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Quality Resource Guide
MetLife designates this activity
for 1.0 continuing education credit
for the review of this
Quality Resource Guide and successful
completion of the post test.
FIRST EDITION
Digital Dental Impressions
Educational Objectives
Following this unit of instruction, the practitioner
should be able to:
1. Understand the history of digital impression
systems.
2. Describe the basic function of a digital
impression system.
3. Discuss new developments in equipment and
software for digital impression systems.
4. Recognize evolving clinical applications for
digital systems in a dental office.
5. Compare digital impressions to conventional
impressions relative to clinical technique and
accuracy.
Introduction
A
key clinical process for any general dentist is
the ability to accurately replicate the patient’s
intraoral condition. Dentists do this routinely
for diagnostic as well as therapeutic procedures. This
has traditionally been accomplished with conventional
impression materials that are placed in a gel or puttylike consistency using a tray, set in a manageable time,
and have physical properties that maintain the accuracy
of the impression when poured in stone for the model.
This clinical workflow to produce a stone model relies
on proper handling of several materials and processes
that may result in distortions leading to inaccurate
models. The application of digital impressions to
replicate the patient’s intraoral condition attempts to
improve the accuracy, efficiency, and workflow.
History
D
r. Francois Duret presented his thesis titled
“Optical Impressions” in France in 1973. It may
be the earliest description of digital technology
applied to dentistry. He went on to develop and
patent a Computer-Assisted Design/Computer-Assisted
www.metdental.com
Machining (CAD/CAM) device for dentistry in 1984.
The first marketed application of a digital impression
approach for restorative dentistry was in the early
1980’s by Dr. Werner Mormann, a Swiss dentist,
and Marco Brandestini, an Italian electrical engineer.
Siemens Dental marketed the concept in 1987 as the
CEREC System.1,2
Digital impression systems are based on CAD/CAM
technology, which generally consists of three distinct
steps or processes. Several articles have described
the process in considerable detail.3-6 The process
is initiated by using a camera or scanner to record
the patient’s intraoral condition to a computer. A
software program is used to manage the digital file
and design the size and contour of the final restoration
or appliance. The last step is to transmit the digital
design file to a milling chamber for production of the
final restoration or appliance.
There are a variety of digital systems in the dental
marketplace that apply the CAD/CAM process. One
way to categorize these systems is to separate them
into Digital Impression systems and Chairside CAD/
CAM systems. Each system relies on the ability to
digitally record the intraoral condition in the dental
office setting using a camera or scanner. What
distinguishes the various systems is how the data is
managed once it has been recorded in the dental office.
Digital impression systems focus on the first step of the
CAD/CAM process - recording the intraoral condition
to a computer program. The primary focus of a digital
impression software program is to identify and manage
the digital file as it is electronically transferred out of the
dental office for fabrication of the desired restoration or
appliance. The Chairside CAD/CAM systems apply all
three steps of the CAD/CAM process in the dental office
in a technique to deliver the restoration in a single
appointment. This Quality Resource Guide will focus
on Digital Impressions; a companion QRG will discuss
Chairside CAD/CAM systems. (Table 1 summarizes the
available digital impression systems).
Author Acknowledgements
Dennis J. Fasbinder, DDS ABGD
Cinical Professor, and Director of the
Computerized Dentistry Program
University of Michigan School of Dentistry
Private Practice, Ann Arbor, Michigan
Dr. Fasbinder has no relevant financial
relationships to disclose.
The following commentary highlights
fundamental and commonly accepted
practices on the subject matter. The
information is intended as a general overview
and is for educational purposes only. This
information does not constitute legal advice,
which can only be provided by an attorney.
© Metropolitan Life Insurance Company,
New York, NY. All materials subject to
this copyright may be photocopied for the
noncommercial purpose of scientific or
educational advancement.
Published December 2014. Expiration
date: December 2017. The content of
this Guide is subject to change as new
scientific information becomes available.
MetLife is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental
Association to assist dental professionals
in identifying quality providers of continuing
dental education. ADA CERP does not approve
or endorse individual courses or instructors,
nor does it imply acceptance of credit hours by
boards of dentistry.
