Implementing Digital

D e n t i s t r y i n t o Yo u r E s t h e t i c
Dental Practice
a, b
Lawrence Fung, DDS *, Phil Brisebois, BA

KEYWORDS
 Digital dentistry  Intra oral scanners  Smile design  CAD/CAM milling
 3D printing

KEY POINTS
 The use of digital dentistry is on the increase as costs to acquire digital technology have
gone down dramatically and allowed for more practitioners to integrate digital equipment
with reduced investment.
 One of the most significant benefits of digital technology in dentistry is the ability to
streamline processes that can be cumbersome via the analog way.
 In digital dentistry, it is important to understand the advantages and disadvantages of
each device or system available.

INTRODUCTION

When we look around, it is amazing yet eerie to see how surrounded we are by tech-
nology. The word technology comes from 2 Greek words, translated into techne and
logos. Techne means art, skill, craft, or the way, manner, or means by which a thing is
gained. Logos means word, the utterance by which inward thought is expressed, a
saying, or an expression. Literally, then, technology means words or discourse about
the way things are gained. In today’s more relevant definition of technology, it can be
broken down into 4 working subsets: technology, an object, knowledge, and last, a
process. For the purposes of this article, the authors expand on all of these subsets
for digital dentistry. Digital dentistry and its implementation into practice is more
than just the piece of equipment. It is important to understand more than how to
use the device, the nuances of the technology, the processes involved, and how
the technology fits into your existing practice system.

a
UCLA Center for Esthetic Dentistry Lecturer, 6101 West Centinela Avenue, Suite 375, Culver
City, CA 90230, USA; b UCLA Center for Esthetic Dentistry Lecturer, Founder NOVO Dental
Studios & GRAVIDEE, 465 N Roxbury, Suite 703, Beverly Hills, CA 90210, USA
* Corresponding author.
E-mail address: Lawrencf@[Link]

Dent Clin N Am 64 (2020) 645–657

[Link] [Link]
0011-8532/20/ª 2020 Elsevier Inc. All rights reserved.
646 Fung & Brisebois

As with anything new to an existing system, there are pros and cons of modifying a
single process within the current work flow; digital applications are just additional tools
in your toolbox, like a hammer and a screwdriver.
In digital dentistry, it is important to understand the advantages and disadvantages
of each device or system available. From a well-rounded understanding, you will be
able to see how and if it fits within your practice. Just like any other instrument, digital
technology also has its limitations; in some situations digital technology works very
well, whereas in other circumstances, digital technology may be contraindicated, simi-
larly to using a screwdriver instead of a hammer. Herein, the authors discuss digital
technology in dentistry, its advantages, shortcomings, and it potential to elevate
how to practice contemporary dentistry with a vision to the future.
The use of digital dentistry is on the increase as costs to acquire digital technology
(digital radiology, for example) have decreased dramatically and allowed for more
practitioners to integrate digital equipment with reduced investment. For the purposes
of this article, the authors focus on the acquisition of patient data by exploring digital
intraoral scanners and digital radiography and they touch briefly on digital photog-
raphy. They also look at the applications one can have with the digital data, and their
potential outputs-associated 3-dimensional (3D) printing and milled restorations.
One of the most significant benefits of digital technology in dentistry is the ability to
streamline processes that can be cumbersome via the analog way. The biggest incen-
tive about creating more efficiency in a dental practice is the ability to provide consis-
tent high-quality dentistry while decreasing costs for the patient. In any business, the
net operating income, namely, the amount of money left over after expenses, is some-
thing that cannot be ignored, and therefore, reducing the chair time needed per pro-
cedure will bring about more revenue generated on a daily basis, and digital dentistry
can speed up certain processes, allowing for a more efficiently run practice. In the au-
thors’ practice, for example, new patient data acquisition time was reduced dramat-
ically with the use of digital technology, especially when considering the time
needed for preliminary physical impressions, to pour up the models, to mount the
case as well as to store the cases.
In the authors’ practice, the new patient record includes a full set of photographs,
intraoral scan, and a full-mouth radiograph set. A scan will allow the practitioner to
evaluate the dentition and discuss with the patient immediately on a 3D model versus
having to wait to pour up a case, mount on an articulator, and then bring the patient
back to discuss the findings. Because data are stored digitally, the practitioner can
reference the acquired data at any time, thus enabling the practitioner to go back
into these digital files to reexamine the patient to ensure nothing was overlooked.
Another advantage of digital dentistry is how the practice can expand their bound-
aries when assembling the dental team. In an esthetic dental practice, having an
exceptionally capable ceramist in the team and using digital technology enable the
practitioner to work remotely and send patients’ cases to practically any ceramist
throughout the globe. In addition, with the quality of digital photography and its accu-
racy at capturing color, shade match can be done remotely as well. With the use of
calibrated gray cards and polarized lens photography, accurate color information
can be transmitted to the ceramist; this can eliminate the need for a custom shade
appointment that would have normally had to be done in person by the ceramist.
Another noteworthy advantage of transitioning and embracing digital capabilities is
demonstrating to existing as well as new patients how updated your approach is. Not
only do patients appreciate seeing that their caregiver is up-to-date but also many
admire clinicians who are leaders in technology, and they become your biggest advo-
cates. By the same token, as patients become increasingly aware of advances in
 Implementing Digital Dentistry 647

