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Meeting high functional and aesthetic demands with ceramic solutions
CBCT volume to aid in planning for mandibular implant placement. (Image: Dr Ross Cutts)
Dr Ross Cutts

Dr Ross Cutts

Thu. 3. May 2018

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Undoubtedly, digital dentistry is the current topic. Over the last five years, the entire digital workflow has progressed in leaps and bounds. There are so many different digital applications that it is sometimes difficult to keep up with all the advances. Many dentists are excited about the advantages of new technologies, but there are an equal number who doubt that the improved clinical workflow justifies the expense.

I have many times heard the argument that there is no need to try to fix something that is not broken. It is so true that impressions have their place and there are certainly limitations to the digital workflow that anyone using the technology should be aware of. For me, however, the benefits of digital far outweigh the disadvantages. In fact, the disadvantages are the same as with conventional techniques.

Chairside CAD/CAM single-visit restorations have been possible for over 20 years, but it was only recently that we became able to mill chairside implant crown restorations after the release of Variobase (Straumann) and similar abutments. I made my first CEREC crown (Dentsply Sirona) back in 2003 with a powdered scanner, and the difference from what I remember then to how we can make IPS e.max stained and glazed restorations (Ivoclar Vivadent) now is amazing.

An investment not an expense

The results of a survey regarding the use of CAD/ CAM technology were published online in the British Dental Journal on 18 November 2016. Over a thousand dentists were approached online to take part in the survey and the 385 who replied gave very interesting responses. The majority did not use CAD/CAM technology, and the main barriers were initial cost and a lack of perceived advantage over conventional methods.

Thirty per cent of the respondents reported being concerned about the quality of the chairside CAD/CAM restorations. This is a valid point. We must not let ourselves lose focus that our aim should always be to provide the best level of dentistry possible. For me, digital dentistry is not about a quick fix; it is about raising our performance and improving predictability levels by reducing human error.

In the survey, 89 per cent also said they believed CAD/CAM technology had a major role to play in the future of dentistry. I really cannot imagine that once a dentist has begun using digital processes that he or she would revert to conventional techniques.

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What is digital implant dentistry?

Many implant clinicians have probably been using CAD/CAM workflows without even realising it, as many laboratories were early adopters, substituting the lost-wax technique and the expense of gold for fully customised cobalt–chromium milled abutments (Fig. 1).

One of my most important goals in seeking to be a successful implantologist is to provide a dental implant solution that is durable. We have seen a massive rise in the incident of peri-implantitis and have found that a large proportion of these cases can be attributed to cement inclusion from poorly designed cement-retained restorations (Fig. 2). Even well designed fully customised abutments and crowns can have cement inclusion if the restoration is not carefully fitted (Fig. 3). This has led to a massive rise in retrievability of implant restorations, with screw-retained crowns and bridges now being the goal. However, making screw-retained prostheses places even greater emphasis on treatment planning and correct implant angulation.

With laboratories as early adopters, we have been milling titanium or zirconia customised abutments for over ten years (Fig. 4). What has changed recently in the digital revolution is the rise of the intraoral scanner. We now have a workflow in which we can take a preoperative intraoral scan and combine this with a CT scan using coDiagnostiX (Dental Wings) in order to plan an implant placement accurately and safely. We can also create a surgical guide to aid in accurate implant placement, have a temporary crown prefabricated for the planned implant position and then take a final scan of the precise implant position for the final prosthesis.

Accuracy of intraoral scanners

Figures 4 to13 show the workflow for preoperative scanning, which includes the implant design, guide fabrication and surgical placement of two fixtures. Intraoral scanners have improved over the last few years, and their accuracy and speed provide a viable alternative to conventional impression taking. The digital scan image comes up in real time and you can evaluate your preparation and quality of the scan on the screen immediately. Seeing the preparation blown up in size no doubt improves the technical quality of your tooth preparations. The scan can then be sent directly to the laboratory for processing.

While we do not think of intraoral scanners as being any more accurate than good-quality conventional impressions, there are many benefits of scanning, such as no more postage to be paid for impressions, vastly reduced cost of impression materials, almost zero re-impression rates and absolute predictability.

Of course, there are steep learning curves with the techniques, but once a clinician has learnt the workflow, there really is no looking back.

