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Keywords Abstract
Intraoral digital impression; CAD/CAM;
conventional impression.
With the techniques of computer-aided design and computer-aided manufacturing
(CAD/CAM) being applied in the field of prosthodontics, a concept of intraoral
Correspondence
digital impressions was put forward in the early 1980s. It has drawn comprehensive
Sun Jian, Department of Prosthodontics, attention from dentists and has been used for dental prosthesis fabrication in a number
Ninth People’s Hospital, Shanghai Jiaotong of cases. This new digital impression technique is expected to bring about absolute
University School of Medicine, Shanghai Key digitization to the mode of prosthodontics. A few published articles have indicated
Laboratory of Stomatology, Shanghai 200011, that dental prostheses fabricated from intraoral digital impressions have exhibited
China. remarkable advantages over those from conventional impressions in several respects.
E-mail: doctorsunjian74@aliyun.com The present review discusses intraoral digital impression techniques in terms of the
following aspects: (1) categories and principles of intraoral digital impression devices
This work was supported by Medicine and currently available; (2) operating characteristics of the devices; and (3) comparison
Engineering Combination Project of Shanghai of the manipulation, accuracy, and repeatability between intraoral digital impression
Jiaotong University (Project Number: and conventional impression.
YG2011MS07) and Shanghai Leading
Academic Discipline Project (Project Number:
T0202, S30206).
doi: 10.1111/jopr.12218
With electronic technology, digital technology, and advanced contrast, direct intraoral digital impressions can avoid errors
manufacturing technology being applied in the field of dentistry, more than a conventional impression can. Additionally, this
digitization in diagnosis and treatment has become a major saves time for making conventional impressions and plaster
trend in prosthodontics. Computer-aided design and computer- models and lowers the cost of materials. Recent developments
aided manufacturing (CAD/CAM) have been employed in the in the field of intraoral digital impression offer great progress.
fabrication of restorations, especially ceramic crowns and fixed Several outstanding intraoral scanning systems were generated
dental prostheses (FDPs), since the 1980s.1 A few published during the past two decades. An increasing number of fixed
articles have indicated that dental prostheses fabricated from prostheses are now manufactured with intraoral digital impres-
intraoral digital impressions have exhibited remarkable ad- sions, which have become a pivotal part of the digitization of
vantages over those from conventional impressions in several prosthodontics.6
respects.2-4 CAD/CAM systems are composed of three major parts: (1)
Many CAD/CAM systems are now available for design a data acquisition unit, which collects the data from the region
and production of restorations based on conventional silicone of the preparation teeth and neighboring structures and then
impressions.5 In these cases, a plaster cast is made from the sil- converts them to virtual impressions (an optical impression is
icone impression and is sent for extraoral scanning, where the created at this moment directly or indirectly); (2) software for
plaster cast is fixed on the extraoral scanner platform. Although designing virtual restorations anchored in virtual impressions
the accuracy of extraoral scanning is adequate, the intraoral out- and setting up all the milling parameters; and (3) a computer-
line depictive process of a conventional impression is hard to ized milling device for manufacturing the restoration with solid
perfectly reproduce due to the deformation of impression mate- blocks of the chosen restorative material.6 The first two parts
rials and plaster. Therefore, the inadequate precision of plaster of the system play roles in the CAD phase, while the third is
casts is not optimal for completing CAD/CAM procedures. In responsible for the CAM phase.
CAD/CAM systems can be divided into two types based on digitally scanning, the dentist holds the scanner and aims the
digital data sharing capacity: open and closed.7 Closed systems camera towards the scanned area. The camera tip should be
offer all CAD/CAM procedures, including data acquisition, a few millimeters away from the tooth surface or should just
virtual design, and restoration manufacturing. All the steps are slightly touch the surface.6 The dentist is asked to slide the
integrated in the unique system. There is no interchangeability camera head over the teeth in a single direction gently so as
between different systems. Open systems allow the adoption of to generate the successive data into a 3D model. This seam-
original digital data by other CAD software and CAM devices. less scanning process can express a notable depth of field. In
There are still several obstacles and deficiencies to address addition, the scan can be interrupted and resumed at any time
in intraoral digital impressions. Some systems need a layer by the operator. A new technology of shake detection system
of powder spray on the tooth surface, and the inhomogeneous can ensure the 3D images are only captured when the camera
powder thickness may slightly transfigure the tooth outline. An- is stable and still, so it can avoid any possible inaccurate data
other major problem is scanner displacement during the scan- due to shaking or trembling of the operator’s hand.6
ning process, which may affect scanning accuracy. When scanning is complete, the preparation can be shown
This article reviews the characteristics of some major intrao- on the monitor and looked over from any angle. The virtual
ral digital impression devices currently available, and focuses die is cut on the effective model, and the finish line is outlined
on categories, principles, and operation. We also discuss the by the dentist directly on the die image. Then, a CAD system
differences between intraoral digital and conventional impres- “biogeneric” proposes an idealized restoration design to let the
sions. dentist makes adjustments using a number of on-screen tools.
Once satisfied with the restoration, the dentist can mount a
block of ceramic or composite material with the desired shade
Categories, principles, and operating in the milling unit and start to produce the physical restoration.
characteristics During the design stage, color-coded tools determine the degree
The main intraoral digital impression systems currently avail- of interproximal contact and ensure the finished restorations
able on the market include CEREC, Lava C.O.S. system, iTero, require minimal adjustments, if any, before cementation. The
E4D, and TRIOS. They vary from each other in terms of key dentist can either capture the teeth digitally and fabricate a
features such as working principle, light source, the necessity of restoration in a single visit, or can transfer the data to the dental
powder coat spraying, operative process, and output file format. laboratory by CEREC Connect R
, which can in turn select the
restoration design virtually and mill it in the laboratory.10
This type of intraoral scanner can be used for single crowns,
CEREC system
veneers, inlays, onlays, and implant-supported FDPs. For
The CEREC 1 system (Sirona, Bensheim, Germany) was crowns over implants, the prepared abutment can be directly
brought to market in 1987 together with the Duret system as the scanned,6 or a scan body seated on the implant can be scanned
first intraoral digital impression and CAD/CAM device.8 This by the dentist. A scan body is a plastic coping with markers
system is designed with the concept of “triangulation of light,” that provide 3D registration of the implant location.12
in which the intersection of three linear light beams is focused The CEREC system is a closed system, exporting the dig-
on a certain point in 3D space.1 Surfaces with uneven light ital impression data as a proprietary format file that works
dispersion adversely reduce the accuracy of scans. Therefore, on Sirona’s supporting CAM devices such as CEREC MC and
adoption of an opaque powder coating of titanium dioxide is CEREC In-Lab. The CEREC MC is a chairside milling unit that
required for producing uniform light dispersion and increasing can provide single-appointment treatments. Earlier, the CEREC
scan accuracy.9 chairside milling unit was not capable of milling FPDs and some
Currently, the most prevalent CEREC system is its fourth- high-strength ceramic materials. Therefore, these types of cases
generation product, known as CEREC AC Bluecam. It captures had to be milled through CEREC In-Lab. With recent devel-
images using a kind of visible blue light emitted from an LED opments in CEREC devices, the CEREC MC X and CEREC
blue diode as its light source. The CEREC AC Bluecam can MC XL combined with CEREC AC Omnicam can be used for
capture one quadrant of the digital impression within 1 minute a majority of indications and materials, including FPDs and
and the antagonist in a few seconds. The newest CEREC sys- zirconium oxide.9
tem, CEREC AC Omnicam, was brought to market in 2012.
The Omnicam imaging technique is a style of continuous imag-
Lava C.O.S. system
ing, where consecutive data acquisition generates a 3D model,
whereas Bluecam imaging is a single image acquisition. Om- LavaTM C.O.S. (Lava Chairside Oral Scanner; 3M ESPE,
nicam can be used for a single tooth, quadrant, or full arch, Seefeld, Germany) is an intraoral digital impression device
but Bluecam can only be applied for a single tooth or quadrant. invented in 2006 and brought to market in 2008. It works un-
Powder-free scanning and precise 3D images with natural color der the principle of active wavefront sampling.13 This principle
are the most prominent features of Omnicam. The powder-free refers to obtaining 3D data from a single-lens imaging sys-
feature has particular benefits for a larger scanning area.10 tem. Three sensors can capture clinical images from diverse
Tooth surfaces with uneven light dispersion adversely reduce angles simultaneously and generate surface patches with in-
the accuracy of scans. Accordingly, it is wise to make an opaque focus and out-of-focus data by proprietary image-processing
powder coating of titanium dioxide before scanning to induce algorithms.14 Twenty 3D datasets can be captured per second,
uniform light dispersion and improve scan efficacy.11 When embodying over 10,000 data points in each scan.2 This allows
the system to produce a precise scan out of 2400 more datasets during one scan. These focal depth images are separated at the
(or 24 million data points). The manufacturer states that the level of approximately 50 µm, allowing the camera to acquire
high data redundancy ascribed to many overlapping pictures precise data of tooth surfaces.17 Parallel confocal scanning with
ensures the highly accurate image quality.2 the iTero system can capture all structures and materials in the
The Lava C.O.S. has the smallest scanner tip—only 13.2- mouth without coating teeth with scanning powders.6 This sys-
mm wide. The scanner sends out pulsating visible blue light tem uses red laser as a light source and consists of a host
as light source and works with a mobile host computer and a computer, a mouse, a keyboard, a screen, and a scanner.15
touch-screen display.6 When the prepared tooth is finished by rinsing, retraction,
Similar to CEREC AC Bluecam, the Lava C.O.S. also re- hemostasis, and air drying, the dentist puts the scanner over
quires a powder coating spray on the tooth surface before scan- the tooth and starts the scan process. Scans over prepared teeth
ning. After the mouth is rinsed and air dried, the particular should involve the following areas: occlusal, lingual, buccal,
powder (LavaTM powder for chairside oral scanner; 3M ESPE) and interproximal contacts of the adjacent teeth. If any shake
is sprayed on the tooth surface to form a homogeneous layer. is detected, the system requires a rescan. After completion,
In the progress of scanning, the dentist should start with the a 45° angle view from buccal and lingual directions of the
posterior tooth area and move the camera forward, ensuring remaining teeth in the arch and opposite arch are achieved.
both buccal and lingual sides are captured.10 The Lava C.O.S. Eventually, a buccal scan of the patient’s centric occlusion is
can display the images seized in the mouth on the touch screen obtained. The system will carry out a virtual bite registration
at the same time. With real-time visibility, dentists can imme- instantly.18
diately see if they are receiving enough information from the According to Birnbaum et al,10 “once the digital impression
preparation. Once it is confirmed that all necessary details were has been completed, the clinician can select from a series of
captured on the preparation scan, a quick scan of the rest of diagnostic tools to evaluate the preparation and complete the
the arch is required. If the display shows a critical missing or impression. The occlusal reduction tool shows in vivid color
blurry area in the scan, the dentist simply needs to rescan this how much clearance has been created in the preparation for
specific area, and the software will be amended automatically.10 the restoration selected by the clinician. A margin line tool is
The dentist then scans the opposite arch in the same manner. available to assist in viewing the clearly defined margin. Once
Finally, a scan from the buccal side with the patient in occlu- the clinician has completely evaluated all aspects of the digital
sion is taken, and the system will articulate the maxillary and impression, adjustments, if any, are made at that time and a few
mandibular teeth automatically to create a bite record.15 additional scans will register the changes that were made to the
After reviewing all the scans, the dentist can fill out an on- prepared tooth.”10,19
screen laboratory prescription. The data are wirelessly trans- The completed digital impression is conveyed to the Cadent
ferred to the laboratory, where a technician cuts the die accord- facility and the dental laboratory through a HIPAA-compliant
ingly and digitally marks the margin with customized software. wireless system. Upon laboratory review, the digital files are
The digital data are virtually ditched after being transferred to output to a model by Cadent. The model is milled from a pro-
3M ESPE. Afterward, the data is normatively articulated with prietary blended resin and is pinned, trimmed, and articulated
the opposing and bite scans.10 according to the clinician-created digital impression. The pre-
A stereolithography (SLA) model is created by the manu- cision of milled models and dies is secured by Cadent industrial
facturer and delivered to the laboratory. Despite the different 5-axis milling machines.10
system name, it is not dedicated solely to the creation of Lava Cadent models have a unique feature. Among them, one
crowns and FDPs. All types of finish lines may be reproduced model can be used as either a working model or soft-tissue
on the SLA dies, which allows any type of crown to be manu- model. By ditching the dies effectively, the dies and models
factured by the dental laboratory.10 are precisely developed, and the inaccuracies of hand trimming
In most cases, the Lava C.O.S. also exports data files in a pro- are eradicated. Then, the definitive restoration is specifically
prietary formatted manner, which can be designed and manu- processed at the laboratory using the digital prescription.20
factured only by its supporting CAD software and CAM device. iTero is an open system in the treatment of crowns, FPDs,
Scanning of implant cases is accomplished by Biomet 3i (Palm veneers, implants, aligners, and retainers. It exports digital
Beach Gardens, FL). It uses a healing cap (Encode; Biomet image files as an STL format, which can be shared by any other
3i) attached to the implant before taking an optical impression. lab equipped with a CAD/CAM system. For an optical impres-
After data acquisition, Biomet 3i can mill the abutment. The al- sion of the implant position, iTero partners with Straumann,
ternative option is to deliver the data to Dental Wings software which has contributed considerable enhancement for clinical
(DWOS). The compatibility with other software makes Lava circumstances with implants in recent years. In these cases,
C.O.S. a semi-open system.6 Straumann applies implant components according to CAD soft-
ware DWOS which works on the digital impression data from
iTero.16 A specific transfer is attached at the superior surface
iTero system
over the implants with three spheres, allowing the correct
Cadent Inc (Carstadt, NJ) introduced iTero to the market in implant positioning. The iTero System camera is thereafter
2007. The iTero system captures intraoral surfaces and con- placed over the implant, and the digital impression data is
tours by laser and optical scanning based on the principle of gained in the same way as described previously. As an open
parallel confocal imaging.16 A total of 100,000 points of laser system, iTero is compatible with software that accepts STL
light at 300 focal depths of the tooth structure can be obtained images, such as DWOS.6,16
E4D system ple of ultrafast optical sectioning and confocal microscopy. The
system recognizes variations in the focus plane of the pattern
The E4D system was developed by D4D Technologies, LLC
over a range of focus plane positions while maintaining a fixed
(Richardson, TX) under the principle of optical coherence to-
spatial relation of the scanner and the object being scanned.
mography and confocal microscopy. It uses red laser as a light
Furthermore, a quick scanning speed of up to 3000 images per
source and micromirrors to vibrate 20,000 cycles per second.
second reduces the influence of relative movement between
E4D’s high-speed laser formulates a digital impression of the
scanner probe and teeth.21 By analyzing a large number of pic-
prepared and proximal teeth to create an interactive 3D image.21
tures obtained, the system can create a final digital 3D model
The laser technology traps images from every angle. The soft-
instantly to reflect the real configuration of teeth and gingival
ware builds a library of images. The image library can wrap
color. Similar to the iTero and E4D systems, the TRIOS intrao-
around a precise virtual model in seconds. This system also
ral scanner is a powder-free device in the scanning process.
functions as a powder-free intraoral scanning device. It in-
The TRIOS system boasts an essential trait, “the variation of
cludes a cart with the design center (computer and monitor),
the focal plane without moving the scanner in relation to the
laser scanner head, and a separate milling unit.
object being scanned.”21 According to Logozzo et al,21 “The
When scanning the prepared tooth, the dentist places the
focal plane should be continuously varied in a periodic fashion
intraoral scanner above the tooth while holding down the foot
with a predefined frequency, while the pattern generation means
pedal. After centering the target area on the screen and focusing
the camera, the optical system, and the object being scanned
on the images, the pedal is released, and the images are secured.
are fixed in relation to each other. Further, the 3D surface ac-
The scanner must be held a specific distance from the surface
quisition time should be small enough to reduce the impact of
being scanned. This is achieved with the assistance of rubber-
relative movement between probe and teeth. The scanning sys-
tipped “boots” extending from the head of the scanner. In this
tem has the property of telecentricity in the space of the object
manner a series of pictures from necessary angles is captured.
being scanned and it is possible to shift the focal plane while
The system will integrate these images into a complete 3D
maintaining telecentricity and magnification.”21
impression automatically. Unlike the systems described above,
The operation of TRIOS is relatively simple. The dentist can
the occlusal relationship is not obtained by scanning the closing
hold the scanner at a range of distances to the tooth. Either
mouth from the buccal direction. Instead, it is created with
closely over the tooth or 2 to 3 cm away will not affect the
trimmed impression material and placed on top of the prepared
focus and the capturing of images.21 The 3D profiles of teeth
tooth afterward. The scanner captures a combination of the
and gingiva are generated simultaneously, while the dentist
registration material and the adjacent teeth free of material
moves the scanner gradually above them. After scanning the
coverage. This data is applicable for drawing occlusal heights
upper and lower teeth, a buccal scan can be taken when the
of restorations in following the CAD procedure.10
patient closes into an intercuspal position. The system of the
The 3D digital impression data can be exported as a propri-
host computer will implement a digital registration to create a
etary format or a STL format. For the proprietary closed format,
3D occlusion relationship.
the data is sent to specific DentaLogic software for CAD work. R R
TRIOS includes two parts: TRIOS Cart and TRIOS Pod.
The E4D design system can autodetect and label the finish line R
The TRIOS Pod offers better mobility and flexibility due to its
on the preparation. Once a landmark is marked by the dentist,
simple construction with a handheld scanner only and its com-
the AutogenesisTM featured computer starts to select a proposed R
patibility with other computers or iPad.21 For both the TRIOS
restoration from its anatomical libraries for the related tooth. R
Cart and the TRIOS Pod scanner, clinics can choose either a
Moreover, the operator will modulate the proposed restoration R R
TRIOS Standard or a TRIOS Color solution program. The
with numerous simple tools.10
latter is capable of capturing and demonstrating the teeth and
After the definitive restoration is authorized, the design center
soft-tissue images in real color. The TRIOS system can pro-
will transmit the data to the milling machine. With mounted
vide service in a broad range of indications including crowns,
ceramic or composite blocks in the milling machine and rotary
FPDs, veneers, inlays, onlays, implants, and orthodontic cases.
diamond instruments, which have advantages in replacement R
With the development of TRIOS Color, it is expected that the
of worn or damaged parts, the dentist is able to complete the
patients with a removable partial denture or complete denture
restoration fabrication.10
will be intraorally scanned directly in the future.21
The E4D system file can also be converted to an STL file by
The TRIOS system is an open system that can export 3D
paying a fee to D4D Technology. Thus, the digital impression
data as an STL file or a proprietary file. The STL file can
data can be used by other CAD/CAM systems, and the E4D
work together with other CAD/CAM systems. The proprietary
system can be considered as a semi-open device.
encrypted file can only be designed by 3Shape’s specific CAD
Like the CEREC AC Bluecam and Omnican systems, the
software and 3Shape Dental SystemTM . Additionally, TRIOS is
E4D system can work with a chairside-milling device. That
a professional digital impression acquisition and CAD system,
means this system can also function as a “single-visit treat-
and does not include a CAM milling device.21
ment” and provide high-strength ceramic prostheses or com-
In addition to the five systems described above, other digi-
posite even for minimally prepared teeth.22
tal impression systems are available. A brief summary of key
features of various intraoral digital scanners is presented in
TRIOS system Table 1.21
In 2010, 3Shape (Copenhagen, Denmark) launched a new type Besides the regular use of the intraoral digital impression sys-
of intraoral digital impression system, TRIOS, which was pre- tems mentioned above, other functions should be mentioned.
sented to market in 2011. This system works under the princi- Some types of intraoral scanner, such as E4D DentistTM can
316 Journal of Prosthodontics 24 (2015) 313–321
C 2014 by the American College of Prosthodontists
Table 1 Essential characteristics of intraoral digital impressions systems currently available
CEREC AC Sirona Dental System Active Visible blue light Multiple Yes Yes Proprietary
GmbH (Bensheim, triangulation images
Germany) and optical
microscopy
iTero Cadent Inc (Carstadt, Parallel confocal Red laser Multiple None No Proprietary or
NJ) microscopy images selective STL
317
Intraoral Digital Impression Review
Intraoral Digital Impression Review Ting-shu and Jian
scan the traditional impression made of elastic materials and efficiency, difficulty, and operator’s preference of an intraoral
invert the image to create a virtual model. This procedure is digital impression (iTero) and compared it to a conventional im-
based on the virtue of traditional impression materials yielding pression for single implant restorations. The results indicated
less reflective properties compared to those by the tooth sur- that mean total treatment time was 12’29” for digital and 24’42”
face. Therefore, traditional materials may help to improve the for conventional impressions; mean time of rescan/retake was
accuracy of digital scanning. 1’40” for digital and 6’58” for conventional impressions. Al-
Some kinds of intraoral digital systems are also used for though the total number of digital impression rescans (67) was
instruction and education purposes. E4D CompassTM allows more than that in conventional impression (21), this pilot study
clinical operators to educate and guide themselves on the pos- reached a conclusion that there was a significant difference in
sible therapeutic option prior to initiating treatment. TRIOS R
operation time between these two impression methods. Par-
and iTero contain diagnostic tools to evaluate the preparation, ticipants were asked to answer visual analog scale (VAS) and
which can be used to instruct dental students in proper tooth multiple-choice questionnaires to evaluate their perceptions of
preparation and to grade tooth preparation at dental schools. difficulty, preference, and proficiency for both impression tech-
niques.
Manipulative characteristics of intraoral The results showed that the grade of difficulty was lower
digital impression devices for the digital impression than that at the conventional impres-
sion. The digital impression techniques were more acceptable
Operational process and easier to grasp. The study showed that digital impression
The intraoral digital impression processes of various FDPs are represented a remarkable superiority in efficiency over con-
basically similar. Here we describe a detailed introduction to ventional impressions, and digital impression took less time
a patient with a single all-ceramic crown scan. The patient for rescans despite a larger volume required. This difference
received a standard preparation of the abutment tooth under was produced mainly because in the digital impression, only
clinical criteria. To expose the margin of preparation, two re- the missing and unacceptable areas were rescanned, whereas in
traction cords of selective sizes were placed in the gingival conventional impression, the entire arch needed to be retaken.24
sulcus (Fig 1). After waiting approximately 5 minutes when This difference could also impair the participants’ perception
the sulcus was expanded adequately, the area around the abut- of preference and proficiency.
ment tooth was rinsed and air dried thoroughly for the scanning.
If powder spraying were required in accordance with manufac- Accuracy and repeatability of intraoral
turer’s instruction, a special sprayer would be used to perform digital impression
an opaque powder coating on the surface of prepared tooth (Fig Accuracy between digital and conventional
2). Afterwards, the coronal cord was removed, and secondary impression
spraying was conducted to lay the powder over the area of the
removed cord. Then the digital scanning started. The operator Marginal and internal fitness are important criteria for the suc-
grasped the scanner control to let the scanner tip slide towards cess of FDPs like ceramic restorations. A high level of impres-
the tooth from different directions for capturing images. Ade- sion accuracy is important to assist the fabrication of a precise
quate pieces of 2D pictures taken by the scanner from several restoration. Syrek et al2 conducted an in vivo experiment to
angles were critical to generate precise 3D data of the prepared compare the fitness of zirconia single crowns produced from
tooth (Fig 3). A 3D stereopicture was displayed on the screen an intraoral digital impression with that from a conventional
after the missing and incorrect scanning areas were analyzed silicone impression. Four surfaces (mesial, distal, buccal, and
by the operating system (Fig 4). The system could figure out lingual) per tooth were measured. The median marginal gaps
if this scan was eligible for use or required a rescan. After the in the digital impression group were 50 µm for mesial, 55
scan of the prepared tooth was completed, spraying and scan- µm for distal, 53 µm for buccal, and 51 µm for lingual. In
ning on the antagonists could begin in the same manner (Fig the conventional impression group the gaps were 69 µm for
5). Eventually, a patient’s buccal side scan at oral occlusion mesial, 70 µm for distal, 74 µm for buccal, and 67 µm for
was taken to acquire a bite record (Fig 6). The final digital file lingual. The overall marginal gaps of digital and conventional
output from the scan system was transmitted to the technician impression groups were 49 µm and 71 µm, respectively. The
for further CAD/CAM process or applied for chairside design study concluded that ceramic crowns fabricated from a digi-
and manufacturing. tal impression had a better fit than conventional impressions
did. It also revealed better interproximal contact for the digi-
tal group than the conventional group. The all-ceramic crowns
Manipulative characteristics between digital
manufactured from digital impressions demonstrated narrower
and conventional impression
marginal gaps than the ones from conventional impressions.
