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Desktop and Intra-oral Scanning: Adding another dimension to the virtual patient by Craig E. Scholz, PhD

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by John M. Pobanz DDS, MS

In 2004, I went to hear Dr. David Hatcher speak about the latest convergence in digital imaging in orthodontics. Cone beam computed tomography (CBCT) machines were becoming popular on the market and were able to reveal new aspects of the patient anatomy and provide exciting treatment possibilities. Dr. Hatcher spent a good deal of time describing the “virtual patient,” a digital replication of the “anatomical truth” that could be constructed using data from two-dimensional photographs, X-rays and 3D CBCT data. Recent advances in desktop and intra-oral scanners have given orthodontists additional data to use toward the creation of the virtual patient. With these devices and exciting new advances in software, practitioners can now incorporate precise surface data from the teeth and gums and use this information for an exciting array of treatment possibilities. In his Journal of Clinical Orthodontics cutting edge article earlier this year, Dr. Ron Redmond wrote, “In the race between CBCT and scanning technologies, it appears to me that the intra-oral scanner has taken the lead and is sprinting toward the finish line.”

The two primary means for acquiring digital impression data in office is through the use of desktop scanners, which scan impressions and models, and intra-oral scanners, which can take direct digital impressions. Both types of scanners have several key benefits and limitations that will be described. After the image is acquired, the orthodontist has an exciting set of possibilities for his or her digital data. Archiving, measuring, producing virtual setups, as well as fabricating various appliances all are now possible by utilizing these systems. Many of the systems allow for the creation of a non-proprietary file that can easily be uploaded to a lab so an appliance can be constructed. And some of the newest intraoral scanners and software can be used for printing aligners and other appliances directly in your office, reducing costs and time associated with outside fabrication.

Desktop Scanners
While digital study models have been available (e.g., Cadent’s OrthoCAD service), several new options exist for orthodontists to scan models to create a digital file in their own offices. Several companies have emerged over the past few years, which provide small desktop-scanning devices that can be used to scan models in office. These systems provide an easy way to quickly scan models for storage and also include a variety of software applications. For example, Motion View, Inc., provides a popular desktop scanning solution and offers a host of after-scan features such as ABO and Bolton analyses, measuring tools and the ability to combine scan data with CBCT data. Data is saved in non-proprietary file format so that it can be uploaded to a dental lab for appliance fabrication. An increasing number of dental labs are able to work with the digital files from the scanners to fabricate aligners, Hawley, retainers and a variety of orthodontic appliances.

Desktop scanning solutions can be an effective way to store and retrieve study models. I know several orthodontists who paid for their system after reducing model storage fees in less than one year. The scan time is relatively quick and can be done by an assistant with minimal training. Although less expensive than intra-oral scanners, the major drawback to the desktop solutions is that unlike intra-oral scanners, they still require impressions. This disparity will likely become even greater as intra-oral scanners essentially eliminate traditional impressions and are able to digitize stone models. In addition, desktop scanners have difficulty capturing undercuts in impressions, particularly with crowded lower incisors. Nevertheless, they can provide a useful, cost-efficient way to eliminate model storage, offer treatment-planning tools and deliver a digital output necessary to fabricate appliances.

Intra-oral Scanners
Intra-oral scanners have been popular in general dentistry for years. These handheld wand-type devices connect directly to a computer, large monitor and voice-guided software to assist in capturing the digital impression. The utilization of these scanners gives the dentist the ability to produce a variety of restorations and cosmetic applications such as crown and bridges, veneers and inlays directly from the digital impression. Sirona’s CEREC system is the most utilized scanner in dentistry, although there are an increasing number of units being offered. These include 3M’s Lava system, the E4D system from Henry Schein, the iTero scanner from Cadent and the IOS FastScan. As is the case with many new technologies that are designed for the general practitioner, it isn’t long before they reach the orthodontic market.

