Contents

Acknowledgments
Preface
About the Authors
Part One
1.1 The History of CAM/CAM in Dentistry
Introduction
Dental CAD/CAM Evolution
Dental CAD/CAM Today
Summary
Supplemental Reading
1.2 Digital Scanning and its Applications
Introduction
Components of Digital Scanners for Dentistry
Applications of Digital Dental Scanners
CAD/CAM for Occlusal Analysis
Summary
Supplemental Reading
1.3 Optimizing Preparations & Gingival Retraction for Scanning
Introduction
Preparation Guidelines for Digital Impressions
Tissue Management
Summary
Supplemental Reading
1.4 Designing Restorations
Introduction
Restoration Design
Digitally Designing Restorations
Summary
Supplemental Reading
1.5 Materials Optimized for CAD/CAM
Introduction
Materials for Milled Restorations
Materials for Milling Dentures
Materials for 3D Printed Restorations
Summary
 Supplemental Reading
1.6 Manufacturing and Milling Technologies
Introduction
Subtractive Dental CAD/CAM (Milling) Process
Selecting Milling Machines
Additive Dental CAD/CAM (Printing) Processes
Summary
Supplemental Reading
Part Two
2.1 The Digital Workflow and Its Variations
Introduction
Interoperability: Closed or Open Architecture
File Splitting
In-office Same Day Dentistry, Diagnostics & Record Keeping
Laboratory Processing Workflow
Collaborative Treatment Planning
Digital Denture Planning & Fabrication
Summary
Supplemental Reading
2.2 Role of Cone Beam Computed Tomography Technology in CAD/CAM
Basic Principles of CBCT Scanning Technology
Principles of CBCT Image Quality
Influence of Various Scanning, Reconstruction & Artifacts on Image Quality
Principles of CBCT 3D Image Reconstruction
Applications of CBCT in the CAD/CAM Workflow & Integration With Other
Imaging Modalities
Summary
Supplemental Reading
2.3 Same Day Dentistry
Introduction
Challenges
Summary
Supplemental Reading
2.4 CAD/CAM for Anterior Full-Coverage Restorations
Introduction
Analog Waxups/Digital Design & Fabrication
Completely Digital Diagnostics, Planning, Design & Fabrication
Summary
Supplemental Reading
2.5 Implant Treatment
Implant Treatment
Summary
Supplemental Reading
2.6 The Application of Digital Technology to Denture Fabrication
Introduction
Essentials: Clinical Information Needed for Denture Fabrication
Current Digital Denture Systems
Clinical Procedures in the Digital Denture Workflow
CAD/CAM Design & Prototype Manufacture
Case Study
Summary
Supplemental Reading
2.7 The Digital Era of Orthodontics
Introduction
Understanding Aligner Capabilities & Limitations
Digital Orthodontic Aligner Processes
Patient Report
Moving Forward
Summary
Supplemental Reading
2.8 CAD/CAM Technology in Dental Education
Introduction
The Solution: CAD/CAM Technology
Student Response to Computerized Preparation Evaluation
Clinical CAD/CAM Dentistry in Preclinical Dental Education
CAD/CAM During the Clinical Years
Summary
2.9 Additional Considerations
Overview
Summary
Supplemental Reading
Fundamentals of CAD/CAM Dentistry
The American College of Prosthodontists
Copyright © 2018 American College of Prosthodontists Education Foundation
All Rights Reserved
 Acknowledgments

The American College of Prosthodontists (ACP) acknowledges Dr. Jonathan

L. Ferencz and Dr. Nelson R.F.A. Silva for their generous contribution of
their expertise and content for Fundamentals of CAD/CAM Dentistry. The
authors wish to acknowledge Henry Schein for their generous support in
underwriting the ACP Educational Standards Revision project. In addition,
we are grateful to Ivoclar Vivadent for their generous grant to help offset the
cost of this text.
We also thank Allison DiMatteo for her tireless efforts in providing editorial
assistance. All proceeds generated from the book will be donated to the ACP
Education Foundation.
 Preface

This book is meant to be used as a supplemental learning tool along with the
ACP's Digital Dentistry Curriculum. The book is structured into fifteen
sections, compiled into two main chapters. The sections include learning
objectives, supporting material, summaries and reading lists.
The American College of Prosthodontists is working to ensure that
prosthodontists are prepared to lead the emergence of digital dentistry in
clinical practice. To access and view additional resources available, please
visit the Digital Dentistry Resources page of the ACP website.
We hope these learning tools will be instrumental in your Digital Dentistry
education.
 About the Authors

Dr. Jonathan L. Ferencz

B.S, Rensselaer Polytechnic Institute

DDS, New York University College of Dentistry
Advanced Education in Prosthodontics New York University
College of Dentistry
Diplomate American Board of Prosthodontics
Clinical Professor of Post-Graduate Prosthodontics New York
University College of Dentistry
Adjunct Professor of Restorative Dentistry at the University of
Pennsylvania School of Dental Medicine
Clinical Professor of Dental Medicine at Columbia University
College of Dental Medicine
Past-president, the Greater New York Academy of Prosthodontics
Past-president, the Northeastern Gnathological Society
Past-president, the American College of Prosthodontists

Dr. Nelson R.F.A. Silva

Professor at Departamento of Operative Dentistry at UFMG, Brazil

MSC, Prosthodontics/Biomaterials at University of Sao Paulo, Brasil
PhD, Prosthodontics/Biomaterials at University of Sao Paulo/New
York University
Post-Doc, Biomaterials at New York University
Assistant/Associate Professor at Department of Prosthodontics at
New York University 2004–2012
 Introduction

Dental computer-aided design (CAD) and computer-assisted manufacturing

(CAM) technology is essentially a combination of three processes: data or
image acquisition; image or information analysis and manipulation, or
computer-aided design; and fabrication, or computer-assisted
manufacturing. Data is acquired through a variety of techniques that capture
relevant images, such as digital scanning or digital photography. Software is
then used to render, analyze, and manipulate the images. Milling units or
three dimensional (3D) printers are then used to fabricate the CAD-created
restorations or treatment components.

