CAD/CAM RESTORATIONS

CAD/CAM RESTORATIONS

CAD/CAM RESTORATIONS CONTENTS

INTRODUCTION

HISTORY OF MACHINING SYSTEMS

MACHINING SYSTEMS & THEIR CLINICAL PROCEDURES

STAGES OF FABRICATION : COMPUTERIZED SURFACE DIGITIZATION COMPUTER-AIDED DESIGN COMPUTER-ASSISTED MANUFACTURING COMPUTER-AIDED ESTHETICS COMPUTER-AIDED FINISHING MACHINABLE CERAMICS

ADVANTAGE OF CAD/ CAM SYSTEMS

DISADVANTAGES OF CAD/ CAM SYSTEMS

ANALOGOUS SYSTEMS (COPYING / PANTOGRAPHY METHODS )

SUMMARY

CONCLUSIONS

BIBLIOGRAPHY

PHOTOGRAPHS

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TERMINOLOGY CAD-CAM ceramic - a machinable ceramic material formulated for the

production of inlays and crowns through the use of a computer-aided design, computeraided machining process.

Castable dental ceramic - a dental ceramic specially formulated to be cast

using a lost-wax process.

Ceramic - a compound of metallic and non-metallic elements. Ceramic, dental - a compound composed of metals (such as aluminium,
calcium, lithium, magnesium, potassium, sodium, tin, titanium, and zirconium) and nonmetals (such as silicon, boron, fluoride, and oxygen) that may be used as a single structural component, such as when used in a CAD-CAM inlay, or as one of several layers that are used in the fabrication of a ceramic-based prosthesis. Dental ceramics are formulated to provide one or more of the following properties: castability, mouldability, injectability, color, opacity, translucency, machinability, abrasion resistance, strength, and toughness. Note: all porcelains and glass ceramics are ceramics, but not all ceramics are porcelains or glass-ceramics.

Copy - milling - a process of machining a structure using a device that traces

the surface of a master metal, ceramic, or polymer pattern and transfers the traced spatial positions to a cutting station where a blank is cut or ground in a manner similar to a keycutting procedure.

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Core ceramic - a dental ceramic material that provides a mechanically strong

base onto which a body ceramic (also called dentine or gingival ceramic) can be veneered.

Feldspathic porcelain - a ceramic composed of a glass matrix phase and one

or more crystal phases. An important crystal phase is leucite (K2O. Al2O3.4SiO2), which is used to create a high-expansion porcelain that is thermally compatible with gold-based, palladium-based and nickel-based alloys. A more technically correct name for this class of dental ceramics is leucite porcelains, because feldspar is not present in the final processed porcelain nor is it necessary as a raw material to produce leucite crystals.

Glass-ceramic - a solid consisting of a glassy matrix and one or more crystal

phases produced by the controlled nucleation and growth of crystals in the glass.

Glass-ceramic core - the substructure of a restoration, typically made by

casting glass containing a nucleating agent into a mould, divesting the cast structure, removing the sprue extensions, and ceramming to produce a specific volume fraction of crystals. If necessary for colour and opacity control, the core may then be veneered with a specially formulated porcelain or other ceramic at an elevated temperature. An example is Dicor glass ceramic.

Glass-infiltrated dental ceramic - a minimally sintered Al2O3 or MgAl2O4

core with a void network that has been sealed by the capillary flow of molten glass. Examples include In-ceram (Al2O3) and In-ceram Spinell (MgAl2O4) core.

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Injection-moulded ceramic - a glass or other ceramic material that is used

to form the ceramic core of an inlay, veneer, or crown by heating and compressing a heated ceramic into a mold under pressure. An example is IPS Empress.

Porcelain jacket crown (PJC) - one of the first types of all-ceramic crown,
made from a low-strength aluminous core porcelain and veneering porcelain (with matching thermal contraction coefficient) without the use of a supporting metal substrate except, in some instances, for a thin platinum foil (see ceramic jacket crown).

Shade guide, ceramic - a series of ceramic tooth-shaped tabs mounted on

metal or plastic strips that is designed for comparison of hue/ value, and chroma characteristics with those of natural teeth or existing ceramic restorations. The letter and number code on the metal strip allows the dentist to communicate the perceived appearance properties to a dental technologist who may not be able to observe the teeth to be restored.

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INTRODUCTION
Ceramics are thought to be the first material ever made by man. Dental Ceramic - a compound composed of metals (such as aluminium, calcium, lithium, magnesium, potassium, sodium, tin, titanium, and zirconium) and nonmetals (such as silicon, boron, fluoride, and oxygen) that may be used as a single structural component, such as when used in a CAD-CAM inlay, or as one of several layers that are used in the fabrication of a ceramic-based prosthesis. Dental ceramics are formulated to provide one or more of the following properties: castability, mouldability, injectability, color, opacity, translucency, machinability, abrasion resistance, strength, and toughness. Note: all porcelains and glass ceramics are ceramics, but not all ceramics are porcelains or glass-ceramics. They are among the earliest group of inorganic materials to be structurally modified by man. Although routine use of ceramics in restorative dentistry is a recent phenomenon, the desire for a durable and esthetic material is ancient. Dental ceramics are the most natural appearing replacement material for missing tooth substance available in a range of shades and translucencies to achieve life like results. However, the mechanical properties and physical properties and the manufacturing technique of so-called conventional dental ceramics have revealed certain clinical shortcomings i.e. excessive brittleness, crack propagation, low tensile strength, fracture of the restoration, wear of antagonists and sintering shrinkage. These shortcomings among other factors have limited the indications for dental ceramics. However regardless of the advanced state of

CAD/CAM RESTORATIONS the 300 year old technique of casting each it its steps could induces errors in the final castings. Until 1988, indirect ceramic restorations were fabricated by conventional method (sintering, casting, and pressing) and neither was pore free. Pore free restorations can be alternately produced by machining blocks of pore free industrial quality ceramics. The tremendous advances in computers and robotic could also be applied to revolutionize dentistry and provide both precision and reduce time consumption with the combination of opto electronics computer technique and sinter technology, the morphologic shape of the crown can be sculpted in an automated way. Registration of the mandibular jaw movements or of the functionally generated path in the mouth provides the necessary data for an interference free escape of cusps from their face. The introduction of CAD/CAM systems in later 1980s to restorative dentistry represents a major technological breakthrough. Its possible to design and fabricate ceramic restorations at single

appointment as opposed to the traditional method of making impressions, fabricating prosthesis and using a laboratory for development of the restoration. The sophisticated processing of advanced ceramics for dental restoration lead to the further development of CAD/CAM technologies. The sophisticated processing of advanced ceramic for dental restoration lead to the further development of CAD/CAM. The techniques necessitates digitizing of the prepared teeth or the planned restoration itself and surfacing of the acquired digital data surface before milling paths can be generated. CAD/CAM offers, esthetic anterior crowns / bridges, veneers, as well as posterior restorations. In addition, the use of dental CAD / CAM is supposed to eliminate potential sources of errors in the craftsmanship of the conventional procedure for the manifesting of restoration. In order to access the complex free form surfaces to be dealt within dentistry, 3D computers aided 7

CAD/CAM RESTORATIONS approaches appears to be most promising. Technical, recent material and clinical

innovation in restorative dentistry has increased the complexity of treatment planning and decision making. Many of these advances have not replaced, but have augmented a wide variety of existing materials or treatment protocols, as well as clinical technique and skills. Dentists today can choose from a variety of ceramic materials in dentistry; hence, should be familiar with the range of CAD/CAM systems and all-ceramic materials available for fabrication of CAD/CAM ceramic restorations. This review outlines the developments in the evolution of CAD/CAM ceramic restorations over the last three decades and considers the state of the art in the several extended and innovative applications of dental ceramics. CAD/CAM is an acronym for Computer Aided Design/ Computer Aided Manufacturing (or Milling).

