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Full arch scans: Conventional versus digital impressions - An in-vitro study

[Ganzkieferaufnahmen: Konventionelle versus digitale Abformtechnik - Eine
In-vitro-Untersuchung]

Article in International Journal of Computerized Dentistry · January 2011

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In-vitro evaluation of the accuracy of conventional and digital methods of obtaining full-arch

dental impressions

Andreas Endera, Dr. med. dent.; Albert Mehlb, Prof. Dr. Dr. med. dent.

a
Research assistant, Division for computerized restorative dentistry, Center of Dental

Medicine, University of Zürich

b
Head of Division, Division for computerized restorative dentistry, Center of Dental

Medicine, University of Zürich

Keywords

CAD/CAM, conventional impression, digital impression, full-arch dental impression,

precision, trueness

Corresponding author:

Dr. med. dent. Andreas Ender

Division for computerized restorative dentistry, Center of Dental Medicine, University of

Zürich, Plattenstrasse 11

8032 Zürich, Switzerland

E-mail: andreas.ender@zzm.uzh.ch

Phone: 0041 44 634 31 93

Fax: 0041 44 634 31 91

WORDS: 2125

FIGURES: 7

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Abstract

Objective: To investigate the accuracy of conventional and digital impression methods used to

obtain full-arch impressions by using an in-vitro reference model.

Materials and Methods: Eight different conventional (polyether, POE; vinylsiloxanether,

VSE; direct scannable vinylsiloxanether, VSES; and irreversible hydrocolloid, ALG) and

digital (CEREC Bluecam, CER; CEREC Omnicam, OC; Cadent iTero, ITE; and Lava COS,

LAV) full-arch impressions were obtained from a reference model with a known morphology,

using a highly accurate reference scanner. The impressions obtained were then compared with

the original geometry of the reference model and within each test group.

Results: A point-to-point measurement of the surface of the model using the signed nearest

neighbour method resulted in a mean (10%–90%)/2 percentile value for the difference

between the impression and original model (trueness) as well as the difference between

impressions within a test group (precision). Trueness values ranged from 11.5 µm (VSE) to

60.2 µm (POE), and precision ranged from 12.3 µm (VSE) to 66.7 µm (POE). Among the test

groups, VSE, VSES, and CER showed the highest trueness and precision. The deviation

pattern varied with the impression method. Conventional impressions showed high accuracy

across the full dental arch in all groups, except POE and ALG.

Conclusions: Conventional and digital impression methods show large differences regarding

full-arch accuracy. Digital impression systems reveal higher local deviations of the full arch

model. Digital intraoral impression systems do not show superior accuracy compared to

proper conventional impression techniques. Yet, they provide excellent clinical results within

their indications applying the correct scanning technique.

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Introduction

Dental impressions are used to obtain an imprint of the intraoral situation on an extraoral

physical model. These dental impressions have a wide range of applications ranging from

providing models for treatment planning or patient communication to providing master casts

for the production of final restorations.1–3 The accuracy of dental impressions is especially

significant for the fabrication of a well-fitting restoration.2–4

Different impression materials and techniques have been used to achieve highly accurate

conventional impressions.5,6 The accuracy of these conventional impressions is typically

investigated by in-vitro studies, which evaluate the changes in linear distances between an

original master model and a gypsum model derived from the impression after pouring.5,7,8

Intraoral verification of impression methods is mostly performed indirectly, by comparing the

fit of the final restorations fabricated on the basis of the physical gypsum model.9–12 The

techniques and materials used to obtain a conventional impression, developed over the last

few decades, have shown high accuracy and reliability for the production of single and multi-

unit restorations (fixed partial dentures, FPD’s).13–15

In the 1980’s, the digital intraoral impression system was developed.16–18 According to this

new system, the intraoral situation is analyzed using an intraoral three-dimensional

acquisition device, and a virtual model is created by means of the CAD/CAM software. The

final restoration is fabricated on the basis of the virtual model. For improved accuracy,

measurement of linear distances is not recommended with three-dimensional models.19 The

accuracy of digital models has been investigated by superimposition of the original

geometry.19–22 Then, three-dimensional distances are computed, showing the deviations

between the impression and the original master geometry at each surface point. To execute

this comparison, the exact knowledge of the original master geometry of the intraoral surface

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is required. The accuracy of the knowledge of the master cast geometry limits the

computation of impression deviations because a measurement deviation from the master scan

may be attributed to errors associated with either the master cast scan or the digital

impression. Because of these limitations, thus far, the accuracy of digital impressions has

been investigated only with respect to small parts of the dental arch or geometrical forms.21,23-
25

