Article_5_2_5
COMPUTERIZED DENTAL PROSTHETICS
INTRAORAL SCANS FOR CAD/CAM APPLICATION
Original Article
Judit Borbély1a*, Alexandra Czigola1b, Viktoria Vitai1b, Ivett Róth1b, Péter Hermann1c
1
Department of Prosthodontics, Faculty of Dentistry, Semmelweis University, H-1088 Budapest, Hungary
a
DMD, PhD, Associate Professor
b
DMD, Resident of Department of Prosthodontics
c
DMD, MSc, PhD, Professor and Head of Department of Prosthodontics, Vice-Rector for Education Affairs of Semmelweis Univeristy, Budapest, Hungary
ABSTRACT DOI: 10.25241/stomaeduj.2018.5(2).art.5
OPEN ACCESS This is an
Introduction: There is no doubt the world of dentistry is rapidly changing. Digital innovations Open Access article under the CC
are replacing our traditional techniques. Dentists need to keep up with the speed of today's BY-NC 4.0 license.
ever changing digital world. Peer-Reviewed Article
The aim of the paper is to educate about the concept of digital dentistry, its advantages Citation: Borbély J, Czigola A, Vitai V,
and limitations, and to provide an overview of digital impression taking procedures and the Róth I, Hermann P. Intraoral scans for
CAD/CAM application. Stoma Edu J.
digital workflow for CAD/CAM application. 2018;5(2):110-117.
Materials and methods: The Department of Prosthodontics, Faculty of Dentistry, Academic Editor: Gerwin V.
Semmelweis University (SU) published a series of articles in Hungarian dental paper as part of Arnetzl, DMD, Arnetzl Dental Compe-
tence, A-8041 Graz, Austria
the continuing education program to educate Hungarian dentists at the postgraduate level.
Digital technologies and their novel materials are also introduced into the SU undergraduate Received: May 15, 2018
Revised: May 24, 2018
dental curricula. A Bachelor of Science (BSc) digital dental designer training program is Acccepted: June 06, 2018
also aimed at the Faculty of Dentistry SU in cooperation with the Neumann University of Published: June 07, 2018
Technology and Economics to modernizate the classic profession of dental technician. This *Corresponding author: Assoc.
paper gives a summary of the basic knowledge published in digital dentistry series. Professor Judit Borbély, DMD, PhD,
Department of Prosthodontics, Faculty
Results: The CAD/CAM technology offers a quick and comfortable experience to the patients of Dentistry, Semmelweis University
and an efficient workflow to the dentist and dental technicians. The learning curve is steep Budapest, Szentkirályi u. 47, H-1088
Budapest, Hungary Tel/Fax: (36-1)
to adopt that new technology both in the dental office and on the laboratory side. Educated 4591500 / 59338, e-mail: borbely.
judit@dent.semmelweis-univ.hu
dental students and digital designers have the potential to keep pace with the digital era
change. Copyright: © 2018 the Editorial
Council for the Stomatology Edu
Keywords: CAD/CAM, scanner, intraoral, workflow, dental impression technics. Journal.
1. Introduction most appropriate techniques, systems or materials [1].
The widespread use of digital technology is to Chatham et al. surveyed the undergraduate curricula
transform our everyday life: computers and digital of the UK dental schools in 2014 to determine the
devices offer an easier, faster and more economical degree to which digital dental technologies have been
alternative to conventional methods. The digital introduced. Sixteen schools were surveyed and 11
revolution also has an impact on dental procedures. replied. 55% of those schools did teach digital dental
It is a fact that dentistry changes and undergoes technology, 50% gave lectures or demonstrations
dramatic developments. In order to meet the patients’ while the other 50% allowed practical involvement by
requirements, it is important to expand our dental the student. Seventy-three percent of the schools that
knowledge to digital technologies. replied had dental laboratories using some, but not all
Present day dental students grow up in a world of digital the digital dental technology techniques [1].
