The Transition to Digital Dentistry
Digital impressioning is often described in provocative ways; “paradigm shift,” “revolutionary,” and “game changer” are among the terms used to describe this technology. In fact, articles written about digital impressioning over the past 5 to 10 years might lead one to expect that this dental technology is now the standard of care in most US general dentistry practices. After all, digital impressioning first became available in the mid-1980s with the introduction of Sirona Dental Systems’ CEREC 1 (www.sirona.com).1 Yet in 2013, it is estimated that just 5% to 16% of US dentists use digital impressioning systems.2,3 To gain insight into where digital impressioning is in 2013 and where it is likely going, we spoke with individuals from all facets of the digital impressioning world, including executives from companies marketing some of the top digital impressioning systems, dentists who are experienced users of digital impressioning systems, and the business manager of a large milling company.
A History of Digital Impressioning
Digital impressioning’s history is intertwined with that of another technology, computer-aided design/computer-aided manufacture (CAD/CAM). CAD/CAM systems have been used since the 1960s in the manufacture of automobiles and airplanes.1 CAD/CAM was first applied to dentistry in the early 1970s, when French dentist Dr. Francois Duret introduced CAD/CAM concepts into dental applications in his thesis, “Optical Impression.” In 1984, Duret invented and patented a CAD/CAM device, which he used at the 1989 Chicago Dental Society Midwinter Meeting to demonstrate the fabrication of a crown in 4 hours. Around the same time, Swiss dentist Dr. Werner Mormann and electrical engineer Dr. Marco Brandestini developed the concept for what would become CEREC 1, the first commercially available digital impressioning system, which was introduced in 1985.1 CEREC 1 combined a 3-dimensional (3D) digital scanner with a milling unit to create dental restorations from commercially available blocks of ceramic material in a single appointment. CEREC 1 was designed for the fabrication of ceramic inlays and onlays.
Is Digital Impressioning the Gold Standard?
Twenty-eight years after CEREC 1’s debut, is digital impressioning the gold standard? Keith Haig, director of marketing for 3M ESPE Dental Products (3M™ True Definition Scanner, www.3mespe.com) gave a two-part answer to that question that elegantly sums up the situation: “If you are asking if it is the gold standard because most dentists are using it, that is not yet the case; however, if you ask if it is the gold standard because it’s more accurate and predictable, there is an argument to made for that.”
Michael Augins, president of Sirona (CEREC Omnicam) believes that digital impressioning is the future, the evidence of which can be seen in the fact that even when a dentist uses elastomeric impressions, labs are digitizing the impressions. “It will be the standard of care within 5 to 10 years,” predicts Tim Mack, senior vice president of Align Technology (iTero®, www.aligntech.com). The process is already moving in that direction as dentists who begin with digital imaging get comfortable with that and ease into digital impressioning, says Carrie Nelson, director of marketing for D4D Technologies (E4D Dentist/E4D Solo, www.e4d.com).
Although many see digital impressioning as the gold standard and agree that most dentists will eventually embrace it, some will resist investing in it even if the price comes down, notes Tais Clausen, chief technology officer of 3Shape A/S (TRIOS® 3Shape, www.3shape.com). “Today we see that the younger dentists quickly embrace the new technology while veteran dentists are more wary,” he notes. “But when they see how easy it can be to use, even the older generation wants to convert.”
Dentists already using digital impressioning need no convincing that it represents the future of the industry. “Digital impressioning is the gold standard in my practice already and I believe that one day soon it will become the gold standard for dentistry,” says Richard Rosenblatt, DMD, a dentist based in Lake Forest, Illinois, and an experienced CEREC user and instructor. Perry Jones, DDS, MAGD, an associate professor in the department of Oral and Maxillofacial Surgery at Virginia Commonwealth University School of Dentistry who practices in Richmond, Virginia, is a long-time user of Align Technology’s iTero system. Jones and has lectured and written extensively on its many uses and versatility. For years he was the only dentist in Virginia using digital impressioning, and he is waiting for his colleagues to follow suit.
The majority of dentists will likely adopt digital impressioning once the learning curve for the technology is minimized and the cost of investing in it goes down, says Brent Fredrickson, DDS, a Minneapolis dentist who has had experience with several digital impressioning systems over the past decade and now uses 3M’s True Definition.