Compared to a conventional impression, intraoral digital scan- This outcome was mainly explained by the working procedure
ning can save time and steps for dentists and technicians. Steps difference: in the conventional group, silicone impressions and
eliminated at the dental office include tray selection, material plaster models were made, whereas in the digital group, the
dispensing, material setting, material disinfection, and impres- crowns were designed and manufactured directly from the
sion packaging and shipping. Steps eliminated at the lab include scanning data without needing to fabricate an intermediate
plaster pouring, die cutting, trimming, articulation, and extrao- model. Additionally, making silicone impressions and plaster
ral scanning. Lee and Galluci23 conducted a study to assess the models could engender inevitable errors from deformation.25
Therefore, the crowns produced from the digital impression with intraoral digital impressions have presented accuracy on
could achieve a higher accuracy level. par with conventional impressions. Although conventional im-
Ender and Mehl26 conducted an in vitro experiment on full- pression materials like poly(vinyl siloxane) and polyether are
arch scanning to evaluate the precision of conventional and well developed and present great accuracy in many prostheses,
digital impressions, and determined the values to be 30.9 µm the intraoral digital impression technique has a distinct superi-
for CEREC Bluecam, 60.1 µm for Lava C.O.S., and 61.3 µm ority in work efficiency and saving of materials.31 The further
for a conventional impression. The authors concluded that the improvement of the intraoral digital impression technique will
accuracy of digital impressions was similar to that of conven- lead to its wide use in dentistry.
tional impressions, potentially due to a powder coat spraying,
which was applied before both Lava C.O.S. and CEREC scan-
ning. Even if the programs inside the scanners were capable of References
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experiment Del Corso et al29 found that the bias error value of 9. CEREC 3: Operating instructions for the acquisition unit. Sirona
the intraoral optical capturing system was 14 to 21 µm. Mehl The Dental Company, Bensheim, Germany, 2004
et al30 reported a 20 µm or less systematic error in extrao- 10. Birnbaum NS, Aaronson HB, Stevens C, et al: 3D digital
ral scanning on plaster casts. These data indicated that both scanners: a high-tech approach to more accurate dental
intra- and extraoral optical scanning could provide decent pre- impressions. Inside Dent 2009;5:70-74
11. Poticny DJ, Klim J: CAD/CAM in-office technology:
cision. The manipulative operation might be the major cause of
innovations after 25 years for predictable, esthetic outcomes. J
the larger discrepancy from intraoral scanning than that from Am Dent Assoc 2010;141:5S-9S
extraoral scanning. An unpredictable spatial movement of the 12. Patel N: Technologies for comprehensive implant integrating
scanner by operator would initiate a change of coordinate sys- three-dimensional digital. J Am Dent Assoc 2010;141:20S-24S
tem and affect the digital fit of images, consequently reducing 13. Rohaly J: Three-channel camera systems with non-collinear
the scan accuracy. On the contrary, an extraoral scan could apertures. United States Patent 2006;7:372-642
maintain a high consistency in multiple scans with a plaster 14. Lava Chairside Oral Scanner C.O.S: 3M ESPE Technical
model fixed on a scanner platform. Additionally, the powder Datasheet, St. Paul, MN, 2009
spray might be a factor in the intraoral scan becoming less 15. Birnbaum NS, Aaronson HB: Dental impressions using 3D
precise. Therefore, scanning devices dispensing with powder digital scanners: virtual becomes reality. Compend Contin Educ
Dent 2008;29:494, 496, 498-505
spraying are desirable to improve the performance of intraoral
16. Garg AK: Cadent iTero’s digital system for dental impressions:
digital impression devices. the end of trays and putty? Dent Implantol Update 2008;19:1-4
17. Kachalia PR, Geissberger MJ: Dentistry a la carte: in-office
Conclusion CAD/CAM technology. J Calif Dent Assoc 2010;38:323-330
18. Glassman S: Digital impressions for the fabrication of aesthetic
The intraoral digital impression technique has been used in ceramic restorations: a case report. Pract Proced Aesthet Dent
prosthodontics to aid the CAD/CAM process. As a relatively 2009;21:60-64
new technique, the deficits in repeatability of the intraoral digi- 19. Jacobson B: Taking the headache out of impressions. Dentistry
tal impression need to be solved, but dental products fabricated Today 2007;26:74-76
20. Cadent debuts “next generation” iTero digital impression system. 26. Ender A, Mehl A: Full arch scans: conventional versus digital
Implant Tribune, US edition, 2007;1(12):14 impressions-an in-vitro study. Int J Comput Dent 2011;14:11-21
21. Logozzo S, Franceschini G, Kilpela A, et al: A comparative 27. da Costa JB, Pelogia F, Hagedorn B, et al: Evaluation of different
analysis of intraoral 3D digital scanners for restorative dentistry. methods of optical impression making on the marginal gap of
Int J Med Tech 2011;5. http://ispub.com/IJMT/5/1/10082# onlay created with CEREC 3D. Oper Dent 2010;35:324-329
22. Tsitrou EA, Helvatjoglu-Antoniades M, van Noort R: A 28. Stimmelmayr M, Güth JF, Erdelt K, et al: Digital evaluation of
preliminary evaluation of the structural integrity and fracture the reproducibility of implant scanbody fit-an in vitro study. Clin
mode of minimally prepared resin bonded CAD/CAM crowns. J Oral Investig 2012;16:851-856
Dent 2010;38:16-22 29. Del Corso M, Aba G, Vazquez L, et al: Optical three-dimensional
23. Lee SJ, Gallucci GO: Digital vs conventional implant scanning acquisition of the position osseointegrated implants: an
impressions: efficiency outcomes. Clin Oral Implants Res in vitro study to determine method accuracy and operational
2013;24:111-115 feasibility. Clin Implant Dent Relat Res 2009;11:
24. Persson AS, Oden A, Andersson M, et al: Digitization of 214-221
simulated clinical dental impressions: virtual three-dimensional 30. Mehl A, Ender A, Mormann W, et al: Accuracy testing of a new
analysis of exactness. Dent Mater 2009;25:929-936 intraoral 3D camera. Int J Comput Dent 2009;12:11-28
25. Quaas S, Rudolph H, Luthardt RG: Direct mechanical data 31. Christensen GJ: Will digital impressions eliminate the current
acquisition of dental impressions for the manufacturing of problems with conventional impressions? J Am Dent Assoc
CAD/CAM restorations. J Dent 2007;35:903-908 2008;139:761-763
Abstract: In the field of Prosthodontics, the concept of digital impressions using CAD/CAM is growing quickly
for impression making procedures over conventional methods. The new technology is easierand precisefor the
clinician and more comfortable to the patient.From various studies it has been found thatdental prostheses
fabricated from intraoral digital impressions displayed various merits over conventional impressions in many
respects. This article discusses the various digital impression systems available in the market, to provide the
clinician complete information and knowledge ofapplication of the technology.
Key Words: virtual impressions, CAD/CAM, precision impressions
I. Introduction
Fabrication of final dental restorations through conventional practices involves a complicated process
the fabrication of final dental restorations. A comparatively new approach employs Computer-Aided
Design/Computer-Aided Manufacturing (CAD/CAM) technology such as to take a digital impression intra
orally, fabricate the master model, and design as well as produce the final restoration.1There are certain
advantages of digital impressions in implant and fixed prosthodontics as we compare with the conventional
impression techniques which include lessened time interval between clinic and dental laboratory, less
discomfort to the patient and elimination of laboratory steps that may lead to more fit issues.The digital
impression concept has become a trend and spreading quickly on the horizon and it is accepted that digital
impressions will solve the limitations and difficulties of the conventional impressions.Dr. Duret first introduced
the CAD/CAM concept to dentistry in 1973 in Lyon, France in his thesis entitled Empreinte Optique, which
translates to Optical Impression. The concept of CAD/CAM systems was further developed by Dr. Mormann, a
Swiss Dentist, and Mr. Brandestini, who was an electrical engineer.28 CEREC was the first commercially
available digital impression system for use in the field of dentistry. Over the last 10 years, systems like 3M Lava
C.O.S., CadentiTero, E4D Dentist, and 3Shape Trios have been introduced. Till date, various CAD/CAM
systems are now available for dental applications. Each employs a specific, distinct technique for making
impressions.
CEREC System
The CEREC 1 system (Sirona, Bensheim, Germany) was brought to market in 1987 together with the Duret
system as the first intraoral digital impression and CAD/CAM device.5 The principle of this system is designed
with the concept of “triangulation of light,” where the intersection of three linear light beams is focused on a
certain point in 3D space.6 CEREC AC Bluecam is the fourth generation product and currently is the most
DOI: 10.9790/0853-1606028284 www.iosrjournals.org 82 | Page
Digital Impressions: A New Era in Prosthodontics
prevalent CEREC system. LED blue diode is the light source which will emit visible blue light for the image
capturing. The CEREC AC Bluecam can capture one quadrant of the digital impression within 1 minute and the
antagonist in a few seconds. In 2012, the latest and newest CEREC system, CEREC AC Omnicam, was brought
to market. The Bluecam imaging technique involves the single image acquisition while the latest Omnicam
takes continuous various images, where a 3D model is generated after data acquisition. Bluecam can only be
applied for a single tooth while Omnicam can be used for a single tooth, quadrant, or full arch. Powder-free
scanning and precise 3D images with natural color are the most prominent features of Omnicam. 7The CEREC
system is a closed system, Sirona’s supporting CAM devices such as CEREC MC and CEREC In-Lab works on
the proprietary format file those contain the digital impression date.8
iTero system
Cadent Inc (Carstadt, NJ) introduced iTero to the market in 2007. They work on the principle of
parallel confocal imaging, the iTero system captures intraoral images and contours them by laser and visual
scanning.11One scan results a total of 100,000 points of laser light at 300 focal depths of the tooth structure.
These focal depth images are separated at the level of approximately 50 μm, allowing the camera to acquire
precise data of tooth surfaces.11 Coating of teeth with scanning powder is not recommended in this system, it can
capture all the structures in mouth without any use of coating powder. Red laser is used as a light source in this
system and further it consists of a host computer, a mouse, a keyboard, a screen, and a scanner. iTero is an open
system in the treatment of crowns, FPDs, veneers, implants, aligners, and retainers. Digital image files are send
as an STL format, which can be shared by any other lab equipped with a CAD/CAM system.
E4D system
The E4D system was developed by D4D Technologies, LLC (Richardson, TX). It works under the
principle of optical coherence tomography and confocal microscopy. 12 Micro mirrors and red laser is used as a
light source to vibrate 20,000 cycles per second. E4D’s are having high-speed laser those formulates a digital
impression of the prepared and proximal teeth such as to create an interactive 3Dimage. The images are
obtained in every angle with the laser technology. The software will compile all the images. The image library
can wrap around a precise virtual model in seconds. This system also functions as a powder-free intraoral
scanning device. It includes a cart with the design center (computer and monitor), laser scanner head, and a
separate milling unit.7The E4D system can work with a chairside-milling device just like CEREC AC Bluecam
and Omnicam systems. That means this system can also function as a “single-visit treatment” and provide high-
strength ceramic prostheses or composite even for minimally prepared teeth. 13
TRIOS system
A new type of intraoral digital impression system, TRIOS, was introduced in 2010, by 3Shape
(Copenhagen, Denmark) and was presented to market in 2011. This system works under the principle of
ultrafast optical sectioning and confocal microscopy.14 They maintain a fixed spatial relation of the scanner and
the object being scanned and recognizes variations in focal plane of the pattern over a range of focus plane.
Moreover, they have a quick scanning speed of up to 3000 images per second thereby reducing the influence of
relative movement between scanner probe and teeth. Analyzing a large number of pictures obtained, this system
can create a final digital 3D model spontaneously to reflect the exact configuration of teeth and gingival color.
Similar to the iTero and E4D systems, the TRIOS intraoral scanner is a powder-free device in the scanning
process.TRIOS include two parts: TRIOSR Cart and TRIOSR Pod. The TRIOSR Pod is having a handheld
scanner which offers better flexibility and mobility, so due to its simple construction it is compatible with other
computers and iPad also.15
II. Conclusion
In prosthodontics, the intraoral digital impression technique aids the CAD/CAM process. As a
relatively new technique, dental products fabricated with intraoral digital impressions have presented accuracy
as compared with conventional impressions but there is a repeatability of the intraoral digital impression which
needs to be solved. Although conventional impression materials like poly (vinyl siloxane) and polyether are well
developed and present great accuracy in many prostheses, the intraoral digital impression technique has a
distinct superiority in work efficiency and saving of materials.The further improvement of the intraoral digital
impression technique will lead to its wide use in dentistry.
References
[1]. Wang CJ, Millstein PL, Nathanson D (1992) Effects of cement, cement space,marginal design, seating aid materials, and seating
force on crown cementation.J Prosthet Dent 67: 786-790.
[2]. Birnbaum NS, Aaronson HB (2008) Dental impressions using 3D digital scanners: virtual becomes reality. Compend Contin Educ
Dent 29: 494, 496,498-505.
[3]. Galhano GA´ , Pellizzer EP, Mazaro JV: Optical impressionsystems for CAD-CAM restorations. J Craniofac Surg2012; 23:e575-
e579
[4]. Rekov ED: Dental CAD/CAM systems: a 20-year success story.J Am Dent Assoc 2006; 137(Suppl):5S-6S
[5]. Mormann WH: The evolution of the CEREC system. J Am DentAssoc 2006;137:7S-13S
[6]. Birnbaum NS, Aaronson HB, Stevens C, et al: 3D digitalscanners: a high-tech approach to more accurate dentalimpressions. Inside
Dent 2009;5:70-74
[7]. CEREC 3: Operating instructions for the acquisition unit. SironaThe Dental Company, Bensheim, Germany, 2004
[8]. Rohaly J: Three-channel camera systems with non-collinearapertures. United States Patent 2006; 7:372-642
[9]. Galhano GA´ , Pellizzer EP, Mazaro JV: Optical impressionsystems for CAD-CAM restorations. J Craniofac Surg2012; 23:e575-
e579
[10]. Garg AK: Cadent iTero’s digital system for dental impressions:the end of trays and putty? Dent Implantol Update 2008; 19:1-4
[11]. Kachalia PR, Geissberger MJ: Dentistry a la carte: in-office CAD/CAM technology. J Calif Dent Assoc 2010; 38:323-330
[12]. Logozzo S, Franceschini G, Kilpela A, et al: A comparativeanalysis of intraoral 3D digital scanners for restorative dentistry.Int J
Med Tech 2011
[13]. Tsitrou EA, Helvatjoglu-Antoniades M, van Noort R: Apreliminary evaluation of the structural integrity and fracturemode of
minimally prepared resin bonded CAD/CAM crowns. JDent 2010; 38:16-22
[14]. Logozzo S, Franceschini G, Kilpela A, et al: A comparativeanalysis of intraoral 3D digital scanners for restorative dentistry.Int J
Med Tech 2011; 5.
[15]. Persson AS, Oden A, Andersson M, et al: Digitization ofsimulated clinical dental impressions: virtual three-dimensionalanalysis of
exactness. Dent Mater 2009;25:929-936
[16]. Quaas S, Rudolph H, Luthardt RG: Direct mechanical dataacquisition of dental impressions for the manufacturing ofCAD/CAM
restorations. J Dent 2007; 35:903-908
[17]. da Costa JB, Pelogia F, Hagedorn B, et al: Evaluation of differentmethods of optical impression making on the marginal gap
ofonlay created with CEREC 3D. Oper Dent 2010; 35:324-329
[18]. Christensen GJ: Will digital impressions eliminate the currentproblems with conventional impressions? J Am Dent Assoc2008;
139:761-763
In digital impressions, intraoral scanners are used to create a digital image of the patient’s teeth,
eliminating the need for traditional impression materials, as well as increasing patient comfort and
decreasing anxiety.7 Using either a laser or video, digital impressioning acquires an image with a digital
scanning device that optically records the patient’s dentition and bite relationship. Light is projected
from the tip of the scanner, and a camera collects data, which are further manipulated to produce a
digital model of the patient’s dentition. Current systems use different light source technologies,
including laser, structured (striped) light, or LED illumination. Some systems require the use of titanium
dioxide powder as a contrast medium, whereas others do not. Data collection methods, strategies, and
size of scanner head may vary between scanners, but each procedure culminates in a digital model of
the patient’s dentition.
Digital impressioning systems allow the use of digital scans in place of physical impression materials.
There is no need to change preparation, retraction, or isolation technique. The only difference is that
instead of taking a physical impression with impression materials, a scanner wand is used intraorally to
record a digital image of the preparation. After scanning, the clinician reviews the digital image to
ensure that all relevant areas are captured as well as to confirm that occlusal clearance is sufficient. A
benefit of digital impressions is that they can be reviewed instantly and at significantly greater
magnification than is available with loupes or even microscopes. If there is a problem with the scan, the
clinician can make changes and re-scan if necessary.8 Once the clinician is satisfied with the
preparation and digital scan, the data file is electronically transmitted to the dental laboratory along with
a prescription. Virtually any type of restoration can be created using a digital impression, from all-
ceramic crowns to gold inlays.
Once the scan is received, the dental laboratory or its manufacturing partner uses special software to
identify preparation margins and digitally mark and trim the dies. At that point, 3-dimensional (3D)
printed or milled models can then be produced for the laboratory to use in fabricating the restoration if
desired. These models can be used to fabricate restorations using both digital and traditional methods
and materials. An interesting new twist with digital impressions and monolithic milled or pressed
restorations is the option for laboratories to produce model-less restorations. This cuts down on
turnaround time and laboratories generally charge less for the restoration.9
As can be seen by the number of new scanner systems recently brought to market, the field of digital
impressions is rapidly growing. Companies such as 3M ESPE and Align Technologies have introduced
and subsequently refined their technologies in the past 5 years. 3M ESPE’s newest scanner, the
3M™True Definition Scanner ( www.3mespe.com), has a smaller wand, costs less, and now has open
architecture, allowing several CAD software brands to use the file for design. Recently, 3M ESPE
announced milling strategies compatible with the E4D® Design Center and Mill ( www.e4d.com) and
TS150™ In-Office Milling Solution (IOS Technologies, Inc; www.ios3d.com), enabling clinicians an in-
office milling option with a 3M ESPE scanner at a significantly lower cost than competitor in-office
milling systems. In the past year, other digital impression scanners such as CS 3500 from Carestream
Dental ( www.carestreamdental.com), TRIOS® from 3Shape, and IOS FastScan (IOS Technologies,
Inc) have also been introduced. Available digital impression and CAD/CAM systems are listed in Table
1.
Chairside CAD/CAM
Chairside CAD/CAM systems include both a scanner and a mill for fabricating a restoration. With these
systems, clinicians can scan, design, and mill a full-contour restoration in-office. As seen with
designated digital impressioning systems, a digital scan is taken of the preparation. Instead of
electronically sending the data file to a dental laboratory for fabrication, the clinician is able to design
the restoration chairside using software included in the CAD/CAM system. When fabricating a chairside
restoration, the clinician can choose a crown, inlay, onlay, or veneer. Most of these software systems
offer design options ranging from copying pre-existing tooth conditions to choosing from a library of
proposals based on morphological details of adjacent teeth. These software programs offer a multitude
of tools to modify the proposed restoration, including tools to adjust interproximal contacts, height of
contour, occlusion, and other characteristics. Depending on the material, restorations may be
customized using stain and glaze and then fired in a porcelain oven, giving the dentist more creative
freedom and control. The finished restoration can be cemented during the same appointment. Patient
responses to these types of systems are generally positive due to the quick turnaround of their indirect
restoration; in most cases, no temporary is required.10
The advantages of chairside CAD/CAM systems are numerous; however, these systems are
significantly greater in cost than a scanner alone, and require extensive training for the entire staff
(Table 2). To attract clinicians who only want to use digital impressioning without milling, companies
offer dentists an option to purchase the scanner without the mill, which provides additional options in
materials and lowers the total investment. To choose which system is best for a particular office, a
review of the type of restorative materials routinely used is a good start. If the majority of indirect
restorations are ceramo-metal based, digital impressions may be the way to go. However, true return
on investment can be achieved if an office is using all-ceramic materials routinely, especially in the
posterior region.
For example, a laboratory with an open-architecture digital impression system may become an
outsourcing partner for other laboratories or choose to integrate new interfaces with emerging CAD
software platforms.12 Open-architecture systems allow individual dentists to work with several different
laboratories and maximize the potential of their investment with options such as implant restorations
and orthodontics.
Closed-system software architecture collects and manipulates data modules by the same
manufacturer, offering laboratory owners security and a one-stop shop for resolving problems. One
company controls both the CAD and CAM configurations, knows the milling unit’s performance
specifications and capabilities, and is able to adapt the CAD and CAM software accordingly.10 For
example, using Sirona Connect, participating Sirona Connect laboratories can receive files from any
CEREC® device, design and mill on an InLab system (Sirona), and deliver a restoration to a dentist
using CEREC. For laboratories that do not want to immerse themselves in all the new technologies and
software from each different manufacturer, closed-architecture systems generally do a great job of
taking the user by the hand from start to finish. The production process from scan to design to milling is
made easy.
There are three ways to effectively manage and displace the soft tissue: mechanically, chemically, and
surgically.13 The most popular technique is to mechanically displace gingival tissue with the use of
retraction cord.14 Retraction pastes can also be used to mechanically displace tissue. Chemicals such
as ferric sulfate or aluminum chloride can be applied as hemostatic agents to shrink soft tissue around
the preparation.15 Diode lasers are becoming more popular as a surgical method of managing tissue.
Lasers are used to trough around the preparation, allowing visualization of the margin and providing
homeostasis as well.
Material Selection
As materials evolve, there is a continual push toward strong yet esthetic restorations. Silica-based
ceramics (feldspathic porcelains, leucite-reinforced ceramics, lithium disilicate ceramics) offer the most
esthetic option, whereas zirconia provides higher strength. One clear advantage of chairside CAD/CAM
restorations is that the solid manufactured block is made under ideal conditions, and furthermore, is
free of porosities. Historically, material options for in-office milling were limited to weaker feldspathic
monolithic blocks. Today, clinicians have material options resulting in a three- to 11-fold increase in
flexural strength.16 Depending on the milling unit, there are many material choices now available in
CAD/CAM blocks, including feldspathic porcelain, nano-ceramics, lithium disilicate, and more (Table 3).
Zirconia blocks are also available, but unless the office has a sintering oven and a laboratory-grade
mill, these materials are generally laboratory fabricated.
Practitioners also have the opportunity to enhance esthetics after milling by staining and glazing for
customized shades.17 Early-generation materials were limited to monochromatic shades, and were not
ideal for anterior restorations. Today, multi-layered translucent blocks are available, allowing clinicians
the option of fabricating anterior restorations.18 Using chairside systems for anterior restorations in not
for everyone; it requires experience and confidence with custom staining/glazing.
Due to its high strength and versatility, zirconia is gaining popularity as a restorative material. When
zirconia was first introduced to the market, it was primarily used as a framework for single crowns and
bridges (in place of metal). Similar to the fabrication of a porcelain-fused-to-metal crown, the zirconia
framework is layered with a ceramic, providing a strong and esthetic restoration. The success of
zirconia as a strong framework led to the development of a full-contour restoration. Advances in
translucency have made monolithic zirconia a widely accepted and used choice due to a minimal need
for tooth preparation (similar to cast gold), low cost, and ability to be used in multi-unit restorations. As
zirconia continues to develop as a more translucent material, it may very well be a viable option for all
regions of the mouth.19
Laboratory Relationship
Doctors who acquire a digital impression system must evaluate their relationship with their dental
laboratory.20 The prospect of losing this relationship can be a strong deterrent for potential CAD/CAM
users who may not fully understand the extent to which they can maintain a partnership with their
laboratory. Adopting CAD/CAM technology into a practice, even at the highest level, does not have to
mean an end to the doctor-laboratory relationship. On the contrary, the integration of digital scanning
technology can enhance this partnership and even save time and reduce remake rates for the
laboratory.
The use of CAD/CAM systems opens doors to the use of other technologies, including 3D printing in
the dental lab. Whereas a mill is a subtractive device because it uses material, 3D printing is
considered an additive device. Some types of 3D printing use special powdered substrates that can
include metal or plastic. This additive property allows several units to be produced simultaneously
rather than adding time with each additional coping, die, etc. This technology can be used in a broad
spectrum of applications, including fabrication of aligners, patterns for fixed prosthodontics, surgical
guides, removable dentures, and models (Figure 3). Traditionally, laboratory crown work has required
detailed model work that includes removable dies for checking margins and building porcelain. Today’s
3D printers are capable of producing models for dental laboratories and milling centers. Technology in
this area continues to advance, offering ever-increasing opportunities for the laboratory/practice
partnership to evolve.21
Integration
Integrating CAD/CAM technology into a dental practice takes commitment and effort, and the learning
curve involved with digital impression should not be underestimated. If an office plans to make the
switch to digital, having a team that is 100% committed will help ensure success, as well as having a
laboratory to communicate with during the transition.22
An overlooked consideration when purchasing in-office CAD/CAM systems is the time and cost of
training team members. Although most systems include some training in the purchase price, and all
offer technical support over the phone and/or online, it is important to note that proficiency will take
time. A highly skilled dental assistant or an in-office laboratory technician can efficiently finish a case in-
office, but only with adequate training, which can be extensive and time consuming. Once the desired
level of expertise is achieved, however, assistants can complete the design and fabrication of the
restoration, thus freeing the dentist’s time. State dental boards have yet to clarify or regulate assistant
usage of digital impression devices. Clinicians must make their own decisions following state laws and
guidelines.
Summary
Over the past 5 years, CAD/CAM has developed at a rapid pace, and it is likely that integration of
different systems will become the industry norm. Smaller intraoral scanners that require no cart are
already appearing on the market, as well as those that do not require contrast medium (powder).
Interdisciplinary case planning is evolving while integrating both cone-beam scans and implant-planning
software for custom abutment and crown design. Digital dentures, partials, splints, and sleep
appliances are appearing on the market in various configurations. One thing is certain—CAD/CAM is
changing the way clinicians look at dentistry, from material selection to technique.
References
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16. Seghi RR, Sorensen JA. Relative flexural strength of six new ceramic materials. Int J Prosthodont.
1995;8(3):239-246.
17. McLaren E, Giordano R. Zirconia-based ceramics: material properties, esthetics, and layering
techniques of a new veneering porcelain, VM9, high-alumina frameworks. Quintessence Dent Technol.
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20. Cohen B. Projecting confidence in your digital capabilities. Journal of Dental Technology.
www.jdtunbound.com/files/pdf-files/ProjectingConfidence
inYourDigitalCapabilities.pdf. 2010. Accessed October 1, 2013.
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Review Article
Digital Impression System –Virtually Becoming a Reality
Gaurang. S. Mistry, Anuradha Borse, Omkar.K. Shetty, Rubina Tabassum
Department in Prosthodontics, Dr. D.Y.patil dental College and Hospital, Nerul, Navi Mumbai,
Maharashtra, India.
Abstract
Corresponding Author Digital impression has been integrated into dentistry since
Dr. Anuradha Borse the1980s. It offers the clinician the ability to offer patients
fixed restorations of all types. The new technology has
Dr. D.Y.patil dental collage and become easier to use for the clinician as well as more
precise, and offers technological advances over earlier
Hospital,
versions. There are different types of lights used to capture
Nerul, Navi Mumbai, Maharashtra, image. Diode lasers, which produce invisible near infrared
wavelengths ranging from 805 nm to 1,064 nm, are for soft
India. tissues only. After image acquisition, the final image is
Pin code- 400706 either stored in the system and used for chairside fabrication
or digitally transmitted to a laboratory for use or the image
Email: borsepatil1986@gmail.com can be send to milling unit for fabrication of prosthesis.
Different system has their own method of determing centric.
There is no wax or impression material between the teeth
Received: 12-12-2013 and the practitioner can guide and easily see if the patient is
closed correctly. There are many advantages in using this
Revised: 14-01-2014 advance technology. The overall goal of this article is to
Accepted: 24-01-2014 provide the clinician with information on digital impression
in dentistry and the clinical application of the technology.
Key words: Digital scanner, Camera, Software,
dentin bonding agents.