Furthermore, conventional and digital impressions of the same dental morphology have not

been compared using the same evaluation method. In recent years, a new highly accurate

measuring method has been established for the measurement of full-arch dental models.26

With this method, it is possible to compare conventional and digital impressions obtained

using the same geometry, which is verified with a specially adapted, highly accurate reference

scanner. A few studies have attempted to assess the accuracy of both digital and conventional

full-arch dental impressions with this method.27,28 The accuracy of a dental impression is

determined by two factors: trueness and precision (ISO 5725-1). The trueness describes the

deviation of the tested impression method from the original geometry.4 Precision indicates the

deviations between the impressions within a test group.25 Precision and trueness, together,

describe all aspects of a specific impression method.

The aim of this in-vitro study was to evaluate different conventional and digital methods used

to obtain full-arch dental impressions, with respect to trueness and precision. In addition, the

deviation patterns were visually analyzed to determine the typical deviations associated with

each impression method. The null hypothesis was that there were no significant differences

between conventional and digital impression methods with respect to trueness and precision.

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Materials and Methods

A steel reference model was fabricated from a patient’s upper jaw impression with two full

crown and one inlay preparation. This reference model was scanned with a highly accurate

reference scanner (Infinite Focus Standard, Alicona Imaging, Graz, Austria), using a special

scanning protocol for large objects (IFM software 3.5.0.1, Alicona Imaging). The scan data of

this reference scan (REF) was then compared with all other test groups, as described in a

previous study.26 All impressions were obtained from this reference model at room

temperature (23°C) and ambient humidity. For every test group, five impressions of the

reference model were obtained (n = 5).

Conventional impressions:

For all conventional impressions, standard metal stock trays (ASA Permalock, ASA Dental,

Bozzano, Italy) were used. The impressions were placed on top of the master model, moved

to its final position, and then left in this position until the end of the setting time. The trays

were then lifted from anterior to posterior to remove the impression from the model.

The following materials were used to obtain conventional impressions: POE, polyether

material (Impregum, 3M ESPE, Seefeld, Germany), VSE: vinylsiloxanether material

(Identium, Kettenbach, Eschenburg, Germany), VSES: direct scannable vinylsiloxanether

material (Identium Scan, Kettenbach), and ALG: alginate impression material (Blueprint

Cremix, Dentsply, Konstanz, Germany).

For the groups using POE, VSE, and VSES, a tray adhesive was applied to the impression

tray. POE, VSES, and ALG impressions were obtained as monophase impressions, according

to the manufacturer’s instructions. VSE impression was obtained with a sandwich impression

technique using heavy and light body material (Table 1).

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All impressions were disinfected for 10 minutes (Impresept , 3M ESPE, Seefeld, Germany).

After storage for eight hours, type IV dental stone (Cam-Base, Dentona AG, Dortmund,

Germany) was poured over the impressions from groups POE, VSE, and ALG, which were

then stored for 48 hours. Next, all casts were scanned with the reference scanner (Infinite

Focus, Alicona Imaging) using the highly accurate protocol for scanning large objects. The

scan data were exported in the STL data format. The impressions from group VSES were

trimmed with a scalpel at the marginal and palatal areas to ensure optimal visibility of the

occlusal and approximal parts of the tooth surfaces. Impressions from group VSES were

scanned with the reference scanner (Infinite focus) after sputtering the surface. Before

sputtering, the impressions of the VSES group were extraorally digitized, using a laboratory

scanner (iSeries, Dental Wings Inc., Montreal Canada). This protocol can generate digital

STL data from a direct impression scan, without the need of pouring the intraoral impression

(VSES-dig).

Digital impressions:

The following digital impression systems were used: CER: CEREC Bluecam (Sirona Dental

Systems, Bensheim, Germany), OC: CEREC Omnicam (Sirona Dental Systems), ITE: Cadent

iTero (Cadten LTD., Or Yehuda, Israel), and LAV: Lava COS (3M ESPE).

The reference model was scanned according to the manufacturer’s instructions (ITE, LAV) or

using self-developed scanning strategies (CER, OC). For group CER, a matting powder

(Sirona OptiSpray, Sirona Dental Systems), and for group LAV, a dusting powder (Lava COS

Powder, 3M ESPE, Seefeld, Germany), was used to pre-treat the surface of the master model

before obtaining an optical impression. The scan data were directly exported from the

acquisition unit (CER, OC) or sent for postprocessing (ITE, LAV) and then exported as an

STL data file (Table 2).

