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Comparison of digital and conventional impression techniques: Evaluation of

patients' perception, treatment comfort, effectiveness and clinical outcomes

Article  in  BMC Oral Health · January 2014

DOI: 10.1186/1472-6831-14-10 · Source: PubMed

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RESEARCH ARTICLE Open Access

Comparison of digital and conventional

impression techniques: evaluation of patients’
perception, treatment comfort, effectiveness and
clinical outcomes
Emir Yuzbasioglu*, Hanefi Kurt, Rana Turunc and Halenur Bilir

Abstract
Background: The purpose of this study was to compare two impression techniques from the perspective of
patient preferences and treatment comfort.
Methods: Twenty-four (12 male, 12 female) subjects who had no previous experience with either conventional or
digital impression participated in this study. Conventional impressions of maxillary and mandibular dental arches
were taken with a polyether impression material (Impregum, 3 M ESPE), and bite registrations were made with
polysiloxane bite registration material (Futar D, Kettenbach). Two weeks later, digital impressions and bite scans
were performed using an intra-oral scanner (CEREC Omnicam, Sirona). Immediately after the impressions were
made, the subjects’ attitudes, preferences and perceptions towards impression techniques were evaluated using a
standardized questionnaire. The perceived source of stress was evaluated using the State-Trait Anxiety Scale.
Processing steps of the impression techniques (tray selection, working time etc.) were recorded in seconds.
Statistical analyses were performed with the Wilcoxon Rank test, and p < 0.05 was considered significant.
Results: There were significant differences among the groups (p < 0.05) in terms of total working time and
processing steps. Patients stated that digital impressions were more comfortable than conventional techniques.
Conclusions: Digital impressions resulted in a more time-efficient technique than conventional impressions.
Patients preferred the digital impression technique rather than conventional techniques.
Keywords: Digital impression, Clinical efficiency, Patient comfort, Patient preference

Background and precise restorations using CAD/CAM technology

The introduction of computer-aided design/computer [4-7].
aided manufacturing (CAD/CAM) technology in dentis- According to the 8th edition of The Glossary of Pros-
try has resulted in more accurate manufacturing of pros- thodontics Terms, “impression” is defined as “a negative
thetic frameworks, and greater accuracy of dental likeness or copy in reverse of the surface of an object; an
restorations, and the technology has improved since the imprint of the teeth and adjacent structures for use in
1980s [1,2]. The development strategy of CAD/CAM dentistry” [8]. The accuracy of the impression depends
techniques included automating the production process on the materials themselves [9-13], impression tray types
and optimizing the quality of restorations by using new [14-16], and impression techniques [17-19]. Each step in
biocompatible materials, especially high performance the process introduces potential human and/or material
ceramics, such as zirconia and lithium disilicate [3]. Sev- error [20,21].
eral reports have demonstrated the potential for accurate There is some variability in impressions and the result-
ing master casts, depending on the technique and mater-
* Correspondence: [email protected] ial used by the operator [22]. The accuracy of master
Department of Prosthodontics, School of Dentistry, Istanbul Medipol casts has been the subject of numerous research projects,
University, Istanbul, Turkey

© 2014 Yuzbasioglu et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
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distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public
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and is dependent on numerous items, including the water/ Inclusion/exclusion criteria

