biology

Review
Chairside CAD/CAM Materials: Current Trends of
Clinical Uses
Giulio Marchesi *, Alvise Camurri Piloni , Vanessa Nicolin, Gianluca Turco and Roberto Di Lenarda

Department of Medical, Surgical, and Health Sciences, University of Trieste, 34127 Trieste, Italy;
alvise.camurripiloni@gmail.com (A.C.P.); nicolin@units.it (V.N.); gturco@units.it (G.T.);
rdilenarda@units.it (R.D.L.)
* Correspondence: gmarchesi@units.it

Simple Summary: The interest in chairside Computer-aided design/computer-assisted manufactur-

ing (CAD/CAM) restorations has increased the diversity of the restorative material. The promise of
accurate, esthetic restorations delivered rapidly to the patient has manly benefits for clinicians in
the light of minimally invasive dentistry dictates. New materials have been developed by the indus-
try in order to offer ceramic, composite, and hybrid materials with optimized properties, suitable
mechanical and aesthetic features. However, this comes at the expense of making the application
more complicated. This article is aimed at providing an overview regarding the main advantages
and disadvantages of the CAD/CAM chairside materials.

Abstract: Restorative materials are experiencing an extensive upgrade thanks to the use of chairside
Computer-aided design/computer-assisted manufacturing (CAD/CAM) restorations. Therefore, due
to the variety offered in the market, choosing the best material could be puzzling for the practitioner.



The clinical outcome of the restoration is influenced mainly by the material and its handling than


by the fabrication process (i.e., CAD/CAM). Information on the restorative materials performances
Citation: Marchesi, G.; Camurri can be difficult to gather and compare. The aim of this article is to provide an overview of chairside
Piloni, A.; Nicolin, V.; Turco, G.; CAD/CAM materials, their classification, and clinically relevant aspects that enable the reader to
Di Lenarda, R. Chairside CAD/CAM select the most appropriate material for predictable success.
Materials: Current Trends of Clinical
Uses. Biology 2021, 10, 1170. https:// Keywords: CAD/CAM; chairside; resin; ceramic; block; hybrid ceramic
doi.org/10.3390/biology10111170

Academic Editor: Zipei Zhang

1. Introduction
Received: 21 September 2021
Accepted: 9 November 2021 In dentistry, the synergic effect of the introduction of digital technologies on one side,
Published: 12 November 2021 and the evolution of materials with suitable mechanical and aesthetic features on the other
side, has led to a profound change in prosthetic restorative dentistry.
Publisher’s Note: MDPI stays neutral More and more colleagues are using Computer-aided design/computer-assisted man-
with regard to jurisdictional claims in ufacturing (CAD/CAM) chairside technology, and manufacturers are increasingly expand-
published maps and institutional affil- ing their material offering with the aim of reducing armchair operating times while having
iations. high standards of precision and aesthetics.
CAD/CAM technology is a digital workflow that requires three steps:
1. Impression with software associated with an over-the-counter scanner or intrao-
ral camera;
Copyright: © 2021 by the authors. 2. Digital data processing using a program to delimit dental preparation, occlusion, and
Licensee MDPI, Basel, Switzerland. restoration contacts;
This article is an open access article 3. Restoration production is designed using subtractive manufacturing processes, which
distributed under the terms and require milling the desired restoration starting from a block of material.
conditions of the Creative Commons
The first generation of CAD/CAM machinery appeared in the market in the 1980s,
Attribution (CC BY) license (https://
and it was only able to design and produce ceramic indents. Nowadays, the main chairside
creativecommons.org/licenses/by/
systems (e.g., PlanScan, Carestream, or CEREC) are using a “full-digital workflow”, which
4.0/).

Biology 2021, 10, 1170. https://doi.org/10.3390/biology10111170 https://www.mdpi.com/journal/biology

Biology 2021, 10, 1170 2 of 11

can produce different prosthetic devices such as inlays/onlays, veneers, endo-crowns,

bridge crowns, and implant abutments, to name some [1,2].
For the first 15 years or so, the feldspathic ceramics (Vita Mark I, Vita Zahnfabrick, Bad
Sackingen, Germany) was the only one available for CEREC. Feldspathic ceramics were
modified in order to be used for small occlusal inlays. Then, the need for superior mechanical
properties induced the development of new materials that could extend the indications of
CAD/CAM restorations (onlays, crown). Examples of these microstructures are leucite, lithium
disilicate glass-ceramics, and zirconia. Some of the aforementioned materials could be found
in a pre-crystallized stage in order to guarantee rapid milling. Nevertheless, a post-milling
crystallization is mandatory to access the final shade and the proper mechanical strength. In
chairside technology, the use of monolithic materials is preferred. Indeed, digital anatomical
modeling allows having minimal thicknesses avoiding the main mechanical complication of
“bi-layer” systems (i.e., the chipping of coating ceramics) [3].
Recently CAD/CAM resin composite and hybrid ceramic materials have been in-
troduced. Benefits are easy intraoral repair with light-cured restoratives and a faster
production rate since firing is not needed [4].
CAD/CAM materials for chairside production can be classified according to the
composition of the materials (Table 1). Each category offers mechanical and physical
features and unique indications for specific clinical applications. The CAD/CAM chairside
system represents only the production process, while the clinical outcome of the restoration
is mainly influenced by the type of material chosen to carry out the restoration and the way
in which it is managed. (Table 2). The purpose of this article is to offer a quick, summary
overview of these constantly evolving materials, which today propose diverse restoration
methods to the clinician.

