ISSN: 2320-5407 Int. J. Adv. Res.

8(10), 1214-1223

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/11956

DOI URL: http://dx.doi.org/10.21474/IJAR01/11956

RESEARCH ARTICLE
INTRAORAL SCANNING SYSTEMS - A CURRENT OVERVIEW

Dr. Sheela Kannan1, Dr. Chalakuzhiyil Abraham Mathew2 and Dr. Roseline Savarimuthu Paulraj3
1. Post Graduate Student, Department of Prosthodontics, KSR Institute Of Dental Science And Research, KSR
Kalvi Nagar, Thokkavadi, Tiruchengode, Tamil Nadu -637215.
2. Head of the Department, Department of Prosthodontics, KSR institute of Dental Science and Research,
Tiruchengode.
3. Post Graduate Student, Department of Prosthodontics, KSR institute of Dental Science and Research,
Tiruchengode.
…………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Intraoral scanners (IOSs) are devices used for capturing direct optical
Received: 30 August 2020 impressions in dentistry. IOS eliminates the errors that are encountered
Final Accepted: 30 September 2020 with the conventional impression making procedures. The last decade
Published: October 2020 has seen an increasing number of optical IOS devices, and these are
based on different technologies. The objective of this review article is
Key words:-
Intraoral Scanner, Digital Impression to discuss intraoral scanners with regards to its technology, generation
And Scan Path systems, scanning paths, necessity of a powdering medium, accuracy
(Trueness and precision), intermaxillary relationship registration,
commercially available IOS, clinical recommendations, advantages,
disadvantages, indications and contraindications. Digital impressions
with IOS is likely going to be a routine procedure in dentistry in the
near future.
Copy Right, IJAR, 2020,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
Since the eighteenth century, conventional impression techniques have been used to register the three dimensional
geometry of dental tissues. [1-3] A passive fit is a primary factor for the long term clinical success and survival of an
implant-supported fixed dental prosthesis (FDP). The precise transfer of the three-dimensional (3D) intraoral
implant relationship to the master cast is a critical step to achieve a passive fit. [4-5]

Despite being considered a trivial and well-established procedure in dental practice, a number of problems are
encountered like incorrect impression tray selection, separation of material from impression tray, tears or voids with
the impression materials or cast, tray to tooth contact, material shrinkage, bio-safety norms for disinfection
,temperature sensitivity, limited working time, inaccurate pouring and expansion of dental stone. Over trimming of
the casts and breakage during shipment could lead to substantial loss of patient data. [6-7] Other than the above
problems any compromise in the manual steps during prosthesis fabrication also may lead to misfit of the
prosthesis.[4,5,8] Some patient’s perceive the conventional impression making procedure as an unpleasant treatment
experience. Extra in-office space will also be required If physical models are to be stored. [9] Although most of the
above technical, mechanical, and biological problems can be reduced by standardization of work sequence, they
cannot be entirely eliminated.[4,5,8] Digital impression making using intraoral or extra oral scanners may be an
approach to improve the accuracy of dental restorations, as by their nature these processes tend to eliminate the
errors caused by the conventional impression making procedures, simplifies the oral rehabilitation procedures and
eliminates the requirement of physical storage space. [10,11]

Corresponding Author:- Dr. Sheela Kannan 1214

Address:- Post Graduate Student, Department of Prosthodontics, KSR Institute Of Dental Science
And Research, KSR Kalvi Nagar, Thokkavadi, Tiruchengode, Tamil Nadu -637215.
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Intraoral Scanner Technologies:

The IOS is a medical device composed of four main components: the measurement probe, the control or computing
system, the machine that handles the movement of the probe and the measurement software. [12]

The goal of IOS is to record with precision the three-dimensional geometry of an object. [13]

Digital impressions can be made using two methods, directly using an intraoral scanner, which allows the clinician
to directly acquire the data from the prepared abutment without the need to make conventional impressions and
pouring the casts, and thereby results in a 3D virtual model. The second method is by using an extra oral laboratory
scanner, which involves scanning of the dental impression or gypsum casts to create a 3D model. The restoration is
then designed on a computer using the acquired 3Dvirtual model, with specially designed software, and then 3D
printed. Both the impression techniques (done using intraoral and extra oral scanners) need to be accurate to deliver
an accurately fitting prosthesis. [14]

