CAD/CAM in-office technology

Innovations after 25 years for predictable, esthetic outcomes

Daniel J. Poticny, DDS; James Klim, DDS

nnovations and improvements to the CEREC Acquisition Center (AC) with Bluecam system (Sirona Dental
Systems, Charlotte, N.C.) and to the materials supporting it have made it possible for dentists to produce
esthetic restorations rapidly that are reliable and predictable for a wide range of applications. The CEREC
system was introduced in 1985 and was the first to use the
chairside computer-aided design/computer-aided manufacturing (CAD/CAM) concept. Another CAD/CAM system,
E4D Dentist (D4D Technologies, Richardson, Texas), was
introduced in 2008. CEREC AC and E4D Dentist are
capable of producing almost any type of single-unit ceramic
or composite restoration and have contributed to the
growth of in-office CAD/CAM. Because Sirona was the originator of this technology and nearly all of the global clinical
evidence regarding CAD/CAM systems is about CEREC
AC, in this article, we focus on innovations in CEREC AC
and the materials that support its use.
Since 1985, more than 27,000 CEREC units have been
installed for in-office use in more than 50 countries. Dentists have placed more than 20 million restorations produced with these units. CAD/CAM is part of many dental
schools curricula. CEREC ACs laboratory counterpart
(CEREC inLab, Sirona Dental Systems) is used routinely
by 4,500 dental laboratories worldwide, and 7.5 million restorations are produced annually with CEREC AC and
inLab (written communication, J. Bizzell, marketing manager, clinical CAD/CAM, Sirona Dental Systems, April
2010). Although CAD/CAM is innovative, it differs from
traditional treatment and manufacturing methods and has
been one of the most critically examined restorative dental
procedures despite its record of success. The results of a
2001 review of the literature showed that restorations
made with CAD/CAM performed better than any other
restorative material and equivalent to cast gold for restorations of the same type.1 On the basis of the number of

ABSTRACT
Background. The in-office application of
computer-aided design/computer-aided manufacturing (CAD/CAM) has evolved continually
across 25 years, and material enhancements
made in conjunction with this evolution have
improved the speed and precision with which
dentists can place high-quality, esthetic restorations for almost every dental application.
Methods. The authors present an overview
of the CEREC Acquisition Center (AC) with
Bluecam system (Sirona Dental Systems,
Charlotte, N.C.) and available materials.
Results. On the basis of the growth of
CAD/CAM, the manufacturer has made substantial improvements to all aspects of the
CEREC AC systemincluding hardware, software and materialsduring the past 25 years.
Conclusion. Dentists can create laboratorygrade restorations in their offices with little
disturbance to work-flow patterns. This is possible, because of innovations to the system
that make CAD/CAM feasible for most dental
practices.
Key Words. CAD/CAM; work flow;
ceramics; lithium disilicate.
JADA 2010;141(6 suppl):5S-9S.
Dr. Poticny maintains a practice in general dentistry focusing on
esthetic care, Grand Prairie, Texas. Address reprint requests to Dr.
Poticny at Suite B, 2630 S. Carrier Parkway, Grand Prairie, Texas,
75052-5000, e-mail djpoticny@earthlink.net.
Dr. Klim maintains a private practice in cosmetic and restorative
dentistry, Santa Rosa, Calif.

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CEREC units that have been installed in dental

offices and laboratories and with the introduction
of additional systems such as E4D, one can state
that CAD/CAM is becoming pervasive. In-office
fabrication of restorations that were laboratory
produced in the past can fit within the work flow
of dental offices. Through the use of rapid prototyping and automation, dentists can create
esthetic, efficiently produced crowns, veneers,
onlays and inlays.
CERAMIC MATERIALS FOR IN-OFFICE
CAD/CAM ADHESIVE APPLICATIONS