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HISTORY OF MACHINING SYSTEMS

1971 - CAD/ CAM technologies were introduced to the dental profession. 1979 - Heitlinger and Rodder followed by, 1980 -Moermann & Brandestini began to share this approach. 1983 -First dental CAD/CAM prototype was presented at the Garanciere conference in France. 1985 -The first CAD/ CAM crown was publicly milled and installed in a mouth without any laboratory involvement. 1986 -The first generation Cerec 1 (Siemens Corp) was introduced. 1994 -The second generation Cerec 2 (Siemens Corp) was presented. 1999- The third generation Cerec 3 (Sirona,Benheim,Germany) 2003- Cerec 3D (Sirona,Benheim,Germany) Since 1971 a considerable activity in research & development has emerged in the field of machined restoration/reconstruction at different universities & industrial companies. Parallel to CEREC, many other types of systems were introduced into the market. They are CAP, COMET, DENStech, Inlac, Nissan, DCS-Precident & LAVA.

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Application of CAD/ CAM techniques was actively pursued by three groups of researches
A. Group supported by Henson International of France. B. Combined group effort between the University of Zurich and Brains, Brandestini Instruments of Switzerland. C. University of Minnesota, supported by the U.S. National Institute of Dental Research. Although each group had a slightly different philosophy and approach, they worked towards a common goal of integrating engineering applications of automation in the creation of dental restorations.

French system

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CAD/CAM RESTORATIONS A. Optical impression Laser scanner B. Data processing By Shape recognition software C. It has a library (memory) describing theoretical teeth. The system uses: 3-D probe system based on electro-optical method Surface modelling and screen display Automatic milling by a numerically controlled 4-axis machine

Swiss system
Optical impression - Optical topographic scanning using a 3-D oral camera Data processing - By an interactive CAD unit The system uses: A desk top model computer Display monitor permitting visual verification of quality of data being acquired Electronically controlled 3-axis N/ C milling machine

Minnesota system
A. Optical impression - Photograph based system using a 35-mm camera with magnifying lens.

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CAD/CAM RESTORATIONS B. Data processing - Data obtained in the dental office is sent to another location for processing and machining. 3-D Reconstruction uses: Direct line transformation and an alternative technique proposed by Grimson Milling with a 5-axis N/ C machine.

Triad of fabrication: Fabrication of a restoration whether with traditional lost-wax

casting technique or a highly sophisticated technology such as a CAD/ CAM system has three functional components: A. Data acquisition B. Restoration design C. Restoration fabrication

Subtractive Methods
Grinding of porcelain restorations out of a preformed block either by means of CAD/ CAM or by using a copy milling unit can be done by the so-called subtractive methods.

Machinable Ceramic system (MCS) for dental restorations:

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CAD/CAM RESTORATIONS Digital Systems (CAD/ CAM) Direct Indirect Three steps : 1. 3-dimensional surface scanning 2. CAD - Modelling of the restoration 3. Fabrication of the restoration.

Analogous systems (Copying methods)

Copy Milling/ Copy Grinding or Pantography Systems Two steps: 1. Fabrication of prototype for scanning; 2. Copying and reproducing by milling Erosive techniques Sono Erosion Spark Erosion

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MACHINING SYSTEMS CAD/CAM (Digital) Direct Indirect Cerec 1 Automill, DCS President, Cicero, Denta, Cerec 2 Denti CAD, Sopha - Bioconcept Cerec 3 TRIAD OF FABRICATION

COPYING SYSTEMS (Analogous) Copy Milling Erosion Manual Automatic SonoSpark erosion Ceramatic II DFE DCP Erosonic erosion DFE Procera

Celay

Traditional technique

High technology 16

CAD/CAM RESTORATIONS Data acquisition or information by impressions and translated into articulated stone casts Restoration design is the process of creating the wax pattern Data acquisition or information is captured electronically, either by a specialized camera, laser system, or a miniature contact digitizer. Restoration design is done by the computer either with interactive help from the user or

automatically. Restoration fabrication includes all the Restoration fabrication includes machining procedures from dewaxing upto the final with computer controlled milling machines, casting (lost wax technique) electrical discharge machining and sintering

CONTACT DIGITIZER LASER CAMERA IMPRESSION DATA ACQUISITION CASTS & DIE COMPUTERIZED DESIGN WAX PATTERN RESTORATION 17

CAD/CAM RESTORATIONS DESIGN INVEST ELECTRICAL DISCHARGE MACHINE MACHINE SINTER Fabrication CAST TRADITIONAL LOST WAX TECHNIQUE CAD / CAM

Creation of a restoration with traditional & CAD/ CAM techniques Digital Systems Computer aided design and computer aided manufacturing (CAD/ CAM) technologies have been integrated into systems to automate the fabrication of the equivalent of cast restorations. CAD/CAM milling uses digital information about the tooth preparation or a pattern of the restoration to provide a computer-aided design (CAD) on the video monitor for inspection and modification. The image is the reference for designing a restoration on the 18

CAD/CAM RESTORATIONS video monitor. Once the 3-D image for the restoration design is accepted, the computer translates the image into a set of instructions to guide a milling tool (computer-assisted manufacturing [CAM]) in cutting the restoration from a block of material. Stages of fabrication : Although numerous approaches to CAD/ CAM for restorative dentistry have evolved, all systems ideally involve 5 basic stages: Computerized surface digitization Computer-aided design Computer-assisted manufacturing Computer-aided esthetics Computer-aided finishing (The last two stages are more complex and are still being developed for inclusion in commercial systems). Computerized surface digitization : 3D-surface digitizing or scanning methods are separated into : Direct (at the tooth) Indirect methods(via impression making & model fabrication or via pro-inlay) Mechanical Optical sensors

Types of computerized surface digitization techniques:

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CAD/CAM RESTORATIONS 1. Photogrammetry 2. Moir 3. Laser scanning . 4. Computerized tomography (CT) scanning 5. Magnetic resonance imaging (MRI) 6. Ultrasound 7. Contact profilometry Mechanical scanning conducted by a profilometer or pinpoint sensor is very precise, but have several shortcomings. Among the various methods of optical surface scanning, the active (laser) triangulation has been proven the most suitable, however it requires nonreflective surfaces for scanning (contact powder coating). Laser technique and contact digitization are the most promising approaches from the point of view of cost and accuracy. FLOW CHART SHOWING SEQUENTIAL EVENTS OCCURING DURING CAD-CAM TECHNIQUE OF FABRICATING A CERAMIC RESTORATION The cavity preparation is scanned stereo-photogrammetrically, using a three-dimensional miniature video camera The small microprocessor unit stores the three dimensional pattern depicted on the screen The video display serves as a format for the necessary manual construction via an electric signal

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CAD/CAM RESTORATIONS The microprocessor develops the final three-dimensional restoration from the two dimensional construction The processing unit automatically deletes data beyond the margins of the preparation The electronic information is transferred numerically to the miniature three-axis milling device Driven by a water turbine unit, the milling device generates a precision fitting restoration from a standard ceramic block The entire process of electronic designing and subsequent milling of a ceramic restoration requires approximately 10 to 15 minutes.