Chris Brown, business manager of Apex Milling (www.apexdentalmilling.com) in Ann Arbor, Michigan, expects dentists to overwhelmingly adopt digital impressioning in the not-too-distant future. Labs are already well on the way. Given the current technology in use with today’s scanners, however, Brown doesn’t think they are ideal in every case. “Traditional impression materials can provide a quicker, better result in situations in which a dry field can’t be maintained. In my opinion, we should always put our best foot forward. In many cases, digital impressions are the most accurate, efficient method, but not for every case.”
Barriers to Adoption
Cost and the learning curve are the most frequently mentioned hurdles slowing the adoption of digital impressioning, though there are other factors to address. Manufacturers are very aware of the need to remove these barriers, and have worked over the years to continuously improve the technology, the ease of its use, and the learning curve associated with adopting it.
Cost
Dentists usually cite the high cost of investing in digital impressioning as their main concern. Although the costs vary depending upon whether the practice intends to send the digital impression files to third party labs or do their own CAD/CAM milling, adopting new technology requires a capital investment any way you look at it. Augins describes the market for digital impressioning as “segmented,” with prices at the high end remaining the same, whereas at the lower end, prices are falling.
But price doesn’t exist in a vacuum. Clausen maintains that dentists view pricing as less of a hurdle if critical technological barriers are crossed. As he sees it, digital impressioning technology was not at the threshold where it made sense to many dentists to invest in it until recently. “The convenience of using it, the accuracy of the digital impressions, the time it takes to capture the image, and whether the labs can work with the images—these were fundamental barriers apart from cost. If any one of these elements was compromised, the dentist would default to traditional impressioning—no matter what the cost was,” he says. Now that TRIOS has crossed these thresholds, offering open digital files and a scanner that captures a bigger field and allows extremely accurate, fast image capture, the system is now faster and more accurate than traditional impressioning—making the decision to invest in digital impressioning easier. “With the recent addition of color scanning, TRIOS is even more attractive, both in terms of clinical advantages and enhancement of the scanning experience,” Clausen says.
Cost concerns are compounded by the need for systems that are forward compatible. In other words, the dentist wants to be sure that when the next version of the system comes out, the previous one will be compatible with it. “We’ve really put our money where our mouth is,” says Haig. “For those who bought the Lava™ COS a few years ago, we have an extremely attractive upgrade price for the 3M True Definition Scanner.”
Dental practitioners may not want to invest in digital impressioning because they are focusing on their high success rate with conventional impressions. “But on any given day when they’re suffering through the 5% of problems, [dentists] are compromising their appointment book because they are trying to get a restoration to fit, the staff is backed up, the patients are backed up—the emotional cost is extremely high at that point,” Mack points out. “Not to mention the difficulty for the patient who has to come back.” His data suggest that with traditional impressions, crowns or prosthetics do not fit at least 5% of the time; with iTero, this is cut back to only a small fraction of cases (0.3%).
Technophobia
Dentists are notoriously slow adopters—even by their own estimation. Rosenblatt uses the term “paralysis by analysis” to describe how slowly dentists approach new technology. “We tend to analyze and analyze,” he says. “When you are taught one way to do things at school, it is a lot of effort and cost to change that when you are out on your own.”
Many of today’s practicing dentists are still thinking about the earliest incarnations of digital impressioning, which were more complicated than today’s systems. “Unfortunately, they are operating under outdated assumptions,” says Jones. “They don’t realize that most systems have eliminated the need to dust the teeth with powder before scanning, that they allow all types of restorations, and they have open files so you can use any lab.”
Despite the wariness, the number of dentists adopting digital impressioning is growing annually. Sirona is seeing 2% to 2.5% yearly growth, and Augins estimates that 16% of US dentists are using digital impressioning. Of those, 14% use digital impressioning bundled with milling and 2% use stand-alone chairside systems and send images to the lab for fabrication of models and restorations.
Although this percentage may seem quite slow, it is similar to the adoption rate of digital radiography, which is now at greater than 60% penetration. “There is an evolution of adoption—the ‘digital waterfall,’ in which dentists first go digital by getting computers in the operatory for practice management, and then they get digital x-rays, followed by digital impressioning and milling—and finally, 3D cone beam,” says Augins, who predicts that 80% of dentists will be using digital impressioning in 10 to 15 years. “We should remember that digital x-ray technology didn’t crack 50% penetration of the market until around the 15-year mark,” Mack points out.