The original ceramic material for CEREC 1 (the first

CEREC system), Vitablocs Mark I (Vident Zahnfabrik, Bad Sckingen, Germany), was a fineparticle, feldspar-based ceramic that could be compressed into a block (hence the name Vitablocs2)
that then could be machined into dental restorations.
Vitablocs Mark II (Vident Zahnfabrik) replaced
Vitablocs Mark I in 1987 and still is being used; by
default, it has the longest clinical track record.3
Vitablocs Mark II is a fine-grained, high-glass
content feldspar-based ceramic and was the only
material available until 1997.
Laboratory-based IPS Empress (Ivoclar
Vivadent, Amherst, N.Y.) is fixed to the tooth by
means of adhesive bonding. It was the basis of a
chairside material called ProCAD (Ivoclar
Vivadent) and was composed of 40 percent infiltrated leucite glass. After modifications in processing and manufacturing were made to improve
its strength and esthetics, ProCAD became IPS
Empress CAD. The performance level for IPS
Empress (ProCAD) is substantiated in the
literature.4
In 1997, Paradigm MZ100 blocks (3M ESPE, St.
Paul, Minn.) were introduced. They are a highly
filled (85-90 percent), ultrafine silica ceramic particle embedded in a bisphenol A-glycidyl methacrylate resin matrix. The material was developed as an
alternative to porcelain, and it had the advantages
of containing a composite that is dense, uniform
and free of polymerization shrinkage and that can
be shaped anatomically in a milling machine, which
is in contrast with traditional methods of composite
handling and placement. In 2003, 3M ESPE introduced a 30 percent-by-weight leucite block called
Paradigm C (the C identifies it as a ceramic).
In 2006, Ivoclar Vivadent introduced a lithium
disilicate ceramic called IPS e.max CAD that has
the properties of a structural and esthetic ceramic.
In 2007 Sirona Dental Systems introduced
CEREC Block, which is similar to Vitablocs Mark
II but with a different shading nomenclature.
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All CAD/CAM materials can be integrated

esthetically. With the exception of Paradigm
MZ100 blocks, all of these materials can be
stained or glazed. Both finishing methods are
equal in terms of performance and function, and
the dentist chooses which method best meets the
patients esthetic needs.5 CEREC AC is the only
CAD/CAM system capable of making use of all of
the available materials.
INNOVATIONS IN THE CEREC ACQUISITION
CENTER

The success of the CEREC AC process is a function

of all the aspects of sound clinical dentistry: case
selection, preparation, control of the oral environment, correct application of the CAD/CAM system,
esthetic integration and finishing, and adhesive
placement. Preparation geometries and reduction
parameters are specific for full-ceramic restorations whether they are fabricated in the office or
the laboratory, but overall reduction of the tooth is
equivalent to that used for porcelain-fused-tometal restorations. Total ceramics must be free of
internal binding that could contribute to the propagation of internal microfractures, which could not
occur with a casting. Preparation geometries must
account for this requirement. As opposed to the
retentive preparation forms required for conventionally cemented restorations, preparation forms
for bonded ceramics are relatively devoid of retentive features and sharp angles; instead, they rely
on adhesion to enamel and dentin.6,7
Once the preparation is complete, the dentist
examines the adjacent proximal surfaces and
refines them if necessary before obtaining the digital impression that shows the proximal surfaces
of the neighboring teeth and all elements of the
preparation. One advantage of obtaining a digital
impression is that preparation and margin assessment can be done instantaneously. The dentist
can use diode lasers to create a gingival trough
and facilitate imaging in subgingival conditions to
reveal all margins to the digital camera clearly.
Virtual models can be rendered seconds after
imaging so that the dentist can assess the preparations adequacy. The dentist can make corrections to the preparation, as reimaging can occur in
a timely fashion, thereby streamlining work flows.
The CEREC AC uses blue-wavelength light
instead of the infrared light technology used in the
earlier CEREC Acquisition Unit (Sirona Dental
ABBREVIATION KEY. AC: Acquisition Center.
CAD/CAM: Computer-aided design/computer-aided
manufacturing.

