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Dentures...Really? Experience the Digital Difference



Date: 2021-11-29 08:00:00

Location: Online Webinar

Contact Hours: 1 Live CE

Event Details

Fabricating traditional acrylic dentures has not appreciably advanced in over 100 years! This time-consuming procedure requires multiple appointments and a trusted lab technician who performs many steps by hand. Sadly, the cascade of inaccuracies during the treatment process can lead to a less than desirable result for the patient, decreased productivity, and even more frustration for the dentist.
Digital dentures are now available that offer significant improvements in esthetics, fit, durability, and turnaround time. This hands-on course will connect the dots to implement the digital denture workflow in your practice immediately with the iTero scanner. Discussion will identify current denture presentations and appointment sequence details that are necessary to attain a new level of predictability and minimize appointments. Clinicians and their teams will gain confidence in scanning and discover the benefits of a digital record utilizing an iTero scanner.
Please join us for an in-depth look at the technology and materials that are revolutionizing how current dentures are being created. Learn what was old, is now new, and how exciting the digital denture process is to replace missing teeth!

Learning Objectives
After completing this webinar, participants will be able to:
  • Identify the four types of current denture cases
  • Familiarize themselves with the edentulous arch anatomy and patient characteristics
  • Organize patient information for the lab to maximize the outcome
  • Comprehend how to scan with an iTero scanner an edentulous arch and a removable prosthesis 
  • Practice assigning delegable tasks to staff
  • Recognize the differences of current denture materials
Event 20 of 20

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Digital Implantology with 3D Scanners



Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this webinar, participants will be able to:
• Scan for implant crowns and analog models 
• Use a 3D Printer to make models and temporaries
• Scan Bodies and Ti Bases
• Print digital hybrid temporaries
• Use digital labs, mills, and milling centers to make their final implant restorations


In this one-hour lecture, Dr. de Oliveira will discuss how he incorporated intraoral scanning, milling and 3D printing in his dental office to place and restore implants. Dr. de Oliveira will cover everything you need to get started using this incredible, impression-free technology. Dr. de Oliveira will discuss scanner ROI, the basics of intraoral scanning, and what you can make with the 3D scan. This includes 3D-printed analog models, temporaries and how to get the final restoration, either milled in-house or sent to the lab. 

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 93 of 157

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Super-Easy, In-House Orthodontic Aligners



Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

  • Compare the cost and time savings that can be achieved by producing aligners in-house 
  • Identify which equipment and materials are needed for aligner production
  • Decribe the complete workflow—from scanning, designing, 3D printing, and manufacturing—and how these steps can be delegated to staff


You love aligner orthodontics, but are you concerned about the high lab fees that most popular companies charge? With in-house 3D printing, you can stop paying those fees and gain more independence and control over manufacturing (and tooth movement). Most professionals believe this process is too labor intensive, but it actually isn’t.

Dr. Joshua Howard will show you how easy it is to produce quality aligners with digital scanning and in-house 3D printing. He’ll show you how to delegate steps to dental assistants and how to get your whole dental team on board with a digital workflow. By the end of the webinar, you’ll know the proper equipment, materials, and techniques you need to be successful.

Supported through an unrestricted educational grant from Formlabs Dental

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 79 of 157

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

New Technology to Improve Diagnostics



Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this webinar, participants will be able to:
-Create a patient’s database efficiently and effortlessly
-Discern the importance of doctor-patient communication and why patients might not proceed with treatment
-Determine how to increase ROI when using an intraoral scanner
-Discover near-infrared imaging (NIRI) technology as a new standard in cavity detection and patient compliance


Intraoral scanners have been around for quite some time. These valuable tools were first designed to facilitate the impression process for both dental practitioners and patients. Advancements in technology have increased the applications of intraoral scanning over time. Dr. Frederic Poirier uses digital scanning on almost every one of his patients to increase case acceptance and improve diagnostics. Learning about new technological developments in intraoral scanning will allow clinicians to better understand the multitude of benefits offered from these devices.

Supported through an unrestricted educational grant from Align Technologies

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 59 of 157

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A Fully Integrated Diagnostic Process Through Advances in Scanning Technology

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Date: 03-25-2020 08:34:06 am

The iTero Element 5D imaging system is the first intraoral 3D scanner integrated with near-infrared imaging (NIRI) technology. NIRI has the potential to revolutionize patient treatment and the overall workflow in dental offices. This technology provides practitioners with an aid for early detection of interproximal caries above the gingiva, which is one of the gravest threats to oral health (equal in seriousness to periodontal disease) per the World Health Organization (WHO). In the near-infrared electromagnetic spectrum range of 0.7 to 2.0 μm, the iTero Element 5D Imaging System uses light of wavelength (= 850 nm), which interacts with the hard tissue to provide additional data of the tooth structure. The dentin will appear bright, with areas of pathology or demineralization appearing as white spots on the display. The iTero Element 5D imaging system, the latest incarnation of NIRI technology, is an “innovative, integrated optical diagnostic aid,” using a class 1 laser, as Keshav stated in the iTero Element 5D Clinical Guide (Near-infrared imaging technology in dentistry — iTero Element 5D). It gives practitioners the ability to view multiple dimensions of data, as well as to virtually manipulate the model for a comprehensive view. It is the logical next step in digital diagnostic technology and is quickly replacing both conventional impressions and first-generation intraoral scanners. Advanced scanning technology together with artificial intelligence (AI), streamline the treatment and diagnosis process into the future of dentistry.


Impact of Technology Adoption for Practice Growth In this paper, the ways that adoption and integration of new technologies [particularly,NIRI, the iTero Element 5D imaging system, and artificial intelligence (AI)] will overhaul dental office workflow, optimize diagnosis and treatment planning, and improve practice efficiency are highlighted. Conventional methods of diagnosing dental caries and other oral pathologies rely on visual and tactile methods coupled with radiography (X-ray). These methods can have significant drawbacks based on visibility, accessibility, and subjective judgment, equal in seriousness to periodontal disease.1 First-generation intraoral scanners (IOS) required the application of powder to the teeth for opacification; this could be clumsy and messy for the practitioner or dental assistant, as well as the patient. Moreover, these early intraoral scanners functioned as little more than digital impression systems. Since then, advances in laser technology and scanning speed, as well as enhanced displays featuring in-color 3D models of the dental arches, like the iTero Element 5D imaging system,have broadened the appeal and functionality of IOS technology for use in general dentistry.2 The most cutting edge of these is the use of NIRI for diagnostic imaging, which works by emitting infrared light into the surface of the tooth. The light diffuses through the highly scattering dentin, reflecting off the enamel of the crowns and creating an image of the occlusal surfaces. While much new decay occurs in pits and fissures, and therefore cannot be detected with conventional X-rays because of the overlapping topography of the tooth surface of posterior teeth,3,4 dentists can check for this type of caries with a probe. NIRI scanning is especially useful for detecting interproximal caries above the gingiva that is difficult to see with the naked eye or X-rays, and impossible to detect by probing. In a survey of practitioners who use the iTero Element 5D scanner as part of their diagnostic protocol, 87% of surveyed participants indicated they increased the number of diagnosed interproximal caries above the gingiva by 56% on average. Near-infrared imaging has the potential to allow for superior diagnostic efficiency, particularly when synced with emerging dental AI technologies for enhanced diagnostics and restoration design.

