CAD/CAM Restorations

Applications-inlays, onlays, veneers, crowns, bridges, implants, and implant prostheses    

Stages of fabrication
 
CSD-computerized surface digitization
CAD-computer-aided (assisted) design
CAM-computer-aided (assisted) machining
CAE-computer-aided esthetics (currently theoretic)
CAF-computer-aided finishing or polishing (which are currently theoretic steps)

Classification

Chairside or in-office systems

(1) Cerec (Siemens system)-inlays, onlays, veneers
(2) Sopha (Duret system)-inlays, onlays  (and Crowns)

Laboratory systems

(1) DentiCAD (Rekow system)-inlay, onlays, veneers, crowns
(2) Cicero (Elephant system)-porcelain fused-to-metal crowns

 
Materials

a. Feldspathic oorcelains (Vita)
b. Machinable ceramics (Dicor MGC)
c. Metal alloys limited use)

Cementing

- Etching enamel and/or dentin for micromechanical retention
- Bonding agent for retention to etched surface
- Composite as a luting cement for reacting chemically with bonding agent and with silanated surface of restoration
- Silane for bonding to etched ceramic (or metal) restorations and to provide chemical reaction
- Hydrofluoric acid etching to create spaces for micromechanical retention on surface or restoration

Properties

1. Physical properties

a. Thermal expansion coefficient well matched to tooth structure
b. Good resistance to plaque adsorption or retention

2. Chemical properties-not resistant to acids and should be protected from APF

3. Mechanical properties

a. Excellent wear resistance (but may abrade opponent teeth)
b. Some wear of luting cements but self-limiting
c. Excellent toothbrush abrasion

4. Biologic properties-excellent properties
 

Structure of gypsum products

Components
 
a. Powder (calcium sulfate hemihydrate = CaSO4½H2O)
b. Water (for reaction with powder and dispersing powder)

Bonding Agents

Applications-composites, resin-modified gIass ionomers, ceramic bonded to enamel restorations, veneers, orthodontic brackets, and desensitizing dentin by covering exposed tubules (Maryland bridges, composite and ceramic repair systems, amalgams and amalgam repair, and pinned amalgams)

Definitions;-

Smear layer - Layer of compacted debris on enamel and/or dentin from the cavity preparation process  that is weakly held to the surface (6 to 7 MPa) , and that limits bonding agent strength if not removed

Etching (or, conditioning)- smear layer removal and production of microspaces for micromechanical bonding by dissolving –minor amounts of surface hydroxyapatite crystals

Priming..- micromechanical (and chemical) bonding to the microspaces created by conditioning step.

Conditioning/priming agent-agent that accomplishes both actions

Bonding- formation of resin layer that connect  the primed surface to the overlying restoration (e.g., composite) .. –

Enamel bonding System-for bonding to enamel (although dentin bonding may be a Second step)

Dentin bonding system  for bonding  to dentin (although  enamel bonding  may have been a first step)

•        First-generation dentin bonding system for bonding to smear layer

•        New-generation dentin bonding system- for removing smear layer and etching intertubular dentin to allow  primer and/or bonding agent to diffuse into spaces between collagen and form hybrid zone

Enamel and dentin bonding system-for bonding to enamel and dentin surfaces with the same procedures

Amalgam bonding  system for bonding to enamel, dentin, and amalgam, dentin and amalgam during an amalgam placement procedure or for amalgam repair

Universal bonding system-for bonding to enamel, dentin, amalgam, porcelain , or any other substrate intraorally that may be necessary for a restorative procedure  using the  same set of procedures and materials

Types

Enamel bonding systems

Dentin bonding systems

Amalgam bonding systems

Universal bonding systems

Structure

o        Components of bonding systems

o        Conditioning agent-mineral or organic acid

Enamel only   37% phosphoric acid

Dentin only or enamel and .dentin---37% phosphoric acid, citric acid, maleic acid, or nitric acid

o        Priming agent

Hydrophobic-solvent-soluble, light cured monomer system

Hydrophilic-water-soluble, light-cured monomer system

Bonding agent

BIS-GMA-type monomer system

UDMA-type monomer system

Reaction

Bonding occurs primarily by intimate micromechanical retention with the relief created by the conditioning step

Chemical bonding is possible but is not recognized as contributing significantly to the overall bond strength

Manipulation-follow manufacturer's directions

Properties

Physical-thermal expansion and contraction may create fatigue stresses that debond the interface and permit micro leakage

Chemical-water absorption into the bonding agent may chemically alter the bonding

Mechanical-mechanical stresses may produce fatigue that debonds the interface and permits microleakage

Enamel bonding-adhesion occurs by macrotags (between enamel prisms) and microtags (into enamel prisms) to produce micromechanical retention

Dentin bonding-adhesion occurs by penetration of smear layer and formation of microtags into intertubular dentin to produce a hybrid zone (interpenetration zone or diffusion zone) that microscopically intertwines collagen bundles and bonding agent polymer

Biologic

Conditioning agents may be locally irritating if they come into contact with soft tissue

Priming agents (uncured), particularly those based on HEMA, may be skin sensitizers after several contacts with dental personnel

Protect skin on hands and face from inadvertent contact with unset materials and/ or their vapors

HEMA and other priming monomers may penetrate through rubber gloves in relatively short times (60 to 90 seconds)

Waxes

Many different waxes are used in dentistry. The composition, form, and color of each wax are designed to facilitate its use and to produce the best possible results.

Applications

o    Making impressions
o    Registering of tooth or soft tissue positions
o    Creating restorative patterns for lab fabrication
o    Aiding in laboratory procedures

Classification

a. Pattern waxes-inlay, casting, and baseplate waxes
b. Impression waxes-corrective and biteplate waxes
c. Processing waxes-boxing, utility, and sticky waxes

Types

1) Inlay wax-used to create a pattern for inlay, onlay or crown for subsequent investing and casting in a metal alloy.
2) Casting wax-used to create a pattern for metallic framework for a removable partial denture
3) Baseplate wax-used to establish the vertical dimension. plane of occlusion. and  initial arch form of a complete denture
4) Corrective impression wax-used to form a registry pattern of soft tissues on an impression
5) Bite registration wax-used to form a registry pattern for the occlusion of opposing models or casts
6) Boxing wax-used to form a box around an impression before pouring a  model or cast
7) Utility wax -soft pliable adhesive wax for modifying appliances, such as alginate impression trays
8) Sticky  wax-sticky when melted and used to temporarily adhere pieces of metal or resin in laboratory procedures

Components

a. Base waxes-hydrocarbon (paraffin) ester waxes    
b. Modifier waxes-carnauba, ceresin, bees wax, rosin, gum dammar, or microcrystalline waxes
c. Additives-colorants

Reaction-waxes are thermoplastic

Properties

Physical

a. High coefficients of thermal expansion and contraction
b. Insulators and so, cool unevenly; should be waxed in increments to allow heat dissipation

Chemical

a. Degrade prematurely if overheated
b. Designed to degrade into CO2and H2Oduring burnout

Mechanical-stiffness, hardness, and strength depend on modifier waxes used
 

Manipulation

Mixture of powder and liquid is painted onto working cast to create shape for acrylic appliance à  After curing of mixture, the shape and fit are adjusted by grinding with burrs and stones with a slow-speed handpiece .Acrylic dust is irritating to epithelial tissues of nasopharynx and skin and may produce allergic dermatitis or other reactions.  Grinding may heat polymer to temperatures that depolymerize and release monomer vapor. which may be an irritant

Impression Material