Digital Scanning

Digital scanning involves creating a detailed digital model of the patient’s

mouth. This replaces conventional physical impressions made with trays and
impression materials. The scanners capture optical impressions that can be
used for diagnostics, treatment planning, and the creation of restorations.

 Advantages of Digital Scanning

- Accuracy: Digital scanners provide highly accurate 3D representations

of a patient’s dentition and surrounding structures. This leads to better
fitting prosthetics and fewer adjustments.
- Patient Comfort: Patients generally prefer digital scanning to traditional
impressions, which can be uncomfortable due to the use of large trays
and impression material.
- Efficiency: Scanning can be faster than traditional impressions, with
the digital files being immediately available for analysis and fabrication,
reducing the time needed for restorations.
- Improved Communication: The digital files can be shared quickly and
easily between the dentist, lab, and other specialists, improving
collaboration and ensuring a more precise treatment outcome.

 Applications in Implant Dentistry

- Pre-Surgical Planning: Digital scans allow for precise pre-surgical

planning, including virtual implant placement and surgical guide
creation. This improves the accuracy of implant positioning, reducing
complications and increasing the success rate.
- Immediate Loading Protocols: Digital scanning supports same-day
implant protocols by enabling the immediate creation of provisional
restorations.
- Custom Abutments and Crowns: The digital workflow allows the
creation of custom abutments and crowns that fit precisely on the
implant, improving the aesthetics and function.
 Challenges and Limitations
- Learning Curve: Dentists and technicians need to be trained in digital
workflows, and there may be an initial learning curve associated with
integrating new technology.
- Cost: High-quality intraoral scanners are expensive, though the long-
term benefits often outweigh the initial investment.
- Scanning Edentulous Areas: While digital scanning is highly effective
for patients with natural teeth, scanning edentulous areas (areas
without teeth) can be more challenging and less accurate due to the
lack of landmarks and stitching errors.

 Research and Studies

Several studies have compared the accuracy of digital scanning with

traditional impressions in implant dentistry, consistently finding that digital
techniques offer comparable, if not superior, precision.

Types of scanners
Intraoral scanners (IOS) and laboratory scanners are both used for capturing
digital impressions of implants, but they differ significantly in terms of
application, workflow, and precision.

Eg. of intraoral scanners 3Shape TRIOS, ITero Element, Medit i700, Dentsply
Sirona Primescan.

Eg. of laboratory scanners 3Shape E4, Amann Girrbach Ceramill Map

,066Medit T710, Exocad D900L by Dental Wings, Zimmer Zfx Evolution

Scanner.

Laboratory scanner
Intraoral scanner
comparison between intraoral and laboratory scanners:

1. Location of Use

• Intraoral Scanners :

• Used directly in the patient’s mouth.

• Operated chairside.

• The entire impression is done digitally without the need for

traditional physical molds.

• Laboratory Scanners:

• Scan physical models of the patient’s dentition and implants.

• Requires physical impressions first (traditional methods like

silicone or alginate) before scanning.

2. Workflow

• Intraoral Scanners:

• Streamline the workflow by capturing digital impressions directly

from the patient.

• Eliminates the need for traditional molds and the transportation of

physical models to the lab.

• Digital files can be sent immediately to the lab or in-house

CAD/CAM systems for designing restorations (crowns, bridges, implant
abutments).

• Faster for designing and producing restorations.

• Laboratory Scanners:

• Used after obtaining traditional impressions.

• The physical model is poured, typically using plaster or resin,

which is then scanned to create a digital 3D model.

• Often part of the CAD/CAM process where the laboratory

technician designs restorations based on scanned data.

• More suitable for complex cases or when higher accuracy is

required in prosthesis fitting.
3. Accuracy

• Intraoral Scanners:

• Accuracy is high for single-unit restorations and simple implant

cases.

• Can be more prone to inaccuracies in full-arch scans due to

potential issues with stitching multiple images together.

• May encounter difficulties with capturing edentulous spaces or

deep implant sites, especially if visibility is restricted.

• Laboratory Scanners:

• Generally more accurate than intraoral scanners, especially for

full-arch or multiple implant restorations.

• Laboratory scanners are stationary, meaning they can use high-

precision technologies like structured light or laser scanning to create highly
detailed models.

• Typically have a higher level of accuracy when scanning physical

models compared to IOS scans in complex cases.

4. Speed and Efficiency

• Intraoral Scanners:

• Faster process overall because the impression is taken digitally in

real time.