Table 1. Summary of the products presented in the study.

Categories Description Commercial Name Manufacturer

Vitablocs Mark II Vita Zahnfabrik
CEREC Blocs Dentsply Sirona
Feldspathic ceramic
Vitablocs Triluxe Vita Zahnfabrik
Vitablocs RealLife Vita Zahnfabrik
Leucite-reinforced IPS Empress CAD Ivoclar Vivadent
Adhesive ceramic ceramic Initial LRF Block GC
IPS e.max CAD Ivoclar Vivadent
Lithium disilicate Amber Mill HASS
Tessera Dentsply Sirona
Lithium silicate zirconia
Celtra Duo Dentsply Sirona
reinforced
Paradigm MZ100 3M
Brilliant Crios Coltene/Whaledent
Composite resin Bis-GMA composite Grandio Blocks Voco
LuxaCam composite DMG Fabrik
Tetric CAD Ivoclar Vivadent
Lava Ultimate 3M
Cerasmart GC
Shofu Block HC Shofu
Nanoceramic
Hybrid ceramic Cerasmart GC America
Mazic Duro Vericom co.
Avencia Block Kuraray Noritake Dental
PICN Enamic Vita Zahnfabrik
Biology 2021, 10, 1170 3 of 11

Table 1. Cont.

Categories Description Commercial Name Manufacturer

CEREC Zirconia e.max Dentsply Sirona
ZirCAD Ivoclar Vivadent
Zirconia Tetragonal zirconia Katana Zirconia Block Kuraray Noritake Dental
Mazic Zir Vericom co.
LuxaCam Zircon HT Plus DMG Fabrik
TelioCAD Ivoclar Vivadent
Cad Temp Vita Zahnfabrick
Resin PMMA Mazic Pro Vericom co.
LuxaCam PMMA DMG Fabrik
ArtBlock Temp MERZ
Coltene Whaledent (Alstatten, Switzerland); Dentsply Sirona (Bensheim, Germany); DMG Fabrik (Hamburg, Germany); GC (Tokyo, Japan);
GC America (Alsip IL, USA); HASS (Gangwon-do, Korea); Ivoclar Vivadent (Schaan, Liechtenstein); Kuraray Noritake Dental (Tokyo,
Japan); MERZ Lütjenburg, Germany); Shofu (Kyoto, Japan);Vericom co. (Gangwon-do, Korea); Vita Zahnfabrick (Bad Sackingen, Germany);
Voco (Cuxhaven, Germany); (3M Oral Care (St. Paul, Mn, USA).

Table 2. Features and indications for the use of the chairside CAD/CAM materials.

Feldspathic and Lithium Disilicate

Material/ Leucite- and Zirconia-
Resin Composite Hybrid Ceramic Zirconia Resin
Characteristics Reinforced Reinforced
Ceramic Lithium Silicates
Ceramic
nanoparticles in
Glassy matrix + Glassy matrix + Inorganic fillers resin matrix
Microstructure Polycrystalline Resin polymers
Crystalline loads Crystalline loads in resin matrix Ceramic Network
infiltrate of
polymer
Optic properties Excellent Good Medium Good Good Weak
Bonding aptitude Excellent Excellent Excellent Excellent Medium/weak Excellent
Clinical experience
Clinical Rapid milling, Rapid milling, Rapid milling,
(e.max), Esthetic,
experience, Direct composite Direct composite Direct composite
Mechanical Mechanical
Advantages Esthetics, Wide reparation, reparation, reparation,
strength, Wide strength
range shade, Mechanical Mechanical Mechanical
range shade,
Translucidity properties properties properties
Translucidity
Less than
Disadvantages Relative fragility conventional Optical properties Optical properties Translucidity Esthetic
ceramic
Temporary
Veneer, inlay, Veneer, inlay, onlay, Veneer, inlay, Veneer, inlay, restorations:
Indications onlay, overlay, overlay, crown, onlay, overlay, onlay, overlay, Crown, bridge, Veneer, inlay,
for the use crown, bridge bridge anterior and crown, bridge of crown (except abutment onlay, overlay,
anterior posterior, abutment small extent Lava Ultimate) crown, bridge of
small extent

2. Materials and Methods

2.1. Adhesive Ceramics
Glass-ceramics materials were the first to be developed for CAD/CAM systems. They
are characterized by a significant amount of glass components, which makes them among
the most translucent and aesthetic materials, providing a “chameleon” effect that allows
the restoration to mimic the color of the existing tooth. The first material used with
chairside was Vita Mark I feldspathic pottery in 1985, and since today, this type of class of
ceramic materials has had a remarkable increase in bending force resistance from 125 to
375 MPa [5,6].
Biology 2021, 10, 1170 4 of 11

