Digital Versus Conventional Impressions in Fixed

Prosthodontics: A Review
Pekka Ahlholm,1 Kirsi Sipilä, DDS, PhD,1,2,3,4,5 Pekka Vallittu, DDS, PhD, CDT,6,7,8 Minna Jakonen, DDS,
PhD,9 & Ulla Kotiranta, DDS,1,10
1
Institute of Dentistry, University of Eastern Finland, Bachelor of dentistry, Kuopio, Finland
2
Oral and Maxillofacial Department, Kuopio University Hospital, Kuopio, Finland
3
Research Unit of Oral Health Sciences, Faculty of Medicine, University of Oulu, Oulu, Finland
4
Medical Research Centre, Oulu, Finland
5
Department of Oral and Maxillofacial Surgery, University Hospital, Oulu, Finland
6
Department of Biomaterials Science and Turku Clinical Biomaterials Centre – TCBC, Turku, Finland
7
Institute of Dentistry, University of Turku, Finland, Turku, Finland
8
Welfare Division, City of Turku, Finland
9
Health Centre of Kuopio, Kuopio, Finland
10
Department of Oral and Maxillofacial Diseases, University Hospital, Kuopio, Finland

Keywords Abstract
CAD/CAM; digital impression; conventional
impression; impression accuracy.
Purpose: To conduct a systematic review to evaluate the evidence of possible benefits
and accuracy of digital impression techniques vs. conventional impression techniques.
Correspondence
Materials and Methods: Reports of digital impression techniques versus con-
Pekka Ahlholm, Institute of Dentistry, ventional impression techniques were systematically searched for in the following
University of Eastern Finland, BOX 1627, databases: Cochrane Central Register of Controlled Trials, PubMed, and Web of
FI-70211 Kuopio, Finland. E-mail: Science. A combination of controlled vocabulary, free-text words, and well-defined
[email protected] inclusion and exclusion criteria guided the search.
Results: Digital impression accuracy is at the same level as conventional impression
The authors deny any conflicts of interest. methods in fabrication of crowns and short fixed dental prostheses (FDPs). For fabrica-
tion of implant-supported crowns and FDPs, digital impression accuracy is clinically
Accepted June 19, 2016
acceptable. In full-arch impressions, conventional impression methods resulted in
better accuracy compared to digital impressions.
doi: 10.1111/jopr.12527
Conclusions: Digital impression techniques are a clinically acceptable alternative
to conventional impression methods in fabrication of crowns and short FDPs. For
fabrication of implant-supported crowns and FDPs, digital impression systems also
result in clinically acceptable fit. Digital impression techniques are faster and can
shorten the operation time. Based on this study, the conventional impression technique
is still recommended for full-arch impressions.

The abbreviation “CAD/CAM” denotes computer-aided design system, digital impressions are taken by intraoral scanner,
and computer-aided manufacturing. Developed in the 1950s, which, like an ordinary camera, collects information about pro-
CAD/CAM technology enables modelling, design, and manu- jecting light. Reproducible tissues are shown on the hardware
facture of objects, for example in industrial processes. In den- display as natural looking. The main structures of the pros-
tistry CAD/CAM technology has been used since the 1980s thetic design in terms of data are 3D in the prepared teeth,
to produce inlay and onlay fillings, crowns, laminates, fixed the adjacent teeth, and the occlusion with the opposing bite.
dental prostheses (FDPs), and implants, and is increasingly The intraoral scanner measures the light reflection times of the
used by dentists and technicians. The brand name “CEREC” subject surface. The description, based on data and calcula-
was the first CAD/CAM system used in dentists’ offices and tion algorithms to copy the software, calculates and generates
came on the market in 1987. It was initially designed for the a computer screen image of the prepared area.1
manufacture of esthetic ceramic restorations. Over the years, The dentist is responsible for monitoring a copy of gradua-
the system has developed into the fourth version of the hard- tion from a chair next to the reception screen and ensures that
ware, enabling the manufacture of inlay and onlay fillings, critical sites are correct. Intraoral cameras use video technique
crowns, laminates, FDPs, and even implants. In the CAD/CAM or still photo technique for scanning. Still images are based on

