430

Journal of Oral Science, Vol. 62, No. 4, 430-434, 2020

Original article
Practicability of a chairside approach for characterizing CAD/CAM resin-based composites
Dominic Gold, Sebastian F. Hahnel, Oliver Schierz, and Angelika Rauch
Department of Prosthodontics and Materials Science, University of Leipzig, Leipzig, Germany
(Received December 5, 2019; Accepted February 4, 2020)

Abstract: Perception of tooth shades is subjective and not rated exactly based composites have certain advantages in that restorations have high
the same by different individuals. In terms of dental esthetics, chairside edge stability and low layer thickness; furthermore, intraoral repairs are
individualization of dental restorations might help to improve patient simple since no hydrofluoric acid is needed [13,14]. In terms of esthetics,
satisfaction. This investigation aimed to validate the practicability of a mono- and multilayer blocks are available and CAD/CAM resin-based
chairside approach for staining resin-based composite restorations. Thir- composites can be characterized using a lab- and chairside approach with
teen inexperienced and 13 experienced participants were recruited to first light-curing characterization materials. In comparison to ceramic materi-
individualize two CAD/CAM resin-based composite crowns in random- als, CAD/CAM resin-based composites are advantageous in that esthetic
ized order with light-curing characterization material using two reference results can be achieved without additional firing, and only light-curing
crowns as templates. They then evaluated the characterization procedure. materials are needed (Figs. 1a, 1b). Thus, additional and expensive equip-
The processing times were recorded, and the clinical quality of the indi- ment is not required, and the time needed to finish the restoration can be
vidualized crowns was evaluated by two blinded master dental technicians. minimized since no firing is necessary and the work can be done using
Of the 52 crowns examined, 90.4% were assessed as suitable for insertion; only a conventional light curing unit. Although chairside staining of CAD/
there was no difference in quality attributable to the different degrees of CAM resin-based composites is promoted by the manufacturers, to the
experience of the operators. The average time required for characteriza- authors’ knowledge no previous studies have validated the practicability of
tion of the second crown was significantly shorter than for the first crown the technique in terms of processing time or the quality of the individual-
(30.9/43.0 min), indicating that the procedure can be implemented using a ized restorations. Furthermore, no investigation has determined whether
chairside approach. Among the operators, 80.8% said they would use the this technique can be used by inexperienced operators, or whether it can
individualization technique and staining material again. Chairside stain- only be performed by experienced practitioners. As many dental nurses
ing of CAD/CAM resin-based composite restorations with light-curing now individualize restorations fabricated using a chairside CAD/CAM
characterization materials is practicable and can be recommended for both approach, this issue appears to be of particular relevance.
experienced and inexperienced users. The working hypothesis of the present study was that the degree of
experience of the operator would not lead to any differences in the process-
Keywords; cerec, color, esthetics, permanent dental restoration ing time or quality of the individualized CAD/CAM resin-based composite
crowns.

