The Use of CAD/CAM

in Dentistry
a,b, b,c
Gary Davidowitz, DDS *, Philip G. Kotick, DDS

KEYWORDS
 CAD/CAM  CEREC  E4D  iTero  Lava COS
 Dental laboratory

Computer-aided design (CAD) and computer-aided manufacturing (CAM) have

become an increasingly popular part of dentistry over the past 25 years.1 The
technology, which is used in both the dental laboratory and the dental office,
can be applied to inlays, onlays, veneers, crowns, fixed partial dentures, implant
abutments, and even full-mouth reconstruction. CAD/CAM is also being used in
orthodontics.
CAD/CAM technology was developed to solve 3 challenges. The first challenge was
to ensure adequate strength of the restoration, especially for posterior teeth. The
second challenge was to create restorations with a natural appearance. The third chal-
lenge was to make tooth restoration easier, faster, and more accurate. In some cases,
CAD/CAM technology provides patients with same-day restorations.
Dentists and laboratories have a wide variety of ways in which they can work with
the new technology. For example, dentists can take a digital impression and send it
to a laboratory for fabrication of the restorations or they can do their own computer-
aided design and milling in-house.
When laboratories receive a digital impression, they can create a stone model from
the data and either continue with traditional fabrication or rescan the model for milling.
Alternatively, the laboratory can do all of the design work directly on the computer
based on the images received.
This article discusses the history of CAD/CAM in dentistry and gives an overview of
how it works. It also provides information on the advantages and disadvantages,
describes the main products available, discusses how to incorporate the new tech-
nology into your practice, and addresses future applications.

a
International Advanced Aesthetic Dentistry Program, NYU College of Dentistry, 345 East 24th
Street, New York, NY 10010, USA
b
Department of Cariology and Comprehensive Care, NYU College of Dentistry, 345 East 24th
Street, New York, NY 10010, USA
c
International Comprehensive Dentistry Program, NYU College of Dentistry, 345 East 24th
Street, New York, NY 10010, USA
* Corresponding author. Department of Cariology and Comprehensive Care, NYU College of
Dentistry, 345 East 24th Street, New York, NY 10010.
E-mail address: [email protected]

Dent Clin N Am 55 (2011) 559–570

doi:10.1016/j.cden.2011.02.011 dental.theclinics.com
0011-8532/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
560 Davidowitz & Kotick

HISTORY OF DENTAL CAD/CAM

Computer-aided design and manufacturing were developed in the 1960s for use in the
aircraft and automotive industries,2 and were first applied to dentistry a decade later.
Some of the most important figures in dental CAD/CAM development are Drs
François Duret of France, Werner Mörmann of Switzerland, Dianne Rekow of the
United States, and Matts Andersson of Sweden.
Dr Duret was the first person to develop a dental CAD/CAM device, making
crowns based on an optical impression of the abutment tooth and using a numer-
ically controlled milling machine as early as 1971.3 He produced the first dental
CAD/CAM restoration in 19834 and demonstrated his system at the French Dental
Association’s international congress in November 1985 by creating a posterior
crown restoration for his wife in less than an hour.5 Dr Duret later developed
the Sopha system.
Dr Mörmann was the developer of the first commercial CAD/CAM system. He con-
sulted with Dr Marco Brandestini, an electrical engineer, who came up with the idea of
using optics to scan the teeth. By 1985, the team had performed the first chairside
inlay using a combination of their optical scanner and milling device. They called the
device CEREC, an acronym for computer-assisted ceramic reconstruction.6
Dr Rekow worked on a dental CAD/CAM system in the mid-1980s with colleagues at
the University of Minnesota. This system was designed to acquire data using photo-
graphs and a high-resolution scanner, and to mill restorations using a 5-axis machine.7
Dr Andersson developed the Procera (now known as NobelProcera, Nobel Biocare,
Zurich, Switzerland) method of manufacturing high-precision dental crowns in 1983.8
He was also the first person to use CAD/CAM for composite veneered restorations.9
Early technology permitted the creation of inlays, onlays, veneers, and crowns.
More recently, CAD/CAM systems have been able to provide fixed partial dentures
and implant abutments.
Another use of CAD/CAM is in orthodontics. One example of this is Invisalign (Align
Technology, Inc, Santa Clara, CA, USA), a treatment that uses multiple clear, remov-
able appliances designed and manufactured via CAD/CAM to straighten teeth.
CAD/CAM systems are becoming increasingly popular in dental offices. More than
30,000 dentists around the world own scanning and milling machines; 10,000 of these
are in the United States and Canada. Worldwide, more than 15 million CEREC resto-
rations alone have been completed.10