First developed in the 1940s for industrial and engineering applications

designed to make machining complex parts in large numbers easier and
faster, CAD/CAM systems were initially used in the automotive and
aerospace industries. CAD/CAM wasn’t introduced to dentistry until the
1970s, when François Duret first conceived of how these technologies could
be applied to the profession. His original rationale was that by using
computer-controlled machine tools, a dental restoration could be fabricated
with less effort, less variability, and at reduced production costs. While this
model worked well for other industries, a fundamental challenge for using
CAD/CAM in dentistry was that each part—or dental restoration—is
uniquely different because it must fit a tooth preparation for an individual
patient.
The application of technology to the creation and fabrication of dental
restorations was later refined in the 1980s by Dr. Werner Mörmann with the
development of the CEREC System (Sirona) for same day chairside
restorations. He succeeded and was able to produce a ceramic inlay
restoration using computer-assisted technology, the acronym for which stands
for Chairside Economical Restoration of Esthetic Ceramics.
Despite many initial difficulties in this first effort (i.e., creating detailed
occlusal morphology and achieving acceptable marginal fit), the first CEREC
restorations were composite inlays that were heat processed and cemented
with resin cement. Early studies of these restorations revealed degradation at
the composite inlay margin, which was improved upon with the introduction
of ceramic as a material for inlay fabrication.
With this pioneering system, an intraoral camera was used to measure or scan
the intracoronal tooth preparation, the inlay was then designed, and the
restoration carved from a solid block of ceramic material by a milling
machine small enough to be located in the dental office. This system was the
first operational system that could produce same day ceramic restorations and
quickly became the leader in CAD/CAM dentistry.
Dr. Matts Andersson subsequently developed a CAD/CAM system for
producing titanium copings (NobelProcera® CAD/CAM System, Nobel
Biocare). In the early 1980s, base metal alloys were gaining popularity in
dentistry due to a drastic increase in the price of gold. There were reports of
patient allergic responses to the nickel in some of these alloys, along with
risk of exposure to beryllium toxicity by the dental technician. In response to
these negative side effects, the use of titanium was suggested. However,
traditional lost wax techniques for casting titanium were considered
problematic, so Dr. Andersson proposed fabricating titanium copings by
spark erosion and composite veneers using CAD/CAM technologies. This
evolved into a successful commercial manufacturing system whereby dies
were scanned, restorations designed, and all-ceramic materials used for
milling in centralized production facilities. This concept of networked
production systems spread and was utilized by a number of companies.
Although dental CAD/CAM applications have expanded to multiple teeth
restorations, implant abutments and surgical guides, and full-arch dentures,
early CAD/CAM systems were limited to single tooth restorations, such as
inlays, onlays, crowns, and veneers. Additionally, the hardware and software
of early systems only enabled a two dimensional (2D) view of the scanned
images, since the associated computer’s capacity was unable to store the data
required for 3D images.
 Dental CAD/CAM Evolution

Since then, a variety of manufacturers have introduced CAD/CAM “systems”

and/or components for both dental practices and dental laboratories.
CAD/CAM hardware, as previously described, includes a digital scanner, a
computer, and production equipment (e.g., milling unit or 3D printer).

Although image manipulation and restoration design are completed using

CAD software, the manufacturing itself requires CAM software to enable a
fully automated process. Depending on the software, CAM capabilities today
could include production of multiple restorations based on specific
parameters (e.g., material, restoration type). Although early CAM software
only allowed variations in material, currently available options enable greater
productivity, process control, and cost-efficiency.
The CAD/CAM “systems” available for dentistry range from complete
systems that scan, design, and mill, to those that only perform certain
functions, such as digital scanning only, exclusively designing restorations,
or only milling restorations. As a result, today it is possible for fabrication
and production of restorations to take place in three environments: chairside
in the practice; dental laboratories; and milling centers.
Among the complete “systems” introduced has been the E4D Dentist System
(formerly E4D Technologies), which is now known as Planscan (Planmeca)
in 2008 for same day CAD/CAM dentistry in the dental practice (Figure 1.1-
1). Its differentiating innovation was its unique and open architecture that
enabled integration of select workflow components (e.g., digital scanners,
CAD software, milling unit), rather than the entire system, according to user
preferences.

Fig. 1.1-1 The Planmeca PlanMill® 40

Other chairside CAD/CAM systems (i.e., in dental practice) available today

include CEREC ® AC from Sirona, LAVA™ COS from 3M ESPE, iTero ®
from Cadent, and Trios from 3Shape. However, of these, only the CEREC
AC has CAM capabilities incorporated. The LAVA COS, iTero, and Trios
are considered dedicated, stand-alone digital impression systems. For
laboratories, the CEREC inLab ® MCXL milling unit is available.

Digital Impression/Scanning Devices

Digital impression systems refer to the hardware (i.e., computer-based
cameras or scanners) that captures digital images of the teeth and soft tissues,
or analog models and impressions, and the software required to manipulate
the images and manage patient information. The first intraoral scanner
required the use of a powder (i.e., titanium dioxide) to ensure acquisition of
accurate digital images. Today, a variety of “powderless” digital scanners are
available. Digital impression intraoral scanning devices were originally a part
of complete in-office CAD/CAM systems (e.g., CEREC; E4D
Dentist/Planscan) produce a digital impression of prepared teeth but, again,
are now available as stand-along devices.
The benefits of digital impression taking include eliminating the need for
alginate or elastomeric impression materials and their accompanying
impression trays and increased patient comfort. Rather than following
cumbersome analog procedures, a scanning wand is used to digitally capture
the impressions.
Intraoral scanning systems optically (digitally) scan objects using one of two
techniques: amplified light (i.e., laser beams) or visible light (i.e., light
beams). The software associated with the scanners processes the images
either on a computer in the dental practice, or transfers them via the Internet
to a laboratory or milling center.
Regardless of how they are captured, digital impression images can be
viewed instantly on a computer screen and transformed into a virtual model.
The ability to instantly evaluate the image (i.e., digital impression) quality
allows the dentist to identify potential problems (e.g., incorrect preparation
design or unclear margins) and correct them, then retake the image.
Transferred to laboratories electronically, these digital impressions can then
be used to create traditional (i.e., cast stone) or virtual (i.e., digital) models, or
as part of the CAD/CAM restoration fabrication process (i.e., milling or 3D
printing). Alternatively, the files can be used for digitally designing milled
restorations chairside (i.e., in office CAD/CAM). If the dental practice does
not use digital impression technology, an analog impression and/or model can
be taken and sent to a CAD-capable laboratory for scanning.

Dental CAD/CAM Software

After scanning images, digital impression files are typically saved in .stl
format. However, different digital impression system manufacturers may use
a proprietary version of this file type that precludes its use with systems
available from other manufacturers (i.e., closed system). This restricts
dentists and laboratories to only using the computer design system/software
and production unit (i.e., mill or 3D printer) specifically intended for that
specific digital impression system. Fortunately, this is changing and, in recent
years, digital dental technology companies have set aside the proprietary
nature of their systems to accommodate an “open architecture” that provides
dentists and laboratories with greater flexibility in terms of the hardware and
software they choose. As a result, more dentists can work and collaborate
with a wider variety of laboratories and specialists, since they are no longer
confined to working with the systems their colleagues use.
In general, however, CAD software automatically recommends a standard
restoration type or design. This recommended restoration design can then be
refined by the operator (e.g., dentist, dental assistant, laboratory technician).
Refinements typically involve margin placement, emergence profile, material
thickness, and cusp morphology. Some software enables users to overlay a
virtual wax-up of proposed restorations onto the virtual preparation to fine-
tune restoration dimensions.
Additionally, today’s CAD software provides a variety of tools for additional
modification, including adjusting the occlusion, height of contour, and
interproximal contacts. In recent years, an assortment of CAD libraries has
been developed to enable greater ease of restoration design.
Use of CAD techniques and today’s dental CAD software helps to enhance
productivity, improve restoration design quality, and facilitate collaborative
communication between dental treatment team members. A variety of dental
CAD/CAM software is available, with capabilities and applications ranging
from restoration design to orthodontic analysis, and from implant surgical
planning to disease monitoring. But, overall, CAD software enables the user
to design a restoration or prosthesis from start to finish by replicating the
same processes (e.g., margin placement, block out of undercuts, anatomical
modifications) typically performed by a dental technician.