dentistry, if you do not have the updated technology in your office, they may question
your professional abilities. One great example is with the significant advertising being
done by those clear aligner therapy startups, such as Smile Direct Club, and how their
stores feature intraoral scanners. As more and more of the public are aware of these
scanning technologies, the more they expect it to be the norm.

DRAWBACKS OF DIGITAL TECHNOLOGY IN DENTISTRY?

Startup Costs
The costs are still relatively high when considering acquiring digital dental equipment.
Many of the systems operate on a subscription-based licensing platform. For
example, some Digital Smile Design Apps require a yearly subscription. Likewise,
some intraoral scanners have a monthly or annual fee, and cloud-based data storage
for backups often comes with a fee. Training is usually provided by the equipment
distributor, but any advanced instructional use of technology is not. Because of the
limited resources provided by many digital companies, the learning curve can be quite
steep initially.
Lack of Standardized Work Flows
It is the authors’ experience that digital dentistry currently lacks well-defined universal
work flows that can be seamlessly integrated into any practice. Interoperability is an
issue, and different data acquisition devices from different companies will export
different file types. Although the universally accepted digital scan file is stereolithogra-
phy (STL), some of the scanners will prefer to export in their own native scan files, such
as a polygon file format (PLY) or in the case of 3shape, it will export as a Digital Imaging
and Communications in Medicine format (DCM), which will need to be converted to
STL.
Limited Access to Digital Partners
One of the biggest challenges of digital is finding other members of the dental team
that use digital technology, because many of the higher-end small-scale laboratories
are still not fully digital because of the lack of digital case submission volume. The cost
for the small laboratories to acquire printing technology in-house and digital design
software may not be economically feasible if most of their current client list is not
digital.
Intraoral Scanners and Scanning
The following are some of the current popular scanners. In the graph, the pros and
cons of each system are displayed. Speed and cost can vary, and there is no consis-
tent correlation between those mentioned above and output quality. Some require
additional equipment to operate them (like a laptop for 3Shape). Although some scan-
ners may be more accurate, the size of the intraoral camera may be an obstacle for
some circumstances, like capturing distobuccal cusp of maxillary second molars or
a limited size oral cavity (ie, pediatric dentists and orthodontists). A learning curve
and adjustment for scanning, and scanning sequence and digital workflow present
other challenges when integrating digital impressions.1 Also, determining deep mar-
ginal finish lines of prepared teeth2 can be exceedingly more challenging and require
an additional skill set to be learned.
The Digital Dentistry as part of the restorative process can be broken down into 3
step: Data-acquisition, design, and manufacturing. In this section, the different op-
tions and systems for digital impressions are discussed. Although there are several
different digital impression systems on the market today, there are only 3 categories
648 Fung & Brisebois

these systems can be categorized into: (1) scan only (stand alone); (2) scan, design,
and output to a third-party mill; and (3) all-in-one ecosystem.

Stand-alone systems
There are several stand-alone systems on the market today; however, the following 5
would be considered the most relevant scanners. They include Cerec Primescan,
Carestream CS, iMedit 500, iTero, and Trios. Each of these scanners makes a very
high-quality digital impression, and all have specific features and benefits designed
to enhance the user experience.
It is important to note that although each of these scanners will make an impression
in color, that this color image is not always transferred to the laboratory for fabrication.
In order to achieve the highest-quality restorative outcome, it is extremely important to
understand the technology and software that your laboratory is using to process your
digital impressions. For example, although itero, Carestream, Cerec, and Medit all
make digital impressions in color, the STL that is provided to the laboratory for fabri-
cation is a black and gray scale image, making it more challenging and most times
impossible to mark the margin, especially with veneer and equigingival preparations.

