Computer-assisted milling of dental restorations using a new CAD/CAM data acquisition system

Jrgen Willer, Dr med dent,a Albrecht Rossbach, Prof Dr med dent,b and Hans-Peter Weber, DMD, Dr med dentc Center of Dental Medicine, University of Hannover, Hannover, Germany; and Harvard School of Dental Medicine, Boston, Mass. Background. Recent technologic innovations have created possibilities for restorative dentistry, such as
computer-aided design and computer-aided manufacturing (CAD/CAM).

Purpose. This article presents a new CAD/CAM process that has been developed for the fabrication of
dental restorations. Methods. This process uses an improved imaging technique, successfully applied in other industries. Imaging is accomplished with 2-dimensional line grids projected onto an object, which allows for a mathematical reproduction of prepared and unprepared tooth surfaces, including those that are outside the direct line of light. The relative position of the sensor to the surface of the object is controlled automatically. Conclusions. This system, which is undergoing clinical testing, allows the generation of various types of highly accurate dental restorations (inlays, onlays, crowns, and fixed partial dentures) from a number of different materials. Acquired digitized data points are directly translated from the sensor to the electronic controls of the milling machine to provide various manufacturing possibilities, including copy milling and accurate reproduction of occlusal tooth surfaces in various materials. (J Prosthet Dent 1998;80:346-53.)

CLINICAL IMPLICATIONS
Assuming continued improvements, CAD/CAM technology holds promise for being an important technology to fabricate dental restorations in the future. Consistent quality and precision are achievable in this process that should, at some point, be less labor intense and less expensive than techniques currently used. Various aspects of the CAD/CAM process still need improvement, such as the quality and the speed of intraoral imaging.

ong-term success of fixed single and multiple unit prosthodontic restorations depends, to a considerable extent, on the accuracy of fit between restoration and prepared tooth structure. With the commonly applied lost-wax-casting technique in the production of metal castings or frameworks, their accuracy is greatly influenced by the dimensional properties of investment and casting alloy.1-3 In addition, casting imperfections, such as porosities or impurities due to the presence of corrosion-prone mixed crystals, can cause the quality of cast restorations to be severely impaired. Likewise, poor solder joints, underdimensioned or nonhomogeneous metal frameworks can affect the quality and, thus, the long-term success of crowns and fixed partial dentures (FPDs). With the aid of x-ray defectography, it was possible to demonstrate that roughly a third of all cast restorations exhibit manufacturing-related deficiencies.4
aResearch

Associate, Department of Prosthodontics, Center for Dental Medicine, University of Hannover Medical Center. bProfessor and Chair, Department of Prosthodontics, Center for Dental Medicine, University of Hannover Medical Center. cNagle Associate Professor and Chair, Department of Restorative Dentistry, Harvard School of Dental Medicine. 346 THE JOURNAL OF PROSTHETIC DENTISTRY

Milling of dental restorations from a block of base material, such as metal, ceramic or resin, is proposed as an alternative for fabricating restorations. This technology promises results of greater accuracy and structural homogeneity. With quality as the objective, the significant advantage in using milling technology lies in the fact that cold working of rolled structures and ceramic materials will always yield homogenous material structures. To produce milled restorations with accurate fit, digitization of the prepared tooth surface and converting the data into control signals for computer-assisted milling is requested. In this regard, computer-aided design and computer-aided manufacturing (CAD/CAM) technology in dentistry has encountered numerous problems, because the shapes of prepared teeth and dental restorations cannot be described with regular geometric methods because of their unlimited number of degrees of freedom. Therefore, when using current CAD/CAM technology, data acquisition has to be performed with digital mechanical scanning of the cast parts or by point-based optical systems.5-9 High-speed data acquisition with the aid of complex free-form surface geometry has so far been an unsolved problem. In addition, problems arise in the generation of cusVOLUME 80 NUMBER 3

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tomized occlusal surfaces. Some techniques, with varying amounts of effort, enable the creation of occlusal surfaces by transferring digitized data obtained from measurements of a reference denture or from recordings of mandibular joint movements, the latter being a time-consuming process with considerable variations in precision.10-16 The purpose of this article is to present a new CAD/CAM process that has been developed for the fabrication of dental restorations.

