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Invited Review Computer‑aided design/computer‑aided

manufacturing in dentistry – Future is present
Vidya K. Shenoy, Bharath Prabhu M
Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka, India

Address for correspondence: Dr. Vidya K. Shenoy, E‑mail: vidsks@rediffmail.com

ABSTRACT
Computer‑aided design/computer‑aided manufacturing (CAD/CAM) restorations have developed at rapid pace since their
introduction offering accuracy and more options. The paradigm shift from traditional techniques to CAD/CAM technology has
brought about a revolutionary change in the way the restorations are fabricated. Impression techniques, burnout oven, and
casting machines have been replaced by model scanning and CAD/CAM milling machines. Keyboards, monitors, and cursors
have replaced Bunsen burners, wax, and carving instrument to fabricate crown and bridge prosthesis. CAD/CAM technology
offers automated production, patient comfort, esthetically pleasing and strong restorations and cost‑effectiveness to laboratories.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

• Computer‑aided design/computer‑aided manufacturing technology is now a viable, predictable, and efficient alternative
to traditional methods for fabrication of dental restorations
• It has innumerable clinical applications including fabrication of indirect restorations, occlusal splints, implant
prosthodontics, maxillofacial prosthodontics, and orthodontics.

Key words: Ceramics, computer‑aided design/computer‑aided manufacturing, milling devices

INTRODUCTION FUNCTIONAL COMPONENTS OF

COMPUTER‑AIDED DESIGN/

T he incr eased demand for all‑ceramic

restorations in both the anterior and posterior
regions has led to evolution of computer‑aided design
COMPUTER‑AIDED MANUFACTURING
SYSTEM

and computer‑aided manufacturing (CAD and CAM)
technology systems. Pioneered by Mörmann[1] in the
early 1980s, the first CAD/CAM system called Cerec®
System (Sirona Dental systems,Germany) opened
the era of CAD/CAM in dentistry. The ever growing
CAD/CAM technology was fueled by the evolution
of computing power and precise acquisition units
and milling machines. Thus, digital systems offer the
opportunity to avoid traditional, analog impressions
offering patient comfort, and efficient workflow.
All CAD/CAM systems consist of three components
[Figure 1]:[2,3]
• Scanner: It captures and transforms geometry
into digital data that can be processed by the
computer [Figure 2]
• CAD modeling software: Software that processes
data and converts the actual dental model into virtual
dental model by producing a data set [Figure 3]
• CAM production: A production technology that
transforms the data set into the desired product
[Figure 4].

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DOI: How to cite this article: Shenoy VK, Prabhu MB. Computer-aided
10.4103/2229-5194.173229 design/computer-aided manufacturing in dentistry – Future is present.
J Interdiscip Dentistry 2015;5:60-4.