Introduction Materials and Methods

In dental practice, fabrication of fixed restorations is a popular approach In August 2018, 13 undergraduate dental students (inexperienced users)
for providing patients with esthetically pleasing tooth replacements within and 13 dental technicians (experienced users) were recruited to individual-
a single visit. All-ceramic restorations produced using a chairside approach ize a CAD/CAM resin-based composite for the first time (Grandio blocs HT
are associated with high patient satisfaction, high survival rates and good A2, VOCO, Cuxhaven, Germany). All users received the same one-hour
clinical quality over long observation periods [1-4]. They can also be indi- lecture on the use of CAD/CAM resin-based composites and light-curing
vidualized in the direct presence of the patient using stains, thus facilitating characterization materials; the latter were available in white, blue, yellow,
highly esthetic results, since it has been shown that less than half of labo- orange, and brown (FinalTouch, VOCO). The inexperienced users were
ratory-fabricated restorations adequately match the adjacent natural teeth familiar with the handling of direct resin-based composites from one clini-
[5]. Moreover, the perception of color is very subjective and dependent on cal course each in dental prosthodontics and preventive/operative dentistry.
emotional sensitivity, suggesting that the rating of any individual restora- In addition, they had completed a two-hour hands-on course for staining of
tion will not be exactly the same [Chu et al., Color in dentistry: a clinical dental ceramics in the previous academic year. The experienced users had
guide to predictable esthetics, 12-14, Quintessence Publishing, 2017]. In at least one year of professional experience.
this context, chairside individualization might help to improve patient Two crowns (#16 and #36) were fabricated and individualized by an
satisfaction, adherence and acceptance of the newly inserted restoration. independent dental technician prior to this study and served as character-
Various manufacturers have provided instructions on the chairside ization templates (Fig. 2). Each reference crown was stained in five areas
staining procedure and a number of case reports have addressed this issue according to the manufacturer’s instructions. The crowns were assigned to
[6-9]. One disadvantage of staining dental ceramics is that subsequent the operators in random sequence. During the staining process, the opera-
glazing must be carried out, requiring additional equipment and time tors had access to the manufacturer’s information and the same working
(about 25 min for glaze firing and cooling). Furthermore, differences in the materials, and were instructed to characterize the crowns in accordance with
mixing ratios of ceramic powders or frequent corrective firings can result the manufacturer’s specifications (Table 1). The processing time required
in large variations of coloring and translucency [10,11]. for each individualization was recorded by an independent observer. At the
In addition to ceramics, various resin-based composites are available end of the procedure, the participants were asked to complete an evaluation
as definitive restoration materials that can be used for computer-aided form in which they rated the processing time, application and polishing of
design/computer-aided manufacturing (CAD/CAM) [12]. Indirect resin- the materials as well as their overall impression on a 5-point Likert scale
(very good, good, sufficient, insufficient, poor). All data were collected in
Correspondence to Dr. Angelika Rauch, Department of Prosthodontics and Materials Science, an anonymized manner so that two master dental technicians who were
University of Leipzig, Liebigstr 12, Leipzig 04103, Germany not involved in the characterization of the crowns were able to blindly
Fax: +49-341-9721-309 E-mail: [email protected]
assess the conformity of the quality in relation to the reference crowns
J-STAGE Advance Publication: August 31, 2020
using magnifying loupes. Shape, color, contamination, occlusion, polish-
Color figures can be viewed in the online issue at J-STAGE.
doi.org/10.2334/josnusd.19-0507 ing (one-step polishing system, Dimanto, VOCO), and overall impression
DN/JST.JSTAGE/josnusd/19-0507 of quality were rated using an evaluation sheet, and in the event of differ-
 431

a b

Fig. 1   a: try-in of the CAD/CAM resin-based composite crown #14. In comparison to the adjacent teeth, white spots are missing. b: crown #14 was
individualized with light-curing stains using a chairside approach.

Fig. 2   The reference crowns (left to right: vestibular, oral, occlusal) were each characterized in five areas for treatment of #16 in the maxilla (upper
row) and #36 in the mandible (lower row).

Table 1   Staining procedure for a CAD/CAM resin-based composite (Grandio blocs, VOCO) with light-curing characterization materials (Final-
Touch, VOCO)

Step Procedure
1 Preparing characterization patterns (rotary instrument)
2 Cleaning of the restoration with water dry
3 Drying of the restoration with moisture-free and oil-free air
4 Application and light-curing of a suitable adhesive
Insertion of color with e.g. metal cannulas, brush, probe, root canal instrument* (maximum layer thickness)

white: white spots, halo effects, masking of discolorations  (0.5 mm)

blue: translucent enamel areas, opalescent regions (0.5 mm)
5
yellow/orange: dentin core, fissures, enamel characteristics (0.5 mm)
orange/brown: enamel cracks, fissures (orange 0.5 mm/brown 0.3 mm)
*It is possible to mix colors or even mix color and composite for different color intensities.
6 Light-curing: 20 s, minimum light-output of 500 mW/cm2
7 Covering stains with suitable restorative composite + light-curing
Polishing with a one-step system°
8
°Results of the present study favor multistep polishing systems and low contact pressure.

