لخّصلي

Digital dentistry: an overview
of recent developments for CAD/CAM generated restorations F. Beuer,1 J. Schweiger2 and D. Edelhoff3
VERIFIABLE CPD PAPER
As in many other industries, production stages are increasingly becoming automated in dental technology. As the price
of dental laboratory work has become a major factor in treatment planning and therapy, automation could enable more competitive production in high-wage areas like Western Europe and the USA. Advances in computer technology now en- able cost-effective production of individual pieces. Dental restorations produced with computer assistance have become more common in recent years. Most dental companies have access to CAD/CAM procedures, either in the dental practice, the dental laboratory or in the form of production centres. The many benefits associated with CAD/CAM generated dental restorations include: the access to new, almost defect-free, industrially prefabricated and controlled materials; an increase in quality and reproducibility and also data storage commensurate with a standardised chain of production; an improve- ment in precision and planning, as well as an increase in efficiency. As a result of continual developments in computer hardware and software, new methods of production and new treatment concepts are to be expected, which will enable an additional reduction in costs. Dentists, who will be confronted with these techniques in the future, require certain basic knowledge if they are to benefit from these new procedures. This article gives an overview of CAD/CAM-technologies and systems available for dentistry today.

1. DEFINITION
   The term ‘CAD/CAM’ in dental technol- ogy is currently used as a synonym for prostheses produced by ‘milling technol- ogy’. This is not entirely correct. CAD is the abbreviation for ‘computer-aided design’ and CAM stands for ‘computer- aided manufacturing’. The term ‘CAD/ CAM’ does not provide any information on the method of fabrication.
   All CAD/CAM systems consist of three components:


2. A digitalisation tool/scanner that
   transforms geometry into digital data that can be processed by the computer
   1*Assistant Professor, 2Head of Laboratory, 3Associate Professor, Department of Prosthodontics, Ludwig- Maximilians University, Munich, Germany *Correspondence to: Dr Florian Beuer, Pacific Dental Institute, 12750 SW 68th Avenue, Portland, Oregon, 97223, USA
   Email: [email protected]
   Refereed Paper
   Accepted 28 March 2008
   DOI: 10.1038/sj.bdj.2008.350
   ©British Dental Journal 2008; 204: 505-511


3. Software that processes data and, depending on the application, produces a data set for the product to be fabricated


4. A production technology that trans- forms the data set into the desired product.


5. CAD/CAM PRODUCTION CONCEPTS IN DENTISTRY
   Depending on the location of the com- ponents of the CAD/CAM systems, in dentistry three different production concepts are available:
   • chairside production
   • laboratory production
   • centralised fabrication in a
   production centre.
   a) Chairside production
   All components of the CAD/CAM system are located in the dental surgery. Fabrica- tion of dental restorations can thus take place at chairside without a laboratory procedure. The digitalisation instrument is an intra-oral camera, which replaces a conventional impression in most clinical
   situations. This saves time and offers the patient indirectly fabricated resto- rations at one appointment. At present, only the Cerec® System (Sirona) offers this possibility. Other producers also plan to introduce chairside CAD/CAM systems to the market. Since the Cerec® system functions with water-cooling, a variety of materials can be processed, from glass-ceramic to high performance oxide ceramic. Clinical observations on ceramic inlays are available over a period of 21 years. Scientific literature reported success rates for CAD/CAM produced inlays of 90% after ten years and 85% after 12 and 16 years.1-3 Historically, this system was the first CAD/CAM system in dentistry and is currently available in its third product generation. One of the benefits of this very mature system is the software that has been supplemented by a very exact three-dimensional recon- struction of the occlusal surface.
   b) Laboratory production
   This variant of production is the equiva- lent to the traditional working sequence
   BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
   505
   © 2008 Nature Publishing Group
   IN BRIEF
   • CAD/CAM technology is widely available, but little is known about it by the general dental practitioner.
   • This article informs the practitioner about recent developments in the field of digital dentistry.
   • Information outlined in this article could aid the cost-effective production of dental prostheses.
   PRACTICE

