Cerec, Planmeca and Trios compared https://instituteofdigitaldentistry.com/cad-cam/review-of-the-intra-oral-scanners-at-ids-2019/

Do you feel it’s difficult to tell the difference between each CAD/CAM system when they all say they are the best system?

Have you looked into CEREC, 3Shape and Planmeca Systems and wonder what the Pros and Cons are of each?

CAD/CAM Scanners Compared

Cerec Omnicam

3Shape Trios

Planmeca Emerald

Scanning Speed

Although early in the game the CEREC Omnicam trumped all competitors in scanning speed, now other CAD/CAM systems have caught up. The CEREC Omnicam provides a smooth and seamless scanning experience with few if any areas that can be faulted. Sometimes scanning very lustrous surfaces such as gold crowns can slow down scanning as they can require you to go over the area multiple times (or use a scan spray) but in reality, this is a non-issue and happens to every scanner. The Omnicam is still one of the best scanners on the market which is remarkable considering it has been on the market for around five years, while the competitors are much newer. 

Regarding scanning speed, the 3Shape TRIOS is as fast if not faster than the CEREC Omnicam. It is an efficient scanner with a realistic HD scanning aesthetic. It is by far the most visually appealing scanner on the market. The recently released Planmeca Emerald is also a high-speed scanner. Intra-orally it is as quick as the other two and seems to be the smoothest scanning experience of the three. It does need a little more attention to pick up interproximal areas however. The scanning image produced by the Emerald appears to be a lower resolution and is not as high definition as the Omnicam or TRIOS. As scanning technology plateaus the scanning speeds of these three competitors seems to have equalised.

Scanner Size & Ergonomic Design

The CEREC Omnicam has the smallest scanner head and weighs approximately 315 grams. The benefit of the more compact scanner is ease of use especially in smaller mouths and tight to reach places (think distal of the upper 2nd molars). The Omnicam scanning head is smaller than its competitors as it has no inbuilt heater. 

3Shape TRIOS is the largest scanner of the three. It contains an inbuilt heater, and the scanning head is larger than the Omnicam. It weighs slightly more than the Omnicam at 340 grams. Unlike the others, 3Shape comes in many configurations including pen-grip, handle and wireless configurations. This enables the 3Shape to fit many preferences. 

The Emerald is the middle of the pack in terms of size. It is however the lightest scanner by a large margin weighing approximately 240 grams. It has an ergonomic design and is used in pen-grip. The low weight of the scanner and the relatively small size makes it comfortable to hold and navigate around the oral cavity. 

They are all reasonably sized and can be easily used in every patient and every mouth size. Each one of these scanners is comfortable to hold and there was no major gripes in their shape and design. The newer scanners do have a more ergonomic shape and fit in the hand more comfortably. 

Inbuilt Heater

The Omnicam is the smallest scanner because it has no inbuilt heater. An inbuilt heater in the TRIOS and Emerald scanners prevents fogging of the scanner mirror (in the scanning tip) while in use in the mouth. These scanners can scan intraorally for extended periods of time with little issue. 

With the CEREC Omnicam, the heater is found on the cart instead and heats up the scanner head while the scanner is docked on the cart and not in use. Although this is usually sufficiently warm and doesn’t fog for simple quadrant scanning, it can be a nuisance for those trying to do full mouth scans or beginners who need to take their time scanning in the mouth. 

It also becomes a nuisance if you forget to turn on the CEREC before using the scanner as it takes around 10 minutes to heat up sufficiently. When the Omnicam fogs up while scanning, it can no longer be used efficiently and fails to pick up images. This will require you to have a high-speed suction nearby or to place the scanner on the cart for a few minutes to heat up which disrupts the workflow. Experienced CEREC users will rarely have this issue as they can scan efficiently, but having the inbuilt heater is no doubt very useful especially when taking full-arch scans.

Full Arch Scanning

Doing simple quadrant scans is quick and straightforward in all systems. A real test of scanning effectiveness and speed is how quickly it can handle a full arch scan. The TRIOS tops the list here. A combination of its fast scanning and its inbuilt heater makes it easily the quickest scanner to carry out a full arch scan. 

The Emerald for us comes next. It is also a fast and smooth scanner. The simple fact of having an inbuilt fan makes the whole process easier and quicker. Although when used by experienced hands the Omnicam is more than capable of handling full arch scans, it is by no doubt the hardest to do, especially for beginners. 

Although the CEREC fans may be annoyed by this comment, I would recommend they try one of the other scanners for this purpose, and they will notice the difference. 