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Chairside Economical Restoration of Esthetic Ceramics

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Cerec System The CEREC (Ceramic Reconstruction) system ( Siemen/sirna corp.) was originally developed by Brains A.G. in Switzerland and first demonstrated in 1986, but had been repeatedly described since 1980. Identified as CEREC CAD/CAM system, it was manufactured in West Germany and marketed by the Siemens group. Cerec System consists of : 25

CAD/CAM RESTORATIONS A 3-D video camera (scan head) An electronic image processor (video processor) with memory unit (contour memory) A digital processor (computer) connected to, A miniature milling machine (3-axis machine)

The Optical impression A small hand held video camera with a 1cm wide lens (scanner) when placed over the occlusal surface of the prepared tooth, emits infrared light which passes through an internal grid containing a series of parallel lines. The pattern of light and dark stripes which falls on the prepared tooth surface is reflected back to the scanning head and onto a photoreceptor, where its intensity is recorded as a measure of voltage and transmitted as digital data to the CAD unit.

Procedure The prepared and surrounding tooth surfaces are coated with CEREC powder (L.D. caulk TiO2 and talc) to eliminate light reflections and to obtain an opaque reflective surface (few m thick only). The hand-held camera is positioned over the prepared tooth, and an image of the preparation is then simultaneously projected onto the screen.

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CAD/CAM RESTORATIONS The camera is adjusted until the image is clear and properly angulated for all aspects of the prepared tooth to be visible in complete focus. The video search mode enables assessment whether the camera viewing axis is compatible with the inlay/ onlay path of insertion. If viewing is acceptable the three dimensional scanning is triggered by the release of the foot pedal. The operator now checks the preparation and its three-dimensional representation for corrections or modifications to be made, if necessary. Once the appropriate optical orientation is generated, the operator can 'freeze-frame' the preparation into a static image. Designing the Restoration The proposed restoration is designed by tracing frame lines on the optical impression (fixed image) which is projected onto the screen. A cursor controlled by reverse 'mouse' located on top of the unit is used to define the limits/ boundaries, starting from the gingival margin and moved along the internal line angles at intermediate positions commands the computer which draws a continuous line, through all placed points and displays it on the screen. The operator can carefully examine, edit and if necessary, even modify the pattern at any moment in the procedure. After the margins, walls, proximal contour and contact as well as the location of marginal ridges are established, the electronically designed proposed restoration can be viewed as a 3dimensional model on the monitor, and stored automatically on the program disk (floppy). Milling of the Ceramic restoration

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CAD/CAM RESTORATIONS The restoration is milled (4-7minutes) with a diamond wheel from a premanufactured and standardized ceramic block in the milling chamber of the CAM unit. Factory standardized, preformed dental porcelain blocks are homogenous and almost pore-free (Vita Cerec blocks; Dicor Cerec blocks).

The CAM unit

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A pump system with an attached water reservoir located at the base of the mobile cart maintains the water pressure required for the hydraulic driven water turbine in the milling chamber. During milling about 5 liters of water is cycled internally which eliminates the need for external water supply and drainage. The water reservoir system also contains a microporous filter that traps any of the loosened diamond particles separated from the wheel for future retrieval. 29

CAD/CAM RESTORATIONS Procedure The appropriate ceramic block is selected from a series consisting of different sizes and shades. The ceramic block is mounted on a metal stub (retainer), inserted into the milling unit and the grinding operation is initiated. Grinding of the ceramic restoration is done by a diamond-coated disk/ wheel in conjunction with a high velocity water-spray, which simultaneously cools and cleans the milling disk. The restoration is milled from the mesial to the distal proximal surfaces with the block rotating along its central axis and being steadily advanced forward during the milling process. In addition, the diamond wheel not only rotates but also translates up and down over the porcelain block being milled. A series of steps or cuts (200-400) are required for milling a ceramic restoration. At the end of the milling operation, the completed restoration falls to the bottom of the chamber from where it can be readily retrieved.

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The computer program associated with the milling process has additional interesting features such as : Before the milling process, the screen displays the dimensions of the restoration from one proximal surface to the other in 1/900th of an mm. During the milling operation, the screen continuously informs the operator of the percentage of completion. A continuous readout is displayed concerning the cutting efficiency of the diamond wheel, thereby indicating the probable need for replacement. Clinical shortcomings of Cerec 1 system Although the CEREC system generated all internal and external aspects of the restoration, the occlusal anatomy had to be developed by the clinician using a

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CAD/CAM RESTORATIONS flame-shaped, fine-particle diamond instrument and conventional porcelain polishing procedures were required to finalize the restoration. Inaccuracy of fit or large interfacial gaps. Clinical fracture related to insufficient depth of preparation. Relatively poor esthetics due to the uniform colour and lack of characterization in the materials used. Cerec 2 system The Cerec 2 unit (Siemen/ Sirona), based on the process developed by Morman & Brandestini was introduced in September 1994, and is the result of constant further development via different generations of Cerec units to eliminate the previous limitations. The major changes include : Enlargement of the grinding unit from 3 axes to 6 axes. Upgrading of the software with more sophisticated technology which allows machining of the occlusal surfaces and the complex machining of the floor parts. Other technical innovations of Cerec 2 compared to Cerec 1 The improved Cerec 2 camera - new design, easy to handle, a detachable cover (asepsis/sterilization), reduction in the pixel size/ picture element to improve accuracy and reduce errors. Data representation in the image memory and processing increased by 8 times, while the computing capacity is 6 times more efficient.