2.2. Feldspathic and Leucite-Reinforced Ceramics

Today two types of ceramics of this category are basically available on the market. One
group consists of feldspathic ceramics (Vitablocs Mark II, Vita Zahnfabrik; Bad Sackingen,
Germany, and CEREC blocks, (Dentsply Sirona; Bensheim, Germany); the other group
is composed of leucite-reinforced ceramic (IPS Empress CAD, Ivoclar Vivadent; Schaan,
Liechtenstein; LRF block, GC). Feldspathic and leucite-reinforced ceramics present a preva-
lence of the glass phase (55% to 70%), which makes them among the most translucent and
most aesthetic ceramic materials [7].
Currently, it is indicated with regard to these materials to use them for partial adhesive
restorations such as veneer and onlay, overlay. For traditional restorations such as bridges,
it is indicated up to 3 elements in the front area and individually up to the level of the
second premolar [8].
These materials are available as monochrome blocks or as polychromatic blocks
(Vitablocs Triluxe forte and Vitablocs RealLife, Vita ZahnFabrik) and possess translu-
cency and a chromatic range that simulates one of the native dental tissues: dentine and
enamel [9]. Since adhesive ceramic materials have been available for more than 25 years,
the results and observations of several long-term clinical trials are nowadays available. The
average survival rate for inlay and onlay leucite restorations in the posterior area is 96.7%
after 9 years [10].
A recent meta-analysis estimated survival rate between 92% and 95% for 5811 adhesive
restorations (onlays, overlays) with feldspar ceramics at 5 years and 91% at 10 years for
2154 restorations [11]. No significant difference in the survival rates has been reported
based on the number of dental surfaces restored [12].

2.3. Lithium Disilicates and Zirconia-Reinforced Lithium Silicates

Glass ceramics with improved resistance properties represented a paramount devel-
opment in the field of fixed prostheses. IPS e.max CAD (Ivoclar Vivadent) was introduced
in 2006 as a lithium disilicate with a bending resistance over 350 MPa and significantly
greater fracture resistance than previous adhesive glass ceramics [13]. It is characterized by
a glass matrix embedding small needle-shaped crystals with dimensions around 0.2–1 µm.
In the CAD/CAM method, lithium disilicate is supplied only in partially crystallized form
(purple color), in which the block consists of lithium metasilicate (Li2SiO3) and for the
rest by the crystallized nucleus of lithium disilicate (Li2Si2O5) that provide a “soft” state
(bending resistance of 140 MPa). This makes the block easier to mill while reducing the
wear of the milling cutters [13]. Post milling, the material must be subjected to a two-stage
firing cycle in a ceramic furnace for 10 min and involves the complete crystallization and
the transformation of the metasilicate into lithium disilicate with an increase in bending
resistance over 440 MPa [14]. The crystallization kinetics and microstructure of the disili-
cate are significantly influenced by thermal and mechanical processes. According to some
studies, heating the material for longer times (14 min at 840 ◦ C) leads to improving its
mechanical features, increasing its hardness its elastic modulus [15]. Lithium disilicate
is indicated for partial adhesive restorations such as veneer and onlay, overlay, and for
crown restoration. Several studies have shown that the performance of monolithic crowns
in lithium disilicate after 8 years has shown survival rates of up to 94.8% and 10 years at
96.7%; reducing significantly the incidence of complications due to chipping [16–19]. A
recent clinical study based on monolithic lithium disilicate crowns applied on the chairside
showed a survival rate of 83.5% and a complication-free rate of 71.0% after 10 years [20].
As for the use of bridges, they can be used up to 3 elements in the posterior sector, and
according to a clinical trial at 10 years, there would be no difference in terms of survival
between this material and ceramic-metal ones [21].
Lithium disilicate has also demonstrated the possibility of being used as a single
crown for implant restorations and as a single hybrid implant abutment supported by
titanium tibase [22,23].
Biology 2021, 10, 1170 5 of 11

Another machinable dental glass-ceramic block composed of lithium disilicate is the

Amber®Mill (HASS, Gangwon-do, Korea), which exhibits a flexural strength of around
300 MPa. It is indicated for table tops, veneers, inlays/onlays, and crowns or can be used
for anterior and premolar 3-unit bridges.
This material also allows being used adhesively for veneer, overlay, and onlay. In
the posterior sectors, a minimum thickness of 1.5 mm is generally recommended to have
a proper distribution of stresses [24]. The current tendency in tooth wear treatment is to
avoid any tooth tissue preparation (“No prep”) using very low thickness prostheses (table
tops) with minimum thicknesses that range from 0.5 to 1 mm [25,26].
A new generation of high-strength CAD/CAM ceramics introduced since 2012 is
represented by zirconia reformed lithium silicate (ZLS) in which the glass matrix is rein-
forced with lithium silicate crystals, 4–8 times smaller than those of lithium disilicate, to
which a tetragonal zirconia component (10% by weight) is added in order to improve its
mechanical properties [27].
At present, this type of glass ceramic is supplied in two different ways from manufac-
turers in presintered blocks (Vita Suprinity PC, Vita Zahn Fabrick) or in already sintered
blocks (Celtra Duo, Dentsply Sirona). Such ceramic glass materials are suitable for the
restoration of individual adhesives (veneer, onlay, overlay) in the anterior and posterior
zone. According to some authors, these materials would be more resistant to fracture,
easier to be milled (especially the presintered systems), and easier to be polished to the
armchair [28,29]. The sintered block (Celtra Duo) comes in an already fully crystallized
state that can be polished by hand or have a further heat treatment before delivery. The
hand polishing of the restoration improves the bending resistance up to 210 MPa, while
the heat treatment allows obtaining a further improvement up to 370 MPa. Currently,
only a few clinical works are available in the literature, but the data show that Celtra
Duo in adhesive restorations in the anterior teeth, premolar, and molar (92 restorations in
71 patients) exhibit a 3 years survival rate of 99% [30].
In 2021 Dentsply Sirona is introducing a new advanced lithium disilicate CAD/CAM
blocks (Tessera, Dentsply Sirona). This ceramic is characterized primarily by the fact that it
can be fired exceptionally quickly. The glaze firing takes only four and a half minutes, and
the fast firing time is made possible by the new composition of the ceramic composed of
disilicate of lithium and virgilite, a lithium aluminum silicate. It is indicated in the anterior
and posterior region for crown, inlay, onlay, and veneer.

