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FEBRUARY 2020 V16 CE eBook 1

CE EBOOK

D I G I TA L W O R K F LO W

Interaction of CBCT,
Intraoral Scanning, and
CAD/CAM in Dentistry:
An Overview
Robert Pauley, Jr., DMD

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM DENTAL • Published by AEGIS Publications, LLC © 2020
 CE eBook
Continuing Dental Education
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Interaction of CBCT,
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Intraoral Scanning, and

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CAD/CAM in Dentistry:
CREATIVE
Claire Novo

EBOOK DESIGN

An Overview
Jennifer Barlow

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About the Author

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Interaction of CBCT, Intraoral
Scanning, and CAD/CAM in Dentistry:
An Overview
Robert Pauley, Jr., DMD
ABSTRACT
Dental implants have become an
increasingly preferred option for
patients with partial or complete
edentulism. Digital technology has
advanced to streamline and improve
the workflow for patients who are
receiving implants. This article will
focus on the use of a digital workflow
to optimize surgical and prosthetic
results. A digital workflow for
implant treatment protocols includes
3-dimensional cone-beam computed
tomography, intraoral scanning, and
CAD/CAM. This article will explain
each of these technologies, discussing
how they are used both individually
and together to form a comprehensive,
effective digital workflow.
LEARNING OBJECTIVES
• Describe the use of intraoral
scans and cone-beam computed
tomography data to treatment plan
and ultimately dynamically guide
predictable implant placement.
• Explain how intraoral scan
technology can reduce chairtime at
acquisition and also at the seating
appointment.
• Discuss common intraoral scanning
mistakes that may disrupt the
workflow between the dentist and the
laboratory technician.
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P
artial or complete edentulism adversely affects quality of
life and can have a derogatory effect on the maintenance
of an individual’s overall health.1,2 Nearly 1 in 5 Americans
65 years or older have lost all their teeth.3 Anyone with tooth loss
may be a candidate for implants; therefore, incorporating digital
workflow technology for implant treatment may be a useful plan
for any dental office.
The field of digital dental workflow has made great technologi-
cal advancements due to improvements in tools such as intraoral
scanners, CAD/CAM, cone-beam computed tomography (CBCT),
and software programs. These technologies have improved the
communication between clinician, technician, and patient. The
digital workflow streamlines processes, reducing treatment times
and costs.4 As a result, clinical practices are shifting to virtual-
based workflows, and digital dentistry is becoming an increasingly
substantial discipline.5 This article will discuss how to achieve the
goal of using technology to make dental workflows more accurate
and predictable, ultimately saving time and money.
An implant workflow or restorative workload begins with a di-
agnostic workup, which will include a complete medical and dental
history, hard- and soft-tissue charting, radiographs, and camera im-
ages. Digital technology such as intraoral cameras, extraoral cameras,
radiographic sensors, panoramic images, intraoral scanners, and
CBCT machines all contribute to developing a data set for each
patient. The data set will help with communication between everyone
involved in the treatment plan. Overall, the introduction of digital
systems into the diagnostic routine, and their application together with
3-dimensional (3D) data of bone topography, have made it possible to
reconcile the two central aspects of oral implant surgery: (1) planning
an ideal prosthetic solution with (2) the given anatomic situation.6
CONE-BEAM COMPUTED TOMOGRAPHY
The introduction of CBCT in the late 1990s represented an unparal-
leled advancement in dentistry, especially in the field of implant
surgery, in part because it greatly reduced radiation exposure to
FEBRUARY 2020

Fig 1. Different CBCT views allow the dentist to measure widths to determine whether an implant can be placed or whether bone
regenerative procedures will be needed before or in conjunction with implant placement.
patients compared with multislice CT.7-9 The in-
formation generated by CBCT offers the potential
of improved diagnosis and treatment planning for
a wide range of clinical applications in implant
dentistry.10 Originally, CBCT scans were obtained
with the patient wearing a radiographic template
with fiducial markers.11 However, now there is
also a radiographic template-free computer-guided
implant surgery workflow that can be used for
partially edentulous patients.12 If there are enough
remaining teeth, image fusion of the intraoral
scan data and the CBCT data can be performed
by matching resin markers placed in the patient’s
mouth.6 A CBCT scan obtains the patient’s bone
height, thickness, and angulation (Figure 1). This
information is important for treatment planning
because the next step is for the CBCT data to be
imported into virtual implant planning software to
formulate a prosthetically driven implant surgical
plan.13 These planning data are then transferred to
a surgical template that can be physically fabricated
in a variety of ways, either in or out of the office,
and using a variety of materials, including ceramic,
lithium disilicate, and zirconia.14
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Studies support the use of CBCT in dental im-
plant treatment planning particularly in regard to
linear measurements, 3D evaluation of alveolar
ridge topography, proximity to vital anatomical
structures, and fabrication of surgical guides.15 The
International Congress of Oral Implantologists rec-
ommends that all CBCT examinations, as well as
other radiographic examinations, must be justified
on an individualized needs basis.15 The benefits to
the patient must outweigh the potential risks. This
is again why it is critical to obtain a thorough medi-
cal and dental history, in addition to performing
comprehensive clinical examinations.
In addition to its use in diagnostics and treat-
ment planning, a CBCT scan can be used for
postsurgical evaluations (Figure 2). A postsurgi-
cal scan can be taken and placed over the image
of the treatment plan to evaluate how close the
implant is to the original plan. The practitioner
may want to implement the cotton roll technique,
in which a cotton roll is placed on areas to high-
light the area on the CBCT.16 The cotton roll
works by keeping the soft tissue pushed down
to better visualize the bone. Similarly, cotton
FEBRUARY 2020