innovation and technology, so the need to include
digital technology in their curriculum is evident for 1.1. Aim
them [1]. However the dental curriculum has not really The aim of this paper is basic digital education. To
changed in 50 years. It has not been revised. Much has discuss the concept of digital dentistry, its advantages
been added to what dentists must know, considering and limitations, and to provide an overview of digital
digital technology, there are all those new technologies, impression-taking procedures, to clarify the basic steps
new CAD/CAM materials etc. but the curriculum of the digital workflow, to introduce the direct method
has not been changed [2]. Most practicing dentists of intraoral scanning to construct a virtual cast for CAD/
received their professional training before the advent CAM application. The purpose of the paper also includes
of the digital dental technology. Once they become clarifying the difference between chairside and labside
interested in the new technologies and in developing systems, discuss the features of intraoral impression-
new skills they demand continuing education courses. taking such as accuracy, the time factor and the patient’s
There is a severe need to include digital dentistry subjective comfort, to present comparative data on
in the undergraduate and postgraduate education the precision of digital impressions made by intraoral
programs. If digital technologies and their novel scanners to laboratory scanning of conventional casts
materials are not introduced into the dental curricula and to compare the traditional impression-taking
dentists and technicians will not fully understand the method to the digital one and provide a short summary
range of new technologies available to them and will on the advantages and difficulties of the scanning
not be able to make informed decisions regarding the procedure.
110 Stoma Edu J. 2018;5(2): 110-117 http://www.stomaeduj.com
INTRAORAL SCANS FOR CAD/CAM APPLICATION
Original Article
2. Material and methods
The Department of Prosthodontics, Faculty of Den-
tistry, Semmelweis University has been working with
digital impression-taking systems since 2011. Digital
technologies and their novel materials have been in-
troduced into the department’s undergraduate dental
curricula. A Bachelor of Science digital dental designer
training program is also aimed at the Faculty of Dentist-
ry SU in cooperation with the Neumann University of
Technology and Economics to modernizate the classic
profession of dental technician. A series of articles has
been published in the Hungarian dental paper in 2017
as part of the continuing education program to edu-
cate Hungarian dentists about digital dentistry. This pa-
per gives a summary of the digital dentistry series.
Figure 1. Dental students practice digital impression taking at the De-
3. Results partment of Prosthodontics of Semmelweis University, Budapest.
In 2018 all four Hungarian dental schools teach digital
technology, they give lectures and demostrations
and 50% have also practical training. All four dental
laboratories of those schools use some digital
techniques (Fig. 1). Dental technology educational
programs are faced with serious challenges, including
rapid changes in technology, inadequate funding
for educational programs, and the need to develop
curricula that reflect current industry needs [3]. The
high cost to purchase equipment and the investment
of time and expense in staff training encourages non-
university educational systems and trainings.
Manufacturers and commercial dental laboratories
offer a selection of continuing education courses for
international dentists. Some courses are accredited
by universities and the participants are awarded
certificates and European Credit Transfer System (ECTS) Figure 2. Laboratory scanner creates a 3-dimensional set of points by in-
credits [4]. Online knowledge centers and webinars formation of sectioned cast or impression.
provided by manufacturers offer promising new
opportunity for self-education [5].
Digital technology introduced new nomenclature for
dental procedures: digital workflow, CAD/CAM systems,
indirect CAD/CAM impression technique, direct CAD/
CAM impression technique, digital impressions,
virtual casts, intraoral scanners, close or open systems,
charside or labside systems. These elements are drafted
in italics in the following text.
3.1. Digital workflow
3.1.1. Indirect CAD/CAM method Figure 3. CAM (Computer-Aided Manufacturing) machine milled crowns
The digital workflow starts with a device which is from zirconia block.
suitable for mapping real forms. Indirect CAD/CAM The computer makes the virtual cast that serves as
method is built on conventional impressions. The basis for CAD/CAM workflow. During CAD (Computer-
virtual cast is created by digitizing the gypsum cast Aided Design) the dental technician designs dental
(or the conventional impression) with a laboratory restorations, most often crowns, veneers, inlays or
scanner [6] (Fig. 2). The virtual cast is a realistic, colorful onlays and bridges. The CAD software enables the
digital model of the patient’s oral cavity. This method technician to design the framework of the restorations
has some distorting effects enclosed: conditions of or the anatomical, final form. Applying CAM (Computer-
impression-taking, material properties of alginate, Aided Manufacturing) the restorations are milled from
silicone or gypsum (shrinkage of impression material, solid blocks with dental milling CNC machines (Fig. 3).
dilation or shrinkage of gypsum) and sectioning of There are different types of materials to mill: ceramics,
casts. Furthermore, the laboratory scanner has some zirconia, PMMA, metal alloys or titanium.
degree of distortion.