June 2010

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Systems). The CEREC AC Bluecam allows dentists to produce virtual models of a higher resolution than those of the earlier CEREC Acquisition
Unit system and has benchmarks that are
approaching those established with laboratory
scanners.8 The fit and marginal accuracy of restorations created with CEREC AC are commensurate with those of restorations produced in the laboratory from the same or like materials.9 A light
film of reflective powder is applied to the surfaces
in preparation for their being recorded with a new
blue spray film developed by Sirona Dental Systems that is optimized for use with the bluewavelength light. The powder can be applied quickly and lightly, it can be rinsed easily with water, and
it does little to contaminate the operating field.
The CEREC AC system includes a new camera
that will automatically detect the ideal time to capture the image and release the shutter, thus eliminating the need for the dentist to push buttons or
operate a foot switch. The shutter will not release
until the system applies image stabilization automatically and the tooth to be scanned is within the
shutters extended focal range of 14 millimeters and
blur free. The deep, 14-mm focal range permits the
camera to rest on the tooth if needed to allow access
to tight distal molar regions, while keeping the
image in sharp focus from the tips of cusps to the
preparation margins. This feature allows for the
necessary information to be captured in one image,
instead of multiple images. Once this image is
obtained, the dentist can move the camera mesially
or distally to obtain images of the next tooth needed
to construct the virtual model. A five-tooth quadrant
model can be constructed with five or fewer images
in less than 20 seconds, and full-arch scans can be
obtained in 60 to 90 seconds owing to improved software algorithms that construct the virtual model
rapidly and discard unusable information automatically.10 Restoration proposals generally require minimal editing, and the dentist can design most restorations successfully in five to seven minutes by
using a proprietary biogeneric database that creates
tooth forms specific to the needs of the patient.10-12
CEREC AC articulates the opposing arches in
two ways. The first involves the use of a negative
image of a bite registration material to produce a
virtual working opposing model, thereby eliminating the need to scan the opposite arch separately. The second is by scanning both arches separately and then acquiring a third scan with both
arches in a closed, centric position. The camera lens
is placed parallel to the buccal surface of the closed
arches, and one or two buccal images are sufficient
for the software to articulate correctly the maxillary

and mandibular virtual model in the patients closed

centric relationship, ensuring that the restoration
can be designed to accommodate the patients
occlusal schematics. The CEREC AC software has
additional design features. Correlation is a copyand-paste function that creates a reproduction of the
prepreparation condition or a wax-up in the correct
vertical orientation (occlusion). Replication can
copy a contralateral tooth (for example, tooth no. 9
when restoring tooth no. 8) and create a mirror
image of it on the preparation, permitting symmetrical design through the use of the mirrored twin.
Once the physical design for the restoration is
complete, the dentist chooses a restorative
material. As a general rule, he or she needs to
consider the factors of value, hue and chroma, in
that order. Value equates to translucency, with
darker being more transparent, which means that
value will have more influence on outcome than
will chroma or hue. If they are prepared properly,
most low-translucency (IPS Empress CAD LT,
Ivoclar Vivadent) or high-translucency (IPS
Empress CAD HT, Ivoclar Vivadent) blocks available in standard Vita A, B, C and D shades
(Vident, Brea, Calif.) can blend effectively with
existing enamel and dentin to create an even dispersion of light much like that of natural tooth
structure, owing to their leucite glass content.
IPS Empress CAD Multi Block (Ivoclar
Vivadent) has all of the properties of the IPS
Empress CAD block, but it is polychromatic as
most teeth are. It is layered by chroma and value,
which mimics the polychromatic effect of natural
dentition internally and eliminates the need for
external application of surface stain (Figure 1). If
full coverage is necessary (Figure 2), the dentist
can position the virtually designed restoration
within the projected value gradients of the physical block to meet the given clinical condition
(Figure 3). Because this gradient effect is built in,
staining is not needed, and surface gloss can be
achieved through polishing alone rather than
glazing. IPS Empress CAD Multi Block is a logical choice when available shades correspond to
the patients dentition and there is no underlying
condition such as metal cores or posts that would
influence the value of the restoration.
Once the dentist selects the block that matches
the patients dentition, he or she can begin milling
by using the MC XL milling unit (Sirona Dental
Systems) and complete a full-contour crown in five
minutes.13 This milling unit is designed to shape
the final restoration with minimal damage to the
ceramic block by using an intermittent-touch
process with a water-soluble lubricant under a conJADA, Vol. 141

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Figure 1. IPS Empress CAD Multi

Block (Ivoclar Vivadent, Amherst,
N.Y.) has value gradients and polychromatics built in, which eliminates
the need for surface staining. Image
of IPS Empress CAD Multi Block
reproduced with permission of
Ivoclar Vivadent, Amherst, N.Y.

