PERSPECTIVES
Impressions are changing
Deciding on conventional, digital or digital plus
in-office milling
igital dental impres-
D sion devices have
been introduced to
the profession, poten-
tially eliminating the
need for taking conventional
impressions for crowns and fixed
prostheses. I have discussed this
concept in previous columns in
this journal.1,2 However, addi-
tional changes to the concept are
emerging, creating confusion
among dentists and causing
them to wonder whether there is
a need to change their impres-
sion techniques. The many ques-
tions I hear about this topic
from dentists attending contin-
uing education courses can be
distilled into the following four.
d“Should I continue to make
impressions in the conventional
manner using conventional
materials?” Both scientific evi-
Gordon J. Christensen, DDS, MSD, PhD
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
O B S E R VAT I O N S
dence and clinical observation
have shown that currently avail-
able impression materials—
vinyl polysiloxane, polyether,
the newer material vinylsilox-
anether and the older revers-
ible hydrocolloid—provide excel-
lent reproduction of tooth
preparations.3-9
d“Should I purchase a device
that makes digital impressions?”
With a digital impression device,
the clinician creates the impres-
sion digitally and sends the data
to a laboratory capable of
working with this technology;
the laboratory then creates the
restorations and sends them to
the dentist for placement. Two
popular digital impression
devices now competing on the
market are the iTero (Cadent,
Carlstadt, N.J.) and the Lava
Chairside Oral Scanner C.O.S.
JADA, Vol. 140
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(3M ESPE, St. Paul, Minn.).
Both of these devices limit the
dentist to the use of laboratories
that have, and are trained to
use, the laboratory devices asso-
ciated with the respective
impression devices. These
devices and this technical con-
cept are proving themselves to
be viable alternatives to conven-
tional impression making.10-14
d“Should I purchase a device
that makes digital impressions
and also provides the ability to
mill some types of restorations
in the clinical office?” The two
competing devices are CEREC
(Sirona Dental Systems GmbH,
Bensheim, Germany) and the
E4D Dentist System (D4D Tech-
nologies, Richardson, Texas).
The ability of computer-aided
design/computer-aided manufac-
turing (CAD/CAM) devices to
produce clinically acceptable
restorations has been reported
many times in the dental litera-
ture.15-27 Other companies soon
http://jada.ada.org October 2009 1301
PERSPECTIVES OBSERVATIONS
will enter the market and be
competitive with the CEREC
and E4D milling devices.
d“Should I purchase a device
that enables me to make digital
impressions now and upgrade to
in-office milling later if I like?”
At this point, only the entry-
level CEREC and E4D devices
offer the initial ability to make
digital impressions only and an
option to upgrade to in-office
milling down the road. However,
it is rumored that other compa-
nies will provide this option in
the future.
Although research reports
and clinical comparisons con-
tinue to come forth regarding
the acceptability of the above
concepts and devices, in my
opinion and clinical experience,
the accuracy of properly accom-
plished impressions—whether
conventional or digital—is no
longer a question with any of
the concepts.
There are other questions
dentists should ask about these
four choices:
d“Are there major advantages
to making digital impressions
instead of conventional
impressions?”
d“Should I purchase a digital
impression device at this point
in the concept’s development,
and will digital impressions
dominate impression making in
the future?”
d“Would a device that makes
digital impressions and also
mills restorations in the dental
office fit into my practice?”
d“Am I sure I want to invest
this amount of money in a
device that still is being devel-
oped and refined?”
I will discuss these questions
on the basis of both scientific
research and clinical observa-
tion, and I will make sugges-
tions for clinicians who are con-
1302 JADA, Vol. 140 http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
sidering changing to the use of
digital impression techniques
and to the in-office milling of
restorations. The predictions
included below are opinions
based on my significant experi-
ence with all of the devices and
concepts discussed and on my
global contacts with practicing
dentists in continuing education
courses.
USING CONVENTIONAL
IMPRESSION TECHNIQUES
Most dentists are comfortable
with conventional impression
materials and techniques as
used for crowns and fixed pros-
theses. It is difficult for anyone
to change from a successful and
relatively moderate-cost tech-
nique to an unknown and expen-
sive one. As I noted previously,
current impression materials
are excellent. I often have iden-
tified elastomer impression
materials as among the most
adequate of all dental materials
in fulfilling their intended pur-
pose. However, digital impres-
sions have advantages, as
described in the next section.
Dentists must consider whether
the advantages of the digital
impression technique outweigh
their familiarity with conven-
tional impression procedures
and their clinical success with
conventional impression tech-
niques. There appears to be no
urgency to change from the use
of conventional impressions
unless practitioners are
impressed with the positive
characteristics of digital impres-
sions outlined below. I predict
that digital impression tech-
niques will grow in use gradu-
ally and, eventually (many years
from now), will dominate the
impression procedures for
inlays, onlays, crowns and fixed
prostheses.
October 2009
PURCHASING A DEVICE
THAT MAKES DIGITAL
IMPRESSIONS ONLY
In my opinion, many dentists do
not enjoy or have interest in the
laboratory aspects of dentistry.
These dentists are satisfied to
make tooth preparations and
impressions, send the impres-
sions to a competent laboratory
technician and seat the restora-
tions a few days later. If you are
positive that you do not want to
be involved with any of the steps
in the milling procedure, and
you have made the decision to
make digital impressions, you
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may purchase any of the four
devices described in this column
at roughly similar prices to
make digital impressions only.