Fig 2. Left: Postsurgical evaluation of a bone graft in site No. 8 after extraction and graft. Right: Overlay of a CBCT after dynamically guided
placement of an implant in site No. 6, showing the implant was ultimately placed where planned.
rolls can be used before a CBCT scan involving
a denture: lingual cotton rolls can be used to keep
the tongue away from the lingual slope of the
complete denture; occlusal cotton rolls permit
visualization of the occlusal surface details; and
buccal cotton rolls can keep the cheeks and lips
away from the denture surface.17 Thus, apart from
radio-diagnostic possibilities, CBCT may offer
a huge therapeutic potential related to surgical
guides and further prosthetic rehabilitation.18
A CBCT scan can provide dentists with more
precise diagnostic information than traditional
radiography and impressions, especially when
combined with intraoral scanning.
INTRAORAL SCANNERS
Intraoral scanners allow a dentist to skip creating a
physical impression of a tooth meant for restoration,
as well as create more accurate and cleaner scans
for a laboratory technician to use to create quality
restorations. A digital workflow does not mean the
dentist must mill in-house; digital data can be sent
to a laboratory or milled in-house, depending on
preference. The accuracy of a digital impression
technique to fabricate the implant restoration and
abutment for a dental implant using an intraoral laser
scanner may greatly improve the quality of these
restorations. Intraoral scanners allow an immediate
determination of the quality of an impression and
have the capacity to easily send the models to the
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laboratory using email or a software program, thus
reducing expense and time. Compared with physical
impressions, intraoral scans are often more comfort-
able for the patient and faster.
A variety of intraoral scanners and software
are on the market. It is important to consider the
quality of the data derived from scanning when
choosing which device to incorporate into a dental
practice.19,20 Intraoral scanners and software are
used in one of the most critical first steps in the
2D/3D digital design process: documenting a pa-
tient’s smile (Figure 3). The use of dynamic smile
documentation provides more efficient diagnoses,
more consistent treatment plans, and improved fi-
nal results.21 This design process can be performed
in an entirely digital workflow and will help with
all rehabilitative procedures. The advantages of
using video documentation are that it facilitates and
simplifies the documentation process and improves
smile design, facial analysis, treatment planning,
team communication, and patient education.22
Although intraoral scanners are integral to the
digital workflow, they are not without limitations,
and there is a learning curve for adopting intraoral
scanners into a dental clinic.23-25 Dentists who
are more comfortable in the digital technology
world will likely find it easier to adopt intraoral
scanners into their practice than dentists who are
less experienced in technological innovations.23-25
Additionally, unlike the conventional impression
FEBRUARY 2020
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Fig 3. Intraoral scanning documents a patient’s smile from various views. Fig 4. Dynamic guided implant treatment-planning panoramic with
intraoral scan imported, allowing treatment planning with occlusion between arches.

materials, light cannot physically detach the gum
and therefore cannot register nonvisible areas.26
Similarly, commonly cited challenges with in-
traoral scanners and optical impressions include
difficulty in detecting deep margin lines in pre-
pared teeth or in cases of bleeding.27 Practice,
proper attention, and strategies for highlighting
preparation lines and avoiding bleeding make it
possible for clinicians to detect a satisfactory opti-
cal impression even in difficult contexts.19
CAD/CAM
Computer-guided surgery has been validated
since the introduction of digital technology in the
early 2000s as an efficient and reliable technique for
obtaining functional and esthetic outcomes (Figure