CAM Fabrication
While industrial computer numerical control (CNC) machines use variety of
tools ( i.e., drills, saws, lathes) to the intended parts and components, dental
milling machines use burs. Because the manner in which these milling units
will be used varies (i.e., a few restorations produced per day or week;
hundred to thousands per week or month), cost, size, and production
mechanisms and capacity vary significantly among available systems.
Essentially, dental milling units use a subtractive process that removes
material from a block produce restorations of the shape and size determined
by the dentist using CAD software. The efficiency of the milling units
depends upon a number of factors, including the number of axes and burs it
contains. Original chairside or desktop milling units typically operated with
three or four axes and were designed for light production volume and
uncomplicated restorations. Today, however, chairside and desktop milling
units are available with five axes, which enables control of the grinding tool
in three linear planes and two rotary axes (Figure 1.1-2).

Figure 1.1-2 The Roland DWX-50 5-Axis Dental Milling Machine

Production laboratory and milling center CAM units use five axes and are
typically larger, faster, and inclusive of robotic automation for handling the
material and restorations (Figure 1.1-3). They also function with a higher
level of precision.
 Figure 1.1-3 The HAAS VF-2TR – Axis Vertical CNC Machining Center

However, additive manufacturing processes (i.e., 3D printing) are being used

increasingly in dentistry for producing orthodontic aligners, surgical guides,
removable and implant-supported dentures, and fixed restorations. Whereas
milling units remove material using burs, 3D printing adds material through
an additive process.

Dental CAM Material Diversification

Original dental CAD/CAM materials included feldspar-based, fine particle
ceramics that were compressed into a blocks (e.g., Vitablocs Mark I, VITA).
However, in the late 1980s, fine-grained, high glass content feldspar-based
ceramic (Vitablocs II, VITA) was introduced, followed in 1997 by a ceramic
alternative composed of resin-based silica (e.g., Paradigm MZ100, 3M
ESPE). Since then, a variety of metal-free options have been introduced to
meet the need for esthetic and durable materials capable of being processed
through CAM methods. These included reinforced resin ceramic (e.g., LAVA
Ultimate CAD/CAM, 3M ESPE), lithium disilicate (e.g., IPS e.max CAD,
Ivoclar Vivadent), ceramics (e.g., LAVA, 3M ESPE; Cercon, DENTSPLY),
and high-strength ceramics (e.g., alumina, zirconia).
In recent years, manufacturers have introduced material blocks that exhibit
shade variations among cervical, body, and incisal aspects in order to more
easily process CAD/CAM restorations that demonstrate superior, natural-
looking esthetics. These materials currently include IPS e.max CAD Multi
(Ivoclar Vivadent), as well as Vitablox Triluxe Forte and Vitablocs RealLife
(VITA).
 Dental CAD/CAM Today

Today, dental CAD/CAM systems enable users—whether dentists or

laboratory technicians—to design and produce a final restoration within
minutes, not hours or days.

Additionally, the role of other technologies (e.g., cone beam computed

tomography) in the dental workflow is expanding, particularly when
combined with digital intraoral impressions and facial scanning technology.
On-going enhancements to CBCT hardware and software are making the
technology more applicable for routine dentistry, as well as for such
specialties as endodontics, implantology, and orthodontics.
In fact, with CAD/CAM processes, orthodontic treatments are now being
performed differently, with almost every treatment phase capable of being
virtually programmed before tooth movement begins.
 Summary

Overall, dental CAD/CAM affords dentists and their properly trained team
members—as well as dental laboratories—greater control over the
restorative process, and patients benefit from enhanced comfort and
convenience (e.g., no uncomfortable or unpleasant impression materials in
their mouth, reduced gag reflexes, enhance restoration quality and durable).

New workflow models are facilitating enhanced collaboration, and

restorations that once took weeks now require mere hours. These workflow
models allow delivery of same day anterior and posterior full-coverage
restorations and partial coverage restorations; thorough treatment planning of
veneers; enhanced patient involvement and planning of anterior restorations;
and more precise and predictable implant treatments.
However, fixed restorations are just the beginning. Whether produced via
CAD/CAM milling processes or in combination with 3D printing, removable
prosthodontics are also being transformed by technology and new digital
workflows.
With digital workflows for removable prosthodontics, dentists and
laboratories can better facilitate treatment planning, try-in, and delivery of
final dentures in fewer and more convenient appointments, providing
dentures with better fit and greater comfort, enhanced durability, and more
life-like esthetics.
Clearly, there is a lot to learn, and dental education is embracing digital
processes to enhance preclinical education and student evaluations. In
particular, computerized preparation evaluation is transforming how students
learn and practice tooth preparations, providing opportunities to refine their
skills and develop confidence that they are working toward the ideal.
 Supplemental Reading

Alter D. Subtractive computer-aided manufacturing in dental milling.

Producing high-quality restorations with greater detail and consistency.
Inside Dental Technology. February 2014; 5(2).
Att W, Girard M. Digital workflow in reconstructive dentistry. In: Ferencz
JL, Silva NRFA, Navarro JM, eds. High-strength Ceramics: Interdisciplinary
Perspectives. Quintessence Publishing Co, Inc. Chicago, IL, 2014: 260–77.
Birnbaum NS, Aaronson HB, Stevens C, Cohen B. 3D digital scanners: a
high-tech approach to more accurate dental impressions. Inside Dentistry.
April 2009; 5(4).
Bunek SS, Brown C, Yakas M. The evolving impression of digital dentistry.
Inside Dentistry. January 2014; 35–39.
Harsono H, Simon JF, Stein JM, Kugel G. Evolution of chairside CAD/CAM
dentistry. Inside Dentistry. October 2012; 76–81.
Helvey GA. Zirconia and computer-aided design/computer-aided
manufacturing (CAD/CAM) dentistry. Inside Dentistry. 2008; 4(4).
Patel D. CAD/CAM design techniques for predictable anterior restorations.
Inside Dentistry. February 2015; 62–8.
Patel N. Contemporary dental CAD/CAM: Modern chairside/lab applications
and the future of computerized dentistry. Compend Contin Educ Dent. 2014;
35(10): 739–46.
Poticny DJ. CAD/CAM today: a 22-year retrospective. Inside Dentistry.
November/December 2008; 4(10).
Shull GF. An update on CAD/CAM dentistry. Dental Learning. 2015; 4(2):
1–9.
 Introduction

In dentistry, taking an impression is the process of acquiring and transferring

anatomical information for the purpose of creating indirect restorations (e.g.,
inlays, onlays, crowns, veneers, implant abutments, and fixed or removable
prostheses). This technique-sensitive procedure is essential for providing
well-fitting, functional, and esthetic restorations, as well as treatment
planning surgeries and orthodontic movement.