2.4. Resin Composite Materials

Although introduced in the 2000 s, CAD/CAM resin composite materials have become
very popular in chairside. The Paradigm MZ100 (3M Oral Care, Seefeld, Germany) was the
first resin composite introduced in the market in CAD/CAM blocks with the possibility of
different dyes and with a percentage of filler (silica zirconia 0.6 µm in diameter) up to 85%
by weight. The bending strength reported for the Paradigm MZ100 is 157 MPa, similar to
the bending resistance of feldspathic ceramic materials [31].
According to some authors, this material, if adhesively cemented, would have a proper
mechanical resistance even at reduced thicknesses counterpoised by a limited resistance
to abrasion [32,33].
Starting from 2016, the Brilliant Crios (Coltene/Whaledent; Coltène, Alstatten, Switzer-
land) this material is a reinforced composite containing amorphous silica particles (<20 nm)
and glassy ceramic barium particles (<1.0 µm) embedded in a cross-linked methacrylate
matrix. The manufacturer reports a filling of 70.7% by weight and a filling of 51.5% by
volume, which translates with a bending resistance of 198 MPa and an elastic modulus
of 10.3 GPa. The elastic modulus, similar to that of dentine, is suggested to minimize the
concentration of stress in the restoration and avoid fractures. The indications for these
materials are those for onlays, overlays. In the literature, there is minimal clinical research
on CAD/CAM composites, the average survival rate at 10 years is 95% [34].
Biology 2021, 10, 1170 6 of 11

Tetric CAD (Ivoclar Vivadent, Liechtenstein) is an aesthetic composite with resin

matrix composed of Bis-GMA, Bis-EMA, TEGDMA, UDMA nano-filled 70% with barium
glass and silicon dioxide. According to the data provided by the production company, the
bending resistance is 273.8 MPa, an elastic modulus of 10.2 GPa.
LuxaCam Composite (DMG, Hamburg, Germany) consists of a composite matrix of
special polymers in which silicate glass filling substances are embedded. The ratio between
the two materials is optimized so that the mechanical values (164 MPa flexural strength
and 10.1 GPa elasticity module) are as close as possible to the ones exhibited by the natural
tooth. Following manufacturer’s indications, these materials are suitable for table tops,
inlays, onlays, veneers, partial crowns, crowns, and bridges (also multi-unit, up to three
bridge units).
Grandio Blocks (VOCO GmbH, Germany) is a highly filled (86%) CAD/CAM restora-
tive material that is based on a nanoceramic hybrid technology. It has a flexural strength of
250–290 MPa and 15.5 GPa elastic modulus with a coefficient of thermal expansion similar
to the dentin and enamel.

2.5. Hybrid Ceramics

Hybrid ceramics are a new category of CAD/CAM chairside materials that have
been designed to take advantage of the reduced fragility and increased fracture resistance
typical of composite resins combined with the unique aesthetic characteristics of the ceramic
materials. At present, they are divided into two different classes: nanoceramic resin blocks
that are made industrially by high-temperature and high-pressure processes, in which the
composite resin (generally present Bis-GMA, UDMA, UTMA, and Bis-EMA) is coupled
with a ceramic filler (up to 80% by weight) and polymer-infiltrated-ceramic network (PICN)
blocks in which the ceramic structure at (86% by weight) is industrially infiltrated by
composite resin (14% by weight) [35].
Hybrid ceramics have proved to be easier to be milled and without the need for addi-
tional thermal cycles. Moreover, they exhibit high bending resistance and the possibility
of being used even at reduced thicknesses [36]. With regard to nanoceramic materials,
the first to be introduced on the market is Lava Ultimate (3M Ultimate, 3M Oral Care),
which contains particles of silica (20 nm) and zirconia (4 to 11 nm) up to 80% in weight.
According to the manufacturer, an advantage for nanoceramic material over CAD/CAM
composite blocks is the ability to maintain a high shine surface finish. The manufacturer
reports a bending force resistance of about 200 MPa [37]. Nanoceramic blocks are used for
occlusal coverage or inlays/onlays in the posterior zone, by the way, not for the realization
of crowns [38]. At the moment, we only have a 5-year clinical study showing that this
adhesively cemented CAD/CAM nanoceramic material for overlays and onlays has similar
behavior to that of feldspathic ceramics in the posterior sector [39].
Another nanoceramic on the market is Cerasmart (GC America, Alsip IL, USA), which
is a block characterized by an organic resin matrix containing particles of silica filler and
barium glass up to 71% by weight. The resistance to bending force is reported for Cerasmart
of 230 MPa, and this material is indicated for the restoration of a single tooth (cuspidal
coatings, indents, and crowns). Recent clinical work demonstrates its use with suitable
results for two-year inlays and onlays compared to lithium disilicate [40].
On the market, there are numerous other materials belonging to this category, includ-
ing Block HC (Shofu, Kyoto, Japan) characterized by a resinous matrix based on UDMA
and TEGDMA filled 68% with silica and zirconia silicates. The resistance to bending force
reported by the manufacturer is 170–190 MPa and an elastic modulus of 7.8 GPa.
The Katana Avencia Block (Kuraray, Noritake, Dental) is a hybrid ceramic consisting
of UDMA, and methacrylate polymers filled 62% with silica oxide and aluminum with
bending force resistance of 230 MPa and compression force resistance of about 680 MPa
following manufacturer data.
From experience obtained with In-Ceram system infiltrated glass ceramics, in 2013
Vita Zahnfabrik introduced the Enamic, which can be considered a real new type of
Biology 2021, 10, 1170 7 of 11