Two things are happening in favor of digital impressioning’s adoption: a much greater comfort with technology in our homes, workplaces, and clinical environment—which was not the case when digital x-rays emerged in the mid-1990s—and the expectation among doctors and patients alike to have technology. When digital x-rays first appeared, it took about 10 years before the resolution and diagnostic quality of digital matched film—a drag that Mack believes won’t happen with adoption of digital impressioning, because from the very beginning, the diagnostic and therapeutic quality was better than that of conventional impressioning.
The Learning Curve
Time is precious for dental professionals, and the learning curve associated with digital impressioning is another critical hurdle for those contemplating this technology. Long-time dentists may be less comfortable with new technology than recent graduates of dental school. Dentists are resistant to change and feel that if something is working, why bring in something new that could potentially make things worse? They may fear the potential change in in scheduling, and think that it’s not worth the trouble when they are already so efficient. “Dentists have to learn that patience overcomes the learning curve,” says Fredrickson.
All of the companies marketing digital impressioning systems make training a huge priority. “Once they commit to the new technology, the dentist and staff are immediately scheduled at training classes at E4D University,” says Nelson. D4D Technologies also provides training and integration in clinicians’ offices, as well as ongoing support and remote diagnostics. The company assists the practice with maximizing E4D’s open architecture system so that the dentist can either fabricate restorations chairside or use the E4D SKY™ Network to send .stl files to E4D certified labs or any third-party provider.
Integration of the technology into the practice is critical. This is because there are going to be changes in the amount of time dentists spend with patients in the impressioning function, along with new opportunities for the dentist to delegate scanning to a dental auxiliary, says Haig. 3M ESPE provides ongoing support for integration into the practice with both in-office training and remote access to experts.
“It’s important that the doctor gets to a point where it’s more convenient to take a digital impression than an analogue one. The doctor has to feel confident with the device, so we pay a lot of attention to training,” says Clausen. 3Shape Academy provides expert group and customized training and continuing support via webinars, training videos, and online support in all major languages and time zones. 3Shape also provides TRIOS hands-on training at many dental events, such as Chicago Midwinter and IDS in Cologne. Periodic dedicated road events with training will be held across the United States.
Align’s clinical trainers spend 1 to 2 days inside the dental practice, working with the staff and doctors to learn to navigate the iTero. They are chairside with the first 4 or 5 patients and can observe whether everyone in the practice is comfortable with it by the end of the day. Users are also guided through individual cases via the Optimized Scanning Protocol, with visual/audible prompts to help users capture all the critical data.
Sirona’s partner, Patterson Dental, provides educational training throughout the country and on-site, as well as via online resources and expert help.
Adopting Digital Impressioning
Different concerns and interests motivate dentists who make the investment in digital impressioning. Rosenblatt has been a CEREC user for 10 years and purchased his system 6 years ago when he started his own practice. “It was the first piece of equipment I bought, before the ink on the practice loan was dry,” he says. As an associate in another practice, he saw that one of the most profitable changes had been to keep indirect restorations for single or multiple posterior units in-house and use the lab for the bigger cases.
“I’m not trying to put labs out of business; I love my labs and still use them for a lot of things, but if you look at the numbers on the ‘slam-dunk’ cases you do, and add up those numbers over 5 years, you are already paying for the system,” Rosenblatt notes. Consider also the hidden costs of second visits and tying up a chair. “Certainly one-visit dentistry is a win-win for both doctor and patients and has the greatest ‘wow’ factor in my practice,” he says.
Patients’ dislike of and discomfort with traditional impressions was what motivated Jones. “They universally hate it. I want to make changes that make the patient’s experience—and the doctor’s experience—great,” he says. Once the iTero was fully integrated into his practice, Jones realized that he was getting a return on investment (ROI) far more quickly than he expected, and he wanted other dentists to fully understand the financial benefits of digital impressioning.
Fredrickson was committed to the idea of digital dentistry because of the improved quality control and better results for patients. With the 3M True Definition and a CAD/CAM system, he offers his patients one-appointment crown visits. The integration of the technology into his practice has created an excellent ROI and had a great effect on the efficiency, workflow, and productivity of his practice. “My total time in the 1-day crown process is down to 60 to 70 minutes, which allows me to see other patients, do exams, and work on new treatment plans. Instead of paying a lab, we make the crown in our office, and I’m continuing to be productive.”
Practice Integration
Like other dentists who use digital impressioning, Fredrickson found that there were positive changes in workflow once the technology was fully integrated into his practice. “The learning curve with the 3M True Definition keeps getting easier. We love the predictability, accuracy, and consistency that it provides.”
