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Review Article
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Computerized technology for restorative dentistry

DENNIS J. FASBINDER, DDS

ABSTRACT: Computers have had a meaningful impact on the dental office and dental practice leading to significant
changes in communication, financial accounting, and administrative functions. Computerized systems have more
recently generated increasing diversity of application for the delivery of patient treatment. Digital impression systems
and chairside CAD/CAM systems offer opportunities to integrate digital impressions and full contour restorations in the
dental office. Systems rely on single image and video cameras to record the digital file that is the foundation for an
accurate outcome. This article presents key aspects of computerized technology using the CAD/CAM process. (Am J
Dent 2013;21:115-120).

CLINICAL SIGNIFICANCE: The review of computerized systems for in-office patient treatment provides information and
evidence for decisions on integrating these systems in a dental practice.

: Dr. Dennis J. Fasbinder, University of Michigan School of Dentistry, 1011 N University, Ann Arbor, MI 48109-
1078, USA. E- : djfas@umich.edu

Introduction systems are generally divided into two broad categories.

Computers have had a meaningful impact on the dental
office and dental practice leading to significant changes in
communication, financial accounting, and administrative
functions. Computerized systems have more recently
generated increasing diversity of application for the delivery
of patient treatment. Computerized Dentistry and Digital
Dentistry are terms that have been used to describe the
clinical application of Computer Assisted Design, Computer
Assisted Machining (CAD/CAM). CAD/CAM systems are
found in both dental laboratories and dental offices as both
doctors and laboratory technicians work to discover the
advantages and limitations of these systems.
There are three general processes involved with the
CAD/CAM workflow.1 The first process is to record the
geometry of the patient’s dentition and soft tissues to a
computer. For many years dentists have been using
conventional impression techniques to create stone models
that the dental laboratory scans in a bench top device. More
recently, intraoral scanners or cameras have been introduced
that allow dentists the opportunity to do the scanning process
without the need for conventional impressions and stone
models. The second process involves utilization of the
scanned information in a CAD software program. The
program is utilized to propose a volume model of the desired
prosthesis on the virtual model of the dentition. Additional
software editing tools allow for customization of the
restoration specific to the needs of the case. And the third
process is to utilize the digital proposal of the prosthesis to
direct a machining device to fabricate the desired outcome.
Many dental laboratories have recognized the benefits of
utilizing the CAD/CAM process for years as a means to
increase production while controlling costs. Often times the
systems can be used to extend the working hours of the dental
laboratory by programing equipment to mill designed
restorations after typical working hours. The challenge for
many dentists as newer techniques and systems are introduced
is to understand which of the three processes; imaging,
designing, and fabrication, of the CAD/CAM workflow are
desirable and useful for a dental practice. Currently marketed
Digital impression systems focus on the imaging process and
rely on dental laboratories to complete the design and
fabrication processes, and chairside CAD/CAM systems focus
on integrating all three processes in the dental office.
Dentists routinely use conventional impression materials
to record the intraoral condition for laboratories to fabricate
desired restorations and prostheses. Limitations in the use of
these materials and techniques are well known to the
profession. Digital impression systems focus on a similar
outcome, a replica of the patient’s dentition for laboratories to
utilize during case fabrication. However, they also avoid a
number of factors that negatively influence restoration
outcomes, such as volumetric changes in the manipulation of
impression materials and stone models, distortion of
impressions or models, abrasion or fracture of the models, and
issues in shipment of cases. Digital impressions are not
susceptible to changes in accuracy once they are recorded and
electronic transmission of the files to dental laboratories is
completed efficiently with no loss of accuracy.
The essential outcome of a digital impression system is the
digital file. The most common designation of the digital files
is stereolithography files or .stl files. The digital data file is
transmitted to the dental laboratory and may be used in two
general workflows to complete the case. One option is to
transmit the data file to a processing center to have working
models fabricated. The models are returned to the laboratory
in approximately 3 working days and the laboratory may use
any fabrication process to complete the case on the working
models. More recent innovative processes have included
removable prostheses, orthodontic appliances, and bitesplints
besides the usual fixed restorations associated with
CAD/CAM systems. The second option is to import the
digital data file to a CAD software program to virtually design
either a coping or full contour restoration. The models may be
used to apply the surface veneer to the coping and to refine
the full contour restorations.2 Alternatively, a full contour
restoration may be fabricated without the benefit of the
models. The True Definition Scanner,a iTerob system, and
TRIOSc are the three most common digital impression
systems (Figs. 1A-C).
 American Journal of Dentistry, Vol. 26, No. 3, June, 2013
116 Fasbinder