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To compare the test groups with the reference model, the scan data were superimposed using

special diagnosis software (IFM software 3.5.0.1, Alicona Imaging), which uses best-fit

algorithms to match two surfaces. It calculated the distance from a surface point of model one

to the closest surface point of model two using the signed nearest neighbor method. The value

and orientation of the calculated distance were obtained. This procedure was repeated for each

surface point of model one. In total, the software computed approximately 2 million distances

per match. The distance data were saved as a text file and imported into a statistical program

(SPSS21, IBM Corp, IL, USA). The 10% and 90% percentile of all the distance values were

calculated. The (90%–10%)/2 percentile served as a measure of the differences between the

two matched models. The geometry of 80% of the model surface shows less deviation

compared to the reference model. The (90%–10%)/2 percentiles of all superimpositions were

summarized, and the mean, median, and standard deviation were calculated (SPSS21, IBM

Corp). Additionally, a difference image of each match was saved as a screenshot for visual

analysis of the deviation pattern.

The trueness of each test group was assessed by superimposing each model scan (n = 5) with

the model reference scan data set. The precision was calculated as the mean difference

between all superimposition combinations within one test group (n = 10).

Statistical analysis

All (90%–10%)/2 values were analyzed with a statistical program (IBM SPSS Statistics 21,

IBM, NY, USA). The Shapiro–Wilk test was used to examine the normal distribution.

Levene’s test was used to assess the equality of variances for all test groups (p < 0.05). The

Kruskal–Wallis test was used to assess differences between the different test groups.

Statistical differences between the test groups were analyzed by using the one-way ANOVA

with the posthoc Tukey-HSD test (p < 0.05).

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Results

In this study, no equality of variances and no normal distribution were found by the Levene’s

test and Shapiro–Wilk test. The Kruskal–Wallis test revealed statistical differences between

the test groups (p < 0.05). According to the results of the one-way ANOVA, the mean values

of trueness and precision were statistically different between the test groups.

Trueness of full-arch impressions

The trueness of all the test groups is shown in Table 3 and Figure 2. Groups VSE, VSES, and

CER showed the highest trueness (p < 0.05), with a mean deviation of 13.0 µm, 11.5 µm, and

23.3 µm, respectively, from the reference data set. The digital impression systems of groups

VSES-dig (35.1 µm), ITE (35.0 µm), OC (37.3 µm), LAV (44.9 µm), and ALG (37.7 µm)

were not significantly different amongst each other (p > 0.05), but were significant different

from those of groups VSE, VSES, and CER. The significantly highest deviations were found

in group POE, with a mean distance of 60.2 µm to the reference model (Table 3).

Conventional impressions in group POE showed large deviations of above 100 µm within the

model as distortions of the dental arch (Fig. 4a). In contrast, the visual analysis of group VSE

revealed a very homogeneous distance pattern (Fig. 4b). No region of the impression showed

deviations higher than 20 µm, except the distal tooth, with deviations of up to 50 µm. The

same pattern of deviation was visible in group VSES, but with some artifacts in the occlusal

fissure lines (Fig. 4c). In group VSES-dig, larger deviations, especially at the inclined

surfaces of the teeth, were visible (Fig. 4d). In contrast, group ALG showed local deviations

at different areas, with differences of up to 60 µm (Fig. 4e). Group CER showed local

deviations at one end of the dental arch of up to 80 µm, and, in general, a slight distortion

toward the distal end (Fig. 4f). Models from group OC showed an increasing deviation toward

one end of the dental arch, with maximum differences of up to 100 µm (Fig. 4g). In contrast,

group ITE showed a diagonal shift in the digital model, with negative deviations in the

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premolar region on one side of the dental arch and the distal molar region on the other side

(Fig. 4h). The digital models in group LAV showed irregular deviations with either local

deviations or complete quadrant shifts (Fig. 4i).

Precision of full-arch scans

Groups VSE (12.3 µm), VSES (14.6 µm), and CER (19.5 µm) showed the highest precision

among all the test groups, whereas group POE (66.7 µm) showed the lowest precision (Table

3, Fig. 3). In group POE, wavelike deformations were visible as rotational strains of the dental

arch (Fig. 5a). Visual analysis revealed positive and negative deviations for group VSE of

approximately 20 µm (Fig. 5b). The deviation pattern was homogeneous across the entire

model, except for one distal molar tooth, with deviations of up to 50 µm. The same deviation

pattern was visible in group VSES, with some artifact spots at the fissure areas of the

premolars and molars (Fig. 5c). In group VSES-dig, larger deviations, especially at the more

inclined surfaces in the anterior region, were visible (Fig. 5d). In group ALG, a large

deviation between the impressions of up to 150 µm was visible at the anterior and premolar

region (Fig 5e). Group CER showed local deviations between the digital models of up to 80