This article may be cited as: Mistry GS, Borse A, Shetty OK, Tabassum R. Digital Impression
System –Virtually Becoming a Reality. J Adv Med Dent Scie 2014;2(1):56-63.
Introduction
“Impression” has different meaning in life impressions. So, to overcome the inaccuracy
but in dentistry, impression is negative form digital impression were introduced using
of teeth or other tissues of the oral cavity. scanner and prosthesis are fabricated using
Impression has it’s importance in various software and milling machine. The first
aspects of dentistry especially in digital scanner was introduced in 1980s for
prosthodontic dentistry, to perform various dental impressions since then, development
procedure like inlays, onlays, crowns, engineers at a number of companies have
veeners impression has to be made using enhanced the technologies and created in-
different materials and techniques. office scanners that are increasingly user-
Earlier impression plaster was used to make friendly and producing precisely fitting
impressions, but with time it was replaced by dental restorations. These systems are
reversible and irreversible hydrocolloid and capable of capturing three-dimensional (3D)
then elastomeric impression materials. Still, virtual images of tooth preparations from
there is lack of some accuracy in making which restorations may be directly fabricated
56
Mistry GS et al. Digital Impression System.
57
Mistry GS et al. Digital Impression System.
Different system uses a different method to laser and optical scanning to digitally capture
acquire the images. The earlier versions of the surface and contours of the tooth and gum
Cerec® employed an acquisition camera that structure. The Cadent iTero scanner captures
depended on an infrared laser light source, 100,000 points of red laser light and has
advancements in the performance of blue perfect focus images of more than 300 focal
light-emitting diodes (LEDs) in parameters depths of the tooth structure. All of these
that are relevant for 3D acquisition cameras focal depth images are spaced approximately
have now surpassed the quality of the longer- 50 µm apart. This system does not require the
wavelength infrared light source. The shorter- use of powder.1
wavelength intense blue light projected by the The LAVA Chairside Oral Scanner (LAVA
blue LEDs allows for greater precision of the COS, 3M ESPE) takes a completely different
resultant optical image. The camera projects a approach using a continuous blue light LED
changing pattern of blue light onto the object video stream of the teeth. It consists of a
(Figure 3) and then reads it back at a slightly mobile cart containing a CPU, a touch screen
different angle, referred to as “active display, and a scanning wand, which has a
triangulation technique.” 13.2-mm wide tip and weighs 14 ounces. The
camera at the tip of the wand contains 192
blue LED cells and complex optical system
comprised of multiple lens. Thus, this system
is able to capture approximately 20 3D data
sets per second, or close to 2,400 data sets per
arch, for an accurate and high-speed scan.5
CEREC and LAVA currently require the use
of powder for the cameras to register the
topography. Each system uses a system-
specific handheld device to scan the site.
(Figure 4).
Figure 3: Cerec AC bluecam camera captures
an image of teeth using shorter wavelength
blue
It uses a telecentric beam, which permits the
capture of essential information from all of
the prepared tooth’s surfaces in a single view.
The entire area being impressed needs to be
coated completely with a layer of
biocompatible titanium dioxide powder to
enable the camera to register all of the tissues.
The powder is easily removed afterwards
with air and water.1 Figure 4: cerec handheld device, and lava
The E4D (D4D TECHNOLOGIES), a COS handheld device.
complete powder free chair side CAD/CAM The cerec 1 was an integrated acquisition and
system, takes several images using a red light milling unit that was moved from operatory to
laser to reflect off of the tooth structure. operatory. The teeth were powdered with an
The iTero system uses parallel confocal opaquing medium and images were taken
imaging to quickly capture the digital with the camera2. One study found that the
impression. Parallel confocal imaging uses average camera angulation error by clinicians
58
Mistry GS et al. Digital Impression System.
was just under two degrees. The impression (Figure 6 ) for a coping that can then be
process necessitates achieving adequate placed on the acrylic model for the porcelain
visualization of the margins of the tooth or other material to be added; LAVA can be
preparation by proper tissue retraction or used to print via stereolithography (SLT)
troughing and hemostasis.1,6 physical models.
Bluecam uses blue-light light emitting diodes
(LEDs) to create highly detailed digital
impressions using shorter wavelengths of
light than earlier systems.
Software
Following image acquisition, the final image
is either stored in the system and used for
chairside fabrication or digitally transmitted
to a laboratory for use. Cerec and E4D system
is a complete system that allows the
restoration to be made chairside.3
Figure 6: Lava COS.
CEREC Connect is used to export the final
digital image directly to a Laboratory. A Alternatively, the digital impression can be
CEREC inLab milling unit is used to fabricate sent to a laboratory for any CAD/CAM or
the prosthesis3. traditional restoration fabrication. A chairside
The iTero system offers two options – system is being developed that will scan a
transmission of the digital image to an iTero traditional impression in the office and create
laboratory where a model is milled using the a digital impression file (3Shape). During the
image and can then be used in a traditional scan, a pulsating blue light emanates from the
manner to create the restoration in wand head as an on-screen image of the teeth
CAD/CAM and non- CAD/CAM laboratories appears instantaneously. The dentist guides
alike, thereby transforming the software the wand over the occlusal surfaces, rotates
image into a physical model; alternatively, the the wand so that the buccal surfaces are
digital image can be used to create the scanned, then rotates again to capture the
restoration using CAD/CAM (Figure 5).3 lingual surfaces. The “stripe scanning” is
completed once the dentist returns to
scanning the occlusal of the starting tooth.1,3,5
The E4D dentist system consists of a cart
containing the design center (computer and
monitor) and laser scanner (Figure 7), a
separate milling unit, and a job server and
router for communication.
59
Mistry GS et al. Digital Impression System.
The scanner, termed the IntraOral Digitizer, ability to capture a bite from the buccal with
has a shorter vertical profile than that of the the patient closed in total contact and
cerec, so the patient is not required to open as occlusion. There is no wax or impression
wide for posterior scans. Therefore, once material between the teeth and the
proper retraction and hemostasis have been practitioner can guide and easily see if the
obtained, scanning begins by simply placing patient is closed correctly. The software
the IntraOral Digitizer directly above the simply matches up the upper and lower scans
prepared tooth. The scanner must be held a and places them in centric. The clinician can
specific distance from the surface being then see this bite from all angles on the
scanned—this is achieved with the help of screen, including from the lingual, and can
rubber-tipped “boots” that extend from the also look through the upper to the lower
head of the scanner. Placing these rests on occlusal planes to examine points of contact
adjacent teeth steadies the scanner at this (Figure 9).
optimal distance. The user holds down the
foot pedal while centering the image. Once
the desired area is centered on the on-screen
bulls eye, the pedal is released and the image
is captured (Figure 8).
60
Mistry GS et al. Digital Impression System.
From the impression to the model – Figure11: CEREC AC unit and bluecam
comparison of process steps7 (Table 1) scanner.
61
Mistry GS et al. Digital Impression System.
References
Differentiation chart of various camera 1. Nathan S. Birnbaum; Heidi B. Aaronson;
available7,2 (Table 2) Chris Stevens; Bob Cohen. 3D Digital
Scanners: A High-Tech Approach to More
Benefits of digital impression3,8,9 Accurate Dental Impressions; Inside
A. Accuracy of impressions Dentistry; April 2009; 5, (4).
62
Mistry GS et al. Digital Impression System.
63
Myths vs.
Realities
Digital Impressions: A Dentist’s and a Laboratory Technician’s Perspectives
Introduction
Are you ready for digital dentistry? The jCD recognizes that you may have
Dr. John F. Weston and Mr. Matt Roberts, for their perspectives regarding
into their current workflow. The jCD is pleased to offer you both a dentist’s
f or
d y ?
re a t r y
u t i s
y o en
re al d
A git
di
Reality
Capturing all the teeth in an arch is dependent upon two
Opening Remarks from Dr. John Weston things: total time allotted to capture the data and acces-
sibility to all areas of the mouth via the scanning wand.
Many of the systems on the market are able to obtain full
I
t is rare to read any dental publication arch impressions after some experience.1 Some utilize a
scanning contrast medium of powder or liquid and others
lately without seeing news about digital do not; either way, scanning more teeth obviously takes
longer than a typical single crown or “quadrant” digital
impression systems. While the majority of impression. However, clinicians quickly become more ef-
ficient and comfortable the more they use the technology
dental offices have not yet adopted this and are better able to scan more difficult cases. Full arch
data are required when using digital impressions for fab-
technology, digital scanning is gaining in rication of many dental prosthetics including orthodontic
aligners, bite guards, snore guards, removable partial den-
popularity as prices move downward and more tures, and larger multi-unit restorative cases. As a result,
having the ability to capture all of the teeth will become
dentists come to understand the accuracy increasingly important for full digital impression integra-
tion (Figs 1 & 2).
and efficiency of these systems. But many
these systems.
Myth
The scanner is too large to access the entire mouth.
Reality
While many of the scanning wands are considered
large and cumbersome to some extent, the trend
shows devices are getting smaller and more efficient.2
It is definitely possible to capture almost all areas
of the dental arch, with the exception of the distal
surface of second molars, with many of the current
wands. It must be noted that this is also a difficult
area to impress using traditional analog impressions.
Most of the time, a clear occlusal surface with mini-
mal buccal and lingual is sufficient. When the second Figure 3: Full arch scan completed with True Definition
molar is the tooth to be restored or the distal contour scanner.
of a second molar is required, wand size becomes a
major factor, narrowing the choices available. Howev-
er, when the second molar is prepared, scanning this
area is much easier because the distal contour is now
a flat surface and converging toward the occlusal. As
wands get smaller and capture technology improves,
access to challenging areas of the mouth will improve
even more, with digital scanning likely becoming the
choice for impressions in difficult areas (Figs 3-5).
Myth
The need for tissue retraction/tissue management is
not as important as with conventional impressions.
Reality
Retraction is just as important with digital scanners.3
In other words, a camera can see only what the cli- Figure 4: iTero (top) and LYTHOS (bottom, Ormco; Orange,
CA) digital scanner wands.
nician can see. If tissue, moisture, or debris is cover-
ing a margin, the camera is unable to scan the area.
However, the amount of retraction that is required
in many cases is less when using digital scanners. If
the margin is visible, even slightly, the camera will see
it.4 Most clinicians find that adequate retraction can
be achieved using retraction pastes and/or very small
diameter retraction cord. Retraction systems used for
analog impressions also work well, including lasers
and zirconia-tipped high-speed instruments. In addi-
tion, subtle differences in tissue and tooth can be vi-
sualized using the various imaging tools available on
the systems for accurate margin marking and place-
ment. Some systems also employ color-rendering
technology for easier distinguishing of tooth structure
and tissue. Whether margins are marked in the labo-
ratory or by the clinician, when it comes to accurately
Figure 5: Intra-oral scanner (Cyrtina; Zwaag, The
distinguishing margins, slight tissue retraction is re- Netherlands).
quired (Figs 6-10).
Figure 8: Subtle differences in tissue and tooth shown. Figure 9: Color rendering used to show differences in teeth
and tissue.
Figure 10: Example of cross-sectional margin marking. Figure 11: Example of an accurately scanned veneer case on
an additive stereolithography (SLA) model.
Myth
Digital impressions are not as accurate as convention-
al impressions.
Reality
Studies show digital data are far superior to traditional
polyvinyl silane or rubber base impressions.5,6 An
optical image will always be more precise than an
analog negative. With the added ability to manipulate
the images for viewing of margins and preparation
details, one can hardly ignore that digital impressions
provide the ability to improve the quality of our
restorations. We also know that stone plaster distorts Figure 12: Digital impression of a scan body.
as it sets. Traditional impressions can be subtly
distorted with no way to absolutely determine this
clinically until the restoration is tried in the mouth.3
Patients swallow and move around, trays can bend,
and moisture can silently contaminate the area while
we wait for final set.7 With optical scans, movement
is not a factor and moisture is detected easily as
it can be seen, cleared away, and an accurate scan
completed.1 Once the data are captured, we know they
are accurate.8 A comparison would be our ability to
now easily visualize, manipulate, and diagnose more
accurately using digital radiographs over traditional
analog films (Fig 11).
Myth
Digital impressions cannot be used for implants.
Figure 13: Digital impression of an implant abutment.
Reality
All of the systems currently on the market can be
used to capture permanently seated custom and stock
abutments for any implant system. A handful of the
systems are also able to utilize scan bodies for ac-
curate fixture-level impressions and complete digital
design of abutments and subsequent restorations.
“Model-free” custom abutment and final crowns can
be designed at the same time, eliminating steps and
improving accuracy.9 In addition, since implant res-
torations are inherently unforgiving with regard to fit,
the accuracy of digital impressions are well suited for
this technology. Either way, recording implant data is
an important aspect for digital impressions, and we
will see more workflows coming on line with all sys-
tems in the very near future (Figs 12-14).
Reality
Most systems on the market, once fully implemented,
save time due to faster impression making.8,10,11 There
is a learning curve and one has to look back at the
time and training that was required to master analog
impressions. In most cases, after a few weeks of con-
sistent use, most clinicians will be faster with digital
scans. This is not just due to increased skill level but
from a reduction of re-makes. Most digital systems al-
low you to visualize the impression as it is being made
including the ability to go back and “stitch-in” miss- Figure 15: Accurate SLA model shown on a veneer case.
ing pieces of data. This saves time when compared to
a complete re-do with analog impressions. Once fully
implemented into the office workflow, a typical quad-
rant scan averages 30 to 60 seconds, with full arch
scans inside of a few minutes.11 When using analog
systems, multiple impressions due to voids and distor-
tion are not uncommon and result in more time and
increased use of materials. Even experienced clinicians
can have occasional re-takes when using analog sys-
tems. This is not a factor with digital. Once you have
the image on the screen, there is no need for a re-take.
The real time savings becomes evident at delivery.
Whether using chairside milling or lab-fabricated, res-
torations made via digital impressions typically show
improved fit with minimal adjustments.12
Reality
Most systems on the market were designed for classic
single or double tooth quadrant dentistry. Some are
specifically designed for model-free in-office milling
with the option to connect directly to the clinician’s
laboratory for traditional model-based or model-free
fabrication.13 Not all systems on the market have the ac-
curacy or detail to predictably fabricate multiple units
and cross-arch dentistry, bridges, or implant bars.14
Normally these cases require very accurate scanning
and models, equivalent to high-density stone models
used in precision analog dentistry.15 Currently, when
models are required, they are fabricated primarily us-
ing reductive or additive processes. Clinicians should
investigate the abilities of digital scanning systems so Figure 17: Postoperative; digital scanned veneer case.
they purchase the one that best suits their needs. If
planning digital workflows for cross-arch and anterior
cases, accurate models will most likely be required
(Figs 15-17).
4. Fasbinder DJ. Digital dentistry: innovation for restorative treat- While a digital scanner is no crutch for poor
ment. Compend Contin Educ Dent. 2010;31 Spec No 4:2-11; technique, its use can help dentists quickly
quiz 12.
identify and correct hard and soft tissue
5. Syrek A, Reich G, Ranftl D, Klein C, Cerny B, Brodesser J. Clini- management issues before they become a
cal evaluation of all-ceramic crowns fabricated from intraoral
digital impressions based on the principle of active wavefront problem in the model or final restoration.
sampling. J Dent. 2010;38(7):553-9.
8. Touchstone A, Nieting T, Ulmer N. Digital transition: the col- Dr. Weston is an Accredited Fellow of the AACD. He is the owner of
and practices at Scripps Center for Dental Care in La Jolla, California.
laboration between dentists and laboratory technicians on CAD/
CAM restorations. J Am Dent Assoc. 2010 Jun;141 Suppl 2:15S-
Disclosure: Dr. Weston receives honoraria from 3M ESPE for teaching
9S. courses that use their products.
A
lthough digital impressions have The difference occurs when you are unsuccessful on your first im-
pression attempt. With conventional impression material, you have
been around for quite a while, to retake the entire impression to recover the missing detail on one
of two marginal areas; with the newest generation of digital impres-
and most practitioners are aware of their sions you can simply rescan the area with the problem and add
those data to the original digital impression. On cases that are hard
existence, there seems to be a general to isolate, the digital impression can be taken incrementally as each
tooth is isolated, thus eliminating the need to have perfect isolation
lack of information about their on an entire arch at one time for the impression. A further benefit in
some of the software is that it can be programmed to identify areas
advantages. While it appears that a of inadequate reduction at the time of the impression, allowing the
dentist to go back and reduce further, then rescan just that area and
small group of dentists in the U.S. are add it to the impression (Figs 1 & 2).
of the new systems, while others are not Figure 1: iTero digital impression of an inlay preparation on tooth #14.
myths.
Figure 2: In the iTero system, models are milled from the digital
impression at a milling center, and then shipped to the user.
Myth
Digital impressions are not as accurate as convention-
al impressions.
Reality
As with many areas of dentistry, there are various stud-
ies1,2 and opinions relating to accuracy in the digital
impressions. I have worked successfully with iTero im-
pressions (Align Technology; Santa Clara, CA) since
its introduction in 2005 with very good clinical re-
sults. We have used these impressions for both single
units and bridgework with equal success. Although
not a published study, conventional and digital im-
pressions were taken on many cases, the restorations
were fabricated on the digitally generated models, and
Figure 3: Implant impressions are created by attaching “scan bodies” to
then fit back to the stone dies from the conventional
the implants prior to completing the digital scan. The software recognizes
impressions. We observed no difference in fit between
the position of the implant from the position of the scan body. The 3Shape
the two impressions techniques. laboratory scan here shows three scan bodies in the lower left quadrant.
Myth
Digital impressions cannot be used for implants.
Reality
This is certainly a myth. Both the CEREC Omnicam
(Sirona Dental; Charlotte, NC) and iTero systems are
capable of taking implant impressions. A scan abut-
ment is attached to the implant and the digital scan
is completed. The software identifies the location
of the implant based upon the position of the scan
abutment; the models can then be fabricated with an
implant abutment in that position. Many of the digi-
tal impression companies either already offer this or
have working prototypes to solve this need.3 As with
every aspect of new technology, a dentist looking to
Figure 4: Although this case was completed with a scan of a laboratory
purchase a digital impression system should be certain
model, a digital impression would have allowed the digital design process to
that the system being considered offers the features begin much more quickly, avoiding the model fabrication time.
needed for the intended use in practice (Fig 3).
Myth
Digital impressions are not reliably faster than elasto-
meric impressions.
Reality
Digital impressions can be faster than conventional
impressions. I have seen demonstrations where full-
mouth impressions were taken, including bite reg-
istrations, in under two minutes with the new color
TRIOS system from 3Shape (New Providence, NJ). The
CEREC Omnicam is equally fast (Figs 4-6).
Reality
Some systems do still require powder and some
do not. Many of the lower-cost systems do require
powder. The more expensive systems are powder-
free.4
Summary
Digital impressions are here to stay. Anyone who
questions this should try to remember the last
time they loaded a roll of Ectachrome into a cam-
era, or developed x-ray film in their office. When
considering purchasing a digital impression sys-
tem, the consumer should try as many as possible Figure 6: Models of the digital impressions can be printed with various 3-D
to find one that fits his or her individual needs. printing systems. Restorations can then be conventionally fabricated or
Systems range in price from around $15,000 to digitally designed.
more than $40,000, and have many significant
differences in size and capability. Ease of use in
the mouth varies and software options also vary
from system to system (Fig 7).
References
2. Kim SY, Kim MJ, Han JS, Yeo IS, Lim YJ, Kwon JB. Accuracy
of dies captured by an intraoral digital impression system
using parallel confocal imaging. Int J Prosthodont. 2013
Mar-Apr;26(2):161-3. doi: 10.11607/ijp.3014.
Waldemar D. Polido*
* PhD and MSc in Oral and Maxillofacial Surgery, PUCRS. Residency in Oral and Maxillofacial Surgery, University of Texas, Southwestern Medical Center,
Dallas. Private Practice, Porto Alegre, Rio Grande do Sul State, Brazil.
scanning technologies are so recent that they are notably in the areas of restorative dentistry, or-
not yet ready for clinical use. Actually, impression thodontics and orthognathic surgery.
taking using elastomers, for all its inherent prob-
lems, has been used in dentistry for 72 years! Dedicated Digital Impression Systems
Digital impression and scanning systems were Dedicated digital impression systems elimi-
introduced in dentistry in the mid 1980s and nate several cumbersome dental office tasks, such
have evolved to such an extent that some authors as selecting trays, preparing and using materials,
predict that in five years most dentists in the U.S. disinfecting impressions and sending impressions
and Europe will be using digital scanners for im- to the lab. Moreover, lab time is reduced by not
pression taking.2 having to pour up plaster, place pins and replicas,
In Orthodontics digital impression taking has cut and shape dies or articulate models.
been used successfully for several years with sys- With these systems, final restorations are pro-
tems like Cadent IOC/OrthoCAD, Dentsply/ duced in models created from digitally scanned
GAC ‘s OrthoPlex, Stratos/Orametrix SureSmile data instead of plaster models made from physical
and EMS RapidForm. impressions. Additionally, they enhance patient
CAD-CAM (Computer Aided Design and comfort, improve patient acceptance and under-
Computer Aided Manufacture) systems avail- standing of the case. Digital scans can be stored on
able today are capable of feeding data through hard disks indefinitely, while conventional mod-
accurate digital scans made from plaster models els, which can break or chip, must be physically
directly to manufacturing systems that can carve stored, which requires additional office space.
ceramic or resin restorations without the need The iTero digital impression system (Cadent
for a physical copy of the prepared teeth, adja- Inc., USA) (Fig 1) entered the market in 2007.
cent teeth and antagonist teeth.
With the development of new high-strength
restorative materials with aesthetic properties,
such as zirconia, lab techniques have been devel-
oped whereby master models obtained through
impressions with elastic materials are digitally
scanned to create stereolithic models (prototyp-
ing) on which restorations are performed. Even
with such high-tech improvements, it is clear
that these second-generation models are not as
accurate as stereolithic models made directly
from data obtained from 3D digital scans of the
teeth using 3D scanners specially designed for
this purpose.
Two types of systems are available on the
market today: CAD/CAM systems and dedicat-
ed three-dimensional digital impression systems
(3D). This article reviews the characteristics of
dedicated 3D digital impression systems not only
because this is the state-of-the-art today but
because it shows great promise for the future, FIGURE 1 - iTero scanner equipment.
FIGURE 2 - iTero scanner. FIGURE 3 - Image showing the digital model for prosthetic dentistry.
It uses a parallel confocal imaging system to per- fitted on the device comprises 192 LEDs and
form fast digital scans, capturing 100,000 points 22 lens systems.
of laser light and producing perfect focus images The method used to capture 3D impressions
of more than 300 focal depths of tooth struc- involves a technology called Active Wavefront
tures. All of these focal depths are spaced no Sampling. Lava’s “3D in Motion” concept fea-
more than 50 micrometers (50 µm) apart. Paral- tures a revolutionary optical design, image pro-
lel confocal digital scanning captures all elements cessing algorithms and real-time model recon-
and materials found in the mouth without the struction, which captures 3D data in a video
need to apply any materials to the teeth, and it sequence and models data sets in real time. The
can accurately capture supragingival and subgin- scanning unit contains a complex optical system
gival preparations (Figs 2 and 3). that comprises multiple lenses and blue LED
Because it features direct scanning and does cells. The Lava COS system can capture 20 3D
not require the use of scanning powder, Cadent’s data per second, or close to 2400 data sets per
iOC scanner provides orthodontists and their as- arch, for accurate, high-speed scanning.
sistants with flexibility in a host of clinical ap-
plications. It provides highly accurate orthodon- Benefits to Clinicians and Labs
tic scanning with real-time viewing in adults The greatest benefit for dental lab technicians
and adolescents, in patients with various mouth and dentists in adopting digital technology lies in
openings and in full and partial arches. In addi- eliminating many chemical processes. By virtu-
tion, iOC’s software architecture allows data to ally eliminating these processes, error accumula-
be exported and used in integration with other tion in treatment and in the manufacturing cycle
orthodontic office management software, such as is no longer an issue. Some of these processes are:
OrthoCAD (Fig 4). curing the impression material, curing the plaster
Another option for digital impression tak- and base, curing the investment material in res-
ing is the 3M ESPE Lava Chairside Oral Scan- toration dies, and retraction or shrinkage of con-
ner (COS) system. This system is mounted on ventional feldspathic ceramic materials.
a mobile cart with a CPU, touch-screen moni- By eliminating conventional impression-
tor and a 13 mm thick scanning unit. A camera taking procedures, clinicians no longer need to
FIGURE 4 - Image showing a digital model for Orthodontics. FIGURE 5 - Using the digital scanner to take a checkbite impression.
worry about the possibility of error due to air movements in orthognathic surgery cases, for
bubbles breaking the impression materials, dis- example, substantially facilitates diagnosing and
placement and movement of the tray, tray deflec- planning of these complex cases.
tion, insufficient impression material, inadequate Rheude et al5 compared the use of digi-
impression adhesive, or distortion resulting from tal models with traditional plaster models in
disinfecting procedures.3 orthodontic diagnosis and treatment planning.
Furthermore, and particularly important in They concluded that in most cases digital mod-
orthodontics and orthognathic surgery cases, tak- els can be successfully used as part of the orth-
ing checkbite impressions (centric occlusion) odontic records. It is noteworthy that the more
has historically been accomplished through the the examiners used digital models the more
use of silicone materials or bite wax. When im- the diagnoses resembled those of conventional
pressions are taken digitally, nothing is placed models. This indicates a modest learning curve
between maxillary and mandibular teeth. This before digital models can be compared to con-
dramatically reduces the risk of an inadequate ventional models.
interocclusal relationship (Fig 5). Leifert et al4 took space measurements in con-
ventional (plaster) models and in digital models
Discussion (OrthoCad system, Cadent, USA) and concluded
As in implant dentistry and oral and maxillofa- that the accuracy of software for space analysis in
cial surgery, for example, where digital images ob- digital models is just as clinically acceptable and
tained by Cone-Beam CT scans are imported into reproducible as in conventional plaster models.
a special software for 3D design and implementa- Incorporating digital scanning in daily prac-
tion of virtual surgeries, the use of digital models tice does not require any additional processes
in orthodontics has proven an excellent technique or procedures to be learned by either ortho-
and possibly the future method of choice to handle dontists or their assistants. Consultations for
digital models in this dental specialty. obtaining orthodontic records remain virtually
The integration of scanned models with digi- unchanged in terms of time and goals, with the
tal images obtained by Cone-Beam CT, which added benefit that patient satisfaction is signifi-
enable the simulation of orthodontic/surgical cantly enhanced.