Patient Experience During the Visit

Unlike conventional dental X-rays, NIRI does not expose the patient or the practitioner to ionizing radiation and its potentially harmful effects, and is therefore safe to use whenever a clinician suspects the presence of dental caries or other pathology that may be hidden by enamel.1 A scan can provide more nuanced information and serve as an adjunct to traditional radiographs and intraoral photos, and in some cases even replace conventional diagnostic methods. This a clear advantage, improving patient education and dental office workflow, and reducing risk associated with diagnostic X-rays. IOS has the broadest indications for clinical use; virtual impressions created with NIRI technology are used in a wide range of procedures in general dentistry and across specialist disciplines, including prosthodontics, implantology, and orthodontics.5 The images can be worked with easily to give a comprehensive view of the oral anatomy. Dental researchers, including those who conducted a 2017 Massachusetts Institute of Technology study of 10 subjects with varying dental conditions, agree that quality of near-infrared images is superior to that of conventional radiographs; they are a better diagnostic aid.4,2,6,7 Likewise, a 2018 study compared NIRI to digital bitewing (DBW) radiography for both intra- and interexaminer reliability, using 12 examiners and 100 images. Reliability on both counts was significantly better with the near-infrared images when used for caries detection.7

Better Patient Communication and Comfort

Patients today are more educated and better informed about their health than ever before. Most want to understand the diagnosis process and be proactive in treatment. However, in a 2013 study on patient understanding and recall by Misra et al., the authors strongly concluded that “patients do not recall as much advice and agreed actions about future dental care as dentists believe they have discussed. These results have implications for patient adherence with oral health instructions.”8 It is reasonable to assume that the disconnect between the information doctors provide and what patients can recall could be improved by utilizing visual aids, including scans. The ability to show patients a picture of their oral health, as opposed to, or as an aid to, merely explaining it to them verbally, is a powerful educational tool with the potential to improve patient compliance. As an example of the power of harnessing technology, a 2018 study of 291 adolescent dental patients showed that the influence of a mobile app for oral health education increased users’ knowledge and produced a measurably better standard of oral hygiene.9 Overall, this indicated that patients respond positively to technological and visual aids.
The iTero Element 5D imaging system has a larger display screen and is built to capture data faster than the previous generations of the Element scanners. These features enable the doctor to evaluate the patient scan chairside and direct a patient’s attention to particular areas shown on the screen as a diagnosis is delivered. As we like to say, a picture is worth a thousand words, and indeed, patients show more confidence and greater understanding in interpreting scanned images alongside their doctors than they do when being shown a dental radiograph. Images produced by the iTero Element 5D imaging system look familiar to the layperson; they closely resemble digital photos and other common computer images that have become ubiquitous in everyday life. This can be helpful in the education of patients and help them to better understand treatment. In fact, out of practitioners surveyed, 100% of users agree that the iTero Element 5D scanner enables better patient education and understanding of their oral health. This, in turn, can translate into increased patient acceptance of treatment. For instance, the same survey found agreement among users that the imaging and visualization capabilities of iTero Element 5D scanner lead to increased patient acceptance of recommended caries treatment.Patient experience is also augmented due to the fact that the process of taking the scan is often more comfortable than traditional impressions and radiographs. The speed and ability of discussing their images chairside with their doctor also please the patient. Engaging them in this process encourages them to ask questions, thereby allowing the dentist to address any concerns. This ultimately empowers the patients to make well-informed decisions on treatment. In particular, the time lapse feature distinctly highlights any change over time, whether the topic of concern is tooth wear or movement. The outcome simulator gives a 60-second demonstration of the potential outcome, along with time lapse, which compares scans over time to infer progress.4 Patients can therefore see and easily understand the changes occurring in their mouth. They are much more likely to proceed with treatment when they fully comprehend the situation and the implications of choosing not to treat. With a scan, they can fully visualize what is going on.
Time saved by using an advanced scanning diagnostic aid such as the iTero Element 5D imaging system allows doctors and technicians to dedicate attention to patients’ personal experience and increases their acceptance of recommended treatment. The presence of cutting-edge technology in the dental office fosters patient confidence, as they can see that their doctor uses the most up-to-date diagnostics. This added confidence can further lead to increased acceptance of treatment.For example, a survey of practitioners who incorporated the iTero Element 5D scanner into their diagnostic protocol found that 79% of participants reported an average increase in patient acceptance of interproximal caries treatment by 71%. In the final analysis, more advanced diagnostics fosters better communication and happier, healthier patients. The combination of patient satisfaction and higher rates of recommended treatment acceptance due to better diagnostics, along with the timesaving efficiency of NIRI scanning, is an equation for boosting practice incomes.

Increased Restorative Cases with Better Clinical Outcomes

The iTero Element 5D imaging system’s overall efficiency creates a more streamlined workflow in the dental office. With the iTero Element 5D, a scan is taken at the beginning of every visit. Other diagnostic methods may or may not be necessary, as the scan does not replace the physical intraoral or extraoral examination. However, it is our experience that an initial scan often eliminates the need for cumbersome, time-consuming X-rays, which would also mean that patients are not subjected to the emission of ionizing radiation. In his practice, Dr. Nolting found that by using the iTero Element 5D imaging system, approximately 5% more caries was detected than with conventional diagnostics. This is partly attributable to the streamlining effect on office workflow — now doctors using advanced scanners can see more patients because of the reduced time involved, but they can also detect pathologies that might previously have been overlooked. Compared to conventional radiographs, a 3D scan provides a more comprehensive approach that enables the doctor to view all surfaces of every tooth. Thus, scanning is more efficient for revealing interproximal caries decay above the gingiva.
In a survey of practitioners incorporating the iTero Element 5D scanner into their current diagnostic protocol, 79% of survey participants reported an average increase of 32% in the number of treated restorative cases, while reporting an average increase of 57% in the number of treated interproximal caries. These increases resulted in an average hike in business revenue of 25% and 34% for the practice, respectively. Also, in treatment, being able to see into the tooth’s internal anatomy allows dentists to be more conservative with the tooth structure, based on the quality of enamel that is preserved. This leads to increased patient health, preventative efficacy, well documented practice volume and growth, as well as improved retention of patients. In a survey of iTero Element 5D scanner users, 93% of those surveyed agreed that with the improved communication capabilities of the iTero Element 5D scanner, they expect to improve practice patients’ retention rate. By starting every appointment with a scan, practitioners will have the upper hand in detecting interproximal caries above the gingiva in its earliest stages, even before it shows up on a bitewing radiograph.