The CEREC OmniCamd and the

E4D Dentiste system are the only
currently available chairside CAD/
CAM systems.3 These systems
permit the application of all three
steps of the CAD/CAM process to
be integrated in the dental office
enabling complete control of the
final restoration. The design and
milling processes can be completed
in a short enough time period to
enable the restoration to be com-
pleted in a single appointment
resulting in improved efficiency and
convenience for the patient as there
is no need for a temporary restora-
tion or second appointment to de- Fig. 1. A. True Definition. B. iTero System (Cadent). C. TRIOS System.
liver the restoration. Both chairside
CAD/CAM systems can fabricate single tooth ceramic or
composite inlays, onlays, veneers, and crowns. The imaging
workflow for these systems is very similar to that of the
digital impression systems, however dentists and their
treatment team must also learn to design full contour
restorations as well as the milling and fabrication process.
This is obviously a greater learning curve to master compared
to the imaging process alone. Both the CEREC OmniCam and
E4D Sky network chairside CAD/CAM systems can be used
as purely digital impression systems for cases desired to be
fabricated in the dental laboratory (Figs. 2,3).
COMPUTERIZED SYSTEMS
All in-office computerized systems rely on the ability to
accurately and efficiently record the intraoral condition to a Fig. 2. CEREC OmniCam System with MCXL mill (Sirona Dental).
software program, creating a virtual model of the dentition
and soft tissues in a digital impression file. An intraoral
scanner or camera is the key piece of equipment dentists must
consider when evaluating systems.
Generally, intraoral scanners or cameras can be separated
into two types. Single image cameras record individual
images of the dentition. The iTero, E4D, and TRIOS cameras
are single image cameras. The TRIOS camera records images
at such a rapid rate that it approaches the functional
appearance of a video camera. About three teeth can generally
be included in a single image. To record larger areas of the
dentition, a series of overlapping individual images are
recorded that the software program can assemble into a larger
three-dimensional virtual model. The camera is positioned
through different angles to ensure accurate recording of data
below the height of contour that would be hidden from the Fig. 3. E4D Dentist System and mill (D4D Technology).
camera if only an occlusal view was obtained. Those areas not
visualized by the camera in the overlapping images would camera and the OmniCam camera has live color streaming for
then be extrapolated by the software program to fill in the video recording capability. These cameras function similar to
missing data areas in the virtual model. Calculated areas of any video camera in that the image is recorded as the camera
the data are only acceptable in areas of the virtual model that is moved around the dentition. The more teeth captured in the
would not adversely affect the final restoration such as video recording, the larger the virtual model created in the
proximal areas distant from the prepared tooth (Fig. 4). software. The learning curve for video recording is much
The second type of intraoral scanner or camera is the more easier since moving the camera intraorally while watching the
recently introduced video camera. The Lava Chairside Oral model form on the video monitor is fairly intuitive. The
Scannera (COS) was the first video camera introduced. The camera is moved as needed to fill-in the missing areas of the
True Definition camera is the newest version of this video model and to record the desired size of the virtual model.
American Journal of Dentistry, Vol. 26, No. 3, June, 2013
Fig. 4. Note areas of inconsequential missing scanned data extrapolated by
the E4D software program in the cervical aspects of the teeth adjacent to the