PRACTICE
between the dentist and the laboratory. The dentist sends the impression to the laboratory where a master cast is fab- ricated first. The remaining CAD/CAM production steps are carried out com- pletely in the laboratory. With the assist- ance of a scanner, three-dimensional data are produced on the basis of the master die. These data are processed by means of dental design software. After the CAD-process the data will be sent to a special milling device that produces the real geometry in the dental labora- tory. Finally the exact fit of the frame- work can be evaluated and, if necessary, corrected on the basis of the master cast. The ceramist carries out the veneering of the frameworks in a powder layering or overpressing technique.4-7
c) Centralised production
The third option of computer-assisted production of dental prostheses is cen- tralised production in a milling centre. In this variation, it is possible for ‘sat- ellite scanners’ in the dental laboratory to be connected with a production cen- tre via the Internet. Data sets produced in the dental laboratory are sent to the production centre for the restorations to be produced with a CAD/CAM device. Finally, the production centre sends the prosthesis to the responsible laboratory. Thus, production steps 1 and 2 take place in the dental laboratory, while the third step takes place in the centre.5,8 As a result, the configuration of the prosthe- sis remains in the hands of the dental technician. The benefit of outsourcing CAM production is to be found in the small investment requirement, since only the digitalisation tool and soft- ware have to be purchased, still having access to a high quality production pro- cess. In addition, this procedure results in greater independence, since there is no relation to a particular production technology (such as, eg milling tech- nology). It must, however, be noted that presently almost all CAD/CAM systems are only available as closed systems. In other words, if one acquires a scanner from one manufacturer, this implies, in the case of a closed system, that there is only access to that manufacturer’s pro- cesses and line of products. In addition, the dental laboratory loses the income
Fig. 1 White light projector pattern during the scanning process by an optical scanner
Fig. 2 Screen-shot of CAD-construction of 14 single crown copings
506
BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
Fig. 3 Different possibilities of the working axis: 3 spatial directions X, Y and Z (3 axis milling devices); 3 spatial directions X, Y, Z and tension bridge A (4 axis milling devices); 3 spatial directions X, Y, Z, tension bridge A and milling spindle B (5 axis milling devices)
© 2008 Nature Publishing Group