Concerns or complaints about a CE provider
may be directed to the provider or to ADA
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Accepted Program Provider FAGD/MAGD
Credit 11/01/12 - 12/31/16
Address comments to:
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MetLife Dental
Quality Initiatives Program
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Quality Resource Guide – Digital Dental Impressions 1st Edition
Table 1 - Dedicated Digital Impression Systems
System
True Definition
Scanner
iTero Intraoral
Digital Scanner
TRIOS Scanner
Apollo DI
IOS FastScanI
Manufacturer
3M ESPE
2006 as Lava COS
Align Technology, Inc.
2007
3Shape
2010
Sirona Dental
IOS Technologies Inc 2010
Camera
3D in motion; Active
wave front sampling
– first video capture
Parallel Confocal
Imaging Technique
Principle of Confocal
Microscopy
LED Video
Active triangulation
scanning. Hold wand still
and camera moves within
the wand.
Reflective Powder
Yes
No
No
Yes
No
Monitor
(virtual models)
Monochromatic
Touch screen
Color
RealColor scans
Monochromatic
Touch Screen
Monochromatic
Orthodontic
Application
Yes
Invisalign
Unitek
Yes
Invisalign
Requires add-on
module
Yes
Clear Correct
Yes
Orchestrate (model storage
and removable appliances)
Implant Application
Yes
Straumann
Biomet 3i
Yes
Dentsply Zimmer
Yes
Yes
Yes
Glidewell Lab
Early digital scanners utilized a process of
recording overlapping single images that were
stitched together by the computer software to
create larger models. The number of images
recorded, the speed of recording, and the size
of the data file were greatly influenced by the
graphics capability and processing speed of
computers. The ability to process much larger
digital files improved as computer processors
evolved, resulting in increased quantity of images
as well as the current trend to move to video
data files.
The first clinical application developed for
digital impression systems was to fabricate
single tooth restorations (inlays, onlays,
veneers, and crowns). As the systems have
advanced, additional applications have been
implemented including diagnostic planning,
orthodontic treatment planning and appliance
fabrication, implant planning, surgical guide
fabrication, abutment design and fabrication,
and applications for removable appliances.
www.metdental.com
Digital Cameras and Scanners
C
urrently marketed scanners rely on a
number of imaging technologies confocal microscopy, optical coherence
tomography, stereovision, triangulation, and
interferometry. A more detailed engineering
discussion of these technologies as they apply
to recording intraoral images may be found in
Logozzo and coworkers publication.7
One common concern of many dentists is the
size of the camera used for scanning. Most
manufacturers have trended towards cameras
approaching the size of dental handpieces
assuming that dentists are very comfortable
using handpieces intraorally and a camera of
similar size would be able to be applied in a
familiar and comfortable fashion. In general, this
may seem like a good idea, however the size of
the camera is also an ergonomic concern. Similar
to curing lights, the entire camera does not need
to fit in the mouth, only the working tip of the
camera. Although a small sized camera head is
an obvious advantage for intraoral access, the
ergonomics of the camera body may be a greater
influence on the ease of intraoral scanning since
it has a direct impact on the maneuverability of
the camera.
Digital Impressions Compared to
Conventional Impressions
T
he workflow for a conventional impression
using elastomeric materials includes a
series of procedures that must be properly
managed to ensure accuracy. This includes
proper mixing and placement of the impression
material, proper disinfection and handling prior
to model fabrication, proper measuring and
handling of stone when pouring the model, and
proper recovery of the model from the impression.
These procedures are not without problems and
limitations, however they have been managed
by most dentists to provide accurate replicas
of the intraoral condition for decades. One
significant limitation of the conventional method
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Quality Resource Guide – Digital Dental Impressions 1st Edition
is the degradation of accuracy when multiple
pours are made in the same impression. Digital
impressions obviously avoid many of the potential
problems of conventional impressions with the
added advantage that models can be fabricated
with equal accuracy an unlimited number of
times as the digital file does not go through any
sort of accuracy degradation as it is repeatedly
processed.