Creating Efficiency for Restorative Workflows and Labs

In the past, many dentists have felt pressured to invest in maintaining in-house laboratories for creating accurate restorations. Now, scanning can replace the time-consuming process of creating a model and then using wax to build the teeth back up in the laboratory, which can take a significant amount of time per tooth. With the iTero Element 5D imaging system, the dental assistant, hygienist, or the dentist performs the scan and hits “send” — it’s that simple. Models can be delivered to the office within 2–3 days using a lab workflow or fabricated chairside within 1–2 hours using a 3D printer. This replaces the traditional processes that required having a full-time technician on staff and the additional physical space for a lab. A streamlined practice resulting from adopting new digital technologies will need fewer employees and less space, thus positioning NIRI scanning as the default method of monitoring and diagnostics. In terms of restorations, for example, a major implication is the time savings that can be achieved per crown. Digital impressions have been shown to be a satisfactory alternative to conventional methods for creating impressions. A 2013 study by Seelbach et al. concluded that digital impression systems allow the fabrication of fixed prosthetic restorations with similar accuracy to that of conventional impression methods.10 Thus, scanning saves precious office time, enabling dentists to outsource many of the tedious steps associated with restorations, and to focus their own efforts on design and finishing. It is also a useful method of documenting ongoing problems and treatment. Not only useful for crown and bridge work and diagnostics, scanning can be seamlessly incorporated into everyday practice to help practitioners monitor patient oral health. The iTero Element 5D imaging system is more versatile than older generations of scanners, and it is expressly compatible with Invisalign. With Invisalign’s solid comparability behind the iTero, there is a drive to continue to improve design and functionality, to make it more than just a scanner, but a more comprehensive diagnostic aid.

Ease of Use and Accuracy

The iTero Element 5D imaging system offers a light and sleek scanning wand. It is userfriendly; scanning at a rate of 6,000 frames per second, 20 times faster than the earlier models of the iTero scanner with little to no learning curve.11 This system offers screenshot capability as well as various views including intraoral camera, NIRI, and monochrome. A comprehensive archive of instructional videos is available on iTero’s Support website,12 making it simple and easy for technicians to get questions answered and get quick training on how to use the technology in every diagnostic context. The system’s website ( also provides the clinician with the ability to store cases, a feature that affords the practitioner the luxury of reviewing cases at their own discretion. Scanning is noninvasive. When compared to conventional impressions, the use of an intraoral scanner has the ability to improve the patient experience with regard to comfort, gagging, breathability, tastes, and smells. It is easier, cleaner, safer, and more patient-friendly than other diagnostic aids and methods.

Prevention of Harmful Radiation Associated with Radiographs

The advantages of NIRI imaging over X-rays cannot be overstated. Beside the practical advantages — overall time efficiency, labor (and, thus money)-saving, files that are easy to delete and redo, ease of storing files in digital form, and transfer of images between practitioners via electronic transfer,5 the most obvious desirable outcome is eliminating the risk of irradiation for both patient and practitioner. In 2018, Hwang et al.published a review of 2,158 studies to summarize the results of studies of the association between exposure to dental X-rays and health risk. Although the level of exposure from dental diagnostic X-rays is lower than that of medical radiation, there is an innate risk from radiation exposure.13 Therefore, for certain categories of patients, notably those at low risk of developing caries, and also pregnant women, regular bitewing radiographs are neither indicated nor advisable.14,7 Any iagnostic aid or technology that helps eliminate the need for X-rays marks an advance in treatment approach. Moreover, NIRI technology is shown to be as effective in detecting interproximal caries above the gingiva as radiography,1 perhaps even better — a University of California School of Dentistry study found that with traditional radiography, interproximal caries above the gingiva are undiagnosed up to 40% of the time.15 For conventional X-rays to reliably detect a carious lesion, there must be a certain amount of decay present. A near-infrared image can help the dentist to detect interproximal caries above the gingiva weeks or months before it is severe enough to show up on a conventional radiograph. Starting every appointment with a scan will reduce the number of X-rays taken, and thus reduce exposure to radiation, while increasing diagnostic accuracy. Even in ambiguous cases, where the doctor feels an X-ray is
required to be more confi dent in diagnosis, an initial scan is always an effective aid to rule out an unnecessary step and increase patient confidence.

Evolution of Dental Office Technology

As has been true in other professions, technological advances are streamlining the dental workplace and helping reduce health risks to clinicians and patients alike. NIRI technology fits in well with the prevailing mode of comprehensive dentistry,as it is a way for clinicians to include the patient, clearly showing them, with easy-to-understand images, the intricate relationship between good oral health and overall well-being. It seems reasonable to extrapolate that NIRI technology should be a useful aid for underscoring the implications of forgoing treatment. For practices that were already on the way to digitizing much of the paper workfl ow and daily management (scheduling, communications, etc.), using digital diagnostics actually speeds up the integration of new technology. The trend toward turning practices digital is saving time, energy, and money and preserving the best possible oral health for patients.In a current dental practice, every visit should begin with a scan. Whereas a full set of intraoral photos is recommended for new patients, a 3D scan combined with 2D high-quality image capturing eliminates this need. The more ubiquitous NIRI technology becomes, the greater the comfort and familiarity it will have for both patients and offi ce staff. Office staff prefer the ease and efficiency of scanning to old-school methods like impressions and X-rays.

THIRD CASE REVIEW — Dental Fluorosis
These images show a common enamel disorder — dental fluorosis. Fluorosis, resulting from excess fluoride exposure during tooth formation, can give teeth a white, opaque appearance. In more severe cases, pitting and enamel loss can occur, leading to brown stains that can mimic the appearance of dental caries.16 Fluorosis can affect the structural anatomy of the tooth. This case highlights NIRI’s advantage in detecting changes in the structural integrity of the enamel. Figure 10 shows a color scan of the affected area. Note the opaque white coloration at the top of the cuspid. Intraoral photo (Figure 11) of the same area looks much the same, with the affected tooth showing the same discoloration. Finally, the NIRI image (Figure 12) shows dental fluorosis on the mandibular left canine #22.