from producing the framework, since it is fabricated in the production centre.
Many production centres also offer laboratories without a scanner the pos- sibility of sending the master cast to the centre for scanning, designing and fab- rication. The additional veneering of the frameworks for prosthetic restorations is carried out in the dental laboratory.
Recently, dentists have been offered the possibility of sending the impres- sion directly to the production centre (biodentis). This application is presently limited to ceramic inlays only.
An additional simplification in CAD/ CAM production consists of intraoral data collection (optical impression). This means a digitalisation of what is now only an ‘analogue’ step in the production process. This could lead to additional improvement in quality and cost reduc- tion. New software developments will make it possible to directly judge the quality of the preparation intraorally, before data are finally sent to the dental laboratory or production centre.
3. CAD/CAM COMPONENTS 3.1 Scanner
Under the term ‘scanner’ one under- stands, in the area of dentistry, data collection tools that measure three- dimensional jaw and tooth structures and transform them into digital data sets. Basically there are two different scanning possibilities:
• optical scanners
• mechanical scanners.
a) Optical scanners
The basis of this type of scanner is the collection of three-dimensional struc- tures in a so-called ‘triangulation proce- dure’. Here, the source of light (eg laser) and the receptor unit are in a definite angle in their relationship to one another. Through this angle the computer can calculate a three-dimensional data set from the image on the receptor unit.9 Either white light projections or a laser beam can serve as a source of illumina- tion (Fig. 1). The following can be named as examples of optical scanners on the dental market:
• Lava Scan ST (3M ESPE, white light projections)
• Everest Scan (KaVo, white light projections)
• es1 (etkon, laser beam). b) Mechanical scanner
In this scanner variant, the master cast is read mechanically line-by-line by means of a ruby ball and the three-dimensional structure measured. The Procera Scan- ner from Nobel Biocare (Göteborg) is the only example for mechanical scan- ners in dentistry. This type of scanner is distinguished by a high scanning accu- racy, whereby the diameter of the ruby ball is set to the smallest grinder in the milling system, with the result that all data collected by the system can also be milled.5,10 The drawbacks of this data measurement technique are to be seen in the inordinately complicated mechanics, which make the apparatus very expen- sive with long processing times com- pared to optical systems.
3.2 Design software
Special software is provided by the manufacturers for the design of vari- ous kinds of dental restorations. With such software, crown and fixed partial dentures (FPD) frameworks can be con- structed on the one hand (Fig. 2); on the other hand, some systems also offer the opportunity to design full anatomi- cal crowns, partial crowns, inlays, inlay retained FPDs, as well as adhesive FPDs and telescopic primary crowns.11 The software of CAD/CAM systems presently available on the market is being continu- ously improved. The latest construction possibilities are continuously available to the user by means of updates. The data of the construction can be stored in vari- ous data formats. The basis therefore is often standard transformation language (STL) data.9 Many manufacturers, how- ever, use their own data formats, spe- cific to that particular manufacturer, with the result that data of the construc- tion programs are not compatible with each other.
The systems available on the market are differentiated mostly in their con- struction software. While many systems emphasise an indication spectrum that is as broad as possible, other manufac- turers place emphasis on intuitive use and user-friendliness.
PRACTICE 3.3 Processing devices
The construction data produced with the CAD software are converted into mill- ing strips for the CAM-processing and finally loaded into the milling device. Processing devices are distinguished by means of the number of milling axes:
• 3-axis devices • 4-axis devices • 5-axis devices.
a) 3-axis milling devices
This type of milling device has degrees of movement in the three spatial direc- tions. Thus, the mill path points are uniquely defined by the X -, Y -, and Z – values (Fig. 3). The calculation invest- ment is therefore minimal. A milling of subsections, axis divergences and convergences, however, is not possible. This demands a virtual blocking in such areas. All 3-axis devices used in the dental area can also turn the component by 180° in the course of processing the inside and the outside. The advantages of these milling devices are short milling times and simplified control by means of the three axes. As a result, such mill- ing devices are usually less costly than those with a higher number of axes.
Examples of 3-axis devices: inLab (Sirona), Lava (3M ESPE), Cercon brain (DeguDent).
b) 4-axis milling devices
In addition to the three spatial axes, the tension bridge for the component can also be turned infinitely variably (Fig. 3). As a result it is possible to adjust bridge constructions with a large verti- cal height displacement into the usual mould dimensions and thus save mate- rial and milling time.
Example: Zeno (Wieland-Imes).
c) 5-axis milling devices
With a 5-axis milling device there is also, in addition to the three spatial dimensions and the rotatable tension bridge (4th axis), the possibility of rotat- ing the milling spindle (5th axis) (Fig. 3). This enables the milling of complex geometries with subsections, as for example, lower jaw FPDs on converg- ing abutment teeth (end molar tipped towards the medial plane) (Fig. 4), or also crown and FPD substructures that,
BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
507
© 2008 Nature Publishing Group