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Digital vs. Conventional Impressions in Fixed Prosthodontics Ahlholm et al

triangulation or parallel confocal laser scanning. Systems take Search in PubMed

several still images from which a 3D image can be formed.
(“computer-aided design”[MeSH Terms] OR (“computer-
These are basic principles, and in addition to this each man-
aided”[All Fields] AND “design”[All Fields]) OR “computer-
ufacturer uses its own techniques. Intraoral cameras may also
aided design”[All Fields] OR (“cad”[All Fields] AND
use multiple techniques for data collection. LAVA C.O.S. (3M
“cam”[All Fields]) OR “cad cam”[All Fields]) AND “digital
ESPE, St. Paul, MN) and Lava True Definition scanner (3M
impression”[All Fields] AND “conventional impression”[All
ESPE) use active wavefront sampling for data collection from
Fields] (MeSH, Medical Subject Heading).
which video image is formed. CEREC AC Bluecam (Sirona
Dental System GmBH, Bensheim, Germany) uses active tri-
angulation and optical microscopy to produce still images. Search in Web of Science
The CEREC AC Omnicam (Sirona Dental System GmBH) (“computer-aided design” OR (“computer-aided” AND “de-
CAD/CAM system uses video for data collection. iTero (In- sign”) OR (“cad” AND “cam”) OR “cad cam”) AND “digital
visalign; Cadent Inc, Or-Yehuda, Israel) and 3Shape Trios impression” AND “conventional impression.”
(Copenhagen, Denmark) use the parallel confocal method to
produce digital data.1,2 These two phases, digital impression Search in the Cochrane Central Register
and design software, are called the CAD phases. In the CAM of Controlled Trials
phase, prosthetic restoration is manufactured from a solid block
of selected material in the milling unit. Manufacturing technol- (“computer-aided design” OR (“computer-aided” AND “de-
ogy used by the dentists’ office is generally based on subtractive sign”) OR (“cad” AND “cam”) OR “cad cam”) AND “digital
techniques. Additive systems and techniques are used by the impression” AND “conventional impression.”
technicians to produce more-complex restorations.3
Good marginal and internal fit, along with high mechanical Inclusion criteria
strength, good interfacial adhesion to veneering material and The literature search included only English-language articles
luting cement, are the most important factors in improving the in the field of dentistry, published in peer-reviewed dental jour-
prognosis of the prosthetic restoration of, for example, a crown. nals. To identify further studies, the reference lists of iden-
Each of the ceramic and impression manufacturing phases tified articles of digital impressions vs. conventional impres-
alters the dimensions and the fit of the final restoration. Addi- sions were screened. Unpublished reports or abstracts or case
tionally, the milling accuracy is also influenced by the material, reports as well as reports that did not cover both conventional
including the filler size of a resin composite, for example. A and digital impression techniques were not included. The selec-
minimal marginal gap prevents plaque accumulation and the tion of included titles was followed by an abstract search. After
risk of formation of secondary caries. Most investigators use agreeing on abstract inclusion, a full-text search followed. Final
the marginal gap criteria established by McLean and von Fraun- selection of articles was based on full-text reading. The
hofer, who concluded that a maximum of 120 µm is allowed for search design was as follows: Electronic search: “digi-
marginal opening. Values between 50 and 200 µm are reported tal impression versus conventional impression”→Review of
with the absence of an objectively accepted threshold.4 The abstracts→Review of full texts→Individual selection of the
accuracy of dental impressions is determined by the trueness final articles.
and precision values, which together describe the accuracy of
a specific impression method. The trueness is determined by
the deviation of the tested impression method from the original
Results
geometry. The difference between trueness and precision is Identified articles
that precision indicates the deviations between the impressions
The search yielded 17 references from the PubMed, 9 from
within a test group. Linear distance measurements are the most
Web of Science, and 1 from the Cochrane Central Register
commonly used method for accuracy of conventional intraoral
of Controlled Trials. Based on the assessment of the titles,
impressions with gypsum casts, and they are restricted to a few
abstracts, and the full text, 16 articles were selected from
measurement points.5 The aim of this study was to conduct a
PubMed, 9 from Web of Science, and 1 from the Cochrane
systematic review to evaluate the evidence of possible benefits
Central Register of Controlled Trials. The total number of ar-
and accuracy of digital impression techniques vs. conventional
ticles was reduced to 19 because some studies were identi-
impression techniques in FDP fabrication.
fied from two databases. One article was found in all three
databases, and 7 articles were found in both PubMed and Web of
Materials and methods Science.
Search strategy
Digital impression versus conventional
An electronic search of publications from 1987 to 2015 was
impression for fabrication of crowns and FDPs
established from three electronic databases: PubMed, Cochrane
Central Register of Controlled Trials, and Web of Science. The The studies evaluating the impression accuracy for crowns
search strategy used a combination of controlled vocabulary and short FDPs are presented in Table 1. Anadioti et al6 con-
and free-text words. The detailed search design and strategies, ducted an in vitro study to evaluate the 3D and 2D marginal fit
including keywords, developed for each database are presented of pressed and CAD/CAM lithium disilicate crowns. Crowns
below. were made based on digital and conventional impressions using