OVERVIEW OF CAD/CAM

In brief, in-office dental CAD/CAM systems consist of a handheld scanner, a cart that
houses a personal computer together with a monitor, and a milling machine.
The scanner head is placed intraorally above the tooth preparation and the resulting
data appear on the monitor as 2-dimensional (2-D) or 3-dimensional (3-D) images.
Design work is done on the monitor and the instructions are sent to a computer-
assisted processing machine for milling.
Restorations are milled from prefabricated blocks of porcelain. Options include feld-
spathic, leucite, or lithium disilicate materials as well as blocks of composite.11 After
the restoration is examined and approved, it is polished and inserted using conven-
tional bonding techniques.
Results with in-office milling machines appear to be as good as those from labora-
tory milling machines. A systematic review of 16 articles that comprised 1957 restora-
tions found no significant differences in 5-year survival rates between chairside
CEREC restorations (90.2% to 93.8%) and Celay laboratory restorations (82.1%).12
 The Use of CAD/CAM in Dentistry 561

ADVANTAGES AND DISADVANTAGES OF CAD/CAM

The use of CAD/CAM technology for dental restorations has numerous advantages
over traditional techniques. These advantages include speed, ease of use, and quality.
Digital scans have the potential to be faster and easier than conventional impres-
sions because casts, wax-ups, investing, casting, and firing are eliminated.13 Accord-
ing to Sirona, half-arch impressions with the most recent version of CEREC take
40 seconds and full-arch impressions take 2 minutes.14 CAD/CAM also makes design
and fabrication faster; a full-contour crown takes just 6 minutes to mill.15
Having a milling machine on site means that patients can receive their permanent
restoration the same day they come in, without making a second appointment.
Patients no longer need to have provisional restorations, which take time to fabricate
and fit.13 If anesthetics are needed, they only need to be administered once.
The quality of CAD/CAM restorations is extremely high because measurements and
fabrication are so precise. In a study of 117 subjects by Henkel,16 each subject had 2
crowns made. One crown was made based on physical impressions using standard
trays and impression material and another was made based on electronic impres-
sions. Without knowing which one was which, dentists chose the crown based on
the electronic impression 68% of the time.
Perhaps this difference in the finished product should not be surprising, given the
wide variation in quality of traditional impressions. Writing in a 2005 article,
Christensen17 stated that he had seen impressions sent to laboratories in which
more than 50% of the preparation margins were not discernible. Traditional impres-
sions suffer from problems, such as bubbles and tears in the impression material,
cords or other debris embedded in the impression material, and missing teeth.17
CAD/CAM restorations have a natural appearance because the ceramic blocks
have a translucent quality that emulates enamel, and they are available in a wide range
of shades.13 Ceramic wears well in the mouth, even when used for posterior teeth;
because it is no more abrasive than conventional and hybrid posterior composite
resins, it causes minimal wear to the opposing teeth.13
Finally, quality is consistent because prefabricated ceramic blocks are free from
internal defects and the computer program is designed to produce shapes that will
stand up to wear.
Savings in time and labor have the potential to reduce costs, and the promise of
faster, high-quality restorations should appeal to patients and patients are also happy
to avoid the need for gag-inducing impressions.
Another benefit is that all the scans can be stored on the computer; whereas, stan-
dard stone models take up space and can chip or break if stored improperly.18
Still, CAD/CAM systems have disadvantages. The initial cost of the equipment and
software is high, and the practitioner needs to spend time and money on training.13
Dentists without a large enough volume of restorations will have a difficult time making
their investment pay off.
Just as with conventional impressions, in taking an optical scan the dentist needs to
obtain an accurate recording of the tooth in need of restoration. The scan needs to
emphasize the finish line and precisely duplicate the surrounding and occlusive teeth.
Digital scanning requires the same type of soft-tissue management, retraction, mois-
ture control, and hemostasis that is so important for conventional impressions.
Digital impression systems may not save time as they are currently used because of
the need for multiple steps. For example, dentists who use certain scanners must first
send the images for a cleanup process, which is followed by setting of the margins by
a dental technician. The images next go to the clinician’s dental laboratory for review
562 Davidowitz & Kotick

and then back for model milling. Finally, the models and dies are then sent to the clini-
cian’s dental laboratory for fabrication of the restoration.16