The laboratory scanner creates a 3-dimensional set 3.1.2. Direct CAD/CAM method
of points based on information of the sectioned cast. The Direct CAD/CAM method means that the digital
Stomatology Edu Journal 111
INTRAORAL SCANS FOR CAD/CAM APPLICATION
data set is created by intraoral scanning. Intraoral
Original Article scanners are intraoral devices for capturing direct
optical impressions [6] (Fig. 4). Intraoral scanners are
based on different data capture principles: confocal
laser technology, confocal microscopy, triangulation,
wavefront sampling, multiscan imaging, stereopho-
togrammetic video, accordion fringe interferometry
[7,8].
It is important that the user takes digital impressions
according to the manufacturer’s instructions. This
method can eliminate many inaccuracies derived
from indirect CAD/CAM impression process. However,
the traditional principles of the impression-taking
procedure are still alive, soft tissue control and isolation
remain basic principles. The scanning process ends
with biterecord. There are intraoral scanners which can
also determine the tooth-color.
The next step following the digital impression-taking
procedure is to evaluate the quality of the virtual cast
(Fig. 5). Inaccuracies can be eliminated by the dentist
directly chairside within this step. The occlusal and axial Figure 4. Trios intraoral captures optical impressions of the prepared
reduction, the insertion direction can be observed on teeth for the direct CAD/CAM method.
the computer screen with built in tools of software.
The margin line can also be checked enlarged by the
software.
Any imperfections of the virtual cast can be corrected
without the need to retake the whole impression.
Additional images of the areas of interest can be added
to previous scan. When satisfied with the impression
and resulting virtual cast, it is sent to laboratory with
the digital worksheet via e-mail.
There are open and closed dental CAD/CAM systems.
Closed systems’files can be opened by the manufacturer’s
CAD software only. Closed systems are CEREC AC and Figure 5. Full arch virtual casts in ICP position on computer screen after
E4D systems. Most intraoral scanners work with an open scanning.
system and they are compatible with several types
of CAD softwers and milling machines (for example
3Shape TRIOS, Planmeca PlanScan, CEREC Omnicam,
iTero Element, Carestream CS 3500, 3M True Definition,
GC Aadva, DWIO Dental Wings, KaVo Lythos, Dentium
Rainbow, Zfx IntraScan, MFI Condor IOS, etc) (7).
3.2. Direct CAD/CAM workflow
3.2.1. Labside system
The labside workflow of CAD/CAM technology means
The labside workflow of CAD/CAM technology means
that the dental technician processes data coming
from the dental office. The technician performs the
preparatory work on the virtual cast, model occlusion
with CAD software and design restoration on the
computer screen (Fig. 6).
The technician sets the margin line and the space for
the cement. After that the framework or the full-contour
restoration is designed. The anatomical occlusion surface
and contour of the teeth can be made individually. The Figure 6. Dental technician designs restoration on computer screen with
software contains the color of the restoration, so the CAD software.
suitable block is chosen for the milling. Digital planning the restoration, then data sets are sent for milling to the
does not exclude model making. From the digital data centre. Procera is a well-known example for milling centre.
a polimer model can be made by milling, 3D printing or It is specialised for milling technically sensitive materials
with stereolithography (SLA) [9]. The final restoration can like high strength ceramics and titanium (Figs. 9, 10).
be checked on this model (Figs. 7, 8).