Scan, design, and output to a third-party mill

The next category of products is used for scanning the patient, but also has the ability
to add chair-side design software. Although purchased separately, Trios by 3Shape
allows seamless integration, and with additional modules can be purchased directly
from 3Shape and added to the Chairside Dental Desktop software. These modules
include Implant Studio, Smile Design, Restorative Design, Ortho Simulator, Caries
Detection, and the CAM software required to output design to an in-house mill. Other
intraoral scanners can also be integrated as part of chair-side systems, but unlike
3Shape, use a second party design software called exocad ChairsideCAD.

All-in-One ecosystem
The systems available in this category are Planmeca Emerald and Sirona Cerec. These
systems allow a dentist and team to make a digital impression of a patient in their of-
fice, use the internal design software to design a restoration for the patient, and mill
that restoration using an integrated in-office mill. These systems have proven to be
very successful for some users but require a very specific workflow to be clinically suc-
cessful. Both systems are simple in their setup: included is an intraoral scanner with
built-in design software and a mill with built in CAM software,“call it plug and play.”
The challenge lies in the processing of the material and patient timing. The 2 most
commonly used materials in dentistry are Emax and zirconia, and both require post-
processing and sintering times that range from 45 minutes to 10 hours. A true benefit
can be seen using this technology to mill composite and polymethyl methacrylate for
inlays/onlays and also temporaries. In addition, both the Planmeca Emerald and
Sirona Cerec are also available as a stand-alone system, whereby digital impressions
can be made and sent to the laboratory for fabrication.
When investing in technology, it is important to consider one’s potential future use. If
the goal is to eventually have the ability to be self-sufficient and produce most resto-
rations in-office, it is important to consider the workflow and available options for each
specific scanner system when planning a purchase. The integration and workflow are
not as seamless as many manufacturers promote, and each system has their own
nuances.
Just like the system setup for the dental operatory, the dental laboratory has a va-
riety of different hardware and software that can be used to design and fabricate indi-
rect fixed restorations, digital dentures, implant planning, surgical guides, and
 Implementing Digital Dentistry 649

restorations, as well as other dental devices. Nowadays, most if not all dental pros-
thetics can be fabricated using CAD/CAM technology.
Although all systems are open and produce an STL file, the file format is in gray scale
and does not demonstrate colors and therefore cannot differentiate between tooth
and tissue colors. It is the responsibility of the scanner manufacturer to produce a
color-ready file or alternatively a file that can export the finish-line position ready to
be used by the laboratory for margin evaluation and restoration design. The inability
to view the file in color may create a real challenge for the restorative dentist when
evaluating a digital impression for finish-line reproducibility.
Regardless of the scanner’s ability to import and export into laboratory software in
color, they all work well to make digital impressions for crown and bridge, implants
workflow, dental appliances, smile design, and treatment planning. The key with all
of the systems still boils down to the quality of dentistry. None of the scanners have
the ability to see through tissue, and therefore, it is essential that tissue be retracted
properly from the margin, as well as preventing fluids from hindering a qualifying
impression. Equally important, the digital impression must be evaluated on screen
before being sent to the laboratory for fabrication (Fig. 1).
Fig. 2 demonstrates a workflow for the initial new patient visit. Once the data are
acquired from the patient, the information is uploaded into the patient management
software or onto a HIPPA-compliant storage program. With the use of digitally
collected patient dental conditions, they can be viewed with the patient for clear
communication and dental education.
The work flow chart in Fig. 3 is for indirect restorations and or dental appliances,
such as an occlusal guard. The process is not really different from the analog way;
instead of making an impression with polyvinyl siloxane impression material, you
would just capture the prepared data or dentition digitally. The biggest caveat of digital
dentistry is the ability to have the preparation or impression sent to the laboratory
immediately, saving pickup travel time, with zero risk for cross-contamination. Another
big advantage of digital is the ability to review the preparation or impression to ensure
there are no inaccuracies present that may warrant a new impression. A big advantage
of digital for indirect preparations, especially onlay preparations, is the ability to see
interocclusal reduction in real time to help reduce underreduction. Reviewing prepa-
rations in real time in occlusion will also help aid the practitioner from overreducing
preparations as well, allowing for the esthetic dentist to be as minimally invasive as
possible.
It is important to understand dental technology is changing at the fastest rate yet,
and it is imperative to keep up-to-date. Luckily, there are more resources available on-
line than ever, including continuing education courses and forums that can easily be

Fig. 1. (A) Scan made in color; (B) scan exported as a black and white STL into 3D software.
650 Fung & Brisebois

Fig. 2. Workflow for the initial new patient visit.

found on social media platforms that allow for crowdsourcing to help solve any digital
dentistry problems the clinician may have.