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Ahlholm et al Digital vs. Conventional Impressions in Fixed Prosthodontics

Table 1 Precision of crowns fabricated by using digital and conventional impression techniques

Marginal gap
Study (mean/median)
Author type Experimental group N (µm) Internal fit (µm)
6
Anadioti et al, 2015 In vitro PVS impression/IPS e.max Press crowns 15 40
PVS impression/e.max CAD crowns 76
Lava C.O.S/IPS e.max Press crowns 75
Lava C.O.S/IPS e.max CAD crowns 74
Seelbach et al, 20137 In vitro CEREC/Empress CAD 10 88
Lava C.O.S./Lava zirconia 29
iTero/Copran Zr-i 50
Single-step putty-wash impression/Lava zirconia 36
Single-step putty-wash impression/Cera E alloy 44
Two-step putty-wash impression/Lava zirconia 35
Two-step putty-wash impression/Cera E alloy 56
Zarauz et al, 20164 In vitro iTero/zirconia 26 80.2 111.4
One-step silicone impression/zirconia 133.5 173.0
Syrek et al, 20108 In vivo Lava C.O.S./Lava zirconia 18 49
Two-step silicone/Lava zirconia 71
Abdel-Azim et al, In vitro Lava C.O.S./e.max 10 89.8
201510 iTero/e.max 89.6
Two-step PVS impression/e.max 9 112.3
Almeida e Silva et al, In vitro Lava C.O.S./zirconia 12 63.9 58.4
201411 Conventional impression/zirconia 65.3 65.9