A common challenge with all impression
techniques is their ability to accurately capture
subgingival margins. There are several essential
principles that the clinician must abide by to make
an accurate digital impression. The clinical area
to be impressed must be free of debris, isolated
from blood or moisture, and soft tissues need to
be retracted from the preparation margins and
tooth contours. These principles equally apply
to both conventional and digital impressions.
As much as clinicians would like to record
preparation margins and tooth contours through
soft tissues, blood, or moisture, this is not
currently possible. Digital scanners are line-ofsight recorders. The scanner or camera can only
record what is visible to the lens. Structures or
surfaces obscured by debris, fluids, or soft tissues
are also obscured from being accurately recorded
in much the same way they are for conventional
impressions. However, there are advantages to
digital impressions in regions difficult to impress
because of soft tissue interference or moisture.
Sometimes clinicians remove a conventional
impression from the mouth only to find there is
a small bubble or tear at a critical margin. The
only way to correct this deficiency is to redo the
entire process and remake the impression. Some
digital impression scanners offer the opportunity
to “correct” or modify existing images without
the need to redo the entire impression. Sections
of the scan can be deleted from the virtual model
and that small section rescanned and added to
the existing virtual model saving considerable
time and discomfort for both the dentist and
patient.
Evaluation of the accuracy of a conventional
impression is a critical decision in the dental
office as it determines the ultimate accuracy of
www.metdental.com
the final restoration. Many times discrepancies
are not identified until the model has been
fabricated.
With conventional impressions
this occurs well after the patient has left the
dental office, with no opportunity to immediately
correct the discrepancy. Digital impressions
offer the opportunity to evaluate the impression
immediately after scanning by magnifying it 20X
on the computer monitor. This aids detection of
discrepancies while the patient is still in the chair
with the potential to correct them immediately.
Digital systems do not record the “occlusion”
from the opposing arch but rather record the 3D
shape of the opposing teeth and then virtually
mount them against the preparation and adjacent
teeth. The software program is able to detect the
areas of contact between the two virtual models
similar to articulating paper detecting contact
points between opposing mounted stone models.
The digital mounting also has the advantage of
detecting degrees of contact or intersection to help
in developing the desired occlusal contact points
and lateral interferences.
Advantages and Disadvantages of
Digital Impressions
See Table 2.
Accuracy of Digital Impressions
I
t is a well-accepted principle that the accuracy
of a dental restoration or appliance can only
be as good as the accuracy of the impression,
be it conventional or digital. Digital impressions
have been shown to be at least as accurate as
conventional impressions and often times, more
accurate. An in vitro study compared the accuracy
of models made from full arch conventional
and digital impressions.8 Master models were
repeatedly scanned with the Lava COS system
and impressed repeatedly with polyvinylsiloxane
impression material to fabricate replica models.
The accuracy of the replica models was measured
with a computer graphic analysis program. There
was no significant difference in the accuracy of
the replica models compared to the master models
using either impression technique.
Table 2 - Advantages and Disadvantages of Digital Impressions
Advantages of Digital Impressions
• Less patient chair time required; increased clinical efficiency
• No need for distasteful impression materials potentially leading to gagging
• More comfortable impression process for the patient, creating less anxiety
• Technology tends to be engaging for a patient and provides evidence of state-ofthe-art care
• Indefinite electronic storage - with less space needed
• Eco-friendly aspects include eliminating the need for disposable plastic trays and
impression materials - digital impressions are disposed of with the “delete” button
• Distortion-free model remakes possible indefinitely since the original file is available
for repeated model processing
• Able to detect preparation undercuts and/or inadequate preparation reduction prior
to transmitting case to the lab with the potential to correct the problems during the
same appointment.
Disadvantages of Digital Impressions
• Increased initial capital investment for equipment
• Unknown length of time digital files will be able to be managed because of future
developments in software
• Infection control procedures for the scanner are more time consuming
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Quality Resource Guide – Digital Dental Impressions 1st Edition
Another in vitro study reported the marginal
and internal fit of a Fixed Partial Denture
(FPD) fabricated from conventional and digital
impressions.9 An acrylic master cast with prepared
abutment teeth for a FPD from #19 to #21 was
fabricated. CAD software was used to measure
margin gap, internal adaptation, and cervical
discrepancies between the FPDs. The marginal
gap was not significantly different between
conventional and iTero digital impressions with
the internal and cervical discrepancies less for the
digital impressions.