Unfortunately, despite enhancements to the ease of use, detail reproduction,

high elastic recovery, and dimensional stability of various analog elastomeric
materials used for capturing impressions (e.g., polyvinyl siloxane, polyether,
hybrids), obtaining an accurate reproduction of the oral anatomy using
traditional techniques is wrought with the potential for errors both in the
dental practice and at the laboratory. Among them are patient discomfort,
delays and increased chair time, need for additional appointments, and
unpredictable restorations that must be remade.
For example, trays required for delivering analog impression materials to the
mouth may damage soft tissues, inadequately conform to the patient’s oral
anatomy, and contribute to patient discomfort (e.g., gag reflex, anxiety). The
impression materials may become unpredictable when placed in the mouth
(i.e., react with oral fluids), and often cannot be removed for several minutes
to help ensure that they have set completely and captured a high level of
intraoral hard and soft tissue detail. Additionally, other types of impressions
are needed for fabricating properly fitting restorations besides those of the
affected teeth, such as impressions of the opposing arch and the patient’s bite
in the area of concern (i.e., bite registration).
Assuming the impressions are acceptable and free of voids, tears, or bubbles
that could affect the quality of the fabricated restorations, they must then be
used either in the dental practice or laboratory for pouring stone models. This
process, also, can present difficulties in terms of proper mixing and
accurately identifying margins.
Fortunately, the introduction of digital intraoral scanning (IOS) and benchtop
scanning to dentistry enables dentists and laboratories to eliminate many of
the problematic techniques and characteristics associated with making
traditional, analog impressions and models. Simultaneously, digital scanning,
when combined with computer-aided design (CAD) and computer-assisted
manufacturing (CAM) processes, also allows dentists and laboratory
technicians to use innovative yet proven restorative materials to create
restorations demonstrating greater accuracy of fit, anatomical form, esthetics,
and strength. Accuracy is inherent in the digital impression and not affected
by factors such as material distortion, improper model handling, improper
model pouring techniques, inaccurate trimming and margination of dyes by
an outsourced technician who did not create the preparation. In essence,
digital dental scanners replace traditional analog impression materials and
techniques with a technological and software driven approach for accurately
and efficiently capturing and duplicating essential clinical information.
As a result, digital impressions have made the impression-taking process
more efficient and cost-effective. These digital impressions can then become
part of the patient’s file, used for designing and fabricating restorations either
in the dental practice or dental laboratory, shared among members of the
treatment team (e.g., restorative dentist, oral surgeon, periodontist,
laboratory, etc.), and used for collaborate treatment planning in new and
exciting ways. Additionally, almost any type of restoration can be designed
and fabricated from a digital impression.
What remain significantly important to the success and predictability of both
analog and digital impression processes, however, are preparation design and
the gingival retraction techniques employed to ensure clear and unobstructed
access to, and visualization of, the margins, finish lines, and gingival
contours.
Additionally, understanding digital dental scanning technology—and its
capabilities and roles in emerging dental process workflows—is also
beneficial for maximizing accuracy, efficiency, and integration of this
paradigm-changing tool.
 Components of Digital Scanners for Dentistry

Differentiating the capabilities and applications of IOS and benchtop

scanners in dentistry are the camera type and image capturing mechanism,
type of light transmitted from the scanning device, architecture (i.e., open,
closed), and whether they are stand-alone digital scanning systems or
components of a complete dental CAD/CAM system. Additionally, the
features and benefits of digital dental scanning systems vary and ultimately
influence their ease-of-use and functionality. These attributes include IOS
wand size, benchtop scanner size and camera operation, powder-coating
requirements, scanning method, and color capture capabilities, among
others.

Camera
Digital scanners for dental applications record information by capturing
images via a scanning device and camera. The camera component of digital
scanners records details of either the intraoral condition or analog objects
(e.g., elastomeric impressions, stone models). Initial offerings essentially
scanned a series of single images that were stitched together to form a virtual
model; image quality and computer speed were factors limiting the size and
details of the resulting digital models.
IOS scanner cameras are typically contained in a scanner wand, while
benchtop scanner units usually house two cameras or sensors attached to a
rotation mechanism; the objects being scanned are rotated (i.e., 3-axis or 5-
axis) to allow the scanner to accurately and completely capture details from
multiple perspectives.
Today's IOS cameras are more compact and approximately the size of a
dental handpiece. Although these smaller cameras promote better intraoral
access and easier scanning, they may not facilitate sufficient range of motion
for full-arch scanning. However, if slightly larger camera bodies are
ergonomically designed, for easier maneuverability, then intraoral scanning
of the complete arch may be possible.
Original benchtop scanners used tactile probes for scanning analog objects
(e.g., analog impressions, stone models), but today typically use light
triangulation (e.g., laser or striped light), which projects light onto the object,
with sensors capturing and converting the details into a 3D image. Some
benchtop scanner cameras use high-resolution devices to record detailed
information (e.g., surface texture) but, like some intraoral scanners, may
require the use of a reflective powder coating. Scanning capabilities range
from scanning dies to recording data for full-arch patients, to scanning analog
casts and impressions to scanning articulated models; some benchtop
scanners may be limited to only scanning casts created from scannable
gypsum.