Here at our clinic, our six dental assistants are all trained to carry out intra-oral scanning, they all agree that when scanning alone without an assistant holding the suction nearby the TRIOS is the easiest for full arch scanning.

Ease of Use

Most scanners excel in ease of use and functionality. Ease of use comes from the software that supports the hardware. The workflow for each scanner is intuitive and follows a simple step by step progression basically identical across each system. This workflow is as follows: Scanning, Margination, Designing and then Milling. 

The CEREC system outclasses the other two systems as it seems to be made and designed for dentists who want to mill on-site in mind. Overall the CEREC workflow is the most reliable, efficient and works the best. Little additions like having the remaining milling time on the cart while the mill might be in another room is beneficial for those who do not want to keep walking over to the mill to check (while they may be seeing another patient during milling). 

The TRIOS software seems to lack the same intuition in some areas. When using the 3Shape Cart for instance, once you ready to design you need to send the scan to a cloud and then essentially download the scan onto another computer loaded with the design software. Although simple and completed with a click or two, it involves extra steps and takes a few minutes as the scans are uploaded and downloaded, compared to the CEREC in which designing is done on the cart. 

Regarding the Planmeca Emerald, the software (called Romexis) lets the otherwise fantastic scanner down a little. Although it has been updated to improve scanning speeds, the entire software feels outdated and hasn’t changed significantly since the Planscan (older generation scanner) 5 years ago. Although it does the job, the software feels and looks dated compared to the CEREC and TRIOS systems and it feels more sluggish.

Automatic Design Proposals

The automated design aspect of the software is the part where the CEREC software excels by a large margin. What we mean by automatic design proposals (aka autogenesis) is the automatically designed restoration the software fabricates for you after you have scanned and proceeded to the design stage of the workflow. 

It is incredible how the CEREC software reads the adjacent teeth and uses the shape, size and even anatomy to give you a proposal 95% of the time perfect (especially for simple single visit crowns, onlays and bridges). Remember, the software will only give you an excellent design proposal if you give it a quality preparation scanned well. Don’t forget to reduce enough occlusally and ensure your margins are smooth!

The 3Shape software leaves a lot to be desired in this aspect. Although we have used the lab version of the software which is generally much better, we will be comparing the standard in-clinic version (called TRIOS Design Studio) which most dentists will purchase and be using. The automatically designed restorations are chosen from a library of preset tooth morphologies, and although they usually look good and there is a large selection to choose from, often the proposals fabricated by the software will require at least some adjustment to ensure good morphology and occlusion. It just doesn’t feel as seamless as the CEREC software.

The Planmeca software is similar to the TRIOS System in this regard. It needs similar adjustments to the design proposal like the 3Shape system, but is usually good enough to be milled with little input. The Planmeca design proposals are not quite as nice from a morphology viewpoint as the CEREC designs and are also taken from a library of preset designs. The Planmeca library is much more limited than the TRIOS system and doesn’t offer much choice in terms of anatomy and morphology. 

All three systems do a relatively good job with posterior teeth, but anterior teeth are a different story. The design software for each system doesn't do as well to propose aesthetically pleasing anterior teeth and often these require a good grasp of the software to ensure an excellent result. This is getting better and better with time, and it seems CEREC is the best at anterior morphologies too.

Design Tools

Although the Automatic Design Proposals of the CEREC are excellent, it’s following design tools are not the best. They are fleshed out, and there are many tools available, but in some areas, it feels outdated, convoluted and frankly isn’t as good as the 3Shape system. 

The 3Shape design tools feel modern, powerful and give a lot of control and flexibility. Designing and tinkering with any aspect of the design is measured in numerical values (such as cusp inclinations, contact hardness, occlusal hardness, etc.) which helps with accuracy and makes it feel more clinical rather than colour maps (in the CEREC and Planmeca) which can be arbitrary. Yes we know, these colour maps have values set in the options but that is not the point, setting your contact to “blue with a bit of green” on the CEREC is different to “-0.05” in the Trios. The 3Shape Design system feels like dental photoshop with the flexibility it gives you in designing. The UI is also more straightforward and easier to understand than the CEREC UI. 

It also has to be said that the 3Shape implant studio is fantastic and allows you to produce surgical guides efficiently. Also consider that when the TRIOS was released, it came out with many unique and useful improvements to the digital workflow such as automatic margin detection. These have since been added to the CEREC system in software patches in what seems to be a to and fro between the two companies.