DIGITAL WORKING PROTOTYPE

Fig. 4 is the result of performing a digital smile design from an intraoral mockup to a
final product. Doing a digital wax-up is a great way for patients to preview and try
out their final product without any kind of tooth preparation.
The initial presentation of the patient was the top image. The chief complaint was
that the patient did not like the diastema between #8 and #9 and that the laterals
felt too narrow. The patient also had some bonding done before but was tired of the
need to keep replacing the composites and wanted something more long term.
With digital smile design, we were able to show the patient a visual representation
of the proposed changes. Once the patient approved the digital smile design, an
intraoral mockup was done to verify fit, esthetics, and phonetics of the new proposed
restorations. Once the patient signed off on the intraoral mockup, the scan was sent to

Fig. 3. Workflow for indirect restorations and or dental appliances, such as an occlusal
guard.
 Implementing Digital Dentistry 651

Fig. 4. Digitally modified smile.

the orthodontist, and they used it as a guide to close the diastema between #8 and #9
and create some restorative spacing on the mesial and distal of #7 and #10 to allow for
minimal reduction for the proposed feldspathic veneers.
A summary of the whole procedure as seen in Fig. 5 is from start to final product.
The case was done digitally and remotely with a laboratory, and shade matching
was only done chair-side with photography; no try-in was needed. The patient did
not have to travel to the laboratory, saving time and allowing for the practice and pa-
tient to use any ceramist in the world.

Fig. 5. Initial and postrestorations and orthodontics. (Courtesy of Lawrence Fung, DDS,
Culver City, CA.)
652 Fung & Brisebois

Fig. 6. Initial presentation. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)

The chief complaint is the narrow laterals that were restored with conservative com-
posite restorations and the diastema between the 2 centrals (Fig. 6). The patient not
only wanted to close the diastema between the centrals but also wanted more
fuller-looking lateral incisors. The patient wanted the least minimally invasive proced-
ure done.
In this case, once the digital wax-up was provided by the digital designer, using a
SprintRay Pro (Los Angeles, California), the models for putty matrix fabrication and
evaluation were printed in-house (Fig. 7). The SprintRay Pro (Figs. 8 and 9) is a digital
light projector (DLP) printer that can print 2 inches in height per hour, so in this case,
the print took about 45 minutes. For 3D printing, there are DLP and SLA (STL). The
latter is significantly older but more accurate yet slower than the former. DLP, howev-
er, is starting to catch up in micron accuracy. A big benefit of DLP is the machines are
much less expensive than the SLA machines.3 The SprintRay Pro, which was used to
print the smile design models, is a DLP.
The patient, after reviewing the smile preview, was able to have an intraoral
mockup done to visualize immediately the proposed changes. Although the patient
is wearing this mockup, the mockup can be adjusted intraorally, and the new con-
tours can be scanned to help aid the digital designer when finessing the digital
wax-up (Fig. 10). The digital wax-up will serve as a blueprint for the new final resto-
rations and temporaries. The materials used for the intraoral mockup was Telio CS
from Ivoclar. The putty matrix used to duplicate the wax-up to the dentition was
Flexitime from Kulzer.
Fig. 11 shows 2 shades, one for the closest match and a second to offer as a com-
parison. The shade guide the author likes to use is VITA Classical. One of the biggest
advantages of digital dentistry is increased efficiency in the workflow.

Fig. 7. Printed model. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)
 Implementing Digital Dentistry 653

Fig. 8. SprintRay Pro 3D printer. (Courtesy of SprintRay, Los Angeles, CA.)

In Fig. 12, the shade identification is marked so the ceramist can verify the shade
classification. Always include comparison shades as a way for the ceramist to cali-
brate color.
The filter removes unwanted reflections from the teeth that are caused by a flash.
These highlights can send false information to the ceramist. In the cross-polarized
photograph, you can see the hypersaturation of color and contrast much better
(Fig. 13). These filters are great, especially where any decalcification may be present,
and aids the ceramist when fabricating the custom restorations. The product the
author uses is polar_eyes from PhotoMed.

Fig. 9. SprintRay die and model resin. (Courtesy of SprintRay, Los Angeles, CA.)
654 Fung & Brisebois

Fig. 10. Try-in of the digital smile preview. (Courtesy of Lawrence Fung, DDS, Culver City,
CA.)