ing assessments, a consensus was reached by discussion. All crowns were Declaration of Helsinki and all participants provided signed informed con-
evaluated within 5 h in the daytime (on the same day) in a room equipped sent. As the participants received no intervention, and as no safety-relevant
only with north-facing windows. Crowns that received an overall impres- measures were performed, the Ethics Committee at the Medical Faculty
sion of quality score of 1-3 (very good, good, sufficient) were considered of Leipzig University considered that no study approval was necessary.
to be clinically acceptable, and those with scores of 4-5 (insufficient, poor) The waiver issued by the Ethics Committee was submitted to the Journal
as clinically unacceptable. Statistical evaluation of the collected data was of Oral Science.
carried out at a significance level of P < 0.050 (SPSS 22, IBM Corporation,
Armonk, NY, USA). For comparisons of continuous data (age, processing Results
time) the Shapiro-Wilk test for normality was used (all P ≥ 0.145), and
independent or paired t-tests were applied. For categorical data (scores) The average age of the recruited participants (experienced and inexperi-
Mann-Whitney U-test (independent samples) or Wilcoxon signed-rank test enced) was 32.7 ± 10.7 years (min. 22 years, max. 60 years, 53.8% female).
(paired data) was used. The study was performed in accordance with the The distribution within the groups is shown in Table 2.
432

Fig. 3  Processing times for inexperienced (left) and experienced (right) users; the marks represent the individual times, and the dashed lines are
the mean characterization times per crown: first crown (blue/square, t1 43.0 ± 12.1 min; min. 24 min, max. 65 min), second crown (orange/circle, t2
30.9 ± 9.5 min; min. 14 min, max. 50 min).

Table 2   Distribution of participants within the operator groups by age and gender as well as processing times; significance was determined using
independent t-tests

Inexperienced user Experienced user P value

Number 13 13
Number female 8 6
Age in years 25.5 ± 3.6 39.9 ± 10.5 <0.001
Processing time for 1st crown in minutes 50.5 ± 8.9 35.5 ± 10.2 0.001
Processing time for 2nd crown in minutes 37.1 ± 8.6 24.8 ± 5.6 <0.001

Characterization time of quality of 90.4% of the crowns was rated as clinically acceptable for
Comparison of the processing times among the users revealed a statisti- insertion without further processing. The experienced users needed signifi-
cally significant reduction of 12.1 ± 8.7 min between the fabrication of cantly less time than the inexperienced participants. These results partially
the first (43.0 min) and second (30.9 min) crowns (Fig. 3) (paired t-test: refute the working hypothesis, since the processing time differed between
both user groups P < 0.001). The experienced group showed a significantly the user groups; however, user experience had no influence on the quality
shorter individualization time for the processing of both crowns than the of the individualized crowns. Moreover, a relevant effect of practice in
inexperienced group (Table 2). terms of the time required for crown individualization was identified, indi-
cating that the characterization technique has a steep training curve. With
Quality of crowns evaluated by independent master dental technicians regard to this aspect, the time required for the second individualization was
The overall impression of the quality of the individualized crowns was clinically acceptable for both user groups, particularly in comparison with
rated at 2.6 by both user groups. In total, 90.4% of the crowns were staining ceramics. Overall, application of the light-curing characterization
assessed as being clinically acceptable for insertion. Shape and coloring material proved to be clinically acceptable.
were evaluated as matching or partially matching for 82.7% and 71.2% of While utilizing light-curing materials for characterization, a clean
the restorations, respectively. Contaminants on the individualized surfaces workstation is advisable in order to avoid contamination. The one-step
were observed in 9.6% of the crowns, and 42.3% of the polished surfaces polishing system applied to the fabricated crowns produced clinically
showed inadequate (insufficient, poor) results (Fig. 4). There were no sta- insufficient results, suggesting that a multistep system should be used with
tistically significant differences in these criteria between the user groups in low contact pressure. This recommendation has recently been included in
any category (Mann-Whitney U-test; all P ≥ 0.067), nor were any signifi- the manufacturer’s instructions for the CAD/CAM resin-based composite
cant differences identified between the evaluations of the first and second and characterization material. Moreover, a recently published study has
crowns (Wilcoxon signed-rank test: all P ≥ 0.193). indicated that appropriate chairside polishing after intraoral adjustment as
well as laboratory-based polishing after milling can produce CAD/CAM
Evaluation by the operators resin-based composite surfaces with similar roughness [15].
The results of the questionnaire that was answered by the operators revealed Due to the design of this study, the reference crowns could only rep-
that 80.8% of them would be prepared to use chairside characterization resent a small variety of the esthetically challenging aspects of restorative
of CAD/CAM resin-based composite crowns in their everyday clinical dentistry, such as brown spots or discolored fissures. In daily dental prac-
practice; 19.2% said they would not consider it or would tend not to use tice, numerous characteristics would need to be considered; nonetheless,
it. The processing time was evaluated as very good or good by 80.8%, and within the scope of the present study, the two reference crowns provided
76.9% described the application of the characterization materials as very ten different types of modifications. Moreover, only one light-curing char-
good or good. Polishing with the one-step polishing system was rated as acterization system was evaluated, although many more are available such
insufficient by 19.2% (Table 3). as Sinfony Magic for Lava Ultimate (3M, Seefeld, Germany) or OPTI-
GLAZE color for Cerasmart (GC, Leuven, Belgium). As this study focused
Discussion on practicability and handling of the individualization process depending
on the operator’s experience, the characterization procedures were per-
To the authors’ knowledge, the present study is the first investigation to formed under standardized experimental conditions, including a single
have addressed the practicability of chairside characterization of tooth-col- light-curing system and a room equipped only with north-facing windows.
ored CAD/CAM resin-based composite materials. The overall impression A comparison of different light-curing systems in future studies might be
 433