Cost-wise, investment may seem sizeable at With the popularization of digital systems,
first. From a commercial point of view, however, and the tremendous growth in two areas of den-
digital impressions ensure profitability in the tistry that can potentially benefit from digital
medium term. Similarly to direct digital intra- impression taking and digital models (ortho-
oral radiographs, the possibility of reducing the dontics and dental implantology) one can confi-
operational cost of materials and the ability to dently predict that in the coming years we will
view the quality of the procedure in real time, witness a true digital revolution in the dental
reduces the rate of repeat visits and, conse- office. A revolution that will benefit patients in
quently, chair time. And chair time represents terms of more efficient planning, reduced dis-
the major cost in any office. Not to mention the comfort and treatment efficiency.
priceless value of word-of-mouth marketing
derived from patients’ favorable comments on
digital impression taking versus uncomfortable
conventional impression taking with alginate or
other materials.
Further added benefits are the ability to save
the impressions digitally, reducing costs and
freeing up space, which can be exploited in oth-
er ways, e.g., by expanding the patient care area.
Conclusions
By addressing the everyday dental office is-
sues described above, digital impression taking,
given its undeniable benefits, will transform
digital intraoral scanning into a routine proce-
dure in most dental offices in the coming years.
Furthermore, digital impressions tend to reduce
repeat visits and retreatment while increasing
treatment effectiveness. Patients will benefit
ReferEncEs
from more comfort and a much more pleasant
experience in the dentist’s chair. Thanks to digi- 1. Sears AW. Hydrocolloid impression technique for inlays and
fixed bridges. Dent Dig. 1937;43:230-4.
tal impressions, products fabricated in prosthet- 2. Birnbaum N, Aaronson HB, Stevens C, Cohen B. 3D digital
scanners: A high-tech approach to more accurate dental
ic labs will become more consistent and easier impressions. Inside Dentistry. 2009:5(4). Available from: http://
to install, requiring reduced chair time. 3.
www.insidedentistry.net.
Birnbaum N. The revolution in dental impressioning. Inside
Since long before the Industrial Revolution Dentistry. 2010;6(7). Available from: www.insidedentistry.net.
4. Leifert MF, Leifert MM, Efstratiadis SS, Cangialosi TJ.
men has handcrafted and manufactured millions Comparison of space analysis evaluations with digital models
and plaster dental casts. Am J Orthod Dentofacial Orthop.
of different products using analogical processes. 2009;136(1):16e1-16e4.
In the last 30 years, many of these products have 5. Rheude B, Sadowsky PL, Ferriera A, Jacobson A. An evaluation
of the use of digital study models in orthodontic diagnosis and
been converted to digital manufacturing—from treatment planning. Angle Orthod. 2005;75:300-4.
auto parts to civil construction—given its con-
sistent quality and lower cost. It is therefore no
surprise that digital solutions are now being in- Contact address
Waldemar D. Polido
tegrated into many dental procedures. E-mail: cirurgia.implantes@polido.com.br
CAD/CAM Dentistry
and Chairside Digital
Impression Making
A Peer-Reviewed Publication
Written by Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Educational Objectives dental care that will improve their smile and overall appear-
The overall goal of this course is to provide the reader with ance. Annually, an estimated 43 million crowns, bridges,
information on computer-aided design/computer-aided and veneers combined are provided; this number excludes
manufacturing (CAD/CAM) dentistry and digital impres- inlays and onlays.1 All require impression making to create
sions in the dental office. Upon completion of this course, a final restoration.
the clinician will be able to do the following:
1. Know the requirements for ideal impression and model Ideal Impression and Model Properties
materials A master impression for fixed restorations must be accurate
2. Understand the differences between complete in-office at the time of impression making and stable such that the
and chairside digital impression CAD/CAM techniques impression is not distorted prior to development of a master
3. Understand the potential impact of CAD/CAM model and die(s). In addition to accuracy and dimensional
dentistry on productivity and accuracy stability, other required and desirable properties for an ideal
4. Know the potential impact on clinic-laboratory com- impression include short chairside time, biocompatibility, a
munication of chairside digital impression making and material that is safe for the purpose intended, and a user- and
digital photography. patient-friendly material/technique. Currently, the most
popular impression materials for fixed restorations typically
Abstract utilize polyvinylsiloxane or polyether materials. In addition to
Precision and accuracy of master impressions are critical to the the above requirements, an appropriate working and setting
overall excellence and marginal fit of definitive fixed restora- time for the given procedure; strong tear strength; adequate
tions. CAD/CAM offers clinicians, patients and laboratory flowability, hydrophilicity and wettability; ease of removal
technicians methods that are reproducible and accurate, and and elastic recovery, so that any deformation during removal
allows for user- and patient-friendly clinical procedures. of the impression is rapidly reversed; a smell, taste and texture
CAD/CAM systems are available that either digitally scan acceptable to patients; and ease of storage are needed.
and create fixed restorations chairside or that capture chairside
digital impressions that are then sent to a laboratory. In-office Precision and Accuracy
CAD/CAM allows clinicians to provide same-visit indirect Precision and accuracy of the master impression are critical
fixed restorations that are accurate and esthetically pleasing. and cannot be compromised. In terms of overall excellence
Chairside digital impression making allows for the creation and marginal fit, definitive fixed restorations are only as good
of accurate models that can then be used for either traditional as the master dies from which they are created. The master
or CAD/CAM fabrication of restorations, and involves less dies and models, in turn, can only be as good as the impres-
chairside time. In the case of image verification and model sions from which they were derived. To be acceptable, a final
milling in the manufacturer’s facility, standardized quality impression must capture the marginal detail and the tooth
control procedures also benefit the final product. Compared structure apical to the restorative margin. Without these ele-
to a traditional technique, in-office CAD/CAM does not ments, the definitive restoration will be a clinical failure.
require any communication with a laboratory, and chairside
digital impressions enable seamless communication between
the clinician and the laboratory technician. CAD/CAM den- Precision and accuracy of the master impression
tistry is changing the way in which clinicians provide indirect and master dies are critical for clinically
restorations to patients, making the process more patient- and
successful fixed restorations.
user-friendly, reliable and accurate.
Only impressions with all details accurately portrayed can
Introduction be used for clinically successful fixed restorations. The latest
Demographics, combined with the increased demand for traditional impression materials are vastly superior to ear-
esthetic dentistry, have resulted in an increase in the number lier generations and are capable of delivering accurate master
of fixed restorations being provided to patients. Aging baby impressions. Nonetheless, they remain technique sensitive,
boomers and older adults received less preventive care and and the process can be unpleasant for patients. Traditional
more basic restorative work as children and teenagers than impressions also require accuracy during the model-pouring
subsequent generations have. In addition, earlier traditional process. The model must be cast in stone that is hard, durable
restorations were more invasive and led to more loss of tooth and dimensionally stable during setting; that reflects the ac-
substance. Patients continue to receive fixed restorations, curacy of the master impression; and that does not chip, crack,
in part as previous restorations break down and weakened break or lose substance during removal from the impression
tooth structure fails. More patients are also retaining their or during laboratory manipulation. Variability in accuracy has
teeth for longer. Furthermore, patients in all age groups now been found in impressions and resulting casts depending on
demand improved esthetics from dental materials and seek the technique and material used.2 The advent of CAD/CAM
2 www.ineedce.com
offers clinicians, patients and laboratory technicians methods There are a number of considerations in choosing be-
that are reproducible and accurate, and allows for user- and tween an in-office technique (CEREC and E4D) or CAD/
patient-friendly clinical procedures. 3 CAM technology that combines chairside digital impres-
sion making and laboratory fabrication of restorations on
CAD/CAM Dentistry an individual patient basis; these include chairside time
The era of CAD/CAM dentistry began in the 1980s with required, use of a laboratory, laboratory communication,
the arrival of the CEREC 1 (Sirona) machines, followed later standardized quality control, complexity of the case, de-
by Procera (Nobel Biocare). The Procera was specifically de- sirability of a one-visit treatment and esthetic demands.
signed to scan models that had been poured from traditional Since a considerable level of investment is required to
master impressions and to then fabricate metal copings for purchase a CAD/CAM system, it is important to fully
laboratories. The CEREC was designed for a complete in- address these considerations before selecting a specific
office procedure, originally for the fabrication of inlays and system. A further factor with chairside digital impression
onlays.4, 5 The objective was to produce a clinically accurate systems is whether the scan is used to generate models at a
digital impression that captured the marginal detail and tooth manufacturing center or sent de novo to individual labora-
structure apical to the proposed restoration’s margin for the tories. Recently, a third option has been in development:
master model and die(s). Since then, numerous studies have Instead of sending a physical impression, a scan is taken
demonstrated the potential for accurate and precise restora- of the traditional impression and sent to the laboratory. In
tions using CAD/CAM technology.6, 7, 8, 9 Conceptually, the the opinion of this author, this third methodology may be
development of chairside digital impression making is akin to useful for exporting images to remote locations without
the development of digital intraoral photography; both offer as great an investment or learning curve; however, this
accuracy and speed, as well as the ability to indefinitely store system retains many of the potential flaws and disadvan-
the information captured without any material constraints tages inherent with a traditional impression since it is the
and to quickly and easily transfer the digital images from traditional impression that is scanned.
dental office to laboratory and vice versa.
In-Office CAD/CAM and Chairside Digital System considerations include chairside time,
Impression Techniques standardized quality control, number of visits (one
Sophisticated CAD/CAM systems are now available that ei- or two) and esthetic demands.
ther digitally scan and create fixed restorations in-office or that
capture chairside digital impressions that are sent digitally to a
laboratory technician or manufacturing center (depending on E4D (D4D Technologies)
the system). The current in-office systems with chairside mill- The E4D (Figure 1) can be used for all fixed restorations except
ing are the CEREC (Sirona) and E4D (D4D Technologies) bridges and implants, and will scan up to 16 restorations.
machines. Chairside digital impression systems with transfer
of images to a laboratory or manufacturing facility include the Figure 1. E4D machine
iTero, CEREC and Lava C.O.S. systems.
The starting point for all systems is the capture of an ac-
curate digital impression. The ability to capture impressions
digitally can be an advantage in the case of a patient who is
a gagger or cannot tolerate impression material in his or her
mouth for several minutes, or if mandibular or maxillary tori
or other undercuts are present that would make removal of a
traditional impression difficult or impossible without caus-
ing the patient discomfort and/or tearing the margins on the
impression (which results in a useless impression that must
be retaken).10 As there is no physical impression, no disinfec-
tion protocol is required for an impression before it is sent to
a laboratory, nor is there any question of incompatibility of
specific materials with specific disinfectants.
www.ineedce.com 3
The E4D has separate scanning and milling units within rapid with CEREC AC than with previous models due to the
a cart, with automated interunit communication. The scan- continuous capturing of a series of images by the scanner once
ner reflects light from directly above the tooth, using a red in position. The occlusion is recorded by simply scanning the
light laser oscillating at 20,000 cycles per second to capture arches, and digital on-screen articulating paper shows where
the series of images and create a 3-D model. This technology there are contacts. Images of interdigitation of the opposing
requires that the scanner be held a specific distance above the teeth also show if there is sufficient interocclusal clearance for
tooth, aided by rubber stops on the scanner head, and that the the restoration.
area be centered for imaging (aided by a bull’s-eye on-screen
guide). There is no requirement to scan the opposing arch, as Figure 3. On-screen virtual articulating paper marks
the occlusion and occlusal height of milled restorations are as-
sessed from the preparation’s arch and an image of a physical
registration bite. The dentist has the opportunity to examine
the preparation from different aspects for accuracy and to
view the proposed restoration prior to milling. The milling
component includes a touch-screen panel that provides
guidance during the process. The digital scan is transferred
to the milling machine (with wireless or wired transmission),
and the restoration milled from both sides simultaneously.
The E4D does not offer the opportunity to scan and digitally After the clinician has verified that the digital preparation
transfer the images to a laboratory. The E4D scanner can also and interocclusal clearance are satisfactory, the system will
be used to scan a traditional impression for chairside milling digitally mark the margins and provide a digital version of the
of the restoration. proposed restoration prior to its fabrication.The CEREC MC
XL milling center can be used to create full contour crowns in
CEREC six minutes. Alternatively, the MC L Compact Milling Unit
The new CEREC AC gives dentists the choice of imple- can be used. All types of indirect restorations can be created.
menting in-office fabrication or sending the digital images
with CEREC CONNECT directly to the laboratory, where Lava C.O.S.
the restoration can either be milled directly or a model can The Lava C.O.S. system is used for chairside digital impres-
be created for traditional fabrication of the restoration. sion making (Figure 4).
Transfer to the laboratory is only possible if the laboratory The Lava C.O.S. scanner contains 192 LEDs and 22 lens
has CEREC CONNECT. The scanner operates using visible systems with a pulsating blue light and uses continuous video
blue light emanating from light emitting diodes (LEDs) with to capture the data that appears on the computer touch screen
shorter wavelengths of light than previous CEREC models, during scanning. Almost 2,400 data sets are captured per arch.
increasing the accuracy of the scan. Image acquisition is more After scanning the tooth preparation, the dentist is able to
4 www.ineedce.com
rotate and magnify the view on the screen and can also switch The occlusion is captured by taking two interocclusal
from the 3-D image to a 2-D view. The full arch is scanned after views with the patient in centric, after which the dentist
the preparation imaging is complete, followed by the opposing can view the image within 30 seconds and ascertain that
quadrant, and the occlusion is assessed by scanning from the the interocclusal clearance is sufficient for the planned
buccal aspect with the teeth in occlusion and viewing the arches restoration prior to the patient leaving. No bite registration
digitally. The laboratory information is completed after scan- material is required.
ning. The images can be transmitted directly to an authorized The iTero system only allows scanning to begin after the
laboratory where the laboratory technician digitally marks the prescription charting for the restoration (the “lab slip”) has
margins and sections the virtual model prior to sending this been completed in the program, ensuring that the prescrip-
digitally to the manufacturer. The model is then virtually tion is fully entered, with the option to scan either arch first,
ditched, articulated and sent to the model fabrication cen- letting the clinician choose depending on the procedure.
ter for stereolithography (SLA) to create acrylic models. A process flow can be viewed on-screen (Figure 6). After
These models can then be used for conventional labora- the images have been captured, the digital impression is
tory techniques or for CAD/CAM restorations. The Lava transmitted to the manufacturer’s facility and to the selected
C.O.S. lab machine is also available to create CAD/CAM dental laboratory. There are no restrictions on the dentist’s
copings (substructures). choice of dental laboratory.
www.ineedce.com 5
or root surface just apical to the margin. Digital scan- One difference between the various systems is the require-
ning must include proper tissue management to ensure ment for powdering. The CEREC system requires a coating
accuracy. Soft tissue retraction and moisture control are of reflective powder on the dry preparation prior to scanning.
essential in this process (these are also essential for clini- Light powdering is required when using the Lava C.O.S.
cally excellent traditional master impressions).11 A digital system. The E4D system typically does not require powder-
scan should capture the entire restorative margin as well ing, but will occasionally under limited circumstances. The
as approximately 0.5 mm of the tooth/root surface apical iTero system does not require powdering.
to the margin. This information is required by the cera- Restoration-type limitations for CAD/CAM systems
mist or milling machine in order to reproduce the correct vary depending on the system used. Universal systems for
emergence profile, or “egression silhouette” for the final all types of fixed restorations include the CEREC AC, the
restoration.12 iTero and the Lava C.O.S. (the Lava C.O.S. system can
Depending on whether the restorative margin is supra- be used for bridges up to a maximum of 4-units in length).
crevicular (above the gingival tissues), equicrevicular (at Each system utilizes unique scanning technology and oper-
the free gingival margin) or intracrevicular (in the gingival ates with different features and display capabilities.
sulcus), either a traditional single- or double-cord tech-
nique, laser technique, chemical retraction technique, or a Productivity and Accuracy
combination of these can be used to achieve a dry and vis- Digital scans take less time than conventional impres-
ible field. For intracrevicular and equicrevicular margins, a sions, including the bite “registration.” This increases the
double-cord tissue retraction technique can be used, with efficiency and productivity of the office. If the clinician
the more superficial cord removed gently just prior to scan- carefully follows the scanning procedure and checks the
ning. If using a laser to trough the area, thereby creating a on-screen images for margin visibility, preparation form
space between the preparation margin and the tissue (which and interocclusal clearance, it is possible to make adjust-
will also aid hemostasis), it is important to consider the pa- ments and take isolated scans to ensure a precise result.
tient’s tissue type and the principles of biologic width first; The results are instantly visible and enlarged on-screen
there must be sufficient horizontal tissue thickness to avoid as they are captured, enabling this process. In addition
loss of vertical tissue height.13, 14 to the speed of image acquisition compared to traditional
techniques, once the imaging technique has been learned,
the digital images will be accurate for the laboratory and
A digital scan should capture the entire restorative
margin as well as approximately 0.5 mm of the repeat impressions at the request of the lab will not oc-
tooth/root surface apical to the margin. cur. Verbal and visual prompts on scanner positioning and
sequencing may also shorten the learning curve. It has
Focal Depth 13.5 mm 1:1 exact focus Range from 5 to 15mm Range from 5 to 15mm
6 www.ineedce.com
been estimated that scanning takes three to four minutes, soft-tissue management was performed using a double-cord
compared to almost double this for a traditional impres- technique (Figure 7). Note that the margins are completely
sion and bite registration technique. There are no material exposed, the tooth is visible 0.5 mm apical to the margins of
restrictions either, resulting in less risk of either clinic or the preparation and the field is completely dry (Figure 8).
laboratory errors, with no risk of errors due to distortion
of impression or bite registration materials. The accuracy Figure 7. Preparation and soft-tissue management
of scanning the occlusion and occlusal surfaces helps to
reduce the time required for minor occlusal adjustments
at the seating appointment.
Milled iTero CAD/CAM resin (polyurethane) models
are not subject to voids, shrinkage or expansion of materi-
als, or other defects. These models are strong and durable,
resulting in excellent marginal adaptation and fit of the res-
toration, and are resistant to abrasion or chipping; there is
no risk of the restoration being too large due to abrasion of
adjacent teeth interproximally on the model or the occlusal
surfaces of the opposing arch. The Lava C.O.S. system also
creates models, in its case using stereolithography (SLA).
This system provides a solid model and a working model.
The CEREC AC system also utilizes SLA. Virtual articu- Figure 8. Exposure of margins and teeth apical to the margin
lation and CAD/CAM mounting of models also improves
accuracy, and minor displacement of the resin dies does not
occur (as it does with stone dies that are abraded and seg-
mented from stone models). Creating CAD/CAM models
at a manufacturer’s facility allows for standardized quality
control procedures that ensure reliable accuracy.
Clinic-Laboratory Communication
Chairside digital impression making offers an opportunity
for improved communication between the laboratory tech-
nician and the clinician. The dentist accurately transmits
all imaging data, and if desired the laboratory can feed back
proposed designs and restoration contours and margins dig-
itally for the clinician to check.15 Combining digital imaging Once the margins are suitably exposed and the tooth is dry,
with digital photography further improves communication scanning can begin. The scanner is positioned first over the
and delivers optimal visual information. Digital photogra- occlusal surface of the tooth being restored, and the red
phy provides the laboratory with shade and contour nuances strobing light emission signals that scanning has begun.
beyond the realms of shading notations and shade guides.
Shade guide stumps can be photographed overlaid on the Figure 9. iTero scanner over the occlusal surface of the preparation
tooth, which helps to highlight similarities and differences
in areas of the tooth for custom shading and provides infor-
mation on the initial preparation shade so that appropriate
opaquing can occur.16 Well-documented digital photos
supply the laboratory with information on form, shades,
contouring and soft-tissue positions, whether a traditional
or a CAD/CAM technique will be used for the restoration.
Digital scanning and digital photography both offer the
ability to convey accurate digital information between the
clinician and the laboratory technician and vice versa.
Case Study
The case study below demonstrates the iTero method of
creating digital impressions, CAD/CAM resin models
and restorations. Following completion of the preparation,
www.ineedce.com 7
After scanning of the tooth from the required angles and The resin models are then milled, articulated and utilized
scanning of the remainder of the arch, scanning of the oc- for either a traditional or CAD/CAM restoration (Figures
clusion can begin. The clinician can view the interocclusal 14-17). The scanning, resin models and CAD/CAM
distance easily on-screen (Figure 10), and the occlusal clear- restoration result in ease of seating and minimal chairside
ance on the prepared and adjacent teeth can be viewed on- adjustments.
screen in contrasting colors (Figure 11).
Figure 14. Milling of model
Figure 10. Imaging of interocclusal clearance
8 www.ineedce.com
Figure 17. Completed restorations 8 Sjögren G, Molin M, Van Dijken JW. A 10-year prospective
evaluation of CAD/CAM-manufactured (CEREC) ceramic inlays
cemented with a chemically cured or dual-cured resin composite.
Int J Prosthodont. 2004;17(2):241-6.
9 Posselt A, Kerschbaum T. Longevity of 2328 chairside CEREC
inlays and onlays. Int J Comput Dent. 2003;6:231-48.
10 Lowe RA. Digital Master Impressions: A Clinical Reality!
11 Ibid.
12 Shavell HM. The periodontal-restorative interface in fixed
prosthodontics: tooth preparation, provisionalization, and
biologic final impressions. Part I. Pract Periodontics Aesthet Dent.
1994;6(1):33-44.
13 Gunay H, Seeger A, Tschernitschek H, Geurtsen W. Placement of
the preparation line and periodontal health: A prospective 2-year
clinical study. Int J Periodontics Restorative Dent. 2000;20(2):171-
81.
14 Padbury A Jr, Eber R, Wang HL. Interactions between the gingiva
and the margin of restorations. J Clin Periodontol. 2003;30(5):379-
85.
15 Lowe RA. Digital Master Impressions: A Clinical Reality!
16 Lowe RA. Using Digital Photography In Laboratory
Communication.
Author Profile
Dr. Robert A. Lowe received his Doc-
tor of Dental Surgery degree, magna cum
laude, from Loyola University School of
Dentistry in 1982. Following graduation, he
completed a one year Dental Residency. Dr.
Lowe taught Restorative and Rehabilitative
Dentistry for 10 years at Loyola University
School of Dentistry in Chicago, IL. Dr. Lowe has maintained
a full-time private dental practice for 26 years. He is a member
Summary of the American Dental Association, a sustaining member of
In-office CAD/CAM allows clinicians to provide same-visit the American Academy of Cosmetic Dentistry, and a member
indirect fixed restorations that are accurate and esthetically of the American Society of Dental Aesthetics. Dr. Lowe has
pleasing. Chairside digital impression systems allow for the received Fellowships in the Academy of General Dentistry,
creation of accurate and precise laboratory models and res- International College of Dentists, Academy of Dentistry
torations, involve less chairside time, and achieve fine-tuned International, Pierre Fauchard Academy, American College
esthetics that are difficult or time-consuming chairside. of Dentists, and the International Academy of Dento-Facial
CAD/CAM dentistry is changing the way in which Aesthetics. In 2004, Dr. Lowe received the Gordon Chris-
clinicians provide indirect restorations to patients, with fab- tensen Outstanding Lecturer Award for his contributions in
rication of highly precise, accurate models and restorations; the area of Dental Education. In 2005, he received Diplomate
increased chairside productivity; and improved clinic- status on the American Board of Aesthetic Dentistry. Dr.
laboratory communication. Lowe has authored several hundred articles in many phases
of cosmetic and rehabilitative dentistry, sits on the editorial
References board of several dental publications, and has contributed to
1 iData Research Inc., 2007, U.S. Market for Dental Prosthetic dental textbooks. He is a consultant for a number of dental
Devices.
2 Alhouri N, McCord JF, Smith PW. The quality of dental casts used in manufacturers world wide and is active as a key opinion leader
crown and bridgework. Br Dent J. 2004;197(5):261-4. in the development of new materials and techniques.
3 Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview of
recent developments for CAD/CAM generated restorations. Br
Dent J. 2008;204(9):505-11. Disclaimer
4 Giordano R. Materials for chairside CAD/CAM-produced The author(s) of this course has spoken at educational courses
restorations. J Am Dent Assoc. 2006;137(suppl):14S-21S.
5 Calamia JR. Advances in computer-aided design and computer- supported by the sponsors or the providers of the unrestricted
aided manufacture technology. Curr Opin Cosmet Dent. 1994:67- educational grant for this course.
73.
6 Otto T, Schneider D. Long-term clinical results of chairside CEREC
CAD/CAM inlays and onlays: A case series. Int J Prosthodont. Reader Feedback
2008;21(1):53-9. We encourage your comments on this or any PennWell course.
7 Wiedhahn K, Kerschbaum T, Fasbinder DF. Clinical long-term
results with 617 CEREC veneers: A nine-year report. Int J Comput For your convenience, an online feedback form is available at
Dent. 2005;8:233-46. www.ineedce.com.
www.ineedce.com 9
Questions
1. An increase in the number of fixed 11. A system that scans traditional 22. Digital scanners can see through any
restorations being provided to patients impressions, in the opinion of the author, fluid or gingival tissue and obviously have
resulted from _________. retains many of the potential flaws and the ability to displace tissue close to the
a. the increased demand for esthetic dentistry disadvantages inherent with a traditional
b. a lack of restorative materials margin.
impression since it is the traditional im-
c. demographics pression that is scanned. a. True
d. a and c a. True b. False
2. A master impression for fixed restorations b. False
23. A digital scan should capture the
must be _________. 12. All systems require scanning of the
a. accurate entire restorative margin as well as
opposing arch.
b. dimensionally stable a. True approximately __________ of the tooth/
c. biocompatible b. False root surface apical to the margin.
d. all of the above
13. The in-office CAD/CAM systems are a. 0.25 mm
3. Definitive fixed restorations are only as the _________. b. 0.5 mm
good as the master dies from which they a. E4D and CEREC c. 0.75 mm
are created. b. CEREC and Lava C.O.S.
a. True d. none of the above
c. Lava C.O.S. and E4D
b. False d. all of the above 24. One difference between the various in-
4. A final impression must capture the 14. Chairside digital impression systems office CAD/CAM and chairside digital
_________. include the _________. impression systems is the requirement for
a. tooth structure apical to the restorative margin a. E4D and Lava C.O.S.
b. full arch powdering.
b. iTero and Lava C.O.S.
c. marginal detail c. iTero and DTD a. True
d. a and c d. none of the above b. False
5. Variability in accuracy has been found in 15. Depending on the system, model 25. Digital scans increase the efficiency and
impressions and resulting casts depending making following chairside digital im-
on the technique and material used. productivity of the office.
pression making can be achieved using
a. True a. True
__________.
b. False a. stereolithography b. False
6. The era of CAD/CAM dentistry began b. milling of resin 26. It has been estimated that scanning takes
in the _________. c. pouring of plaster of Paris
a. 1970s d. a and b
three to four minutes, compared to almost
b. 1980s double this for a traditional impression
16. Both stereolithography acrylic models
c. 1990s and bite registration technique.
and milled resin models can be used
d. none of the above a. True
for a traditional technique to fabricate
7. Numerous studies have demonstrated the restorations. b. False
potential for accurate and precise restora- a. True
tions using CAD/CAM technology. b. False 27. Virtual articulation and CAD/CAM
a. True mounting of models improves
17. All CAD/CAM systems are indicated
b. False accuracy.
for bridges.