AI in Practice

The use of AI in mainstream medical and dental practices is now possible and becoming more common every day. What is AI, and how will it be integrated into modern dental practice? Generally, the term AI is used colloquially to refer to “smart” machines, those that can learn, communicate, or otherwise display cognitive features and functions that we associate with human beings. However, this is a misnomer — AI is not really “artificial,” but, in fact, is just another aspect of human intelligence and creativity. The intelligence behind the novel technologies associated with AI is human intelligence. These machines are created by humans to perform some of the tasks we do, in the same way that we do them, but often more efficiently.16 As in many other professions, and indeed, in our everyday lives, some argue that AI will soon become an integral player in diagnosis and treatment in the dental field, especially as dental medicine is becoming more tied in with the medical community in general. Dental care is now recognized as an important aspect of overall healthcare. Just as AI is already being utilized in medicine and medical research, it will inevitably pervade dental practice. Many dentists today do not fully realize the impact AI could soon have on their potential production.16 The advent of cloud computing has given intelligent technologies and intelligent machines a foothold in medical and dental practices, and it is likely here to stay. AI is an aid for quick diagnosis and treatment planning.17 This is particularly true in radiology, where deep convolutional neural networks (CNNs), a computational tool that enables computers to map images in layers, and thus to rapidly scan for certain features, enable computers to identify caries and other oral pathology, often as accurately as a human examiner — sometimes more so. CNNs are one of the tools in facial recognition technology that has become so familiar with the use of smartphones.18,16 The combination of AI with near-infrared scanning technology confers distinct advantages for diagnosis and treatment in general dentistry. Machines can work longer and harder than humans in intensive detail-oriented tasks like reading and comparing scans and X-rays. They can rapidly access and sort through massive bodies of archived data for comparisons. In a new study published in July 2019, Hung et al.encourage the use of these kinds of machinelearning methods in diagnosis, particularly for predicting root caries, in older patients. In their study, the algorithms produced had high accuracy in early intervention and treatment in the aging population of the United States.19 In use for some time in orthodontic treatment and monitoring, AI is now also coming to the forefront in restorative and prosthetic dentistry.20 Using AI for design and manufacturing helps to maximize comfortable fit, correct function, and create pleasing esthetics. Designers are already working to make AI user-friendly, with features like voice command and conversational interface, much like the ubiquitous Siri or Alexa. One seemingly mundane, but clever, use of this technology will include smart treatment chairs that can sense the patient’s weight, vitals, and emotional state, and adjust for maximum comfort, safety, and information to the clinician. No longer a futuristic myth, AI dentistry is the new reality. In short, advances in scanning technology and their integration with smart computing platforms will facilitate production and a higher degree of accuracy.

A Roundup of the Benefits

The iTero Element 5D imaging system is leaps and bounds ahead of earlier generation intraoral scanners because of NIRI technology. It is the first integrated dental imaging system to simultaneously record 3D, intraoral color, and NIRI images. Three-dimensional scanning and virtual models are already rapidly replacing plaster models in orthodontia, prompted by the enormous popularity of clear aligners like Invisalign. In that field, the more steps between impressions and the fitting of a final appliance,the more opportunities for information to be lost or blurred. Therefore, appliances from a digital impression tend to fit better and are more likely to fit as intended. Scanning is noninvasive and can be used as often as desired to provide the best patient outcomes for early detection of interproximal caries above the gingiva. Case studies have shown that it takes approximately 4 years before an interproximal lesion is clinically visible,1 whereas the same lesions are potentially discoverable much earlier on a NIRI image. This saves time and money and helps prevent further damage to the teeth. The iTero Element 5D imaging system is an ideal vehicle for chairside education,allowing patients to participate more fully and understand all aspects of their oral health. It is fast and streamlined, comfortable for the patient, and easy for users to master. In addition, the advent of new modes of AI will maximize information gleaned from scans by reliably finding hidden or interproximal caries above the gingiva. AI can then communicate with vast databases known as big data for the most up-to-date treatment options and comparisons, including advanced restorations and prosthetics. All of this can be done rapidly and efficiently, greatly reducing the practice workload while increasing overall productivity. With the ease of just a single scan, the practitioner, the practice, and the patient are awarded all of these benefits.

About the Authors

Tim Nolting, Dr MSc
Dr. Nolting received the Master of Science degree in implantology. He specializes in many fi elds, including oral surgery, periodontology, and laser dentistry. He is certifi ed by the German Society for Ultrasound in Medicine (DEGUM), one of the largest medical and scientific societies in Germany and one of the largest ultrasound societies worldwide, in head and neck ultrasound applications. Dr. Nolting is also certified to perform Botox and fi ller treatment procedures. He is an Investigator in clinical studies.

Frédéric Poirier, DDS
Dr. Poirier received the dental degree from the University of Montreal in 1992, after also receiving a degree in microbiology from the same institution. He opened his private practice in Montreal after graduating in 1996. Dr. Poirier expanded into orthodontics through the Institut Dentaire International (IDI) in Quebec in 1999, an organization affi liated with IAO, where he has successfully treated more than 2000 orthodontic patients in his practice. His professional interests include complete and interceptive orthodontic treatments using functional appliances, braces, and Invisalign, mechanical endodontics, CEREC, esthetics, and occlusion. Dr. Poirier is a member of l’Ordre des Dentistes du Québec, the Canadian Dental Association, and the International Association for Orthodontics. He is also an active member of Gnathos, whose main focus is to offer high-quality continuing education on orthodontics. Dr. Poirier has attended a number of CE classes on orthodontics and has many public speaking experiences to his credit, mostly centered on Invisalign.

Thomas Giblin, BSc, BDent(Hons)
Dr. Giblin, a Specialist Prosthodontist, received the degree in dentistry from Sydney University with honors in 2004. In 2007, after a stint in private practice, Dr. Giblin was accepted into a 3-year Advanced Prosthodontics Residency at the University of Texas Health Science Center in San Antonio, regarded as the top program in the USA. While there, he gained a broad education in all aspects of dentistry, including implant, fi xed and removable prosthodontics, as well as sleep dentistry, occlusion, and TMD. Since returning to Australia, he worked in several locations before establishing his current practice, Northern Dental Specialties, Northern Beaches.