the following combinations: conventional impression/pressed marginal gap for the conventional two-step impression group
crown, conventional impression/CAD/CAM crown, digital was poorer, 71 µm, although clinically acceptable. CAD/CAM
impression/press crown, and digital impression/CAD/CAM crowns also had better interproximal contact points.
crown. Two points on the margin and at 0.75 mm above the Abdel-Azim et al10 reported similar marginal accuracy for
margin were measured for the 2D measurements; 3D marginal crown fabrication using Lava C.O.S. and iTero CAD/CAM
fit measurements showed the average marginal fit of the selected systems and PVS impressions. In this in vitro study all measured
area. Measurements revealed that the polyvinyl siloxane (PVS) marginal gaps were clinically acceptable. Almeida e Silva et
impression/IPS e.max press group produced the most accu- al11 conducted an in vitro study to evaluate the marginal and
rate marginal fit, whereas no significant differences in marginal internal fit of four-unit fixed zirconia FDPs based on digital and
fit were found between the other groups. Seelbach et al7 con- conventional impression techniques. They found no statistical
ducted an in vitro experiment to evaluate the precision of crowns differences between the Lava C.O.S. digital impression group
fabricated by using conventional and digital impressions, mea- and the conventional impression group, using Impregum (3M
suring the accessible marginal inaccuracy and the internal fit. ESPE, Seefeld, Germany), although impressions made by the
They concluded that the accuracy of crowns fabricated by us- CAD/CAM system resulted in better marginal and internal fit at
ing digital impressions was at the same level as conventional the premolar mesial and molar distal faces. In both groups the
impressions. results were clinically acceptable. Vennerstrom et al12 reported
Zarauz et al4 conducted an in vivo study to evaluate the similar marginal and internal fit values for crowns manufactured
marginal fit of crowns based on conventional silicone impres- using digital and conventional impression techniques, using
sions and digital iTero impressions. To evaluate the precision CEREC, iTero or Lava C.O.S. CAD/CAM systems.
of crowns fabricated using conventional and digital impres-
sion systems, 26 crowns were made on each technique and
cemented on their corresponding clinical preparation. Means Digital impression versus conventional
of the internal misfit and marginal misfit were measured using impression for fabrication of implant-supported
stereomicroscopy of 2-mm-thick slices in a buccolingual orien- crowns and FDPs
tation. Results were more accurate for the digital system. Based An in vitro study by Abdel-Azim et al13 discovered the
on this, a computer-aided impression system and CAD/CAM influence of computer-aided impression options on the
technology can improve the marginal adaptation of all-ceramic accuracy of dental implant-based single units and complete-
single crowns. Further, Syrek et al8 and Ting-Shu and Jian9 arch frameworks. They reported that conventional impressions
reported 49 µm for median marginal gap of crowns fabricated resulted in a smaller marginal discrepancy than digital meth-
using the Lava C.O.S. CAD/CAM system, while the median ods for a single-implant framework. For single implants the

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Digital vs. Conventional Impressions in Fixed Prosthodontics Ahlholm et al