hybrid ceramic. This type of material is called PICN (polymer-infiltrated-ceramic network),

in which the ceramic structure reinforced with leucite and zirconia (86% by weight) is
infiltrated by a resin base (UDMA, TEGDMA) (14% by weight).
The mechanical properties of the material are at an intermediate level between that
of adhesive ceramics and that of highly filled composites. It has an elastic modulus of
around 30 GPa [6]. The ceramic component improves wear resistance; however, it can
make the material more fragile and susceptible to fracture. The polymer mesh improves
the fracture resistance of the material thanks to its ability to undergo plastic deformation.
This material is suitable for inlays, onlays, and crowns, and the manufacturer claims a
bending resistance of about 130 MPa [41]. The manual final polishing of this material is
fast and allows to obtain surfaces with a polishing comparable to the ceramic materials
one. The final modification is limited to the use of supercolors and cold glazing. This type
of material must be cemented in an adhesive way to the tooth structure for both overlays
and crowns.
Clinical trials on these materials are unfortunately limited due to their recent introduc-
tion on the market; at the moment, only a few 3-year clinical works are showing a survival
rate of 97.4% for inlays and 95.6% for overlays [42].
Mazic Duro (Vericom, co., Gangwon-do, Korea) is a radiopaque hybrid ceramic
intended for use in dental CAD/CAM milling procedures. The polymeric matrix consists of
a high degree of cross-linking monomer. The inorganic fillers are barium, aluminiumsilicate,
silicon dioxide, and zirconia. The total content of inorganic fillers is approximately 80%,
and particle size is between 0.01 and 1 mm.

2.6. Zirconia
Zirconia is a heterogeneous polycrystalline ceramic and is characterized by excellent
mechanical properties (flexural strength 500–1200 MPa, elastic modulus of 210 GPa) and
suitable aesthetic properties but is not susceptible to traditional acid bite procedures [43,44].
Both in vivo and in vitro, it has excellent biocompatibility, reduced plaque retention com-
pared to titanium, and has the lowest rate of wear against the antagonist among the various
integral ceramics [45].
From a chemical-physical point of view, zirconia is a metal oxide characterized by
polymorphism and allotropy and is present in nature in 3 different crystalline structures: cu-
bic (from the melting point to 2680 at 2370 ◦ C), tetragonal (2370 to 1170 ◦ C), and monocline
(1170 ◦ C at room temperature).
Zirconia is mainly used in both tetragonal and cubic phases. At room temperature after
post-sinter cooling, zirconia crystals may experience irreversible spontaneous transforma-
tion to the monocline form with an increase in crystal volume of 4–5% and the generation of
high compressive stress within the material that is called phase transformation toughening
(PTT). PTT is exploited in prosthetics since zirconia has the possibility to block or at least
slow down the progression of micro-cracks and fractures within the material, transforming
from the tetragonal to the monocline phase [46]. At the industrial level, zirconia is stabi-
lized with oxides such as yttrium, magnesium, cerium, and lanthanum, and these oxides
can be lost as a result of trauma, superficial modifications (occlusal adjustments, finishing),
and aging of the material. Zirconia is an opaque restoration material with aesthetic and
less captivating properties than glass ceramics, suitable for masking dyschromic stumps or
stumps with metal restorations. Recently, 30–35% cubic zirconia with high translucency
has been introduced. Beyond the improved optical properties, however, it has significantly
lower mechanical resistance values with residence to the bending between 500 and 900 MPa
due to the size of cubic granules that are larger than those tetragonal [47,48].
The zirconia chairside provides for the processing only soft-machining or the use
of presintered zirconia that makes it more easily breakable, reducing processing times,
the wear of the machinery creating negligible internal porosity [49]. On the other hand,
this procedure provides for zirconia to be milled with an oversizing of 25% of the final
volume, which will then have to be compensated during the sintering phase. This material
Biology 2021, 10, 1170 8 of 11

is indicated for the manufacture of single crowns, implant abutment, and it is possible
with chairside blocks to create bridges up to three elements. The minimum thickness of
monolithic restorations is 0.5 mm [50].
The first block introduced on the market in 2016 was Cerec zirconia (Dentsply Sirona),
characterized by multilayer pre-colored zirconia blocks. In the same period, an induction
furnace for sintering (SpeedFire, Dentsply Sirona; Bensheim, Germany) was introduced,
which significantly reduced the sintering time to less than 20 min, thus allowing the design,
processing, and delivery of the restoration in a single appointment. Bending resistance
and fracture resistance is at least three times higher than that of ceramic adhesive glass
materials. The resistance to the fracture force reported for zirconia is more than 1000 MPa.
The high strength of zirconia allows both traditional cementation and adhesive cementation,
although there is no evidence in the literature of which is the cementation method that
guarantees the greater resistance to retention. Being a new category of CAD/CAM chairside
materials, formulations with greater translucency and sufficient strength to be cemented
rather than glued with adhesive techniques are being developed. Newer materials for
CAD/CAM application such as Katana Zirconia (Kuraray Noritake Dental; Tokyo, Japan),
Mazic Zir HT, Mazic Zir Ultra HT (Varicom co., Korea), LuxaCam Zircon HT Plus (DMG,
Hamburg, Germany), IPS e.max and zirCAD (Ivoclar Vivadent), were introduced with
better translucency and aesthetic result. However, to date, there is limited clinical evidence
regarding these materials.