powder ratio, vacuum versus hand mixing [23-25], and the Twenty-four subjects (12 females, 12 males, aged 21.87
type of dental stone and its compatibility with impression ± 2.76 years) who fulfilled the following inclusion criteria
materials [26]. were recruited after an initial examination: no experi-
Digital impression and scanning systems were intro- ence with either conventional or digital impressions,
duced in dentistry in the mid 1980s. It was predicted good general health, good oral hygiene, no periodontal
that most of the dentists in the U.S. and Europe would disease, and good mental health. Prerequisites for exclu-
be using digital scanners for taking impressions within sion in the study were previous impression experience,
the next decade [27]. Digital impressions offer speed, fixed or removable prosthetic rehabilitation, orthodontic
efficiency, ability of storing captured information indef- treatment and preventive appliances, history of use of
initely and transferring digital images between the dental space maintainers in mixed dentition, moderate to ex-
office and the laboratory [28]. The advantages of the cessive dental anxiety.
digital impressions and scanning systems are improving
patient acceptance, reducing the distortion of impression Clinical scenario
materials, 3D pre-visualization of tooth preparations, A clinical scenario of an “excessive destruction of a man-
and potential cost- and time-effectiveness [29]. dibular molar and crown fracture of the lateral incisor,
Several studies on the accuracy of intraoral scanners which would be restored by post-core and all ceramic
and digital impressions have been published, testing crowns” was explained to the subjects during their
single-unit restorations [30-33], several teeth in a row orientation to the clinical settings of the study. Subjects
[34-36], quadrants [37], and full arch scans [38,39]. watched an informational video illustrating the restora-
A recent report by Lee & Gallucci [40] compared the tive steps of the clinical scenario. The impression phase
operator’s preference of digital versus conventional im- was excluded from the video.
plant impression techniques. In this in vitro study, inex-
perienced students made impressions on a customized Conventional impressions
model instead of live patients. The overall perception of One operator selected the proper tray for both arches of
the inexperienced students was that they preferred the the subject, and applied the adhesive (Polyether Tray
digital impression technique. Until now there have been Adhesive, 3 M ESPE, Dental Products, St. Paul, MN,
no clinical studies comparing the digital and conven- U.S.A.). The conventional impressions of mandibular
tional impression techniques. and maxillary arches were made by polyether impression
The aim of this clinical trial was to evaluate the effect- material (Impregum Penta Soft Quick Step MB, 3 M
iveness, clinical outcomes, and patients’ preferences and ESPE, Dental Products, St. Paul, MN, U.S.A.) with stock
attitudes towards the digital impression technique com- trays using the monophase impression technique. The
pared to the conventional impression technique. The interocclusal relationship was recorded with a polysilox-
first null hypothesis was that there is no difference in ane bite registration material (Futar D, Kettenbach
effectiveness and clinical outcomes between the conven- GmbH & Co. KG, Eschenburg, Germany). All materials
tional and digital impression techniques. The second were used according to the manufacturers’ guidelines
null hypothesis was that there is no difference in pa- and performed by the same operator (E.Y.).
tients’ preference and treatment comfort between the The effectiveness and clinical outcomes of the conven-
conventional and digital impression techniques. tional impression technique was evaluated by measuring
the total treatment time, including the individual steps
Methods (Figure 1): A) tray selection, B) adhesive application, C)
Study design & patient selection upper/lower impression, D) bite registration. The treat-
A controlled clinical trial was designed. The study popu- ment time was measured in seconds and recorded for
lation consisted of first year dental and medical students each step by a second operator (R.T. & H.B.). Immedi-
of the İstanbul Medipol University who had no experi- ately after the impressions were made, the attitudes and
ence with either conventional or digital impressions. The perceptions of the subjects towards the conventional im-
subjects were informed in detail about the possible risks pression technique were evaluated using a standardized
and benefits, and all signed an informed consent form. questionnaire. The subjects’ perceived source of stress
The study was performed following the principles out- was also evaluated using the State-Trait Anxiety Scale
lined in the Declaration of Helsinki on experimentation immediately after the impression technique.
involving human subjects. The study protocol was
reviewed and approved by the Ethical Committee of Digital impressions
the Istanbul Medipol University, Istanbul, Turkey, A digital impression appointment was scheduled for the
(No:10840098-74). same patients 2–3 weeks following the conventional
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Figure 1 Conventional impression technique. Conventional impression technique. A) Adhesive application, B) Impression tray loading,
C) Upper and lower arches impression, D) Bite registration.