THE COMET SYSTEM

The COMET system (COordinate MEasuring Technique, Steinbichler Optotechnik GmbH, Neubeuern, Germany) described herein allows the generation of a 3-dimensional data record for each superstructure, with or without the use of a wax pattern.17 Optical, full-surface, high-speed digitization allows for model abutment surfaces and wax patterns of the final restoration to be recorded with speed and precision. This technique provides opportunities for the fabrication of fixed dental prostheses. The complex free-form surfaces of abutments and wax patterns are recorded with CAD to initiate a milling-based manufacturing process for crowns, partial denture structures, or superstructures supported by implants. The COMET system uses a pattern digitization and surface feedback technique,18 which accelerates and simplifies the 3-dimensional representation of tooth shapes while allowing individual customization and correction in the visualized monitor image before milling. The final restoration is then milled or ground from any desired material by an associated milling unit. As in conventional prosthodontics, the COMET system uses stone dies fabricated from impressions. Three steps are involved: (1) digitizing data from the die surface or a wax pattern surface; (2) mathematical processing of data to program the milling machine; and (3) milling of copings, crowns, multiunit restorations, and implant abutments. Three procedural options are currently feasible. 1. An impression is obtained of the prepared abutments in the patient and the master cast poured in diestone. The planned restoration is then waxed and the surface of the completed wax pattern optoelectronically scanned and digitized. After removing the wax pattern from the die, the surfaces of the abutments in the cast are digitized as well. The individual views are linked by special software. Thus, single crowns, inlays, onlays, and FPD frameworks can be made of various metals or metal alloys, ceramics, or resin materials. 2. The prepared abutment surface and contact and occlusal surfaces of the adjacent and opposing teeth on the master model are digitized. A CAD program is used to generate the new crown surface; whereas, the
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Fig. 1. Optical setup for data recording. Sensor consists of white light projector and CCD camera. Object to be measured is moved on rotatable table in front of sensor.

crown interior is computed from the abutment surface data. 3. For the production of custom copings, it is sufficient to digitize the prepared abutment on the master cast. Exterior and interior surfaces of the copings are computed by the software.

Digitizing
The COMET system is characterized by an optical sensor that is capable of capturing between 400,000 and 1 million data points simultaneously, depending on the resolution of the charge-coupler device (CCD) camera used. The sensor permits rapid surface generation of objects and evaluation of the manufactured products. By superimposing an observation light bundle onto a projection light bundle, planes are formed that divide the object. Through lines with equal distances from the optical sensor, the software can compute the 3-dimensional coordinates directly. To do so, a sensor equipped with an integrated white-light projector and CCD camera is used (Fig. 1). This sensor is automatically oriented onto the object, which is fixed onto a rotatable plane table at a point that is about 30 cm in front of the point of intersection of the 2 lens projections. Automatic measurement software determines how many views must be taken to reconstruct the object exactly. The various views are then linked together in the computer to form the tooth or prepared surface. The white-light projector projects a line grid at a prescribed angle onto the object to be measured, and the CCD camera records the resultant pattern. Evaluation of the projected pattern is performed with the phase-shift method,17 and any ambiguities can be eliminated by rotating the grid during measurement. Finally, from the geometric relationships in a triangle, the
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Fig. 2. Triangular measurement principle for recording objects coordinates.

Fig. 4. Point cloud of COMET System.

Fig. 3. Insert enlargement of finish line. Finish line has been clearly identified by sensor without necessity of tracing it on monitor.

object coordinates for each individual pixel are determined (Fig. 2). If the angles a and b and the base b are known, the position of the object point is defined. The base b, namely, the distance between the projected grid point in the projection optics and the pixel in the imaging optics of the video camera, is predefined by the sensor design and thus given. Angle a, which describes the line of observation for the respective object point, is determined by the image location on the video camera, namely, by the pixel coordinates and the midpoint of the imaging lens. Angle b is determined for each individual pixel. Depending on the resolution, 788 581 pixels (standard resolution) or 1024 1024 pixels (enhanced resolution) are available for digitization, corresponding to 400,000 and 1,000,000 measurement points, respectively, per view. Optical properties of the cast surface are important
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for optoelectronic digitization. Surface roughness and transparency are of particular significance. The surfaces to be measured must not be overly smooth to avoid undesirable light reflections. Roughness depth should not be less than the wavelength of the 0.4 to 0.7 m light source and should not exceed the desired precision. Optical digitization enables consecutive, contactfree determination of all 3-dimensional coordinates of the surfaces of wax and abutment patterns. The wax pattern remains on the die for optoelectronic measurements. After completion of this step, the pattern is removed and the die of the prepared abutment measured. In this situation, the system automatically recognizes preparation boundaries without requiring these to be redrawn (Fig. 3). The optical scanning and subsequent digitization permit determination of the 3-dimensional coordinates of points on the surface of an object without making contact, with high scanning density and speed. The point cloud describing the surface can be used directly to generate a CAD model and to describe milling paths (Fig. 4). With the use of surface feedback, modeling errors can be detected and, if necessary, corrected by the CAD system. The process has many advantages. (1) It possesses a high lateral density of measurement points (2) Steps in the object or various independent objects in the measurement space are digitized without ambiguity. By comparison, the usual Moir processes available on the market can only be used to capture contiguous, homogenous surfaces. The rotation of the grid will, in contrast, generate an unambiguous coding of the lines within the space. (3) The sensor provides absolute 3-dimensional coordinates that permit a complete shape description through automatic linking of different digitization views. (4) Despite a small selected base, the sensor transmits precise coordinates, thereby minimizing shadow areas and problems on object undercuts. The smaller
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Fig. 6. Digitized FPD framework in graphic representation.