2.7. Resins
Interim prostheses represent a paramount part of the fixed prosthodontic treat-
ment and are usually made from conventional resin materials such as poly(methyl),
poly(ethylene), and bis-acrylate composite resins. Polymethyl methacrylate (PMMA)-
based polymers are pre-polymerized without incorporation of fillers and stored until usage.
Their mechanical properties depend mainly on their chemical composition and their cross-
linked structure. Structural properties may be better than the ones of the conventional
resins, such as low mechanical stability due to porosity, absence of voids, and lower poly-
merization shrinkage that occur during mixing, packing, and setting. Interim prostheses
can be made in a shorter chairside time. These PMMA-based polymers could also be used
for long-term interim prostheses. The most common are:
LuxaCam PMMA DMG, Hamburg, Germany) is a copolymer based on PMMA >99%.
ArtBlock Temp (MERZ Dental GmbH, Germany) is composed of highly cross-linked
interpenetrated OMP-N (Organic Modified Polymer Network) without inorganic fillers,
has a flexural strength of more than 90 MPa and an elastic modulus of 2680 MPa.
TelioCAD (Ivoclar Vivadent, Schaan, Liechtenstein) is composed of PMMA and is
used to produce full-contour single-tooth and multiple-unit temporary restorations using
CAD/CAM technology. It has a flexural strength of 130 MPa and a flexural modulus of
3200 MPa, a Vickers hardness of 190 HV, and a water absorption less than 28 µg/mm3 .
CAD Temp (Vita Zahnfabrik, Germany) is a particular fiber-free, homogeneous, high-
molecular, and cross-linked acrylate polymer with a microscopic filler named MRP (micro-
filler reinforced polyacrylic). In this material, developed by VITA, inorganic microfillers are
polymerized into the network and a completely homogeneous, methyl methacrylate-free
material, which exhibits superior material quality and outstanding abrasion resistance. It
has a flexural strength higher than 80 MPa and an elastic modulus of 2800 MPa.
Mazic Pro (Vericom co., Korea) is a provisional hybrid composite for CAD/CAM
restoration containing 10 nm ceramic filler and pearl-type polymer with flexural strength
170 MPa and surface hardness equal to 25 HV.

3. Conclusions
Due to the various materials available nowadays, the term chairside CAD/CAM
restoration is not fully explicative of the actual restorations. Understanding the material
Biology 2021, 10, 1170 9 of 11

features, their pros and cons, and how they have to be handled will play a paramount role
in choosing the specific material for a particular clinical situation.
The outcome of the clinical treatment is strictly related to the attention paid to choosing
the unique properties and features of the various categories of CAD/CAM materials. The
success of chairside restorations depends on several factors such as material selection,
restoration design, occlusion, and cementation.
At the moment the chairside CAD/CAM materials are recent and there are only
limited evidence and narrow clinical experience of such material use. Some material
offered few years ago have been withdrawn of the market. The clinician must choose the
material best suited to his works habits.

Author Contributions: Conceptualization, G.M. and A.C.P.; Methodology, G.M.; Investigation,

A.C.P., G.M., G.T. and V.N., Writing, G.M., A.C.P. and G.T., Writing-review and editing G.M., G.T.,
V.N. and R.D.L. All authors have read and agreed to the published version of the manuscript.
Funding: The study was funded by grants from MICROGRANT D70 University of Trieste (Italy):
Microgrant 16376 to Giulio Marchesi.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The study did not report any data.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Mörmann, W.H. The origin of the CEREC method: A personal review of the first 5 years. Int. J. Comput. Dent. 2004, 7, 11–24.
[PubMed]
2. Vichi, A.; Sedda, M.; Del Siena, F.; Louca, C.; Ferrari, M. Flexural resistance of Cerec CAD/CAM system ceramic blocks. Part 1:
Chairside materials. Am. J. Dent. 2013, 26, 255–259. [PubMed]
3. Zarone, F.; Di Mauro, M.I.; Ausiello, P.; Ruggiero, G.; Sorrentino, R. Current status on lithium disilicate and zirconia: A narrative
review. BMC Oral Health 2019, 19, 134. [CrossRef] [PubMed]
4. De Kuijper, M.C.F.M.; Gresnigt, M.; Kerdijk, W.; Cune, M. Shear bond strength of two composite resin cements to multiphase
composite resin after different surface treatments and two glass-ceramics. Int. J. Esthet. Dent. 2019, 14, 40–50. [PubMed]
5. Li, R.W.; Chow, T.W.; Matinlinna, J.P. Ceramic dental biomaterials and CAD/CAM technology: State of the art. J. Prosthodont. Res.
2014, 58, 208–216. [CrossRef] [PubMed]
6. Da Silva, L.H.; De Lima, R.; Miranda, R.B.; Favero, S.S.; Lohbauer, U.; Cesar, P.F. Dental ceramics: A review of new materials and
processing methods. Braz. Oral Res. 2017, 31, e58. [CrossRef] [PubMed]
7. Vichi, A.; Carrabba, M.; Paravina, R.; Ferrari, M. Translucency of ceramic materials for CEREC CAD/CAM system. J. Esthet.
Restor. Dent. 2014, 26, 224–231. [CrossRef] [PubMed]
8. Conrad, H.J.; Seong, W.J.; Pesun, I.J. Current ceramic materials and systematic with clinical recommendations: A systematic
review. J. Prosthet. Dent. 2007, 98, 389–404. [CrossRef]
9. Lambert, H.; Durand Jacquot, B.; Fages, M. Dental biomaterials for chairside CAD/CAM: State of the art. J. Adv. Prosthodont.
2017, 9, 486–495. [CrossRef]
10. Schulte, A.G.; Vöckler, A.; Reinhardt, R. Longevity of ceramic inlays and onlays luted with a solely light-curing composite resin.
J. Dent. 2005, 33, 433–442. [CrossRef]
11. Morimoto, S.; Rebello de Sampaio, F.B.W.; Braga, M.M.; Sesma, N.; Özcan, M. Survival rate of resin and ceramic inlays, onlays
and overlays: A systematic review and meta-analysis. J. Dent. Res. 2016, 95, 985–994. [CrossRef]
12. 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.
13. Chen, Y.M.; Smales, R.J.; Yip, K.H.; Sung, W.J. Translucency and biaxial flexural strength of four ceramic core materials. Dent.
Mater. 2008, 24, 1506–1511. [CrossRef] [PubMed]
14. Tysowsky, G.W. The science behind lithium disilicate: A metal-free alternative. Dent. Today 2009, 28, 112–113.
15. Lien, W.; Roberts, H.W.; Platt, J.A.; Vandewalle, K.S.; Hill, T.J.; Chu, T.M. Microstructural evolution and physical behaviour of a
lithium disilicate glass-ceramic. Dent. Mater. 2015, 31, 928–940. [CrossRef]
16. Gehrt, M.; Wolfart, S.; Rafai, N.; Reich, S.; Edelhoff, D. Clinical results of lithium disilicated crown after up to 9 years of service.
Clin. Oral Investig. 2013, 17, 275–284. [CrossRef]
17. Pieger, S.; Salman, A.; Bidra, A.S. Clinical outcomes of lithium disilicate single crowns and partial fixed dental prostheses: A
systematic review. J. Prosthet. Dent. 2014, 112, 22–30. [CrossRef] [PubMed]
Biology 2021, 10, 1170 10 of 11