The most widely used digital format is the open STL (Standard Tessellation Language) or a locked STL-like
Format. This format is used in many industrial fields and describes a succession of triangulated surfaces, where each
triangle is defined by three points and a normal surface. However, other file formats have been developed to record
color, transparency, or texture of dental tissues (such as Polygon File Format, PLY files). Irrespective of the type of
imaging technology employed by IOS, all cameras require the projection of light to record individual images (These
systems have a field of view in the form of a cone, so they cannot collect information from those hidden surfaces,
being necessary to make several shots of the same area to collect all the information) or videos(It records the
scanned areas in a similar way as a video camera through sequential shots at high speed) and are compiled by the
software after recognition of the POI (points of interest).[13,15,16]

The intraoral scanning systems currently available are differentiated by characteristics such as the operating
principle, the light source, the need to eliminate the shiny surfaces, the operating system and the export file formats.
[17]

Generations of Intra Oral Scanners:

There has been a gradual evolution to five generations of the system. [18]
1. First generation scanners consisted of a single radiation source and a single detector and information was
obtained slice by slice.
2. The second generation was introduced as an improvement and multiple detectors were incorporated within the
plane of the scan.
3. The third generation was made possible by the advancement in detector and data acquisition technology.
4. Fourth generation included a moving radiation source and a fixed detector ring. Angle of the radiation source
was taken into account. More scattered radiation was seen in this system.
5. Fifth generation scanners were developed to reduce ―motion‖ or ―scatter‖ artifacts. [18]

Light Projection and Capture:

Within the 3D reconstruction field, there is a clear distinction between passive and active techniques. Passive
techniques use only ambient lighting to illuminate the intraoral tissues and they rely on the texture of an object.
Active techniques use white, red, or blue structured lights projected from the camera onto the object that is less
reliant on the real texture and color of tissues for reconstruction. In active techniques, a luminous point is projected
onto an object and the distance to the object is calculated by triangulation. An alternative is the light pattern
projection, such as line or mesh projections. The surface reconstruction can be achieved with a compilation of
images or videos. [13, 16]

Distance to Object Technologies:

Triangulation:
Triangulation is based on a principle that the position of a point of a triangle (the object) can be Calculated knowing
the positions and angles of two points of view. These two points of view may be produced by two detectors, a single
detector using a prism, or captured at two different points in time. [13] (Ref fig a)

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Confocal:
Confocal imaging is a technique based on acquisition of focused and defocused images from selected depths. This
technology can detect the sharpness area of the image to infer distance to the object that is Correlated to the focal
length of the lens . The object can then be reconstructed by successive images taken at different focuses and aperture
values and from different angles around the object. [19, 20] (Ref fig b)

Active Wave front Sampling (AWS)-It is a surface imaging technique, requiring a camera and an off-axis aperture
module. The module moves on a circular path around the optical axis and produces a rotation of POI (Point of
interest). Distance and depth information are then derived and calculated from the pattern produced by each point.
[21]
(Ref fig c)

Stereophotogrammetry:
This technology estimates all coordinates (x, y, and z) only through an algorithmic analysis of images. [16] It relies on
passive light projection and software, the camera is relatively small, its handling is easier, and its production is
cheaper[13] (Ref fig d).

Determining distance to the object. (a) Triangulation: Distance BC could be determined according to the formula BC
= AC × sin (^A)/sin (^A+^C ) (b) Confocal: distance to the object is determined according to the focal distance. (c)
AWS requiring a camera and an off-axis that moves on a circular path around the optical axis and produces a
rotation of interest points. (d)Stereophotogrammetry is a technology that generates files by algorithm analyzing
numerous pictures.