mean marginal gap was 24.1 µm for conventional impressions precision were evaluated from five conventional impressions
compared to 61.4 µm for digital impressions. In full-arch im- with a vinyl siloxanether impression material and from five
pressions a 135.1µm mean marginal gap was measured for digital impressions of the reference model made with the
conventional impressions compared to 63.1 µm for the dig- CEREC AC Omnicam. The results showed that the trueness
ital impressions. Additionally, Lee et al14 conducted an in and the precision of the digital complete-arch impression were
vitro study to compare the accuracy of implant impressions less accurate than those of the conventional impressions. The
made with digitally manufactured models vs. gypsum models deviation patterns of conventional and digital impressions were
vs. CAD/CAM system models. The digital impressions were also different. In their earlier in vitro study Ender and Mehl18
made with the iTero system and the conventional close-tray evaluated the precision of conventional and digital impressions
impressions with a VPS material. Gypsum models represented on full-arch scanning, showing that the accuracy of digital
more details in grooves and fossae compared to CAD/CAM impressions was similar to that of conventional impressions.
models. According this study, milled models based on digi- Later, Ender et al19 studied impression accuracy of quadrant
tal impressions were comparable to gypsum models based on impressions and found that digital quadrant impressions
conventional impression. were comparable to conventional methods based on a level of
precision; however, the precision differed significantly between
the digital impression systems including Lava True Definition
Digital impression versus conventional
Scanner, Lava Chairside Oral Scanner, Cadent iTero, 3Shape
impression for full-arch FDPs
Trios, 3Shape Trios Color, CEREC Bluecam Software 4.0,
Studies concerning the impression accuracy for fabrication CEREC Bluecam Software 4.2, and CEREC AC Omnicam.
of full-arch FPDs are presented in Table 2. Ender and Mehl5
published an in vitro study on the accuracy of conventional and
Time efficiency and operator’s perception
digital impression methods used in full-arch dental impressions.
Four digital impression systems (CEREC Bluecam, CEREC Several studies have compared the conventional and digital im-
AC Omnicam, iTero, Lava C.O.S.) and four conventional pressions from both the patient’s and the dentist ́s point of view.
impression materials were used. A highly accurate reference In 2014 Yuzbasioglu et al20 showed that the overall treatment
scanner was used to evaluate the accuracy for both full-arch time and impression time were lower with the digital impres-
conventional and digital impressions of the same dental mor- sion technique as compared to conventional methods. The dig-
phology. The results showed that the highest trueness and pre- ital impression took approximately 248.48 ± 23.48 seconds
cision was measured for CEREC Bluecam, vinylsiloxanether, and conventional impression 605.38 ± 23.66 seconds. The pa-
and direct scannable vinylsiloxanether. In general, local tients felt the uptake of digital impressions with CEREC AC
deviations of the full arch-impressions were higher for digital Omnicam more pleasant and kept it as a primary option. Fur-
impression systems as compared to conventional impression ther, Lee et al21 evaluated the difficulty level and the operator’s
methods. perception of digital and conventional implant impressions. In
Flügge et al15 conducted an in vivo study to evaluate the this in vitro study 30 experienced professionals and 30 den-
practical application and precision of digital scanning. Ten tal students made impressions of a single implant model. The
full-arch intraoral scans with the iTero CAD/CAM system and student group scored a mean difficulty level of 43.1 for the
10 conventional Impregum impressions were taken of one pa- conventional impression technique and 30.6 for the digital im-
tient. Plaster casts based on conventional impressions were pression technique on a 0 to 100 a visual analog scale (VAS).
then scanned again with iTero and a model scanner. The results Sixty percent of the students preferred the digital impression
showed that the lowest precision was measured for iTero scans and 7% the conventional impression as their first choice. The
from the patient. Extraoral model scanning with iTero showed clinician group scored a mean difficulty level of 30.9 for con-
a higher precision than the patient’s iTero scans. The high- ventional impressions and 36.5 for digital impressions on a 0
est precision was measured for stone model scanning. Another to 100 VAS scale. In the clinician group, 33% preferred the
study, by Güth et al,16 also evaluated the accuracy of full-arch digital impression and 37% the conventional impression. Forty
impressions based on digital and conventional impression tech- percent of the clinicians chose the digital impression as the
niques. This in vitro study used a straight bar between mandible most effective technique, and 53% preferred using the con-
quadrants. This approach was shown to be a reliable method to ventional impression. The conventional impression was more
analyze deviations in full-arch scans. Test group data were an- difficult for the student group than it was for the clinician group.
alyzed using inspection software to determine the aberration of The difficulty level of the digital impression was the same in
the bar length, the linear shift, and the angle deviation caused both groups. It was also found that the student group preferred
by the digitalization method. Lava True Definition scanner C the digital impression as the most efficient impression tech-
showed same or higher accuracy compared to conventional Im- nique, and the clinician group had an even distribution in the
pregum impressions. For the linear shift in Y- and Z-axis and choice of preferred and efficient impression techniques. An in
for the overall angle and the angle in the coronal direction the vivo study reported that the digital impression technique was
digital scanner showed significantly lower values as compared a more efficient and convenient method than the conventional
to conventional methods. impression method. The use of digital technique also resulted
Ender and Mehl17 investigated if the new reference scanner in better occlusal contacts as compared to conventional impres-
was capable of measuring the accuracy of conventional and sion techniques. The mean total procedure times for digital and
digital full-arch impressions. In this in vitro study trueness and conventional impression techniques were 14:33 ± 5:27 and

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Table 2 Precision of full-arch dental FDPs fabricated using digital and conventional impression techniques (results are in µm)

Author Study type Experimental group N Trueness (µm) Precision (µm)