prepared tooth.
Similar to the single image cameras, areas of the dentition that
are not recorded have the data extrapolated by the software
program to complete the virtual model surface (Fig. 5). As
above, calculated areas of the model are not acceptable if they
would adversely affect the final restoration in some manner.
A number of references are available that describe the
engineering principles and function of the various cameras in
greater detail.4-7
Both types of computerized systems record the digital files
as “.stl” files. An important consideration is what applications
are available with the proprietary .stl file a specific system
records. The chairside CAD/CAM systems have closed
systems in which the digital file is utilized by software and
equipment specifically designed for the chairside process by a
single manufacturer. However, this is a more significant issue
for dental laboratories as they evaluate how many software
programs and milling devices are required to handle the
various forms of .stl files from the different systems. Many of
the laboratory-based CAD/CAM systems have the capability
of accepting .stl files from any digital impression system to
limit the equipment needs of the laboratory and allowing
dentists few limitations in the desired use for the digital file.
Similarly, when chairside systems are used as digital impres-
sion units, the .stl files transmitted to the dental laboratory
may also be utilized by a number of laboratory-based CAD
programs.
DIGITAL IMPRESSIONS
It is axiomatic that the accuracy of the final restoration can
only be as good as the accuracy of the impression. This is true
for both digital and conventional impressions. There are
several basic concepts that are essential for making an
accurate impression and these concepts need to be equally
applied for both digital and conventional impressions. The
area must be well isolated, soft tissues retracted from
preparation margins, and all areas of the dentition and soft
tissue accurately recorded.
A common question many dentists have about digital
systems is to what degree can they record subgingival
margins? As much as dentists may want to digitally record
Computerized technology in restorative dentistry 117
Fig. 5. The CEREC CAD program will calculate and fill-in areas of inconse-
quential missing data (tan areas on lingual of the molar and second premolar).
Fig. 6. Example of subgingival margin recording with the Lava COS scanner
following retraction of the gingival tissues.
preparations through saliva, blood, or soft tissues, this is not
possible today. The cameras are line of sight. This means that
the camera can only record what is visible to the camera lens.
So those structures or margins obscured by saliva, blood, or
soft tissue are not visible to the camera and will not be
accurately recorded.
Soft tissue retraction and isolation are important concepts
for both conventional and digital impressions. However, there
is some advantage to the use of digital impressions
subgingivally as significant retraction of soft tissues vertically
beyond margins areas is not required. Conventional
impressions require sufficient soft tissue retraction beyond the
margin to allow at least 1 mm of impression material to
record tooth structure beyond the margin to ensure the entire
margin is recorded in the impression. Digital impressions only
need the soft tissue to be retracted laterally to visualize the
margins (Fig. 6).
Digital impressions provide excellent immediate feedback
on the quality of the recorded virtual model. Within seconds
of completing the recording, the virtual model is visible on
the computer monitor. The virtual model can be rotated in
three dimensions as well as magnified to evaluate critical
areas of the model prior to transmitting the file to the dental
laboratory or proceeding with the chairside design.