Reconstruction Technologies:
One of the major challenges in generating a 3D numerical model is the matching of POI taken under different
angles. Distances between different pictures may be calculated using an accelerometer integrated in the camera.
Using algorithms, similarity calculation defines POI coincident on different images. This POI can be found by
detection of transition areas, such as strong curvatures, physical limits, or differences of grey intensity (―Shape
fromSilhouette‖).[22] A transformation matrix is then calculated to evaluate similarity between all images such
asrotation or homothety. Each coordinate (x, y, and z) is extracted from the projection matrix, and a file is then
generated. [13]

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Scan Paths:
In addition to the different technical modes employed for functioning of the various scanners, a correct scan path is
decisive for successful scanning results at the present state of the technology.Various scientific analyses have showed
that the scan path influences the accuracy of the data captured when using conofocal scanners, in both invitro and
invivo studies.[23,24] Scan path means that the intraoral scanner must be moved according to a specific pattern in order
to obtain the greatest possible precision of the virtual model.This is to ensure that the individual images generated by
the optical system are superimposed with sufficient accuracy.[25]

Practitioners also have to maintain a fluid movement, always preserving a steady distance and the tooth centered
during recording. The camera should be held in a range of between 5 and 30mm of the scanned surface depending on
the scanners and technologies.[13] Especially for the capture of large areas such as quadrants and full-arch,a sufficient
data volume must be generated not only in the mesiodistal direction but also by adding lateral images to complete the
scan path and above all,to close it again by crossing over the occlusal surface and returning to the starting point of
the scan movement.The capture of structureless areas and or in the areas with a steep downward slope (anterior
mandibular area),often proves to be difficult. This in turn, requires particular system-dependent strategies. Rather than
relying solely on the technical specifications, it is therefore also important for users to try out for themselves the scanning
systems in which they are interested.[25]However,with the aid of guided scanning procedures,the user is instructed step-
by- step during the scan as to how to guide the intraoral scanner over the dental arch.Guided scanning procedures
facilitate the implementation of the procedure.[13]

Powdering:
A trinocular imaging is done using a HD video camera. Three accurate views of the tooth are recorded by the three
tiny video cameras at the lens. [26] A light dusting of powder is needed in a thin layer of about20–40 μm; the coating
is done during the digitizing process to reduce reflectivity from multiple translucent layers of the tooth and
restorative material at unpredictable angles. [27] This powder coating enhances scanning accuracy by increasing the
number of surface data points and providing uniform light dispersion. Titanium dioxide opaque mixture, Zirconium
oxide with amorphous silica and aluminum hydroxide are the powders used. [28]

Another strategy to overcome this difficulty employed by some systems is to use cameras with a polarizing filter.
Accordion fringe interferometry (AFI) uses two light sources to project three patterns of light, called ―Fringe
patterns‖, onto the teeth and tissues. As a fringe pattern hits the surface, it distorts and takes on a new pattern based
on the unique curvature of the object. Distortion in this fringe pattern is known as ―Fringe curvature‖ (Ref fig e).

Fig e: Accordion fringe interferometry.

A high definition video camera records the surface data points of fringe curvature. These scanners have a higher
dynamic range of luminosity, allowing reflective surfaces to be scanned without powder coating. Both AFI and 3D
in motion video imaging use HD video cameras rather than a sensor to rapidly capture images in real time. [28]

Accuracy of Intraoral Scanners:

Accuracy is an important factor for the success and long term survival of the prosthesis. According to ISO 5725-
1and -2, the accuracy is described by two measurement methods: Trueness and Precision. Trueness indicates the
closeness to a true value and precision indicates the level of reproducibility when the process is repeated. [29, 30]

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According to the research of Gimenez et al[20]: The accuracy of a digital impression system when considering
clinical parameters like experience of the operator, the angulation, and the depth of the implants didnot necessarily
dependent upon the performance of the operator or his experience. The distance from which the object is scanned,
affects the predictability of the accuracy of the scanner and the error increased with the increase in the length of the
scanned section[20]. Guth et al: The mean trueness of conventional impression using a polyether was 77 µm (SD 36
μm) and for digital impression was 89 µm (SD 48 μm) with True Definition. [31] A study by Ender et al. concluded
that the accuracy of the IOS is widely studied and accepted within the clinical parameters in those cases scanned for
single unit prosthetics and quadrants. However, there is some controversy as to the accuracy in the registration of
full-arch impressions. The precision of the IOS is limited in most of the in vitro studies to the accumulated error
from the conventional impression taking, elaboration of the model, scanning of the master model with the IOS and
superposition using the software [24]. Muller et al. reported that the zigzag strategy for intraoral scanning has a lower
trueness value but a better precision value than buccal–occlusal‑palatal strategy[32]. Hussam et al., from his study
stated that none of the technologies reached the required trueness and precision values and were considered
unreliable for multiple implant impression[33]. This leads us to believe that if more in vivo studies were carried out,
this accumulation of errors would decrease since so many steps would be reduced and the accuracy of these scanners
could be more reliably assessed.