µm, which were mostly located in the posterior part of the dental arch (Fig. 5f). Group ITE

showed a similar deviation pattern with a larger deviation of up to 120 µm at one distal end of

the model (Fig. 5h). OC models differed partly on one side of the model, with increasing

deviations of up to 130 µm (Fig. 5g). This deviation was caused by a flexion of the digital

model at the anterior region. Digital models in group LAV showed local deviations at the

premolar region or a flexion across the anterior region, with increasing differences toward one

distal end (Fig. 5i).

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Discussion

The aim of this study was to assess the accuracy of digital and conventional full-arch

impressions. With the increasing use of digital intraoral impression systems, the total

elimination of a physical model using conventional impression systems is possible.18 On the

basis of the results of this in-vitro study, the zero hypothesis, i.e., conventional and digital

impression systems are equally accurate, has to be rejected.

This study revealed large differences in trueness and precision depending on the method used

to obtain full-arch impressions. Conventional impressions using vinylsiloxanether material

(VSE, VSES) showed the highest accuracy together with digital impressions made with an

optimal scanning strategy in group CER. Several studies have evaluated the trueness and

precision of digital impressions focusing on single preparations or FPD preparations.5,4,13,22,25

In these small parts of a dental arch, digital impressions shows high accuracy and are suitable

for use in lieu of conventional impression methods.

In case of a complete digital workflow based only on digital data, not only the preparation

itself but also the entire dental arch needs to be accurate. If not, occlusion and articulation of

the digital models will not be appropriate, leading to less precise restorations. Only a small

number of studies have investigated full dental arch models with respect to digital

impressions.26,28,29 The quality of a reference scanner is a limiting factor for the assessment of

trueness with respect to intraoral geometries and the number of measuring points. A previous

study showed high accuracy of a new reference scanner for scanning full-arch geometry.26

Using this reference scanner, a direct comparison of conventional and digital impressions is

possible.

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The results of the present study show a large variation of the accuracy of different

conventional and digital impression methods. Within the limitation of this in-vitro study,

group VSE showed the most significant precision and trueness. In contrast, group POE

showed very high inaccuracies. This may be due to the steel surface of the reference model.

The low surface tension of polyether led to close contact with the dry steel surface, and

therefore, a high force was needed to remove the impression tray from the model. Other

studies have also reported lower accuracy of polyether materials compared to vinylsiloxane

materials.30

A comparison between groups VSES and VSES-dig showed that digitizing of conventional

impressions with an extraoral scanner is not more accurate than direct intraoral scanning. The

impressions in group ALG showed a very irregular deviation pattern. The high local deviation

of the alginate material limits the use of this impression material.

Digital impressions showed different deviation patterns. While systems with single image

stitching (CER, ITE) showed more local deviation at the distal end of the dental arch, video-

based systems (OC, LAV) appeared to be more prone to compression of the dental arch. This

was visible as increasing deviations to the distal end within one quadrant. This kind of

deviation can be explained by error propagation when scanning the anterior teeth with little

geometrical structure and stitching the single images together.

In general, an optimal scanning strategy is necessary for all the digital impression systems to

attain optimal results. Deviations of 100 µm and above across the full arch may lead to

inaccurate fitting of the upper and lower jaws, which can be very problematic in the case of

large rehabilitations. Single-unit restorations as well as up to four-unit FPD’s can be

fabricated from digital impression data. The clinical success of these restorations has been

shown in several studies.12,14,31

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Three-dimensional measurements of model deviations are being increasingly used in recent

years. The advantages of three-dimensional measurement over linear distance measurement

are the high number of measuring points and the possibility of assessing the local spots of

deviation. The results of this study provide a deeper understanding of the nature of deviations

in dental impressions and can help to avoid these errors in future studies on impression-taking

methods.

At present state, digital intraoral impressions do not show higher accuracy and precision

compared to conventional impression systems. However, the elimination of processing steps

within the digital workflow provides higher reliability.14,15 Clinical dentists should evaluate

digital intraoral scanning systems not only for the production of CAD/CAM restorations but

also for extended diagnostic possibilities by means of the digital dental model.32

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Conclusion

Within the limitations of this in-vitro study, all digital impression systems were found to be

capable of measuring full dental arches. This study showed that the different conventional and

digital impression methods differ largely in terms of full-arch accuracy. Evaluation of the full-

arch accuracy of dental impressions showed that, compared to conventional impression

methods, digital intraoral impression systems show higher local deviation of the dental arch.