Light Source/Image Capture

Currently available digital scanning systems—whether intraoral or benchtop
—emit different types of light (e.g., laser, structured (striped) light, visible
light, or light emitting diode [LED] illumination) through their cameras to
capture data via sensors that will ultimately be manipulated by computer
software to create a three dimensional (3D) image. Original digital dental
scanners required application of a light-reflective titanium dioxide powder on
the object being scanned prior to taking digital impressions. Many updated
scanners are now powderless, eliminating the additional step to further
increase patient comfort and/or improve efficiency.
Light beam scanners acquire images of the teeth or analog models from
different positions which are then combined and rendered into a 3D visual
representation in one of three ways: still image capture (active triangulation);
video capture (active wavefront sampling); or real-time imaging (ultrafast
optical sectioning). Active triangulation dental scanners acquire images by
emitting three linear light beams that intersect to identify a particular point in
a 3D space. Active wavefront sampling scanners (e.g., Lava C.O.S., 3M
ESPE) emit blue light through a single lens system that is detected by sensors
at different angles, which then capture video images in order and assemble
them into a 3D rendering; teeth or objects being scanned must be powdered
coated. Ultrafast optical sectioning digital dental scanners (Omnicam, Sirona)
resemble video scanners in their continuous acquisition of images of the teeth
or models being scanned, but the 3D images they produce are based on real
geometric data, not computerized interpretations.
An advantage of laser beam scanners, which capture images through either
parallel confocal imaging or laser triangulation imaging, is their ability to
acquire accurate images with precise detail without needing to use a
reflective coating. Parallel confocal digital dental scanners emit parallel laser
beams and optical scanning filtered light through the scanner head, which hit
the object being scanned at a specific focal distance and then bounces them
back through a small pinhole; only light reflected from the scanned object at
the proper focal point returns through the pinhole. For highly reflective
surfaces (e.g., enamel, polished or glazed porcelain, ceramic, metallic
restorations), no powder coating is needed. The reflected beams are converted
into digital images when they reach the sensor.
Laser triangulation intraoral scanners emit a single wavelength of red laser
light as mirrors simultaneously oscillate to acquire still images of the object
being scanned from multiple perspectives. This contributes to greater
accuracy, but these scanners cannot record tooth color information. The
images are then converted into a 3D rendering.

File Formats/Architecture
Digital impression files are typically saved in .stl format. However, because
many manufacturers maintain their own proprietary .stl file format (i.e.,
closed architecture), universal application of .stl digital impression files may
be difficult. This type of file format is very common for complete chairside
CAD/CAM systems, since one manufacturer has produced the digital
scanner, design software, and milling unit; therefore, that manufacturer’s
digital files cannot be shared across different chairside CAD/CAM systems.
As a result, many dentists and laboratories have been faced with using a
single proprietary computer design software and/or milling unit system that is
compatible with the digital impression system they use. Fortunately, an
increasing number of manufacturers today are more willing to open their
proprietary .stl files for use with different CAD/CAM systems (i.e., open
architecture).
Open architecture files are not dependent on the equipment manufacturer, can
be used with a variety of design software to create a restoration, and can then
be further used by any number of CAM units to produce dental restorations,
regardless of the milling unit’s or 3D printer’s manufacturer. This enables
dentists and laboratories greater flexibility in sharing files across a variety of
systems from different manufacturers and, therefore, with each other.

Complete Dental CAD/CAM Systems

Complete CAD/CAM systems include an IOS, design software, and milling
unit for fabricating a restoration. Dental practices can use these systems to
scan, design, and mill full-contour and partial-coverage restorations in-office.
As previously described, IOS that are components of a complete dental
CAD/CAM system eliminate the need for traditional analog impression
materials and techniques, but rather than send digital files to a laboratory for
restoration fabrication, the design and manufacturing steps are performed in
the dental office. This enables practices to provide same day for many
patients, making provisional restorations and follow-up cementation
appointments unnecessary.
With complete in-office dental CAD/CAM systems (CERECA AC Bluecam,
CEREC Omnicam, Sirona; Planscan, Planmeca)—as well as stand-alone IOS
—the scanner is used to take a digital scan of the patient’s preoperative
condition. These images can be viewed and evaluated with the patient
chairside to enhance understanding of their condition and/or any treatments
that are required. Additionally, computer software can be used to design and
propose restorations to treat the identified intraoral problems, as well as
demonstrate possible esthetic changes to the patient’s smile.
When preparations are performed, the IOS is used to scan those, also, rather
than take traditional analog impressions. A benefit of intraoral scans of
preparations is the ability to view them immediately at significantly higher
magnification in order to evaluate them and identify any possible problems
that might negatively affect restoration fabrication (e.g., undercuts, sharp line
angles). Areas requiring adjustment can be corrected, rescanned immediately,
and re-evaluated.
Once the digital impressions are approved by the dentist, the computer
software enables identification and marking of restoration margins on the
virtual model, as well as designing of the restoration (e.g., crown, inlay,
onlay, or veneer) using design tools (e.g., adjust interproximal contacts,
height of contour, occlusion, morphological details). The restoration design
file is then transferred electronically to the in-office milling unit for
production, after which—depending upon the material used—it can be
stained, glazed, and fired, then definitively cemented during the same
appointment.

Stand-Alone Intraoral Scanners

Stand-alone or dedicated IOS are available today (e.g., iTero Digital
Impression System, Align Technology; True Definition Scanner, 3M ESPE;
IOS FastScan, IOS Technologies; Trios, 3Shape) that enable dentists to work
with their preferred laboratory and/or specialist colleagues, not just those
using the same proprietary equipment (Figure 1.2-1a-c). This helps to
facilitate communication, treatment planning, and a higher level of patient
care. Stand-alone digital scanners are used for the same functions as those
available with complete CAD/CAM systems (i.e., scan preoperative
condition, scan preparations, evaluation, treatment planning, virtual model
creation), but the extent to which restorations are designed in the dental
practice may vary.

Figure 1.2-1a Intra-oral scanning

Figure 1.2-1b Model scanning

Figure 1.2-1c Impression scanning

The digital impression file can be sent directly to a dental laboratory for
creation of a digital model and subsequent fabrication of definitive
restorations, or for creation of a 3D printed surgical guide for implant
placement.
Additionally, it is also possible to use an IOS to digitally scan implant
abutments or scan bodies for fabrication of implant-supported restorations.
Alternatively, digital impressions resulting from IOS can also be used for
creating digital models that form the basis for programmed orthodontic
treatment using 3D printed clear aligners.
Like IOS that are components of complete in-office CAD/CAM systems,
stand-alone scanners relieve dental practices of the time-consuming processes
involved with analog restorative techniques, including tray selection,
dispensing and setting materials, disinfection, and shipping impressions to a
dental laboratory. Laboratories also experience efficiencies by eliminating the
need to pour models, cut and trim dies, or articulate models. Although the
laboratory still fabricates the definitive restorations, they are created based on
digital data and virtual models, not stone or gypsum models produced from
analog, elastomeric impressions.
 Applications of Digital Dental Scanners

Developing virtual models and digital diagnostic wax-ups from digital scans
enables dentists and laboratories to perform a variety of restorative tasks in
ways that facilitate greater patient comfort and understanding of the their
condition and proposed treatment plans. (Figure 1.2-2–1.2-10). Additionally,
scanned images and virtual models represent significantly enhanced visual
aids for diagnosing disease during consultation and collaboration, and new
applications for digital impressions to enhance patient care are continually
being introduced.

Figure 1.2-2 Although the intraoral scanner was significant in

identifying esthetic issues with tooth #7, what was most significant was
the ability to utilize the immediately available images—along with
significant magnification—to explain complicating factors to the patient
for greater understanding of treatment requirements.
Figure 1.2-3 For example, this lingual view was useful in clearly
demonstrating and explaining to the patient the need to address the
extensive crack on the lingual aspect. The patient immediately accepted
a treatment plan to restore tooth #7 with a full-coverage crown
restoration.