• Immediate feedback allows for chairside modifications if needed

(e.g., re-scanning areas with errors or gaps.)

• Improves patient comfort, as there’s no need for traditional

impression materials.

• Laboratory Scanners:

• Slower, as they rely on traditional impressions being sent to the

lab, where they are then processed and scanned.
 • However, once the physical model is scanned, the laboratory
scanners can offer a high level of detail and can handle larger, more complex
cases more efficiently.

5. Patient Experience

• Intraoral Scanners:

• More comfortable for the patient, as it eliminates the need for

physical impression materials that can cause gagging or discomfort.

• Digital scans are less invasive and faster, reducing chair time for
the patient.

• Laboratory Scanners:

• Requires traditional impression techniques, which may be

uncomfortable for patients, especially those with gag reflexes or anxiety.

• The patient has to wait longer for restorations as physical models

are sent to the lab for processing and scanning.

6. Cost and Accessibility

• Intraoral Scanners:

• Initial cost of the equipment is high, but can save on impression

materials and lab shipping costs in the long run.

• Ideal for practices looking to adopt digital workflows and reduce

the need for physical impressions.

• Some brands also offer subscription models, adding to ongoing

costs.

• Laboratory Scanners:

• Lower upfront costs for dental practices, as the scanner is housed

in the laboratory.

• Laboratories may charge for the scanning and digital design

services, adding to the cost for the dental practice.

• Better suited for practices that prefer to use traditional

impressions and outsource scanning to a laboratory.
7. Types of Cases

• Intraoral Scanners:

• Suitable for straightforward single-unit implants, crowns, and

bridges.

• Less ideal for full-arch cases, where the scanning process may
result in some inaccuracies.

• Laboratory Scanners:

• Preferred for complex implant cases, such as full-arch

restorations or multiple implants.

• Better at capturing large, edentulous areas, and providing more

precise scans for these difficult cases.

8. Integration with CAD/CAM Systems

• Intraoral Scanners:

• Directly integrated with CAD/CAM systems for chairside milling of

restorations, allowing for same-day dentistry.

• The digital file can be immediately transferred to a dental lab or

in-house for further processing.

• Laboratory Scanners:

• Part of the CAD/CAM workflow in the lab, where restorations are

designed and milled after the model is scanned.

• Often used in conjunction with other lab-based tools for more

complex custom prosthetics.

 Scan bodies :
A scan body is a component used in digital dentistry during intraoral scanning
to capture the exact position and orientation of dental implants. It helps in
creating an accurate 3D digital impression, which is then used for the
fabrication of prosthetic components like crowns or bridges. The scan body
connects to the implant, and its geometry is recognized by scanning software,
which interprets its position relative to the surrounding teeth and tissue. Scan
bodies vary based on material, connection type, and design.
Main types of scan bodies:

1. Material-Based Scan Bodies

• Titanium Scan Bodies:

• Pros: Strong, durable, and provides high

accuracy.

• Cons: Can cause artifacts during scanning

due to reflective properties.

• PEEK (Polyetheretherketone) Scan Bodies:

• Pros: Non-reflective, lightweight, and highly

compatible with intraoral scanners.

• Cons: Less durable than titanium but highly

accurate for digital workflows.

• Zirconia Scan Bodies:

• Pros: Excellent biocompatibility and good

scan quality.

• Cons: More expensive and can be brittle.

2. Connection-Based Scan Bodies

• Internal Hex Scan Bodies:

• Designed for implants with internal hexagonal

connections.
 • Morse Taper Scan Bodies:

• Used with implants that have a

Morse taper connection.

• Conical Connection Scan Bodies:

• For implants with conical

connections.

3. Design-Based Scan Bodies

• Pre-Fabricated Scan Bodies:

• Manufactured by implant companies, these are pre-made and

widely available for specific implant systems.

• Custom Scan Bodies:

• Custom-made based on patient-specific anatomy, offering a

personalized fit.

• Multi-Unit Scan Bodies:

• Designed for use in multi-unit abutment systems,

typically in full-arch restorations.

4. Digital vs. Analog Scan Bodies

• Digital (CAD/CAM) (intraoral) Scan Bodies:

• Used exclusively in digital workflows, directly scanned with

intraoral scanners.
 • Analog (laboratory) Scan Bodies:

• Used in traditional workflows where

impressions are taken and then digitized.

