Intra-oral scanners in the dental office

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Intra-oral scanners in the dental office—the countless benefits for both clinicians and patients and the practical aspects of digitalisation

Fig. 1: Drs Werner H. Mörmann and Marco Brandestini proudly presenting a CEREC prototype in 1986. (All images: Dr Ahmad Al-Hassiny)

Tue. 1. August 2023

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Dentistry is undergoing a radical transformation. The use of intra-oral scanners (IOSs) instead of traditional physical impressions is gaining more and more ground. Virtually all disciplines of dentistry, including prosthodontics, orthodontics, conservative dentistry, implantology and oral surgery, can benefit from the multitude of advantages of the digital workflow.1–3 The adoption of digital technologies and IOSs, in particular, has skyrocketed across the globe. The uptake of these devices is as high as 40%–50% in some developed countries, and it is expected to continue to rise globally.4 It can be concluded that digital dentistry is no longer the future but the here and now.

While scanners have surged into mainstream dentistry relatively recently, CAD/CAM technology was introduced to dentistry in the 1970s.5 Its history dates back to 1973, when Dr François Duret proposed the idea of optical impressions for application in dentistry. Ten years later, he demonstrated the first crown produced using a patented electro-optical scanner to take a digital impression and CAD/CAM system for the fabrication of the crown.6

Drs Werner Mörmann and Marco Brandestini recognised the potential of this market and developed a similar system in 1983 at the University of Zurich, independent of Dr Duret’s work. In the same year, they created the first CEREC prototype unit (Sirona Dental Systems; Fig. 1).7, 8 The very same CEREC that many dentists around the world utilise today was first envisioned so long ago.

Since their earliest inception, IOSs have been optical in nature, utilising laser or structured light technology. The optical impression made by an IOS is carried out by taking a scan inside the patient’s mouth of the target teeth or gingivae directly. The light projected from the IOS reflects off the soft and hard tissue into a sensor in the IOS, which is then converted into a digital impression by software. The software then creates a 3D image of the surface of the prepared tooth, the gingiva, the antagonistic tooth or the dental occlusion (Fig. 2–4).9

As opposed to laboratory scanners, IOSs are designed to obtain digital impressions directly in the patient’s mouth. Therefore, their design has been limited by the shape of the oral cavity, and the general appearance of these scanners across all the different manufacturers does not vary significantly (Fig. 5).

Benefits of IOSs

The benefits of intra-oral scanning compared with conventional impressions are endless. These advantages are well established both in literature and by the thousands of anecdotes provided by clinicians worldwide. Adopting the use of intra-oral scanning in the practice is a no-brainer.

The benefits of using an IOS in the practice include improved clinical efficiency, improved comfort for patients and ease of use for the clinician.10, 11 Intra-oral scans are just much faster and, with the right training, easier to carry out than a physical impression.12 A full-arch intra-oral scan can be carried out within 45 seconds confidently these days by an experienced user.

Patients also far prefer intra-oral scans to physical impressions. This is logical and self-explanatory. When an IOS is used, patients are less likely to gag, and the entire process of having the impression taken is more efficient and less messy. Using an IOS also has a wow factor. Patients are extremely impressed by this technology when shown it.11 This can help improve communication and build patient rapport and trust (Fig. 6).

Further benefits include the ease of storage. No longer do you need to have cupboards full of stone models. A digital file is easy to store and, more importantly, easy to share. By using an IOS, you open the door to a world of possibilities by being able to utilise the various design services all around the world. This is all possible because it is much easier to send a scan file in an email to a laboratory on the other side of the world than to try send it a stone model.

Multiple studies have compared the accuracy of conventional impression techniques with that of digital impressions. The latest studies have concluded that digital scans have comparable accuracy13 or are even superior14 to physical impressions. However, it is important to note that not all scanners are made equal, and some devices are unable to maintain accuracy in scanning more complicated structures, such as edentulous arches, or in scanning for full-arch implant prostheses.15

With all the advantages of IOS, what are the downsides? Well, the reality is just two considerations. The first is investment cost, which as an industry I think we just need to accept, as the undeniable fact is that using an IOS will make dentistry so much better for you and your patients. It will make dentistry more enjoyable for you. After all, you have to spend money to make money.