8. Chairside digital impression making and a. True a. True
digital intraoral photography both offer b. False b. False
_________.
18. During scanning, one system provides 28. Milled CAD/CAM resin models are
a. accuracy and speed
b. the ability to digitally transfer images
a series of visual and verbal prompts
customized for the patient being __________.
c. the ability to indefinitely store the information
treated. a. not subject to voids, shrinkage or expansion of
captured
d. all of the above a. True materials
b. False b. are resistant to abrasion
9. The ability to capture impressions digi-
tally can be an advantage in the case of a 19. For all chairside digital impression c. are resistant to chipping
patient who cannot tolerate impression systems, the lab slip must be completed d. all of the above
material in his or her mouth for several before scanning can begin.
a. True 29. Combining digital imaging with
minutes, or if mandibular or maxillary
b. False digital photography further improves
tori or other undercuts are present.
a. True 20. The ability by the dental laboratory tech- communication and delivers optimal
b. False nician to digitally trim virtual dies helps visual information, compared to one of
10. Considerations in choosing between where there is evidence of _________. these techniques alone.
an in-office technique or CAD/CAM a. hard-tissue impinging on the margin
b. soft-tissue impinging on the margin a. True
technology that combines chairside
c. an overexposed scan of the image b. False
digital impression making and laboratory
d. all of the above
fabrication of restorations on an indi- 30. CAD/CAM dentistry is changing the
vidual patient basis include _________. 21. Both traditional impressions and CAD/ way in which clinicians provide indirect
a. complexity of the case CAM scanners require a dry, visible field
restorations to patients.
b. standardized quality control for accurate impression making.
c. chairside time required a. True a. True
d. all of the above b. False b. False
10 www.ineedce.com
ANSWER SHEET
Address: E-mail:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
4. Know the potential impact on clinic-laboratory communication of digital impression making and digital photography For immediate results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
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If paying by credit card, please complete the
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No following: MC Visa AmEx Discover
Objective #2: Yes No Objective #4: Yes No
Acct. Number: _______________________________
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: _____________________
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3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
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___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
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___________________________________________________________________ AGD Code 017, 250
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Earn
4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
An Overview of CAD/CAM and Digital Impressions
by Paul Feuerstein, DMD
Educational Objectives touches the tooth to give an optimal focal length; this
The overall goal of this section of this two-part course is to system does not require the use of powder. The LAVA
provide the clinician with information on CAD/CAM sys- Chairside Oral Scanner (LAVA COS, 3M ESPE) takes a
tems and the potential benefits of the various systems. completely different approach using a continuous video
Upon completion of this section, the clinician will be stream of the teeth.
able to do the following: CEREC and LAVA currently require the use of powder
1. Describe the types of CAD/CAM systems available. for the cameras to register the topography. Other scanner
2. Describe the clinical applications and benefits of systems are also available.
current CAD/CAM technology.
Figure 1. CAD/CAM systems
Abstract
Currently, two genres of CAD/CAM systems exist. One is
used only in-office, while the other genre is a combination
of in-office scanning and image transmission and milling
of restorations or pouring of models in the laboratory. All
systems start with scanning of the preparation, the method
depending on the specific system.
CAD/CAM systems have developed considerably, offer-
ing accuracy and more options than previously. It can be
envisioned that CAD/CAM technology developments will
continue to offer dentistry more options for its use, including
further CAD/CAM integration of procedures and imaging
enhancements.
Introduction
There are two current genres of in-office CAD systems.
One genre is a complete system where the practitioner can
scan preparations, design restorations and manufacture a
finished product in the office, in one visit. The other system
concentrates on the scanning/digital impression and the
practitioner then exports that information to a traditional
dental lab or to a designated CAD/CAM laboratory for
restoration or substructure fabrication. Both genres offer Each system uses a system-specific handheld device to scan
benefits compared to traditional methods and a number of the site (Figure 2).
systems are available for the practitioner to choose from,
each using different technology to achieve the end results.1,2 Figure 2. CEREC (upper image) and LAVA COS (lower image)
Image Acquisition
Each system uses a different method to acquire the images.
The first system introduced was the CEREC 1 in 1986. The
CEREC 1, 2 (1994) and 3 (2000) systems (Sirona Dental)
have all used a still camera to take multiple pictures that are
stitched together with software. The E4D (D4D TECH)
takes several images, using a red light laser to reflect off of
the tooth structure and only requires the use of powder in
some limited circumstances. The application of powder to
the tooth is quick and simple, taking only seconds, and the
powder is easily removed afterwards with air and water.
The iTero system uses a camera that takes several views
(stills), and uses a strobe effect as well as a small probe that
2 www.ineedce.com
Image Retention/Transmission The LAVA system enables transmission of the data directly
Following image acquisition, the final image is either to the LAVA lab machine (Figure 5 ) for a coping that can then
stored in the system and used for chairside fabrication or digi- be placed on the acrylic model for the porcelain or other material
tally transmitted to a laboratory for use. CEREC is a complete to be added; LAVA can be used to print via stereolithography
system that allows the restoration to be made chairside and (SLT) physical models. Alternatively, the digital impression
until the introduction of the E4D system was the only CAD/ can be sent to a laboratory for any CAD/CAM or traditional
CAM system achieving this. All other systems discussed restoration fabrication. A chairside system is being developed
are used with an indirect method and are digital impression that will scan a traditional impression in the office and create a
systems rather than full CAD/CAM systems. digital impression file (3Shape).
The form that digital transmission takes for the indirect
CAD/CAM methods depends on the system used. CEREC Figure 5. LAVA COS image
Connect is used to export the final digital image directly to a
laboratory, where the lab can mill, polish, stain and glaze these
restorations to a level that is sometimes not practical in the
dental office, using a CEREC inLab milling unit (Figure 3).
www.ineedce.com 3
Figure 6. Imaging of occlusion and proper contacts matching the accuracy of the impression.
Using the in-office CAD/CAM systems, the restoration is
precisely milled to the information given by the software and
the images on the screen. There is of course room for operator
error if the practitioner modifies either of these two param-
eters outside of the recommendations; however the newest
software versions give a very clear alert. Less time is also re-
quired for occlusal adjustments of the final restoration, even
although while centric occlusion is accurately recorded using
scanners lateral excursions may not be digitally perfect.
4 www.ineedce.com
are cut and trimmed by the laboratory computer and set up References
almost like a jig-saw puzzle with interlocking pieces, and 1 Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview of
recent developments for CAD/CAM generated restorations. Br
cannot shift during manipulation. This is a great advantage Dent J. 2008 May 10;204(9):505-11.
over saw-cut plaster dies, even if they are held in a special 2 Henkel GL. A comparison of fixed prostheses generated from
matrix. CAD/CAM dies do not “wiggle”. conventional vs digitally scanned dental impressions. Comp Cont
Ed Dent. Aug 2007;28(8):422-31.
3 Marras I, Nikolaidis N, Mikrogeorgis G, Lyroudia K, Pitas I. A
Table 2. Potential benefits of CAD/CAM systems virtual system for cavity preparation in endodontics. J Dent Educ.
2008 Apr;72(4):494-502.
Accuracy of impressions 4 Freedman M, Quinn F, O’Sullivan M. Single unit CAD/
Opportunity to view, adjust and rescan impressions CAM restorations: a literature review. J Ir Dent Assoc. 2007
No physical impression for patient Spring;53(1):38-45.
5 Raigrodski AJ. Contemporary materials and technologies for all-
Saves time and one visit for in-office systems ceramic fixed partial dentures: a review of the literature. J Prosthet
Opportunity to view occlusion Dent. 2004 Dec;92(6):557-62.
Accurate restorations created on digital models 6 Otto T, De Nisco S. Computer-aided direct ceramic restorations: a
10-year prospective clinical study of Cerec CAD/CAM inlays and
Potential for cost-sharing of machines onlays. Int J Prosthodont. 2002 Mar-Apr;15(2):122-8.
Accurate, wear- and chip-resistant physical CAD/CAM 7 Fasbinder DJ. Clinical performance of chairside CAD/CAM
derived models restorations. J Am Dent Assoc. 2006 Sep;137 Suppl:22S-31S.
No layering/baking errors 8 Tinschert J, Natt G, Mautsch W, Spiekermann H, Anusavice
KJ. Marginal fit of alumina-and zirconia-based fixed partial
No casting/soldering errors dentures produced by a CAD/CAM system. Oper Dent. 2001 Jul-
Cost-effective Aug;26(4):367-74.
Cross-infection control 9 Akbar JH, Petrie CS, Walker MP, Williams K, Eick JD. Marginal
adaptation of Cerec 3 CAD/CAM composite crowns using two
different finish line preparation designs. J Prosthodont. 2006 May-
CAD/CAM systems can save time, and after consideration Jun;15(3):155-63.
of the financial investment, they are cost-effective. The ad- 10 Freedman M, Quinn F, O’Sullivan M. Single unit CAD/
vent of accurate scanning, transmission and fabrication of CAM restorations: a literature review. J Ir Dent Assoc. 2007
Spring;53(1):38-45.
laboratory CAD/CAM restorations offers an opportunity to,
in effect, cost share on the required equipment. Last but not
least, CAD/CAM also aids cross-infection control.10 Author Profile
www.ineedce.com 5
Maximizing and Simplifying CAD/CAM Dentistry
by Sameer Puri, DDS
6 www.ineedce.com
that 92% of 617 veneers placed between 1989 and 1997 were of light than earlier systems. This results in increased preci-
clinically acceptable.11 CEREC 3 software was considerably sion. Unlike previous generations of scanners, which took
more advanced than its predecessor, making the in-office one image at a time, the Bluecam is a “continuously on”
procedure simpler. Both CEREC 2 and 3 restorations were camera that once you turn it on with a click of the mouse,
found to meet American Dental Association acceptable pa- it stays on, snapping images automatically as soon as the
rameters. 12 In a one-year study of 20 crowns milled chairside camera is held still over a patient’s tooth. This allows the
using CEREC 3, Otto found all clinically acceptable at one- clinician to take a quadrant of images in as little as a few
year follow-up with no fractures or loss of retention.13 Fol- seconds. All the user has to do is simply place the camera
lowing its original introduction, CEREC 3 offered several over the tooth, move the camera to the desired area to
technology advances, including streamlining of the graphics be captured and hold the camera still. Once the image is
interface, an occlusal-surface design based on biogenerics captured, the camera is moved to the next tooth and the
(the patient’s existing dental structures) and the ability to subsequent images are captured to create a virtual model
preset the desired luting gap dimensions.14,15 of the restoration.
The clinical case below shows the use of CEREC AC.
Latest Developments
The most current version of the CEREC system is the new Clinical Case:
CEREC AC, a modular unit that contains an acquisition unit The patient presented to the office for an examination.
(Figure 1) and was introduced in January 2009. A separate Initial examination revealed the patient had dental recon-
milling unit (Figure 2) has evolved to allow it to fabricate struction done approximately seven years ago. The radio-
virtually any type of individual restoration with ease and graphic examination revealed recurrent decay on teeth #18
precision unmatched by its predecessors. and #19 (Figure 3).
The main feature of the new system is the camera, which is Digital impressions were taken with the CEREC AC and
referred to as the “Bluecam” and uses the blue spectrum of used to fabricate a digital mode. As the preoperative contours
visible light and is the most accurate version fabricated. Blue- of the teeth to be replaced were close to ideal, the contours of
cam uses blue-light light emitting diodes (LEDs) to create the teeth were copied by taking images of the teeth prior to
highly detailed digital impressions using shorter wavelengths removing the existing crowns.
www.ineedce.com 7
Figure 5. Scanned preparation Contours, occlusion and contacts can all be modified on the
initial proposal.
8 www.ineedce.com
After milling, the restorations are esthetically enhanced 5 Sturdevant JR, Bayne SC, Heymann HO. Margin gap size
and prepared for bonding. A stain and glaze process is com- of ceramic inlays using second-generation CAD/CAM
pleted and appropriate colored stains are utilized to give the equipment. J Esthet Dent. 1999;11(4):206-14.
6 Mörmann WH, Schug J. Grinding precision and accuracy
restoration depth and final esthetics (Figure 11).
of fit of CEREC 2 CAD-CIM inlays. J Am Dent Assoc. 1997
Jan;128(1):47-53.
Figure 11. Final esthetic restorations 7 Schug J, Pfeiffer J, Sener B, Mörmann WH. Grinding
precision and accuracy of the fit of CEREC-2 CAD/CIM
inlays. Schweiz Monatsschr Zahnmed. 1995;105(7):913-9.
8 Parsell DE, Anderson BC, Livingston HM, Rudd JI,
Tankersley JD. Effect of camera angulation on adaptation of
CAD/CAM restorations. J Esthet Dent. 2000;12(2):78-84.
9 Reiss B, Walther W. Clinical long-term results and 10-year
Kaplan-Meier analysis of CEREC restorations. Int J Comput
Dent. 2000 Jan;3(1):9-23.
10 Posselt A, Kerschbaum T. Longevity of 2328 chairside
CEREC inlays and onlays. Int J Comput Dent.
2003;6:231-48
11 Wiedhahn K, Kerschbaum T, Fasbinder DF. Clinical long-
term results with 617 CEREC veneers: a nine-year report.
Int J Comput Dent. 2005;8:233-46.
The restorations are definitively bonded to the teeth, the oc- 12 Estefan D, Dussetschleger F, Agosta C, Reich S. Scanning
clusion is verified and adjusted as needed, and the patient is electron microscope evaluation of CEREC II and CEREC
dismissed (Figure 12). III inlays. Gen Dent. 2003:51(5):450-4.
13 Otto T. Computer-aided direct all-ceramic crowns:
Figure 12. Final bonded restorations preliminary 1-year results of a prospective clinical study. Int
J Perio Rest Dent. 2004 Oct;24(5):446-55.
14 Dunn M. Biogeneric and user-friendly: the CEREC
3D software upgrade V3.00. Int J Comput Dent. 2007
Jan;10(1):109-17.
15 Reich S, Wichmann M. Differences between the CEREC-
3D software versions 1000 and 1500. Int J Comput Dent.
2004 Jan;7(1):47-60.
Author Profile
www.ineedce.com 9
Questions
1. Each system uses a different method to 12. A complete CAD/CAM system 23. CAD/CAM restorations have been
_________. eliminates a second visit for the patient. found to meet American Dental Associa-
a. prepare the tooth a. True
tion acceptable parameters.
b. acquire the model b. False
c. acquire the images a. True
13. Scanning an image and viewing it on
d. all of the above b. False
a computer screen allows the clinician
2. There are two current genres of in-office to_________. 24. A new scanner uses blue-light light
CAD systems. a. review the preparation and impression
a. True emitting diodes (LEDs) to create
b. make immediate adjustments to the preparation
b. False c. retake the impression if necessary highly detailed digital impressions
3. All digital impression systems require the d. all of the above using shorter wavelengths of light than
use of powder. 14. Less time is required for occlusal adjust- previously.
a. True
ments of the final restoration using the a. True
b. False
newest software versions.
4. The _________ system uses a camera a. True b. False
that takes several views (stills), and uses a b. False 25. A “continuously on” camera scanner is
strobe effect as well as a small probe.
a. CEREC 1
15. It is easier to visualize the details on available that once you turn it on stays
b. LAVA COS
a screen in a _________, as opposed to
on and snaps images automatically.
c. iTero
reading the _________.
a. positive view; negative in the impression tray a. True
d. all of the above
b. negative view; positive in the impression tray b. False
5. The _________ system uses a continuous c. negative view; neutral in the impression tray
video stream of the teeth. 26. The milling time for full coverage
d. none of the above
a. iTero
16. There is no room for operator error CAD/CAM porcelain crowns can range
b. CEREC
c. LAVA Chairside Oral Scanner using CAD/CAM systems. from __________minutes for a molar
d. none of the above a. True restoration.
b. False
6. Each system uses a system-specific a. 5 to 10
handheld device to scan the site. 17. All CAD/CAM systems are indicated
b. 5 to 15
a. True for bridges.
b. False a. True c. 10 to 20
7. Laboratories can only create restorations b. False d. none of the above
from digital impressions if they have 18. Digital impression systems that export 27. Patients appreciate the convenience of
CAD/CAM units. the impression data to the laboratories
a. True and directly milling restorations offer the no provisional restorations.
b. False same accuracy as in-office milling. a. True
8. It is possible to fabricate _________ using a. True b. False
CAD/CAM systems. b. False
a. only crowns 28. The first CAD/CAM system for
19. The use of CAD/CAM systems
b. crowns, bridges, inlay, veneers and onlays _________. the dental office was developed by
c. substructures and copings a. saves time __________.
d. b and c b. aids in cross-infection control
a. Prof. Dr. Werner Schmidt
9. Some CAD/CAM systems are able to cap- c. removes the possibility of layering and baking errors
ture a bite from the buccal with the patient d. all of the above b. Prof. Dr. Werner Moermann
closed in total contact and occlusion. c. Prof. Dr. Ernst Baumgartel
20. It is possible in the future that abutment
a. True
and implant scans will be combined. d. none of the above
b. False
a. True
10. An option to visualize the occlusion 29. The margins of prepared teeth can be
b. False
includes _________ completely visualized and marginated
a. using virtual articulation paper
21. CAD/CAM restorations can be
fabricated from _________. using CAD/CAM.
b. viewing the bite from all angles on the screen and
looking through the upper to the lower occlusal a. acrylic a. True
planes to examine points of contact b. resin b. False
c. milling the wax bite c. porcelain
d. a and b d. all of the above 30. CAD/CAM technology has become
11. A virtual waxup system can be used for 22. Reiss et al. found a _________success rate easier to use as well as more precise, and
the _________. for CAD/CAM crowns. offers technological advances over earlier
a. creation of dies a. 82%
versions.
b. creation of partial frameworks b. 87%
c. creation of porcelain c. 92% a. True
d. a and b d. 97% b. False
10 www.ineedce.com
ANSWER SHEET
Address: E-mail:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
2. Know the clinical applications and results achievable using current CAD/CAM technology. For immediate results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
Course Evaluation P ayment of $59.00 is enclosed.
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. (Checks and credit cards are accepted.)
If paying by credit card, please complete the
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No following: MC Visa AmEx Discover
Objective #2: Yes No Objective #4: Yes No
Acct. Number: _______________________________
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: _____________________
Charges on your statement will show up as PennWell
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________ AGD Code 017, 250
www.ineedce.com 11
Spring 2013
impressions
72 E. Concord Street, B-303C
Boston, Massachusetts 02118
http://dentalschool.bu.edu
Digital
Dentistry
Forging the future of dentistry
facebook.com/budental
contents
digital
Spring 2013
dentistry
Dr. Russell
26
Giordano
Introduces Rock
Star Ceramic
A closer look at ENAMIC and
the product launch.
Dentistry Gone
30
Digital: Inside
GSDM’s Cutting-
Edge Technology
It’s not news to say that the world
has gone digital. But...dentistry?
Task Force on
34 Digital Dentistry
The people at GSDM who are shaping
the future of dental education.
Quoted
sections
4
50th anniversary kickoff • Global Health office
3 News in Brief
named • Faculty speak in Parents Magazine and
Metrowest Daily News • International Elective
Externship in Mexico, Honduras, and Guatemala
14
55
Spring 2013
Impressions managing Leslie Friday Photography Phone 617-638-5147
A publication for the Editor Bostonia magazine BU Photography, F A X 617-638-4895
alumni and friends of Jackie Simon Getty Images, iStockphoto EMail becottem@bu.edu
Boston University Kevin Holland
Assistant Director of
Henry M. Goldman Assistant Dean for Cover photo Boston University’s
Publications & Media
School of Dental Medicine Development & iStockphoto policies provide for equal
Relations
Alumni Relations opportunity and affirmative
Dean Send correspondence
Contributors and address changes to: Editor, action in employment and
Jeffrey W. Hutter Stacey McNamee
Julia Bookout Impressions, Communications admission to all programs of
Director of Alumni Relations
Editor Communications Manager Office, Boston University, Henry the University.
Namita Raina M. Goldman School of Dental
Mary Becotte Kimberley Branca
Associate Director of Medicine, 72 E. Concord Street, 0413
Director of Communications Director of Development B-303C, Boston, MA 02118
& External Relations Marketing & Communications
Kaylee Dombrowski
Design Please recycle.
Alumni Coordinator
Jackie Simon
I am delighted to share that as part of our Both a Task Force and a Steering Committee have
Applied Strategic Plan, we continue to imple- worked very closely with the SmithGroup archi-
ment the Group Practice Model. In support of tectural firm to analyze existing space and utiliza-
that model, I have established a Task Force to tion, understand future direction and needs,
Implement Digital Dentistry at the Henry M. develop and present several facility option solu-
Goldman School of Dental Medicine. This task tions, and develop a Facility Master Plan for our
force has been charged with determining the School.
necessary facilities, equipment and support Our proposed solutions are currently under
required to create a seamless all-inclusive digital consideration by President Brown and the
patient record to facilitate comprehensive treat- University Space Committee and we hope to be
ment planning and efficient delivery of oral able to share definitive plans with you soon. Once
healthcare at the highest quality of care using the facility plans are approved by the University
dear alumni and friends,
digital dental technologies. I look forward to their Trustees, our work to fund the new facility will
In the aftermath of the findings and I will certainly keep you updated on begin in earnest. Your support will be critical to
events surrounding the progress. our ability to transform our School as we Choose
2013 Boston Marathon, I As you know, throughout the calendar year to be Great and in so doing we realize my and
of 2013 the Boston University Henry M. what I hope is now your vision for the Boston
join my fellow Bostonians
Goldman School of Dental Medicine (GSDM) University Henry M. Goldman School of Dental
and all of the members of will celebrate our 50th Anniversary of the found- Medicine becoming the premier Center of
our Henry M. Goldman ing of our School by Dr. Goldman. The festivities Excellence in Oral Health Education, Research,
School of Dental Medicine began with a kick-off Alumni Reception Friday, Patient Care and Community Service in this nation
(GSDM) in prayer for the February 1 at our reception held during the and the world.
Yankee Dental Congress in Boston. Additional
victims and their families. 50th Anniversary Alumni Receptions have been
As an active member of our Sincerely,
held in Arizona, Washington, California, Hawaii,
community, GSDM stands and Italy. These will be followed by events and
ready to help our neighbors receptions across the country and the world
throughout 2013.
in any way we can as our
I hope that each of you will be able to attend
city and neighbors continue one of our celebratory events in 2013. Our
Jeffrey W. Hutter, Dean
to cope with the impact of alumni and friends have certainly been central to
these tragic events. our success and growth thus far and you will
undoubtedly be a very important part of our cel-
ebration and our future.
At each of these events, and in the pages of
previous issues of this magazine, I have shared
details with you about the Boston University
“Choose to be Great” $1 billion dollar fundraising
campaign. This One Billion Dollar Campaign, the
first of its kind for Boston University, marks a
significant moment in the history of our
University and our School. What also makes this
Campaign different than others is that the
money we are able to raise will remain with the
Henry M. Goldman School of Dental Medicine.
The money we raise will be ours to use and will
go to the funding of our new facility, along with
the establishment of endowed Professorships
and Scholarships.
We began implementing our Applied
Strategic Plan in March 2011 and as part of this
implementation, we have been working very
closely with the University on a facility proposal.
2 Im pr es s i on s | Spring 2013
NewsinBrief
GSDM
10
By the Numbers
Dean Hutter concluded the program by saying, “Together,
we can build on the momentum of a legacy of innovation and
fund our proposed new facility to provide us with the infra-
structure required to bring excellence to all of our programs
US dental schools using the newest as we build together
CEREC system (GSDM is one.) a future that is truly “It means a great deal
great for our Henry to me,” Dean Hutter said,
M. Goldman School of
“to see our community
we're digital
14
education, research,
Percent of private dental prac-
tices with a CEREC CAD/CAM system oral health care, and
community service to improve the overall health of the global
population.”
460
A video commemorating the past 50 years and the future
of our School then premiered at the reception.
we're ahead of the times
5 to 10
impressed with her intelligence, dedication, motivation, can-do
attitude, and wonderful personality. As with the other student
award winners here with us this afternoon, Nadia represents the
reason why the future of our profession is so very bright.”
4 Im pr es s i on s | Spring 2013
Challenges Become Opportunities on Mexico Mission
As you might imagine, coordinating an international externship is a feat when unexpected chal-
lenges happen. That was the case when Erik Engelbrektson, Patrick Moore, and Josephine Verde,
all DMD 13, set out for San Blas, Mexico from October 4 to October 15, 2012, with LIGA, The Flying
Doctors of Mercy. Dr. Jonathan
Mission supervisor Dr. Fred Kalinoff was forced to cancel his trip last minute for medical reasons,
leaving GSDM students without a mentor and unable to practice dentistry. Thanks to quick think-
Shenkin
ing from Assistant Director of Extramural Programs Kathy Held and a lot of compassion from Ismael Featured
Montane DMD 10 AEGD 11, the group had a new preceptor—Montane—just days later. After receiving in Parents
the phone call from Held, Dr. Montane jumped on a plane to Mexico. Magazine
Montane participated in a Project Stretch mission as a student in 2010 and returned as a co-super-
visor with Frank Schiano CAS 01 DMD 06 AEGD 07 earlier in 2012. This time, Montane led his team in Parents Magazine’s
providing comprehensive care. In a letter to Montane following the trip, Held said: “The tasks you faced Jan Sheehan spoke
to Clinical Assistant
and your judgment calls were commendable.”