OFFICE-BASED DEVICES

Four products are presently available for digital impressions in the dental office:
CEREC AC (Sirona, Charlotte, NC, USA), E4D Dentist (D4D Technologies, Richardson,
TX, USA), iTero (Cadent, Carlstadt, NJ, USA), and Lava COS (3M ESPE, St Paul, MN,
USA). Taking digital impressions allows dentists to do away with selecting trays, mix-
ing materials and waiting for them to set, cleaning up the mess from the impressions,
disinfecting the impressions, and shipping the impressions to a laboratory.
The CEREC and E4D devices can be combined with in-office design and milling;
whereas, the iTero and Lava COS devices are reserved for image acquisition only.
In-office milling allows same-day restorations.
The CEREC System
CEREC, introduced in 1987, was the first dental system to combine digital scanning
with a milling unit. The system allows dentists to provide restorations made from
commercially available ceramic blocks in a single visit.
The earliest models produced inlays and onlays only.6 The newest model, known as
CEREC AC powered by BlueCam (Sirona, Charlotte, NC, USA) and introduced in
2009,19 also has the ability to take half-arch or full-arch impressions and create
crowns, veneers, and bridges.
The current acquisition system employs intense blue light from blue light-emitting
diodes (LEDs). The camera projects blue light onto the teeth, which reflects it back at
a slightly different angle. This method of visualization is referred to as active
triangulation.
To use the system, the entire tooth preparation to be scanned is coated with a layer
of special titanium dioxide powder, which makes translucent areas of the teeth
opaque and permits the camera to register all of the tissues. Several optical impres-
sions are then taken from an occlusal orientation, being sure to obtain images of
the tooth to be restored as well as the adjacent and opposing teeth. The scanner is
able to focus automatically.
After the impression is complete, a 3-D rendering of the tooth to be restored
appears on the monitor. The dentist is able to mark where the die should begin and
end based on this image. The software program then generates a proposed restora-
tion based on comparisons to the surrounding teeth, which can then be altered or fine
tuned as needed.
After the design is approved, the milling process can begin. A block of ceramic or
composite material in the correct color is simply inserted into the milling unit.15
Alternatively, the dentist can obtain a digital impression and send the data to a dental
laboratory. The laboratory can then design and mill the restoration using CAD/CAM
technology. They can also use the digital image to fabricate a hard resin model based
on the data and proceed to fabricate the restoration in the conventional manner.
The E4D Dentist System
The E4D Dentist system, which made its debut in 2008, is presently the only other
system besides CEREC that permits same-day in-office restorations.18 Dentists can
purchase the design center and laser scanner alone, or also purchase the milling unit.
This system includes a laser scanner, called the IntraOral Digitizer, along with
a design center and milling unit. The scanner is small, so patients do not need to
open their mouth as wide (Fig. 1).
 The Use of CAD/CAM in Dentistry 563

Fig. 1. E4D. (Courtesy of D4D Technologies.)

The E4D system requires the use of powder in some but not all cases. To use the
system, the restoration site is prepared as it is for a traditional impression. The scanner
is placed near the target tooth, and has 2 rubber feet that hold it a specific distance
from the area being scanned.
Looking at a computer monitor, the image of the target tooth is centered on the
screen. A foot pedal is then released, which activates the image capture using soft-
ware called ICEverything (D4D Technologies, Richardson, TX, USA). The software
on the screen then prompts the dentist to adjust the scanner for the next image. As
each picture is taken, the software gradually creates a 3-D image. The image can
then be viewed from any angle to confirm that the scan is complete.
Instead of scanning the opposing arch, an occlusal registration is created with an
impression material and is placed atop the target tooth. The scanner captures the
combination of registration material and uncovered teeth, using this information to
design restorations of the correct heights.
The design system automatically detects the finish lines and marks them on the
screen. After the dentist approves these markings, the computer proposes a restora-
tion model for the target tooth. Currently, one advantage of E4D is that the designer
can work on up to 16 restorations at once.
564 Davidowitz & Kotick

As soon as the restoration is approved, the data are transmitted to either the
in-house milling machine or a dental laboratory. The office milling machine will then
manufacture the restoration from the chosen blocks of ceramic or composite.