PRACTICE
as a result of anatomically reduced for- mation, demonstrate converging areas in the exterior of the frame.
Example in the Laboratory Area: Ever- est Engine (KaVo).
Example in the Production Centre: HSC Milling Device (etkon).
The quality of the restoration does not necessarily increase with the number of processing axes. The quality results much more from the result of the digitalisation, data processing and production process.
4. MILLING VARIANTS a) Dry processing
Dry processing is applied mainly with respect to zirconium oxide blanks with a low degree of pre-sintering. This offers several benefits:
• Minimal investment costs for the milling device
• No moisture absorption by the die ZrO2 mould, as a result of which there are no initial drying times for the ZrO2 frame prior to sintering.
Disadvantages:
• The lower degree of pre-sintering
results in higher shrinkage values for the frameworks.
Some manufacturers also offer the
option of milling resin material in a dry milling process [Zeno 4030 (Wieland- Imes), Lava Form and Cercon brain].
b) Wet milling
In this process the milling diamond or carbide cutter is protected by a spray of cool liquid against overheating of the milled material. This kind of process- ing is necessary for all metals and glass ceramicmaterialinordertoavoiddam- age through heat development. ‘Wet’ processing is recommended, if zirconium oxide ceramic with a higher degree of pre-sintering is employed for the milling process. A higher degree of pre-sintering results in a reduction of shrinkage factor and enables less sinter distortion.
Examples: Everest (KaVo), Zeno 8060 (Wieland-Imes), inLab (Sirona).
5. MATERIALS FOR CAD/CAM PROCESSING
The list of various materials for process- ing by CAD/CAM devices depends on
Fig. 4 Pinned master cast of converging abutment teeth for a fixed partial denture in the mandible. At least a 4 milling axis is required for the milling unit to fabricate a substructure for this situation
Table 1 Selection of resin materials for CAD/CAM systems
Name
Manufacturer
CAD/CAM system
Description
CAD-Waxx
Vita
inLab
Filler-free acrylic polymer for lost wax technique
Cercon base cast
DeguDent
Cercon
Residue-free cauterisable resin for lost wax technique
Everest C-Cast
KaVo
Everest
Residue-free cauterisable resin for lost wax technique
CAD-Temp Block
Vita
Cerec 3, inLab
Fibre-free acrylic polymer with micro-filler for long-term temporary full and partial crowns and FPDs up to two pontics
Everest C-Temp
KaVo
Everest
Fibre reinforced polymer for long-term temporary crowns and FPD frameworks, requiring an additional veneering
Artegral imCrown
Merz
Cerec 3, inLab
Semi individual blanks for anterior long-term provisional single crowns
the respective production system. Some milling devices are specifically designed for the production ZrO2 frames, others cover the complete palette of materials from resins to glass ceramics and high performance ceramics. The following materials can normally be processed on dental CAD/CAM devices:
a) Metals
At present, titanium, titanium alloys and chrome cobalt alloys are processed using dental milling devices. The mill- ing of precious metal alloys has been shown to be of no economic interest, due to the high metal attrition and the high material costs.
Examples: coron (etkon: non-precious metal alloy), Everest Bio T-Blank (KaVo, pure titanium).
b) Resin materials
On the one hand, resin materials can be used for the milling of lost wax frames for casting technology; on the other hand, it is possible to use resin materials directly as crownandFPDframeworksforlong-term provisional or for full anatomical long- term temporary prostheses (Table 1). Pre- fabricated semi-individual polymer blanks (semi-finished) with a dentine enamel layer are provided by one manufacturer (artegral imCrown, Merz Dental). The exterior contour conforms to an anatomi- cally complete anterior tooth crown, while the internal aspect of the crown is milled out of the internal volume of the blank.
c) Silica based ceramics
Grindable silica based ceramic blocks are offered by several CAD/CAM systems
508
BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
© 2008 Nature Publishing Group

