MAINJOT

Recent advances in composite

CAD/CAM blocks
Amélie Mainjot, DDS, MS, PhD
Dental Biomaterials Research Unit (d-BRU) and Department of Fixed Prosthodontics
Institute of Dentistry, University of Liège (ULg) and University of Liège Hospital (CHU)
45 Quai G.Kurth, Liège, 4020, Belgium. E-mail: [email protected]

The introduction of composite CAD/

CAM blocks has generated new indi-
rect restorative materials with improved
properties when compared to artisanal,
light-cured composites. There is, how-
ever, some confusion about the different
available products, which is exacerbat-
ed by incomplete information provided
by manufacturers, who sometimes refer
to them as “hybrid ceramics,” while a re-
cent classification has termed them “res-
in-matrix ceramics.”1 Advances made Fig 1 PICNs differ significantly from classic com-
posite materials with dispersed fillers incorporated
in current composite CAD/CAM blocks
by mixing in a monomer mixture, in that a PICN ma-
are associated with: 1) new microstruc- terial is the result of the infiltration of a pre-sintered
tures: classic dispersed filler microstruc- glass-ceramic scaffold with a monomer that is sec-
ture on one side and resin infiltration of ondarily polymerized. This ceramic network forms a
real skeleton, with specific mechanical properties.
a ceramic network (polymer-infiltrated-
ceramic-network or PICN) on the other;
2) new polymerization modes: with high
temperature (HT), or with high temper-
ature/high pressure (HT/HP); 3) new
matrix composition: UDMA as the main
component instead of Bis-GMA; 4) aug-
mented filler content; and 5) more ho-
mogeneous structures with fewer flaws.
Consequently, two classes of CAD/CAM
blocks must be distinguished: those with
dispersed fillers, which are HT polymer-
ized and constitute most of the marketed
products (eg, Lava Ultimate, 3M; Cer-
asmart, GC; Shofu Block HC, Shofu),
Fig 2 Example of fillers that are incorporated by
and PICN materials, which are HT/HP mixing in a monomer mixture, thus producing a dis-
polymerized (Enamic, Vita).2 PICN ma- persed filler composite material.

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terials are the result of the infiltration of PICNs, have shown impressive results
a pre-sintered glass-ceramic scaffold in terms of mechanical properties,3,5-7
with a monomer, which is secondarily as well as low toxicity and monomer re-
polymerized (Fig 1). They differ signifi- lease, compared to light-cured compos-
cantly from all other composite mater- ites.8 Moreover, CAD/CAM composites
ials, which contain dispersed fillers in- exhibit a better machinability than glass-
corporated by mixing (Fig 2). It must be ceramics in terms of milling time, dam-
noted that the term “hybrid ceramic” is age tolerance,7,9-11 and the ability to be
a confusing commercial name, which is milled in very low thicknesses.12 Con-
used for both dispersed filler and PICN sequently, high-performance CAD/CAM
materials. composites, particularly experimen-
The ceramic network of PICN materials tal PICNs, could compete with glass-
constitutes a 3D scaffold of interconnect- ceramics such as lithium-disilicate for
ed (in contrast to dispersed) particles: It bonded partial restorations and poster-
forms a skeleton, which is able to distrib- ior crowns, notably on implants, due to
ute stresses more effectively in all direc- their property of absorbing masticatory
tions and to promote resistance to break- forces.3,13 These materials could be par-
down phenomena.3 This microstructure ticularly apt for the development of mini-
also gives the material a modulus of mally invasive treatment strategies such
elasticity between enamel and dentin, as “no-prep” treatment of worn dentition
while dispersed filler composites show a (Fig 3a to u). Current issues are related
modulus of elasticity lower than dentin.4 to the study of the wear, bonding, and
PICN materials have to be etched prior cytocompatibility properties of the differ-
to bonding, whereas dispersed filler ma- ent varieties of CAD/CAM composites.
terials have to be sandblasted. There is also a crucial need to validate
On the other hand, new polymeriza- the in vitro results of these new products
tion modes used for CAD/CAM blocks, with clinical studies. Finally, manufac-
especially HT and, most of all, HT/HP, turers should provide more complete in-
are shown to significantly increase the formation regarding their product poly-
degree of conversion and to improve merization process, microstructure, and
many material properties. Recent re- composition, which significantly influ-
search outcomes about CAD/CAM com- ence the properties of CAD/CAM ma-
posites, especially about experimental terials.

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c d

Fig 3 (From: Mainjot et al,2 reprinted by permission of SAGE Publications Inc.) “No-prep” pilot clinical
case of worn dentition restored with minimally invasive bonded partial restorations (table tops and palatal
veneers), milled in Enamic (PICN) with the Cerec MC XL machine (Sirona). (a to d) Pre-op clinical situation.
(e) A wax-up simulating the restoration of the tooth tissues is performed on the duplicate of the models after
endodontic retreatments, replacement of amalgams with direct composites, impressions, and analysis of
occlusal relationships.

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g h i

k l

Fig 3 (f) The restorations are simulated in the Cerec system after scanning the models and wax-up, re-
spectively. The restoration design corresponds to tissue loss; there is no preparation of teeth. (g to i) 0.2-mm
thick table top, directly after milling. (j) Enamic restorations on models, after slight occlusal adjustments and
polishing. If there are no important esthetic issues, restorations are not stained, as in the present case. Indeed,
stains are just light-cured composite materials, which are brushed on the restoration surface but which have
poor mechanical (notably in terms of wear) and biological properties compared with the PICN material. All
restorations are bonded in 2 consecutive half-days (no provisional stage in this case) and direct composite is
placed on the buccal faces of the maxillary incisors. (k) Minimal preparations of maxillary incisors and canine
for the realization of buccal veneers in pressed lithium-disilicate glass-ceramic (IPS e.max press). Ceramic
material is preferred for esthetic purposes. Incisal edges of mandibular incisors and canines are restored
with direct composite. (l) Enamic crowns for implants placed on teeth 16, 24, 36, and 46 (Ceramill Motion 2,
Amann Girrbach). These crowns have to be bonded on a titanium abutment.

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o p

q r

Fig 3 (m and n) Final views of treatment, and 9-month follow-up. (o to r) Pre- and post-op views.

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Fig 3u Periapical radiographs of the completed
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