1. Keshav, P. Near infrared imaging technology in dentistry– iTero Element 5D. http://
5DClinical-Guide.pdf. June 13, 2019.
3. Bühler C, Ngaotheppitak P, Fried D. Imaging of occlusal dental caries (decay) with
near-IR light at 1310-nm. Opt Express. 2005;13(2):573–582.
4. Neel Shyam VK, Dharshini TP, Raghavi D, et al. IR imaging for dental caries. Int J
Trends in Eng Technol. 2018;28(1):15–19.
5. Mangano F, Gandolfi A, Luongo G, Logozzo S. Intraoral scanners in dentistry: A
review of the current literature. BMC Oral Health. 2017;17(1):149.
6. Angelino K, Edlund D, Shah P. Near-infrared imaging for detecting caries and
structural deformities in teeth. IEEE J Transl Eng Health Med. 2017;5: 2300107.
Published online Apr 19, 2017. doi: 10.1109/JTEHM.2017.2695194.
7. Litzenburger F, Heck K, Pitchika V, et al. Inter- and intraexaminer reliability of bitewing
radiography and near-infrared light transillumination for proximal caries detection and
assessment. Dentomaxillofac Radiol. 2018;47(3): 20170292. Published online Feb 7,
2018. doi: 10.1259/dmfr.20170292.
8. Misra S, Daly B, Dunne S, et al. Dentist-patient communication: What do dentists
and patients remember following a consultation? Implications for patient compliance.
Patient Prefer Adher. 2013;(7):543–549.
9. Marchetti G, Fraiz FC, Nascimento WMD, Soares GMS, Assuncao LRDS. Improving
adolescents’ periodontal health: Evaluation of a mobile oral health app associated
with conventional educational methods: A cluster randomized trial. Int J Paediatr Dent.
10. Seelbach P, Brueckel C, Wöstmann B. Accuracy of digital and conventional
impression techniques and workfl ow. Clin Oral Investig. 2013;17(7):1759–1764.
Element-Brochure-For-General-Practitioners.pdf. Sept 12, 2019.
12. Digital Smile Design promotion video. YouTube. Mar 16, 2019.
13. Hwang SY, Choi ES, Kim YS, et al. Health effects from exposure to dental diagnostic
X-rays. Environ Health Toxicol. 2018;22(4).e2018017. doi: 10.5620/eht.e2018017.
14. Jablonski-Momeni A, Jablonski B, Lippe N. Clinical performance of near-infrared
imaging system VistaCam iX Proxi for detection of approximal enamel lesions. BDJ
Open. 2017;3:17012. June 30, 2017.
15. DenBesten P, Li W. Chronic fl uoride toxicity: Dental fl uorosis. Monogr Oral Sci.
2011;22:81–96. doi: 10.1159/000327028.
16. Deshmukh SV. Artifi cial intelligence in dentistry. J Int Clin Dent Res Organ 2018;10:47–48.
17. Cooper M. Why artifi cial intelligence is the future of dentistry. http:// cial-intelligencefuture-
dentistry. Nov 2, 2017.
18. Masakazu M, Katsuhiko M, Yusuke M, Yuji K. Subject independent facial expression
recognition with robust face detection using a convolutional neural network. Neural
Netw. 2003;16:555–559.
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data analytics. Orthod Craniofac Res. May 2019;22 Suppl 1:8–13. doi: 10.1111/ocr.12279.

These claims area based on a survey conducted in May 2019 of n = 15 practitioners
who participated in a global limited market release, working with iTero Element 5D
for an average period of 6 months, representing both GPs and Orthos in CAN, EU,
and APAC, who were presented with a level of agreement scale from strongly agree
to strongly disagree with the following statement: “Incorporating the iTero Element
5D scanner into my current diagnostic protocol, I’ve diagnosed a higher number of
interproximal caries above the gingiva, on my patients at my practice,” and then
asked to estimate the average increase.
Article 14 of 48

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

INTRAORAL SCANNING: Improving Efficiency and Advanced Workflow



Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

Educational Objectives

After completing this course, participants will be able to identify the potential advantages of digital impression systems over conventional impressions, as well as be able to:
  1. Comprehend how digital impressions are being used to fabricate dental restorations
  2. Understand how digital impressions are impacting orthodontics
  3. Learn how digital impressions are being used in implantology
  4. Recognize the potential benefits of CAD/CAM technologies
  5. See the potential in diagnostics and communication with patients.

Download this course PDF


Digital impressions are reshaping the way modern dentistry is being practiced. They are able to eliminate some of the issues found with conventional workflow and provide clinicians with unique advantages compared to traditional impression techniques. With various implications in the field, digital scanners are making their mark on the profession. This article will review some of the advantages of digital impression systems over their conventional counterparts, as well as review how they are currently being used in practice today.

COMMERCIAL SUPPORTER: This educational activity is made possible through an unrestricted educational grant from Align Technologies.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 38 of 157

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Clinical Precision with a Streamlined Digital Restorative Workflow

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Date: 01-15-2020 07:58:00 am

The iTero Element 2 intraoral scanner is equipped with next-generation computing power that enables reduced scan processing and faster start-up time, allowing a full-arch scan to be performed in as little as 60 seconds.

There are many benefits to digital intraoral scanning, but the greatest is that you can really zoom in and see whether you’ve captured everything.

And if you missed something, such as debris on a tooth, you can delete the scan in just that area, rescan that one little spot, and seamlessly reinsert it into the original scan. If you miss an area using impression material, you’d have to take a new impression of the entire arch or quadrant.

In my practice, digital scans are the vehicle that drives the entire restorative process, and this case is a great example. The patient was a 52-year-old man who had a cantilevered restoration that was in need of replacement. It was determined that replacing the cantilevered restoration with a single-tooth implant would be the best long-term option. I prepped tooth No. 12 to the gingival margin and made a cantilevered temporary over that area so the implant could be placed.

About 8 weeks later, I took a digital impression (iTero Element 2 Intraoral Scanner, Align Technology). There’s a myth circulating around dentistry that you can’t scan anatomy that’s subgingival, but with proper gingival retraction, this is something I’ve been doing successfully for years. By contrast, traditional impression taking can force impression material below the gingival margin and create a thin film of impression material. This thin film doesn’t create the most accurate impression because it can distort easily. iTero Element 2 intraoral scanner

Once I hit the send key on my iTero Element 2 scanner, Align Technology received the case and sent it to Dentsply Sirona, who digitally designed the custom Atlantis abutment with the proper clearance, angulation, and parallelism to the adjacent prepped tooth. It’s important that the abutment is designed in parallel with the prep so that there is no insertion issue with the crown and implant crown. My lab, Broadway Dental in Feasterville, PA, approved the design the next day.