Professor in the
The team treated 60 patients a day totaling 240 patients. Montane estimates the team did in one
Department of Health
week what a private practice in the U.S. would accomplish in several weeks. Policy & Health
“Each day on a mission trip is probably equivalent to a week in a clinic in the U.S.,” says Montane. Services Research Dr.
“When you go back to school, it gives you a better Jonathan Shenkin for
frame of reference for how to approach each situa- “You don’t have your hand held the February 2013 arti-
tion. You become a clinician.” on an international externship,” cle, “The Fight Against
Engelbrektson agrees. Cavities.” The article
“You don’t have your hand held on an international he says. “Now, as we return to offers tips for keeping
externship,” he says. “Now, as we return to school, we school, we have more knowledge young children’s teeth
have more knowledge and experience so we can make free of decay.
and experience so we can make Dr. Shenkin’s tips:
stronger decisions while still under faculty supervision
in the patient treatment center.” stronger decisions while still under • Start cleaning the
mouth early. “A
Engelbrektson reflects on how the residents affected faculty supervision in the patient child can get a cav-
him: “ They were so gracious even if they had waited the
treatment center.” ity even if s/he
whole day. Every time they’d leave and smile, that just only has one
gave me energy for the next patient.” —Erik Engelbrektson DMD 13 tooth,” he says.
The team visited four area schools to offer screenings • Lose the pacifier by
to about 400 children. They invited to the clinic those age two or use one
who needed fillings and extractions. that is “orthodonti-
Ismael Montane DMD 10, AEGD 11 cally-correct.”
Verde reflects on the tough choices required of and a young patient in San Blas
them: “It’s challenging because you know you’re • If a child has no
cavities by age four,
fixing a problem by extracting a bad tooth, but you
s/he is likely in
also know you’re potentially causing a problem
good shape for the
down the road.” rest of childhood.
Verde, Engelbrektson, and Moore all recall the • Insist on dental
mission as an incomparable learning experience. sealants
As for Montane, he enjoyed his new role as a Dr. Shenkin is a
team leader. spokesperson for
Said Dean Jeffrey W. Hutter, “On behalf of the the American Dental
entire Boston University Henry M. Goldman School Association and has
of Dental Medicine community, I would like to a private practice in
express appreciation for Dr. Montane’s enthusias- pediatric dentistry
in Augusta, Maine.
tic readiness to step in for mission supervisor Dr.
His advocacy focuses
Fred Kalinoff so that the students could treat these
on effecting change
needy patients. Dr. Montane has demonstrated the in oral health policy,
core values of responsibility, excellence, and ser- with particular atten-
vice that the Goldman School of Dental Medicine tion to the oral health
aims to instill in all of its students.” of children.
6 Im pr es s i on s | Spring 2013
➜ Global and Population Health
New Position for Dr. Michelle Henshaw
Dean Jeffrey W. Hutter appointed Dr. Michelle Henshaw to the Dr. Henshaw received a BS in Psychology from Columbia University in
position of Associate Dean for Global and Population Health, effec- 1989, a BS in Dental Science and a DDS from the University of California at
tive February 1, 2013. San Francisco in 1993, and a MPH with a dual concentration in Epidemiology/
Biostatistics and Health Services from Boston University School of Public
In this capacity, Dr. Henshaw leads efforts related to devel-
Health in 1996. She was a General Practice Resident at the Brockton Veterans
oping and showcasing the Henry M. Goldman School of Dental
Administration and a Faculty Training Fellow in Geriatric Dentistry for the US
Medicine’s (GSDM) position as a world leader in global health
Department of Health and Human Services/Bureau of Health Professions at
and interprofessional care initiatives. She leads a new Office of Boston Medical Center/Boston University School of Medicine from 1993–1994.
Global and Population Health. “I have every confidence that Dr. Dr. Henshaw earned a Certificate of Advanced Graduate Study in Dental Public
Henshaw will excel in her new role,” said Dean Hutter. He contin- Health at GSDM in 2000.
ued, “Establishing the Office of Global and Population Health is an Dr. Henshaw has been a Professor in the Department of Health Policy
important strategic expansion for our School as we continue to con- and Health Services Research at GSDM since 2008. She previously served
tribute to the global profile of Boston University.” that department as an Associate Professor from 2004–2008 and Assistant
The Office of Global and Population Health actively support Professor from 1997–2004. Prior to that, she served as Assistant Professor in
students, faculty, and staff in their efforts to improve the health the Division of Dental Care Management from 1996–1997.
Dr. Henshaw has served as the Project Director at the Chelsea School Dental
of the world’s populations, and facilitates interdisciplinary health
Center, the Director of Community Health Programs at GSDM, Dental Director
research, teaching, and practice across all departments and pro-
at the Boston Center for Refugee Health and Human Rights at Boston Medical
grams at GSDM and the University, with a special emphasis on
Center, and Co-PI for Clinical and Community Liaison Core at the CREEDD. She
global health and interprofessional care. Dr. Henshaw retains her has served as Co-Director at the CREEDD since 2005, and as Assistant Dean for
previous responsibilities related to Community Health Programs, Community Partnerships and Extramural Affairs at GSDM since 2006.
the Northeast Center for Research to Evaluate and Eliminate Dr. Henshaw has received numerous awards and honors including: ADEA
Dental Disparities (CREEDD), and Community Partnerships and Gies Foundation 2011 William J. Gies Award for Innovation in the Dental
Extramural Affairs. She also retains her appointment as Professor Educator category; NIH-NCMHD Health Disparities Scholar, 2004–2007;
in the Department of Oral Health Care Access Program Scholar, Santa Fe Group and ADTA, 2002;
Health Policy & Health Community Campus Partnerships for Health Fellow, 2002; Spencer N. Frankl
Services Research. Excellence in Teaching Faculty Award, 2000;
“Establishing the Office Geriatric Dental Fellowship Award, Boston
Dr. Henshaw has
of Global and Population University Goldman School of Dental Medicine,
been charged with:
Health is an important 1997; Best Overall Presentation and Use of
establishing an orga-
strategic expansion Graphics, University of Iowa Health Sciences
nizational structure
for our School as we Center, 1997; Omicron Kappa Upsilon Society,
that identifies and Member, 1993–Present; Chancellors Award,
continue to contribute
addresses the chal- University of California at San Francisco,
to the global profile of
lenges of develop- 1993; Professional Development Award,
Boston University.”
ing and conducting University of California at San Francisco,
global health training, —dean jeffrey w. hutter 1991; California Dental Association Award,
research, and service University of California at San Francisco, 1991;
projects; working with and Mendelson Scholar Award, University of
California at San Francisco, 1989–1993.
the School of Medicine, School of Public Health, and health-
Dr. Henshaw is a member of several
related professional schools on the Charles River Campus to
professional organizations including:
create programs that will rigorously prepare trainees for collabora-
American Association for Dental Research; American Association of Public
tive practice and interprofessional care; administering national and Health Dentistry; American Dental Association; American Dental Education
international community-based educational programs; adminis- Association; American Public Health Association; International Association
tering and expanding the GSDM community service and service for Dental Research; Massachusetts Dental Society; and Massachusetts
learning programs; and seeking funding for innovative research and Public Health Association.
educational programs that will catalyze the development of inter- Dr. Henshaw has written numerous articles for several dental health
disciplinary translational research projects that provide a firm scien- publications including the American Journal of Public Health and the
tific base for clinical practice and public health policy. Journal of Dental Education.
8 Im pr es s i on s | Spring 2013
➜ international elective externship
you sometimes find in Boston.
“They’re cut off. If you want to go down
the hill it would take three or four hours
to walk,” she says. “I don’t think they had
access to processed foods. I don’t think
they could afford coca cola.” Whether by
choice or by chance, it’s a small win for the
residents of Buena Vista and dental health
providers treating them.
Also joining the team were Christina
Woo DMD 13 and Boston-area dentist Dr.
Chris Choi.
Global Brigades is a unique externship
experience. First, the group pairs dental
and medical students (called “profession-
als”) with undergraduate students working
toward those professions. GSDM students
not only had the chance to serve the people
of Buena Vista, but they also served as
mentors for pre-dental students on the trip.
Pre-dental students helped out as dental
assistants.
Teaching the
Second, Global Brigades asks volunteers
Jung Ahn, Anna Lechowicz, and to spend a portion of their mission working
Christina Woo (all DMD 13), Clinical
Importance of
outside of their field of expertise as well.
Instructor Gladys Carrasco, and Boston- This can include any of the areas Global
area dentist Dr. Chris Choi volunteered
Oral Health in in Buena Vista, Honduras, with Global Brigades works in: architecture, business,
Brigades in January. (above) Jung Ahn dental, environmental, human rights, medi-
Honduras
with a young Honduran patient cal, microfinance, public health, or water.
On their last day in Honduras, GSDM vol-
first Spanish-speaking dentist to join the unteers helped build a community center
If given a choice, most people would mission, realized that patients were only that will be a permanent site for one physi-
choose not to see the dentist. That’s the asking to see the dentist if they had tooth- cian and one dentist in Buena Vista.
problem students and staff encountered aches. She took on the task of teaching the Global Brigades follows the theory of
on their January 9-15, 2013 mission to local population, in their native language, “holistic development.” According to the
Buena Vista, Honduras. Upon arriving at the how the dentist can help with everyday oral group’s website, this is “a system of collec-
school where Global Brigades had set up health care. tively implementing health, economic, and
a pharmacy and medical and dental clinic, “We need to educate the people about education initiatives to strategically meet a
residents of the small coffee-growing com- why they need to see the dentist,” she says. community’s development goals.”
munity checked off a form to see only the “There are a lot of other diseases we can “We at the Goldman School of Dental
physician or the physician and the dentist find out just by looking at their mouths.” Medicine are so proud of Jung Ahn,
as well. Most people did not check the The number of dental appointments Anna Lechowicz, Christina Woo, and Drs.
“dentist” box. increased dramatically, from 10 people the Carrasco and Choi,” said Dean Jeffrey W.
“They thought seeing the dentist auto- first day to 40 the second and even more Hutter, “not only for their commitment to
matically meant extractions,” says Jung Ahn on the third and final day. teaching the importance of regular oral
DMD 13, who volunteered. “So they were Anna Lechowicz DMD 13 noted that health care but also for mentoring the
really afraid at first.” despite the lack of oral health education, next generation of dental students on this
Clinical Instructor Gladys Carrasco, the some people’s teeth were even better than extraordinary mission.”
DEAN UPDATES ON On Tuesday, November 20, 2012, Dean Committee. Dean Hutter praised the
PROSPOSED NEW FACILTY Jeffrey W. Hutter held a special meeting of work of SmithGroup, the architecture firm
the Boston University Henry M. Goldman GSDM has worked with in developing the
School of Dental Medicine (GSDM) GSDM Facility Master Plan and evaluating
Faculty and Staff to provide an update as multiple sites for a proposed facility on
to the status of a proposed new facility. the BU Medical Campus.
Since the Applied Strategic Plan was Dean Hutter will keep the GSDM com-
launched in March 2011, progress included munity apprised of pertinent updates as
discussions with the leadership of Boston the planning for a proposed new facility
University and the University Space continues.
10 Im pr es s i on s | Spring 2013
Dr. Errante Looks to Strengthen Relationships, In Memoriam
Affect Policy at Leadership Institute
The American Dental Education Association (ADEA) welcomed Dr. Margaret
Clinical Associate Professor
Errante to the ADEA Leadership Institute on January 14, 2013. The ADEA Leadership
Emeritus Dr. Thomas A. Arm-
Institute is a yearlong program designed to
strong
develop individuals at academic dental institu-
passed
tions to become future leaders in dental and away on
higher education. April 1,
In an acceptance letter, Executive Director 2013.
Dr. Richard Valachovic said, “You have joined a He was
cadre of the nation’s most promising dental edu- a distin-
cators and upon graduation will become one of guished
only 285 members of this prestigious institute.” member
Dr. Errante says she is honored to have of our
faculty who had received the Spen-
been given the opportunity by Dean Hutter to
cer N. Frankl Award for Excellence
attend the ADEA Leadership Institute.
in Teaching.
“I am excited to participate in the yearlong
Dr. Armstrong was born in
program that among other initiatives will focus Barbados on October 30, 1931 and
on strengthening relationships within our institution and nationwide,” she says. “The was a Newton resident for nearly
program will also introduce policy issues affecting academic dentistry and I will be 41 years. He received a Bachelors
given an opportunity to speak as an advocate with national policy makers.” of Science in Chemistry and a
Leadership Institute graduates from our School say Dr. Errante is more than qualified. DDS, both from Howard University.
Dr. Ronni Schnell says, “Dr. Errante will be a wonderful asset to her peer group in He maintained a private practice
the Leadership Institute. She brings with her a wealth of knowledge and experience, in family dentistry in Washington,
while stepping out of her environment and collaborating with colleagues from other D.C., until 1972, when he moved to
Boston to practice at the Roxbury
dental institutions. I wish Dr. Errante all the best in her yearlong program; she is cer-
Comprehensive Clinic (RCC) at
tainly up for the challenge.”
BU. He joined the GSDM faculty
Dr. John Guarente says, “Dr. Errante has vast experience operating private dental
in 1973. He later became director
practices and this will only strengthen at the Leadership Institute, which proves how the of RCC while maintaining private
educational component can fit within the operational model. I know that she will take practices in Mattapan and Jamaica
full advantage of this opportunity to explore the approaches of different institutions.” Plain. He retired in 2004.
Members will meet for four workshops over 2013–2014. He was a member of Omicron
Dr. Errante is a Clinical Assistant Professor in the Department of General Kappa Upsilon, the National Dental
Dentistry, Director of the BU Dental Health Center, and Director, Clinical Operations Society, and the Massachusetts
at our School. Dental Society.
He was predeceased by his
parents, Ethelin and Thomas; his
Dr. Joseph Boffa Executive sister, Doreen Aleta Green; and
Featured in Metrowest Director of two brothers, James Athelston
Daily News HealthLink and Darnley Archibald Armstrong.
Associate Professor in the Department Wellness of He leaves behind his wife, Ida
of Health Policy & Health Services New England. (Mason) Armstrong; his two
Research Dr. Joseph Boffa guest authored daughters, Lorna C. Armstrong
He praises Part
Batson and Julia Pamela
an op-ed article, “Don’t sacrifice health to D for lowering
Armstrong Goring; his grand-
cut deficits,” in the January 18, 2013, issue non-prescrip- daughter, Serena C. Batson; his
of the Metrowest Daily News. tion drug medi- brothers, Francis Bishop, Aubrey,
“Congress must do the right thing,” cal spending and Winston; and many siblings-
he says, “in order to preserve some of and hospital in-law, nieces, and nephews.
the programs that actually work to keep admissions and saving billions overall. Donations may be sent to the
America healthy.” “Preventing and managing chronic American Cancer Society or The
Dr. Boffa urges Congress to avoid cuts diseases among our retirees should be a Parkinson’s Disease Foundation.
in Medicare Part D, citing both research national priority,” he says, “not a ledger
and cases he witnessed personally as to balance.”
Mutual Gratitude Shared In one case, Chinnici extracted four teeth from a little girl
who returned the following day with a bag of fresh bananas.
by Students and Patients on Another girl, named Erica, made a bracelet for Chinnici and
sent it through Erica’s brother and mother when they visited
Guatemala Mission the mission’s clinic the next day. Chinnici was still wearing
If someone pulled out one or more of your teeth, would this bracelet upon her return to Boston. All seven students
you think of giving her a gift the following day? Lauren who provided dental services in Poptun were received with
Chinnici DMD 13 was on the receiving end of this seemingly appreciation: Many hugs were shared around the treatment
unlikely experience when she received gifts from several rooms during the mission.
patients that she saw during her international externship in On this trip directed by the non-profit organization LIGA
Poptun, Guatemala, in January 2013. International (The Flying Doctors of Mercy), two groups of
DMD 13 students traveled to Poptun: Danielle Berkowitz,
Nadia Daljeet, and Caitlin Reddy from January 10 to 21 and
Lauren Chinnici, Christina Donnelly, Michelle Holzinger, and
Hilary Linton along with Assistant Professor Kathy Held. The
team leader for the Poptun mission was GSDM alum Kevin
Acone MET 02, DMD 07.
Despite challenging conditions at the makeshift clinic,
attendees described a positive experience during which they
were able to improve their dentistry skills and confidence in
their work and judgments. With no X-rays, poor lighting, and
limited material and equipment, each student saw from 60
to 100 patients every day, performing consultations, extrac-
tions, fillings, and applying fluoride varnish. They worked
10 to 11 hours daily seeing patients who were often suffer-
ing from numerous dental problems. Communication with
patients was also difficult because the students did not share
a common language. Christina Donnelly managed to keep
children smiling by using only a handful of phrases she knew,
like “¿te gustan los perros?” That is, “Do you like dogs?”
Nadia Daljeet described the mission as “my best experi-
ence in dental school.” Danielle Berkowitz reported that
“the trip was an amazing experience in which my abilities
were used for the greater good of a poor population.” Caitlin
Reddy wrote in her feedback: “Invaluable experience. Can’t
say enough about it.”
Dean Jeffrey W. Hutter praised the students’ work: “These
students embody the mission of GSDM to provide community
service to improve the overall health of the global population.
On behalf of the School, I extend my thanks to them for serv-
ing as positive global representatives for the School.”
12 Im pr es s i on s | Spring 2013
Assistant Professor
Kathy Held and school-
children in Guatemala
Good Works
and Good Hope
dentist cares for underserved
communities here and abroad
14 Im pr es s i on s | Spring 2013
GSDM | Spotlight
feeding their families, paying Board chair Kevin Tarpley says he recruited Gabriel
because of his science background and his personal
bills, taking care of elders.” story, describing him as humble, a deep thinker, and
a team player. “It’s great when we introduce board
members to the students,” many who come from Haiti,
Gabriel stayed at Codman after graduation and “because they can say, ‘Look, I can become a dentist,’”
in 2009 joined Forest Hills Dental Office, which his Tarpley says. That message resonated with Gabriel,
father ran and they later bought together. Many of who is on the development committee and academic
their clients are low-income, have state health insur- excellence committee.
ance, and come from Central America, Haiti, or other Gabriel also mentors dental students he meets at
parts of the Caribbean. the Annual Haitian Health Career Seminar held at the
“Before they can pay for dental care,” Gabriel says, Medical School each spring, coaching them on issues
“they have a lot of other things to consider, feeding from good study habits and organizational skills to
their families, paying bills, taking care of elders. In our choosing classes and dental techniques. Sheina Jean-
community, most of us don’t just care for ourselves; we Marie MED 08 says he mentored her through the
care for elders and other people in our families.” admission process to Tufts School of Dental Medicine,
and they regularly chatted whenever she had questions
Missions, Military, and Mentorship about the profession. “It was refreshing to speak with
Gabriel often works with patients to establish pay- someone who knew the experience and was able to
ment plans for uninsured care, counsels them on which walk you through every step of the way,” she says.
insurance best serves their needs, and refers them to “Mentoring helped me get where I am right now,”
other dentists for specialized care. He also regularly Gabriel says. “I was a good student, but if I didn’t have
sends money to his mother and her family in Haiti and people who were interested in me and showed me the
pays his brother’s rent and college loans. way to go so that I could become a dentist, I probably
For the past four summers, he has traveled with the wouldn’t have made it.”
Hispanic Dental Association to Haiti or the Dominican
Republic, where he gives free preventive and restorative This article was written by Leslie Friday and first appeared in
care to hundreds of poor patients—some of whom have the Fall 2012 issue of Bostonia.
16 Im pr es s i on s | Spring 2013
GSDM | Spotlight
Dr. David Russell Dr. Russell is settling into his new role at GSDM and
making progress on the implementation of the group
joins gsdm as the director of
practice model and in other areas. “Through the sup-
the group practice experience port of Dean Hutter, Dean Guarente, and the GSDM
and team leadership faculty, the group practice model will become a fabu-
lous new reality as the way we treat our patients and
➜ On November 1, 2012, Dr. David teach our students,” he said. “It’s been an honor to help
Russell joined the Boston University Henry develop the program. The enthusiasm of the entire
M. Goldman School of Dental Medicine community has been electric.”
(GSDM) as the director of the group practice Dr. Russell earned a BA in Theology and Music at
experience and team leadership, and clinical Boston College, a DMD from Tufts University School
associate professor of general dentistry. of Dental Medicine, and an
He reports to Associate Dean for Clinical MPH from Tufts University
Education Dr. John Guarente. Dr. Russell had School of Medicine. He
previously served GSDM as a consultant at also completed a gen-
the Curriculum Summit II held in March 2012. eral practice residency
at Overlook Hospital in
Summit, New Jersey. He is
a past member of the Board
Dr. Russell’s
of Registration in Dentistry
role at GSDM is
for Massachusetts, hav-
clearly aligned with
ing been appointed by
and supportive of
Governor Romney He
Goal 2 of GSDM’s
was also a Robert Wood
Applied Strategic
Johnson Health Policy fel-
Plan: provide excel-
low in the office of Senator
lence in lifelong
Orrin Hatch. He comes to
dental education
GSDM directly from his
and scholarship. He
position at Gentle Dental,
provides leadership
where he was the director
in the development,
of doctor relations from
implementation,
2008 to 2012.
and sustainability of
The first part of Dr.
vertically integrated
Russell’s career was in aca-
teams within group
demia, at Tufts University
practices that have
School of Dental Medicine,
designated spaces,
and his experience is broad
staff, faculty, and
and innovative. He was
pre-doctoral students
associate dean for clini-
and post-doctoral residents. The group practice model
cal affairs, associate clinical professor and associate
will create a sense of continuity of care for our patients
professor of prosthodontics and operative dentistry,
within a patient-centered clinical education construct
and course director of oral diagnosis and treatment
for faculty-guided, student-provided, high-quality oral
planning. Prior to that, he held positions at Tufts as
health care. Once the group practice model is in place,
assistant dean for clinical affairs; adjunct professor
Dr. Russell will continue to monitor, develop, revise as
of veterinary surgery; lecturer in dental anatomy and
needed, and supervise the group practices regarding
operative dentistry; and course director, operative
efficiency, student progress, quality assurance, and
dentistry remedial course. Dr. Russell was instrumental
competency requirements.
in the design and development of the group practice
of a Woman
Association; the Massachusetts
Dental Society; Pierre Fauchard
Academy; Omicron Kappa Upsilon
Dental Honor Society; the American
katherine haltom, dmd 79, omfs 82
Dental Education Association; the
American Public Health Association;
Dr. Katherine Haltom DMD 79, OMFS 82, has a
the American Association of Public
Health Dentistry; the American
Association of Dental Boards; and
➜ thriving solo practice in Framingham,
the Northeast Regional Board of Massachusetts. She kindly spoke to Impressions staff about
Dental Examiners. He maintains a her experience as the first female Resident and the first
private practice in Boston. female Chief Resident in the GSDM Oral & Maxillofacial
“We are thrilled that Dr. Russell
has joined the Boston University Surgery program under Dr. Donald Booth. While the
Henry M. Goldman School of Dental profession has certainly become more open to women
Medicine faculty,” said Dean Jeffrey over the years, according to the American Association of
W. Hutter. “His expertise and lead-
ership skills make him uniquely Oral and Maxillofacial Surgeons (AAOMS), in 2012–
qualified to serve as director of the 2013, only 11% of OMS faculty and 14% of Residents
group practice experience and team currently in training are women. Dr. Haltom shares her
leadership.”
experience and wisdom with prospective female oral
surgeons for success in this largely male profession.
18 Im pr es s i on s | Spring 2013
What led you to a career as an oral surgeon? our dental patients. To this day I focus on comprehensive medical care
My father was a wonderful physician so I was always intrigued and being aware of treating the mouth as part of the whole body.
with medicine and thought I would pursue medicine as a career. In terms of the OMS program, what set it apart was Don Booth.
When I went away to college at Hollins College in Roanoke, VA, my He was very focused on teaching us to treat our patients with kid
father encouraged me to pursue other interests, maintaining that I gloves and great respect for the tissue. He had a reputation for deli-
had already spent a great deal of time studying sciences. I focused on cate and beautiful procedures and his patients had virtually no swell-
history, psychology, and art, along with many science courses and I ing. He used to tell the almost exclusively male Residents, “You must
became fascinated with speech pathology. As I took speech pathol- operate with the hands of a woman.” What he meant by that was
ogy courses, primarily working with stutterers, I found myself much that there are plenty of rough surgeons out there and this is not what
more interested in the patients with severe facial anomalies and even- we are about at GSDM. Oral surgery requires a great deal of delicacy,
tually realized that I was drawn to oral surgery. which he tried to communicate by insisting OMS students operate
I asked my father if he knew any oral surgeons in Nashville. If with the hands of a woman.
I could spend the summer months working for an oral surgeon I Do you see differences between the environment for women in den-
thought I could see how interested I really was in oral surgery as tistry now versus when you were in school?
a career. I worked for Dr. Jim Nickerson in Nashville, TN, for three My fellow Residents very much treated me like “one of the guys,”
consecutive summers. He was a recent Vanderbilt OMS graduate and I honestly felt that if I worked hard and pulled my own weight
and full of enthusiasm. I really felt like I was in my element and put in I was accepted. I did notice some resistance to my role as Chief
many long hours in the office and in the operating room. By the time Resident, but Dr. Booth counseled me to just get on with taking the
I enrolled in dental school, I had extensive exposure to office based leadership role assigned to me by Dr. Maloney.
oral surgery and the complex workings of orthognathic surgery in the After graduation I stayed at GSDM and taught full time for four
operating room. years, becoming the Director of the Oral Surgery Clinic and became
I moved to Boston for personal reasons and enrolled in a master’s part of the Oral & Maxillofacial Surgery faculty group practice. I loved
program at Boston College in biochemistry, with an eye toward dental teaching and I was able to become board certified during that time.
school. My father didn’t want me to pursue dental school or oral sur- At the same time I was working weekends and taking calls for another
gery. He remembered that the few women he had known in medical oral surgery group and I truly did enjoy both. Eventually I decided to
school had been discriminated against and mistreated and he didn’t focus on private practice. I found as I interviewed around that there
want that for me. Once I decided on my path for Oral Surgery, he was were inappropriate questions about my plans for marriage and family
my biggest advocate. that would certainly never be asked today.
