Lab Tribune Middle East & Africa No. 3, 2018

Lab Tribune Middle East & Africa No. 3, 2018

Dental Technician Int’l Meeting was a success / Materials and systems for all ceramic CAD/CAM restorations

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PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

www.dental-tribune.me

Dental Technician Int’l
Meeting was a success
By Dental Tribune MEA / CAPPmea
DUBAI, UAE: This May CAPP (Centre
for advanced Professional Practices)
hosted another meeting that was
dedicated to the dental technicians
from the MEA region and beyond.
The meeting was a part of the annual
congress, 13th CAD/CAM & Digital
Dentistry Conference & Exhibition
that was held in beautiful arena of
Madinat Jumeirah Conference Centre on 04-05 May 2018. Dental Technician Sessions were an accomplishment not only for dental laboratory
owners and dental technicians but
also for the entire dental technology
profession.
The event was spread over two very
active days for all participants and
welcomed 154 dental technicians.
On the first day there were seven
various tables where the hands-on

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Vol. 8 • Issue 4/2017

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CAD/CAM
international magazine of

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2017

immediately and ask their personal
questions. The practical demonstrations, at the same time, provided inspiration and offer means of trouble
shooting.

interview
“Dentistry has finally arrived in the digital age”

case report

Aiham Farrah, CDT from Syria during his lecture presentation at the Dental Technician
Int’l Meeting.

trainings took place. The tables operated simultaneously with a rotation
of several groups for each table. The
trainings were help in small groups
(10 seats available per session) in or-

der to have the highest impact. Outstanding dental technicians presented various topics of a great interest
to the dental technicians. The participants had an opportunity to interact

On the second day Saturday 05 May
2018, Dental Technician International Meeting scientific programme
took place and a line-up extraordinary dental technicians who provided their best interpretations of the
latest novelties in the dental technicians profession. Aiham Farrah,
CDT, from Syria spoke about Flawless Lab-Fabricated Dental Restorations, followed by Philippe De Moyer
from Belgium who had a lecture on
Innovative Method in Guided Surgery to Prepare Immediate Loading
and Place Dental Implant. Rik Jacobs
from the Netherlands introduced 3D
Printing on the Edge of Conversion
and Eric Berger from France finished

Screw-retained implant-supported restoration
in the edentulous maxilla

cone beam supplement
Dynamic navigation for reliable
and predictable flapless implant placement

the day with his lecture on “Aesthetic
Realization with VITA: Cut Back on
VITA Block”.
The next edition of Dental Technician Meeting will be held on 12-13
April 2019 in Madinat Jumeirah Conference Centre.
For more information contact CAPP:
Tel: +971 4 347 6747
Mob: +971 50 2793711
Web: www.cappmea.com

Hossein Basaeri from Iran representing Dentium during his hands-on
training at the Dental Technician Int’l Meeting

Aiham Farah from Syria representing Ivoclar Vivadent during his handson training at the Dental Technician Int’l Meeting

Rik Jacobs from the Netherlands representing Next Dent during his
hands-on training at the Dental Technician Int’l Meeting

3shape hands-on training at the Dental Technician Int’l Meeting

Eric Berger from France during his lecture presentation at the Dental
Technician Int’l Meeting

Philippe De Moyer from Belgium during his lecture presentation at the
Dental Technician Int’l Meeting

Materials and systems for all
ceramic CAD/CAM restorations
By Drs. Christian Brenes, Ibrahim
Duqum & Gustavo Mendonza, USA
Dental crowns have been used for
decades to restore compromised,
heavily restored teeth, and for aesthetic improvements. New Computer Aided Design/Computer Aided

Manufacturing (CAD/CAM) materials and systems have been developed and evolved in the last decade
for fabrication of all-ceramic restorations. Dental CAD/CAM technology
is gaining popularity because of its
benefits in terms of time consuming,
materials savings, standardisation of

the fabrication process, and predictability of the restorations.
The number of steps required for
the fabrication of a restoration is
less compared to traditional methods (Fig. 1). Another benefit of CAD/
CAM dentistry includes the use of

new materials and data acquisition,
which represents a non-destructive
method of saving impressions, restorations and information that is
saved in a computer and constitutes
an extraordinary communication
tool for evaluation.

