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Short Communication

Sang J. Lee Digital vs. conventional implant


German O. Gallucci
impressions: efficiency outcomes

Authors affiliations: Key words: material sciences, prosthodontics, biomaterials


Sang J. Lee, German O. Gallucci, Department of
Restorative Dentistry and Biomaterials Science,
Harvard School of Dental Medicine, Boston, MA, Abstract
USA Objectives: The aim of this pilot study was to evaluate the efficiency, difficulty and operators
preference of a digital impression compared with a conventional impression for single implant
Corresponding author:
German O. Gallucci restorations.
Department of Restorative Dentistry and Materials and methods: Thirty HSDM second year dental students performed conventional and
Biomaterials Sciences
Harvard School of Dental Medicine
digital implant impressions on a customized model presenting a single implant. The outcome of
Harvard University the impressions was evaluated under an acceptance criteria and the need for retake/rescan was
188, Longwood Avenue decided. The efficiency of both impression techniques was evaluated by measuring the
02115 Boston, MA, USA
Tel.: +16174325764 preparation, working, and retake/scan time (m/s) and the number of retakes/rescans. Participants
Fax: +16174320901 perception on the level of difficulty for the both impressions was assessed with a visual analogue
e-mail: german_gallucci@hsdm.harvard.edu scale (VAS) questionnaire. Multiple questionnaires were obtained to assess the participants
perception on preference, effectiveness and proficiency.
Results: Mean total treatment time was of 24:42 m/s for conventional and 12:29 m/s for digital
impressions (P < 0.001). Mean preparation time was of 4:42 m/s for conventional and 3:35 m/s for
digital impressions (P < 0.001). Mean working time including retakes/rescans demanded 20:00 m/s
for conventional vs. 8:54 m/s for digital impression (P < 0.001). On a 0100 VAS scale, the
participants scored a mean difficulty level of 43.12 (18.46) for conventional impression technique
and 30.63 (17.57) for digital impression technique (P = 0.006). Sixty percent of the participants
preferred the digital impression, 7% the conventional impression technique and 33% preferred
either technique.
Conclusions: Digital impressions resulted in a more efficient technique than conventional
impressions. Longer preparation, working, and retake time were consumed to complete an
acceptable conventional impression. Difficulty was lower for the digital impression compared with
the conventional ones when performed by inexperienced second year dental students.

Digital Dental Technology (DDT) for fab- assessment of the implant prosthetic space,
rication of dental restorations including (2) depth of restorative interface, and (3)
computer-aided design/computer-assisted ma- emergency profile configuration before pro-
nufacturing (CAD/CAM) has been in devel- ceeding with laboratory steps (Patel 2010).
opment since the 1980s (Mormann et al. A few studies investigated the efficiency
1987). Its rapid expansion and incorporation and accuracy of the digital impression in
into the field of dentistry has been docu- tooth-supported fixed prosthesis (Glassman
mented since the beginning of 1990s (Priest 2009; Persson et al. 2009; Syrek et al. 2010);
2005; Miyazaki et al. 2009). The digital however, there have not been any standard-
impressions for conventional fixed prostho- ized and randomized clinical studies looking
dontics play an important role in the devel- at the efficiency, accuracy and clinical viabil-
opment of DDT because they are the first ity of the digital impression in implant resto-
step towards a full digital line of prosthetic rations. In this context, scientific validation
fabrication. Benefits of the digital impression on DDT and in particular for digital impres-
have been presented as: (1) improved patient sion for implant rehabilitations is paramount
acceptance, (2) reduced distortion of impres- to understand the impact of this new tech-
Date:
Accepted 16 January 2012 sion materials, (3) pre-visualization of the nology on modifying well-established con-
preparation three-dimensionally, and (4) ventional protocols.
To cite this article:
Lee SJ, Gallucci GO. Digital vs. conventional implant potential cost and time effectiveness (Chris- The objective of this pilot study was to
impressions: efficiency outcomes.
tensen 2009). Digital impressions for implant evaluate the efficiency, difficulty and opera-
Clin. Oral Impl. Res. 00, 2012, 15
doi: 10.1111/j.1600-0501.2012.02430.x rehabilitations, would allow for: (1) virtual tors preference of digital impressions compared

2012 John Wiley & Sons A/S 1


Lee & Gallucci ! Digital vs. conventional implant impressions

with conventional impressions for single


(a) (b)
implant restorations. The null hypothesis
was that there is no difference in the
efficiency of conventional and digital impres-
sion techniques when applied to impression
procedure for single-implant restorations.