We have three different scanners in the practice: the iTero (Align Technology), the CEREC Omnicam (Dentsply Sirona) and the Straumann CARES Intraoral Scanner (Dental Wings; Fig. 14). The CEREC Omnicam is fantastic for simple chairside CAD/CAM restorations, such as IPS e.max all-ceramic restorations on Variobase abutments. For truly aesthetic results, we, of course, still have a very close working relationship with our laboratory, but, undoubtedly, patients love the option of restoration in a day. Being able to scan an implant abutment and then an hour later (to allow for staining and glazing) fitting the definitive restoration is a game changer. Patients also love watching the production process as they see their tooth being milled from an IPS e.max block.

Figures 15–19 show the production process, including the exposure of the implant, the abutment seating, the scan flag on top of the abutment, the healing abutment during fabrication and the delivery of the final prosthesis. However, for more than single units or aesthetic single-unit cases, we use the iTero and Straumann scanners. The latter we have only had at our disposal since February. While it is a powdered system at the moment, this is due to change this month. Particularly with implant restorations, the need to apply a scanning powder is a limitation, owing to a lack of moisture control contaminating the powder. The technology, however, is superb, as is the openness of the system, which provides the advantage of being able to export files into planning software. A colleague of mine even uses it for his orthodontic cases now instead of wet impressions.

We invested in the iTero scanner five years ago and have used it for everything, from simple conventional crowns and bridges to scanning for full-mouth rehabilitations. When fabricating definitive bridgework, we use Createch Medical frameworks for screw-retained CAD/CAM-milled titanium and cobalt–chromium frameworks. Even though intraoral scanning appears extremely reproducible and accurate, I still use verification jigs where needed to ensure our frameworks are as accurate as possible. There are many intricacies that we consider and tips and techniques that we employ to make the scans more accurate that we have developed over time. The closer the scanbodies are together, the more accurate the scan is. Also, the more anatomical detail, such as palatal rugae or mucosal folds, the better the scans can be stitched together.

Figure 20 shows a CBCT volume to aid in planning for mandibular implant placement (Fig. 21) and realising the implant placement. We exposed the fixtures and placed Straumann Mono Scanbodies (Fig. 22). Then, we took an iTero scan of the fixtures in situ (Fig. 23) and made a verification jig from this (Fig. 24) to ensure passive implant positioning. The iTero models were made (Fig. 25) and a Createch titanium framework was used to support porcelain in a screw-retained design (Fig. 26). The last two figures show the excellent outcome and accurate framework seating (Figs. 27 & 28).

Choosing your workflow

There are many different systems on the market now, each offering a one-stop shop. If you are considering investing in a digital scanner, then take some advice from colleagues. One of the most important things is to ensure the system you opt for is an open one that allows you to extract the digital impression data into different software. We extract our files into CT planning software, model production software, chairside milling for stents, temporaries and definitive restorations, and now orthodontic planning software. I am convinced there will be yet more advances with time. The size of the camera is critical—some can be very cumbersome—and it is worth asking the salesperson what developments are underway.

Some companies are more on the cutting edge than others. My favourite at the moment is the Straumann scanner. Its design is light and user-friendly and it synchronises perfectly with implant planning software coDiagnostiX. Furthermore, while it offers a chairside milling unit, it also synchronises perfectly with my laboratory for larger cases.

To conclude, digital implant dentistry is the future and so why not take advantage of it and help improve your clinical outcomes?

Editorial note: A list of references is available from the publisher. This article was published in CAD/CAM - international magazine of digital dentistry No. 03/2017.

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3D-printed hybrid composite restorations represent a promising digitally fabricated option in implant prosthodontics, though clinical outcomes vary depending on material and manufacturing technique. (Image: Dental Pro Content/Adobe Stock; clinical images: Dr Francesco Mangano)
Dr Francesco Mangano

Dr Francesco Mangano

Thu. 29. January 2026

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In recent years, 3D-printed polymer-infiltrated ceramic resins, also defined as hybrid composites, have emerged as a promising option for definitive dental restorations. These innovative materials combine the advantages of resin composites and ceramic fillers, offering improved strength, aesthetics and biocompatibility compared with traditional provisional resins.1–4 Unlike conventional composites, hybrid formulations are specifically designed for long-term use. They exhibit superior wear resistance and optical integration. This makes them highly suitable for daily prosthodontic applications.1–4 Moreover, hybrid composites offer better stress absorption, intra-oral reparability, ease of polishing and reduced wear of the opposing teeth than zirconia and lithium disilicate.1–4

To date, most studies on these 3D-printed hybrid composites have been in vitro analyses. These analyses have shown that restorations printed with these materials have high marginal accuracy, comparable to that of milled restorations. However, they also have lower mechanical properties than restorations fabricated by conventional milling.5–10 The only available in vivo clinical studies have shown differing results, depending on the material used.11–13