The incorporation of dental technology has not only brought a new
range of manufacturing methods
and material options, but also some
concerns about the processes involv-

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similar to IPS Empress but with a
finer particle size; this material was
designed to be use with the CEREC
system (Sirona Dental) and was
available in different shades.2 More
recently, the introduction of IPS
Empress CAD (Ivoclar Vivadent) and
Paradigm C that according to the
manufacturer (3M ESPE) is a 30 to 45
percent leucite reinforced glass ceramic with a fine particle size.10

Fig. 1: Number of steps comparison between traditional methods of all-ceramic restorations and CAD/CAM restorations.

Fig. 2: Vita Mark II block.

To overcome esthetic problems of
most CAD/CAM blocks having a
monochromatic restoration, a different version was developed as a
multicoloured ceramic block, which
was called VITA TriLuxe (Vident) and
also IPS Empress CAD Multiblock;
the base of the block is a dark opaque
layer, while the outer layer is more
translucent; the CAD software allows
the clinician to position or align the
restoration into the block for the desired outcome of the restoration.11,12

Fig. 3: In-house milled crown from an E-max block.

onto an enlarged die that is fabricated from the scanned data.[16]
The enlarged fabricated core shrinks
to the dimensions of the working
die when sintered at 1,550 °C; this
material offers a very high strength
core for all-ceramic restorations; the
crown is finished with the application of feldspathic porcelain.17 More
recently, In-Coris AL (Sirona Dental) has been introduced as a highstrength aluminum oxide block
with similar mechanical properties
as Procera.18

Lithium disilicate
Lithium disilicate is composed of
quartz, lithium dioxide, phosphor
oxide, alumina, potassium oxide
and other components. According to
Saint-Jean (2014) the crystallization
of lithium disilicate is heterogenous
and can be achieved through a two or
three stage process depending if the
glass ceramic is intended to be used
as a mill block (e-max CAD) or as a
press ingot (e-max press). Lithium
disilicate blocks (Fig. 3) are partially
sintered and relatively soft; they are
easier to mill and form to the desired
restoration compared to fully sintered blocks; after this process the
material is usually heated to 850 °C
for 20 to 30 minutes to precipitate
the final phase. This crystallization
step is usually associated with a 0.2
percent shrinkage accounted for
the designing software.19 Nowadays,
blocks of lithium disilicate are available for both in-office and in-laboratory fabrication of all-ceramic restorations; monolithic blocks require
layering or staining to achieve good
esthetic results.8 Different in vitro
studies that evaluate the marginal
accuracy of milled lithium disilicate
reveal that these restorations could
be as accurate as 56 to 63 microns.20
According to the manufacturer specifications, the designing principles
for lithium disilicate are produced
by default in the designing software,
but in full all-ceramic crowns structures the minimum thickness must
be applied in the preparation design
(Table I).

Fig. 4: Full arch implant supported prosthesis milled from a
partially sintered sintered (green state) zirconia puck.

ing restorations’ fit, quality, accuracy, short and long-term prognosis.1
The purpose of this document is to
provide a review of the literature regarding the different materials and
systems available up until 2015 in
the USA.

CAD/CAM materials
Glass ceramics
The first in-office ceramic material was Vitablock Mark I (Vident);
it was a feldspathic-based ceramic
compressed into a block that was
milled into a dental restoration. After the invention of the Mark I block,
the next generation of materials for
CAD/CAM milling fabrication of
all-ceramic restorations were Vita
Mark II (Vident) and Celay, which
replaced the original Mark I in 1987
for fine feldspathic porcelains primarily composed of silica oxide and
aluminum oxide.2,3 Mark II blocks
are fabricated from feldspathic porcelain particles embedded in a glass
matrix and used for single unit res-

Fig. 5: STL file of an intraoral scan.

torations available in polychromatic
blanks nowadays. On the other hand,
Celay ceramic inlays have been considered clinically acceptable by traditional criteria for marginal fit evaluation.4
Dicor-MGC was a glass ceramic material composed of 70 percent tetrasilicic fluormica crystals precipitated
in a glass matrix; but this material
is no longer available on the market.[5] Studies from Isenberg et al.
suggested that inlays of this type of
ceramics were judged as clinically
successful in a range from 3–5 years
of clinical service.6-8 In 1997, Paradigma MZ100 blocks (3M ESPE) were
introduced as a highly filled ultrafine
silica ceramic particles embedded in
a resin matrix; the main advantage
of this material is that it can be use
as a milled dense composite that was
free of polymerisation shrinkage but
cannot be sintered or glazed.9
In early 1998, IPS ProCAD (Ivoclar
Vivadent) was introduced as a leucite reinforced ceramic, which was