The round-headed implant scan body (Dentsply Sirona) was converted to a replica of the abutment in the milled model right next to the adjacent natural prepared tooth No. 12. Before receiving a physical model, my dental lab was able to use the digital fi le to design the crown and implant crown on the digital model. So, within 3 days, the implant abutment was milled and shipped to my lab along with the model from Align.

The implant (Astra Tech Implant System EV, Dentsply Sirona) has a unique interface that provides one-position-only placement, which eliminates any difficulty when inserting the implant abutment and crown. The final crown was placed 2 weeks after the final impression was captured. Because of the digital scan, I had perfect impressions, perfect preps, and the case wrapped up beautifully when I inserted the final restoration.

Clinical precision is only one advantage of using the intraoral scanner. Treatment acceptance is another—it’s amazing how patients can self-diagnose once they see their problems on the screen. Sometimes, I’ll show patients a scan and they’ll ask, “Why aren’t you doing this other crown?” It’s tough to hit a patient with a $3,000 dental bill, so I might tell them that since it’s not horrible, we can take care of it down the road. To my surprise, once they see the scan, the patient will often say, “Let’s do them both.”

Intraoral scanning with a system like the iTero Element 2 scanner doesn’t just create revenue through case acceptance. It’s important to note that every time you scan, you save money. In the long run, you’ll get a better-fitting restoration with fewer remakes, fewer problems, and a “wow” factor that leaves patients with the feeling that dentistry is actually a science instead of someone just drilling on their teeth.

preop radiograph

Figure 1: Preop radiograph




digital impression using itero element 2

Figure 2: Digital Impression (iTero Element 2
Intraoral Scanner, Align Technology) of natural
tooth and scan body simultaneously


occlusal view of impression showing natural tooth

Figure 3: Occlusal view of impression showing
natural tooth and scan body



milled model showing tooth prep

Figure 4: Milled model showing tooth prep No. 12
and implant abutment analog No. 13



occlusal view of final restoration

Figure 5: Occlusal view of final restoration




buccal view of final restoration

Figure 6: Buccal view of final restoration


Go-To Product Used in this Case: iTero Element 2 

The iTero Element 2 provides improved screen resolution while minimizing scanner footprint due to its slim 21.5" monitor and 16:9 widescreen viewing format. The enhanced color offers a more thorough look at patients' oral health. Designed with a center-mounted wand cradle, the system provides ideal ergonomics during scanning. The integrated lithium-ion battery provides easy mobility from operatory to operatory without the need to plug in for power or reboot. The improved wand touchpad is as intuitive as gesturing on a smartphone and can be used to switch between scanning segments or rotate the model on screen. 


Article 13 of 48

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Peer Reviewed Article: Acquisition of iTero Element Intraoral Scanners

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Date: 01-15-2019 06:19:22 am

Acquisition of iTero Element Intraoral Scanners: Three-Year Examination of Practice Volume Changes and Economic Impact

Digital intraoral scanning can support practice growth and profitability by giving the dental patient and the practitioner the ability to visualize Invisalign® treatment outcomes together. Analyses were undertaken to evaluate the economic impact of digital scanning on Invisalign practice receipts to determine the percent increase in gross receipts for Invisalign that were associated with the introduction of an iTero Element® intraoral scanner (i.e., the case lift). An interrupted time series analysis was applied to 72 months (36 months prior to, and 36 months following, scanner introduction) of Invisalign receipt data from 616 orthodontic practices worldwide. Similarly, the trending of monthly Invisalign receipts after scanner introduction (i.e., pre-post slope change) and the projected impact of scanner introduction were also examined for specific practices that represented general practices (GPs; n = 1,115) worldwide with low-volumes (i.e., 5 or fewer Invisalign receipts in the 12 months prior to acquiring the iTero Element intraoral scanner) and low-volume orthodontic practices worldwide (n = 1,076). This secondary analysis was extended to worldwide GPs across 24 months (n = 363) and 36 months (n = 135) post-scanner introduction, and for worldwide orthodontists at 24 months (n = 421) and 36 months (n = 141) as well. The analyses showed that acquisition of an iTero Element intraoral scanner was associated with a statistically significant increase in Invisalign practice receipts at the time of scanner introduction. When projected across the first 36 months after scanner acquisition, this increase amounted to an average of an additional 59.23 receipts for the sample of 616 orthodontic practices worldwide, and an additional 28.61 and 80.27 receipts, respectively, for the low-volume general practitioners and orthodontists.
Digital scanning is a gateway to efficiency within today's dental practice, enabling practitioners to fulfill important clinical and patient objectives with accuracy and predictability.1,2 For the clinician, it provides vital information that includes three-dimensional visualization of the patient's anatomy and the display of intraoral structures in the detail necessary for accurate diagnosis and treatment.3 Digital scanning with iTero scanners (Align Technology, Inc., San Jose, CA) enables the practitioner to leverage efficiencies throughout a digital restorative or orthodontic workflow, with a broad range of applications that include Invisalign® treatment, custom-milled models, custom implant abutments, and chairside milling connections. For these reasons, iTero scans have been used in more than 2.6 million restorative crown, bridge, and implant cases,4 and in 7.6 million orthodontic scans.4  
Historically, treatment has been accomplished with the use of traditional (analog) impressions and two-dimensional imaging (e.g., radiographs and photographs). However, a number of challenges can impact the reliable and accurate capture of the patient's intraoral anatomy using traditional elastomeric impressions (Table 1).1-3,5 With digital scans, there are fewer opportunities for errors during impression taking, with errors occurring related to an incorrect scanning technique and failure to verify scans before releasing them. Both digital and traditional impressions require proper soft tissue management and adequate isolation. Further, the opportunity to use virtual/milled/printed models removes sources of errors observed with poured models. Digital (scanned) impressions have been found to be at least as, or more, accurate compared to traditional impressions. Additionally, patient difficulty in breathing or gagging can be encountered during traditional impression taking.6 The ability of digital scanning to provide a superior chairside experience has been observed, as well as greater efficiency and reduced chairside time compared to traditional impression taking,7-9 with one study finding that digital impressions were 59% faster.10

Whereas elastomeric impression materials have remained relatively constant in material composition and clinical application over recent years, digital scanning experiences continued innovation and development. Recent advances for iTero Element scanners include processors that enable high definition color scanning of the patient's arch, which can be completed in as little as 60 seconds,11 and that integrate applications such as iTero TimeLapse visualization and the Invisalign Outcome Simulator technology. Each supports the diagnostic and communication capabilities of the practitioner—the iTero TimeLapse tool with its ability to display and quantify changes to intraoral structures over time, and the Invisalign Outcome Simulator with its capacity to help patients visualize potential Invisalign treatment outcomes. "We use the Invisalign Outcome Simulator for all of our Invisalign patients and for all types of appliances that the laboratory makes for us," states Dr. Cayetana Manglano, an orthodontist in Valencia, Spain. "We use it for all applications, and for every single patient." To this point, in a recent study it was found that 60% of patients who were shown Invisalign Outcome Simulator results with the iTero Element scanner started Invisalign treatment.12 In examining practice volume changes associated with acquisition of a digital scanner, the principal author observed, "A strong hypothesis is that the increase [i.e., in practice receipts] is due to the scanner's capacity to preview the potential outcome of Invisalign therapy to a patient during the consultation phase by use of the Invisalign Outcome Simulator."13
In a recent study, it was found that 60% of patients who were shown Invisalign Outcome Simulator results with the iTero Element scanner
started Invisalign treatment.