Figure 1.2-4 The lingual view of the digital impression scan shows
details of the patient’s preoperative tooth morphology, soft tissue
architecture, and extensive lingual crack on tooth #7.

Figure 1.2-5 The facial view of the digital impression scan shows the
patient’s upper arch in exacting detail for diagnosis, analysis, and
treatment planning.
Figure 1.2-6 Tooth #7 was prepared for a full-coverage crown
restoration, the preparation scanned, and the tooth provisionalized.

Figure 1.2-7 The patient was pleased with the provisional restoration,
which was later scanned and, using the design software, morphed to
conform to the preparations to create a virtual mockup of the definitive
CAM restorations.

Figure 1.2-8 View of the proposed restoration prior to milling.

 Figure 1.2-9 After milling and prior to firing, staining, and glazing, the
restoration was tried in to confirm fit.

Figure 1.2-10 View of the definitive in-office CAD/CAM restoration

following cementation.

Shade Matching
Whereas digital shade taking can be accomplished using a variety of
photospectrometers, current CAD/CAM developments are enabling shade
taking and matching with a single system (e.g., Trios, 3Shape). Early shade
taking technology used digitally acquired scans to map the colors of teeth
(e.g., ShadeEye NCC, Shofu Dental Corporation; ShadeVision, X-Rite Inc.).
Moving forward, rather than relying on human interpretation of shade, which
is wrought with errors resulting from the influence of daylight, artificial light,
clothing color, and individual optical perceptions, CAD/CAM shade taking
will eliminate color discrepancies and save time. With CAD/CAM shade
taking, the scanner automatically detects the shades of adjacent teeth as it
captures images of the affected teeth and/or preparations. Then, the identified
shades can be indicated in the digital impression files and/or restoration
design files.
Diagnosis/Monitoring
Intraoral digital scans facilitate enhanced diagnosis of oral lesions, pathology,
and dental disease. When combined with cone beam computed tomography
(CBCT), these digital files help dentists to develop more objective and
comprehensive assessments of a patient’s condition. Fortunately, a number of
CBCT systems are available today (e.g., iCAT, Imaging Sciences
International; Galileos, Sirona; Gendex, Gendex Dental Systems; ProMax,
Planmeca). Integrating CBCT with intraoral scanning will also help to
redefine dental procedures, particularly for implant dentistry,
orthodontic/orthognathic therapies, and other oral-maxillofacial treatments.
Certainly digital caries detection tools (e.g., Logicon, Carestream) can be
incorporated into the diagnostic process as a means to verify the presence of
questionable lesions. Considering that the manner in which dental operatories
are illuminated could influence the accuracy of visual radiograph assessment,
utilization of such digital technology could enhance caries diagnostic
abilities.
 CAD/CAM for Occlusal Analysis

Similarly, other enhancements to IOS are enabling imaging of other aspects

of the jaw and entire quadrants, including adjacent and opposing teeth. The
relationship of the upper and lower teeth to each other can also be scanned
intraorally, either via intraoral bite registrations or scanning from the buccal
aspect, and the data used for designing occlusal surfaces and/or assessing
uneven wear patterns indicative of occlusal issues (Figure 1.2-11 through
Figure 1.2-14). When this data is combined with other biometric findings
(e.g., jaw motion trackers) that suggest stomatognathic disease or dysfunction
(i.e., temporomandibular joint disorder), a more specific and appropriate
treatment plan can be developed.
Figure 1.2-11a-b Based on intraoral scans from the buccal aspect, the
intercuspation of proposed maxillary restorations with the natural
mandibular teeth could be analyzed, along with the occlusal scheme of
the proposed restorations.
Figure 1.2-12a-b Based on the occlusal analysis, it was determined that
the anticipated 3-unit fixed partial denture should be fabricated with
core material (b) overlayed with a veneering ceramic (a). File splitting
capabilities enabled the software to visualize the core and veneer
together.

Figure 1.2-13a Occlusal view of the restoration.

Figure 1.2-13b Buccal intercuspation view of the completed restoration.

Figure 1.2-14 Buccal view of the virtual mockup of the proposed

restoration.
 Summary

Because they represent ideal tools for more accurately and efficiently
capturing relevant intraoral patient information, as well as based on their
ability to facilitate treatment planning and restorative processes, the use of
digital impressions is rapidly growing.

To keep pace with demands for greater functionality and interoperability,

manufacturers are introducing more innovative digital dental scanners on an
on-going basis.
The benefits of incorporating digital dental scanning are many. Digital scans
can be retained electronically in practices and laboratories, eliminating the
physical space requirements for storing conventional models, as well as the
risks of chips, breaks, and distortion. Patients experience greater comfort,
convenience, and understanding of their condition and treatment objectives
when digital impressions are used compared to analog techniques, and
practices themselves benefit from the efficiencies associated with no longer
needing to use conventional impression materials.
When used as part of a complete in-office dental CAD/CAM system, dentists
can provide state-of-the-art restorations within hours, with restoration design
and fabrication being performed chairside with computer software and
milling technology.
 Supplemental Reading

Att W, Girard M. Digital workflow in reconstructive dentistry. In: Ferencz

JL, Silva NRFA, Navarro JM, eds. High-strength Ceramics: Interdisciplinary
Perspectives. Quintessence Publishing Co, Inc. Chicago, IL, 2014: 260–77.
Birnbaum NS, Aaronson HB. Digital dental impression systems. Inside
Dentistry. February 211. 7(2).
Bunek SS, Brown C, Yakas M. The evolving impressions of digital dentistry.
How CAD/CAM technology continues to drive innovation. Inside Dentistry.
January 2014; 35–39.
Burgess JO, Lawson NC, Robles A. Comparing digital and conventional
impressions: assessing the accuracy, efficiency, and value of today’s systems.
Inside Dentistry. November 2013; 68–74.
Child PL. Digital dentistry: Is this the future of dentistry? Dental Economics.
2011; 101(10).
Duke ES. Taking the mystery out of CAD/CAM in dental practice. Compend
Contin Educ Dent. 2004; 25(2): 140–3.
Fasbinder D. Using digital technology to enhance restorative dentistry.
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Dentistry. September 2014; 43–48.
Ganz SD. The next evolution in CBCT: combining digital technologies. A
precise approach to planning dental implant reconstruction enhances
accuracy. Inside Dentistry. February 2012; 9(2).
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digital construction process. Int J Comput Dent. 2012; 15(2): 109–23.
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Compend Contin Educ Dent. 2012; 33(9): 692–3.
Pakkala T, Kuusela L, Ekholm M, et al. Effect of varying displays and room
illuminance on caries diagnostic accuracy in digital dental radiographs. Caris
Res. 2012; 46(6): 568–74.
Patel N. CAD/CAM and 3-D vision beyond expectations, both clinically and
in business. Dental Economics. 2014.
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and the future of computerized dentistry. Compendium. Nov/Dec 2014. 739–
46.
Patzelt SBM, Bishti S, Stapmpf S, Att W. Accuracy of computer aided
design/computer aided manufacturing-generated dental casts based on IOS
data. JADA. Nov 2014
Patzelt SB, Emmanouilidi A, Stampf S, Strub JR, Att W. Accuracy of full-
arch scans using intraoral scanners. Clin Oral Investig. 2014 Jul; 18(6):
1687–94.
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impression techniques and workflow. Clinical Oral Investigations.
September 2013. 17(7).
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 Introduction