In 2014, the Enamic (VITA) material
was released as a ceramic network
infiltrated with a reinforcing polymer network that has the benefits of
a ceramic and resin in one material,
but no clinical data are available.14

Alumina-based ceramics
Alumina blocks (Vitablocs In-Ceram
Alumina, VITA) are available for milling with the CEREC system (Sirona
Dental) and now compatible with
other milling machines as well. Due
to the opacity of alumina- based ceramic materials, the In-Ceram Spinell (VITA) blocks were developed
as an alternative for anterior aesthetic restorations; it is a mixture of
alumina and magnesia. Its flexural
strength is less than In-Ceram Alumina, but veneering with feldspathic
porcelain for a more esthetic result
could follow it after the milling process.14,15
Nobel Biocare developed Procera
material; for its fabrication high purity aluminum oxide is compacted

During the crystallisation process,
the ceramic is converted from a
lithium metasilicate crystal phase to
lithium disilicate. Some commercial
types of ceramics are Empress CAD
(Ivoclar Vivadent) and IPS E-max.
The first one is a leucite based glass
ceramic with a composition similar to Empress ceramic. IPS E-max
was introduced in 2006 as a material with a flexural strength of 360 to
400 MPa (two to three times stronger than glass ceramics); the blocks are
blue in the partially crystallised state
but it achieves the final shade after it
is submitted to the firing process in a
porcelain oven for 20 to 25 minutes
to complete the crystallisation; the
final result is a glass-ceramic with a
fine grain size of approximately 1.5
µm and 70 percent crystal volume
incorporated in a glass matrix.20
In 2014, Vident released Suprinity;
the first ceramic reinforced with zirconia (10 percent weight); this material is a zirconia reinforced lithium
silicate ceramic (ZLS) available in a
precrystallized or fully crystallized
(Suprinity FC) state indicated for all
kind of single all-ceramic restorations.

Zirconia
Material thickness
Staining technique
Cut-back technique
Layering technique

Anterior
1.2
1.2
0.8

Premolar
1.5
1.5
0.8

Values are expressed in millimetres
Table 1: Recommended dimensions for E-max CAD by Ivoclar Vivadent.

Molar
1.5
1.5
–

Veneers
0.6
0.6
–

Zirconia has been used in dentistry
as a biomaterial for crown and bridge
fabrications since 2004; it has been
useful in the most posterior areas of
the mouth where high occlusal forces are applied and there is limited
interocclusal space.22
Zirconia is a polymorphic material
that can have three different forms

depending on the temperature:
monoclinic at room temperature,
tetragonal above 1,170 °C, and cubic
beyond 2,370°C. According to Piconi
(1999) ‘the phase transitions are reversible and free crystals are associated with volume expansion’. Different authors state that when zirconia
is heated to a temperature between
1,470 °C and 2,010 °C and cooled, a
volume shrinkage of 25 to 35 percent
can occur that could affect marginal
fit or passiveness of the restorations.22 This feature limited the use of
pure zirconia until 1970 when Rieth
and Gupta developed the yttria-tetragonal zirconia polycrystal (Y-TZP)
containing 2 to 3 percent mol-yttria
in order to minimize this effect.10
One of the most interesting properties of zirconia is transformation
toughening; Kelly (2008) describes
it as: ‘A phenomenon that happens
when a fracture takes place by the
extension of an already existing defect in the material structure, with
the tetragonal grain size and stabilizer, the stress concentration at the
tip of the crack constitutes an energy
source able to trigger the transformation of tetragonal lattice into the
monoclinic phase’. This process dissipates part of the elastic energy that
promotes progression of cracks in
the restoration; there is a localized
expansion of around 3.5 percent that
increases the energy that opposes
the crack propagation.4
Zirconia restorations can be fabricated from fully sintered zirconium
oxide or partially sintered zirconium
oxide blanks (green-state). Proponent of milling fully sintered zirconia claim that fitness of restorations
is better because it avoid volumetric
changes during the fabrication process. On the other hand, the partially
sintered zirconia (Fig. 4) is easier and
faster to mill and proponents of milling partially sintered blanks claim
that micro cracks can be induced to
the restoration during the milling
process and it also requires more
time and intensive milling processes; this micro defects or surface flaws
can affect the final strength of the final restoration and could potentially
chip the marginal areas; however
further research is needed about this
topic.10
One of the first systems that used zirconia was In-Ceram Zirconia (Vident),
which is a modification of the In-Ceram Alumina but with the addition
of partially stabilised zirconia oxide
to the composition. Recently many
companies have integrated zirconia
into their CAD/CAM workflow due
to its mechanical properties, which
are attractive for restorative dentistry; some of these properties are:
high mechanical strength, fracture
toughness, radiopacity for marginal
integrity evaluation, and relatively
high esthetics.13,14
Different manufacturers are using
zirconia as one of their main materials such as: Ceramill Zolid (Amann
Girbach), Prettau (Zirkonzahn), Cercon (DENTSPLY), BruxZir (Glidewell
Laboratories), IPS ZirCAD (Ivoclar Vivadent), Zenostar (Ivoclar Vivadent),
inCoris ZI (Sirona Dental), VITA InCeram YZ (Vident), among others.
Companies have introduced materials that are in combination with
zirconia to improve its properties
in different clinical situations. Lava
Plus, for example, is a combination
of zirconia and a nano-ceramic.