The scanners developed for orthodontics are able to scan the entire arch relatively quickly and precisely, and eliminate the tasks associated with conventional impressions completely. Not surprisingly, patients’ preference of digital impressions over conventional ones is significant (77 percent in Sonis, et al., 2010 JCO study). Soon we will see a whole host of intraoral scanners at the orthodontic meetings, led by the iTero scanner from Cadent (which was purchased by Invisalign in 2011). The iTero scans can be quickly uploaded to Invisalign, used to produce aligners and are also available for OrthoCAD digital model system. Many other companies including 3M and IOS FastScan will have intra-oral scanners on the market for orthodontists soon.

There are several important factors to evaluate when considering these devices, the first of which is the cost. Intra-oral scanning systems can range from $20-55K and some of these systems also charge “per scan” fees for converting and saving files. It is important to factor in these fees and to determine if the system allows for saving non-proprietary files (usually STL) that can be used by most dental labs. Similar to low-cost color printers, the long-term costs of replacing ink cartridges (paying “per click” fees with scanners) often outweigh lower up-front expense. In addition, scan times between systems vary significantly. I have heard reports of full scans ranging from five to 30 minutes depending on the patient and scanning system – clearly an important variable when choosing a system. Finally, many of the scanners require a small amount of coating on the teeth to improve the quality of the scan, the notable exception being the iTero system. While this coating might add slightly to operating expenses and chairtime, it can also improve the scan quality.

Putting it All Together
All the mentioned scanning devices are equipped with software to record the scan and to save the digital file. Two notable companies have incorporated the intra-oral scan data in enhanced ways. The first of these is Anatomage, a CBCT software system, which is widely used among orthodontists. The company offers its InVivo software on many new 3D CBCT machines and allows for the reconstruction, measurement, simulation and manipulation of CBCT data. It also offers several services, including the creation of surgical guides and digital models created from a single CBCT scan with its Anatomodels service. With the addition of the digital study model to existing CBCT data and photos, the practitioner is able to visualize both hard and soft tissues, gingival lines and coloration. These digital models can be extremely useful in the creation of surgical guides, temporary anchorage device placement and bracket positioning. Anatomage also provides viewing software so that the digital file may be easily shared with any specialist involved with the case.

Vultus Orthodontic Technologies is another interesting company, which enables the orthodontist to scan, manipulate and print appliances on site. The foundation of the software was built by Rapidform, a leader in 3D CAD software systems that has developed CAD systems in the automotive, aerospace and other high-tech industries. The Vultus product allows the orthodontist to use a desktop or intra-oral scanner of his or her choice to capture the data and then manipulate the data using CAD software. With some basic training, it is easy for the user to make quick adjustments to the digital impression to create sequential tooth movements. Once these changes are saved to the file, they can be easily printed in the office using a 3D printer or uploaded to a lab for fabrication. Since the orthodontist is in control of the design of the appliances, he can quickly print as many as are needed for the individual case. And the cost of creating aligners and other appliances is significantly decreased since the movements are planned by the orthodontist and fabricated locally. Dr. Todd Ehrler, the CEO of Vultus says, “This technology is the future of orthodontics. Our focus is combining cutting-edge technology with the professional training and judgment of the orthodontic specialist. We show orthodontists how to implement this technology in their practices and then get out of their way.”

The Future
The dental anatomical truth and the virtual patient are much closer today than they were even five years ago. The addition of digital impressions to the clinical picture adds an important new dimension in constructing the virtual patient. One can imagine the not too-distant-future when smaller, less invasive devices will be used to record the intra-oral areas and will be fully integrated with hard- and soft-tissue data. These devices will be able to directly transfer data to software, which will allow the doctor to manipulate the file and push it directly to fabrication. Soon, a fully integrated model of the entire dental anatomy will be available and as common as a chairside computer terminal. As mentioned, technology is now available to allow for the production of appliances directly in the orthodontists’ office. Adding digital impressions with existing photographic records, 2D X-rays and 3D digital imaging pushes the orthodontists’ understanding of the patient’s anatomical truth to new levels. The increasing precision and dynamic confluence of digital data continues to make it an exciting time to be an orthodontist.
Author Bio
Craig Scholz, PhD, is the director of emerging technology at Ortho2 and owns two dental imaging centers in Southern California. He can be reached at cescholz@ortho2.com, or visit www.ortho2.com for more information.
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October 2025
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