118 Fasbinder
Fig. 7 A, B. Buccal scan is used to align the opposing virtual models in
maximum intercuspation
A critical function of digital impressions is to record the
interarch relationship of the opposing recorded models. The
prevailing technique is to have the patient close into maximum
intercuspation and scan the facial aspect of the opposing
quadrants in this static position. The software program uses the
buccal scan to match the facial surfaces of the opposing
recorded models to reproduce the patient’s vertical dimension
of occlusion (Fig. 7A,B). No current system has the ability to
record functional lateral or protrusive movements for mounting
of the opposing models. One study8 has evaluated the accuracy
of the buccal scan to reproduce the vertical dimension of
occlusion using a digital impression system based on video
recorded virtual models. There was no significant difference in
the occlusal vertical dimension between the master mounting
and the mounted models generated from the digital impressions
with the buccal scan.
PRODUCTIVITY
Productivity and efficiency are key factors many dentists
consider when evaluating new workflows. The length of time
required for making a digital impression is an important feature
to consider. Obviously, comfort and confidence with the use of
an intraoral camera will influence the time required to record a
digital impression. This involves not only manipulating the
camera intraorally to visualize the various surfaces of the denti-
tion but also the ability to make the intraoral movements while
watching the computer monitor. This is often likened by many
new users to learning to use a handpiece while visualizing the
process in an intraoral mirror. Anecdotal reports by experienced
users indicate that routine use of digital impressions is more
efficient than the usual 5-7 minute set times of polyvinyl-
siloxane impressions. One recent study9 reported that scanning
was 10 minutes faster than conventional impressions for single
abutments and short span fixed partial dentures.
American Journal of Dentistry, Vol. 26, No. 3, June, 2013
A randomized clinical trial10 questioned the efficacy of
digital impressions by comparing crowns fabricated with
either iTero digital impressions or a conventional impression
technique. The study reported that both the time to make a
digital impression and the time required to adjust the crown
for delivery were significantly higher when the digital method
was used. However, there were no significant differences in
crown margin fit reported between the digital impression and
conventional impression techniques. Another randomized
clinical trial11 also measured the time required for crown
adjustment in preparation for delivery and clinical margin fit
using a digital impression system (Lava COS) and a conven-
tional impression technique using polyvinylsiloxane. There
was no significant difference in the time required to adjust the
crowns prior to cementation based on the impression tech-
nique.11
ACCURACY
Since any desired outcome, be it a crown or removable
appliance, is dependent on the accuracy of the intraoral
recording, the accuracy of the outcome should be the starting
point for considering the clinical usefulness of a digital im-
pression process. A commonly referenced study12 examined
over 1000 crowns made with polyvinylsiloxane impressions
after 5 years of clinical service and reported that a marginal
gap of less than 120 microns would be clinically acceptable
for cemented restorations.12 Digital systems have been
reported to fabricate restorations with margin fit well less than
this standard.
Digital impressions have been shown to be at least as
accurate as conventional impressions and often times, more
accurate. One study13 compared the accuracy of models made
from full arch conventional and digital impressions. Three
master models were scanned three times with the Lava COS
and impressed three times with polyvinylsiloxane impression
material and models were fabricated from each scan and
impression. The accuracy of the models was measured with a
commercial graphic analysis program. There was no sig-
nificant difference in accuracy of the models compared to the
master models with either impression technique. Another
study14 compared the fit of crowns fabricated using intraoral
digital impressions to those fabricated using conventional im-
pressions.14 Two zirconia crowns were fabricated for each of
20 patients on the same tooth preparation. One crown was
fabricated from a digital impression using the Lava COS
system, and the other crown from a conventional silicone
impression. At the time of cementation, the margin fit was
measured using a replica technique. The crowns fabricated
using a digital impression had a significantly better margin fit
(49 microns) than those fabricated from a conventional
impression (71 microns).
CEREC has over 25 years of both laboratory and clinical
research confirming the accurate outcomes possible with the
chairside CAD/CAM system. One laboratory study15
measured the fit of CEREC crowns compared to those
fabricated using a variety of laboratory techniques. There was
no significant difference in crown margin fit between the
chairside CAD/CAM and laboratory fabricated techniques
with CEREC crowns having a mean margin gap of 65.5 ±
24.7 microns for ceramic crowns and 66.0 ± 14.1 microns for
American Journal of Dentistry, Vol. 26, No. 3, June, 2013
composite crowns. One study16 evaluated the margin fit of
CAD/CAM composite crowns using different margin designs.
They reported 105 ± 34 microns for a beveled margin, 94 ± 27