Was it an unusual choice for a woman at that time? I eventually joined a group practice started by Dr. Norm
In general, yes, more so for Oral & Maxillofacial Surgery. However, Nathanson, who turned out to be an important mentor in my early
as I recall, GSDM was way ahead of the rest of the country on the career and beyond. Dr. Nathanson was a true lifelong learner and
gender imbalance issue. I believe we were somewhere near 25% was eager for all of the latest techniques that I had been taught by Dr.
female DMD students when I graduated in 1979. I credit Dean Frankl Booth. He was still a student—the oldest young person I ever knew.
for being very forward thinking about the DMD program, the School, Once he retired, Dr. Nathanson was also extremely supportive of me
and the profession. I also credit Dr. Booth’s vision for the Oral Surgery when I decided to leave the group practice and strike out on my own.
department. Other mentors include my wonderful father, Tom Haltom, Don Booth,
When I interviewed for the DMD program, I told my interviewer Tom Kilgore, Jim Nickerson, David Sortor, and Phil Maloney of Boston
that I wanted to be an oral surgeon, but he discouraged me from set- City Hospital.
tling on a specialty at that early stage. After completing the DMD In the 80s there was also a fair amount of patient resistance to
program, I applied to OMS Residency programs at both GSDM and being treated by a female oral surgeon at that time. Today it’s very
Vanderbilt and was the first female accepted to both programs. I ulti- different. Things have evolved and I think you will continue to see the
mately decided to continue on at BU, which I am so very happy about. numbers of female oral surgeons climb. In general, colleagues and
I loved Boston and it was at Boston City Hospital where I met the love patients accept female oral surgeons because now women are every-
of my life, Larry Joyce. where, in every profession.
And while I loved GSDM and being in Boston, I did feel a great Things really started to shift in the 1990s. It just seemed like
responsibility as the first woman accepted into the OMS program. I women were everywhere in the workplace. Women seemed to be
was very conscious of representing all future women applicants as the turning out in great numbers in general dentistry and in the other
first female Resident. dental specialties and I could feel the change among colleagues and
What sets GSDM apart? among patient acceptance. There was no longer any hesitation or
From the time of Dr. Goldman, the focus at BU has been on the doubt about a female dentist or oral surgeon.
whole patient and the whole body. At that time, many other den- If you are a female dentist seeking to specialize in oral and maxil-
tal schools focused exclusively on the mouth. I felt the total body lofacial surgery, I am a big advocate of group practice in order to make
approach was a great preparation for treating patients. At that time, work/life balance possible. It can be difficult to find that balance, but
the first two years were spent in classes with the medical students, as I tell young college students and dental students who come to me
which really helped us to think about the whole body when treating seeking advice, it IS possible!
Frank Schiano CAS 01, Monique Mabry Bamel Nazila Bidibadi Joseph Calabrese
DMD 06, AEGD 07 DMD 90 CAS 82, DMD 87 DMD 91, AEGD 92
20 Im pr es s i on s | Spring 2013
GSDM | Spotlight
250K
ALUMNI BOARD PLEDGES
Loretta Castellanos
Nunez DMD 91
TO SUPPORT SCHOOL Josephine Pandolfo
CAS 74,DMD 79,PERIO 82
The board is offering these funds to support Dean Jeffrey W. Hutter’s goal of construct-
ing or acquiring a new building for the School.
Tina Valades DMD 84, immediate past president of the board, described the discus-
“I think alumni sions that led to this pledge, which occurred during her tenure as president. “We were
inspired by Dean Hutter’s vision of where the School needs to go at this point in its his-
understand what tory,” she said.
The board reviewed the fundraising pyramid and pinpointed the level at which they
they’ve been able wanted to contribute. All the members agreed, and as a group they formed the donation
structure. Dr. Valades added, “Everyone on the board is very committed and dedicated to
to accomplish as the School, and this pledge was one way we could show our commitment.”
Dr. Valades added, “The School needs to grow in order to maintain its excellent repu-
graduates of GSDM. tation, and this financial pledge—along with additional alumni support—is essential to
ing has given us our to alumni of all ages and career phases. GSDM alumni know firsthand that the field of
dentistry is changing rapidly and how crucial it is for the School to remain competitive,
livelihood. We all according to Valades. “I think alumni understand what they’ve been able to accomplish
as graduates of GSDM,” she said. “Our GSDM training has given us our livelihood. We all
want to give back to want to give back to the profession and to the School.”
Board President Mitch Sabbagh DMD 87 noted the importance and significance of giv-
the profession and ing back to GSDM. “Our professional achievements are a direct result of our education,”
said Dr. Sabbagh. “The board’s pledge and alumni support overall are essential to ensure
to the School.” future generations of GSDM students receive the same exceptional training that we did.”
The GSDM Alumni Association Board members making the five-year pledge are:
–Tina Valades DMD 84
Mitch Sabbagh DMD 87, president; Tina Valades DMD 84, immediate past president;
Frank Schiano CAS 01 DMD 06 AEGD 07, secretary; Monique Mabry Bamel DMD 90;
Dr. Nazila Bidabadi CAS 82, DMD 87; Joseph Calabrese DMD 91, AEGD 92; Shadi Daher
DMD 90, OMFS 94; William Gordon DMD 81, ORTHO 90; Claudia Grail PEDO 90;
Ralph Hawkins ENDO 89; Zhimon Jacobson DMD 86, PROS 80, PROS 81; Bing Liu DMD
03; Robert Miller DMD 84, PERIO 86; Richard Mungo PEDO 75; Loretta Castellanos
Nunez DMD 91; Josephine Pandolfo CAS 74, DMD 79, PERIO 82; Steve Perlman PEDO
76; Megan Ryan GMS 06, DMD 10; Ronni A. Schnell DMD 81; John West ENDO 75; and
Donald Yu ENDO 81.
22 Im pr es s i on s | Spring 2013
GSDM | Spotlight
Aspen
and Frankl ➜ In fall 2012, six students each received an ominous email:
they were to report for a “mandatory meeting” with Assistant
Scholarship Dean of Students Dr. Joseph Calabrese and Assistant Dean for
Admissions Catherine Sarkis.
Awardees Speaking to the students’ humble nature, upon receiving the email, each of them
Sustain the immediately tried to recollect something they might have said or done wrong. The
summons felt reminiscent of being called to the principal’s office. One of the stu-
GSDM Spirit
dents, Marina Gonchar DMD 14, recounts walking into Dr. Calabrese’s office, find-
ing Ms. Sarkis sitting there, the door being closed, and feeling “so scared.”
Far from having done something wrong, each student had excelled.
Gonchar—like Benjamin Irzyk DMD 14, Antonio Maceda-Johnson DMD 15,
Keely Matheson DMD 15, Andrew Pham DMD 15, and Lyle Smith DMD 15—had
been summoned by Dr. Calabrese and Ms. Sarkis because of their academic
and personal achievements. Gonchar and Irzyk learned that they were being
awarded the Aspen Dental Scholarship. Maceda-Johnson, Matheson, Pham, and
Smith learned that they were receiving the Spencer N. Frankl Scholarship.
continued
mediate “vibe” of friendli- School. Irzyk also supports the efforts of Oral Health
Promotion Director Kathy Lituri in Community Health
ness and support. Programs activities by volunteering for events such as
Christmas in the City and Countdown to Kindergarten. He
describes reflecting at the end of a long day of volunteer-
Dean Jeffrey W. Hutter said of the six, “On behalf of ing on all that happened and feeling rewarded…and tired.
the entire Boston University Henry M. Goldman School Irzyk describes as “really rare” the great job that
of Dental Medicine community, congratulations to Student Affairs does in making students feel comfortable
Marina, Benjamin, Antonio, Keely, Andrew, and Lyle for with coming to them with any need. He also says that
being honored as scholarship recipients.” He continued, having the “assistant dean of students or the assistant
“I am very proud to have such remarkable representa- dean of admissions really getting involved within the
tives for the School.” community of students and being a resource for us is
The criteria that Dr. Calabrese and Ms. Sarkis apply really special.”
when deciding the recipients for both the Aspen and Marina Gonchar describes GSDM as unique for
Frankl scholarships include strong academic perfor- its culture of balancing a high level of education with
mance, demonstration of ethical and professional behav- encouragement to be involved in social activities that
ior, and active participation in School and community allow an “escape” from the stresses of school. As
activities outside the classroom. Both scholarships are Chair of the Boston University chapter of the American
for $5,000 and intended to assist students with the Student Dental Association (ASDA), Gonchar contrib-
expense of dental education. utes to the continuation of this beneficial culture.
Ms. Sarkis said of the scholarship recipients, “They About receiving the scholarship, Gonchar says, “I was
represent excellence in academics and character and so honored. It’s really hard to be in dental school because
embody the values held by the Boston University Henry you’re trying to do your best, you’re studying all the
M. Goldman School of Dental Medicine.” Dr. Calabrese time, and in third year you’re seeing patients and trying
concurred: “It is so enjoyable to be able to reward stu- to balance studying, so to be recognized for what you’re
dents who have made outstanding achievements and doing, to be chosen out of so many people, is just such
contributions to the School.” an honor.”
The humility with which the students received Gonchar describes the doors of Student Affairs as
the awards, together with the great appreciation they always open, and help immediately available to address
expressed for those who had helped them in their not just student problems, but any type of problem. She
achievements, lend a clue to their selection. The award- feels that this is unique to GSDM.
ees describe a culture of supportiveness at Boston
University Henry M. Goldman School of Dental Medicine The Spencer N. Frankl Scholarship
(GSDM)—students, faculty, and staff all working hand in Established in July 2006 and named after the
hand to help each other achieve and improve. School’s former dean, the Spencer N. Frankl Scholarship
What sets apart Gonchar, Irzyk, Maceda-Johnson, is an endowed annual scholarship of approximately
Matheson, Pham, and Smith as exceptional are the out- $5,000. While there is normally only one recipient
standing ways that they perpetuate the supportive and per year, there were four recipients in 2013: Antonio
selfless culture at GSDM.
24 Im pr es s i on s | Spring 2013
GSDM | Spotlight
Maceda-Johnson, Keely Matheson, Andrew Pham, and him determine what steps he needed to take to be a suc-
Lyle Smith, all DMD 15. cessful applicant.
Originally from Venezuela, Antonio Maceda-Johnson Pham now carries forward the supportive spirit that
is very active outside of the classroom; he serves as the Ms. Sarkis showed to him when he was an undergrad by
ASDA representative for his class and is chair of the being active in the ASDA pre-dental society. He helps
Community Service Committee for the Boston University students in the ways he was helped when he was inter-
chapter of the Hispanic Dental Association. ested in GSDM: he gives tours to undergraduates, helps
Maceda-Johnson says that he knew from the moment them to understand the application process, and offers
he stepped foot into GSDM for his interview that it was tips on increasing one’s chances of being accepted. Pham
the right place. He felt an immediate “vibe” of friendli- says, “It is a great opportunity because I was in the same
ness and support. situation once, and I can give them some insight and
Maceda-Johnson describes his own happiness at help them with the ins and outs.”
GSDM and hopes future students will have the same Pham also cites his father as a great influence
experience. He recounts the start of his first year and how on him, and also his uncle—a clinical instructor
students were competitive and only worried about their in the Department of Orthodontics & Dentofacial
Andrew Pham says that when listing pros and cons to help
him choose a dental school, he put Ms. Sarkis in the “pro” col-
umn. She had been a vital resource for Pham.
grades—until, that is, the second-year students stepped in Orthopedics—Dr. Khiem Pham-Nguyen.
to help. He says that “by the time you finish your first year, As an undergraduate at Boston University, Lyle Smith
students have helped you so much that they have made found a school that pushed him hard to reach his fullest
you a better applicant for future residencies than them- potential. Never one to avoid a challenge, Smith con-
selves.” It is a culture of selflessness, and Maceda-Johnson siders the culture of excellence one of the reasons he
is dedicated to keeping this culture going. decided to stay at BU for dental school.
Keely Matheson is dedicated to her work with ASDA. Smith is grateful to Dr. Calabrese and Ms. Sarkis for
In her first year, she started a yoga initiative and by her recognizing him with this award and echoes the other
second year is getting even more people involved. She awardees’ appreciation for Student Affairs.
says that she would never have been able to work on
the health initiative without the support of the School. Perpetuating the Spirit of GSDM
Matheson has embraced and worked to enhance the The outstanding characteristics that unite the Aspen
School’s support of balancing life and work. Dental Scholarship winners and the Spencer N. Frankl
Matheson found it ironic to receive a scholarship decided Scholarship winners are their drive and dedication to car-
upon by Dr. Calabrese and Ms. Sarkis because they were both rying on the core values that set GSDM apart from other
instrumental in her choice of GSDM. They were present on her dental schools: respect, truth, responsibility, fairness, and
interview day, and the impression they left with her made her compassion.
decision of which dental school to choose very easy.
Andrew Pham says that when listing pros and cons
to help him choose a dental school, he put Ms. Sarkis in
the “pro” column. She had been a vital resource for Pham
when he was struggling to get into dental school, helping
26 Im pr es s i on s | Spring 2013
Dr. Russell Giordano at the
2013 Chicago Dental Society
Midwinter Meeting
D
weeks. Production has since increased to meet the unprecedented demand.
Dr. Russell Giordano’s new hybrid ceramic is a rock star in “You may be able to do less tooth preparation and save
the world of dental materials. more of the natural tooth as well,” Giordano adds.
ENAMIC is a flexible ceramic that combines the best As of the product launch, ENAMIC was approved for use
properties of a conventional composite resin with those of in crowns, no-prep veneers, inlays, onlays, and on top of
a conventional ceramic. It can withstand stress better than implants. It is designed to be used with the CEREC CAD/
conventional ceramics, and it’s easier to work with. CAM system now in wide use at GSDM. In the future, Gior-
“It’s better all around,” says Dr. Giordano, who is associ- dano expects dentists will be able to use ENAMIC to make
ate professor and director of biomaterials in the Henry M. bridges, chair side, in one visit. Potential applications include
Goldman School of Dental Medicine (GSDM) Department posts, cores, and bracket materials. Implants and implant
of Restorative Sciences & Biomaterials. “It doesn’t wear as abutments are a possibility.
badly as composite resins, doesn’t wear the opposing teeth, “As biomaterials researchers, we want to solve problems that
is very color stable, has some flexibility like a composite exist in dentistry, help patients, and help dentists, all so that we
resin does—but not too much—and it matches the proper- can provide better long-term results for the patient,” Giordano
ties of dentin very well.” says. “This is one of the products that should do that.” Giordano
That’s important, he says, because research shows that presented Enamic during the Mid-winter Meeting Laboratory
when the restoration has the same stiffness value as dentin, Technician Day. Dean Jeffrey W. Hutter attended the meeting
the result is more stable. ENAMIC is about 86% ceramic, and the presentation and said, “I was absolutely delighted with
so the stiffness value is close to dentin. Moreover, it can be the impressive presentation of Enamic made by Dr. Giordano.”
adjusted as needed. He continued, “We are very proud to have him on our faculty.
“As biomaterials
researchers, we want
to solve problems that
exist in dentistry,
help patients, help
dentists, all so that
we can provide better
results for the patient
long term.”
—Dr. Russell Giordano
He is a valued member of GSDM and Boston University.” is that its components are completely interconnected. “If you look
For Giordano, the development of ENAMIC has been a long- at ceramics and porcelains, you have pieces of crystal floating in
standing labor of love. a sea of glass; if you look at composite resin, you have pieces of
His relationship with ceramics began in the late 1980s when he glass floating in a sea of resin. ENAMIC is the only material where
was studying CAD/CAM materials at Massachusetts Institute of all the components are connected to each other.”
Technology’s Ceramics Processing Research Laboratory. The proj- Many believed it couldn’t be done, including, at one time,
ect was required research as part of the prosthodontics degree VITA. Company representatives had such trouble recreating
he was pursuing at Harvard School of Dental Medicine. He was Giordano’s work in Germany that they sent someone overseas to
supposed to become a dentist and join his father’s practice, but film him working. But Giordano always believed in the product,
Giordano was hooked on ceramics research. and he credits Dr. Norbert Thiel, director of research at VITA, for
VITA sponsored a program at MIT to improve existing ceramics. also believing.
When Giordano joined BU he began working on a combination of “I always thought that we’d be able to get this product made,
ceramic and resin-based polymer materials, trying to find one that and there were a lot of good properties that we found in it along
would be more stress-resistant and easier to work with. In 1996, the way, so that was really motivational,” Giordano says. “This is
he had made enough progress to apply for a patent on what would a material that I think will have a lot of applications, not only in
become ENAMIC. dentistry but also outside of dentistry, more than other materials
“It’s something that wasn’t in existence, at least for dental in existence.”
materials, so there really wasn’t any path to follow,” Giordano Some of those applications include countertops, tile, and armor.
says when asked why he has been working on the material for so “In theory, ENAMIC would lend itself to being a good lightweight
long. “It took a while to figure out if the material was completely armor because of its properties and structure,” Giordano says. “And
homogeneous, that it was cured properly, and such.” it will be easier if you don’t have to make it look like a tooth!”
To date, there is no product similar to ENAMIC on the market. Right now, no one is about to put on a suit of ENAMIC, but that
Dr. Giordano says that the ceramic’s most notable characteristic future may not be far off.
28 Im pr es s i on s | Spring 2013
(right, from top) The VITA
Enamic block, a strip of Enamic
blocks, press for Enamic.
(below) Stress from contact with
opposing teeth is absorbed and
distributed throughout the resilient
ENAMIC due to its hybrid structure.
(opposite page) Dr. Giordano
on the floor at the CDS
Midwinter Meeting
Dentistry
Gone
Digital:
Inside GSDM’s Cutting-
Edge Dental Technology
It’s not news any more to say
that the world has gone digital.
Music, film, textbooks, games,
lectures, you name it.
But…dentistry?
closeup of the Nobel Biocare
scanner in the GSDM Simulation
Learning Center Technology Lab
30 Im pr es s i on s | Spring 2013
wide shot
of the
Boston University Henry M. Goldman School scanner
of Dental Medicine (GSDM) is now one of a
handful of top-tier dental schools practicing Transforming dental education
digital dentistry. GSDM is already solidly front Not only is digital dentistry an enormously beneficial change in the
world of dental medicine, it has also transformed dental education.
and center in the future of dentistry.
Dental students will soon graduate with the ability to do everything in
digital dentistry from inlays to onlays to crowns and even orthodon-
A sea of change for dentistry tics—current research suggests patients could one day undergo digital
A transformation in the nature of a visit to the dentist’s office is orthodontic treatment. Second-year GSDM students attend a series of
underway. Patients will say farewell to X-rays altogether, thanks to lectures on dental materials, and they start using CAD/CAM software
high-resolution, three-dimensional images of teeth and tissue created in the School’s computer laboratories by their third year.
through Optical-Coherence Tomography, or OCT, which makes it pos- In 10 years, we may no longer teach students to make physical im-
sible for dentists to detect tooth decay in patients far sooner than with pressions. And while that will likely please students, even happier will
traditional X-rays. Patients will no longer have to bite down on sharp- be the patients who no longer have to sit still with impression material
edged film cards; researchers are working on an inch-wide rectangular hardening in their mouths.
sensor that enters information directly into a digital dental file with the
click of a button. Radiation exposure will drop by nearly 20 percent.
Pairing the Practice Setting
And digital radiography is just the beginning. and Technology
Sirona, the world’s largest manufacturer of dental technology, has The forthcoming group practice model will be crucial in helping us to
helped bring cutting-edge dental technology to GSDM. Faculty are integrate digital dentistry.
trained in Ceramic Reconstruction (CEREC) technology and instruct In March 2012, Drs. Carl McManama and Cataldo Leone convened
students in its use. The software enables dental practitioners to restore the Curriculum Summit II, gathering student, faculty, and staff repre-
teeth using a variety of materials, guided by an intraoral scanner. The sentatives to discuss what the group practice model at GSDM will look
intraoral scan can then be imported to Cone Beam Scans to enable like and how it will affect both student education and patient care.
comprehensive implant treatment planning. Currently, about 14 per- Denise Cavanaugh of the Washington, DC–based consulting firm
cent of private practices are using computer-aided design and comput- Cavanaugh, Hagan, Pierson & Mintz facilitated the proceedings. “In a
er-aided manufacturing (CAD/CAM) to create custom crowns, inlays, survey given by the Dental School prior to the Summit,” she said, “80
onlays, implants, veneers, and other types of dental restorations. The percent of graduates said they will go to work in a group practice set-
rest are taking physical impressions and relying on outside laboratories ting, so I am confident that moving to a group practice model at GSDM
to do CAD/CAM restorations. will serve to better prepare students.”
The transition to the new dental practices made possible by digital Also playing an active role in the meeting was the newly appointed
dentistry will be seamless for patients, although they will surely be Director of the Group Practice Experience and Team Leadership and
pleased with the changes they do notice. Rather than coming in for Clinical Associate Professor of General Dentistry Dr. David Russell (see
multiple, lengthy visits, they will soon be able to visit GSDM, have their article, p. 17.) At the time, he was director of doctor relations at Gentle
digital radiographs made, their teeth scanned, and their digital impres- Dental. Dr. Russell is the former associate dean for clinical affairs at
sions made, all within just one or two visits. Instead of from four to five Tufts University School of Dental Medicine, which has relied on a
required visits for dentures, two will be enough. Fewer visits means group practice model for the last 15 years. Having worked with several
fewer missed appointments, and less money lost for the School. And institutions to help them set up group practice models, he was able to
no one expects patients to complain about coming in less often. provide examples and insights into many of the topics discussed during
the Summit.
Digital innovations:
What’s on Dr. Giordano’s horizon?
Sirona Smile Design VITA digital shade selection
This software to be released in summer 2013 allows you Only about 20% of dentists have digital systems to
to import a photo of the patient smiling into the scanning select tooth shade. “Most dentists are using very old
software and show the patient what his or her mouth will shade guides that don’t cover the entire spectrum of natu-
look like post-restoration. ral teeth,” Dr. Giordano says. VITA introduced its digital
shade device about 10 years ago and is now on its fourth
Sirona Prep Check iteration, which will be available at GSDM. The guide
Recently released, this software allows students to automatically tells students the best matching shade.
compare their preparations to the School’s accepted stan- Bleaching shade guides are available too, which help both
dard. Students scan in their preparations and the software the patient and the dentist understand how far they’re
tells them where they need to fix it, add more material, progressing during tooth whitening.
take off less, and so on. “Students get a lesson on their
own, digitally,” Dr. Giordano says.
*GSDM is able to be a leader in digital dentistry thanks to strategic corporate partnerships. Nobel Biocare; 3M; VIDENT; Henry Schein;
Sirona; and Kavo Kerr Group have all played an active role this year, as GSDM envisions the digital future.
32 Im pr es s i on s | Spring 2013
Say, “goodbye” to impression materials!
This Chairside Oral Scanner, a gift from 3M,
will soon make digital impressions possible.
Task Force on
Digital
Dentistry (top and bottom right) The
Dr. Giordano, Dean Jeffrey W. Sirona CEREC CAD/CAM
Hutter, and other GSDM faculty (botttom left) The VITA digital
shade selector
have recently visited with leading
digital dental companies, including
Nobel Biocare, Henry Schein, and
KAVO Group, in addition to Sirona
and VIDENT.
In April 2013, the Dean appointed
Dr. Giordano as chair of the Task
Force to Implement Digital Dentistry
at the Henry M. Goldman School for
Dental Medicine. Dr. Giordano is the
School’s resident expert on digital
dentistry, having spent 20 years
researching in that area.
Dr. Giordano looks forward to
working with Task Force members
to determine what each department
needs to proceed further into digital
dentistry and create a seamless
interaction among all departments
with respect to digital dentistry.
Task Force members:
Mr. Andy Burke
Dr. John Cassis
Dr. Chao Ho Chien
Dr. Richard D’Innocenzo
Mr. Evan Donato
Mr. Gerard Dorato
Dr. Stephen Dulong
Dr. Margaret R. Errante
Dr. Neal Fleischer
Dr. Yael Frydman
Dr. Anita Gohel
Dr. John Guarente
Dr. Fred Hains
Dr. Michelle Henshaw
Mr. Ibrahim Kachouh
Dr. Celeste Kong
Dr. Mohamed Masoud Alums! How do you go digital?
Mr. John Reilly
Dr. David Russell How do you use digital dentistry in your practice?
Dr. Arthur Sun
Dr. Jason Zeim We want to hear from you. Send us your com-
Task Force Consultants: ments and photos at sdmalum@bu.edu.
Dr. Serge Dibart
Mr. Michael Haddad
Dr. Judith Jones
Dr. Carl McManama
Dr. Ronni Schnell
34 Im pr es s i on s | Spring 2013
alumni etc.
New role for Stacey McNamee • Alpha Omega at Fenway with Wally • 50th Anniversary celebrations
class notes
news
Message From
Alumni Board President
Mitch Sabbagh
dear fellow alumni, fee, and studying together. It also included valued
During the early part of my four years as a advice from an instructor, guidance from administra- “Some say it takes
DMD student, beginning in 1983, I returned home tion, or having a lost chart returned. We all realized a village to raise a
to New York regularly to see my family, have a that we were relying on each other in order to reach child, but I believe
home-cooked meal, and reconnect with friends congruent and divergent goals within our profession. it takes family—a
who were also making their way toward adulthood. We were all in this together—as a family. family of people
There I found comfort and renewal in surrounding The ease with which we gave of our time who care enough to
myself with the people and places that had helped and compassion to each other during those days invest their friend-
shape me up to that point. I had begun my career should not end with graduation. As alumni, we ship and unwav-
as a pre-doctoral dental student at the Boston are the guiding forces of our extended family and ering support in
University Henry M. Goldman School of Dental our responsibility does not end with merely giv- service to your
Medicine (GSDM). Some say it takes a village to ing advice to soon-to-be graduates. Our generous future aspirations
raise a child, but I believe it takes family—a family philanthropy is no different that what we received and goals.”
of people who care enough to invest their friend- from our own families as we embarked on our —Mitchell V. Sabbagh
ship and unwavering support in service to your careers. We are charged as the professionals we DMD 87
future aspirations and goals. have become to perpetuate the success of GSDM
Although I had taken student loans to pay for as we celebrate our first 50 years.
my education, I still received “donations” from I encourage all of you to give back to the GSDM
my parents in the form of spending money and a family with your time, your wisdom, and your
Texaco credit card. My sister was great at freez- resources. I also encourage you to turn to your
ing leftovers for me to take back to Boston and GSDM family when you need assistance with a
my brother’s sense of fashion seemed to find its referral, when you are looking to expand or sell
way into my closet. Friends would visit with tooth- your practice, or simply to reconnect with a long
themed gifts (which I still receive to this day) that lost classmate.
would cheer me on toward becoming “Doc.” No Family has been central to my success, as I
one does it alone. know it has been to each of yours. Now let us all
What became apparent during my years at band together as family to ensure the future suc-
GSDM was that another family was emerging and cess of GSDM.
offering just as much, if not more support, than my
own family. It was the administration, faculty, staff, Sincerely,
and fellow students here at GSDM who were shar-
ing my journey. The atmosphere created by Dean
Frankl that continues today under the leadership of
Dean Hutter is one of collegiality, camaraderie, and Mitchell V. Sabbagh DMD 87
warmth. This included sharing notes, exchanging President, Boston University Henry M. Goldman
ideas, borrowing supplies, carpooling, grabbing cof- School of Dental Medicine Alumni Association
36 Im pr es s i on s | Spring 2013
(l-r) Dean Jeffrey W.