for the production of inlays, onlays, veneers, partial crowns and full crowns (fully anatomical, anatomically par- tially reduced) (Table 2). In addition to monochromatic blocks, various manu- facturers now offer blanks with multi- coloured layers [Vitablocs TriLuxe (Vita), IPS Empress CAD Multi (IvoclarVi- vadent)], for the purpose of full anatom- ical crowns. Due to their higher stability values, lithium disilicate ceramic blocks are particularly important in this group; they can be used for full anatomical ante- rior and posterior crowns, for copings in the anterior and posterior region and for three-unit FPD frameworks in the ante- rior region due to their high mechanical stability of 360 MPa.12-15 Glass ceramics are particularly well suited to chairside application as a result of their trans- lucent characteristics, similar to that of natural tooth structure; they pro- vide aesthetically pleasing results even without veneering. As a result of their relatively high portion of glass, these ceramics are, in contrast to oxide ceram- ics, etchable with hydrofluoric acid and thus can be inserted very well using adhesive systems.16,17
d) Infiltration ceramics
Grindable blocks of infiltration ceramics are processed in porous, chalky condi- tion and then infiltrated with lanthanum glass. All blanks for infiltration ceram- ics originate from the Vita In-Ceram system (Vita) and are offered in three variations:
• Vita In-Ceram Alumina (Al2O3): suit- able for crown copings in the anterior and posterior region, three-unit FPD frameworks in the anterior region18
• Vita In-Ceram Zirconia (70% Al2O3, 30% ZrO2): suitable for crown copings in the anterior and posterior region, three-unit FPD frameworks in the anterior and posterior region. Thanks to its superior masking ability this ceramic is suitable for discoloured abutment teeth19,20
• VITA In-Ceram Spinell (MgAl2O4): has the highest translucency of all oxide ceramics and is thus recom- mended for the production of highly aesthetic anterior crown copings, in particular on vital abutment teeth and in the case of young patients.
Fig. 5 Enlarged zirconium oxide after the milling process before sintering to the desired dimensions
e) Oxide high performance ceramics
At present, aluminum oxide and zir- conium oxide are offered as blocks for CAD/CAM technology.
Aluminum Oxide (Al2O3)
This oxide high performance ceramic is ground in a pre-sintered phase and is then sintered at a temperature of 1520°C in the sintering furnace. Aluminium oxide is indicated in the case of crown copings in the anterior and posterior area, primary crowns and three-unit anterior FPD frameworks. The ground frames can be individually stained in several colours with Vita In-Ceram AL Coloring Liquid.5,21-23 Examples of grindable alu- minum oxide blocks: In-Ceram AL Block (Vita), inCoris Al (Sirona) available in an ivory-like colour (Color F 0.7).
Yttrium stabilised zirconium
oxide (ZrO , Y-TZP) 2
Zirconium dioxide is a high-performance oxide ceramic with excellent mechanical characteristics. Its high flexural strength and fracture toughness compared with other dental ceramics offer the possibil- ity of using this material as framework material for crowns and FPDs, and, in appropriate indications, for individual implant abutments. The addition of three molecules of Y2O3 results in a stabilising tetragonal phase at room temperature,
which, as a result of a transition to a monoclinic phase can prevent the pro- gression of cracks in the ceramic (Trans- formation strengthening).24-27 Examples of Zirconium oxide blocks: Lava Frame (3M ESPE), Cercon Smart Ceramics (Degu- Dent), Everest ZS und ZH (KaVo), inCoris Zr (Sirona), In-Ceram YZ (Vita), zerion (etkon) and Zeno Zr (Wieland-Imes)
Processing can take place in different density stages
a) Green stage processing
Green stage: blank without heat treat- ment, ie an object pressed from ceramic powder and binding agents.
Since there was no pre-sintering, the object is as soft as chalk. This permits very easy processing, but results, due to the low degree of stability, in great problems in transport and application. Processing is by means of carbide metal grinders without liquid cooling. The green stage has an open porosity, and in firing a 25% linear shrinkage is to be expected. At present, zirconium oxide is not processed as a green stage in any of the CAD/CAM systems on the market.
b) White stage processing
White stage: pre-sintered blanks.
As a result of the thermal pre-treatment the organic compressing additives have vanished and the blank has an adequate
PRACTICE
BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
509
© 2008 Nature Publishing Group