Intermaxillary Relationship Registration:

A complex clinical step is a common source of error due to cumbersome and imprecision of bite registration
materials. By contrast, impressions using IOS only require a new acquisition of vestibular faces when the patient is
in occlusion. Maxillary and mandibular arches are then aligned with a matching process. Even if this complex
algorithm requires coincident areas positioned under different planes. A recent study reported that only one left and
one right lateral occlusal record is required for software alignment, with a minimum dimension of 12 × 15mm.[34,35]

Commercially Available Intraoral Scanning Systems:

Some of the commercially available intraoral scanners are listed in table 1. [11, 25, 36-40]

Table 1:- Commercially Available Intraoral Scanners.

Intraoral Company Working Light Imaging Necessity In- Output
scanner principle Source Type of coating office format
millin
g
CEREC Sirona Dental Active triangulation Visible Multiple Yes Yes Proprietar
AC blue System and optical blue images y
cam GmbH microscopy light
(Bensheim,
Germany)
CEREC- Sirona, Triangulation LED Images No yes Closed
omnicam (Bensheim, System
Germany)
Itero Cadent Inc Parallel confocal Red Multiple No No Proprietar
(Carstadt, microscopy laser Images y or
NJ) selective
STL
E4D D4D Optical Laser Multiple Occasionall Yes Proprietar
Technologies, coherence Images y y
LLC tomography
(Richardson, and confocal
TX) microscopy
LAVA- 3MESPE Active wavefront Pulsating Video Yes No Proprietar
COS (St.Paul, MN) sampling visible y
blue
light
LAVA- 3M ESPE, Active wavefront Visible video Yes Yes STL
True Seefeld, Sampling blue imaging

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definition Germany Active triangulation light technolog

y
TRIOS 3Shape A/S Confocal LED Multiple No No Proprietar
(TS) (Copenhagen, microscopy Images y or STL
Denmark)
Planscan Planmeca, Confocal Blue Image or No Yes STL
Richardson, Microscopy Laser video
Texas,united Or Triangulation Emission acquisitio
states n
3D MHT Spa Confocal Moire a 3 images Occasionall No STL
Progress (Verona, microscopy kind of y
Italy)-MHT structure
Optic d light
Research AG
(Niederhasli,
Switzerland)
IOS IOS Active triangulation LASER Image Yes No STL
Fastscan Technologies,Sa and scheimpflug acquisitio
n Diego,CA. principle n
Carestrea Carestream Triangulation Unique image No YES STL
m Dental, Atlanta, light acquisitio
3500(cs) Georgia, United guidance n
State system
ZFX Zfx GmbH, Confocal LASER Image or No No STL
intrascan Dachau, Microscopy video
Germany and acquisitio
moiré effect n
detection
MIA3D Densys Ltd Active Visible 2 images Yes No ASCII
(Migdal stereophotogrammet light
HaEmek, Israel) ry
DPI-3D Dimensional Accordion fringe Wave Multiple No No STL
Photonics interferometry length Images
International, (AFI) 350
Inc to500
(Wilmington, nm
MA)
STL – Standard Tesselation Language , LED – Light Emitting Diode, LASER – Light Amplification by Stimulated
Emission of Radiation , ASCII – American Standard Code for Information Interchange

Clinical Recommendations:-
From the conflicting outcome of various studies, the scanning systems, scanner acquisition process and powder
application do not appear to be major influencing factors on the accuracy of IOS. The multiple variables which can
influence the accuracy of IOS are span length, scanning sequence and scanned surface morphology. While IOS can
be safely used to acquire diagnostic models and treatment planning purposes, some recommendations are required
for definitive prosthesis fabrication. According to the current evidences, IOS should only be used for short-span
prosthesis that follows a confirmative occlusal relationship with the opposing arch. This is facilitated by scanning
the maxillary and mandibular arches when they are at maximal intercuspation. For longer span prosthesis, in
addition to accurately recording the tooth surface, the occlusal relationship has to be registered, which is very
difficult to record by IOS after preparing several teeth. This recommendation is supported by clinical studies which
indicate that 3 or 4-unit prostheses fabricated by IOS impressions exhibited similar accuracy to the prostheses
fabricated by conventional techniques.