Another option of the computer-assisted production 3.2.2. Chairside systems
is centralised production in a milling centre. In this We must not forget that initially intraoral scanners were
variation, it is possible for the local laboratory to design developed for chairside solutions (CEREC). The main
112 Stoma Edu J. 2018;5(2): 110-117 http://www.stomaeduj.com
INTRAORAL SCANS FOR CAD/CAM APPLICATION
idea was to make restorations without the need for scanners were evaluated in terms of trueness and
Original Article
dental laboratory. A chairside system means that every precision (an acrylic model with the embedded
step of the workflow is in the hands of the dentist. typodont teeth was scanned and datasets were
Digital impressions are taken in the dental office with superimposed): 3Shape trios, 3M True Definition, iTero,
an intraoral scanner, designing the restoration is done CS3500, CEREC Omnicam, Planmeca, Planscan [14].
chairside and even the milling and finishing is done in The accuracy of virtual data gained from intraoral
the office. Its great advantage is that it offers One Day scanners is influenced by many factors. For example,
Dentistry. Inlays, onlays, solo crowns can be made for the palatum and toothless areas do not give enough
patients within a few hours. Monoblocks restorations information to make a useful digital model [15, 16].
are milled with the CAM unit, which need small Virtual models obtained by digital impressions were
adjustments (staining, polishing, sintering) before shown to be more accurate than their conventional
cementation. counterparts when Polyvinyl-siloxane impressions and
The main difference between those restorations milled digital impressions with three intraoral scanners (iTero,
by labside and chairside systems are the extension and Figure 7. Polymer model made by 3D printing from digital data.
the materials used. Chairside systems are made for solo
restorations as mentioned before (veneers, crowns,
inlays, onlays, small full contours), and temporaries.
Labside milling in the dental laboratory or in the milling
centres offers you more options due to the precision
of 5-axis milling and high-strength materials, labside
offers extended prosthetic appliances.
Figure 8. Polymer models are printed with pins holding the ICP position
4. Discussion and mounted on an adjustable articulator for veneering.
4.1. Features of taking digital impressions - accuracy,
time factor, patient’s comfort
There are numerous factors that can easily describe
the clinical use of the digital impression procedure. The
investigation of some of these factors can be measured
objectively, for example accuracy and scanning time.
This is a well-researched area in literature. Other
features of intraoral scanners can be described with
subjective parameters for example patient’s comfort
and dentist’s satisfaction.
4.1.1. Accuracy of digital impressions
The fit of the final restoration depends on the quality of
the impression, therefore accuracy of intraoral scanners Figure 9. CAM/Computer Assisted Manufacturing: Blocks for zirconium-
dioxide frameworks, lithium disilicate monolithic restorations and PMMA
is one of the most important features. Accuracy consists
temporary restorations.
of trueness and precision. Trueness describes how close
our data are to the original true value. Precision shows
the relative deviation of the repeated measurements
[10] (Fig. 11).
In a blind study, crowns developed using intraoral
scanning technology were preferred over crowns
generated using conventional impressions and
criteria of marginal fit, contacts, occlusion, and
time of adjustment in nearly 70% of cases [11].
It was found that digital quadrant impression methods
achieve a level of precision, comparable to the
conventional impression techniques (precision ranged
from 18.8 to 58.5 μm). However, there are significant
differences in terms of absolute values and deviation
pattern [12].
The direct digitalisation with Lava C.O.S. showed
statistically significantly higher accuracy compared to
the conventional procedure of impression-taking and
indirect digitalisation when datasets were generated
and superimposed by a best fit algorithm. It could
be shown that direct digitalisation accomplished the
most accurate results, followed by digitized polyether Figure 10. PMMA block manufactured in Roland DG DWX-50 milling
impression, and indirect digitalisation [13]. machine. Advantage of PMMA temporary restorations fabricated by CAD/
According to a study in 2015 the following scanners CAM technology is that they last long. Polymer’s resistancy is much better
were found acceptable in clinical practice when than temporary materials used for conventional chairside technique.
Stomatology Edu Journal 113
INTRAORAL SCANS FOR CAD/CAM APPLICATION
CEREC, TRIOS) were made from a PMMA model for
Original Article comparison [17] (Fig. 12).