60 © 2015 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow

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Shenoy and Prabhu: CAD/CAM in dentistry
Figure 1: Functional components of Computer-aided design/computer-
aided manufacturing
Figure 3: Computer-aided design. Image courtesy: Katara Dental
Lab Pune
Scanner
It is a data collection tool that measures three‑dimensional
(3D) jaw and tooth structures and transforms them into
digital data sets. It is composed of a high‑resolution
camera that reads the finest details of the surface to
be scanned. There are two different types of scanners
available commercially.
• Optical scanners
• Mechanical scanners.
Optical scanners
It involves the principle of “triangulation procedure”
for capturing the 3D structures. The scanner takes the
image of the cast. White light or laser beam is used as
a source of illumination and a digital camera which is
represented by the receptor unit registers the reflected
patterns. Therefore, the source of light and the receptor
unit are in a definite angle to one another and through this
angle the computer can calculate a 3D data set from the
image on the receptor unit.[4] For example , Lava™ Scan ST
(3M ESPE, USA) KaVo Everest (KaVo Dental Ltd.,Germany).
Journal of Interdisciplinary Dentistry / May-Aug 2015 / Vol-5 / Issue-2
Figure 2: Intraoral scan. Image Courtesy: Katara Dental Lab, Pune
Figure 4: Image courtesy: Katara Dental Lab Pune. Milling process
Mechanical scanner
In this technique, scanning is accomplished by reading the
master cast mechanically line‑by‑line by means of a touch
probe (ruby ball) around the object, and the 3D structure
is measured,[5] e.g., Procera Scanner (Nobel Biocare,
Switzerland). This provides a high scanning accuracy.
However, drawbacks include complicated mechanics, cost,
and long processing times.
Factors to be considered while scanning
During scanning, all required details for the restoration
fabrication should be captured by the scan and visualized.[6]
Depending on the system, a light and rapid dusting of an
opacifier may be required prior to capturing the digital
scans.[7] The preparation can be viewed from every angle
on the monitor. Slight movement of the patient while
scanning would compromise data quality and may lead
to restoration misfit.
Computer‑aided design software for
restoration design
The scanned data is converted into STereoLithography
format.[8] Several CAD software programs are available
commercially for designing virtual 3D dental restorations.
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Shenoy and Prabhu: CAD/CAM in dentistry
The software program is proprietary to the CAD/CAM
system and cannot be interchanged among systems.
When the design of the restoration is complete, the CAD
software transforms the virtual model into a specific set
of commands. These in turn drive the CAM unit which
fabricates the designed restoration.
Computer‑aided manufacturing production
The data sets from the CAD software are converted into
milling sequence using CAM software and finally loaded
into the milling device to mill a part out of the stock
material [Figure 5]. CAM software may be integrated
with CAD software or sometimes a standalone separate
programs. The CAM software must be configured with
specific information about the mill including the size and
shape of the cutting tools, the material being milled, the
spindle controller, and the motors that move or rotate the
stock and spindle.
Milling devices
Milling devices are classified based on the number of
milling axes.[3]
3‑axis devices
This type of milling device moves in the three spatial
directions, i.e.,  X, Y, and Z. They are capable of milling
from the top or bottom of the stock material but are unable
to mill undercuts, which is adequate for routine crown and
bridge work. The advantages of these milling devices are
short milling times and simplified control by means of the
three axes. For example,  inLab (Sirona Dental Systems,
Germany), CNC milling machines (vhf,Germany).
4‑axis devices
This type of milling device moves in the four spatial
directions, i.e., X, Y, Z, and the rotatable tension bridge.
Figure 5: Computer-aided design/computer-aided manufacturing
production concepts
62
Mills with four axes can mill undercuts in only one
direction. For example, Zeno (Wieland‑Imes).
5‑axis devices
In this milling device, in addition to the three spatial
dimensions and the rotatable tension bridge, milling
spindle can be rotated (5th axis). Five‑axis milling devices
can mill undercuts in each direction and are beneficial
when milling custom implant abutments that may have
undercut areas or for large‑span bridges. For example,
Everest Engine (KaVo).
Milling sequence
There are three basic routines in the milling sequence,
i.e., roughing, finishing, and detail. Roughing is the step
where bulk material is removed quickly with the largest
diameter cutting tool available. Finishing is an intermediate
step that removes the material left over from roughing
with a smaller tool. In the final milling sequence is done
with a smaller cutting tool than the finishing tool.
Materials
Manufacturers fabricate the material in a solid block
form ready for the milling process. The material must be
capable of being milled without damage to the material.