Hutter; Alissa Trujillo; and
Ariel Trujillo DMD 97,
PERIO 00
Stacey McNamee with them to help achieve and promote the
greatness of each one of our departments and
Assumes Expanded Role programs is a truly exciting opportunity.”
In January 2013, Director of Alumni Relations
McNamee continues her role as primary liaison
Stacey McNamee assumed an expanded
with the GSDM Alumni Association, work-
role within the Office of Development and
ing with Alumni Association President, Mitch
Alumni Relations. McNamee, a long-term
Sabbagh DMD 87, and the Alumni Board to
and beloved staff member of the Henry M.
support their leadership efforts on behalf of
Goldman School of Dental Medicine (GSDM),
the GSDM alumni body. As part of this role,
was promoted to Director of Alumni Relations
McNamee serves on the 50th Anniversary
and Annual Giving, and is charged with direct-
Celebration Committee, which helped plan the
ing all aspects of departmental fundraising at
celebration to mark the 50th anniversary of
the School. Working closely with department
the founding of GSDM by Dr. Henry Goldman
chairs, faculty, and staff, McNamee ensures McNamee, who was instrumental in organiz-
in 1963. This yearlong celebration that will
that each department and program effectively ing the event.
include alumni events both nationally and
engages their alumni constituencies at the
internationally was launched on February 1 at Dean Hutter spoke about the role of Henry M.
highest levels of communication and pro-
the 2013 Yankee Dental Congress. Goldman School of Dental Medicine alumni
gramming, aligning alumni in their efforts to
support their respective departments. In addition, McNamee leads all annual fund in the historic, University-wide One Billion
activities, partnering with the newly recruited Dollar Campaign as an essential part of fund-
The University and ing GSDM’s proposed new facility and the
Chair of the GSDM Annual Fund, Dr. Carl
GSDM publicly establishment of endowed Professorships and
McManama. McNamee assumed her new
launched Boston Scholarships.
role as part of a top priority of Dean Jeffrey
University’s first
W. Hutter to create a fully-staffed Office of Dean Hutter highlighted GSDM’s yearlong
ever comprehen-
Development and Alumni Relations. She con- celebration of the 50th Anniversary of the
sive campaign,
tinues to report to Kevin Holland, Assistant founding of the School by Henry M. Goldman
“Choosing to
Dean of Development and Alumni Relations. in 1963. He said, “This is a very special
be Great,” in
Holland says, “In the three years I have moment for our School. I know each of you
September 2012,
worked with Stacey, I have found her to be a will join me and seize this moment. Together,
which will allow
tremendous resource to the Office. Given her we can build on the momentum of a legacy of
each School to target all fundraising dollars
tenure here, she knows many of our alumni innovation and fund our proposed new facility
to their own priorities. The campaign, with
personally and is tireless in helping connect and build a future that is truly great.”
an ambitious goal of one billion dollars, is
alums to each other, and helping create a
focused on helping each School achieve its
closer alumni body.” Dean Hutter closed the evening by presenting
highest priorities. GSDM’s campaign priorities
a video that was produced specifically for the
were selected after an exhaustive yearlong
50th Anniversary Celebration commemorat-
Applied Strategic Planning Project, which
included input from every constituency within alumni gather ing the past 50 years and highlighting what
the GSDM community. McNamee, a member in arizona for lies ahead for the School.
of the Applied Strategic Planning Committee, 50th anniversary
will now focus on raising funds to support celebration
each department’s highest priorities identified Elective Externship
as critical to help GSDM achieve its goal to On March 8, 2013, GSDM alum Ariel Trujillo
DMD 97, PERIO 00 and his wife Alissa Trujillo
Turns Ovalles into
become the premier academic dental institu-
tion promoting excellence in dental education, hosted an alumni reception at the Windgate “A Whole Different
research, oral health care, and community Ranch in Scottsdale, Arizona, as part of the Dentist”
service to improve the overall health of the School’s 50th Anniversary Celebration. “It blew me away.” That’s how Fransheska
global population. Dean Jeffrey W. Hutter joined the gathering Ovalles DMD 14 sums up her mission
of GSDM alumni, staff, family, and friends. to Guatemala with Dentistry for All in
McNamee states, “Our alumni body is by far the February 2013.
greatest strength of this Institution and I have He addressed the crowd, beginning by thank-
been so fortunate to count many of them as per- ing the reception hosts as well as Director of Dentistry for All is a nonprofit led by
sonal friends during my time at GSDM. Working Alumni Relations & Annual Giving Ms. Stacey Executive Director and GSDM alum Brad
news class
Dentistry in
Comi is among
the most chal-
lenging you
will find. Many
Krusky DMD 97. The organization’s vision is to rence for Dentistry for All that Ovalles described as residents there
help people in impoverished regions of the world the highlight of the trip. This was her first experience have a condition
maintain a better quality of life through better den- treating patients with special needs. called osteope-
tal health. The organization serves the Philippines,
She spent three hours working with a team of five
trosis, literally
Nicaragua, and Guatemala. This particular trip took translating as
Ovalles to Comitancillo (aka Comi) and a new site in people to help one special little girl. “We were just
all in it together and basically restored her whole “stone bone.”
La Choleña, a town near Guatemala City.
mouth,” Ovalles said.
A Whole New World
This was Ovalles’ first significant chance to treat
Ovalles says that, being from a third-world country so many children, and she loved it. Trip director Dr.
herself, some aspects of Comi such as the lack of Shane Fisher thought she was so gifted that he is
water were no surprise to her. She was, however, sur- trying to convince her to change her present post-
prised by how the residents stuck to their traditions. graduate plans and apply to a program in advanced
specialty education in pediatric dentistry.
“I’ve never seen anything like it,” she says. “They
dress in traditional clothing, farm everything, and A Unique Anatomy
speak their own dialect. Someone would translate
from their dialect to Spanish so I could translate Dentistry in Comi is among the most challenging
from Spanish to English for the dental team.” As a you will find. Many residents there have a condition
courtesy, the team followed the local tradition of called osteopetrosis. Literally translating as “stone
covering their knees and shoulders. bone,” it is an inherited disorder that causes the
bones to harden and become denser.
A pleasant surprise was that several patients with
special needs came in for treatment, a rare occur- “They have a completely different anatomy,” Ovalles
said. “Their bone is like nothing we’ve ever seen in
38 Im pr es s i on s | Spring 2013
(l-r) Jose Alamo DMD 06,
Steve MacHardy DMD 07,
Christina Thompson DMD
06, Melissa Knudsen DMD alumni Jose Alamo DMD 06, Frank
13, Rachel Lukas DMD 13, Casarella DMD 88, Steve MacHardy
Elizabeth Walker COM 98,
DMD 07, Christina Thompson DMD 06,
DMD 06, ORTHO 10
and Frank Casarella DMD 88 and Elizabeth Walker COM 98, DMD
06, ORTHO 10.
50th Anniversary
Celebrations make
Yankee 2013 an event
to remember
Alumni, faculty, students, and staff celebrated the
start of GSDM’s 50th Anniversary Year throughout
the 2013 Yankee Dental Congress and gathered for
an historic kick-off reception.
BU Alumni Association President & Dean’s Advisory Board Member Shadi Daher DMD 90,
OMFS 94; BU Provost Dr. Jean Morrison; and Dean Jeffrey W. Hutter
Dean Hutter with Dean’s Advisory Board member Dr. Ernesto Muller PERIO 61
Andrew Chase DMD 93, ORTHO 98; Monique Mabry Bamel DMD 90; and
Jonathan Bamel DMD 83
Alireza Hakimi ENG 86; Nazila Bidibadi CAS 82, DMD 87; and Dean Hutter
(l-r) Aanya Sanghvi DMD 09; Talia Schechter Miller DMD 09, AEGD 10, PEDO 12;
Kadambari Rawal AEGD 10; Amir Dadhkah AEGD 10; Beatrice Deca DMD 09, AEGD
10; Rares Deca DMD 09, AEGD 10; and Adriana Baiz AEGD 10, Endo 13
40 Im pr es s i on s | Spring 2013
(left) Kyle Findly
DMD 03, Mitch
Sabbagh DMD 87,
Harnet Schnitman
DMD 86, Director
of Alumni Relations
GSDM Alumni Board President Mitch Sabbagh DMD 87 & Annual Giving
Stacey McNamee,
and Assistant Dean
of Students Dr.
Joseph Calabrese
Laurie Dylis Murphy DMD 91 (left) and Linda Massod DMD 91 (above, from left)
Nina Oh CAS 05, GMS
08, DMD 12; Amy
Mann GMS 08, DMD
12; Courtney Brady
DMD 11; and Julia
Barbagallo DMD 12
Dean Hutter, Nadia Malik DMD 13, and Dr. Joseph Calabrese
news class
(l-r) Spiro Saati CAS 74, DMD 80; Josephine
Pandolfo CAS 74, DMD 79, PERIO 82;
Wally the Green Monster; Richard Zavada
DMD 14; Murray Miller ORTHO 83; Emrey
Moskowitz-Porath SPH 03; and David Dano
AEGD 12 at Fenway Park
Alpha Omega at Dr. Farsai Appointed
Fenway: Grand Slam Consultant to
for Dentistry ADA Council on
On December 9, 2012, the billboard over Scientific Affairs
the stands in Boston’s historic baseball In March 2013, the American Dental
park read “FENWAY PARK & THE Association (ADA) offered Boston University
RED SOX WELCOME ALPHA OMEGA Henry M. Goldman School of Dental Medicine
INTERNATIONAL DENTAL FRATERNITY.” (GSDM) Associate Professor of General
The occasion was a gathering of members Dentistry and alum Paul Farsai DMD 94,
of the Alpha Omega organization (AO) AEGD 95, MPH 97 an appointment as con-
at Fenway to exchange knowledge, foster sultant to the Council on Scientific Affairs
philanthropy, and, of course, to revel in the While Dr. Steinberg’s career moved from den- (CSA). The purpose of the CSA is to provide
distinguished history of Fenway Park and the tistry to baseball, Dr. Lonborg’s career trajectory information and guidance to the dental pro-
Red Sox. followed the opposite path. After retiring from fession and the public on a wide spectrum of
baseball, Lonborg studied at Tufts University scientific topics. The CSA also administers
Approximately 100 AO members from vari-
School of Dental Medicine to earn his Doctor of the ADA Seal of Acceptance Program.
ous chapters of the organization attended,
Dental Medicine. He has worked as a dentist in
including members from the BU alumni and Professionals who are appointed as consul-
Hanover, Massachusetts ever since.
student chapters; and chapters from Tufts tants to the CSA are chosen for their exper-
and Harvard. The group included visitors The speakers emphasized baseball, dentistry, tise in an area vital to the Council’s work. As
from numerous states, including Connecticut, Alpha Omega, and how they have intersected a consultant to the CSA, Dr. Farsai will be
Maryland, Rhode Island, and New York. in their individual experiences. Drs. Lonborg asked to provide his expert advice on scien-
Children and grandchildren of memb¬ers also and Steinberg took questions after they spoke. tific matters within his area of expertise.
enjoyed the day at Fenway.
President of the Boston Alumni Chapter of “Congratulations to Dr. Farsai on his
The festivities included a brunch; two guest Alpha Omega International Dental Fraternity appointment as consultant to the Council
speakers; a chance to view the 2004 and Emrey Moskowitz-Porath SPH 03 said of the on Scientific Affairs,” said Dean Jeffrey
2007 World Series Trophies; a “meet and day at Fenway: W. Hutter. He
greet” with Wally the Green Monster, the Red continued, “I am
Sox mascot; and a tour of Fenway Park. It was a great event! What a nice opportunity
confident that Dr.
for both active and new Alpha Omega Dental
The two guest speakers were Dr. Charles Farsai will serve
Fraternity Boston Alumni Chapter members
Steinberg, senior advisor to the Red Sox as a valuable
to come together to talk about dentistry and
President Larry Lucchino, and former Red resource for the
baseball as we spent time listening to Dr.
Sox starting pitcher Dr. Jim Lonborg, aka Council.”
Charles Steinberg and Dr. Jim Lonborg. It was
“Gentleman Jim.” fascinating to hear how these two Dentists Since 2008,
were able to intermingle one’s passion for Dr. Farsai has
Besides baseball, the two speakers have one
sports and a career in dentistry. Alpha Omega worked as a
other thing in common: dentistry.
is a great organization for fostering values in contracted expert witness consultant to
In addition to being Senior Advisor to the Red professionalism through learning, mentor- the Commonwealth of Massachusetts
Sox President Larry Lucchino, Dr. Steinberg ing, networking, service to the community, a Executive Office of Health and Human
also holds a Doctor of Dental Surgery sense of family, philanthropic endeavors and Services, Department of Public Health
from the University of Maryland School of creating opportunities for dental students. Division of Health Professions Licensure/
Dentistry. His association with baseball and Board of Registration.
S. Murray Miller ORTHO 83 served as the AO
Larry Lucchino began when he was a public
representative for the Fenway event. Reflecting Dr. Farsai received a Doctor of Dental
relations intern for the Baltimore Orioles.
on the occasion, Dr. Miller said, “Overall, it was Medicine in 1994 and a Certificate of
Larry Lucchino was president of the Orioles at
a great day. Attendance of this event helps sup- Advanced Graduate Study in General
that time. As Dr. Steinberg moved up the pro-
port the educational and charitable work that Dentistry in 1995, both from GSDM. In
fessional ladder, he followed his mentor Larry
is the primary concern of the Alpha Omega 1997, Dr. Farsai received a Master of Public
Lucchino to San Diego and now to Boston. Dr.
organization.” Dr. Miller encourages continued Health from Boston University School of
Steinberg is a founding and charter member
support of the Red Sox and Alpha Omega. Public Health. He also holds a Certificate
of the Academy for Sports Dentistry.
42 Im pr es s i on s | Spring 2013
of Fellowship from the US Department of function of salivary proteins in the article “Anti- A prominent difference between evolution-
Health and Human Services/Bureau of Health candidal activity of genetically engineered arily older and younger salivary proteins is
Professions after completing a two-year fac- histatin variants with multiple functional that the older proteins show multiple domain
ulty training fellowship in geriatric dentistry. domains,” published in the December 12, 2012, duplications in their amino acid sequences.
issue of the online journal PLoS One. Dr. Oppenheim hypothesizes that, given mil-
Dr. Farsai has received numerous honors and lions more years of evolution, histatins might
awards, including selection for Fellowship in This recent article describes how Dr. duplicate their antimicrobial domains. In a
the Pierre Fauchard Academy International Oppenheim and his collaborators genetically sense, Dr. Oppenheim and his collaborators
Honorary Dental Organization; nomina- engineered variants of a type of human salivary were able to speed up advantageous evolution
tion for the Boston University Metcalf Cup protein that is known to exhibit antifungal and by duplicating the antimicrobial domains in
and Prize as well as Metcalf Awards For antibacterial activities. Variants of the protein histatins in their lab.
Excellence in Teaching (University-wide); histatin 3 were produced by duplicating func-
selection for Fellowship in the American tional domains in its amino acid sequence. “It’s a pretty exciting concept to possibly
College of Dentists; and honorary faculty show evolutionary anticipation, but this
membership at the Boston University The findings are significant in several aspects. could also be clinically exploited by making
Lambda Mu Chapter of the Omicron Kappa First, the study demonstrates that duplicating molecules which are more active,” said Dr.
Upsilon national honor dental society. active domains in histatins can enhance their Oppenheim of the findings.
antifungal properties. This suggests that these
Dr. Farsai has published extensively, with a peptides can be exploited for clinical purposes. In fact, histatin preparations have already
focus on topics in geriatric and special needs In addition, the been shown to be effective in reducing can-
dentistry. His professional affiliations include findings may pro- dida infections (thrush) in AIDS patients. Dr.
the American Academy of Developmental vide an evolution- Oppenheim explains that clinical applications
Medicine and Dentistry, American College ary explanation for could be as simple as an antibacterial and
of Dentists, American Dental Association, the existence of antifungal mouthwash. Clinical applications of
American Dental Education Association, frequent domain genetically enhanced histatins outside of den-
Academy of General Dentistry, American duplication in older tistry, such as treatments for skin infections,
Society for Geriatric Dentistry (Special Care salivary proteins. are also possible.
Dentistry), Massachusetts Dental Society,
North Shore District Dental Society, Omicron Leading in the early Using a substance that the body produces
Kappa Upsilon, Lambda Mu Chapter (Boston research of these naturally has many advantages over com-
University School of Dental Medicine), histadine-rich salivary proteins, Dr. Oppenheim mon chemical antiseptics like chlorhexidine.
Pierre Fauchard Academy, Joint Commission and his team of researchers were the first to Synthetically-produced chemicals always
on National Dental Examinations describe the complete amino acid sequences carry the potential to produce allergies or sen-
(ADA-JCNDE), and the Academy of of the proteins, to outline their ability to kill sitivities in patients, Dr. Oppenheim notes.
Osseointegration. pathogens in the human oral cavity, and to call
them histatins. There are compelling reasons to move for-
Dr. Farsai also maintains a private practice in ward with research into large scale clinical
Swampscott, Massachusetts. The hypothesis in Dr. Oppenheim’s recently production. First, there is the advantage that
published research that functional domain histatins are naturally occurring substances
duplication would lead to amplification of the in the body that will be less susceptible
antifungal properties in histatins comes in part to immune resistance. In addition, resis-
Promising Research from evolutionary research. In research on tance to existing antifungal and antibacte-
on Genetically proteins found in the saliva of various types of rial treatments is increasing. According to
Enhanced primates, Dr. Edwin A. Azen established that Dr. Oppenheim, clinical use of genetically
Antimicrobial histatins are evolutionarily young—less than
40 million years old—as compared to older
enhanced histatins is not far off. So far, bring-
ing down the cost of production is one of the
Salivary Proteins salivary proteins like mucins. The conclu- greater obstacles.
Henry M. Goldman Distinguished Scientist, sion is based on the fact that histatins, while
Professor of Periodontology & Oral Biology, and absent in the saliva of New World monkeys, Dr. Oppenheim’s research in oral biology
alum Frank Oppenheim PhD BIOCHEM 74, are found in Old World monkeys. The evo- continues with a quest to understand the
DMD 76, PERIO 77—along with co-authors lution of the two primate groups diverged mechanism by which histatins are able to
Drs. Eva J. Helmerhorst, Urs Lendenmann, around 35 to 40 million years ago, after plate kill microorganisms, such as the fungus
and Gwynneth D. Offner—build on decades tectonics completely separated their habitats Candida albicans.
of research achievement on the structure and by ocean.
news class
(l-r) Dr. Gretchen Gibson,
Dr. Judith Jones, Dr.
Marianne Jurasic, and
Dean Jeffrey W. Hutter
Awards,
Presentations, &
Celebration at AADR
Annual Meeting
Faculty, staff, and students of Boston
University Henry M. Goldman School of
Dental Medicine (GSDM) represented
the School in full force at the International
Association for Dental Research (IADR)/
American Association for Dental Research
(AADR)/Canadian Association for Dental
Research (CADR) General Session &
Exhibition in Seattle, Washington, from
March 20 to 23, 2013.
Erin Breen, DMD 15, who worked in Dr. Mohammad Assaggaf ORAL BIO 13; Said Dean Jeffrey W. Hutter, “It is through
Maria Kukuruzinska’s laboratory in the Mohamed Bamashmous ORTHO 13; Berokh efforts like those shown at this conference
Department of Molecular & Cell Biology, Bavar DMD 13; Ella Botchevar DMD14; that We convey to the global community the
was awarded an AADR Travel Grant spon- Erin Breen DMD 15; Sonal Chhanabhai School’s mission to be the premier academic
sored by the National Institute of Dental and DMD 15; Joshua Gilbert DMD 14; Matthew dental institution promoting excellence in
Craniofacial Research. Green DMD 15; Ritu Gupta ORTHO 13; Erik dental education, research, oral health care,
Harriman DMD 14; Debora Heller PERIO 16, and community service to improve the over-
ORAL BIO 16; Patrapan Juntavee ORTHO 15; all health of the global population.”
44 Im pr es s i on s | Spring 2013
class notes
administers licensure in the profession, is The Canadian Academy of Endodontics
involved in disciplinary situations, and many installed Douglas W. Conn ENDO 95 as
other important issues affecting dentistry. President at its Annual General Meeting in
Last month he was awarded the Gold Medal Edmonton, Alberta, on October 18, 2012.
from the American College of Dentistry for Dr. Conn has practiced endodontics in
distinguished service to ACLM on behalf of Vancouver since 1995. He is a clinical assis-
dentistry and law. It is the highest award pre- tant professor with the Faculty of Dentistry
sented by the organization. Seidberg success- at the University of British Columbia.
fully ran the 5th Annual Conference on Dental
Ethics and Law and will chair the 6th Annual Monica Anand DMD 10 opened an Aspen
Director of Alumni Relations & Annual Giving Stacey Conference in Dallas next year. Dental practice in Waltham, Massachusetts,
McNamee with classmates Dan Greenberg, Joseph in December 2012.
Calabrese AEGD 92, Peter Caviris, Doug Schildhaus PERIO Joseph Gian-Grasso PERIO 73 was elected
93, and Joseph DiBenedetto, all DMD 91, at the Greater
to the Academy of Osseointegration Board of Kiyan Mehdizadeh DMD 12 joined SmileCare
New York Alumni Club meeting in February Bakersfield in Bakersfield, California, in
Directors as President-Elect at the organiza-
The Greater New York Alumni Club has had tion’s 2013 Annual Meeting in Tampa, Florida. January 2013.
an exciting 2013 so far! The group meets Puneet Wadhwa DMD 12 opened an Aspen
every 1-2 months at New York City’s Cornell Michael J. Hunter CAS 82, DMD 86,
OMFS 90 was named president of the Dental practice in Jackson, Tennessee.
Club for dinner, conversation, and CEUs.
Massachusetts Society of Oral and Paul Farsai DMD 94, AEGD 95, MPH
Joseph Calabrese DMD 91, AEGD 92 pre- Maxillofacial Surgeons. He spent eight years 97 and Catherine Sarkis lead the ses-
sented on Success and Failure in Clinical as vice-chair and assistant professor in the sion, “Background Checks and Screenings
Geriatric Dental Medicine on February 6. Department of Oral & Maxillofacial Surgery in Dental Education: Establishing
Burt Langer PERIO 66 discussed Esthetic and the Director of Pain and Anxiety Control Professional Standards,” at ADEA in
Disfigurements on Teeth and Implants on at GSDM. Seattle. Sarkis received the ADEA Council
March 20. Sandra Morin DMD 89, PERIO of Sections Award.
91 spoke on Complications During Implant Brad Krusky
Therapy May 8. DMD 93 and wife Mahadeep Singh (Bobby) Virk ORTHO 06
Danni welcomed and wife Helena Skountrianos hosted the
new son George GSDM alumni reception at the Columbia
Nelson Krusky Tower Club in Seattle during ADEA.
into the world
on December
26, 2012; “just a
tad early and a George Nelson Krusky
smidge shy of 6
pounds,” said his dad, who also reports “both
George and mom are working well together,
and dad is proud to be teaching him to earn
Vincent Celenza PROS 79, DAB member Dan Budasoff
his keep—he’s not quite walking yet, but he’ll
PROS 80, and Burton Langer PERIO 66 at the Greater New
York Alumni Club meeting in March be shovelling snow in no time we’re sure!”
Dean Jeffrey W. Hutter, Sergio De Paoli PERIO 81, Kimberley, and Ron
Nevins PERIO 67
Sherry Bloomfield ENDO 02, Diego Capri PERIO 01, and Dr. & Mrs.
Andrea Chierico PERIO 94, Dean Hutter, and Gianfranco Vignoletti ENDO 82 Christiano Fabiani ENDO 93
46 Im pr es s i on s | Spring 2013
BUIA Board of Directors: Cultural Secretary Dr. Roberto Rossi, Dean Hutter,
President Dr. Tommaso Cantoni, Secretary Dr. Christiano Fabiani, and Counselor
Dr. Diego Capri (not pictured: Counselor Fabio Scutella)
Shiro Kamachi PROS 96, DMD 99; Kumi Kamachi AEGD 94, PROS 97, DMD 99; and
Marisa Bar, BUIA Honorary President Umberto Bar PERIO 63, and Dean Hutter Luca Landi PERIO 97
48 Im pr es s i on s | Spring 2013
The Last Word
What is usually a joyous day for Boston became a time of unspeakable horror as video
and photos were disseminated in real time across the globe. During those days of anxi-
ety, the GSDM family reached out to each other in so many ways: Calls, emails, and
texts went back and forth among classmates, students, families, faculty, and staff. From
Quincy, Massachusetts, to Abu Dhabi and everywhere in between, our GSDM family
members shared their concerns and tried to assure and console each other.
The GSDM family figured large in the events of April 15, Marathon
day. GSDM alumni, students, faculty, staff, and family members
were among the Marathon runners, the first responders, and the
medical teams at the various hospitals treating the wounded. I was,
and am, deeply proud of our GSDM family whose compassion and David Lustbader CAS 86, DMD 86
commitment to service were on full display during that terrible week.
Gerald M. Kramer
THE
50 Im pr es s i on s | Spring 2013
O cto ber 26, 201 3
SAVE
THE
DATE
Post, tag,
tweet, and
“like”. Ask questions,
See photos of your
classmates at recent reconnect with other
events and even watch alums, and find
students explore Central your next associate
American jungles online.
as they treat the
underserved.