CAD/CAM systems
A number of different manufacturers are providing CAD/CAM systems
that generally consist of a scanner,

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CAD System
3Shape
ARTI / Modelliere
CeraMill
Cercon Eye/Art
CEREC
Delcam
Dental Wings
PlanCAD
Exocad
InLab
Procera

Manufacturer
3Shape
Zirkonzahn
Amann Girrbach
Dentsply
Sirona Dentsply
Delcam
Dental Wings
Planmeca
Exocad
Sirona Dentsply
Nobel Biocare

File output
Propietary/STL
STL
STL
Propietary
Propietary
STL
STL
STL
STL
Propietary
Propietary/STL

Table 2: Most popular dental CAD systems available for 2015.

design computer and a milling machine or 3-D printer. Laboratories
are able to receive digital impression
files from dentists or use a scanner to
create digital models that are used
for restorations designing or CAD.
Dental scanners vary in speed and
accuracy. Milling machines vary in
size, speed, axes, and also in which
restorative materials can be milled;
in this category milling machines
could be classified as wet or dry depending if the materials require irrigation.
The development of dental CAD/
CAM systems occurred around 1980
with the introduction of the Sopha
system developed by Dr. Francois
Duret. A few years after that event,
Dr. Werner Mörmann and the electrical engineer Marco Brandestini developed the CEREC-1 system in 1983,
the first full digital dental system created to allow dentists to design and
fabricate in-office restorations. Since
then, the continuous evolution of
systems dedicated to this field has
continued and has exponentially increased in the last decade.14
CEREC systems has evolved into
CEREC Bluecam scanner;accuracies
as close as 17 microns for a single
tooth have been reported by authors
using this system. Recently CEREC
Omnicam was introduced offering
true colour digital impressions without the need of a contrast medium.
In a recent study by Neves et al. (2013)
on the marginal fit of CAD/CAM
restorations fabricated with CEREC
Bluecam, they compared lithium
disilicate single unit restorations to
heat-pressed restorations and 83.8
percent of the specimens had a vertical gap measurement with less or at
least 75 microns.15
The CEREC InLab CAD software (Sirona Dental) was designed for dental
laboratories for a wide range of dental capabilities that can be combined
with third party systems. With this
software, the dental technician is
able to scan their own models using
Sirona inEos X5 (Sirona Dental) scan-

ner and design the restoration; once
this process is completed, the file can
be sent to a remote milling machine
or a milling centre for fabrication in a
wide range of materials.
The Procera system, introduced in
1994, was the first system to provide
fabrication of a restoration using a
network connection. According to
research data the average ranges of
marginal fit of this restorations are
from 54 to 64 microns.20 A computer
integrated crown reconstruction system (CICERO) introduced by Denison
et al. in 1999 included a rapid custom
fabrication of high-strength alumina
coping and semifinished crowns to
be delivered to dental laboratories
for porcelain layering and finishing.15
Another system that was developed
years ago was the Celay system,
which fabricated feldpathic restorations through a copy-milling
process. The system duplicated an
acrylic resin pattern replica of a restoration. Zirkonzahn developed a
similar system called the Zirkograph
in 2003, which was able to copy-mill
zirconia prosthesis and restorations
out of a replica of the restoration.
Some years after, the Cercon system
(DENTSPLY Ceramco) was able to design and mill zirconia restorations
out of a wax pattern.1
Almost at the same time that these
companies developed the first copy
mill prototypes, Lava (3M ESPE) introduced in 2002 the fabrication of
yttria-tetragonal zirconia polycrystal
(Y-TZP) cores and frameworks for all
ceramic restorations. With the Lava
system, the die is scanned by an
optical process, the CAD software
designs and enlarge the restoration
or framework that is milled from a
pre-sintered blank. Studies on marginal adaptation suggest that Lava
restorations have a marginal fit that
can be as low as 21 microns.27 Some
other systems that were able to mill
zirconia were DCS Zirkon(DCS Dental) and Denzir.16
In the last decade, companies have