impressions. The digital impressions were performed was tested on a representative sample of 10 patients.
with the chairside dental CAD-CAM system (Cerec Test-retest reliability was performed to test the reliability
OMNICAM, Sirona Dental GmBH, Wals Bei Salzburg, and internal consistency of the questionnaires. The
Austria). The digital impression electronic data constitu- Cronbach Alpha reliability coefficient of the scales were
ents of the virtual models for both arches and bite regis- found as 0.921, and 0.982, respectively. The adaptation,
tration were recorded. All digital scanning procedures reliability and validity of the Turkish version of the
were carried out according to the manufacturer’s guide- State-Trait Anxiety Scale were evaluated by Öner and Le
lines and performed by the same operator (EY). Compte in 1983 [41].
The effectiveness and clinical outcomes of the digital im-
pression technique were evaluated by measuring the total Statistical analysis
treatment time, including the individual steps (Figure 2): A) Statistical analysis by the Wilcoxon Signed-Rank Test,
entering patient information (including name, last name, with p = 0.05 as the level for statistical significance, was
date of birth, B) laboratory prescription (including shade of performed to evaluate the differences in effectiveness
restoration, material choice of restoration, form of restor- and clinical outcomes between conventional and digital
ation), C) upper/lower scan, and D) bite scan. Treatment impression techniques, using the SPSS 15.0 for Windows
time was measured in seconds and recorded for each step statistical software (SPSS Inc., Chicago, IL, USA).
by a second operator (R.T. & H.B.). Immediately after the The attitudes and perceptions of the subjects on
impressions were made, the attitudes and perceptions of both impression techniques were assessed with a self-
the subjects towards the digital impression technique were administrated questionnaire using a Visual Analog Scale
evaluated using a standardized questionnaire. The subjects’ (VAS) ranging from 0 to 100. The data were analyzed
perceived source of stress was also evaluated using the statistical by the Wilcoxon Signed-Rank Test, with
State-Trait Anxiety Scale immediately after the impression p = 0.05 as the level for statistical significance, using the
technique. SPSS 15.0 statistical software (SPSS Inc., Chicago, IL,
The subjects were also asked to answer a 9-item com- USA).
parative questionnaire including the following research The subjects’ preferences for the impression techniques
questions: Which was the preferred impression tech- were assessed with a 9-item comparative questionnaire,
nique? Which was the recommended impression tech- and the distribution of the answers were evaluated by de-
nique? Which impression technique was more efficient? scriptive analysis using the SPSS 15.0 statistical software
Which impression technique would be most comfortable (SPSS Inc., Chicago, IL, USA).
regarding impression techniques?
Results
Reliability and validity of questionnaires The evaluation of the effectiveness and clinical outcomes
The questionnaires used in this study were pre-tested, for both impression techniques are presented in Table 1.
revised, and retested before use. A pilot questionnaire The mean overall treatment times were statistically
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Figure 2 Digital impression technique. A) Entering patient information, B) Laboratory prescription, C) Upper and lower arches scanning,
D) Bite scanning.

significantly different (p < 0.001), and comparison of the Outcomes of conventional impressions
mean impression times indicated a statistically significant The mean overall treatment time of the conventional
difference (p < 0.001). The mean tray selection time for the impression technique was 605.38 ± 23.66 s. The mean
conventional impression technique and the mean time for treatment times of the individual steps of the conven-
entering patient information for the digital impression tional impression technique was as follows: Mean tray
technique were not statistically significant (p > 0.05). The selection time, 18.87 ± 2.42 s; mean adhesive application
mean adhesive application time for the conventional im- time, 27.75 ± 3.12 s. The mean conventional impression
pression technique was statistically significantly different time of the upper and lower jaws was 240.70 ± 16.38 s
(p < 0.001) from the mean time for entering the laboratory and the mean bite registration time was 91.96 ± 10.74 s.
prescription time for the digital impression technique. The
difference between the mean bite registration time for the Outcomes of digital impressions
conventional technique and the mean bite scan time for The mean overall treatment time of the digital impression
the digital technique was statistically significant (p < 0.001). technique was 248.48 ± 23.48 s. The mean treatment times