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CAD/CAM RESTORATIONS Magnification factor increased from x8 to x12 for improved accuracy during measurements. Monitor can be swiveled and tilted, thus facilitating visual control of the video image. Other changes include modification of the foot control and the keys and their positions on the keyboard. Simultaneous grinding using cylindrical diamonds (2mm diameter, particle #64um, 77,000rpm and cutting speed 8m/s) and radial grinding of the grinding disk (#6um particle, 18000rpm and cutting speed 38m/s). Extended machining options facilitate grounding of complex floor shapes in inlays/ onlays. Provides three different programs for Extrapolation, Correlation and Veneer. Cerec 2 software (Cos 4.20) permits custom veneer preparation and class IV preparations with incisal edge coverage. Improved in rigidity and grinding precision by 24 times. Improved accuracy of fit (reduction in inter-facial gap from 84+38m for Cerec 1 to 56+27m for Cerec 2). Machinable ceramics (Ceramics used in machining systems) are pre-fired blocks of feldspathic or glass-ceramics. Composition : Modified feldspathic porcelain or special fluoro-alumino-silicate composition are used for machining restorations. Properties Excellent fracture and wear resistance 33

CAD/CAM RESTORATIONS Pore-free Possess both crystalline and non-crystalline phase (a 2-phase composition permits differential etching of the internal surface for bonding). Ceramic CAD/ CAM restorations are bonded to tooth structure by : Etching the fitting surface for bonding to enamel Conditioning, priming and bonding (when appropriate) Etching (by HF acid) and priming (silanating) Cementing with luting resin. CAD/ CAM restorations (inlay/ onlays) are fabricated primarily from ceramic materials, while subtractive fabrications of metal alloys or titanium have only been investigated for crowns, copings and bridges.

Machinable Ceramics The industrially prefabricated ceramic ingots/ blanks used are practically porefree which do not require high temperature processing and glazing, hence have a consistently high quality. The blanks measure approximately 9mm x 9mm x 13mm and are industrially fabricated using conventional dental porcelain techniques. E.g.: Vitadur 353 N (Vita Zahnfabrik, Bad Sackingen, West Germany) frit powder is mixed with distilled water, condensed into a 10mm x 10mm x l5mm steel die and fired under vacuum (the temperature is increased at a rate of 60OC/min to 950oC and held for one minute).

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CAD/CAM RESTORATIONS Two classes of machinable ceramics available are : Fine-scale feldspathic porcelain Glass-ceramics

Cerec Vitabloc Mark I : This feldspathic porcelain was the first composition used with the Cerec system (Siemens) with a large particle size (10-50m). It is similar in composition, strength, and wear properties to feldspathic porcelain used for metalceramic restorations. Cerac Vitabloc Mark II : This is also feldspathic porcelain reinforced with aluminum oxide(20-30%) for increased strength and has a finer grain size(4m) than the Mark I composition to reduce abrasive wear of opposing tooth. Dicor MGC (Dentsply, L.D. Caulk Division) : This is a machinable glass-ceramic composed of fluorosilica mica crystals in a glass matrix. The mica plates are smaller (average diameter 2m) than in conventional Dicor (available as Dicor MGC-light and Dicor MGC-dark). Greater textural strength than castable Dicor and the Cerec compositions. Softer than conventional feldspathic porcelain. Less abrasive to opposing tooth than Cerec Mark I, and more than Cerec Mark II (in-vitro study results). MGC - F (Corning Inc.) : Machinable glass ceramic developed to overcome the deficiencies of the Vita Mark II and Dicor MGC. It is tetrasilic mica glass-ceramic with minor compositional and microstructural changes from Dicor MGC to enhance its fluorescence and machinability.

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CAD/CAM RESTORATIONS Pro CAD (Ivoclar AG, Liechtenstein) : The Pro CAD line (Professional Computer Assisted Design) is a product package suitable for all Cerec 2 applications. It is a highstrength optimized, leucite-reinforced glass-ceramic material, available as blocks in different sizes and shades. Celay : This material can be used in both copy milling and CAD/ CAM techniques. According to the manufacturer, it is fine-grained feldspathic porcelain used to reduce abrasiveness with a composition identical to that of Cerec Vitabloc Mark II. In addition, both In-Ceram and Spinell(Vita) are available for processing in the green state in conjunction with Celay. Y-TCP (Yttria Stabilized Tetragonal Circonia Polycrystal): is considered to be the most successful oxide ceramic for dental-medical application. Outstanding mechanical features of Y-TCP combined with light color and translucence provide fascinating possibilities in modern ceramics restoration. The combination of this new material from firm VITA with SIRONA INLAB SYSTEM opens the futuristic perspectives to its user. Confirmed CAD/CAM technology breaks the technical limits of up to now applied dental ceramic restoration in the maximal aesthetic way. Y-TCP confirmed its excellent biological withstanding by over a 30-year long clinical using for hip joint prosthesis in human body. After passing the sintering procedure suggested by firm VITA, with 3 points it possesses the density of bending to DIN EN ISO 6872 of more than 900 Mpa, that is the one of maximal that can be achieved in dental application of ceramics

LAVA

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CAD/CAM RESTORATIONS The Lava all-ceramic system (3M ESPE Dental Products, Seefeld, Germany) also uses a CAD/CAM procedure, to produce a framework consisting of a Y-TZP-based ceramic supplemented by a specially designed veneer ceramic.-The frameworks are fabricated using contemporary CAD/ CAM procedures (scanning, computer-aided framework design and milling) from presintered Y-TZP blanks .The shade of the core material may also be stained to correspond with 1 to 7 shades of the Vita Classic shade system resulting in the ability to develop shading of the restoration which, in turn, may provide the technician with less of a challenge than when required to mask an opaque white ceramic or a grey metal core.This may also eliminate the need to veneer the lingual and gingival aspects of the bridgework connectors.' In this respect, the Y-TZP core utilized for the Lava system has been considered to exhibit increased translucency in comparison with other zinconia-based ceramic core materials. The manufacturers have suggested that an ideal translucency may be achieved as a result of inherent material properties and a low wall thickness. Lava relies on non-contact, photo-optical recording of the surfaces of dies prepared from an impression of the teeth to be restored.The dies and bite registration are digitized by the scanner and are viewed three-dimensionally on the computer screen. The bridge or crown framework may be designed on the computer within the parameters of the system, which set the thickness of the framework and the square area (9 mm') of bridge connectors. Pontic designs are retrieved from a library of designs held by the computer system. It could be considered that the solely computer-aided design is an advantage over other systems which require the technician to make a wax build-up. Long-term clinical data on restorations formed in Lava are not yet available, but communication with a laboratory producing large numbers of Lava frameworks in the 37

CAD/CAM RESTORATIONS UK have not indicated any problems, such as fracture of the framework (Littlejohn L, personal communication, August 2005). Laboratory experimentation by Sorensen with the Lava system for CAD/CAM production of highstrength precision fixed prosthodontics" has demonstrated excellent marginal fit of Lava bridges, while results of a series of laboratory experiments carried out on Lava discs by Curtis and co-workerS14" have indicated that Lava does not lose strength in moist condition,its not adversely affected by grinding by a 20-40 pm bur with water coolant,Following surface loading at simulated masticatory loads flexural strength is not affected and the possibility of inducing a transformation toughening mechanism (counteracting crack propagation) may have been identified. These are promising results, indicating that Lava does not suffer from a common problem with dental ceramics, namely, the adverse effect of oral fluids on their strength. For the clinician, these data show that, if adjustment of the framework is required, this should be carried out using a fine bur with water coolant. At the time of writing, three Lava milling centres are in operation in the UK, while other countries with a number of milling centres include the USA, Italy and Germany. Technicians wishing to utilize the Lava system for construction of bridge or crown frameworks cast dies in the conventional manner, prior to sending these to the milling centre.