Once patient data are collected by the doctor and sent to the laboratory for fabri-
cation, the design workflow becomes the same. When a dentist sends an impres-
sion to the laboratory, whether it is digital or conventional, the same process for
designing and manufacturing will occur. A digital impression should be kept in a
full digital workflow throughout the production process in order to eliminate
inaccuracies.
Using digital technology allows the technician to evaluate the restoration prepro-
duction while looking at all aspects of the case, including interocclusal spacing, emer-
gence profile, margin position, and virtual articulator movements to evaluate
restorations in function. The programs can then help the technician evaluate material
requirements and help to determine if adequate space has been provided to produce
the prescribed restoration. The system can also suggest different materials to produce
a more subtle solution if preparations are less than ideal. The system and its precise
calibration with manufacturer material specifications will also ensure consistent resto-
rations will be fabricated.
With implants, digital technology allows for an easy transfer of information for
transmucosal profile by simple scanning of the restorative site. Fig. 14 is an
example of a surgical plan with an immediate custom healing abutment that was
designed from the preplanned implant coordinates, allowing the surgeon, restoring
doctor, and laboratory to plan the most ideal position of the implant based on the
desired prosthetic outcome. It also allows for the development of soft tissue from
the time of implant placement. The custom healing abutment will begin to support

Fig. 11. Shade selection.

 Implementing Digital Dentistry 655

Fig. 12. Shade tabs chosen. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)

Fig. 13. Shade taken with cross-polarizing lens. (Courtesy of Lawrence Fung, DDS, Culver
City, CA.)
656 Fung & Brisebois

Fig. 14. Surgical plan with an immediate custom healing abutment that was designed from
the preplanned implant coordinates.

Fig. 15. It is effective to digitally record a predeveloped emergence profile and use that in-
formation to design the most ideal custom abutment and restoration.
 Implementing Digital Dentistry 657

and form the tissue profile that will aid in the development of papilla and is easily
modified by simply adding composite if the transmucosal design requires
modification.
In Fig. 15, it can be seen how effective it is to digitally record a predeveloped emer-
gence profile and use that information to design the most ideal custom abutment and
restoration.
In summary, digital dentistry could be a great addition to any practice. It does, how-
ever, have its drawbacks that need to be thoroughly understood. The digital process
and workflows could be superior to conventional techniques in some respects, but the
practitioner must be motivated to create systems in place to maximize the benefit of
digital technology in the practice.
Incorporating a digital workflow into a dental environment is a daunting task.
Whether in a clinical or laboratory environment, workflow options are endless, and
the variety of technology is vast. The benefits of using technology are clear: increased
levels of communication, predictability, and improved patient care.

DISCLOSURE

L. Fung, DDS is a paid consultant for SprintRay 3D printing technologies. P. Brisebois

has nothing to disclose.

REFERENCES

1. Zaruba M, Mehl A. Chairside systems: a current review. Int J Comput Dent 2017;
20(2):119–213. Available at: [Link]
systems-current-review.
2. Mangano F, Gandolfi A, Luongo G, et al. Intraoral scanners in dentistry: a review of
the current literature. BMC Oral Health 2017;17(1):149.
3. All3DP. SLA vs DLP: the differences – simply explained. Available at: [Link]
com/2/dlp-vs-sla-3d-printing-technologies-shootout/. Accessed October 12, 2019.

FURTHER READINGS

Ender A, Mehl A. Influence of scanning strategies on the accuracy of digital intraoral

scanning systems. Int J Comput Dent 2013;16:11–21.
Gurrea DDS. Evaluation of dental shade guide variability using cross-polarized
photography. Int J Periodontics Restorative Dent 2016;36:e76–81.
Hegenbarth EA. Esthetics and Shade Communication: A Practical Approach. Eur J
Esthet Dent 2006;1(4):p340–60.
Reshad M, Cascione D, Magne P. Diagnostic mock-ups as an objective tool for pre-
dictable outcomes with porcelain laminate veneers in esthetically demanding pa-
tients: a clinical report. J Prosthet Dent 2008;99:333–9.
Robertson AJ, Toumba KJ. Cross-polarized photography in the study of enamel de-
fects in dental paediatrics. J Audiov Media Med 1999;22(2):63–70.
Sancho-Puchades M, Fehmer V, Hämmerle C, et al. Advanced smile diagnostics us-
ing CAD/CAM mock-ups. Int J Esthet Dent 2015;10:374–91.
Seelbach P, Brueckel C, Wöstmann B. Accuracy of digital and conventional impres-
sion techniques and workflow. Clin Oral Investig 2013;17:1759–64.
SLA vs DLP: the differences- simply explained. By Ricardo Pires. 2019. Available at:
[Link]