Figure 2. Preoperative view of a

maxillary premolar requiring a fullcoverage restoration to be placed
during the same visit.

stant water-cooled spray. With three-axis milling,

the dentist can use two 64-micrometer grit diamondsone cone shaped and one flat endedto
produce the final result. After milling and
retrieving the restoration from the milling unit, the
dentist verifies the fit and uses surface finishing
techniques to refine the milled ceramic surface by
creating a gloss that promotes a plaque-free surface. The dentist can use impregnated rubber
points or wheels to remove these subsurface flaws,
and then use diamond-impregnated pastes on
bristle brushes that can create a wet look surface
gloss in approximately five minutes (Figure 4).
Alternatively, the dentist can apply and fire lowfusing stains and glazes in 12 minutes or less. The
clinician applies these at his or her discretion. Their
use is recommended if the patients teeth are mottled or crazedif the teeth are polychromatic and
the dentist can use a monochromatic block instead
of Multi Block to create an aged appearance in the
fissure areas or if a glazed surface is preferred to a
glossy surface. With training, auxiliary personnel
can perform finishing techniques satisfactorily for
most clinical conditions. Once finishing is complete,
the dentist places the restoration by using one of a
variety of adhesive options, from total-etch to selfetch techniques. When glazing is applied correctly,
it should not affect occlusion, and only minor equilibration should be necessary. The delivery model for
chairside fabrication alters work flow and the time
expended only a little compared with traditional
methods that involve temporization.
Although IPS Empress CAD blocks and IPS
Empress CAD Multi Block can satisfy most clinical
conditions esthetically and functionally, there will
be situations in which esthetics are requested or
desired, with strength being a mitigating factor,
particularly in the molar regions. The less glass a
ceramic material contains, the stronger it is flexurally. High-strength ceramics such as zirconia and
alumina generally are not regarded as esthetic,
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Figure 3. CEREC Acquisition Center (AC) software (Sirona

Dental Systems, Charlotte, N.C.) rendition of an IPS Empress
CAD Multi Block (Ivoclar Vivadent, Amherst, N.Y.) with proposed restoration shown within the block. Image of CEREC
AC reproduced with permission of Sirona Dental Systems,
Charlotte, N.C.

because their dense, crystalline structure and

absence of glass content create a need for aluminous
porcelains to be layered onto them to achieve
translucency and, thus, esthetic acceptability. These
materials generally cannot be made bondable by
means of acid etching and traditionally are
cemented. IPS e.max CAD has enough glass content
to provide translucency for esthetics and acid-etching
capability for bonding. Conversely, as it has less
glass content than does Empress CAD block, it has a
higher flexural strength that allows for conventional
cementation. Lastly, it can be used as a translucent
coping to which porcelain additions can be made,
allowing for a wide range of clinical indications.
As with all of the glass-infiltrated materials, in
using IPS e.max CAD, dentists must follow proper
preparation principles, even though the material
exhibits higher flexural strength than do the other
chairside materials; however, that strength can be
compromised if the overall reduction of the tooth
does not meet these minimum criteria.14,15 After
preparation is complete in teeth requiring fullcoverage crowns (Figure 5), the dentist chooses a
block shade corresponding to standard Vita shades
with three levels of translucency or opacity. Because
IPS e.max CAD is milled in a precrystallized,
intermediate-strength, lithium metasilicate crystal
blue state to maximize milling functionality and
material performance, all of its blocks originally are
blue, regardless of the final shade chosen (Figure 6).
Therefore, its final strength at full crystallization
and predetermined shade are achieved via a final
19-minute oven-firing cycle, which originally was a
35-minute firing cycle. During this cycle, staining
and glazing take place at the same time as the crystallization process. This process permits the dentist
to apply stain precisely to the intermediate restoration surface after milling, followed by the application
of a spray-on glaze that will not affect the position of
the applied stains. Compared with the 12-minute
cycle for glazing Empress CAD, the 19-minute crys-

June 2010

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Figure 4. Postoperative view of

an IPS Empress CAD Multi Block
crown with total esthetic integration showing surface gloss
achieved through polishing alone,
which eliminated the need for
staining or glazing the surface.