PRACTICE
Table 2 Selection of glass ceramic materials for CAD/CAM systems
Name
Manufacturer
CAD/CAM system
Description
Vitablocs Mark II
Vita
Cerec 3, inLab
Monochrome for inlays, onlays, veneers and full crowns
IPS e.max CAD
Ivoclar Vivadent
inLab, Everest
Monochrome for full anatomical crowns, copings and anterior three-unit FPDs
Vitablocs TriLuxe
Vita
Cerec 3, inLab
Polychromatic for inlays, onlays, veneers and full crowns
IPS Empress CAD Multi
Ivoclar Vivadent
inLab
Polychromatic for inlays, onlays, veneers and full crowns
stability. As a result of pre-sintering, the white body has already had shrinkage of approximately 5%. In the case of CAD/ CAM production of objects from white bodies, the subsequent shrinkage of some 20% (linear) must be taken into consid- eration. Processing of white stage can be either with carbide metal grinders with- out water cooling or with diamond grind- ers with liquid cooling (Fig. 5).8,28
c) Processing in hot isostatic pressing condition
Some systems also process zirconium oxide in HIP (hot isostatic pressed) con- dition with diamond tools and water cooling. The advantages and disadvan- tages are as follows.15,29,30
Advantages:
• No sinter shrinkage, as a result no
sinter distortions
• No sinter furnace necessary
• No additional time needed for
sintering procedure.
Disadvantages:
• Devices with high rigidity
and stability necessary
• Longer milling times, resulting in
lower utilisation of devices
• High wear of the cutters
• No coloured blanks available on the
market yet.
6. FUTURE TECHNOLOGIES Generative production methods
Generative production methods are special CAD/CAM methods, which, in contrast to grinding technology, do not work by subtracting, but rather by add- ing material. In the dental area there are some areas of application for which this technology is already applied. In some production centres, so-called ‘laser sin- tering devices’ are used to produce crown and bridge frames from chrome cobalt alloys. Since the productivity of such devices is very high, dental restorations can be produced very cost-effectively. Basically, geometries are conceivable with this technology that cannot be realised with grinding technology.
7. SIGNIFICANCE FOR THE DENTIST
In recent years, the use of CAD/CAM technology has above all strongly
influenced dental-technical produc- tion procedures. If one ignores chair- side prostheses, the significance of this technology for the dentist is not imme- diately clear. In recent years, CAD/CAM production has clearly expanded the palette of materials for dental prosthe- ses by providing access to new ceramic materials with high dependability.15,28-31 The stability values of zirconium oxide ceramics permit, in many areas of indi- cation, the use of this material as an alternative to metal frames for perma- nent prostheses.30
The production of long-term temporary prostheses has, as a result of the use of a virtual wax up on the computer, become faster, more convenient and more pre- dictable. This method has already been implemented by computer-generated long-term temporary restorations, since it can be modified, by changing the form, to the functional and aesthetic sat- isfaction of the patient during a clinical test phase. The production of the defini- tive prosthesis should also be carried out by CAD/CAM technology and represents merely a copying process of the tempo- rary prosthesis into the definitive pros- thesis by a different material.
In spite of all the benefits of these new methods, the dentist’s working procedures will have to be adapted to the methods of CAD/CAM and milling technology. These include appropriate tooth preparations with the creation of a continuous preparation margin, which is clearly recognisable to the scanner, for example in the form of a chamfer preparation. Shoulderless preparations and parallel walls should be avoided. On the basis of present knowledge, a tapered angle of between 4° to 10° is recom- mended.30 Subsections and irregularities
Fig. 6 Reverse bevel preparation making the preparation border hardly detectable by the CAD-software
on the surface of the prepared tooth as well as the ‘creation of troughs’ with a reverse bevel preparation margin can be inadequately recognised by many scan- ners (Fig. 6). In addition, sharp incisor and occlusal edges are to be rounded. Sharp and thinly extending edges as well as 90° shoulders in a ceramic res- toration can result in a concentration of tension; in addition sharp edges cannot be milled exactly using rounded grind- ers in the milling device. The diameter of the smallest grinder is 1 mm in most systems, so structures smaller than 1 mm cannot be milled precisely. The result is an inaccurate fit.
A 360 degree shoulder or cham- fer preparation is considered to be the appropriate marginal preparation geometries for CAD/CAM produced all-ceramic restorations. In the case of FPDs, the abutment teeth cannot show any divergence.
The precision of fit that can be achieved with the assistance of CAD/CAM sys- tems is reported to be 10-50 μm in the
510
BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
© 2008 Nature Publishing Group