18. Fabbri, G.; Zarone, F.; Dellificorelli, G.; Cannistraro, G.; De Lorenzi, M.; Mosca, A.; Sorrentino, R. Clinical evaluation of 860
anterior and posterior lithium disilicate restorations: Retrospective study with a mean follow-up of 3 years and a maximum
observational period of 6 years. Int. J. Periodontics Restor. Dent. 2014, 34, 165–177. [CrossRef] [PubMed]
19. Sailer, I.; Makarov, N.A.; Thoma, D.S.; Zwahlen, M.; Pjetursson, B.E. All-ceramic of metal ceramic tooth supported fixed dental
prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs). Dent. Mater. 2015,
31, 603–623. [CrossRef] [PubMed]
20. Rauch, A.; Reich, S.; Dalchau, L.; Schierz, O. Clinical survival of chair-side generated monolithic lithium disilicate crowns:
10-years results. Clin. Oral Investig. 2018, 22, 1763–1769. [CrossRef] [PubMed]
21. Kern, M.; Sasse, M.; Wolfart, S. Ten-year outcome of three-unit fixed dental prostheses made form monolithic lithium disilicate
ceramic. J. Am. Dent. Assoc. 2012, 143, 234–240. [CrossRef] [PubMed]
22. Cooper, L.F.; Stanford, C.; Feine, J.; McGuire, M. Prospective assessment of CAD/CAM zirconia abutment and lithium disilicate
crown restorations: 2.4 year results. J. Prosth. Dent. 2016, 116, 33–39. [CrossRef] [PubMed]
23. Pitta, J.; Burkhardt, F.; Mekki, M.; Fehmer, V.; Mojon, P.; Sailer, I. Effect of airborne-particle abrasion of a titanium base abutment
on the stability of the bonded interface and retention forces of crowns after artificial aging. J. Prosthet. Dent. 2020, 26, 214–221.
[CrossRef] [PubMed]
24. Politano, G.; Van Meerbeek, B.; Peumans, M. Non-retentive bonded ceramic partial crowns: Concept and simplified protocol for
long-lasting dental restorations. J. Adhes. Dent. 2018, 20, 495–510. [PubMed]
25. Schlichting, L.H.; Maia, H.P.; Baratieri, L.N.; Magne, P. Novel-design ultra thin CAD/CAM composite resin and occlusal veneer
for the treatment of severe dental erosion. J. Prosthet. Dent. 2011, 105, 217–226. [CrossRef]
26. Angerame, D.; De Biasi, M.; Agostinetto, M.; Franzò, A.; Marchesi, G. Influence of preparation designs on marginal adaptation
and failure load of full- coverage occlusal veneers after thermomechanical aging simulation. J. Esthet. Restor. Dent. 2019, 31, 1–10.
[CrossRef]
27. Elsaka, S.E.; Einaghy, A.M. Mechanical properties of zirconia reinforced lithium silicate glass-ceramic. Dent. Mater. 2016,
32, 908–914. [CrossRef]
28. Lauvahutanon, S.; Takahashi, H.; Shiozawa, M.; Iwasaki, N.; Asakawa, Y.; Oki, M.; Finger, W.J.; Arksornnukit, M. Mechanical
properties of composite resin blocks for CAD/CAM. Dent. Mater. 2014, 33, 705–710. [CrossRef] [PubMed]
29. Sen, N.; Us, Y.O. Mechanical and optical properties of monolithic CAD-CAM restorative materials. J. Prosthet. Dent. 2018,
119, 593–599. [CrossRef] [PubMed]
30. Rinke, S.; Pfitzenreuter, T.; Leha, A.; Roediger, M.; Ziebolz, D. Clinical evaluation of chairside-fabricated partial crowns composed
of zirconia-reinforced lithium silicate ceramics: 3 year results of a prospective practice-based study. J. Esthet. Dent. 2020,
32, 226–235. [CrossRef] [PubMed]
31. Wada, A.; Nathanson, D. Mechanical properties of resin-ceramic CAD/CAM restorative materials. J. Prosthet. Dent. 2015,
114, 587–593.
32. Magne, P.; Schlichting, L.H.; Maia, H.P.; Baratieri, L.N. In vitro fatigue resistance of CAD/CAM composite resin and ceramic
posterior occlusal veneers. J. Prosthet. Dent. 2010, 104, 149–157. [CrossRef]
33. He, L.H.; Swain, M.A. A novel polymer infiltrated ceramic dental material. Dent. Mater. 2011, 27, 527–534. [CrossRef] [PubMed]
34. Fasbinder, D.J.; Neiva, G.F.; Dennison, J.B.; Heys, D.R. Clinical performance of CAD/CAM-generated composite inlays after 10
years: Comparing the longitudinal performance of composite and porcelain. J. Cosmet. Dent. 2013, 28, 134–145.
35. Manjot, A. Recent advances in composite CAD/CAM blocks. Int. J. Esthet. Dent. 2016, 11, 275–280.
36. Coldea, A.; Swain, M.V.; Thiel, N. Mechanical properties of polymer-infiltrated ceramic-network materials. Dent. Mater. 2013,
29, 419–426. [CrossRef] [PubMed]
37. Fasbinder, D.J. Chairside CAD/CAM: An overview of restorative material option. Compend. Contin. Educ. Dent. 2012, 33, 50–58.
[PubMed]
38. Tree, A.; Pascual, A.; Camps, I.; Grau-Benitez, M. Comparative characterization of a novel CAD/CAM polymer-infiltrated-ceramic
network. J. Clin. Expo. Dent. 2015, 7, e495–e500.
39. Fasbinder, D.J.; Neiva, G.F.; Heys, D.; Heys, R. Clinical evaluation of chairside computer assisted design/computer assisted
machining nano-ceramic restorations: Five-year status. J. Esthet. Restor. Dent. 2020, 32, 193–203. [CrossRef] [PubMed]
40. Coşkun, E.; Aslan, Y.U.; Özkan, Y.K. Evaluation of two different CAD-CAM inlays-onlays in a split mouth study: 2-year clinical
follow-up. J. Esthet. Restor. Dent. 2020, 32, 244–250. [CrossRef]
41. Chirumamilla, G.; Goldstein, C.E.; Lawson, N.C. A 2 year retrospective clinical study of Enamic crowns performed in a private
practice setting. J. Esthet. Restor. Dent. 2016, 28, 231–237. [CrossRef] [PubMed]
42. Spitznagel, F.A.; Scholz, K.J.; Strub, J.R.; Vach, K.; Gierthmuehlen, P.C. Polymer-infiltrated ceramic CAD/CAM inlays and partial
coverage restorations: 3 year results of a prospective clinical study over 5 years. Clin. Oral Investig. 2018, 22, 1973–1983. [CrossRef]
43. Zarone, F.; Russo, S.; Sorrentino, R. From porcelain-fused to metal to zirconia: Clinical and experimental considerations. Dent.
Mater. 2011, 87, 83–96. [CrossRef] [PubMed]
44. Denry, I.; Kelly, J.R. State of the art of zirconia for dental applications. Dent. Mater. 2008, 24, 299–307. [CrossRef] [PubMed]
45. Nakashima, J.; Taira, Y.; Sawase, T. In vitro wear of four ceramic materials and human enamel on enamel antagonist. Eur. J. Oral
Sci. 2016, 124, 295–300. [CrossRef] [PubMed]
Biology 2021, 10, 1170 11 of 11