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Figure!1:!Impression!and!matching!procedure!for!conventional!and!digital!full!arch!impressions!

!
Reference!model!/!Scan!
with!reference!scanner!
! (REF)!

! !
Conventional! !!!!!!! !! Tr
impression,!pouring!/! ue
! scan!with!reference!
ne
scanner!(VSE,!POE,!ALG)!
ss!
!
Conventional! (c
! impression!/!scan!with! o
n=5! reference!scanner! m
! (VSES)!
pa
!Conventional! ris
!
impression!and! on! Precision!(Comparison!of!
! extraoral!digitizing! to! all!impressions!within!
(VSESJdig)! ori one!test!group)!(n=10)!
! gi
!Digital!impression!(CER,!
OC,!ITE,!Lava!COS)! na
!
l!
! ge
o
m
et
ry)!
(n
=5
)!

!
!

Table!1:!Impression!procedure!for!conventional!impression!material!

Material Setting time Storage time Tray adhesive Impression

method

POE 10 min 8 hours yes monophasic

VSE 10 min 8 hours yes sandwich

VSES 10 min 8 hours yes monophasic

ALG 5 min 10 min no monophasic

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Table!2:!Impression!procedure!for!digital!impression!

System! Surface!conditioning! Scan!procedure! STLJExport!

CER! Powder! Buccal,!occlusal!and!oral! Direct!

image!from!every!tooth,!

camera!flip!at!the!midline!

OC! None! scan!path:!Occlusal,! Direct!

buccal!and!oral!direction!

of!one!quadrant,!adding!

of!the!second!quadrant!

with!the!same!procedure!

ITE! None! Guided!scanning! After!postprocessing!

according!to!software!

instructions!

LAV! Dusting! scan!path:!Occlusal,! After!postprocessing!

buccal!and!oral!direction!

of!one!quadrant,!adding!

the!second!quadrant!

with!the!same!procedure!

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 !

Table!3:!Trueness!and!Precision!(Mean!±SD,!µm)!of!conventional!and!digital!impression!

! POE! VSE! VSES! VSESJdig! ALG! CER! OC! ITE! LAV!

B A A AB AB A AB AB AB
Trueness! 60.2±25.0 ! 13.0±2.9 ! 11,5±1.3 ! 35.1±5 ! 37.7±34.9 ! 29.4±8.2 ! 37.3±14.3 ! 32.4±7.1 ! 44.9±22,4 !

C A A ABC BC A AB AB BC
Precision! 66.7±18.5 ! 12.3±2.5 ! 14.6±2.6 ! 39.6±19.7 ! 59.6±43.6 ! 19.5±3.9 ! 35.5±11.4 ! 36.4±21.6 ! 63.0±32.8 !

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Figure!2!

Trueness!of!full!arch!impressions,!(90%J10%)/2!percentile,!mean!and!standard!deviation,!(µm)!

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Figure!3!

Precision!of!full!arch!impression,!(90%J10%)/2!percentile,!mean!and!standard!deviation,!(µm)!

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Figure!4!

Difference!pattern!between!impression!and!master!model!(trueness),!colour!graded!from!J100µm!
(purple)!to!+100µm!(red)!for!group!POE!(a),!VSE!(b),!VSES!(c),!VSESJdig!(d),!ALG!(e),!CER!(f),!OC!(g),!ITE!
(h)!and!LAV!(i)!

(a! (b (c) (d) (e

) ) di dir )
!
di di
di re ect
re
! re ct ly re
ct ct ly ex ct
!
ly ly
(f) ex po ly
(g) (h) (i)
ex ex
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dir rte
dir ex
di
!
p pre or
ect dect pre
or
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ct te
ly fro
ly or
ct
te te
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ex m
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ly
d! dex fr
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fr! fr
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p
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te th isit m
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ac ac
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!
 !

Figure!5!

Difference!pattern!between!impressions!of!one!test!group!(precision),!colour!graded!from!J100µm!
(purple)!to!+100µm!(red)!for!group!POE!(a),!VSE!(b),!VSES!(c),!VSESJdig!(d),!ALG!(e),!CER!(f),!OC!(g),!ITE!
(h)!and!LAV!(i)!

w!

(a) (b (c) (d) (e)

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re di re ect re
ctl re ctl ly ctl
y ctl y ex y
ex y ex po ex
(f) (g) (h) (i)
po ex po rte po
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rt po rt d rt
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