Figure 5. Preoperative view of

mandibular molars that needed
full-coverage crowns.

tallization cycle for the spray glaze for IPS e.max

CAD allows for the use of a chairside ceramic and
multiple placement options with only a small time
increase, while effectively incorporating laboratory
procedures with esthetic modification (Figure 7).16
IPS e.max CADs characteristics of high strength,
ability to be milled to full-contour esthetics and
dual placement (bond or cement) can be useful in
creating in-office implant restorations and thin
veneers or in any situation in which strength and
esthetics must be balanced carefully. IPS e.max
CADs strength characteristics have been shown
to be greater than those of zirconia crowns and
porcelain-fused-to-metal crowns.17 The results of
an early clinical study indicate that IPS e.max
CAD can be used as a crown material.18
CONCLUSIONS

Innovations in the CEREC AC system involving

the use of materials such as IPS Empress CAD
Multi Block and IPS e.max CAD have provided
dentists with an efficient and effective delivery
model for the routine placement of all-ceramic
restorations chairside.
The parallel development of alternative chairside
CAD/CAM systems such as E4D Dentist indicates
that awareness of this technology continues to
increase and growth in this area will continue. The
ability to manufacture a restoration chairside while
controlling all of the essential elements of a restorationfrom contours and occlusion to finishing and
choice of placementwithin time frames that are
consistent with those of conventional methods is a
reality. Because of CEREC ACs improved functionality and ease of use with a simplified, expanded
range of material systems, the distinctions between
the dental office and the laboratory have become
more blurred. As a direct result of CAD/CAM technology, ceramics used today are higher in quality
than those used in the past.19 Past perceptions
regarding these technologies no longer apply, and

Figure 6. Milled crowns in the

intermediate-strength, lithium
metasilicate crystal blue state
before final crystallization and
simultaneous stain or glaze
application.

Figure 7. Postoperative view of

the final restorations.

the future of CAD/CAM appears to be secure.

Disclosure. Drs. Poticny and Klim have served as consultants to and
presented educational courses for Sirona Dental Systems, Charlotte, N.C.
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and reasons for failure. J Adhes Dent 2001;3(1):45-64.
2. Welcome to vitablocs.com. www.vitablocs.com/. Accessed
April 22, 2010.
3. Fasbinder DJ. Clinical performance of chairside CAD/CAM restorations. JADA 2006;137(9 suppl):22S-31S.
4. Fradeani M, Redemagni M. An 11-year clinical evaluation of
leucite-reinforced glass-ceramic crowns: a retrospective study. Quintessence Int 2002;33(7):503-510.
5. Chen HY, Hickel R, Setcos JC, Kunzelmann KH. Effects of surface
finish and fatigue testing on the fracture strength of CAD-CAM and
pressed-ceramic crowns. J Prosthet Dent 1999;82(4):468-475.
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Ivoclar Vivadent; 2006.
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Hanover Park, Ill.: Quintessence; 2006.
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561-566.
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MC XL milling machines. Int J Comput Dent 2007;10(1):119-126.
14. Ivoclar Vivadent. IPS e.max CAD Instructions for Use Chairside.
Amherst, N.Y.: Ivoclar Vivadent; 2009.
15. Hill T, McCabe P, Tysowsky G. Bonding and thickness effect on
fracture load of CAD/CAM crown (abstract 2321). J Dent Res 87(special
issue B);2008. http://iadr.confex.com/iadr/2008Toronto/techprogram/
abstract_106992.htm. Accessed April 1, 2010.
16. Ivoclar Vivadent. IPS e.max CAD: lithium disilicate ceramic
blocks. www.ivoclarvivadent.us/content/products/detail.aspx?id=
mcr_t1_1682923291&product=IPS+e.max+System+technicians.
Accessed April 21, 2010.
17. Thompson VP. Durability (reliability) of all-ceramic crowns
(Web cast): http://event.on24.com/eventRegistration/
EventLobbyServlet?target=lobby.jsp&eventid=163956&sessionid=
1&key=B2F0098B49AAEA431E7838ECF9721EFB&eventuserid=
28400352. Accessed April 21, 2010.
18. Fasbinder DJ, Dennison JB, Heys D, Neiva G. A clinical evaluation of chairside lithium disilicate crowns fabricated with a CAD/CAM
system: a two-year report. JADA 2010;141(6 suppl):10S-14S.
19. McLaren EA, Terry DA. CAD/CAM Systems, materials, and
clinical guidelines for all-ceramic crowns and fixed partial dentures.
Compend Contin Educ Dent 2002;23(7):637-641, 644, 646.

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