46. Lughi, V.; Sergio, V. Low degraded temperatures -aging-of zirconia: A critical review of the relevant aspects in dentistry. Dent.
Mater. 2010, 26, 807–820. [CrossRef]
47. Shahmiri, R.; Standard, O.C.; Hart, J.N.; Sisters, C.C. Optical properties of zirconia ceramics for esthetic dental restorations: A
systematic review. J. Prosthet. Dent. 2018, 119, 36–46. [CrossRef] [PubMed]
48. Vichi, A.; Sedda, D.; Fabian Fonzar, R.; Carrabba, M.; Ferrari, M. Comparison of contrast ratio, translucency parameter, and
flexural strength of traditional and “augmented translucency” zirconia for CEREC CAD/CAM system. J. Esthet. Dent. Restor.
Dent. 2016, 28, s32–s39. [CrossRef] [PubMed]
49. Ferrari, M.; Vichi, A.; Zarone, F. Zirconia abutments and restorations: From laboratory to clinical investigations. Dent. Mater.
2015, 31, e63–e76. [CrossRef] [PubMed]
50. Sorrentino, R.; Triulzio, C.; Tricarico, M.G.; Bonadeo, G.; Gherlone, E.F.; Ferrari, M. In vitro analysis of the fracture resistance of
CAD-CAM monolithic zirconia molar crowns with different occlusal thickness. J. Mech. Behave. Biomed. Mater. 2016, 199, 36–46.
[CrossRef]