a d

b e

c f

Fig. 4  Quality of crowns fabricated from CAD/CAM resin-based composites by inexperienced and experienced operators evaluated in consensus
by two independent and blinded master dental technicians.

Table 3   Evaluation of the characterization materials for CAD/CAM resin-based composite crowns by operators (%)

Very good Good Sufficient Insufficient Poor

Polishing 19.2 50.0 11.6 19.2 0.0
Application 11.5 65.4 19.2 3.9 0.0
Processing time 30.8 50.0 15.4 3.8 0.0
Overall impression of operators 11.6 26.9 42.3 19.2 0.0

interesting. Currently, the only case reports available are those describing encourage chairside characterization in daily dental practice.
chairside shading and staining of restorations with light-curing materials Chairside characterization of CAD/CAM resin-based composite resto-
[7]. Future clinical trials (cohort studies, RCTs) will need to investigate rations can be recommended as a technique suitable for both inexperienced
the practicability of chairside characterization, especially in esthetically and experienced users. With even brief training, inexperienced users can
challenging areas such as incisor crowns in adolescent/young patients. achieve processing times similar to those of experienced operators. How-
So far, no long-term clinical studies have investigated the performance ever, for characterized CAD/CAM resin-based composite restorations,
of CAD/CAM resin-based composites. As some in vitro studies have one-step polishing systems might yield clinically insufficient results.
indicated that composites might be influenced by aging and toothbrush
abrasions [16-18] or might show discolorations due to food/drink [19], the Acknowledgments
color stability of characterized resin-based composite crowns in particular The authors thank VOCO GmbH, Cuxhaven, Germany, for providing the
should be investigated. materials for this study.
Although there are data from in vitro studies addressing the mechanical
properties of CAD/CAM resin-based composites [14,20,21], it is unknown Conflict of interest
whether staining, even if coated with direct resin-based composite mate- The authors AR and SH declare that they have received funding for other
rials, might affect certain properties such as hardness, surface quality or studies from VOCO GmbH. The authors DG and OS declare that they have
wear. This lack of knowledge might be the reason why some manufacturers no conflict of interest. This study was not financially supported by a third
(e.g. 3M [Lava Ultimate]) limit the indication of staining to pits and fis- party.
sures. Future investigations, along with the present findings, might help to
434