There is also some evidence that smooth surfaces are easier to capture by light scanners in comparison to irregular
and corrugated surfaces. Thus, if IOS is planned to be implemented, it is reasonable for the clinician to modify the

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preparation design by ensuring smooth and regular surfaces with rounded line angles. The areas of sudden change of
curvature may suffer from greater deviations. Therefore, sharp preparation edges, grooves and boxes are better to be
avoided. Further, it is easier to replicate the rounded line angles by the CAM process on the prosthesis fitting
surface. As the preparation is used digitally to design the prosthesis, it has to be easily read by the software. One of
the frequently encountered limitations of CAD/CAM systems is the precision of the marginal area. Several studies
have indicated that the prosthesis margins are vulnerable to inaccuracy. This may be attributed to difficulties in
locating the prosthesis margin virtually. Nevertheless, more research is desirable to provide recommendations to the
clinicians regarding preparation margin design, saliva control, cost efficiency and long term outcome. [37]

Advantages of Intraoral Scanners:

1. Enhanced patient compliance as patient discomfort is reduced.[41]
2. Can be used in geriatric patients, and in patients with strong gag reflex, trismus, and children or in patients who
are not comfortable with impression materials and trays, in complex cases such as cases with multiple implants
or severe undercuts.[42]
3. Simpler clinical procedures with no bite registration and gypsum casts and thereby no physical space is required
for their storage.[43]
4. Reduces the environmental impact of disposing the materials required for conventional impressions. [18]
5. Provide improved precision and consistency.[18]
6. Provides a clean and streamlined impression method Without any complexity.[18]
7. It aids in visualization of the preparation on a computer display from many perspectives. [18]
8. Offers instant display and feedback for making corrections immediately.[18]
9. It allows the clinician to design the restoration on a computer, while visualizing the opposing dentition. [18]
10. Better communication with dental laboratory technicians and patients. The patient feels more involved when
their scans are shown and discussed with them. This has an overall positive impact on the treatment. [44]
11. Digital impressions have approximately the same accuracy for single tooth restorations and short span fixed
partial dentures when compared to conventional impression techniques.[45]

Disadvantages Of Intraoral Scanners:

1. Difficulty in detecting the sub gingival finish lines of prepared teeth. [46]
2. Difficult to scan with bleeding tissues. [36]
3. Difficulty in learning the working of IOS and operator related errors. [47]
4. Purchasing and managing costs- Expensive. [48]
5. Reflection caused due to saliva, surfaces like enamel crystals or polished surfaces also disrupts the accuracy of
the digital impressions. [49]
6. Powder could be uncomfortable for patients, and additional scanning time is required when powder is
contaminated with saliva during impression as this requires cleaning and re-application of powder. [49]

Indications:
Prosthodontics:
used for Single tooth restorations, resin inlays/onlays, zirconia copings, post and core, removable partial denture
frameworks, fixed partial dentures, Digital smile designing and Obturators. [49]

Implantology:
Implant bridges (4-5 implants), Implant supported bars and guided implant surgery. [50]

Orthodontics:
Diagnosis and treatment planning, aligners and custom made devices. [49]

Contraindications:
1. Long span fixed partial dentures and or fixed full arches. (6-8 element bridges)[50]
2. Long-span implant supported fixed partial dentures and/or fixed full arches. (6–8 implants)[50]
3. Complete removable prosthesis.[50]

Conclusion:-
Intraoral digital scanners help in improving both practice efficiency and the patient experience better than
conventional alginate and polyvinyl siloxane impressions. Digital impressions improve the effectiveness of

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treatment by reducing the visits, which would be beneficial to patients in terms of efficient planning and comfort.
With such numerous advantages and benefits, digital impression will likely be a routine procedure in the near future
and with a few more improvements will lead to its wide use in dentistry.

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