Other machinable ceramics being developed include : Bioglass (Alldent Corp., Rugell, Liechtenstein)

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CAD/CAM RESTORATIONS DFE (Keramik/Krupp Medizintechnir, Essen, Germany; Bioverit / Mikrodenta Corp.) Empress / Vivadent (lvoclar Corp., Schaan, Liectenstein)

Clinical procedures for Cerec CAD/ CAM : Tooth preparation & Optical registration Simple, box shaped preparations suffice for the Cerec three-dimensional scanning and fabrication process. The procedure is not dependent on any cavity preparation size. Simple and complex proximal preparations for both inlays and onlays are readily and correctly milled. Undercuts in cavity walls do not affect the optical scanning and are filled in with composite resin during the cementation. Straight walls with right angles are recommended The 4-6 degree divergence required for cast inlays is not necessary using Cerec system; parallel walls suffice, thereby ensuring maximal preservation of hard dental tissues. The occlusal and proximal cavity margins are not beveled. Instead, the cavity walls and enamel edges are finished using diamond coated finishing stones. The gingival floor is horizontal or declines between 5-15 degrees towards the gingival margin. The optical scanning is facilitated by having clearly defined walls and cavity margins and by the use of rubber dam during the optical scanning and cementation stages. Gingival margins of the preparation must be made clearly visible by the placement of retraction cord, or by use of electrosurgery/ incision surgery. Cementation

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CAD/CAM RESTORATIONS The small quantities of composite resin cement required for cementation ensures a thin layer between the ceramic and the enamel. This thin layer, together with the microretentive bond within the ceramic and enamel apparently minimizes the negative aspects of the polymerization shrinkage and the high thermal expansion of the cement. Composite resin cements blend esthetically with the porcelain and enamel. The clinical advantages of the Cerec system : The restorations made from prefabricated and optimized, quality-controlled ceramic porcelain can be placed in one visit. Translucency and colour of porcelain very closely approximate the natural dental hard tissues. Further, the quality of the ceramic porcelain is not changed by the variations that may occur during processing in dental laboratories. The prefabricated ceramic is wear resistant. The optimized structure of the ceramic enables optimal polishability of the material and low abrasion of the opposing tooth. A tight marginal fit is provided by the adhesive system used between the etched ceramic porcelain and enamel surfaces. The essential measures are: Porcelain ceramic etching (HF 5% for 60 seconds): microretentive adhesive bond between porcelain/ ceramic and the bonding agent/ composite resin cement. Enamel-etching technique (H3PO4 35% for 30 seconds): microretentive adhesive bond between composite resin cement/ bonding agent and enamel. CICERO System 40

CAD/CAM RESTORATIONS Computer Integrated Crown Reconstruction (Elephant industries). This Dutch system was marketed with the Duret(French) system, Sopha Bioconcept and the Minnesota system(Denti CAD) as the only three systems capable of producing complete crowns and FPDs. The Cicero CAD/ CAM system developed for the production of ceramic fused to metal restorations, makes use of: Optical scanning Nearly net-shaped metal and ceramic sintering Computer-aided crown fabrication techniques. Alloy sintering eliminates casting and therewith many processing steps in the fabrication of metal-ceramic restorations. The unique feature of the Cicero system is that it produces Crowns, FPD's and inlays with different layers such as metal and dentin and incisal porcelains, for maximum strength and esthetics. COMET System (Coordinate Measuring Technique, Steinbichler Optotechnik, Neubeurn, Germany) This system allows the generation of a 3-dimensional data record for each superstructure with or without the use of a wax-pattern. For imaging, 2-dimensional line grids are projected onto an object, which allows mathematical reproduction of the tooth surfaces. It uses a pattern digitization and surface feedback technique, which accelerates and simplifies the 3-dimensional representation of tooth shapes while allowing, individual customization and correction in the visualized monitor image. 41

CAD/CAM RESTORATIONS Other Digital Systems The Duret System (Hanson International) The Duret CAD-CAM system was developed by Francois Duret and produced by Sopha (Lyon, France). It was made of 3 discrete units : A camera module A CAD module The milling module Optical impression was made using Electro-optical method (a laser scanner) combining Holography and Moire. The digitized data from the CAD unit is combined with data relating to the dynamic movements of jaw which is provided by a proprietary articulator called the Access Articulator linked to the CAD unit. This original Duret system using highly sophisticated and complex imaging/ designing procedure was designed primarily to fabricate full crowns. However, since its introduction, both the original system and the derivative version the SOPHA system have had limited commercial success. The SOPHA System (Sopha Bioconcept, Inc. Los Angeles, CA) It was commercially introduced in 1990/ 91 in France, but is apparently no longer available. The REKOW System (Digital Dental System)

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CAD/CAM RESTORATIONS It was developed by Dr. Diane Rekow at the University of Minnesota. This system initially used a photogrammetric method for intraoral surface digitization of the preparation using a pen digitizer, but later used mechanical-manual scanning and was marketed for dental laboratory use in Europe by Bego (Bremen, Germany). The Denti CAD system The Denti CAD system is capable of producing restorations from alloys, composites and ceramics. It uses a unique robotic arm digitizer (a miniature mechanical linkage), designed by Foster Miller Inc. (Waltham, Mass, U.S.A.) that can be used both intraorally or on traditional models and dies for tracing the image. The DUXs system/ The Titan System (DCS groups Dental, Allschwill, Switzerland) were introduced in 1991 by DCS/ GIM -Alldent. It consists of: A miniature contact digitizer (pantograph) A central computer A milling unit The digitizer consists of a table that shifts a die or model beneath the contact stylus. This system is currently distributed under the brand name DCS -President (DCS/ Girrbach). Advantage of CAD/ CAM(Cerec system) over other systems :

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CAD/CAM RESTORATIONS Eliminates the procedures like impression model making and fabrication of temporary prosthesis. Dentist controls the manufacturing of the restoration entirely without laboratory assistance. Single visit restoration and good patient acceptance. Alternative materials can be used, since milling is not limited to castable materials. The use of CAD/ CAM system has helped provide void free porcelain restorations, without firing shrinkage and with better adaptation. It can construct various types of ceramic restorations. Hence, can be used as an alternative to metallic restorations allowing placement of esthetic inlays/ onlays in stress bearing areas of posterior teeth (because of its high resistance to abrasion, good marginal adaptation and also as an alternative to complete or full coverage crowns that require extensive tooth reduction). Half and three-quarter crowns and Cerec veneer laminates can also be directly placed as easily. CAD-CAM device can fabricate a ceramic restoration such as inlay/ onlay at the chair-side. Eliminates the asepsis link between the patient, the dentist, operational field and ceramist. The shapes created in the CAD unit are well defined, and thus a factor such as correct dimensions can be evaluated and corrections/ modifications can be carried out on the display screen itself.