Materials and methods

This study was approved by the Harvard


Closed tray impression coping Scanbody
Medical School Committee on Human Stud-
ies (CHS Nr. M20078-101). The study popula- (c) (d)
tion exclusively consisted of second year
dental students at Harvard School of Dental
Medicine (HSDM) who had no exposure to
either conventional or digital implant impres-
sions. Participants signed an informed con-
sent form and were calibrated by attending to
a tutorial session where they watched an
introductory video illustrating the investiga-
tional sequence for both impression tech-
niques. Conventional implant impression Virtual model from digital impression
Participants performed conventional and
Fig. 1. Conventional and digital impression techniques. (a) Closed tray impression coping; (b) scanbody; (c) conven-
digital impressions on a customized maxil-
tional implant impression; and (d) virtual model from digital impression.
lary model (Models Plus, Kingsford Heights,
IN) containing a single, Bone Level, Regular
Crossfit, implant (Straumann, Basel, Switzer- The following acceptance criteria were ment time was measured in minutes/seconds
land) located at the maxillary left second used to evaluate the outcome of both impres- (m/s) and separately accounted for prepara-
premolar area. The customized model was sion techniques: (1) accurate imprint of tion time and working time (Table 1). Work-
mounted on a training laboratory unit to implant areas, (2) absence of voids in the ing time was defined as the time needed to
simulate patient position under a clinical occlusal, buccal, lingual and interproximal achieve an impression meeting the accep-
situation. surfaces of neighboring teeth, (3) absence of tance criteria. When needed, impression
For the conventional impressions, three voids in the occlusal surfaces of opposing retakes (conventional impression) and rescans
different sizes of stock trays were provided. teeth, and (4) proper reproduction of vestibule of the missing areas (digital impression) were
The participants selected the best fitting up to the mucogingival junction. The impres- recorded as additional working time and
trays and applied the adhesive. The conven- sions which did not meet the criteria resulted number of events for each participant. Statis-
tional implant impressions were taken by a in retakes for conventional impression or re- tical analysis by Wilcoxon signed-ranks test
closed tray impression technique using Aqua- scan/additional scans for the digital impres- was carried out to evaluate the differences in
sil Ultra Monophase/LV (Densply, York, PA) sions. efficiency between the conventional and digi-
and an implant impression coping (Fig. 1a tal impression using SPSS system (version
and b). Impressions of the opposing arch were Efficiency 15.0; SPSS, Chicago, IL, USA). A P-value of
taken with Penta Quick VPS Alginate The efficiency of both impression techniques <0.05 was considered statistically significant.
Replacement (3M ESPE, St Paul, MN). was evaluated by measuring the total treat-
Handling of all impression materials was ment time and the number of retakes/rescans Difficulty
performed according to the manufacturers needed to obtain an acceptable outcome Participants perception on the level of diffi-
recommendations. according to the acceptance criteria. Treat- culty for both impressions was assessed with
The digital impressions were taken with i-
TM
Tero (Cadent iTero ,, Carstadt, NJ) digital Table 1. Phases of treatment used for timing
impression system. A scan body (Straumann)
Conventional Digital
was used to digitally transfer the implant
Preparation Tray selection Entering patients information
position. In average 17 different digital scans
time Application of adhesives Creating laboratory prescription
including digital bite registrations were taken Placement/removal of implant Placement/removal of scanbody
for the digital impression technique. The dig- impression coping
ital impression electronic data yielding to vir- Assembly of impression coping and
implant analog into the impression
tual implant models were recorded and sent Working Implant Impression taking (maxilla) Scan of scanbody and
to the fabricant for processing and milling of time Opposing arch Impression (mandible) neighboring teeth
master casts (Fig. 1d). The sequence of the Retakes Scan of opposing arch
Bite registration
scans was performed according to the manu-
Rescans
facturers guidelines.

2 | Clin. Oral Impl. Res. 0, 2012 / 15 2012 John Wiley & Sons A/S
Lee & Gallucci ! Digital vs. conventional implant impressions