Fredrickson no longer needs to pour up models to check the fit, because the marginal fit and the contacts are excellent with no adjustments. His notes that his staff loves the technology because they feel like they are an important part of a team. Patients love getting everything done in one appointment, and they spread the word, which benefits the practice. The practice saves money on lab bills, impression materials, and chair time. Finally, the open platform of the 3M True Definition gives Fredrickson the choice of lab or chairside milling. He does 90% of his own milling; 10% is done at the lab because some cases are more complicated, involve multiple units, or take a great deal of time.
Rosenblatt considers the CEREC to be the cornerstone of his practice. His staff loves not taking polyvinyl siloxane impressions, doing temporaries, or having the side column of the schedule booked with seat appointments and temporary recementations. His patients now expect to have their crowns done in one visit. “If you wonder if that matters, ask your patients if they want two separate, shorter visits to complete a crown that takes 80 to 90 minutes or one 90-minute visit where they get their final restoration with no impressions, second injections, or temporaries. You’ll be shocked at how many would choose that option.”
Many dentists believe digital impressioning has actually improved the quality of their dentistry. “When you see your preparations blown up about 20 times their actual size, you really see the kind of dentistry you are doing, and it forces you to make your preparations even smoother,” says Rosenblatt. This leads to better-fitting restorations and one-visit restorations—no impressions, temporaries, or the cost of a second visit. “It is humbling to see your prep on a 19-inch computer screen. It makes you a better dentist,” agrees Jones.
Table 1 lists some of the pros and cons of incorporating digital impressioning into an existing practice.
The Fun Factor
“One thing that cannot be factored into the ROI is the fun,” says Rosenblatt. He illustrates this point with a story. A year ago at one of his lectures, a 70-year-old dentist questioned how he would ever get a ROI. Rosenblatt told the man he couldn’t ensure that he’d make the money back, but he’d certainly enjoy the rest of his dental career. “The man bought the system,” Rosenblatt continues. “Fast forward 1 year. He recently told me that he did about 500 restorations last year and has never had as much fun doing dentistry as in the last year, and his dentistry has never been better. That made it hit home for me. It isn’t always about the ROI—factoring in the enjoyment of what we do can be hard to quantify.”
References
1. Birnbaum NS, Aronson HB, Stevens C, Cohen B. 3D digital scanners: a high-tech approach to more accurate dental impressions. Inside Dentistry. 2009;5(4):70-77.
2. 3M ESPE donates 12 digital impression devices to the Dugoni School of Dentistry. [Press release]. University of the Pacific Arthur A Dugoni School of Dentistry website. https://dental.pacific.edu/news_and_events/news_archive/3m_espe_donates_12_digital_impression_devices_to_the_dugoni_school_of_dentistry.html. January 12, 2012.
3. Olitsky J. Digital impressioning making its way into dentistry’s mainstream. Compend Contin Educ Dent. 2012;33(9):692-693.
4. Radz G. Clinical impressions of digital impressions. Dental Economics. 2009;99(3). www.dentaleconomics.com/articles/print/volume-99/issue-3/features/focus-on/clinical-impressions-of-digital-impressions.html.
Digital Impressioning Basics
Image capture
Digital impressioning systems replace traditional impression materials (polyvinyl siloxane) through the use of oral scanners that rapidly capture 3-dimensional images and video of the hard and soft tissues in the mouth, and convert these images into electronically transmittable data files.
Preparation
The digital impression image is displayed on a chairside monitor as it is captured, and various software tools allow the operator to evaluate the preparation. The preparation can be corrected immediately, prior to sending the files electronically to a lab or to the dentist’s own on-site milling system if the practice is so equipped.
Fabrication
Working models may be used to fabricate restorations, including crowns, bridges, inlays, and onlays. Digital scanning also allows the data to be used to fabricate “modeless” milled restorations. Scanning software can be used to evaluate properties such as occlusal clearance, allowing immediate adjustment and thus saving the time of having to schedule multiple appointments, as is often the case with conventional impressions.
System configuration
A digital impressioning system can comprise a stand-alone chairside scanning system/monitor in the operatory, with the dentist sending .stl files to a lab for milling of the model and fabrication of restorations, or it can be a 2-part system that includes the chairside scanner/monitor and a separate CAD/CAM chamber in another part of the office capable of milling the model and fabricating restorations based on the data from the digital impressions.