Another in vitro study evaluated the accuracy of
digital impressions and conventional impressions
using the Lava COS scanner, polyether
impressions, and digital scanning of the models
made from the polyether impressions.10 The digital
impression made with the Lava COS scanner
had significantly higher accuracy compared to
conventional impressions and indirect scanning of
the models.
Another study compared the clinical fit of crowns
made from digital and conventional impressions.11
A digital impression using the Lava COS system
and one conventional silicone impression was
made of the same crown preparation in each
of 20 patients. Duplicate zirconia crowns were
fabricated from each impression. Margin fit
for each crown was measured intraorally at the
time of crown delivery using a replica technique.
Crowns fabricated with the digital impression
technique had a significantly better margin fit (49
microns) than those made from a conventional
impression (71 microns).
One randomized clinical study compared
the margin fit of two types of zirconia crowns
made with conventional impressions and digital
impressions.12 A conventional polyvinylsiloxane
impression and a digital impression with the
Lava COS system were made for each of fifty
crown preparations. Crowns were made for each
preparation using the two impression techniques.
Each crown was measured intraorally for margin fit
and internal adaptation using a replica technique.
The crowns made with the digital impression had
a significantly better margin fit (51.45 + 18.59
microns) than those made with a conventional
impression technique (78.62 + 25.62 microns).
www.metdental.com
A more extensive in vitro study compared the
accuracy of ceramic crowns from different digital
impression systems and types of conventional
impression techniques.13 Conventional impressions
were made of a single crown preparation on a
master model using 2-step and single step, puttywash impression techniques. Digital impressions
were made of the master model crown preparation
using the Lava COS, CEREC AC, and iTero digital
systems. The mean margin fit of crowns was
48 + 25 microns for Lava COS, 30 + 17 microns
for CEREC AC, 41 + 16 microns for iTero, 33 +
19 microns for single-step putty wash technique
and 60 + 30 microns for the two-step putty
wash technique. The mean internal fit was 29
+ 7 microns for Lava COS, 88 + 20 microns for
CEREC AC, 50 + 2 microns for iTero, 36 + 5
microns for single-step putty wash technique, and
35 + 7 for two-step putty wash technique. There
was no significant difference in the margin fit or
internal adaptation of the crowns using any of the
techniques.
Clinical Application
T
he learning curve for digital impression
systems is significantly less than for
chairside CAD/CAM systems. The digital
impression is transferred to a laboratory where
the restoration is fabricated so there is no
software design functions or milling functions
for the clinician to master. Development of two
primary skills is necessary to become proficient
in making digital impressions. One is learning to
make the appropriate rotational and translational
movements with the scanner in the mouth to
record the intraoral condition. The second is
management of the administrative functions of the
software program to identify the case, complete
the electronic prescription, and electronically
transmit the case to sites outside the dental office.
Companies marketing a digital impression system
manage the cloud computing functions of digital
file distribution to the locations requested by the
dentist. The company establishes the electronic
connection through conventional Wi-Fi equipment
when the system is installed in the dental office.
Protection of patient privacy is an obvious
concern with the proliferation of digital systems.
Manufacturers of digital systems have developed
HIPPA-compliant safeguards and encryption
process to protect the transmission of digital data
from the dental office to the dental laboratory.
However, the WiFi safeguards in place at the
clinical setting also significantly contribute to
the final HIPPA-compliant safeguards for data
transmission. This should be evaluated during
discussions prior to installation with the digital
system manufacturer representative.