a Visual Analog Scale (VAS) questionnaire. Table 2. Efficiency outcomes measured in time and level of difficulty
Answers were recorded by placing a hash Conventional Digital P-value
mark on a non-numerical 100 mm line rang- Efficiency
ing from Not difficult at all = 0 to Very Preparation time (m/s) 4:42 1:25 (2:508:06) 3:35 0:58 (2:246:42) <0.001*
difficult = 100. Answers were then mea- Working time (m/s) 20:00 6:37 (11:1834:50) 8:54 3:12 (5:3419:44) <0.001*
Retake/rescan time (m/s) 6:58 6:56 (021:37) 1:40 1:05 (05:20) 0.003*
sured in a numerical format ranging from 0
Total treatment time (m/s) 24:42 7:18 (14:2841:24) 12:29 3:46 (8:1624:23) <0.001*
to 100. Statistical analysis by Wilcoxon Total number of retakes/rescans 21 67 <0.001*
signed-ranks test was performed to evaluate Retakes/rescans (N=participants/%) 17/30 (56%) 29/30 (96%)
the participants perception of difficulty Difficulty
VAS (0100) 43.12 18.46 (073.68) 30.63 17.57 (077.89) 0.006*
between the conventional and digital impres-
sion using SPSS system (version 15.0; SPSS). All data are presented as mean SD and range in parentheses.
Measured time is recorded as min:sec.
A P-value of <0.05 was considered statisti-
VAS, visual analogue scale.
cally significant. *
Statistical significance P " 0.05.

Operator perception on preference, Participants responses (VAS) regarding niques. Interestingly, 43% of the partici-
effectiveness and proficiency
their perceptions on the level of difficulty pants considered that, had they gained
The participants were asked to answer a mul-
with conventional and digital impression sufficient experience, the proficiency would
tiple-choice questionnaire on: which was the
technique are presented in Table 2. On a 0 be the same for both impression tech-
preferred impression technique, which
100 scale, the participants scored a mean dif- niques.
impression technique was more efficient, and
ficulty level of 43.12 (18.46) for conven- The participants who chose conventional
had they more experience, which impression
tional impression technique and 30.63 impression (10%) as the effective technique
technique would they become more profi-
(17.57) for digital impression technique employed less working and retake time than
cient. Multiple choice answers for all three
(P = 0.006) (Table 2). those choosing the digital impression tech-
questions were conventional impression, dig-
Participants perception on preference, nique (77%) (Table 3). Especially, the partici-
ital impression, or either technique.
effectiveness and proficiency is presented in pants who chose either technique (13%) had
The distribution of the answers was ana-
Fig. 2. Sixty percent of the participants pre- no retakes on the conventional impression
lyzed by percentages using SPSS (version
ferred the digital impression, 7% the con- and consumed less total and retake/rescan
15.0; SPSS). In addition, descriptive analysis
ventional impression technique and 33% time for both conventional and digital
was also carried out to assess the association
preferred either technique. Regarding partici- impressions.
between efficiency measured in time and par-
pants perception of effectiveness, 77% of
ticipants perception of effectiveness. These
the participants feel most effective with
results indicate which parameters measured
digital impression, 10% with conventional Discussions
in time were most likely to affect the partici-
impression, and 13% with either technique.
pants perception of efficiency.
The participants expected to be more profi- Digital impressions appears to be appealing
cient with more experience in digital (47%) when it comes to efficiency and patient satis-
and conventional (10%) impression tech- faction (Birnbaum & Aaronson 2008). In the
Results

Efficiency assessments for digital vs. conven-


tional impressions are presented in Table 2.
The mean total treatment time was statisti-
cally significant (P < 0.001), resulting in
24:42 m/s for conventional and 12:29 m/s for
digital impression to complete the study.
Mean preparation time was of 4:42 m/s for (a) (b) (c)
Preference Effectiveness Proficiency
conventional and 3:35 m/s for digital impres-
sions (P < 0.001). Comparison of mean work-
ing time including retakes/rescans showed
Fig. 2. Perception of preference, effectiveness and proficiency in percentage. (a) Preference; (b) Effectiveness; and (c)
statistical significance (P < 0.001) demanding Proficiency.
20:00 m/s for conventional vs. 8:54 m/s for
digital impression. When accounting for the
Table 3. Number of participants who chose the most efficient impression technique and time con-
mean retake time only, additional 6:58 m/s sumed for the impressions technique
for conventional and 1:40 m/s for digital Conventional Digital Either
were needed to obtain an impression meeting
N. participantsefficiency (%) 3 (10%) 23 (77%) 4 (13%)
the acceptance criteria (P = 0.003). Twenty- Working time for conventional 21:54 1:52 26:17 7:32 17:38 1:57
one conventional impression retakes Retake time for conventional 2:59 5:10 8:42 6:50 0.00 0.00
occurred in 56% of the participants (17 of Working time for digital 16:33 7:06 12:10 3:18 11:19 2:05
Rescan time for digital 1:03 1:25 1:38 1:06 2:17 0:36
30). For digital impressions, 67 additional
scans were performed by 96% of the partici- All data are presented as mean SD.
Consumed time is recorded as min:sec.
pants (29 of 30).