The Planmeca design software tools have not changed in a significant way since the last generation scanner roughly five years ago. It does the job but feels old-fashioned. The software is also sluggish and doesn’t feel entirely on the same calibre as the other two. It has all the required tools and for simple quadrant/single crown work they are sufficient and work well.

The other advantage of the Planmeca and TRIOS is they can be installed on any computer or laptop. Allowing you to design on a sexy 4k HD 40-inch screen if you wanted to. The CEREC Omnicam screen is a small 19 inches and these days it really should be bigger. Although the CEREC can be attached to a monitor it is a nuisance and is easier to do with the other scanners as the designing software can be downloaded on an external computer and the scanner attached easily by USB. Designing is thus a little more cumbersome on the CEREC as for one you cannot have all the tools present on the screen at once as there is just no room. This means you are continually clicking between menus, but this is a quality of life issue if anything. 

The CEREC Cart also has a ball trackpad rather than a mouse. Although this does not impact the workflow, it is an aspect you will need to consider. It does not make or break the system as most people get used to it and sometimes even prefer it for designing. Just know that at the start it can be frustrating and will involve a learning curve to get used to the trackpad. The CEREC cart has a slot for a USB mouse, but this is not practical unless you want to be using the mouse on your leg. Its easier to just get used to using the trackpad.

CAD/CAM Software Design Stage Comparison

See the different tools of all three software platforms go through the same process.

Software Reliability

The CEREC system has the most significant market share by a good margin partly due to being one of the earliest players in the CAD/CAM scene. They have the most substantial number of users aka software testers which has led to its software being so rigorously fleshed out it is rare to have a single crash. 

Although crashes occasionally occur these are far and few between. Remember the Omnicam still receives regular updates, and those eager to have the latest added tools will find more bugs and crashes than the more stable versions (usually one version older than the most recent released patch until it is tested thoroughly).

These days the software has been patched and ironed out a lot more. It does not crash nearly as much as before, but it is still more common compared to the CEREC and Planmeca. You can imagine the frustration of 5-6 hours of design work being entirely erased by a crash or file corruption. Be advised that this is not always a fault of the software but can also be due to the hardware you are running the design studio on.

Open or Closed Architecture

One of the main downsides of the CEREC System early on was that it used to be a closed system. This means you could only send the CEREC scans to Sirona devices. This was quite a significant limiting factor as for example if you owned a Carestream CBCT you could not marry the CBCT with the Scan from the CEREC. 

When asked about this, Sirona representatives had long explanations. The majority of newer scanners that entered the market were subsequently open systems (allowing them to ‘talk’ with any device from any company). Under what appears to be market pressure, CEREC has recently become partly open. Although reps will say it is a completely open system, it isn’t. The scans can be exported and used, but unless you own the lab version of the software (CEREC inLab), you can not import scans into the CEREC system for milling. Keep in mind if you only own a CEREC Omnicam and Mill, then why would you want to import scans anyway? 

The other two systems (3Shape and Planmeca) are open allowing exporting and importing of scans freely and use with any 3rd party device. This means that a Scan from a TRIOS Scanner can be sent to a Planmeca mill and vice versa. Because of the wide variety of 3rd party machines available, keep in mind that this does mean an open system can run into more issues with the different devices communicating with each other properly, when compared to a closed one.

Cost (£GBP)

Based on the advertised price alone CEREC is the most expensive system. The CEREC Omnicam with the MC XL mill costs over £100,000. It only comes in the cart configuration and a non-wireless scanner. This is more than double the cost of the other systems. The CEREC is also the oldest system out of the three, yet it has aged well and stays very competitive. 

The 3Shape TRIOS scanner ranges from £18,000 - £35,000 as it has several options such as the Cart, TRIOS MOVE or Wireless configurations. The scanner can also be bought in colour or black and white options. Regarding the cost of the milling machine you buy to pair with the TRIOS, this can range from £18,000 to £60,000. The Roland DWX-4W is approximately £21,000. 

The Planmeca Emerald has a cost similar to the TRIOS at a price tag of £28,000. It is a colour non-wireless scanner that only comes in the laptop/desktop configuration. The scanner can be connected to any computer by USB. 

Be aware when buying a TRIOS or Emerald scanner alone without a cart or associated computer with it, you can expect to spend over £1,000 for a computer with the hardware powerful enough to run the demanding scanning and designing software.

There are a number of different payment options and plans available these days. Some large digital dental laboratories also offer a free scanner when purchasing a certain amount of ‘credit’ with them. We generally recommend buying the entire system (scanner and mill) as the real benefits of Digital Dentistry and CAD/CAM are reaped with in-house milling.