4.1.2. Time efficiency (factor) of digital impressions
We have found numerous studies comparing the
time needed for digital and conventional impression-
taking techniques. When investigating the whole
treatment time an average of 260 s is needed for a
digital impression and 620 s for a conventional one.
Bite registration with intraoral scanner took five times
less than with the conventional technique [18].
Although scanning time extends when there are Figure 11. Fit of the final restoration depends on the quality of the im-
abutment teeth in the arch. Scanning 1 abutment is 23 pression. Accuracy consists of trueness and precision. Trueness shows how
minutes, 2 abutments 22 minutes and the whole arch is close is our data to the original true value. Precision shows the relative de-
13 minutes faster than conventional impression-taking. viation of repeated measurements.
As the number of prepared teeth increases, the time of
the intraoral scanning gets closer to the conventional
impression-taking time. In these studies participants had
experience in taking conventional impressions [19].
In Lee and Galucci’s study dental students had no
previous experience on taking impressions. Intraoral
scanning took half the time of the conventional
technique. Consequently, the study shows that without
experience intraoral scanning is still a time saving
technique. It seems that digital technology reduces
patients’ time spent in the dental office [20].
4.1.3. Evaluation of the digital impression-taking
procedure based on the dentist’s and the patient's
subjective comfort
In 2016 Joda et al. investigated digital and conventional
implant impression procedures. They found the
usability and the efficiency of intraoral scanners more
favourable by students (88%) and dentists (64%)
compared to conventional methods [21].
Figure 12. Less time is needed for a full arch intraoral scan compared to
According the previous studies patients prefer digital the conventional impression taking procedure.
impressions to conventional ones. During conventional
impressions patients reported breathing difficulties
and they felt vulnerable, especially when upper
impressions were taken. They were afraid of repeating
conventional impressions rather than repeating digital
ones [22].
Overall both dentists and the patients found it less
stressful when impressions were taken digitally.
4.2. Intraoral scanning possibilities; advantages and
difficulties
In the next session we would like to introduce the Figure 13. Scan bodies are used for implant scanning, they provide the
necessary information for designing the prosthetic appliance.
features of the new technology, which can be a benefit
or an initial difficulty when we use an intraoral scanner CAD software in order to plan the digital prosthetic
[23]. appliance. Manufacturers have already faced the need
to start production of hybrid scan bodies, which are
4.2.1. Difficulties of intraoral scanning compatible with different systems.
Learning the process of intraoral scanning is not an If we are not properly informed about the scanners’
easy task, it is important to follow the instructions given features prior to the purchase, it may be an
by the manufacturers. Digital impression taking is very unpleasant surprise that some companies charge a
different from conventional impression procedure. data management fee. In such a case, after scanning
During scanning as the scanner-head goes above the the data, it is entered into the cloud operated by
surface of the tooth the software adds new data to the the company, from which it can only be sent to the
images that have already been taken. The inappropriate laboratory after payment of the fee. However, most
use leads to insufficient or inaccurate virtual model. manufacturers provide an open system, which allows
For implant scanning scan bodies are used, which are to export the STL files for free.
supported by the manufacturers (Fig. 13). Limitation of intraoral scanners is that they are very
These scan bodies should be compatible with the expensive, however the cost of equipment is expected
114 Stoma Edu J. 2018;5(2): 110-117 http://www.stomaeduj.com
INTRAORAL SCANS FOR CAD/CAM APPLICATION
Original Article
Figure 14. When digital impression taken, the virtual model is appearing Figure 15. Scanned image can be displayed on computer screen and si-
continuously on computer screen. Additional scans are integrated to the multaneously on dental laboratory devices. It helps communication be-
incomplete (white) areas. tween lab and dental office.
Figure 16. Built in software features of intraoral scanners (such as occlusal analysis) make dentists’work lot easier. Some scanners determine tooth shade
and are equipped with intraoral cameras, thus expanding the possibilities of communication between dental lab and dentists.
to decrease in the future as the cost of production of
scanners is declining.
4.2.2. Advantages of intraoral scanning
One great advantage is that the virtual model can be
evaluated immediately chairside on the computer
screen and the preparation can be modified if needed
(Fig.14).