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CAD/CAM RESTORATIONS Using industrially prefabricated ceramic blanks compared to those fabricated by the dental technician is the maintenance of consistently optimally high quality of the material under industrial conditions controlled by the manufacturer. Glazing is not required and Cerec inlay/ onlays can be easily polished. Minimal abrasion of opposing tooth structure because of homogeneity of the material (abrasion does not exceed that of conventional and hybrid posterior composite resins). The mobile character of the entire system enables easy transport from one dental laboratory to another. Disadvantages Limitations in the fabrication of multiple units. Inability to characterize shades and translucency. Inability to image in a wet environment(incapable of obtaining an accurate image in the presence of excessive saliva, water or blood). Incompatibility with other imaging systems. Extremely expensive and limited availability. Still in early introductory stage with few long-term studies on the durability of the restorations. Lack of computer-controlled processing support for occlusal adjustment. Technique sensitive nature of surface imaging that is required for the prepared teeth.

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CAD/CAM RESTORATIONS Time and cost must be invested for mastering the technique and the fabrication of several restorations, to develop proficiency in the operator.

ANALOGOUS SYSTEMS (COPYING / PANTOGRAPHY METHODS ) Copy milling It is the mechanical shaping of an industrially prefabricated ceramic material, which is consistent in quality and its mechanical properties(an improvement over conventional ceramics). Copy milling includes fabrication of a prototype (pro-inlay or crown) usually via impression making and model preparation. Based on the model, a replica of inlay/ crown is made and fixed in the copying device and transferred 1:1 into the chosen material such as ceramic. Materials used The choice of material depends mostly on the type of margin required for the restoration. Virtually any geometry and size can be copy milled as long as there is direct access of the finger guide and cutting tool to the surfaces involved. Because titanium has a very high melting temperature, it is difficult to conveniently cast; however it can be copy milled easily and inexpensively. Composite and ceramic materials are most commonly used for copy milling dental restorations. Erosion methods

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CAD/CAM RESTORATIONS It needs a copy-suitable pre-version (e.g.: pro-inlay) in the form of a negative model of the interior and exterior contour of the restoration for its fabrication. The (metal-based) negative form is prepared either by wax molding and casting or by intensive copper plating of the impression. Sono erosion - for ceramic restorations Spark erosion - for metal restorations

Sono erosion It is based on ultrasonic methods. First, metallic negative moulds (so-called sonotrodes) of the desired restoration are produced, both from the occlusal as well as from the basal direction. Both sonotrodes fitting exactly together in the equational plane of the intended restoration are guided onto a ceramic blank after connecting to an ultrasonic generator, under slight pressure. The ceramic blank is surrounded by an abrasive suspension of hard particles, such as boron carbide, which are accelerated by ultrasonics, and thus erode the restoration out of the ceramic blank. Spark Erosion It refers to 'Electrical Discharge Machining' (EDM) which was used by the tool and die industry during the 1940's and was adapted into dentistry in 1982. It may be defined as a metal removal process using a series of sparks to erode material from a work piece in a liquid medium under carefully controlled conditions. The liquid medium usually, is a light oil called the dielectric fluid. It functions as an insulator, a conductor and a coolant and flushes away the particles of metal generated by the sparks.

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CAD/CAM RESTORATIONS Advantages of EDM desirable for dental applications : EDM is not affected by metal hardness because it is a thermal process. Adhesive characteristics of the workpiece do not affect EDM because it is a noncontact method of removing metal. EDM provides a smooth bur-free surface. EDM can be used to machine thin objects without distortion because there are virtually no mechanical forces created. EDM can be used to make long, small diameter cuts because there is little, if any, torque on the electrode to cause breakage. EDM is accurate to within 0.0001 inch.

The major disadvantage is the cost of the equipment. The Spark Erosion (SAE) unit (Dental Arts Laboratories Inc., Illinois) A graphite or copper electrode acts as a tool that invades the piece of base metal and erodes a negative form in the shape of the electrode. The process is accomplished by lightening like sparks generated between the electrode and the restoration. The sparks melt the alloy by heating it to between 3000C and 5000C. These sparks remove small amounts of the metal substrate within microseconds. The entire process takes place in a dielectric liquid bath that prevents the alloy from burning. Stress characteristics can be eliminated through the application of spark erosion before or after the ceramic or acrylic resin surface is added. The spark erosion method can be applied to any type of conductible metal/ alloy such as gold, base metal and titanium. This method of erosion has been named as SAE Secotec. 48

CAD/CAM RESTORATIONS CELAY System The Celay System (Mikrona AG, Spreintenbach, Switzerland) became first commercially available in 1992. It is a high precision, manually operated copy milling machine and the fabrication principle is the same as for 'Key' duplication. This system was originally designed and intended for use in the dental laboratory, however it may also be used at the chairside. Method An impression(silicone) of the prepared tooth is made and poured in die stone. A prototype resin coping of the restoration (prototype) called 'pro-inlay' (a provisional inlay) is fabricated on the die using a blue light-cured resin(CelayTech, Mikrona Technologies, AG, Switzerland). The cured resin prototype is removed from the die and fixed on the left side of the relay unit using a special retaining device(rod shaped). A prefabricated ceramic blank(eg. - aluminous core ceramic 'In-Ceram') is fixed in the carving chamber on the right side of the relay unit. The reference disk (tracing tool) mechanically traces or scans the surface of the prototype (pro-inlay). Duplicating the movements of the reference disk, the rough milling disk(a coarse diamond instrument with a grit size of 126 m) and a high speed turbine driven by air pressure, machines the rough contour of the ceramic restoration by synchronized grinding over 8-axis for effective bulk reduction. For milling a coping, the lumen of the coping is scanned and milled with coarse ball and round 49

CAD/CAM RESTORATIONS tipped diamonds. Both sides of the relay unit are connected by a geometric transfer mechanism to link the three-dimensional movement of the tracing device with the milling device. During the milling process, the milling chamber is protected with a clear cover and a cooling liquid(Celcool, Mikrona, AG, Switzerland) is sprayed on the blank and on the instrument. Since the rough milling disk is slightly smaller than the scanning disk, it produces a slightly oversized restoration. The final contour of the restoration is developed with 64m grit finishing diamond instruments. To ensure a complete and accurate tracing, the pattern is coated with contact or indicating powder (Celtouch, Mikrona AG, Switzerland). This powder is removed on contact with the tracing instruments so that areas already scanned can be differentiated from the un-scanned areas. The external surfaces are finished with disks and the internal surfaces with roundtipped and sharp/ fine-tipped diamond stones. Final fit of the machined inlay/ coping is examined, and internal discrepancies are marked and reworked with repeated scanning. The internal surface is either acid-etched or air-abraded before silanization and cementation. By combining the Celay system, with elements of In-Ceram technology, copy milled glass-infiltrated aluminous core restorations can be fabricated. In-Ceram or InCeram Spinell materials are machined by Celay and then infiltrated with a sodiumlanthanum glass in a manner similar to that of conventional In-Ceram restorations, and finally veneered with Vitadur Alpha porcelain. The fabrication of copy-milled In-Ceram 50