In a prospective study with a follow-up period of up to three years, Hobbi et al. evaluated the clinical performance of 3D-printed resin composite fixed dental prostheses for posterior restorations.11 In that study, 49 patients were treated with 68 three-unit 3D-printed resin composite posterior fixed bridges (els even stronger, SAREMCO Dental) which were then evaluated for a mean observation period of 22 months.11 At the final recall, only 24 of the 64 restorations remained in clinical service without complications. This indicates limited long-term success owing to a high incidence of fractures, mainly in the connector regions.11 The authors concluded that 3D-printed resin composite fixed dental prostheses offer certain advantages, but should be considered as long-term provisional restorations, because of the high incidence of mechanical failures within three years.11

In contrast, another retrospective analysis examined 145 patients who received 185 short-span implant-supported fixed hybrid composite restorations (Irix Max, DWS Systems) which were fabricated using tilted stereolithography (TSLA). This study reported far more favourable outcomes.13 In this analysis, all the restorations were manufactured using a fully digital, model-free workflow that combined intra-oral scanning, CAD and TSLA printing with the novel Dfab printer (DWS Systems). Of the restorations, 95 had a 24-month follow-up and 90 had a 12-month follow-up.13 Marginal adaptation and occlusal and interproximal contacts were consistently excellent, aesthetics were satisfactory and every restoration remained functional. Complications were uncommon (3.7% prosthetic complications), and no fractures were reported. This yielded an overall success rate of 95.1%.13 The authors concluded that TSLA-fabricated short-span implant-supported hybrid composite restorations can provide high clinical accuracy and have a low complication rate over two years.13

This article presents a simple case of single-implant prosthetic rehabilitation in the posterior mandible. The rehabilitation was carried out through a fully digital workflow that included intra-oral scanning, designing a custom abutment and definitive restoration with CAD software, and fabricating and delivering a definitive 3D-printed hybrid composite restoration (Irix Max; Figs. 1a-f). This case study illustrates how Irix Max 3D-printed hybrid composite restorations can be successfully integrated into a complete digital workflow for implant prosthodontics.

Figs. 1a–f: Overview of the digital workflow for fabrication of a 3D-printed hybrid composite restoration. Intra-oral scan with iTero Lumina (Align Technology; a). CAD modelling with DentalCAD (exocad), producing an STL file of the design for the definitive restoration (b & c). High-precision 3D printing of the restoration with Dfab using Irix Max (d & e), followed by post-polymerisation, polishing and delivery of the restoration to the patient (f).

Figs. 1a–f: Overview of the digital workflow for fabrication of a 3D-printed hybrid composite restoration. Intra-oral scan with iTero Lumina (Align Technology; a). CAD modelling with DentalCAD (exocad), producing an STL file of the design for the definitive restoration (b & c). High-precision 3D printing of the restoration with Dfab using Irix Max (d & e), followed by post-polymerisation, polishing and delivery of the restoration to the patient (f).

Case presentation

The process begins with an intra-oral scan performed with the iTero Lumina scanner (Align Technology; Figs. 2a-c & 3a-c). The innovative iTero Multi-Direct Capture technology offers a threefold larger field of view and maximum capture distance of 25 mm, designed to scan twice as fast and simplify the capture of challenging anatomy encountered in denture, edentulous and other complex cases. This step eliminates the need for conventional impressions, improving accuracy and patient comfort. The accuracy of the intra-oral scanner is essential to the efficiency of the digital chairside prosthetic workflow. High-precision intra-oral scans minimise the need for adjustments and remakes as well as streamline the design and fabrication process. This shortens clinical and laboratory time and improves the reliability of same-day restorative procedures. A recent study showed that this scanner ensures high scanning accuracy and enables immediate integration with the laboratory by transmitting the scan directly via a cloud-based system.14

Fig. 2a–c: The intra-oral scanning with iTero Lumina scanner (a) begins with the antagonist quadrant (b) and then with the master model (c) after removal of the healing abutment, followed by the occlusal registration. In this case, the scan was captured immediately after implant placement, while the sutures were still in position.

Fig. 2a–c: The intra-oral scanning with iTero Lumina scanner (a) begins with the antagonist quadrant (b) and then with the master model (c) after removal of the healing abutment, followed by the occlusal registration. In this case, the scan was captured immediately after implant placement, while the sutures were still in position.

Fig. 3a–c: Intra-oral scanning with iTero Lumina scanner (a) proceeded with the capture of the implant’s spatial position on the master model after the implant scan body had been screwed in: occlusal (b) and buccal (c) view.

