OVERVIEW
The indirect restorative procedure workflow is currently undergoing a significant change. Every few decades, the impression protocols have undergone a significant shift: from copper-bands and compound, to rubber base, to reversible hydrocolloid, to vinyl polysiloxane (VPS), and now to digital capture. Each system worked sufficiently well for its time; however, the demands for accuracy, efficiency, and patient comfort produced a strong impetus for change. In all prior cases, this change was evolutionary, but the shift from physical impressions to digital impressions may well prove to be revolutionary.
Although the technological means of creating an intraoral digital impression of the prepared teeth has been in the marketplace for more than 20 years, it is only recently that it has reached the levels of accuracy and efficiency that our profession demands. In just the last few years, dentistry has gone from a single intraoral digital capture device to 4 (Figures 1 and 2). There are 2 general types of these digital capture devices. There are those capable of a digital capture and in-office milling of the prosthesis (CEREC AC Bluecam [Sirona] and E4D Dentist [D4D Technologies]); these are commonly referred to as chairside CAD/CAM units. There are also those that take digital impressions but retain the fabrication procedures in the laboratory (LAVA C.O.S. [3M ESPE] and iTero [Cadent]); these are commonly referred to as digital impression units (DIUs). For those who do not wish to fabricate restorations within the dental office setting, the CEREC and E4D systems now also allow the choice of taking the digital impressions in the office and transmitting the data for the design (CAD) and milling process (CAM) in the laboratory (CEREC Connect [Sirona] and E4D LabWorks [D4D Technologies]).
DECIDING FACTORS (DIUS VERSUS CAD/CAM UNITS)
In dentistry, like everyday life, new technologies are radically changing the way we see and do things. Many of the processes and materials we have already incorporated into the scope of everyday practice are possible only with these new developments. Digital cone-beam computed tomography (CBCT) scans have become irreplaceable for the evaluation of implant and grafting sites. Digital intraoral x-rays have enhanced the speed and diagnostic abilities of the clinician. Zirconia (ie, LAVA) utilizes a lab-based CAD/ CAM unit for fabrication. Digital photography has revolutionized our ability to communicate with patients, technicians and colleagues. The “paperless practice” is becoming more and more common in dentistry, as well as in medicine. Insurance claims can be submitted digitally. To stay competitive in today’s market, the dental lab business is also moving quickly to various modalities of digital technology (ie, wax printing, stereolithography, CAD/CAM milling.)
No one digital technology is right for every practice. Clinicians must carefully evaluate and consider their goals when looking to adopt digital impressions and/or In-Office CAD/ CAM into their practices.
The DIUs (LAVA C.O.S. and iTero) are best suited for the practices that already function at a very high level (or are hoping to). These are the practices that enjoy the convenience (in terms of fit, design, and aesthetics) of a restoration produced by a third party (dental laboratory), but are also interested in realizing all the benefits that digital impressions have to offer. DIUs are best for doctors who have no inclination to design and finish their own ceramic (laboratory) work.
DIUs do require some brief training to get through the learning curve. However, once the team is comfortable with the scanning procedure, this technology fits very easily within an efficient office protocol. There are almost no changes to inventory or scheduling required. Patients generally prefer the digital impressions to physical (ie, VPS) impressions, which can significantly increase goodwill and word of mouth referrals.
The in-office chairside CAD/CAM systems (CEREC and E4D Dentist) are best suited for the office that wants to enhance efficiency and reduce overhead, while bringing the entirety of the ceramic workflow into the office. Integrating these units into a practice requires a strong drive to make it work and the support of a competent team. Once fully integrated, the reduction in lab bills can be quite significant and result in a significant decrease in overhead. The prospect of “one-day dentistry” and the “wow factor” of the technology may also help to attract new patients.
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