CAM System
BruxZir Mill
CeraMill Motion

Manufacturer
Glidewell
Amann Girrbach

Type
Dry
Wet/dry

Datron D5

Datron

Wet/dry

Denzir
PlanMill
InLab MC XL

Ivoclar
Planmeca
Sirona

Dry
Wet
Wet/dry

LAVA
M1/M5

3M ESPE
Zirkonzahn

Dry
Wet/dry

Procera
Zenotec

Nobel Biocare
Ivoclar

Wet
Dry

Table 3: Most popular dental CAM systems available for 2015.

decided to differentiate
their products by having
a full CAD/CAM platform
or by focusing on specific
areas of expertise like CAD
software and intraoral
scanners; these companies claim to be open
platform because their
systems allow to export
universal files such as STL
or OBJ (Fig. 5) to be used
with the majority of nesting softwares and milling
machines that are able to
import them.
Defenders of closed platforms claim that the integration of different CAD/
CAM systems does not allow for a
good integration between parts and
probably leads to the incorporation
of fabrication errors; at this point
no research about systems integration is available. Table II shows some
of the systems used for dental CAD
with their file output; Table III shows
some of the most used CAM systems
with their material recommendations and capabilities.
Some of the main concerns from clinicians about all-ceramic CAD/CAM
restorations accuracy of fit are: scanning resolution, software designing
limitations, and milling hardware
limitations of accuracy. Clinicians’
and technicians’ experience with the
CAM/CAM system integration is also
a key factor for fabricating good restoration; the computer software per
se will not allow an inexperienced
operator to create an excellent dental restoration from scratch.18

Discussion
Several advantages can be drawn
from including CAD/CAM dental
technology, 3-D scanning and the
use of mill materials for all-ceramic
restorations. Even though clinical
studies have shown that marginal
fit of CAD/CAM restorations is compared to conventional restorations
the fabrication of dental restorations
is still a complex task that requires
experience, knowledge and skills.
The incorporation of new systems
and materials bring a lot of concerns
regarding system implementation,
capabilities and mechanical properties of the different materials. One
of the biggest problems that still remain in CAD/CAM dental systems is
the accuracy of each step in the CAD/
CAM chain, from digital impression
to the milling step. Using computer
aided manufacturing is dependent
on the calibration of hardware with
software in the workflow. Furthermore, the virtual configuration of
the die spacer between the tooth
and the restorations is essential for
the accuracy of the marginal adaptation and has to be calibrated for each
one of the systems. Weittstein et al.

demonstrated that the difference of
fit between CAD/ CAM restorations
is directly related to the gap parameters from the computer design and
also related to the intrinsic properties of the CAD/CAM system.16

Conclusion
This review of current and past literature regarding the evolution,
characteristics, and marginal fit of
milled CAD/CAM all-ceramic restorations materials and systems show
that it is possible to fabricate restorations with the same marginal fit expected from conventional methods
and within the range of clinically accepted restorations. When comparing both methods the advantage of
using CAD/CAM technology is not
to obtain the most precise level of fit,
but rather to obtain a high level of reliability in a large number of restorations; especially when high production levels are expected. However,
there are a limited number of clinical
studies and the diversity of the results between systems and protocols
does not allow us to give a definitive
conclusion.

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This article was published in CAD/
CAM international magazine of digital dentistry No. 03/2016.

Dr Christian Brenes,
DDS.
Master in Prosthodontics. Clinical Assistant
Professor Dental College of Georgia at
Augusta
University. International speaker for Digital Dentistry Education and BlueSkybio
Academy on guided surgery, clinical digital protocols and dental aesthetics.
He can be contacted at:
christian@blueskybio.academy

Dr Ibrahim Duqum, DDS. MS. Clinical Assistant Professor. Department of Prosthodontics at the University of North Carolina at Chapel Hill.
Dr Gustavo Mendonza, DDS. MS. PhD.
Clinical Associate Professor. Department
of Biologic and Materials Sciences, Division of Prosthodontics, University of
Michigan School of Dentistry.

[4] =>

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[cover] => Lab Tribune Middle East & Africa No. 3, 2018

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Dental Technician Int’l Meeting was a success / Materials and systems for all ceramic CAD/CAM restorations

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