The most common application of digital impressions
is the fabrication of dental restorations. There are
two distinct workflows that may be used. One
option is to transmit the digital file to the dental
laboratory where they process a model similar
to what would be done with a conventional
impression. Companies generally have selected
specific model processing applications for their
digital impression systems, but the digital files
may also be used to process alternative types of
models such as milled polyurethane, printed resin,
or resin stereolithography (SLA). Once the model
is fabricated, any standard laboratory procedure
may be used to develop and create the dental
restoration. The second alternative is to input the
digital file to a CAD program to design the desired
substructure or full contour restoration. Once the
design has been milled, the restoration can be
finalized using the processed model. A number of
labs also process “model-free” restorations using
the full contour design from the CAD program
in a cost effective and efficient workflow. The
dental laboratory generally selects the technique
based on specifics of the case and the type of
restoration requested as well as the capabilities of
the laboratory.
Orthodontic Applications
A
s the ease and efficiency of recording
full arch scans has improved, orthodontic
applications for digital impressions have
significantly increased. Digital files are used for
orthodontic diagnosis and treatment planning,
case documentation, as well as appliance
design and fabrication. Of particular interest to
orthodontists is the ability to electronically store
case documentation electronically rather than
committing significant storage areas to cataloging
models and boxes.
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Quality Resource Guide – Digital Dental Impressions 1st Edition
Implant Applications
A
nother rapidly developing clinical
application for in-office digital
impressions is dental implant therapy.
There are two main clinical applications.
One application is in implant case planning.
Planning the implant location based on the
desired parameters of the final restoration is a
very desired approach. Cone Beam Computer
Tomography (CBCT) has developed into a
preferred 3D diagnostic tool for optimizing the
surgical placement of implants. Commercial
software programs are available to combine
the intraoral digital impression with the CBCT
file for planning of the implant case as well as
fabrication of surgical guides based upon the
planned outcome.
A number of dentists use fixture level impressions
with elastomeric materials to record the
3D position of the implant in the alveolus for
laboratory fabrication of custom abutments and
implant retained restorations. The stone model
and implant analogue is scanned in the laboratory
using a bench-top scanner to design the desired
abutment and restoration. Digital impression
systems can now significantly streamline this
workflow with the use of encode abutments or
scan bodies to record intraoral fixture level digital
impressions of implants. They contain unique
surface geometry or markings that allow the
software to specifically align the implant in 3D
within the virtual model. The digital fixture level
impression is transmitted to the dental laboratory
for design and fabrication of the custom abutment
and final restoration.
Conclusion
D
igital impression systems based
on CAD/CAM technolgy are
developing at an ever-increasing
rate. Initial restorative applications have
now expanded to include both diagnostic
and therapeutic applications in orthodontic,
implant, and removable prosthodontics with
new collaborations between companies
promising additional applications. As the
technology continually evolves, dentists
will discover their own level of comfort
and involvement with digital impression
systems to incorporate the new applications
into their dental offices.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
uret F, Preston JD. CAD/CAM imaging in dentistry. Curr Opin Dent 1991;1(2):150-154.
D
Mormann WH, Brandestini M, Lutz F, Barbakow F. Chairside computer-aided direct ceramic inlay. Quintessence Int 1989;20(5):325-339.
Beuer F, Schweiger J, Edelhoff D. Digital dentistry: An overview of recent developments for CAD/CAM generated restorations Br Dent J
2008;204(9):505-11
Birnbaum NS, Aronson HB. Dental impressions using 3D digital scanners: Virtual becomes reality. Compend Contin Educ Dent. 2008;29(8):494505.
Fasbinder DJ Digital dentistry: Innovation for restorative treatment. Compend Contin Educ Dent 2010;31(SI4):2-11.
Fasbinder DJ. Using digital technology to enhance restorative dentistry. Compend Contin Educ Dent 2012;33(9):666-677.
Logozzo S, Franceschini G, Kilpelä A, Caponi M, Governi L, Blois L.A comparative analysis of intraoral 3D digital scanners for restorative
dentistry. Internet J Med Tech 2008 Volume 5 Number 1.
Ogledzki M, Wenzel K, Doherty E, Kugel G. Accuracy of 3M-Brontes stereolithography models compared to plaster models. J Dent Res
2010;89(SI A):abstract #1060.