5. Open vs. Closed System Scan Bodies:

• Open System Scan Bodies: These are compatible with multiple

implant platforms and different CAD/CAM systems, providing flexibility in
digital workflows.

• Closed System Scan Bodies: Designed to work only within a

specific manufacturer’s ecosystem. While limiting cross-compatibility, they
ensure optimal results within that system.

6. Single vs. Multi-Use Scan Bodies

• Single-Use Scan Bodies:

• Disposable and hygienic, used once per patient.

• Multi-Use Scan Bodies:

• Reusable after sterilization, reducing costs over time but requiring

strict hygiene protocols.

Draw backs of digital scanning of full arches implants :

There are still many lingering problems with scanning full arch implant
prosthesis where a passive fit is still questionable. This is due to several
factors affecting the accuracy when taking a digital impression such as
implant position , scanning strategy, light intensity, and arch length .

Additionally, when performing scans of multiple implants, it may be hard for

the IOS to distinguish identical scan bodies and to recognize their locations.
The IOS in this case will analyze dissimilar scan bodies as only one and may
fix images on top of each other .

In addition, obtaining consistent digital scans with edentulous patients is

demanding since the scanned surface may lack reference points between
point clouds that may accompany improper stitching of the images.
Accordingly, the images may be stitched with compounding errors including
imprecise and noisy mesh. Also, the main parts of the scan may be
recognized as redundant and eventually will be cut out by the software’s post-
processing algorithm.

Photogrammetry:
Photogrammetry is based on obtaining reliable information about physical
objects through processes of recording, measuring, and interpreting
photographic images, patterns and electromagnetic radiation patterns. This
method typically requires fiducial markers placed within a patient’s mouth.
Devoid of any direct physical contact with the measured object these images
are then processed by software to create a 3D model of the implant positions
by mathematically relating and stitching together 2-dimensional images,
photogrammetry creates a precise and accurate 3-dimensional representation
of multiple implant positions within an XYZ axis. Despite its effectiveness, the
system has a singular drawback – it does not depict soft tissues. To address
this, a supplementary STL file is necessitated. In this streamlined workflow,
the photogrammetry record meticulously captures implant positioning along
the XYZ axis, while a separate intraoral impression or scan is acquired to
meticulously document the soft tissues. Subsequently, these scans are
seamlessly merged to craft the comprehensive prosthesis for the patient.
Therefore, reliance on intraoral scanners is still necessary to capture tissue
surfaces and bite relationships accurately. Photogrammatery is particularly
useful in cases where multiple implants are placed, such as All-on-4 or full-
arch implant restorations, because it provides a high level of accuracy and
efficiency. It minimizes errors like angular discrepancies and is less affected
by implant angulation, making it ideal for precise multi-implant restorations.

In contrast, intraoral scanners directly capture digital impressions of the oral

cavity using projected light sources. This method promises high precision and
efficiency, eliminating the need for traditional physical impressions. However,
challenges arise in capturing full-arch data comprehensively, particularly in
anatomically complex areas like the posterior regions of the maxilla and
mandible. The direct line-of-sight required for intraoral scanning can be
obstructed by structures such as the tongue or cheeks, potentially leading to
incomplete digital impressions.
 The key distinction lies in the acquisition and identification of targets. During
a photogrammetry scan, targets and the 3D position of implants along the
XYZ axis can be measured extraorally from just one side, eliminating the
need for the entire scan body to detect implant locations. In contrast, intraoral
scanning (IO) loses accuracy when measured between each scan body,
necessitating registration of the scan region (top 1/3 of the scan body) for
implant positioning. Moreover, intraoral conditions (e.g., blood, saliva, soft
tissue) and operator experience impact the accuracy of intraoral scanning.

While intraoral scanners excel in capturing detailed sections of the oral cavity,
they struggle with capturing picture perfect imaging due to the fact that they
capture the image by creating polygon data. In contrast, photogrammetry,
despite its higher cost and external setup, can capture comprehensive data of
multiple implants simultaneously, thereby offering more accurate relationships
between implants in 3D space.