Yearly Fees / Subscription 

Almost every system comes with annual fees these days. CEREC technically doesn’t (what reps will tell you) but if you want any resemblance of good support, servicing and all the latest updates which result in new materials being added to the system, faster scanning and in general large improvements to the workflow you will need to subscribe to the CEREC Club yearly subscription by Sirona. This is the only subscription for the CEREC system and ranges from $3500 to $4500 per year. Take note that when purchasing the CEREC system your first 3 years of the CEREC Club membership are free.

The 3Shape system has the most elaborate subscription-based service. The scanner itself not only has an annual subscription (around £1000-£2500 depending on the scanner you buy) but so do the different design modules. The baseline design software of the TRIOS is purchased for close to £4000 and has an annual subscription of under £350. This software can be used to fabricate fixed prosthetics such as crowns, bridges, onlays, inlays, veneers etc. but for more specialised treatments such as implants or orthodontics, there are design module add-ons. For example, the Implant Studio which has a one off-fee to purchase and then a yearly subscription fee too. Note that the CEREC system comes with all modules included without the requirement of buying design module add-ons.

The Planmeca system has no yearly fees or subscriptions tied to the scanner or software. It also comes with most modules with no added fees. It has very transparent pricing in that what you see is what you get. The Planmeca design software comes with modules for smile design, and orthodontics all included in the base software rather than requiring add-ons to be purchased. One exception is the implant design software for the restoration of implants or fabrication of implant guides which is an additional one-off fee that needs to be purchased. In this sense, the Planmeca subscription framework feels somewhere between the CEREC and the TRIOS.

Don’t forget that each system will also have ongoing costs in terms of milling machine maintenance, which like your car, needs regular servicing to keep running smoothly.

Final Thoughts

Below are comments about the CAD/CAM systems which do not fit in the categories above.

CEREC, TRIOS and Planmeca Emerald are all colour scanners. This is a massive bonus regarding design and margination. It surprises us how some black and white scanners can still compete in this market, but they are out there. Colour scanning is a huge wow factor for patients and an excellent communication tool. 

All three scanners also can scan well without the use of scanning powders. Scanning powders were used in the earlier generations of scanners. They are applied to the teeth to provide a high contrast medium to help the scanner pick up images. These days they still help but are not essential in 99% of cases and only used as an adjunct to scanning.

The 3Shape Cart configuration looks very modern and sharp. It has a touch screen that is used to control the entire system. The touchscreen is very responsive and gives no problems or wrong inputs. One oversight of the 3Shape Cart is it has no inbuilt battery. This is a crucial consideration if your scanner will be used in multiple surgeries between multiple dentists. The cart must be turned off before unplugging and turned on again after moving into another room. This wastes easily 5-10 minutes of computer booting time. The CEREC Cart has a battery inbuilt that will last easily 20-30 minutes of use before plugging again. This is useful when moving between surgeries and another well designed aspect of the CEREC system. The Planmeca system does not come in cart configuration and does not have this issue.

3Shape is developing several exciting software for their system including an elaborate smile design software not yet released. It has to be said that 3Shape is competing in a big way with Sirona in the CAD/CAM scene as they have released/are developing several competitive products. The recently released 3Shape MOVE for instance. The CEREC has an in-built smile design software, but it is underdeveloped and unused.

The Planmeca Emerald and 3Shape TRIOS have removable and autoclavable scanning heads. The scanning head can be removed between patients and sterilised. This provides ideal cross-infection control. The TRIOS scanning heads are a little fragile and can break if not treated carefully. Additional scanning heads can be purchased but they are not cheap. The CEREC Omnicam does not have interchangeable scanning heads. Its scanning head is removable, but this is a time-consuming process compared to the other two systems and requires careful cleaning protocol in an effort not to damage the scanner. Removing the Omnicam scanning head is not practical between patients (and we don't know many dentists who remove the scanning head at all). It generally relies on cold sterilisation or scanning sleeves (which makes scanning slow and annoying) and are not used commonly.

In summary, this is our in-depth look at the three main CAD/CAM systems we have been using in our dental clinic over the past 10 years. In this comparison, we have focused on the clinical aspects rather than technical specifications.

As you can tell there is no clear winner and each system has its faults and benefits. Buying a CAD/CAM system should be based on several factors such as the size of your clinic, the procedures you specialise in, what other dental technology you have in your practice and your budget.