CAD/CAM RESTORATIONS crown substructures with the Celay system combines the positive mechanical properties of glass-infiltrated aluminous core materials with the advantages of industrially prefabricated ceramics. Advantages over conventional In-Ceram technology : The processing time is considerably shorter because die duplication and 10 hour sintering are not necessary. Glass infiltration can be performed in a conventional ceramic furnace in 40 minutes, because of the higher capillary effect of the industrially sintered alumina blank (homogenous structure, even particle distribution). The industrially prefabricated material also has a higher flexural strength than the conventional In-Ceram material. PROCERA System The Procera System (Nobel Biocare, Gioteborg, Sweden) embraces the concept of CAD/ CAM to fabricate dental restorations. It was developed by Andersson M. & Oden A. in 1993, through a co-operative effort between Nobel Biocare AB (Sweden) and Sandvik Hard Materials AB (Stockholm, Sweden). It consists of a computer controlled design station in the dental laboratory that is joined through a modern communication link to Procera Sandvik AB in Stockholm, Sweden, where the coping is manufactured with advanced powder technology and CAD/ CAM technique.

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CAD/CAM RESTORATIONS Steps for fabrication Scanning : At the design station, a computer controlled optical scanning device maps the surface of the master die and is sent via a modem to the Procera production facility. Machining : At the production facility, an enlarged die is fabricated that compensates for the 15-20% sintering shrinkage of the alumina core material. High-purity alumina powder is pressed onto the die under very high pressure, milled to required shape, and fired at a high temperature (1550C) to form a Procera coping. Veneering : The sintered alumina coping is returned to the dental laboratory for veneering thermally compatible low fusing porcelains (All-Ceram veneering porcelain) to create the appropriate anatomic form and esthetic qualities. AllCeram veneering porcelain (Ducera) has a coefficient of thermal expansion adjusted to match that of aluminium oxide (7x10-6/ C). It also has the fluorescent properties similar to that of natural teeth and the veneering procedures require no special considerations. The reported flexural strength of the Procera All-Ceram crown (687 Mpa) is relatively the highest amongst all the all-ceramic restorations used in dentistry (attributed to the 99.9% alumina content). This system can be used to fabricate two types of dental restorations : A Porcelain-fused-to-metal restoration made of titanium substructure with a compatible veneering porcelain using a combination of machine duplication and spark-erosion (The Procera Method, Noble Biocare).

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CAD/CAM RESTORATIONS An all-ceramic restoration using a densely sintered high-purity (99.9%) alumina coping combined with a compatible veneering porcelain. Porcelain fused to metal restoration : The Procera System was initially used to fabricate veneered crowns and fixed partial dentures by combining a titanium substructure with compatible low-fusing veneering porcelain such as Ti-Ceram. Components used Pre-fabricated cold-worked bars or solid cylindrical blanks of Commercially pure Titanium (CpTi) and a low fusing veneering porcelain Ti-Ceram fired at 750C. Procedure The working time required to fabricate the titanium coping is about 35 minutes. It requires two procedures : Mechanical milling process -external surface of titanium coping is milled from the cylindrical titanium blank in 5-6 minutes. Spark erosion process - The internal configuration of the titanium coping is developed in about 8-10 minutes. The internal surface of the titanium coping is air abraded (120m particles of Al2O3) to remove the surface oxide layer accumulated during the spark erosion process. The external surface is also air abraded and then veneered with a low-fusing veneering porcelain compatible with titanium such as Ti-Ceram in the conventional manner and fired at 750C. This method can also be used for milling implant system restorations.

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CAD/CAM RESTORATIONS Advantages (mainly related to use of titanium) Biocompatibility of titanium - suitable for use mainly in metal sensitive patients. Low cost of titanium relative to noble metal alternatives. Standardization of procedure for fabricating titanium coping with consistent results. Accuracy of fit Ti-Ceram is less abrasive than conventional porcelain.

All-ceramic restorations The Procera system has also been used to produce an all-ceramic crown known as Procera All-Ceram Crown which is composed of a densely sintered, high-purity(99.9%) alumina coping combined with a compatible veneering low fusing porcelain such as AllCeram Porcelain(Ducera). Other copying systems Ceramatic II Svstem (Askim Corp., Sweden) In this system scanning is performed automatically, and this applies to the DCP system as well. The DFE -system and Erosonic (ESPE Dental Medizin Corp., Seefeld Germany) They both make use of ultrasonic erosion for the machining of ceramic. For this purpose sonotrodes must be made in advance as negative forms of the inner and outer contours of the restoration. 54

CAD/CAM RESTORATIONS Advantage of milling methods Reducing the labour time needed. Single appointment restorations (in a period of 3 to 13 minutes). Can be used for both direct and indirect fabrications.

Advantages of Celay system over the Cerec system Celay could recreate all surfaces of a restoration whereas Cerec I could not make the occlusal surface. Celay has the potential to fabricate crowns and short-span bridges with In-Ceram system (Vita, Germany).

SUMMARY Ceramic materials have been used in dentistry for well over 200 years. They are the most biocompatible dental restorative materials, because they are chemically very 55

CAD/CAM RESTORATIONS stable. A desirable feature of ceramics is that their appearance can be customized to simulate the colour, translucency and flourescence of natural teeth. A major problem with the use of ceramics as tooth replacement materials is their very low fracture toughness, and the fact that fracture occurs at a very low strain of about 0.1%. In other words, the ceramic structure only exhibits a very low flexibility before fracture. Another problem is that if the ceramic structure is formed by the condensation and sintering of fine frit particles, fusion is accompanied by a relatively large firing shrinkage. Newer ceramic materials and innovative ceramic processing techniques have been introduced in restorative dentistry since the early 1980s. Some of these ceramics still share roots with research that originated in Europe in the 18th century. Today as in the era of Nicholas Dubois De Chemant,most advances are derived from collaborations with the ceramics engineering community. Notable recent progress includes; the advent of predictable ceramic materials and techniques for esthetic complete crowns, partial coverage and laminate veneer restorations; improved metal ceramic esthetics with the advent of opalescent porcelains and framework modifications; introduction of CAD/CAM and machining as a route to fabrication of restorations; improved understanding of the clinical response of all ceramic prostheses and of the material factors that influence clinical longevity. Strong scientific and collaborative foundations presently exist for continued development and improvement of ceramic systems by increasingly well-informed teams of researchers and dentists. No currently available restorative system can be considered the ideal replacement for natural tooth structure. However, in recent years there has been a great amount of attention given to research on and development of ceramic systems for restorative use. Ceramics are playing an increasingly important role in restorative dentistry, and further 56

CAD/CAM RESTORATIONS improvements in fracture resistance and wear properties will no doubt enhance their restorative use. The demand for esthetic dentistry is expected to continue and will be influencial in determining the range of the products available. In the future we expect to see dramatic improvements by the turn of the century, not only in esthetic dental materials, but also the techniques of using these materials. The creativity and artistic skill of the dental ceramists will be paramount in creating a realistic illusion using these technologies. High technology will continue to improve the way we diagnose and design treatment plans for patients with esthetic dental concerns. As hightech costs diminish, more dentists will introduce these technologies into their practices to meet the ever increasing demand.

