micro Computer Tomography (CT). The abutments were connected to the implants and cyclically loaded with 1,200,000 cycles at 100N in a two-axis fatigue testing machine. Afterwards, all specimens were unscrewed and the implants and abutments again were scanned by microscope, SEM and CT. The microscope and SEM images were compared, the CT data were superimposed and the wear was calculated by inspection software. The statistical analysis was carried out with an unpaired t-test. RESULTS Abutment fracture or screw loosening was not observed during cyclical loading. Comparing the microscope and SEM images more wear was observed on the implants connected to zirconia abutments. The maximum wear on the implant shoulder calculated by the inspection software was 10.2μm for group Zr, and 0.7μm for group Ti. The influence of the abutment material on the measured wear was statistically significant (p≤0.001; Levene-test). SIGNIFICANCE Titanium implants showed higher wear at the implant interface following cyclic loading when connected to one-piece zirconia implant abutments compared to titanium abutments. The clinical relevance is not clear; hence damage of the internal implant connection could result in prosthetic failures up to the need of implant removal.

Tooth wear: a systematic review of treatment options

STATEMENT OF PROBLEM Treatment of tooth wear is increasing. Because no evidence-based guidelines are available, the clinician may have difficulties deciding which treatment option to choose to resolve complex situations. PURPOSE The purpose of this systematic review was to identify similarities among treatment options for generalized tooth wear and to develop an approach to rehabilitation based on the best evidence available. MATERIAL AND METHODS A Medline and Cochrane search (for articles published from January 31, 2003, to January 31, 2013) was conducted. Minimally invasive and fully described treatments for generalized tooth wear with esthetically satisfying results were included. Five steps within the treatment procedures were analyzed: diagnostic waxing (DW), occlusal positioning (OP), vertical dimension increase (VDI), restoration, and follow-up. RESULTS Common threads were established within the 5 treatment steps. Nine studies used DW, and 6 performed diagnostic tooth arrangement (DTA). Centric relation was used in 5 studies, and VDI was tested in 8 studies, 5 of which used a removable appliance. Seven studies implemented a provisional stage, and 5 used composite resin at that time. For definitive treatment, composite resin (6 studies) and glass ceramic (6 studies) were used. Seven studies applied a protective appliance, and 5 scheduled regular posttreatment evaluation as means of aftercare. CONCLUSIONS Within the limitations of this systematic review, the present evidence is not strong enough to form conclusions, and the presented similarities cannot be substantiated with evidence. Therefore, comprehensive clinical research into the designated treatment of generalized tooth wear is recommended.

Enhancing the predictability of complex rehabilitation with a removable CAD/CAM-fabricated long-term provisional prosthesis: a clinical report.

Implementing any definitive prosthetic treatment of the residual edentulous ridge involves several risks. The patients expectations may not be completely fulfilled as such treatment procedures include major changes in function and esthetics. Innovative materials, such as high-density polymers based on a highly cross-linked polymethylmetacrylate (PMMA) or composite resin for CAD/CAM-manufacturing are an alternative treatment option. They enhance the predictability of complex rehabilitations, especially in situations where the prognosis of the residual ridge behavior over time is challenging. This article describes an innovative approach of an extended pretreatment phase by using intraoral scanning and CAD/CAM technology for the fabrication of a long-term provisional removable dental prosthesis made of high-density polymer.

Three-unit reinforced polyetheretherketone composite FDPs: Influence of fabrication method on load-bearing capacity and failure types

To investigate the influence of different fabrication methods of three-unit reinforced polyetheretherketone composite (PEEK/C) fixed dental prostheses (FDPs) on fracture load. Forty-five three-unit anatomically supported PEEK/C FDPs were fabricated as follows: i. milled using a CAD/CAM system from an industrially fabricated PEEK/C blank, ii. pressed from industrially fabricated PEEK/C pellets, and iii. pressed from granular PEEK/C. Fracture load was measured and data were statistically analysed (p<0.05). CAD/CAM fabricated FDPs (2,354 N) presented a higher mean fracture load than those pressed from granular PEEK/C material (1,738 N) (p<0.001). CAD/CAM milled FDPs and those pressed from PEEK/C-pellets showed spontaneous and brittle fractures near the pontic without deformation of the FDP. In contrast, granulate pressed FDPs showed some plastic deformation without fracture. CAD/CAM fabricated FDPs, and FDPs pressed from PEEK/C pellets showed higher Weibull moduli compared to FDPs pressed in granular form. Industrial pre-pressing of blanks (CAD/CAM/pellet) increased the stability and reliability of PEEK restorations.

Accuracy of five intraoral scanners compared to indirect digitalization

ObjectivesDirect and indirect digitalization offer two options for computer-aided design (CAD)/ computer-aided manufacturing (CAM)-generated restorations. The aim of this study was to evaluate the accuracy of different intraoral scanners and compare them to the process of indirect digitalization.Material and methodA titanium testing model was directly digitized 12 times with each intraoral scanner: (1) CS 3500 (CS), (2) Zfx Intrascan (ZFX), (3) CEREC AC Bluecam (BLU), (4) CEREC AC Omnicam (OC) and (5) True Definition (TD). As control, 12 polyether impressions were taken and the referring plaster casts were digitized indirectly with the D-810 laboratory scanner (CON). The accuracy (trueness/precision) of the datasets was evaluated by an analysing software (Geomagic Qualify 12.1) using a “best fit alignment” of the datasets with a highly accurate reference dataset of the testing model, received from industrial computed tomography.ResultsDirect digitalization using the TD showed the significant highest overall “trueness”, followed by CS. Both performed better than CON. BLU, ZFX and OC showed higher differences from the reference dataset than CON. Regarding the overall “precision”, the CS 3500 intraoral scanner and the True Definition showed the best performance. CON, BLU and OC resulted in significantly higher precision than ZFX did.ConclusionsWithin the limitations of this in vitro study, the accuracy of the ascertained datasets was dependent on the scanning system. The direct digitalization was not superior to indirect digitalization for all tested systems.Clinical relevanceRegarding the accuracy, all tested intraoral scanning technologies seem to be able to reproduce a single quadrant within clinical acceptable accuracy. However, differences were detected between the tested systems.