Svanborg P, Skjerven H, Carlsson P, Eliasson A, Karlsson S, Ortorp A. Marginal and internal fit of cobalt-chromium fixed dental prostheses
generated from digital and conventional impressions. Int J Dent 2014;2014:534382. doi: 10.1155/2014/534382. Epub 2014 Mar 3.
Guth JF, Keul C, Stimmelmayr M, Beuer F, Edelhoff D. Accuracy of models obtained by direct and indirect data capturing. Clin Oral Invest
2013;17:1201-1208.
Syrek A, Reich G, Ranftl D, Klein C, Cerny B, Brodesser J. Clinical evaluation of all-ceramic crowns fabricated from intraoral digital impressions
based on the principle of active wavefront sampling. J Dent 2010 38(7):553–559.
Fasbinder DJ, Neiva GF, Dennison JB, Heys D, Heys R. Evaluation of zirconia crowns made from conventional and digital impressions. J Dent
Res 2012;91(SI A): abstract #644.
Seelbach P, Brueckel C, Wöstmann. Accuracy of digital and conventional impression techniques and workflow. Clin Oral Invest 2013;17(7):17591764.
www.metdental.com
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Quality Resource Guide – Digital Dental Impressions 1st Edition
POST-TEST
Internet Users: This page is intended to assist you in fast and accurate testing when completing the “Online Exam.”
We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam.
(1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade.
1.What three sequences are included in a CAD/CAM process?
a. Image recording, computer design, 3D printing
b. Image recording, lab design, Subtractive milling
c. Video recording, computer design, 3D printing
d. Image recording, computer design, Subtractive milling
e. Video recording, lab design, 3D printing
2.What was the first marketed CAD/CAM system?
a. Duret Optical Impression system
b. Siemen Scanner
c. CEREC System
d. Ceramic Reconstruction System
e. E4D System
3.What process did the first intraoral scanner use to create virtual
models in the software program?
a. Computer stitching of overlapping single images
b. Video recording
c. Model extrapolation from single images
d. Subtractive image recording
e. Image database copying
4.What is the difference in using conventional PVS impression
materials and digital impressions to record subgingival margins?
a. Conventional PVS impression materials can record deeper
subgingival margins.
b. Both techniques require equally good tissue retraction and moisture
isolation.
c. Digital impressions can record deeper subgingival margins.
d. Conventional PVS impressions deflect soft tissues better than digital
impressions.
5.What is the outcome of most in vitro research studies that
compare conventional PVS impressions to digital impressions
relative to margin accuracy?
a. There is no real difference in accuracy between conventional PVS
and digital impressions
b. Conventional PVS impressions are more time consuming, but more
accurate
c. Digital impressions are generally more accurate than conventional
PVS impressions
d. Conventional PVS impressions using a light body material are more
accurate than digital impressions
e. Only a limited number of digital impression systems are able to
consistently record accurate preparation margins
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6.Digital Impression systems focus on which step of the CAD/CAM
process?
a. Image recording
b. Laboratory computergraphic design
c. In-office milling
d. Computer Assisted Design
e. 3D printing
7. What significant advantage does a Digital Impression system
offer for orthodontic applications?
a. Digital diagnosis
b. Predictive case planning
c. Post-treatment retainer printing
d. Digital model archiving
e. More efficient diagnostic models
8.What significant advantage does a Digital Impression system
offer for implant applications?
a. Clinical and laboratory streamlining of the 3D recording of the
implant in the alveolus
b. Integration of the digital recording with dicom files of CBCT
c. Design and fabrication of surgical guides
d. Design and fabrication of temporary restorations
e. Case documentation
9.Which of the following is not a Digital Impression system?
a. True Definition (3M ESPE)
b. Apollo DI (Sirona Dental)
c. TRIOS (3Shape)
d. iTero (Align Technology)
e. Duret Scanner (Begio)
10.Which of the following is not a disadvantage of Digital Impression
Systems?
a. Increased initial capital investment for equipment
b. Unknown length of time digital files will be able to be managed
because of future developments in software
c. Infection control procedures for conventional impressions are more
time consuming
d. The learning curve is more involved for digital impressions
e. More preventive maintenance of equipment
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Quality Resource Guide – Digital Dental Impressions 1st Edition
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