PRACTICE
marginal area.8,29,32-34 Thus, the demands of the literature concerning marginal adaptation of dental restorations can be reached with this technology;35,36 in addi- tion, this production process achieves an industrial standard that does not have to deal with the variations of manually produced prostheses.23
8. EVALUATION – ADVANTAGES AND DISADVANTAGES OF COMPUTER-ASSISTED PRODUCTION
CAD/CAM technologies have started a new age in dentistry. The quality of dental prostheses has improved signifi- cantly by means of standardised produc- tion processes. This makes very efficient quality management possible. On the one hand it increased the productivity tremendously and changed dental labo- ratories from manufacturers to modern computerised production centres. On the other hand this increase in productivity leads to a competitive capability to pro- duce dental prostheses independent of the manufacturing site, which might be a major factor for the high wage countries to keep business volume in the country. Last but not least CAD/CAM technology has made it possible to machine inter- esting new materials like the high per- formance ceramics and titanium with high accuracy.
However, some drawbacks of this fabri- cation technology have to be mentioned. The high investment for machines might overextend the budget of smaller labora- tories. Some applications are limited due to software and production procedures.
CAD/CAM technology has already changed dentistry and will replace more and more of the traditional techniques in fabricating dental restorations.

1. Otto T, De Nisco S. Computer-aided direct ceramic restorations: a 10- year prospective clinical study of Cerec CAD/CAM inlays and onlays. Int J Pros- thodont 2002; 15: 122-128.


2. Reiss B. Clinical results of Cerec inlays in a dental practice over a period of 18 years. Int J Comput Dent 2006; 9: 11-22.


3. Sjögren G, Molin M, van Dijken J W. A 10-year pro- spective evaluation of CAD/CAM-manufactured (Cerec) ceramic inlays cemented with a chemically cured or dual-cured resin composite. Int J Prostho- dont 2004; 17: 241-246.


4. Luthy H, Filser F, Loeffel O, Schumacher M et al. Strength and reliability of four unit all-ceramic posterior bridges. Dent Mater 2005; 21: 930-937.


5. MayKB,RussellMM,RazzoogME,LangBR. Precision of fit: the Procera AllCeram crown.
   J Prosthet Dent 1998; 80: 394-404.


6. Raigrodski A J. All-ceramic full-coverage restora- tions: concepts and guidelines for material selec- tion. Pract Proced Aesthet Dent 2005;
   17: 249-256, quiz 258.


7. Raigrodski A J, Chiche G J. The safety and efficacy of anterior ceramic fixed partial dentures: a review of the literature. J Prosthet Dent 2001;
   86: 520-525.


8. Reich S, Wichmann M, Nkenke E, Proeschel P. Clini- cal fit of all-ceramic three-unit fixed partial den- tures, generated with three different CAD/CAM systems. Eur J Oral Sci 2005; 113: 174-179.


9. Mehl A, Gloger W, Kunzelmann K H, Hickel R. A new optical 3-D device for the detection of wear. J Dent Res 1997; 76: 1799-1807.


10. Webber B, McDonald A, Knowles J. An in vitro study of the compressive load at fracture of Procera AllCeram crowns with varying thickness of veneer porcelain. J Prosthet Dent 2003; 89: 154-160.


11. Reiss B. Cerec standard 3-D occlusal contouring in comparison with the new biogeneric occlusal morphing: a case report. Int J Comput Dent 2007; 10: 69-75.


12. Sorensen J A, Choi C, Fanuscu M I, Mito W T. IPS Empress crown system: three-year clinical trial results. J Calif Dent Assoc 1998; 26: 130-136.


13. Sorensen J A, Cruz M, Mito W T, Raffeiner O et al. A clinical investigation on three-unit fixed partial dentures fabricated with a lithium disilicate glass- ceramic. Pract Periodontics Aesthet Dent 1999; 11: 95-106.


14. Taskonak B, Sertgoz A. Two-year clinical evaluation of lithia-disilicate based all-ceramic crowns and fixed partial dentures. Dent Mater 2006;
    22: 1008-1013.


15. Tinschert J, Natt G, Mautsch W, Augthun M, Spiekermann H. Fracture resistance of lithium dis- ilicate-, alumina-, and zirconia-based three-unit fixed partial dentures: a laboratory study.
    Int J Prosthodont 2001; 14: 231-238.


16. Sorensen J A, Kang S K, Avera S P. Porcelain-
    composite interface microleakage with various porcelain surface treatments. Dent Mater 1991; 7: 118-123.