References of indirect particle-filled composite resin CAD/CAM partial crowns after 24 months. J
Prosthodont 27, 694-699.
1. Fasbinder DJ (2006) Clinical performance of chairside CAD/CAM restorations. J Am Dent 13. Ruse ND, Sadoun MJ (2014) Resin-composite blocks for dental CAD/CAM applications.
Assoc 137 Suppl, 22S-31S. J Dent Res 93, 1232-1234.
2. Otto T, Mörmann WH (2015) Clinical performance of chairside CAD/CAM feldspathic 14. Pfeilschifter M, Preis V, Behr M, Rosentritt M (2018) Edge strength of CAD/CAM materi-
ceramic posterior shoulder crowns and endocrowns up to 12 years. Int J Comput Dent 18, als. J Dent 74, 95-100.
147-161. 15. Matzinger M, Hahnel S, Preis V, Rosentritt M (2019) Polishing effects and wear perfor-
3. Otto T (2017) Up to 27-years clinical long-term results of chairside Cerec 1 CAD/CAM mance of chairside CAD/CAM materials. Clin Oral Investig 23, 725-737.
inlays and onlays. Int J Comput Dent 20, 315-329. 16. Korkmaz Ceyhan Y, Ontiveros JC, Powers JM, Paravina RD (2014) Accelerated aging
4. Rauch A, Reich S, Dalchau L, Schierz O (2018) Clinical survival of chair-side generated effects on color and translucency of flowable composites. J Esthet Restor Dent 26, 272-278.
monolithic lithium disilicate crowns:10-year results. Clin Oral Investig 22, 1763-1769. 17. Gürdal I, Atay A, Eichberger M, Cal E, Üsümez A, Stawarczyk B (2018) Color change of
5. Wee AG, Monaghan P, Johnston WM (2002) Variation in color between intended matched CAD-CAM materials and composite resin cements after thermocycling. J Prosthet Dent
shade and fabricated shade of dental porcelain. J Prosthet Dent 87, 657-666. 120, 546-552.
6. Kessler JC, Willer RD, Wilson EL (1986) Chairside characterization of porcelain restora- 18. Okamura K, Koizumi H, Kodaira A, Nogawa H, Yoneyama T (2019) Surface properties
tions. Quintessence Int 17, 551-555. and gloss of CAD/CAM composites after toothbrush abrasion testing. J Oral Sci 61, 358-
7. Small BW (1994) Customized, light-cured chairside staining. Dent Econ 84, 75-76. 363.
8. Masek RT (2001) Achieving high-level esthetics with CEREC. Compend Contin Educ 19. Özarslan MM, Büyükkaplan US, Barutcigil C, Özarslan M, Barutcigil K, Türker N (2018)
Dent 22, 19-26. Assessing staining resistance of a CAD/CAM interpenetrating network composite material.
9. Schneider O (2003) Cerec veneers-practical procedure and case presentation. Int J Comput Head Face Med 14, 27.
Dent 6, 283-292. 20. Choi B-J, Yoon S, Im Y-W, Lee J-H, Jung H-J, Lee H-H (2019) Uniaxial/biaxial flexure
10. Yılmaz K, Gonuldas F, Ozturk C (2014) The effect of repeated firings on the color change strengths and elastic properties of resin-composite block materials for CAD/CAM. Dent
of dental ceramics using different glazing methods. J Adv Prosthodont 6, 427-433. Mater 35, 389-401.
11. Lee W-S, Kim S-Y, Kim J-H, Kim W-C, Kim H-Y (2015) The effect of powder A2/powder 21. Hampe R, Theelke B, Lümkemann N, Eichberger M, Stawarczyk B (2019) Fracture
A3 mixing ratio on color and translucency parameters of dental porcelain. J Adv Prostho- toughness analysis of ceramic and resin composite CAD/CAM material. Oper Dent, doi:
dont 7, 400-405. 10.2341/18-161-L.
12. Zimmermann M, Koller C, Reymus M, Mehl A, Hickel R (2018) Clinical evaluation