The second consideration is training. Clinicians need to be aware that, although using an IOS is much easier now than ever before, it still requires some training and practice. Think about your first physical impression compared to now. Thankfully these days with modern IOSs, it is much easier to learn. I can confidently train our new graduate dentists to become very proficient with an IOS within two to three weeks. It just takes some time, training and effort, but it is worthwhile and you will never look back. My advice for buying an IOS is to make sure that your supplier provides adequate training and support, otherwise check out the website of the Institute of Digital Dentistry for an entire library of online courses that will teach you everything you need to know.

Market pressure and changes

Over the past 15 years, we have watched the IOS market grow increasingly competitive. Back then, there were only two main IOS options, CEREC and E4D (now under the Planmeca brand). Now, there are over 15 IOS manufacturers and many more scanners, since this figure does not include all the white-label products. The IOS market has completely blown up.

With this increase in competition and market pressure, we have seen an unprecedented reduction in scanner prices, which is beneficial for clinicians everywhere. As I mentioned, it is well established that the main barrier to adopting intra-oral scanning is cost,16 so the decrease in prices is driving adoption rates of intra-oral scanning. Fifteen years ago, the entry price for an IOS was at least US$60,000. Nowadays, it is a fraction of this, the cheapest entry-level scanner being around US$8,000.

Fig. 6: An example of patient engagement when using the TRIOS MOVE (3Shape). (Image: iDD, institute of Digital Dentistry)

Fig. 6: An example of patient engagement when using the TRIOS MOVE (3Shape). (Image: iDD, institute of Digital Dentistry)

TRIOS 5 (3Shape)

TRIOS 5 was officially launched in September 2022 (Fig. 7). It was a complete upgrade compared with the previous-generation models, TRIOS 4 and 3. TRIOS 5 is a complete redesign and engineered inside and out. According to the manufacturer, this IOS will take scanning to the next level. Unlike TRIOS 4, which was an incremental improvement on TRIOS 3, TRIOS 5 has an entirely new optical engine and build.

3Shape said it has made more than 50 improvements in the TRIOS 5 compared with older generations. Like usual for 3Shape products, it looks incredibly stylish and high-tech. The best part is the cost. TRIOS 5 has a recommended retail price of US$26,000. It being a premium scanner, this is the cheapest price a TRIOS flagship product has ever been released at—a sign of the (market) times.

With the release of TRIOS 5, the company has also taken the opportunity to rethink its other scanner prices to stay competitive. There is now a reduction in cost of all other TRIOS models. For example, TRIOS 4 with the wireless pod is now around US$22,000 (recommended retail price). Additionally, just like other TRIOS scanners, TRIOS 5 has a subscription-free option.

One of the most interesting changes in TRIOS 5 is that it is completely calibration-free. Dentists will no longer need to be concerned about calibrating the scanner before the next patient comes through the door. TRIOS 5 is also 30% smaller and 20% lighter than TRIOS 4, having a total weight (with a battery) of 299 g, making it one of the lightest scanners on the market.

The company has also invested heavily in its battery technology, so TRIOS 5 requires only one battery per day, the company says. This is a welcome improvement, as the battery life of TRIOS 4 was not good. The company says that the user can scan up to 33 patients or scan for 66 minutes per battery. The batteries also have fast-charging capability, enabling the user to charge the battery up to 80% in 60 minutes and fully within 2 hours (Fig. 8).

Finally, the major focus last year for many companies was hygiene. In a post-pandemic world, this will be more important than ever before. TRIOS 5’s closed scanning tips are a completely new design. These are different to all other TRIOS scanning tips, and the focus is making them hygienic and preventing cross-contamination. They are also cheaper and can withstand up to 100 autoclave cycles. TRIOS 4 smart tips have not made a return in TRIOS 5.

Fig. 7: TRIOS 5.

Fig. 7: TRIOS 5.