The aforementioned 2017 study principally explored the connection between iTero scanner introduction and increases in Invisalign treatment starts. The study used data collected from 1,871 general practices (GPs) and orthodontic practices worldwide over a 48-month period, of which 24 months were prior to, and 24 months following, scanner introduction. The results from the interrupted time series analyses showed that acquisition of an iTero scanner was associated with a significant increase in practice receipts of 5.92 and 11.85 Invisalign cases in the first 12 and 24 months, respectively, following scanner introduction.13Noted the authors, "As more data become available over time, it will be worthwhile to re-conduct these analyses. Additional time periods will serve to provide more accurate parameter estimates, in particular the pre- and post-scanner introduction trends."13
The results of a 2017 study showed that acquisition of an iTero scanner was associated with a significant increase in practice receipts in the first 12 and 24 months following scanner introduction.

The following analysis, conducted 12 months following completion of the previous publication, examines this additional time period (i.e., the data examined was for 36 months pre- and post-scanner introduction), using the methodology consistent with the initial study.

Materials and Methods
Dataset Description and Model Identification

As previously,13 global data from practices in North America, Europe, Middle East, and Asia were extracted. This included data from Invisalign orthodontists and general practitioners (GPs) who integrated an iTero Element scanner into their practices during the study period. Invisalign practice receipt data were collected objectively via instrument-driven electronic reporting, consequently ensuring the validity and reliability of the data.

Data were structured according to the number of Invisalign receipts each month prior to iTero Element scanner introduction (i.e., from 36 months prior to 1 month prior) and post introduction (i.e., from 1 month post to 36 months post). Sample sizes were determined based on the available amount of data, and analyses were conducted for practices with sufficient data available for inclusion at pre- and post-12, 24, or 36 months. As practices acquired the scanner at any time during the year, the data time points were not connected to any specific month. Thus, any seasonal effects that may affect Invisalign practice receipts could not be estimated in these analyses, and potential history or cohort confounding effects were unlikely due to the varying month of scanner introduction.

As in the 2017 study, these data were used to determine the "case lift," i.e., the percent increase in gross receipts for Invisalign treatment following the introduction of the iTero Element intraoral scanner. Practice data were analyzed using a segmented regression approach in which an abrupt change in practice receipts was hypothesized at the month of the scanner introduction, which, depending on the analysis, was at month 13, 25, or 37. Pre-scanner introduction time series data were evaluated before model identification to ensure normality and homoscedasticity.14
The initial model included the following terms:
Y1 = b0 + b1 (time) + b2 (intervention) + b3 (time_after_intervention) + e, whereby
b0 represented the constant (i.e., initial level of receipts) for the pre-scanner-introduction data;
b1 represented the slope of the pre-scanner introduction time series;
b2 represented the change in receipts at the introduction of the scanner;
b3 represented the change in slope between pre and post-scanner-introduction; and, e represented the estimate of error (i.e., residual).

In this model, the significance of the b2 term assessed the presence of an abrupt increase in Invisalign practice receipts during the month of iTero Element scanner introduction, and the significance of the b3 term assessed the presence of a longer shift in the trend of Invisalign receipts from pre- to post-scanner introduction. Before parameter estimates were made with the model, an iterative model identification process was employed, whereby: 1) autocorrelation and partial autocorrelation plots of pre-scanner data were visually examined; 2) if autocorrelation was found, the model was adjusted for autocorrelation by conducting a Prais-Winsten AR(1) GLS regression; 3) the results of the Prais-Winsten regression, specifically the produced Durbin-Watson statistics, were examined to determine if the autocorrelation was adequately accounted for; and, 4) autocorrelation and partial autocorrelation plots of regression residuals were examined one final time to assess any lingering autocorrelation.14,15
Figure 1. Time series plot of worldwide orthodontic practices (n = 616) showing Invisalign receipt increase at month 37. Note change in pre- and post-slope values indicating a higher number of monthly receipts than before scanner introduction.
For the analyses relating to the 616 orthodontic practices worldwide, autocorrelation revealed a slow decay in autocorrelation, with significant autocorrelation at the first, and possibly second and third lags. A Prais-Winsten regression was conducted, and the Durbin-Watson statistic showed a change from 1.06 (p < .01) to 2.36 (p = n.s.), showing that no lingering autocorrelation was present.16 Visual inspection of autocorrelation regression residuals confirmed this as well.

The same procedure was used for the secondary analyses, which were applied to the low-volume GP and orthodontic practices (low-volume equating to 5 or fewer receipts in the 12 months prior to acquiring the iTero Element scanner). For these six analyses (i.e., 12-, 24-, and 36-month segments for the GPs and 12-, 24-, and 36-month segments for the orthodontic practices), four revealed significant autocorrelations, resulting in subsequent Prais- Winsten regressions. The other two analyses revealed no initial autocorrelations; thus, traditional regression analyses were performed to estimate the impact of scanner introduction.
Impact of Scanner Introduction on Practice Receipts

As demonstrated in Table 2, in the analysis examining all orthodontic practices (n = 616), all predictors were significant at p < 0.001. As Figure 1 shows, the number of receipts increased through month 37—the month of scanner introduction—at which point there occurred an abrupt increase in Invisalign receipts. To assess the extent of the increase, actual receipts reported were compared to the expected receipts had the scanner not been introduced (i.e., the receipts estimated via a counterfactual regression line using only pre-scanner data). The number of Invisalign receipts as predicted by the counterfactual regression line at time (month) 37 was: Y' = 1.78 + .052(37) = 3.69. The number of practice receipts at time 37 as predicted by the full model was: Y' = 1.78 + .052(37) + .56(1) + .062(0) = 4.26. This signifies a 15.2% increase in practice receipts at the month of the introduction of the scanner.