B
Fig. 5. A. Digitized anterior tooth crown (lateral view). Software program has superimposed wax pattern directly onto abutment die in master cast. Information density is documented by large number of points. B. Digitized anterior tooth crown with milling mount (front view). Fig. 7. Milled occlusal surface of molar as computed by CAD program. Shape of crown can be individually edited and altered on monitor.

the triangulation angle, the fewer are the problems caused by shadowed areas. In the COMET process, the triangulation angle is only 20 degrees; whereas, sensors available up to now have used angles of 30 degrees and greater. (5) Automatic masking excludes uncertain or irrelevant areas from the data recording process. The use of the phase-shift method enables direct recognition of the object surfaces illuminated by the projector, which makes it possible to identify usable areas clearly.

Data processing
The surface of an object to be measured consists of a number of points. Because only a finite number of points can be digitized optoelectronically, a feature of the software computes the nondigitized points and generates a 3-dimensional image of the surface of the object to be measured. Thus, the surfaces of digitized
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wax patterns can be reconstructed as free-form surfaces and represented visually. The pattern of the anchor tooth, also scanned, is linked by the computer to the various views of the wax pattern (Fig. 5, A and B). When manufacturing FPD frameworks, the exterior contours are also generated by digitizing a wax pattern (Fig. 6). To make single crowns, an additional program is available for customization of occlusal surfaces whenever it is useful to do so without a wax pattern (Fig. 7). If no changes to the on-screen CAD design are made, sections comparable to tomograms are automatically laid through the object according to the x-y-z coordinates, and thus shows the contours. This information is necessary for automatic manufacturing (Fig. 8, A through D). For manufacturing copings, the prepared tooth surface is digitized, computed, and shown on the monitor.
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D
Fig. 8. A through D. Horizontal and vertical sections through crown and abutment pattern. Sections, laid within smallest space, compute circumference of crown and perimeter of abutment. All signals to control machining of crowns exterior and interior surfaces are computed by means of these sections.

Coping dimensions are then calculated and the finish line is verified (Fig. 9, A and B).

Milling
Once the milling paths have been computed, the data are transferred to the system coordinates of the milling machine. This milling machine, especially developed for dental applications, is equipped with a multiple-axis, high-speed milling/drilling tool, with
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interchangeable cutters driven by computerized velocity and rotating at a maximum speed of 60,000 rpm. The milling programs enable exact copies of the object to be made with marginal accuracies in the 10 m range. The milling cube measures 120 mm per axis. As previously mentioned, the milling unit allows the generation of various restorations from any material used in restorative dentistry (Fig. 10). Metal or ceramic raw materials come in the form of disks or blocks (blanks)
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A
Fig. 10. Milled FPD framework.

B
Fig. 9. A, Digitized abutment pattern and coping. Contour of coping was generated by CAD program. B, Insert enlargement of crown margin area.

of various widths and are fixed on a mobile platform that is movable in 3 dimensions. Milling takes place in 4 steps: (1) rough milling of outside surfaces for bulk material removal; (2) fine outside milling to finalize the outer contours and surfaces of the restoration; (3) after rotating the workpiece by 180 degrees, rough internal milling; and (4) fine inside milling to produce accurate internal fitting surfaces of restoration. The milling procedure can occur at any time after mathematical processing and can be programmed to run automatically, including overnight.