Fig. 3a–c: Intra-oral scanning with iTero Lumina scanner (a) proceeded with the capture of the implant’s spatial position on the master model after the implant scan body had been screwed in: occlusal (b) and buccal (c) view.

The data is then transferred to DentalCAD 3.2 Elefsina software (exocad) for the CAD of the restoration. This software enables the dental technician to design individual abutments and definitive crowns with functional occlusal surfaces, excellent interproximal contact points and optimal emergence profiles (Figs. 4–6).

Figs. 4a & b: CAD modelling in DentalCAD of the definitive restoration and of the custom abutment, which was to be milled from titanium, to support the restoration (a & b).

Figs. 4a & b: CAD modelling in DentalCAD of the definitive restoration and of the custom abutment, which was to be milled from titanium, to support the restoration (a & b).

Figs. 5a & b: CAD modelling in DentalCAD of the definitive restoration. Photorealistic rendering (a). Aligned master and antagonist models (b).

Figs. 5a & b: CAD modelling in DentalCAD of the definitive restoration. Photorealistic rendering (a). Aligned master and antagonist models (b).

Fig. 6: STL file of the CAD of the definitive restoration.

Fig. 6: STL file of the CAD of the definitive restoration.

Once the design has been finalised, the restoration is fabricated using Dfab (Figs. 7–9). This advanced additive manufacturing technology enables the fabrication of hybrid composite restorations with high accuracy—in less than 20 minutes. The Irix Max resin cartridge provides the hybrid composite material used to fabricate restorations with both high mechanical durability and natural aesthetics. Thanks to the Photoshade system, the material is available in multiple shades, ensuring seamless aesthetic blending. The Photoshade system allows for the customisation of aesthetic parameters, such as shade layering, which is essential for natural integration with adjacent teeth.

Figs. 7a–d: Steps in 3D printing of the definitive restoration with the Dfab printer. The operator opens the Dfab door, secures the grey disposable printing plate, supplied with the cartridge, on to its black carrier (printing block; a) and inserts the assembly into the corresponding upper slot of the printer (b). The operator then inserts the Irix Max cartridge (c) and locks it into the corresponding lower slot (d). The operator can then close the printer.

Figs. 7a–d: Steps in 3D printing of the definitive restoration with the Dfab printer. The operator opens the Dfab door, secures the grey disposable printing plate, supplied with the cartridge, on to its black carrier (printing block; a) and inserts the assembly into the corresponding upper slot of the printer (b). The operator then inserts the Irix Max cartridge (c) and locks it into the corresponding lower slot (d). The operator can then close the printer.

Figs. 8a–e: The operator connects the Dfab printer (a) to the laptop via USB and launches the Nauta Photoshade software, into which he or she imports the STL file of the CAD for the crown (b & c). The software automatically positions the crown and generates the supports and build base (d). The operator only needs to configure the different colour layers (e) within the software to achieve ideal aesthetics and chromatic adaptation in the patient’s mouth.

Figs. 8a–e: The operator connects the Dfab printer (a) to the laptop via USB and launches the Nauta Photoshade software, into which he or she imports the STL file of the CAD for the crown (b & c). The software automatically positions the crown and generates the supports and build base (d). The operator only needs to configure the different colour layers (e) within the software to achieve ideal aesthetics and chromatic adaptation in the patient’s mouth.

Figs. 9a–d: In just 15 minutes, the Irix Max crown is printed (a). Before removing the crown from the printing plate and detaching the supports (b), the operator rinses the restoration in ethanol for a few minutes using a dedicated tool (c). After removing the liquid resin, the operator detaches the restoration (d) and places it in the polymerisation unit.

Figs. 9a–d: In just 15 minutes, the Irix Max crown is printed (a). Before removing the crown from the printing plate and detaching the supports (b), the operator rinses the restoration in ethanol for a few minutes using a dedicated tool (c). After removing the liquid resin, the operator detaches the restoration (d) and places it in the polymerisation unit.

After printing and washing, the restoration is light-polymerised in the Dcure unit (DWS Systems) to ensure complete polymerisation and optimal physical properties. The OptraGloss polishing system (Ivoclar) is then used for polishing and finishing to enhance surface smoothness and gloss (Figs. 10a-d). These steps are essential for achieving long-term colour stability, resistance to plaque accumulation and comfortable occlusal contact for the patient.