The approximate price of a dig-
ital impression device ranges
from $25,000 to $30,000 (J.
Denney, western regional sales
manager, Cadent, oral commu-
nication, Aug. 27, 2009; E.
Neuenfeldt, professional rela-
tions manager, 3M ESPE,
written communication,
Aug. 27, 2009).
Why change from
conventional impressions
to digital impressions? Dig-
ital impressions have several
desirable characteristics:
dThe mess that occurs when
making conventional impres-
sions is eliminated. Dental
assistants are pleased with the
resultant elimination of mixing
and cleanup.
dPatients prefer the simplified
digital impression concept, and
they express relief at not having
to endure the uncomfortable
experience of having a conven-
tional impression made in the
mouth.
dShipping the impression to
the laboratory is merely a dig-
ital transfer via one of many
methods such as e-mail, disk or

flash drive.
dBecause there is no actual,
tangible impression, there is no
need for disinfection or threat of
disease transfer from the
patient to the technician.
dThe tasks of pouring the
impression, making the base
and trimming the dies are
eliminated.
dAssuming that the digital
impression and the digital
interocclusal record have been
obtained accurately, the need to
articulate the casts also is
eliminated.
Are these advantages impor-
tant enough to convince you to
make the change to digital
impressions? Additionally, are
you sure you want to send the
digital impression to a labora-
tory and not mill the restoration
in your own office?
Some dentists do not know
whether they want the responsi-
bility of in-office milling with
the attendant potential need to
modify restorations and to stain
and glaze them before they are
ready to be seated. If you are
one of those dentists, perhaps
you should enroll in a CEREC
course, an E4D course or both to
help you make the decision.
If you still are undecided after
taking such a course, you may
elect to purchase the entry-level
CEREC or E4D device, with the
potential to upgrade if you
decide to add in-office milling in
the future.
PURCHASING A DEVICE
THAT MAKES DIGITAL
IMPRESSIONS AND MILLS
RESTORATIONS
There are now about 25,000
CEREC users worldwide
(Michael Dunn, director of
CAD/CAM Marketing, CEREC,
oral communication, Aug. 13,
2009) and, although the E4D
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
PERSPECTIVES
was released on the market only
recently, there are a growing
number of dentists using that
device as well. There is minimal
independent research comparing
the two devices; however, a
recent comparative project con-
ducted by the staff of Clinicians
Report showed that both devices
were similarly capable of pro-
ducing acceptable milled
restorations.28
Advantages of in-office
milling of restorations. Den-
tists can gain from milling resto-
rations in their offices in several
ways:
dRestorations can be placed in
one appointment, an aspect
many patients regard as a sig-
nificant advantage.
dThe patient receives fewer
anesthetic injections because
there is no second appointment.
dPractitioners report that the
in-office milling concept encour-
ages the use of conservative
tooth preparations such as
onlays, three-quarter crowns
and conservative full crowns.
dIn-office milling eliminates
the need for provisional restora-
tions, with their accompanying
negative characteristics.
dThe clinician controls the
entire procedure; the process
involves no laboratory
component.
dSeveral steps in the pro-
cedure—including imaging,
milling and initial fitting of the
restoration—can be delegated to
qualified staff members while
the dentist treats other patients.
dAccording to experienced
users, the in-office milling con-
cept can be financially accept-
able and even can produce sig-
nificant income.
Disadvantages of in-office
milling of restorations. Not
every aspect of in-office restora-
tion milling is positive.
JADA, Vol. 140
OBSERVATIONS
dThe equipment requires an
initial investment of about
$120,000. Various financial
plans and potential add-ons (at
additional cost) exist.
dLearning to use the device
and fit it into the office routine
requires time and effort.
dTo become and remain profi-
cient in using the software and
hardware, the clinician and staff
members must use the devices
frequently.
After assisting many dentists
in learning about and using in-
office milling, I conclude that it
is a viable concept for some, but
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not all, dentists. I advise inter-
ested dentists to enroll in
courses on in-office milling of
restorations before making a
decision about purchase of
either of the two devices.
SUMMARY
Some dentists face the dilemma
of wanting to keep up with the
technological advances in the
profession while feeling unsure
about embracing the digital
impression technique and the
related in-office milling of resto-
rations. This column provides,
on the basis of scientific evi-
dence and clinical observation, a
candid appraisal of the several
impression options available to
dentists: conventional impres-
sions, digital impressions and
digital impressions accompanied
by the ability to mill restora-
tions in-office.
After considering all options,
dentists must make the decision
themselves concerning whether
or not these concepts fit well
into their practices at this time.
All of the devices and techniques
I have described here, including
conventional impressions, are
producing clinically acceptable
restorations, but the digital
option also can provide signifi-
http://jada.ada.org October 2009 1303
PERSPECTIVES OBSERVATIONS
cant advantages for both den-
tists and patients. ■
Dr. Christensen is the director, Practical
Clinical Courses, and a cofounder and senior
consultant, CR Foundation, Provo, Utah. He
also is the senior academic advisor, Scottsdale
Center for Dentistry, Scottsdale, Ariz.; an
adjunct professor, Brigham Young University,
Provo, Utah; and an adjunct professor, Uni-
versity of Utah, Salt Lake City. Address
reprint requests to Dr. Christensen at CR
Foundation, 3707 N. Canyon Road, Suite 3D,
Provo, Utah 84604.
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental
Association.
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