CONCLUSION The aim of restorative and esthetic dentistry is to restore the decayed or missing part of the teeth with a bio-compatible material that matches natural enamel in appearance and physical characteristics and maintain occlusal anatomy to promote proper 57

CAD/CAM RESTORATIONS oral function. Dental ceramic technology is one of the fastest growing areas of dental material research and development. The past decades have seen the development of several new groups of ceramics. The diversity of dental ceramics continues to stimulate laboratory and clinical research. Systems such as Dicor and Empress are now established, and data regarding the in vitro and in vivo performance of such restorations have been reported widely. Modifications to several systems have been suggested or introduced to overcome certain disadvantages. The potential of the In-Ceram system, remains to be exploited to the full. The diversity and sophistication of some of the CAD-CAM systems may prove to be influential in the future. Each system has its own merits, but may also have shortcomings. Combinations of materials and techniques are beginning to emerge which aim to exploit the best features of each. Glass-ceramic and glass-infiltrated alumina blocks for CAD-CAM restoration production are examples of these and it is anticipated that this trend is likely to continue.

BIBLIOGRAPHY Text Book References 1. John. W. McLean - The Science & Art of Dental Ceramics, Vol. I; Quintessence - 1979. 58

CAD/CAM RESTORATIONS 2. John W. McLean - Science and Art of Dental Ceramics (Bridge Design & Lab procedures), Vol II. Quintessence - 1980. 3. Jack. D. Preston - Perspectives in Dental Ceramics; Quintessence - 1985. 4. G.J. Chiche, Alain Pinault - Essentials of Dental Ceramics - 1988. 5. J. F. Roulet, S. Herder - Bonded Ceramic Inlays; Quintessence - 1991. 6. Barry G. Dale, Kenneth W. Ascheim - Esthetic Dentistry - 1993. 7. R. G. Craig - Restorative Dental Materials 9th ed. - 1993. 8. Ralph W. Phillips - Skinner's Science of Dental Materials 9th ed. - 1994. 9. Sturdevant C, M. Roberson, T. M. Heymann H.O., Sturdevant j.r. - The art and Science of Operative Dentistry, 3rd ed. - 1995. 10. H. T. Shillingberg - Fundamentals of Fixed Prosthodontics ; 3rd edition - 1997. 11. William F. P. Malone, David L. Koth - Tylman's theory and Practice of Fixed Prosthodontics, 8th ed., St Louis - 1997. Journal References 1. Council on Dental Material, Instruments and Equipment (ADA Report) Recent developments in materials and processes for ceramic crowns - JADA 1985;10(4):548-9. 2. Dianne Rekow - Computer-aided design and manufacturing in dentistry : A review of the state of the art - JPD 1987; 58(4):512-6. 3. K. A. Malament - The Cast Glass - Ceramic restoration JPD I987;57(6):67483. 4. F. Duret, Blouin, B. Duret - CAD-CAM in dentistry - JADA 1988;117:715-22. 5. John. W. McLean - Ceramics in clinical dentistry - BDJ 1988; Mar19:187-94. 59

CAD/CAM RESTORATIONS 6. Karl. F. Leinfelder, Barry P. Isenberg, Milton E. Essig - A new method for generating ceramic restorations : a CAD-CAM system - JADA 1989;118:703-7. 7. W.H.Mormann, M. Brandestini, F. Lutz, F. Barbakow - Chairside Computeraided direct ceramic inlays - Q Int 1989;20(5):329-39. 8. J. E. Qualtrough, N. H. F. Wilson, G.A. Smith, - The Porcelain Inlay: A Historical View - Op Dent 1990;15:61-70. 9. Rill G. Banks - Conservative posterior ceramic restorations - A literature review JPD 1990;63(6):619-26. 10. E. Dianne Rekow - Dental CAD-CAM Systems : what is the state of the art? JADA 1991;122:43-8. 11. S. O. Hondrum - A review of the strength properties of dental ceramics JPD 1992;67(6):859-65. 12. N. B. Van Roekel - Electrical Discharge Machining in Dentistry IJP 1992;5(2):114-21. 13. E. Dianne Rekow - High-Technology Innovations and Limitations For Restorative Dentistry. DCNA 1993;37(3):521-24. 14. Heiner Weber, Gerd Frank - Spark erosion procedure : A method for extensive combined fixed and removable prosthodontic care JPD 1993;69(2):222-27. 15. Kenneth J. Anusavice - Recent Developments in Restorative Dental Ceramics JADA 1993;124:72-84. 16. M. Vander Zel Ceramic-fused-to-metal restorations with a new CAD/ CAM system - Q Int. 1993;24(11):769-78. 17. K. Kawai, M. Hayashi, M. Torii, Y. Tsuchitani -Marginal Adaptability and Fit of Ceramic Milled Inlays - JADA 1995;126:1414-9. 60

CAD/CAM RESTORATIONS 18. H. O. Heymann, S. C. Bayne, J. R. Sturdevant, A. D. Wilder Jr, T. M. Roberson The Clinical performance of CAD-CAM generated ceramic inlays (A four-year study) - JADA 1996;127:1171-4. 19. J. Robert Kelly, I. Nishimura, S. D. Campbell - Ceramics in dentistry : Historical roots and current perspectives - JPD 1996;75(1):18-32. 20. M. Andersson, L. Carlsson, M. Persson, B. Bergman - Accuracy of machine milling and spark erosion with a CAD/ CAM system JPD 1996;76(2):187-93. 21. Sven Rinke, A. Huls - Copy-milled aluminous core ceramic crowns : A Clinical report. - JPD 1996;76(4):343-6. 22. W. H. Mormann, A. Bindl - The new creativity in ceramic restorations : Dental CAD-CAM - Q. Int. 1996;27(12):821-8. 23. Marc.A.Rosenblum, Allan.Schulman - A Review of All-Ceramic Restorations. JADA 1997;128:297-307. 24. R. Hickel, W. Dasch, A. Mehl, L. Kremers - CAD-CAM: Fillings of the future? - IDJ 1997;47(5):247-58. 25. Irfan Ahmad - Yttrium-Partially Stabilized Zirconium Dioxide Posts : An approach to Restoring Coronally Compromised Non-vital Teeth - Int. J. Periodont. Rest. Dent. 1998;18(5):455-65. 26. Derek. W.Jones - A brief Overview of Dental Ceramics - J. Can.Dent Assoc 1998;64(9):648-50 & Dental Abstracts 1999;44(2):61. 27. P.Ottl, A. Piwowarczyk, Hans Chritoph Laue, E. A. Hegenbarth - The Procera All-Ceram System - Int. J. Periodont. Rest. Dent. 2000;20(2):151-5

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