The restoration process for full-arch implants requires three distinct records:

1. Preoperative record
2. Photogrammetry record
3. Postoperative soft-tissue record

These records are subsequently exported into design software such as

Exocad or 3Shape, for the creation of an All-On-X prosthesis. Utilizing all
three methods allows for data alignment, aiding in recording the vertical
dimension and establishing the optimal tooth position.
Advantages of Photogrammetry in Implantology:

1. Accuracy: Photogrammetry provides micrometer-level accuracy, often

outperforming traditional intraoral scanners in complex cases like full-
arch implant restorations.
2. Speed: The process is fast, taking only a few seconds to capture the
necessary data points.
3. Reduction in Errors: By accurately capturing the implant positions
without distortion (common in large-area intraoral scanning), the risk of
error in the subsequent prosthesis design is significantly reduced.
4. No Need for Physical Impressions: Eliminates the need for
uncomfortable physical impressions, improving patient comfort and
streamlining the workflow.
5. Integration with CAD/CAM Systems: Photogrammetry data is easily
integrated into CAD/CAM workflows for digital prosthesis design.

Photogrammatery workflow:

1. Placement of Scan Bodies: Special markers or scan bodies are placed

on the implants. These act as reference points that the photogrammetry
system captures.
2. Image Capture: Multiple images are taken from different angles to
accurately capture the 3D positions of the scan bodies.
3. Data Processing: The photogrammetry software processes these
images to create a precise 3D model of the implant positions.
4. Integration with CAD/CAM: The 3D data is exported to CAD/CAM
systems, where it can be used to design custom abutments,
frameworks, or prosthetic restorations.

Key Photogrammetry Systems for Implant Scanning:

- PIC Dental System

- Imetric 4D Dental Scanner
- Elos Accurate® Photogrammetry
- OptiSplint by Panthera Dental
Scan bodies splinting:
Splinting scan bodies is a technique used in certain photogrammetric
workflows to ensure maximum accuracy in complex cases, such as full-arch
implant restorations.

Splinting of scan bodies refers to the physical connection of scan bodies on

multiple implants using a rigid material, such as dental floss, composite resin,
or a prefabricated bar, prior to scanning. The goal is to reduce the micro-
movement of individual scan bodies during the scanning process, which could
otherwise lead to inaccuracies in implant position capture. The splint helps to
“lock” the implants in place during the scan, improving the overall precision of
the photogrammetry system.

Splinting rationale

• Accuracy in Full-Arch Implant Restorations: Full-arch restorations

require capturing the exact position of multiple implants simultaneously. Small
deviations in implant position could result in a poorly fitting prosthesis.
Splinting reduces the risk of errors caused by micro-movements of individual
scan bodies, improving the accuracy of the data.

• Preventing Distortion in Complex Cases: In cases with multiple

implants, such as edentulous patients, splinting can help stabilize the scan
bodies, reducing the chance of scanning distortions or inaccuracies that could
arise from uncoordinated movements.

• Intraoral Scanning Challenges: Unlike traditional impressions,

intraoral scans may struggle to capture the exact implant positions when the
scan bodies are not splinted, especially in cases with divergent implant
angulations or when the patient moves slightly during the scan.
Materials and Methods for Splinting

• Dental Floss and Resin: A common and cost-effective method

involves wrapping dental floss around the scan bodies and then applying a
small amount of composite resin to secure the floss in place. This method
allows flexibility in intraoral splinting.

• Prefabricated Bars: Some clinicians use pre-made metal or resin

bars to splint the scan bodies. These bars can be custom-fitted for individual
patients, providing a highly rigid connection between scan bodies.

• 3D-Printed Splints: Recent advancements in 3D printing have

allowed for the creation of custom splints designed to fit over multiple scan
bodies. These splints can be printed prior to the scanning procedure, offering
precision and rigidity.

Limitations and Considerations

• Time and Skill: Splinting adds additional steps to the scanning

process, requiring skill and time. Improper splinting can lead to inaccurate
results, defeating the purpose of the technique.

• Patient Comfort: For some patients, the added hardware (splinting

material) can make the scanning process more uncomfortable, especially in
full-arch cases.

• Not Always Necessary: In many cases, particularly with modern

photogrammetry systems, splinting is not always necessary. Systems like PIC
Dental are designed to capture implant positions accurately without the need
for splinting, but the choice to use splinting depends on the clinician’s
preference and case complexity.

• A study by Lee et al. (2020) showed that splinting scan bodies in

full-arch implant cases improved the accuracy of photogrammetric scans,
particularly when implants were placed at significant angles.

• Papaspyridakos et al. (2021) found that photogrammetry, with or

without splinting, offers a more accurate alternative to traditional impression
techniques in full-arch implant reconstructions, but the benefits of splinting
were especially noted in more complex cases.
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