2012 John Wiley & Sons A/S 3 | Clin. Oral Impl. Res. 0, 2012 / 15
Lee & Gallucci ! Digital vs. conventional implant impressions

present study, the digital impressions scanning with the well-established CAD/ to achieve the same level of proficiency than
resulted a more efficient technique when CAM systems currently used in implant digital impressions. This suggests that the
compared with conventional impressions for dentistry. learning process for digital impressions
a single implant restoration. Participants in The present study showed that the digital would be simpler than for conventional
this study included dental students with no impression was more efficient than the con- impressions.
exposure to conventional or digital implant ventional impression based not only on the
impression taking. This homogeneous group amount of time consumed for each impression
Conclusions
allowed investigating the efficiency of these technique but also on participants perception.
impression techniques in an objective and Even though there was greater number of res-
(1). Digital impressions resulted in a more
non-biased manner. This is of particular cans performed in the digital impression, the
efficient technique than conventional
importance since results from a different rescan time of the digital impression was sig-
impressions when assessed by total treat-
study population including experienced clini- nificantly less than the retakes of the conven-
ment time. A longer preparation, working,
cians may have been unclear to interpret. tional impression. Rescans or incorporation of
and retake time were needed to complete
This pilot study represents the first one of additional scans were mainly due to the diffi-
an acceptable conventional impression
a series of well-controlled investigations culty in scanning the interproximal contacts
compared with a digital one. Therefore,
comparing digital vs. conventional digital of neighboring teeth next to the implant site
the null hypothesis was rejected.
impressions. While this investigation and the areas of refection from the laser
(2). Digital impressions allows for additional
addressed only the efficiency and operators source. The main difference between retake
re-scans without the need of repeating
preference on both impression techniques, (conventional) and rescan (digital) was influ-
entirely the impression technique. This
several other aspects need further investiga- enced by the possibility of a partial interven-
results in a shorter treatment time.
tions. Future research should include assess- tion to rescan only the missing or
(3). The level of difficulty was lower for the
ment of implant impressions accuracy in unacceptable areas of the digital impression.
digital impression compared with the
producing a working model, experienced On the contrary, the retake of the conven-
conventional ones when performed by
operator being exposed to DDT, clinical com- tional impression involved repeating the
inexperienced second year dental stu-
parison of efficiency and accuracy of both entire impression process. These differences
dents.
impression techniques, comparison between in the process of impression rescan and retake
(4). Digital impressions were deemed as the
full-arch and partial impression, and patient also affected participants perception of effec-
most preferred and effective technique
feedback from both impression techniques. tiveness. Participants who chose the digital
according to the participants perception.
This study yielded initial evidence that the impression as the most effective technique
(5). Conventional impression would require
digital impression can be successfully applied consumed more total treatment and retake
more experience to achieve the same
to the impressions for implant restoration time in achieving an acceptable impression
level of proficiency than digital impres-
based on efficiency and participants percep- with the conventional technique (Table 3).
sions.
tion. However, the limitation of the study is The level of difficulty judged by partici-
that the study was performed in a non-clini- pants was significantly lower for the digital
cal setting which might exclude the effect of than conventional implant impressions. The
patients satisfaction and perception. manipulation of the intra-oral scanner seems
Acknowledgements: This study was
funded by the ITI Foundation (Basel,
A potential benefit of digital impressions to be more user-friendly than the manipula-
Switzerland)Research Grant No. 733-2010.
on implant components would be the possi- tion of impression materials from the con-
The authors wish to express their gratitude
bility of intervention before the osseointe- ventional impression. In addition, the rescan
to the dental students of the HSDM class of
gration has been achieved. In this context, a of the missing areas is more convenient and
2013 who participated in this investigation,
digital impression could capture the intra- less cumbersome than retaking the entire
to Dr Rebecca Betensky, Harvard School of
oral situation at early stages of osseointegra- impression with a conventional technique.
Public Health for statistical advices, to Mr.
tion without the stressing the implant abut- These observations and results presented in
Robert MacArthurArizona School of
ment component. Another advantage of this study may explain the main reasons for
Dentistry & Oral Health for his contribution
using digital implant impressions is the the participants to select the digital impres-
in the data collection, and to Mr. Mohamed
patients level of comfort and treatment sion over the conventional impression.
AlaeddinCDT, Harvard School of Dental
acceptance. In addition, the advent of digital According to the participants responses had
Medicine for his collaboration in the casts
impressions comes to complete the work they had more exposure, conventional
fabrication.
flow of DDT by integrating an intraoral impressions would require more experience

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4 | Clin. Oral Impl. Res. 0, 2012 / 15 2012 John Wiley & Sons A/S
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2012 John Wiley & Sons A/S 5 | Clin. Oral Impl. Res. 0, 2012 / 15

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