Final delivery involves adhesive cementation with Variolink Esthetic resin cement (Ivoclar), which provides secure bonding to the abutment and long-term stability under functional load. Using modern adhesive cements contributes to the retention and marginal seal of the restoration (Figs. 11a-f). For screw-retained restorations, a direct chairside approach is possible. At the six-month follow-up, the 3D-printed Irix Max hybrid composite crown exhibited favourable aesthetics, stable occlusion and harmonious gingival integration, demonstrating the material’s clinical reliability (Figs. 12a & b).

Figs. 10a–d: Polymerisation is completed in a few minutes inside the Dcure polymerisation unit (a–c). At this point, the operator polishes the restoration with the OptraGloss system (d), and the crown can undergo further characterisation. While this final step is useful for optimising the aesthetic outcome, it is optional, since the printer already produces a restoration with a natural colour gradient.

Figs. 10a–d: Polymerisation is completed in a few minutes inside the Dcure polymerisation unit (a–c). At this point, the operator polishes the restoration with the OptraGloss system (d), and the crown can undergo further characterisation. While this final step is useful for optimising the aesthetic outcome, it is optional, since the printer already produces a restoration with a natural colour gradient.

Figs. 11a–f: Delivery of the definitive 3D-printed hybrid composite restoration, cemented on to the individual titanium hybrid abutment. Intra-oral scans illustrating the prepared site, neighbouring dentition and emergence profile (a–c). Buccal view of the titanium hybrid abutment in situ (d). Buccal view of the definitive 3D-printed restoration after cementation (e). Variolink Esthetic DC resin cement used for luting (f).

Figs. 11a–f: Delivery of the definitive 3D-printed hybrid composite restoration, cemented on to the individual titanium hybrid abutment. Intra-oral scans illustrating the prepared site, neighbouring dentition and emergence profile (a–c). Buccal view of the titanium hybrid abutment in situ (d). Buccal view of the definitive 3D-printed restoration after cementation (e). Variolink Esthetic DC resin cement used for luting (f).

Figs. 12a & b: Six-month follow-up of the 3D-printed hybrid composite restoration, showing the restoration’s aesthetic integration and healthy, stable tissue, occlusal view (a) and buccal view (b).

Figs. 12a & b: Six-month follow-up of the 3D-printed hybrid composite restoration, showing the restoration’s aesthetic integration and healthy, stable tissue, occlusal view (a) and buccal view (b).

In conclusion, hybrid composites like Irix Max are a significant advancement in restorative dentistry. When combined with a complete digital workflow—scan, plan, print and deliver—they enable the efficient, precise and aesthetic production of implant-supported restorations. This synergy between materials science and digital technology is redefining contemporary prosthodontic practice. The accuracy of both the intra-oral scanner and the 3D printer is essential for achieving predictable clinical outcomes, and the integration of chairside workflows enhances cost- and time-efficiency, ultimately enabling clinicians to deliver durable, minimally invasive and aesthetic restorations in a streamlined manner.

Editorial note:

This article was published in CAD/CAM—international magazine of dental laoboratories vol. 16, issue 2/2025. The list of references can be found here.

Topics:
Digital Dentistry CAD/CAM 3D Printing
Tags:
3D-printed restorations Align Technology Chairside dentistry DentalCAD Dfab Digital workflows Exocad Intra-oral scanners Itero Ivoclar Tilted stereolithography
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Optimized Dental Implant Osseointegration: Cellular Mechanisms, Timelines, and Patient Factors

Dr. Zeeshan Sheikh Dip.Dh, BDS MSc, M.Perio, PhD, FRCDC, Dip-ABP
Dr. Zeeshan Sheikh Dip.Dh, BDS MSc, M.Perio, PhD, FRCDC, Dip-ABP
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1CE
Live webinar
Tue. 10 February 2026
7:00 pm EST (New York)

ITI Section USA Treatment Planning Live

Prof. Dr. Wael Att
Dr. Robert A. Levine DDS, FCPP, FISPPS, AOD
Dr. Larissa Bemquerer ITI Scholar at Harvard
Prof. Dr. Wael Att, Dr. Robert A. Levine DDS, FCPP, FISPPS, AOD, Dr. Larissa Bemquerer ITI Scholar at Harvard
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Live webinar
Wed. 11 February 2026
11:00 am EST (New York)

Onlays – die elegante Art für eine prothetische Bisshebung

Dr. med. dent. Sven Mühlemann
Dr. med. dent. Sven Mühlemann
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1CE
Live webinar
Wed. 11 February 2026
12:00 pm EST (New York)

Implant Overdentures

Prof. Dr. Samir Abou Ayash
Prof. Dr. Samir Abou Ayash
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1CE
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