6 INSIDEDENTISTRY.NET FEBRUARY 2020


Patient preference was significantly in favor of
a digital technique when compared with
conventional impression techniques because it
often reduces a patient’s stress and discomfort.
4).28,29 Computer-guided implant surgery is defined
by the use of a surgical template that reproduces
a virtual implant position designed from digital
data.30 If a dentist is using a static surgical guide, it
can be created with the use of 3D printing.31 CAD/
CAM software is an essential tool because it is
responsible for guiding robotic devices that design
objects and assemblies in a virtual environment.32
CAD/CAM machines can be used to manufacture
ceramic restorations based on computer-assisted
design and produce a restoration at a single dental
appointment, an increasingly popular process.33
Dentists can directly scan prosthetic preparations
or scan bodies, import those scans into a CAD
program, design the restoration, and mill them in
an esthetic material.34,35 The restorations are then
delivered to the patient through what has been a
succinct digital workflow.
DYNAMIC SURGICAL NAVIGATION
The next step that is possible with fully digital
dentistry is dynamically navigated dental im-
plants. Computer-assisted surgery can be either
static or dynamic. Static guides are 3D printed
from CAD/CAM and 3D data, as described in
the previous section. Dynamic navigation com-
bines digital data from CBCT scans and intraoral
scanners so the surgeon can virtually plan the
ideal implant location and then use that plan to
surgically navigate the exact implant placement.
By using these three technologies together,
the surgeon can plan and place implants with an
optimal restorative goal in mind. Using dynamic
navigation to more accurately place the implant
can result in a more functional and esthetic
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outcome. Dynamic navigation tracks the patient
position and live movements of the handpiece drill
in real time on a computer screen. With dynamic
guidance, the surgeon can view the handpiece’s
position, angle, and depth while drilling as they
relate to the planned implant placement.
Clinical studies show that implants placed
with dynamic navigation are more accurate than
freehand implant placement.36 Static and dynamic
image navigation are both highly accurate sys-
tems; however, dynamic systems have additional
advantages. Patients can be scanned and planned
and have surgery in one day, and plans can be
altered during surgery as needed based on the
clinical situation. Moreover, the entire field can
be visualized throughout the process, allowing
accuracy to be verified at any time.36
CONCLUSION
CBCT, intraoral scanners, and other image-acqui-
sition devices are critical parts of the digital dental
field. They can be used to create a fully digital
workflow for optimal prosthetic results that are
easy to obtain and affordable. Another advantage
of using a digital workflow is that with the creation
of a preoperative mock-up, the patient can see the
impact of the new smile before committing to the
treatment and irreversible procedures, thereby
increasing patient education and case acceptance.
Scientific literature shows that a digital workflow
is more efficient than the previously common
conventional pathway.4 Studies have also found
that overall, patient preference was significantly
in favor of a digital technique when compared
with conventional impression techniques because
FEBRUARY 2020

it often reduces a patient’s stress and discomfort.37
Digital techniques are therefore not only beneficial
for dentists in the time saved and accuracy gained
but preferred by patients as well.
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Implants. 2017;32(1):70-80.
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four intraoral scanners in oral implantology: a comparative in
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FEBRUARY 2020
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Quiz
2 CDE Credits
TO TAKE THE QUIZ, VISIT
http://www.aegisdentalnetwork.com/go/CARECADCAM
ENTER PROMO CODE: IDCADCAM
10. Macedo RG, Robinson JP, Verhaagen
B, Walmsley AD, Versluis M, Cooper PR,
Interaction of CBCT, Intraoral Scanning, and CAD/CAM in Dentistry:
and van der Sluis LM. A novel methodology
An Overview
providing new insights into the ultrasonic
removal of aJr.,
Robert Pauley, biofilm-mimicking
DMD hydrogel
from lateral morphological features of the root
1. When was cone-beam computed tomography 6. Adopting a digital workflow means milling should
canal. Endod J. 2014; 47: 1040–1051.
Intintroduced?
(CBCT) happen where?
11.A.Vandrangi
late 1990s P, Basrani B. Multisonic ul- A. in-house B. in a laboratory
tracleaning in molars with the GentleWave
B. late 1950s C. either A or B D. neither A nor B
system.
C. earlyOral Health. 2015;May:72-86.
21st century
D. early 20th century 7. Compared with physical impressions, intraoral scans
are often what?
2. A CBCT scan obtains what information about the A. more comfortable for the patient B. faster
patient’s bone? C. both A and B D. neither A nor B
A. height B. thickness
C. angulation D. all of the above 8. What does the use of dynamic smile documentation
provide?
3. Which of the following is a material that can be used A. more efficient diagnoses
when physically fabricating a surgical template? B. more consistent treatment plans
A. ceramic C. improved final results
B. lithium disilicate D. all of the above
C. zirconia
D. all of the above 9. What is one of the most commonly cited challenges
with intraoral scanners and optical impressions?
4. In addition to diagnostics and treatment planning, A. that it can be difficult to detect deep margin lines in
what can a CBCT scan can be used for? prepared teeth or in cases of bleeding
A. caries detection B. that materials are not esthetically pleasing
B. postsurgical evaluations C. that there are too many steps involved in the optical
C. root canals impression process
D. all of the above D. That intraoral scanners are too complicated and
expensive
5. When using a cotton roll before a CBCT scan involving
a denture, how is the buccal cotton roll used? 10. Why have studies found patient preference
A. to keep the tongue away from the lingual slope of the significantly in favor of a digital technique when
complete denture compared with conventional impression techniques?
B. to permit visualization of the occlusal surface details A. It is less complicated.
C. to keep the cheeks and lips away from the denture B. It often reduces a patient’s stress and discomfort.
surface C. It is safer.
D. to evaluate how near the implant is to the original plan D. all of the above

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Concerns or complaints about a CE provider may be directed
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TO TAKE THE QUIZ, VISIT a state or provisional board of dentistry
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of approval extends from 1/1/2017 to
ENTER PROMO CODE: IDCADCAM 12/31/2022. Provider #: 209722.

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