Pre- and Post-Scanner Trends on Invisalign Practice Receipts

Among the 616 orthodontic practices, changes were evident in the monthly trends for Invisalign practice receipts following introduction of an iTero Element scanner. In the regression model, parameter b3 represented the change in slope between pre- and post-scanner introduction and was significantly higher than the pre-scanner slope. When projected across the first 36 months after scanner acquisition, this amounted to 59.23 more practice receipts, a 35.76% increase over the expected volume projected via the counterfactual line (i.e., without the scanner).

Impact on Practice Receipts – Low-volume GP and Low-volume Orthodontic Practices

Tables 3 - 5 present the results of the regression analyses for the worldwide low-volume GP practices, and Tables 6 - 8 for the low-volume orthodontic practices. Findings from the analyses show that scanner introduction produced a positive lift for the low-volume GPs in all three analyses (i.e., using 12, 24, and 36 months of pre-post data). Utilizing a sample size of 1,115 GPs across 12 months of post-scanner data, the case lift amounted to 7.19, representing a 326.07% increase in gross receipts for Invisalign treatment. Across 24 months of post-scanner data, a 470.47% increase in gross receipts (case lift = 16.47) was observed for 363 GPs, while 135 GPs experienced a 716.89% increase in gross receipts (case lift = 28.61) over 36 months of post-scanner data, when compared to the volume projected by the counterfactual regression line (i.e., estimated trend without the scanner).
This trend was also evident in low-volume orthodontic practices, with an 286.56% increase in gross practice receipts (case lift of 10.68) across the first 12 months after scanner introduction based on a sample size of 1,076 orthodontists. Across 24 months of post-scanner data, gross practice receipts increased by 1,467.83% (case lift = 37.64), given 421 orthodontists, and across 36 months of post-scanner data an increase of 1,684.45% was observed for gross practice receipts (case lift = 80.27; n = 141).

The results of the analyses of orthodontic practices (n = 616) show that there was a statistically significant growth in practice receipts (b = 0.5618; p < 0.001) at the time of scanner introduction. The post introduction slope was significantly higher than the pre-slope, suggesting an increase in monthly practice receipts. When projected across 36 months, adoption of the iTero Element scanner was associated with an increase of 59.23 receipts (a 35.76% lift). This increase suggested that adoption of the iTero Element scanner translated to an economic benefit for orthodontists. Assuming an average patient fee of $5,500 for an Invisalign case,17 this translates to a total increase in gross receipts of $325,765 over 3 years.

The findings of this study, using 6 years of data, further suggest that an orthodontist's investment in the iTero Element scanner (MSRP = $29,999) would lead to returns in less than one year or sooner. Practice benefits are observed by Dr. Joshua Epstein of Manalapan, NJ: "We do nearly 400 Invisalign cases annually now, which is perhaps a two-fold increase in our production compared to before purchasing an iTero scanner." Similar observations are noted in GP practices, which showed almost the same results in these analyses (discussed below). "Our practices did approximately 25 Invisalign cases yearly prior to incorporating digital scanning," says Dr. Robin Bethell of Austin, TX, "and by the end of our first year with iTero scanners we had finished 80 cases. This year we're targeted to do 400+ cases among our three practices."

A related goal of the study was to explore the projected impact of the iTero Element scanner on monthly Invisalign receipts for low-volume GP and low-volume orthodontic practices across three different pre-post time spans. For all six analyses (i.e., 12-, 24-, and 36-month spans for GPs and 12-, 24-, and 36-month spans for orthodontic practices), the results revealed a significant increase in receipts at the month of the scanner introduction. With regard to the pre-post slope change, three analyses revealed no change in slope, two revealed an increase in slope, and one a slight significant slope decrease. That said, in all analyses the end result was an increase in lift (i.e., more receipts submitted over time) with percentage increases in receipts ranging from 286% to 1684%. Thus, in all analyses, practitioners experienced a net financial gain as a result of acquiring the scanner. For example, for the 36-month analyses, low-volume GP practices saw an increase of $157,355 over three years, and low-volume orthodontic practices saw an increase of $441,458 over the same time period.
It is worthwhile to note that the above estimate is only accurate if the iTero Element scanner is used solely for Invisalign treatments. Of importance, and as discussed in the previous study,13 the iTero scanner has applications in numerous restorative procedures, such as veneers, full coverage crowns, fixed partial dentures, bleaching trays, mouth guards, and for various implant procedures in both the diagnostic and restorative phases of treatment. This suggests that GPs would see a quicker return on investment if the scanner were to be used for multiple purposes and, therefore, that the present study's results underestimate the potential overall economic benefit of adopting an iTero scanner. Longer-term studies, as well as analyses on the economic benefit of the iTero Element scanner for non-orthodontic procedures, remain areas for future exploration and research.
Consistent with the study reported in 2017, the current study's results demonstrate that the adoption of an iTero Element intraoral scanner is associated with a statistically significant increase in Invisalign-related practice receipts in the month directly following scanner introduction for all three sets of analyses. When projected across the first 36 months after the introduction of the scanner to an orthodontic practice, this amounts to a volume lift of 59.23 receipts and translates to an estimated $325,765 increase in gross receipts over 3 years. Similarly, when the analysis is conducted using only low-volume GP practices and low-volume orthodontic practices, there is a pronounced increase of 28.61 and 80.27 receipts, respectively, over the first 36 months. Overall, the findings suggest practitioners stand to see their initial financial investment in the scanner lead to a return on investment within the first year of use following acquisition of the scanner.

Acknowledgment: This study was supported through a grant from Align Technology, Inc.

Conflict of Interest: The authors declare no financial or non-financial interest in the company or the materials cited herein and acknowledge receipt of an expense stipend for composition of this analysis.

Note: Doctor practices in this analysis were located in the following countries: AU, AT, BE, BM, CA, CH, CY, CZ, DE, DK, ES, FI, FR, GB, GR, HK, IE, IN, IT, JP, KR, LI, LT, LU, NL, NZ, PL, PR, PT, RE, RU, SE, SG, SK, TH, TW, US, VN.

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11. Data on file at Align Technology. Scan times vary and depend on individual experience.
12. Based on a survey of n=101 orthodontists and general dentists (from U.S., Canada and U.K, in July 2018; GP=60, ortho=41) who used the Invisalign Outcome Simulator in the past year and were asked, "For the patients who were presented the option of Invisalign treatment in the past 12 months, and for whom you have used the Invisalign Outcome Simulator, what percentage of these patients started Invisalign treatment?"
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