The Cadent iTero

Cadent introduced iTero in 2007 as the first digital impression system for convention-
ally manufactured crowns and bridges. Unlike the other 3 digital impression systems,
which acquire images using triangulation, iTero employs parallel confocal imaging.20
Specifically, the device projects 100,000 parallel beams of red laser light at the teeth
and transforms the reflected light into digital data through the use of analog-to-digital
converters.21
This technology allows scans to be taken without coating the teeth in powder. The
absence of powder means that the scanner can be rested directly on the teeth during
scanning. One disadvantage is that the scanner head is larger than those of the other
3 scanners discussed here.18
To start, information about the patient, including the type of restoration and the
tooth color, is entered into the computer. The system provides voice and visual
commands to guide the dentist through each scan; a typical series ranges from
15 to 30. The monitor combines these scans to provide a 3-D color model of
both arches. The complete scanning process takes about 3 to 5 minutes for
a full mouth.
During the review phase, the dentist is able to review the scan from any angle.
A digital articulator permits the dentist to review the occlusal clearance and make
any needed modifications to the prepared teeth or opposing arch.
After the scan is approved, a dedicated wireless connection transmits the scan to
Cadent for cleanup and initial design. The file then gets transmitted to the dental
laboratory.

The Lava Chairside Oral Scanner

The Lava Chairside Oral Scanner (COS) was launched in February 2008.18 The
system includes a mobile cart, a touch screen display, and a scanner with a camera
at the end (Fig. 2).
The camera, which contains 192 LEDs and 22 lens systems, employs active wave-
front sampling to capture images at video rate.
After preparing the tooth and retracting the gingival tissue, the dentist dries the arch
and gives it a light dusting of titanium dioxide powder. Just enough powder is used to
permit the scanner to identify reference points.
The scan is obtained by moving the wand first over the occlusal surfaces, then over
the buccal surfaces, and finally over the lingual sufaces. An additional scan is taken
of the occlusal surfaces.
The monitor image, which appears instantly, can be rotated and magnified to ensure
that all areas have been scanned properly and no holes appear. The dentist also has
the ability to switch between 3-D and 2-D images. Finally, the system is compatible
with 3-D glasses for a true 3-D experience.
After signing off on the scans, the data is sent wirelessly to the laboratory, where the
die is cut and the margin marked digitally. Then the data go to 3M, where a technician
reviews and synthesizes the images before creating a stone model. This stone model
is then sent to the laboratory.
The Lava COS can be used to make any type of crown or bridge, not just Lava
crowns and bridges.
 The Use of CAD/CAM in Dentistry 565

Fig. 2. Lava COS. (Courtesy of 3M ESPE.)

LABORATORIES

Laboratories are increasingly using CAD/CAM to create restorations. CAD/CAM

technology is the only way to create zirconia copings because the design program
is able to adjust precisely for the shrinkage caused by sintering.
A common way for laboratories to use CAD/CAM is for the laboratory to scan the
stone model with a digital scanner. After waxing up the model, a second scan is
done. The design program combines the 2 images digitally to determine the form of
the restoration.
The best known of these systems is InLab, CEREC’s laboratory-based designing
and milling system. This system is able to fabricate 3-unit bridge frames and automatic
virtual occlusal adjustments. The system is able to mill zirconia cores or full-ceramic
restorations using materials, such as IPS Empress or IPS e.max (both from Ivoclar
Vivadent, Amherst, NY, USA).
566 Davidowitz & Kotick

A major advantage of using CAD/CAM systems in the laboratory is that the final
restoration can look exactly like the provisional. CAD/CAM systems also shorten the
learning curve for new dental technicians, although a dental technician still finishes
each restoration by hand. CAD/CAM technology does not replace the need for skilled
dental laboratory technicians.