Fig. 8: TRIOS 5 with a battery pack inserted at the back of the scanner.

Fig. 8: TRIOS 5 with a battery pack inserted at the back of the scanner.

Practical aspects of digitalisation

There are many things to like about the new TRIOS 5 scanner, but what about actually applying this technology in the dental office? For starters, a dentist needs to take the plunge and invest, accepting that the pros far outweigh the cons. The next step is installation and training. Choose a reputable company and distributor that will offer great installation and onboarding services. If you buy a TRIOS 5, this will come in two forms, either the TRIOS MOVE cart or the laptop version. Both are very easy to install.

The next step is training. When using an IOS, it is crucial to follow recommended scanning protocols or scanning strategies set out by the company. Following correct scanning protocols gives users a methodology with which to ensure the most efficient way to scan and minimises the risk of incorrect stitching of images, which results in inaccuracies. Scanning now is easier than ever before with powerful artificial intelligence (AI) in most devices that effectively guides the user, can identify and remove soft tissue artefacts, and filters scan data to only capture what is important. Scanning protocols have also seen improvements. For example, 3Shape introduced ScanAssist technology, which utilises AI to stitch together data regardless of the strategy used.

Coating the oral cavity in scanning powder is no longer necessary with modern scanners. Although, owing to the optical nature of the scanners, wet and very shiny surfaces can still be a little tricky to capture, these factors are often managed inside the mouth, for example with adequate moisture control or changing the angle of the scanner to prevent light reflection into the sensor.

Almost all modern IOS have some sort of mechanism to prevent condensation on the scanner tip while scanning, such as an external or built-in heater or fan. These factors enable scanning within the oral cavity for a long time without having to stop.

The reality is that, with modern scanners, getting into digital dentistry has never been easier. My recommendation is to take the plunge. You do not want to fall behind, and the sooner you start learning how to use this technology the better.

Market trends

The IOS market has changed significantly over the past 15 years, from single-shoot cameras to scanners that take thousands of images per minute and high-tech AI. Looking into the future, the market trend of IOS seems to be moving towards wireless, battery-powered scanners with removable scanning heads rather than traditional wired ones with fixed scanning heads that require cold disinfection. This is evident in some of the latest major releases in the market, such as TRIOS.

The main market trend we are now seeing is related to software improvements. There has been a significant push by companies to improve their software as a point of difference compared with the multitude of other devices on the market. IOSs are moving away from being just an impression replacement tool to being seen as a valuable tool to be included in patient examination as a communication and treatment planning aid. There are many software modules included in scanner software by prominent companies. These modules include orthodontic simulators, smile design simulators and patient monitoring over time. With the rise of 3D printing in dentistry, we are also seeing companies include a model builder module in their IOS software, which enables the scans to be made into printable models easily and efficiently.

There is no doubt in my mind that, in the future, most of the advancements we will see will continue to be in the software space, especially in the realm of AI and better workflows with other devices that are being adopted in the clinic, such as 3D printers. Although milling machines were never adopted widely in the dental office (again mainly because of cost), 3D printers are much cheaper and enable clinicians to move some production in-house. This is proving to be an exciting area of dentistry, and the scanner companies are taking notice, many creating integrations with popular 3D printers.

Conclusion

There has not been as much advancement in the industry from a technological point of view like there has in the past ten years. Dentistry is completely changing, and with the advent of AI diagnostics, intra-oral scanning data, 3D printing and CAD/CAM software, it is not inconceivable that how we diagnose, plan treatment and execute treatment will radically change in the next five to ten years. If you do not have a scanner yet, it is time to accept the inevitable and invest. The Institute of Digital Dentistry provides on its website a multitude of free resources to help you choose the right scanner for you. It is indeed a very exciting time to be a dentist!

Editorial note:

This article was published in digital—international magazine of digital dentistry vol. 4, issue 1/2023. The list of references can be found here.

3D printing Artificial intelligence CAD/CAM Cerec Digital dentistry Digital impressions Digital workflows in dentistry Digitalisation Intra-oral scanners Milling machine

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