Table 1 Scores of clinical efficiency outcomes of impression techniques

Efficiency Conventional Digital P-value
Tray selection/Patient information 18,87 ± 2,42 19,08 ± 3,57 >0.05
Adhesive application/Laboratory prescription 27,75 ± 3,12 13,63 ± 1,98 <0.001*
Upper impression/Upper scan 240,70 ± 16,38 102,14 ± 17,77 <0.001*
Lower impression/Lower scan 226,10 ± 10,89 98,94 ± 10,56 <0.001*
Bite registration/Bite scan 91,96 ± 10,74 14,68 ± 3,82 <0.001*
Total treatment time 605,38 ± 23,66 248,48 ± 23,22 <0.001*
All data are presented as mean ± SD. Measured time is recorded as seconds. *Statistical significance level p-0.05.
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Table 2 Participants’ evaluation scores and level of self concerns about impression techniques
Evaluation (VAS score) Conventional Digital P-value
Overall discomfort of impression 59,00 ± 37,72 90,04 ± 18,37 <0.001*
Overall time of impression 65,10 ± 41,55 90,28 ± 18,36 <0.001*
Smell/Voice 54,90 ± 39,04 86,52 ± 21,16 <0.001*
Taste/Heat 54,20 ± 28,06 88,16 ± 19,76 <0.001*
Queasiness 48,20 ± 44,53 91,80 ± 20,37 <0.001*
Discomfort during mouth was opened 44,40 ± 36,21 88,04 ± 19,86 <0.001*
Discomfort in TMJ 55,90 ± 43,31 88,68 ± 19,83 <0.001*
Breathing difficulty 59,90 ± 37,90 87,32 ± 21,02 <0.001*
Teeth and Periodontal sensivity 47,10 ± 43,21 85,36 ± 23,70 <0.001*
Total evaluation score 507,25 ± 277,34 827,50 ± 171,11 <0.001*
Level of self concern
Score of STATI-TX 1 41,33 ± 3,84 43,29 ± 3,89 >0.05
All data are presented as mean ± SD. Visual Analog Scale (VAS). *Statistical significance level p-0.05.

of the individual steps of the digital impression technique Discussion

were as follows: the mean time for entering patient infor- In this clinical trial, according to the clinical scenario,
mation, 19.08 ± 3.57 s, and the mean time for entering the the digital impression technique was more efficient than
laboratory prescription time, 13.63 ± 1.98 s. The mean the conventional impression technique. Thus, the first
digital impression time for the upper and lower jaws was null hypothesis was rejected. The subjects also preferred
98.94 ± 10.56 s and the mean bite scan time was 14.68 ± the digital impression technique rather than the conven-
3.82 s. tional impression technique because of its comfort.
Thus, the second null hypothesis was also rejected.
Patients’ preferences and self concerns The study population was standardized and homoge-
The evaluation scores and the level of concerns of the nized by including subjects who had no experience with
subjects regarding the impression techniques are pre- conventional or digital impressions in their dental his-
sented in Table 2. The mean scores of the subjects’ tory. To investigate the clinical outcomes of the two im-
evaluation criteria regarding the two impression tech- pression techniques, homogenizing the study population
niques were significantly different (p < 0.001). The sub- is an acceptable clinical research method to optimize ob-
jects’ level of self concern were evaluated by scores of jectivity and minimize bias. This approach is important
STATI-TX 1. The mean scores were not statistically to avoid reporting the bias of patients who had previous
significant (p > 0.05). All the subjects preferred the experience with the dental impression procedure.
digital impression technique (p < 0.001), and patients’ In this present study, we focused primarily on the effi-
preferences regarding the impression techniques, ac- ciency of the two impression techniques and the prefer-
cording to the 9-item comparative questionnaire, are ence of the patients under controlled clinical conditions.
listed in Table 3. Future investigations should include the assessment of