INCORPORATING CAD/CAM INTO YOUR PRACTICE

The age of CAD/CAM in dentistry has clearly arrived. Now it is up to individual dentists
to decide how much of the new technology they want in their office and how quickly.
Some dentists wish to have the latest technology and are willing to spend the money
to have it. However, another point to consider is patient population. Dentists with
younger, more affluent patients may be able to charge a premium for the convenience
of same-day restorations. On the other hand, those whose practices consist primarily
of direct restorations, removable prosthodontics, and periodontal treatments may not
be able to recoup their investment.
Dentists who wish to begin providing same-day restorations can purchase
a complete CEREC AC or E4D system at a cost of approximately $90,000 to
$112,000.22 A lower-cost option is to purchase a digital scanner only; prices for these
range from about $24,000 to $41,000.22 Each scan costs between $16 and $35.22
Dentists who choose a CEREC AC or E4D scanner have the ability to add a milling
unit at a later date.
Using a digital scanner improves patient comfort because impressions can be
uncomfortable. Using a complete system has the potential to reduce costs related
to impression material, provisional crowns, time in the office, and laboratory bills.
Dr Parag Kachalia estimated that dentists who switch to office CAD/CAM systems
can reduce their laboratory bill by 60% to 70%.22
Dentists who do advanced aesthetic treatment know how important provisional
veneers and crowns are to the overall treatment success. Provisionals are used to
not only protect the exposed tooth tissues and to give a more cosmetic appearance
during the time the permanent restorations are being fabricated but also to allow for
a trial run of the size, shape, and contour of the restorations. Once these parameters
are accepted, the ceramist needs to duplicate them as best as possible in the final
restorations. The use of CAD/CAM allows for the laboratory to do just that in an exact
way. The laboratory technician makes 2 virtual models; one of the provisionals and
one of the final impression of the prepared teeth. They virtually superimpose the
provisionals over the prepared teeth. The veneers are then milled in that precise
shape, with the ceramist cutting back a small portion to allow for layering and detail
work (Figs. 3–7).
Using CAD/CAM technology in this way allows the ceramist to duplicate the emer-
gence profile, incisal edge position, contours, and exact dimensions of the provisional
veneers.

THE FUTURE OF CAD/CAM

Over the next decade, as prices come down and dentists become more comfortable
with the new technology, we can expect to see increased use of CAD/CAM in
dentistry. Same-day restorations will become more popular and will likely expand to
fixed partial and removable dentures. One area for improvement would be represen-
tation of jaw movement using CAD/CAM; current design software only captures
shapes.
 The Use of CAD/CAM in Dentistry 567

Fig. 3. Virtual cutting of the dies. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

Fig. 4. Overlay of provisional virtual model over final virtual model. Note that the teeth
were being lengthened by about 2 to 3 mm. (Courtesy of Jon Brooks, MDT, Smile-Vision.)
568 Davidowitz & Kotick

Fig. 5. Labial overlay of models. Note how emergence profile can exactly mimic the provi-
sionals. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

Scanning, designing, and milling devices are expected to become increasingly

simple and convenient to use. In anticipation of future advances, the CEREC AC is
prepared for voice control and voice output.15 Improvements in technology should
avoid some of the back-and-forth data information between the dentist, the manufac-
turer, and the dental laboratory.
Another potential use of dental CAD/CAM could be in third-world countries where
laboratories and skilled ceramists might not be readily available.5 CAD/CAM tech-
nology could allow technicians to do much of the work and restorations could be
created on the spot.

Fig. 6. Wax-up for provisionals. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

 The Use of CAD/CAM in Dentistry 569

Fig. 7. Final restorations on model. (Courtesy of Jon Brooks, MDT, Smile-Vision.)

SUMMARY

Using CAD/CAM technology in the dental office and laboratory may have seemed like
science fiction 20 years ago, but today it is reality. We now have the ability to create
inlays, onlays, veneers, crowns, fixed partial dentures, implant abutments, and
full-mouth reconstruction using CAD/CAM.
CAD/CAM units are still expensive to purchase and use. But as prices come down
and more health care providers embrace the technology, we can expect digital
scanners and computer-assisted design and manufacturing to become standard in
dentistry.

ACKNOWLEDGMENTS

Devon Schuyler, MA, ELS assisted in the preparation of this manuscript.

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