5
Ender and Mehl, 2015 In vitro Polyether 5 60.2 66.7
Vinyl siloxanether 13.0 12.3
Direct scannable vinyl siloxanether 11.5 14.6
Irreversible hydrocolloid 37.7 59.6
CEREC Bluecam 29.4 19.5
CEREC Omnicam 37.3 35.5
iTero 32.4 36.4
Lava C.O.S. 44.9 63.0
Flugge et al, 201315 In vivo Intraoral scanning with iTero 10 50
Extraoral model scanning with iTero 25
Extraoral model scanning with D250 10
Ender and Mehl, 201317 In vitro Reference scanner 5 5.3 1.6
Conventinal impression 20.4 12.5
CEREC Bluecam 58.6 32.4
Ender and Mehl, 201118 In vitro Conventional Impregum impression 5 55 61.3
CEREC Bluecam 49 30.9
Lava C.O.S. 40.3 60.1
Ender et al, 201519 In vivo Converntional impression/metal full-arch tray 15 18.8
Conventional impression/T-tray 58.5
Lava True Definition Scanner 21.8
Lava Chairside Oral Scanner 47.7
iTero 49.0
3Shape Trios 25.7
3Shape Trios Color 26.1
CEREC Bluecam 4.0 34.2
CEREC Bluecam 4.2 43.3
CEREC Omnicam 37.4

20:42 ± 5:42 minutes, and the mean impression times were italization results are clinically acceptable when concerning
7:33 ± 3.37 and 11:33 ± 1.56 minutes, respectively. The mean crowns. For fabrication of implant-supported crowns and FDPs
scores for the dentist’s assessment of difficulty on a 0–100 VAS digital impression accuracy is clinically acceptable. Trueness
were 24.00 ± 18.02 and 48.02 ± 21.21 for digital and con- and precision differs significantly between the digital impres-
ventional impression technique, respectively. The mean VAS sion systems and impression methods. Local deviations over
scores for the patients’ assessment of discomfort were 6.50 ± 100 µm can lead to inaccurate fitting, thus causing problems in
5.87 and 44.86 ± 27.13 for digital and conventional impres- large prosthetic restorations.5,19
sion techniques, respectively (the value 100 meaning the most Impression accuracy and the fit of the definitive prosthesis de-
discomfort).22 pend on every phase of the process. In conventional techniques
every step, including impression, stone casts, wax patterns,
investment, and casting, must be carried out precisely to achieve
Discussion the best fit. Instead, dental CAD/CAM systems usually need
In this study all reported marginal gaps of crowns fabri- fewer steps (i.e., digital impression, design, and milling), where
cated using digital impressions resulted in clinically accept- the number of error sources is less than in the conventional
able marginal gaps. All marginal gaps were less than 120 µm, method. Additionally, the milling method is standardized.13
which is the clinical acceptable limit. Only Zarauz et al4 re- In fabrication of full-arch FDPs, digital impressions showed
ported crowns’ mean internal misfit and mean marginal mis- higher local deviations than conventional impressions did. As
fit of 173.0 and 133.5 µm for conventional one-step silicone clinical implications of this study, it concluded that the accuracy
impressions compared to 111.4 and 80.2 µm for the digital of CAD/CAM systems and digital impressions is compatible
impression group; however, results comparing the marginal fit with conventional impressions. The time efficiency of digital
between conventional and digital impressions varied. Anadioti impression systems is better than for conventional techniques.20
et al6 reported that IPS e.max crowns fabricated with conven- As to operator’s perception, digital impressions are easier for
tional PVS impressions produced the most-accurate marginal fit inexperienced clinicians.21 On the other hand, distal targets are
compared to conventional impression and CAD/CAM crown, challenging to impress with intraoral cameras. The size of dig-
digital impression and press crown, and digital impression and ital intraoral cameras is still bigger than traditional impression
CAD/CAM crown. This study concluded that indirect dig- trays. Some digital systems, for example CEREC Bluecam,

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Digital vs. Conventional Impressions in Fixed Prosthodontics Ahlholm et al

also require use of titanium oxide to improve the contrast. In students have also shown a preference for this technique, which
dental digital impression systems, the number of error sources means its use will likely continue to grow. Due to the relatively
is smaller than in traditional impression methods. The digital low number of studies, however, additional investigations are
impression is monitored on the hardware display screen, thus needed to confirm these findings.
enabling poorly scanned objects to be reproduced smoothly
without losing the complete impression data. The intraoral
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