The use of intraoral scanners (IOS) for obtaining digital impressions has
made the impression-taking process more efficient and cost-effective. Not
only does digital impression scanning make the majority of analog
impression materials and techniques obsolete, but almost any type of
restoration can be designed and fabricated from a digital impression.

What remain significantly important to the success and predictability of both

analog and digital impression processes, however, are preparation design and
the gingival retraction techniques employed to ensure clear and unobstructed
access to, and visualization of, the margins, finish lines, and gingival
contours.
In fact, the biggest factor in predicting success with dental computer aided
design/computer assisted manufacturing (CAD/CAM) is the dentist’s ability
to properly prepare and retract the teeth. Among the reasons that preparation
and retraction remain important to the success of CAD/CAM restorations are
the capabilities of the IOS scanner and software itself, combined with the
type of milling unit and burs used to manufacture specific types of
restorations (e.g., anterior, posterior, intaglio surfaces) (Figure 1.3-1).
 Figure 1.3-1 The three milling burs shown here are used for
manufacturing different restorations. The one on the left is used for
anterior restorations; the middle for posterior restorations; and the one
on the right for the internal intaglio surface of posterior crowns.

Essentially, if the scanner cannot “see” it, then the digital impression will
lack the specific preparation landmarks necessary for producing a properly-
fitting restoration. Additionally, due to the shape of the milling tools used to
create CAD/CAM restorations, preparations must be shaped and angled
according to the ultimate geometry of the milling tools (Figure 1.3-2 and
Figure 1.3-3).

Figure 1.3-2 The geometry of the milling unit burs limits the types of
 internal angles of restorations that can be produced. Because the
milling unit burs are rounded, they cannot accommodate sharp angles.
In this example of a lower incisor pressed crown, the milling bur would
likely mill the restoration shy of the preparation requirements, creating
a short crown with improper margins.

Figure 1.3-3 Illustration of the manner in which the preparation in

Figure 1.3-2 would need to be modified in order to ensure a proper fit
after milling, based on the shape and geometry of the specific milling
bur. In this example of a lower incisor pressed crown, the milling bur
would likely open up the internal surface, resulting in a loose-fitting
crown.

Although IOS and digital impressions enable dentists to immediately view

images and impressions of preparations at enhanced magnification, the
quality of digital impressions is just as affected by the presence of blood,
saliva, and improperly placed retraction and hemostatic materials as are
analog impressions, particularly because IOS cannot differentiate between
tooth structures, gingival tissue, and debris. Therefore, repeatedly scanning
preparations that gradually become wet from saliva ultimately will produce
distorted and inaccurate impression images (Figure 1.3-4). Additionally,
unlike analog impression materials, the IOS camera does not displace
gingival tissues when capturing images and reading through the surrounding
tissue, making it all the more important to ensure that gingival margins and
subgingival finish lines are easily visible and sufficiently retracted.
 Figure 1.3-4 After repeatedly scanning a preparation that gradually
became wet with saliva, the IOS and CAD software produced a distorted
impression image, since the software cannot differentiate between a dry
tooth and wet tooth.

Interestingly, while taking digital IOS impressions does not require dentists
to deviate from their preferred preparation techniques, there are caveats
associated with preparation design.
Specific parameters for digitally produced restorations ensure sufficient
occlusal clearance, minimal restorative material thickness, and the ability of
CAM systems to properly mill the anticipated restorations. In particular,
preparations that will be digitally scanned for creating CAD/CAM
restorations need to be designed based on how the dental CAD software will
visualize and manipulate the images, as well as how the specific CAM
system produces the restorations.
Fortunately, IOS and CAD software enable immediate visualization, review,
and correction of preparations that deviate from the ideal, after which new
digital impressions can be taken for use in designing the restoration.
However, adhering to recommendations for designing preparations and
achieving isolation/retraction for IOS impressions will help to ensure
accuracy, efficiency, and predictability.
 Preparation Guidelines for Digital Impressions

Despite their tremendous capabilities, IOS are limited in terms of the digital
impression quality they produce, which are affected by the types of margins
and preparation angles that they image.

For example, IOS and subsequent milling units perform better when margins
are flat and the exit angle is 90˚. Therefore, reverse, trough, and feather-edge
margins should be avoided. Other potential problems with IOS impressions
can be encountered when sharp line angles and undercuts are present
(Figures 1.3-5 through 1.3-8). Additionally, depending upon the specific
brand of IOS, CAD software, and milling unit used to fabricate the
restorations, specific guidelines dictate the preparation design for posterior,
inlay/onlay, anterior, and veneer restorations.

Figure 1.3-5 This preparation for a molar full-coverage crown appears

acceptable for a traditional analog-produced restoration. However, to
angles are too sharp to be reproduced by CAD/CAM technology.

Figure 1.3-6 The bur needed to create the ideal preparation is one that
will produce a rounded edge.

Figure 1.3-7 A variety of burs specifically created for CAD/CAM tooth

preparations are available.

Figure 1.3-8 The scanned preparation illustrates the rounded axial-

occlusal portion of the preparation. This rounded design improves the
fit and retention of the milled crown.
Posterior Restorations
It is important to note that each IOS device and CAD/CAM system may have
specific manufacturer recommendations for achieving ideal preparations.
However, in general, when preparing a posterior restoration for IOS, the
internal angles should be rounded, and the teeth should be reduced between
1.5 and 2 mm, and 1 mm at the margin. The entire margin should be visible
from the occlusal aspect (Figure 1.3-9). Heavy chamfer, shoulder, or butt
joint margins, and a 6 to 10˚ taper, are recommended. Angled preparations
and undercuts, which may contribute to insufficient material thickness and
milling challenges, should be avoided.

Figure 1.3-9 Once the margin has been checked for clarity, the scan of
the preparation can be “locked” to prevent over-scanning and the
possibility of replacing accurate data with errors caused by saliva or
the loss of retraction.