Built-in features of the software help to find not properly
scanned surfaces and scan the approximal areas. The
software provides data on adequate material thickness
corresponding to the type of the dental appliance. The Figure 17. Digital impressions save the original form and shape of pa-
virtual model can be modified easy and quick, there is tient’s teeth. The data can be stored for years and help planning of dental
no need to rescan the whole arch. treatment later.
Scanning is more time-efficient than conventional initial status and treatment scans. The final aim is the
impression-taking. No time needed for mixing, setting, evaluation of long term changes in the dental status,
disinfection or casting. such as dental migration, rotation, gingiva recession,
In addition, digital impression taking is an environment- abrasions etc. [7, 24] (Fig. 17).
friendly procedure, as it eliminates the large amount Data of intraoral scanning can be fused with data of
of hazardous waste generated by conventional other 3 dimensional methods, such as CT and CBCT.
impressions in dental practices. Ease of documentation This option opens up completely new perspectives
is an important advantage. Digital models never wipe, for diagnosis, treatment plan, and planning of dental
break, wear out. Patient documentation can be stored surgeries, already used in orthodontics and dental
digitally on a hard disk or in the cloud and can be implantation. Modern undergraduate educational
recalled at any time. (Fig. 15) programs in implant dentistry (including digital
Intraoral scanners have additional functions such as prosthetic treatment) can provide proffessional care
color display and intraoral camera. These functions and a high treatment quality for the patients [25].
also help patient communication as they make the
lesions visible. Some scanners are able to determine
tooth shade and forward that information to the dental 5. Conclusions
laboratory (Fig. 16). Digital dentistry is here to stay and it offers quick and
The scanned data are also an excellent tool for comfortable experience to the patients and an efficient
treatment follow up and to evaluate the patients’ dental workflow to the dentist and dental technicians. The
status. At the University of Zurich, Zimmermann et al. learning curve is steep to adopt that new technology
created a digital database, which records the patient’s both in the dental office and on the laboratory side.
Stomatology Edu Journal 115
INTRAORAL SCANS FOR CAD/CAM APPLICATION
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Judit BORBÉLY
DMD, PhD, Associate Professor
Department of Prosthodontics, Faculty of Dentistry
Semmelweis University Budapest
Szentkirályi u. 47, H-1088 Budapest, Hungary
CV
Doctor Borbély is an Associate Professor at the Department of Prosthodontics, Semmelweis University, Budapest, Hungary.
She graduated from the Dental Faculty of Semmelweis University of Medicine, Budapest, Hungary in 2001, then she began
to specialize in prosthodontics. She received her PhD degree in 2008 on visual and digital methods for tooth shade selection.
She also works in private practice focusing on prosthodontics and aesthetic dentistry. Since 2011 she has been working with
digital impressioning systems. She conducts ongoing clinical research in digital prosthodontics and materials research. She
presents lectures, hands-on clinical and postgraduate courses on ceramics, tooth shade selection and intraoral scanning. She
is a presidential member of the Hungarian Prosthodontic Association and Hungarian Dental Association, she is a member of
Society for Color and Appearance in Dentistry and Hungarian Academy of Esthetic Dentistry.
116 Stoma Edu J. 2018;5(2): 110-117 http://www.stomaeduj.com
INTRAORAL SCANS FOR CAD/CAM APPLICATION
Questions
Original Article
1. Intraoral scanners cannot be based on:
qa. Confocal laser technology;
qb. Confocal microscopy;
qc. Triangulation;
qd. Scanning probe microscopy.
2. It is not true for open CAD/CAM systems:
qa. Files can be opened by the manufacturer’s CAD software only;
qb. For example 3Shape Trios and Planmeca Planscan;
qc. It is compatible with several types of CAD softwares;
qd. It is compatible with several types of milling machines.
3. What does accuracy consist of?
qa. Trueness and deviation;
qb. Precision and deviation;
qc. Trueness and precision;
qd. Quality and quantity.
4. Which material cannot be milled by dental CNC machines?
qa. PMMA;
qb. Ceramic;
qc. Titanium;
qd. Gold.
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Stomatology Edu Journal 117