DISCUSSION
The CAD/CAM technology provides interesting perspectives for the future of reconstructive dentistry as a whole if current problems (outlined in the introduction) are resolved. In regard to the great demand for treatment with fixed dental prostheses, high-precision
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machining is of particular significance, because marginal accuracy and crown margin gaps at the finish line are major factors that determine the quality of fixed prostheses.19-30 Moreover, extension to all processable materials, such as high-performance ceramics, is thereby possible. Abrasive methods continue to allow more exact, indication-specific shape variations and more homogeneous workpieces from a material perspective than casting-related methods. This considerable advantage of milling is gaining significance in light of the increasing demands being made for quality control of dental prostheses.31,32 From a milling standpoint, it is already possible to prepare single crowns and fixed partial dentures from metal or ceramics, which have advantages with respect to stability and offer considerable time savings in their manufacture compared with other methods. Without the risk of underdimensioning, the CAD program can reduce the external contours of crowns and FPD structures to the extent required to construct these individually with veneer ceramic. A more difficult area is that of object measurement and digitizing in regard to precision and/or speed. For example, because an abutment prepared for a crown has any number of degrees of freedom, methods up to now have used mechanical scanning systems or point-based optical systems to obtain a point cloud describing the pattern for surface reconstruction. The most well-known are the Titan system (DCS Research and Development, Raanana, Israel, and DCS Production AG, Allschwil, Switzerland) and the Procera system (Nobel Biocare, Gteborg, Sweden) from the group of systems that use mechanical scanning. Evaluations of the marginal fit of copings and crowns produced with these systems have demonstrated the potential for clinically acceptable results. Experiments
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undertaken with the Titan system yielded a mechanical digitizing accuracy of 3 to 5 m, according to the manufacturer. However, the marginal fit of final restorations ranged from 111 to 270 m.14 Experiments on ceramic crowns produced with the Procera system yielded mean marginal accuracy values of 83 m.33-38 The currently best-known system that uses optical digitizing of prepared tooth surfaces is the Cerec system (Sirona, Bensheim, Germany), which generates an instant optical print and displays it on a monitor as a still, contrast-enhanced image. With the use of a cursor, the marginal contour lines of the reconstruction have to be traced onto this picture, because the optical system can only be used to capture contiguous, homogenous surfaces, there being no feature for rotating the grid. The launch of the improved version, Cerec Mk II, has succeeded in narrowing the marginal gap widths by more than 300 m in some situations. With the milling unit, single-tooth restorations in the form of inlays, onlays, crowns, and veneers can be ground out of ceramic materials.39-49 In comparison, the COMET system uses a combination of strip projection methods with triangulation enabling measurement of the coordinates of all measurement points recorded by a CCD camera not only with high precision but also at high speeds. This improvement in optoelectronics also provides the technical potential for a system able to record the removal of dentin, use digital verification, and monitor through display.50 In addition to pulp-protective preparation, this improvement in optoelectronics will allow geometries to be constructed that further enhance optical recording and subsequent CAD/CAM manufacturing processes. Multiple views of a patterns can be linked and represented in a common coordinate system. The working radius of the optical sensor has been designed with dimensions that permit the measurement of objects of the size of maxillae or mandible model. The COMET system is being developed conceptually in 3 application stages. Stage 1 and 2 applications have already passed successful clinical tests (to be published). In its first application stage, the described technology electronically analyzes any wax pattern produced by a laboratory technician and transfers the data to a milling machine, which in turn will form the final restoration by using any desired material, including proximal and occlusal surfaces. The second stage includes the generation of dental restorations with a CAD program without the need for a wax pattern after digitizing the prepared abutment indirectly from a stone die. The third stage permits direct data acquisition in the oral cavity, and thus eliminates the need for impressions and their inherent inaccuracies. At the current stage of development, intraoral imaging requires approximately 20 seconds, which is still too long to
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achieve accuracies similar to those described for the stage 1 or 2 applications.

SUMMARY
CAD/CAM technology in dentistry continues to progress and is gaining in importance as an alternative to the traditional lost-wax-casting technique. Dental restorations from various solid materials can be generated with high accuracy while involving considerably reduced manual labor and potentially lower costs. This article introduces to the reader a newly developed CAD/CAM process with an improved optical sensor and a data analysis/transfer system that allows for various views of teeth or prepared abutment surfaces to be linked together for an accurate description of their shape and border lines, including areas withdrawn from the direct line of light. The COMET system, which is currently undergoing clinical testing, allows the generation of various types of highly accurate dental restorations (inlays, onlays, crowns, FPDs) from a number of different materials. Different modes of application are possible, from copy milling to the generation of surfaces (including occlusal surfaces) from computer-generated information.
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