Anterior Restorations
Anterior tooth preparations that will be digitally scanned should demonstrate
facial and lingual reductions of between 1 and 1.5 mm, margin area reduction
of 1 mm, and incisal edge reduction of between 1 and 2 mm. Chamfer or
shoulder margins, and a 6 to 10˚ taper, are also recommended.

Onlay Restorations
Unlike anterior and posterior preparation requirements, onlay restoration
preparations that will be digitally scanned do benefit from sharp edges at the
margins to facilitate identification. However, sharp internal line angles, as
well as parallel walls, may contribute to incomplete seating of the final onlay
restoration. Therefore, rounded internal line angles, and a 6 to 10˚ taper of the
internal axial walls, are preferred. More than 1.5 mm of occlusal reduction is
recommended, and butt joint margins are preferred over feather edge
margins. Interproximally, onlay restorations should demonstrate a 100 to
120˚ flare, since undercuts may contribute to open margins.

Inlay Restorations
Similarly, inlay restoration preparations that will be digitally scanned should
demonstrate sharp edges to facilitate identification; occlusal reduction of
between 1.5 and 2.0 mm; rounded internal line angles and internal axial walls
with a 6 to 10˚ taper; and an interproximal flare of between 100 and 120.˚
Additionally, however, preparations for digitally scanned inlay restorations
require an isthmus width of between 1.5 and 2.0 mm, and an isthmus depth of
more than 1.5 mm.

Veneer Restorations
Ideally, veneer preparations that will be digitally scanned should demonstrate
incisal reduction of between 1.0 mm and 1.5 mm, as needed, in addition to
depth cuts of between 0.5 mm and 0.8 mm. However, it’s important to note
that if the veneer restorations will mask underlying tooth structure—and/or
be characterized with hand-layering techniques—additional reduction may be
required.
The facial enamel surface should be prepared to a uniform thickness using a
medium grit, round-ended diamond bur, and care should be taken to ensure
that interproximal chamfer margins are properly prepared.
 Tissue Management

When taking a digital impression, tissue management helps ensure the

margins of the preparation are visible by moving the gingival tissues away
from them and promoting hemostasis. There are several techniques to
effectively manage and move gingival tissues during preparation and when
taking either a digital or analog impression that can broadly be
characterized as mechanical, chemical, and surgical. Among them are
gingival retraction cords, chemical agents, hemostatic materials,
electrosurgery, and laser troughing, in addition to several other methods.

Mechanical Retraction with Cords & Pastes

Mechanically displacing gingival tissue involves physically moving them
from preparation margins to the depth of the sulcus using either a singular
retraction material and technique, or a combination of options (e.g., retraction
cord and hemostatic agent).
One mechanical retraction method is placing retraction cord (e.g., woven,
braided, twisted; non-impregnated, chemically impregnated), which are
available in a variety of diameters and thicknesses (Figures 1.3-10 through
1.3-17).
Figure 1.3-10 Braided retraction cord is placed into the sulcus using a
packing instrument.

Figure 1.3-11 The retraction cord is placed deep into the sulcus around
the circumference of the gingival margin.

Figure 1.3-12 Note that the gingival margin is clearly visible from the
occlusal aspect.
Figure 1.3-13 View of the digital impression in the CAD software. All
aspects of the preparation and margins, including the retraction cord,
are clearly visible.

Figure 1.3-14 The CAD software is used to evaluate the preparation

and margins.

Figure 1.3-15 View of the CAD designed restoration.

 Figure 1.3-16 The restoration is tried in to confirm an excellent, passive
fit.

Figure 1.3-17 View of the completed posterior crown restoration.

Braided cords are preferred by many dentists due to their tight and consistent
weave, which facilitates placement into the gingival sulcus. Braided cords
can be easily pushed into place using either serrated or smooth packing-
placement instruments. Knitted cords, however, are increasingly being used
because their weave remains intact after cutting and during placement,
facilitating ease of use. When wet with astringents, knitted cords expand
within the sulcus to enlarge it for enhanced access and visibility.
Gingival health and sulcus depth typically indicates which retraction cord
technique is ideal (e.g., single cord, double cord). Single cord techniques are
ideal in patients where the sulcus depth is shallow. However, the double cord
technique (i.e., first placing a thin cord deep in the sulcus, followed by a
wider diameter retraction cord) is recommended whenever possible.
Another technique for mechanically displacing gingival tissues involves the
use of retraction pastes, which are putty-like in consistency and demonstrate
hemostatic properties (due to components such as aluminum chloride).
Retraction pastes are considered cordless retraction materials that
atraumatically displace the gingiva, making them ideal complements to other
retraction techniques (e.g., laser troughing, retraction cord). To establish
gingival retraction, the paste is injected into the sulcus, where it produces
constant pressure to move the soft tissue during digital impression scanning
and/or analog impression procedures.

Chemical Retraction
A variety of chemicals (e.g., ferric sulfate, aluminum chloride, racemic
epinephrine, aluminum potassium sulfate, aluminum sulfate, zinc
phenolsulfonate/racemic epinephrine) can be used with gingival retraction
cords to promote hemostasis and shrink the gingival tissues surrounding
preparations. Available as solutions or gels, these astringent or hemostatic
chemicals promote the contraction/retraction of gingival tissues, or
coagulation by constricting blood flow, respectively. When gingival
retraction cords are impregnated with these hemostatic/astringent chemicals,
they demonstrate better tissue displacement in the sulcus.

Surgical Retraction Using Lasers

A surgical option for displacing the gingival tissues surrounding preparations
is troughing it—rather than retracting it—using a soft tissue laser. Used
increasingly to manage soft tissues, laser troughing promotes hemostasis
through coagulation and sealing blood vessels, enhances visualization of the
margin through ablation of the tissue, and typically results in little to no
postoperative discomfort for the patient after the procedure. Soft tissue lasers
have even been shown to reduce bacteria in the sulcus, promote tissue re-
growth, and stimulate faster healing.
Contributing to the effectiveness of soft tissue lasers (e.g., Neodymium YAG
(Nd:YAG) and diode lasers) for gingival troughing is their laser wavelength,
which is specifically absorbable by water and hemoglobin (i.e., oxygenating
protein in red blood cells). The soft tissue laser energy penetrates the gingival
tissues, ablates it, and simultaneously seals blood vessels and nerve endings.
These photo-thermal lend to the efficacy of soft tissue lasers for soft tissue
management during digital impression taking procedures.
 Summary

Concepts of tissue retraction/management will evolve, and new products will

be developed to help dental professionals become more efficient in such an
important clinical step when implementing CAD/CAM technology. Although
using IOS to obtain digital impressions has streamlined the restorative
workflow, preparation design and gingival retraction remain important
considerations to ensure the accuracy and predictability of anticipated
restorations. Therefore, caveats for successfully using digital IOS include
following recommended preparation designs based on the indication, as well
as ensuring proper gingival retraction/management using either mechanical,
chemical, or surgical techniques.
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