microns for a chamfer margin and 91 ± 22 microns for a
shoulder margin using the CEREC 3 system. Another study17
reported on the influence of the degree of preparation taper and
software luting space setting on the marginal fit of CEREC
crowns. The mean marginal gaps ranged from 53 to 108
microns depending on the luting space setting and were not
affected by the occlusal convergence angle of the abutment.
The E4D system has been more recently introduced for
chairside CAD/CAM restorations and has limited published
research on margin fit and internal adaptation. One study18
measured the marginal fit of E4D fabricated crowns on
typodont preparations completed by 62 different clinicians.
Each of the crown preparations was judged as good, fair, or
poor and the quality of the preparation significantly influ-
enced the accuracy of the margin fit. Ideal preparations had
mean margin fits of 38.5 microns, fair preparations had mean
margin fits of 58.3 microns, and poor preparations had mean
margin fits of 90.1 microns. A second in vitro study19
measured the margin fit and internal adaptation of E4D
fabricated emaxCAD crowns. Mean margin fits varied from
79.32 ± 63.18 microns for buccal margins to 50.39 ± 35.98
microns for lingual margins.
Intraoral video recording used by the Lava COS and True
Definition scanners have clinical research demonstrating it is
consistently accurate. One clinical study20 measured the
accuracy of zirconia crowns on 37 crown preparations made
from digital impressions using the Lava COS system. Silicon
replicas were used to measure the internal adaptation and
margin fit of the crowns. The mean margin gap was reported
as 48.65 ± 29.45 microns and the mean axial wall gap was
112.03 ± 55.45 microns with no significant difference in fit
between anterior and posterior crowns. Another randomized
clinical study11 compared the accuracy of two types of zir-
conia crowns made with conventional impressions and digital
impressions using the Lava COS. Both a digital and conven-
tional impression was made for each preparation for 25
zirconia crowns made with a hand layered veneer and 25
zirconia crowns made with a digital veneering process. Both
crowns were measured intraorally for margin fit and internal
adaptation on the clinical preparation using a replica tech-
nique. There was no significant difference in the fit of the two
types of zirconia crowns, however the crowns made with a
digital impression had a better margin fit (51.45 ± 18.59
microns) than those made with a conventional impression
technique (78.62 ± 25.62 microns).
There are few studies that compare multiple systems to
conventional impression techniques relative to accuracy of the
final restoration. One in vitro study21 compared the accuracy
of full ceramic crowns obtained from intraoral scans using
Lava COS, CEREC AC, and iTero systems with two different
conventional impression techniques. The mean margin fit of
crowns was 48 ± 25 microns for Lava COS, 30 ± 17 microns
for CEREC AC, 41 ± 16 microns for iTero, 33 ± 19 microns
for single-step putty wash technique and 60 ± 30 microns for
the two-step putty wash technique. The mean internal fit was
29 ± 7 microns for Lava COS, 88 ± 20 microns for CEREC
Computerized technology in restorative dentistry 119
AC, 50 ± 2 microns for iTero, 36 ± 5 microns for single-step
putty wash technique, and 35 ± 7 for two-step putty wash
technique. There was no significant difference in the margin
fit or internal adaptation of the crowns using any of the
techniques. Another clinical study22 compared the fit of Lava
DVS crowns fabricated using digital impressions from the
Lava COS system and Vita Rapid Layering Technique crowns
using digital impressions with CEREC AC system. Fourteen
patients requiring a posterior crown had two crowns fabri-
cated using each digital impression technique. A replica tech-
nique was used to measure clinical crown adaptation and fit
for both crowns on each preparation. The Lava COS crowns
had a significantly better mean marginal fit (51 microns)
compared to the CEREC crowns (81 microns), however the
difference in fit may not be clinically relevant since both were
well below the accepted threshold of 120 microns.
Conclusion
CAD/CAM technology offers innovative workflows for
implementing digital processes for patient treatment. Evi-
dence of the accuracy of digital impressions has led to early
integration of these systems into dental offices. Success with
digital impressions is dependent on mastering similar skills
required for accurate conventional impressions such as
achieving soft tissue retraction and moisture control to enable
accurate recording of desired structures. The more the process
is understood and the predictability and durability of the
treatment outcome is documented, the more likely these
systems will be integrated with greater confidence.
a. 3M ESPE, St. Paul, MN, USA.
b. Cadent, San Jose, CA, USA.
c. 3Shape, New Providence, NJ, USA.
d. Sirona Dental Systems, Charlotte, NC, USA.
e. D4D Technologies, Richardson, TX, USA.
Disclosure statement: The author has received research grant support and
educational honoraria from Sirona Dental and 3M ESPE.
Dr. Fasbinder is a Clinical Professor and Director, Advanced Education in
General Dentistry Program, the University of Michigan School of Dentistry
where he also maintains a part-time private practice. He directs the
Computerized Dentistry (CompuDent) Unit at the University of Michigan
that is dedicated to research and education on CAD/CAM digital dentistry.
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