17. Sorensen J A, Munksgaard E C. Ceramic inlay movement during polymerization of resin luting cements. Eur J Oral Sci 1995; 103: 186-189.


18. Vult von Steyern P, Jonsson O, Nilner K. Five-year
    evaluation of posterior all-ceramic three-unit (In-
    Ceram) FPDs. Int J Prosthodont 2001; 14: 379-384. 19. Raigrodski A J, Chiche G J. All-ceramic fixed partial
    dentures, Part I: in vitro studies. J Esthet Restor
    Dent 2002; 14: 188-191.


19. Raigrodski A J, Chiche G J, Swift E J Jr. All-ceramic
    fixed partial dentures, Part III: clinical studies.
    J Esthet Restor Dent 2002; 14: 313-319.


20. Dunn M. Biogeneric and user-friendly: the Cerec
    3D software upgrade V3.00. Int J Comput Dent
    2007; 10: 109-117.


21. Tinschert J, Natt G, Hassenpflug S, Spiekermann H.
    Status of current CAD/CAM technology in dental
    medicine. Int J Comput Dent 2004; 7: 25-45.


22. Tinschert J, Zwez D, Marx R, Anusavice K J. Struc-
    tural reliability of alumina-, feldspar-, leucite-, mica- and zirconia-based ceramics. J Dent 2000; 28: 529-535.


23. Curtis A R, Wright A J, Fleming G J. The influence of surface modification techniques on the per- formance of a Y-TZP dental ceramic. J Dent 2006; 34: 195-206.


24. Kosmac T, Oblak C, Jevnikar P, Funduk N, Marion L. The effect of surface grinding and sandblasting on flexural strength and reliability of Y-TZP zirconia ceramic. Dent Mater 1999; 15: 426-433.


25. Swain M V. Limitation of maximum strength of zirconia-toughened ceramics by transformation toughening increment. J Am Ceramic Soc 1985; 66: 358-362.


26. Swain M V, Hannink R H J. Metastability of the martensitic transformation in a 12 mol% ceria- zirconia alloy: grinding studies. J Am Ceramic Soc 1989; 72: 1358-1364.


27. Sailer I, Feher A, Filser F, Gauckler L J et al. Five year clinical results of zirconia frameworks for posterior fixed partial dentures. Int J Prosthodont 2007; 20: 383-388.


28. Tinschert J, Natt G, Mautsch W, Spiekermann
    H, Anusavice K J. Marginal fit of alumina- and zirconia-based fixed partial dentures produced by a CAD/CAM system. Oper Dent 2001; 26: 367-374.


29. Vult von Steyern P, Carlson P, Nilner K. All-ceramic fixed partial dentures designed according to the DC-Zirkon technique. A 2-year clinical study. J Oral Rehabil 2005; 32: 180-187.


30. Luthardt R G, Holzhuter M, Sandkuhl O et al. Reli- ability and properties of ground Y-TZP-zirconia ceramics. J Dent Res 2002; 81: 487-491.


31. Bindl A, Mormann W H. Marginal and internal fit of all-ceramic CAD/CAM crown-copings on chamfer preparations. J Oral Rehabil 2005; 32: 441-447.


32. Stappert C F, Denner N, Gerds T, Strub J R. Marginal adaptation of different types of all-ceramic partial coverage restorations after exposure to an artifi- cial mouth. Br Dent J 2005; 199: 779-783.


33. Sulaiman F, Chai J, Jameson L M, Wozniak W T. A comparison of the marginal fit of In-Ceram, IPS Empress, and Procera crowns. Int J Prosthodont 1997; 10: 478-484.


34. McLean J W. Polycarboxylate cements. Five years’ experience in general practice. Br Dent J 1972; 132: 9-15.


35. McLean J W, von Fraunhofer J A. The estimation of cement film thickness by an in vivo technique.
    Br Dent J 1971; 131: 107-111.
    BRITISH DENTAL JOURNAL VOLUME 204 NO. 9 MAY 10 2008
    511
    © 2008 Nature Publishing Group