Depending on the type of material, dry or wet milling
technique can be employed. Certain ceramic materials
such as lithium disilicate, feldspathic porcelains, and
metals require wet milling whereas zirconia and titanium
can be milled dry or wet. In general, wax and acrylic are
milled dry. The material must be capable of being milled
generally in <20 min with a minimal postmilling processing
time for fabrication of chairside CAD/CAM restoration.
Furthermore, materials should be esthetically pleasing as
milled and able to be customized to the desired shade.
Ceramic blocks (Paradigm MZ 100 [3M ESPE]),
feldspathic glass ceramics VITABLOCS® Mark II (VITA,
Zahnfabrik,Ger many), and high strength ceramics
such as  lithium disilicate (Ivoclar Vivadent Schaan,
Liechtenstein) are most commonly used chairside
CAD/CAM restorative materials.[9]
The materials used to fabricate restorations using
laboratory CAD/CAM systems include ceramics, metal
alloys, composites, titanium, and polyether ether ketone.
The materials used for dental CAD/CAM offer benefits such
as higher quality, user friendliness, and enhanced esthetics.
Computer‑aided design/computer‑aided
manufacturing production concepts
Depending on the location of the components of the
CAD/CAM systems, in dentistry, three different production
concepts are available [Figure 5]:
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Shenoy and Prabhu: CAD/CAM in dentistry
• Chairside/inoffice CAD CAM technique
• Laboratory CAD CAM technique
• Centralized fabrication in a production center.
Chairside/inoffice system computer‑aided
design/computer‑aided manufacturing
technique
All functional components of the CAD/CAM system
are located in the dental office. The chairside technique
involves scanning the tooth preparation and fabricating
the restoration in a milling device in the dental
office itself. A handheld scanner is used to scan the
preparation, entire arch with and without occlusion, e.g.,
 Cerec® System (Sirona Dental Systems, Germany). It is a
single visit procedure eliminating the need for impression
and temporization.
Laboratory computer‑aided design/
computer‑aided manufacturing technique
The dentist sends the impression to the laboratory
where a master cast is fabricated first. The remaining
CAD/CAM production steps are carried out completely
in the laboratory.
This technique requires two visits. During the first visit,
tooth preparation and scanning is accomplished.
There are two options for scanning the preparation:
• The clinician can scan the preparation chairside
and then send the scan to the laboratory by digital
transmission for designing and milling the restoration.
This eliminates the conventional impression procedure
• The clinician sends the impression to the laboratory
where a master cast is fabricated first. The model is
scanned with assistance of a scanner.
The CAD/CAM process then takes place in the laboratory
equipped with CAD/CAM unit.
Milling centers or production set‑up
Local dental laboratories with satellite scanners send the
data sets to the production center for the milling the
restorations and the production center sends the prosthesis
to the responsible laboratory. Thus, scanning and designing
take place in the dental laboratory while the production
takes place in the center.[10] As a result, the configuration of
the prosthesis remains in the hands of the dental technician.
Why use dental computer‑aided design/
computer‑aided manufacturing systems?
• Chairside CAD/CAM technique eliminates a second
visit for the patient
Journal of Interdisciplinary Dentistry / May-Aug 2015 / Vol-5 / Issue-2
• They have been found to have good longevity
and clinically acceptable accuracy of fit because of
standardized manufacturing process[11,12]
• Clinician can visualize the preparation multiple times
and retake the scan if necessary
• Digital impression eliminates discomfort associated
with traditional impression procedure
• Cost‑effectiveness for the dental laboratories.
Applications for computer‑aided
design/computer‑aided manufacturing in
dentistry
With the advent of better and multilayered materials,
the dental applications of CAD CAM have expanded
tremendously to every field of dentistry. Indirect
restorations such as inlays, onlays, single crowns,
fixed dental prosthesis, and occlusal splints can be
fabricated using CAD/CAM technology. Another
convenient application of CAD/CAM includes surgical
stents, frameworks, and bars customized zirconia and
titanium implant abutments,[13] [Figure 6]. Recently,
CAD/CAM has also found its applications in removable
prosthodontics, maxillofacial prosthodontics using rapid
prototyping,[14] and orthodontics.
CONCLUSION
CAD/CAM is part of “today” in dentistry and is defining
the future faster than we think. It helps to improve
production efficiency, labor issues and deliver better
service to the patients. However, the predictability of
the restoration depends on a good preparation, detailed
impression, and a well‑designed esthetic and functional
restoration.
Figure 6: Milled custom implant abutments
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Shenoy and Prabhu: CAD/CAM in dentistry
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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