Table 3 Participants’ preferences about impression techniques according to the 9-item questionnaire
Preferences Conventional Digital
Which impression technique do you prefer in case of one more time for impression procedure? %0 %100
Which impression technique is more comfortable from point of comparison of two impression procedure? %0 %100
Which impression technique do you suggest in case of a friends’ need for impression making? %0 %100
Which impression technique do you prefer from point of time involved with impression procedure? %0 %100
Which impression technique do you prefer from point of feeling taste/smell or voice/heat during impression procedure? %0 %100
Which impression technique do you prefer from point of the size of the intraoral scanner/impression tray used in your %0 %100
mouth during impression procedure?
Which impression technique do you prefer from point of having tooth/gingival sensitivity during impression procedure? %0 %100
Which impression technique do you prefer from point of having difficulty in breathing during impression procedure? %0 %100
Which impression technique do you prefer from point of having gagging reflex during impression procedure? %0 %100
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the accuracy of the impressions produced by experi- and 2). Digital impressions tend to reduce repeat visits
enced versus non-experienced operators, comparison of and retreatment, while increasing treatment effectiveness
using scanning powders versus non-powder scanning, [42]. Patients will benefit from more comfort and a pleas-
and comparison of full arch and partial impressions. ant experience in the dentist’s chair.
There are some limitations of this study. The study The results of study indicate that the efficiency out-
was designed as a comparative-controlled clinical trial, comes of the digital impression technique were higher
and the sequence of the evaluation of the two impres- than that of the conventional impression technique, with
sion techniques was chosen for psychological reasons. respect to treatment time taken up and the perceptions
There is a 2–3-week interval between the two evaluation of the subjects. The effectiveness and clinical outcomes
appointments. This time period was deemed sufficient of both impression techniques (Table 1) were evaluated
to erase from memory an event or a process. The evalu- by recording the treatment time of each step in seconds,
ation process focuses on the outcomes of the impression and were significantly different from each other (p < 0.001).
techniques by means of total treatment time in seconds, The scores of the evaluation criteria regarding the two
and the study does not analyze any differences in preci- impression techniques (Table 2) that affect the subjects’
sion of the two impression techniques. perception differed from one another in a statistically
Another limitation of the study was that only one op- significant manner (p < 0.001).
erator performed the impression techniques to avoid the The differences in the level of treatment comfort eval-
possible inter-operator error, such as the prolonged pro- uated by the subjects, including breathing difficulty,
cessing time taken by an inexperienced operator. The queasiness, discomfort in the TMJ, and discomfort while
main purpose of the study was to focus on the patients’ the mouth was kept open were statistically significant
perceptions and comfort in using different impression (p < 0.001). Thus, the digital impression technique is
techniques. Evaluation by a second operator was not more patient-friendly than the conventional impression
preferred because of main purpose of the study. Further technique. The results of this study present the major
investigations are planned to evaluate the perceptions of reasons why the subjects preferred the digital impression
patients treated by different dental specialties and oper- technique instead of the conventional impression tech-
ator experience to the digital impression technique. nique (Table 3).
The last limitation of this study is that it ignored the
time factors involved in the conventional impression Conclusions
technique, such as pouring and mounting the cast, trim- Within the limitations of this study, the following con-
ming the dies, painting the die spacer, etc. By eliminating clusions can be drawn:
these steps, time for the traditional workflow would be
reduced significantly. Furthermore, the digital impres- 1. The digital impression technique was more efficient
sion technique and digital workflow are designed as the than the conventional impression technique. The
“digital working model” directly from the intraoral scan, overall treatment time for the conventional
without any additional factors. By virtually eliminating impression technique was longer than that for the
the intermediate processes, error accumulation in treat- digital impression technique. Thus, the first null
ment and in the manufacturing cycle is no longer an hypothesis was rejected.
issue. 2. When compared with the conventional impression
The results of this study have revealed clinical evi- technique, the digital impression technique was
dence that the digital impression technique can be ap- accepted as the preferred and effective technique,
plied successfully for the impressions of restorative according to the subjects’ perception. Thus, the
procedures based on clinical outcomes and the patients’ second null hypothesis was rejected.
preferences. However, this study was performed in a 3. The treatment comfort of the digital impression
clinical scenario that excluded the effect of actual treat- technique was higher than that of the conventional
ment conditions, perceived dental anxiety and stress as- impression technique when it was performed by an
sociated with treatment. This is an additional limitation experienced operator.
of this study.
The major advantage of digital impressions is reducing Competing interests
The authors declare that they have no competing interests.
the chair time. The mean total treatment time (p < 0.001)
and the subjects’ evaluation scores (p < 0.001) regarding Authors’ contributions
the impression techniques were significantly different EY is the designed and carried out the clinical study, collected the data for
(Tables 1 and 2). Improving the level of the patients’ analysis , performed the statistical analysis and drafted the manuscript. HK
participated in the design of the study and interpretation of data. RT and HB
comfort and treatment acceptance (p < 0.001) were other were collected the data for analysis. All authors read and approved the final
advantages of the digital impression techniques (Tables 1 manuscript.
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