CLINICAL RESEARCH

Accuracy of a patient 3-dimensional virtual representation

obtained from the superimposition of facial and intraoral scans
guided by extraoral and intraoral scan body systems
Marta Revilla-León, DDS, MSD,a Amirali Zandinejad, DDS, MSc,b Madhu K. Nair, DMD, MS, PhD,c
Basir A. Barmak, MD, MSc, EdD,d Albert J. Feilzer, DDS, PhD,e and Mutlu Özcan, DDS, DMD, PhDf

ABSTRACT
Statement of problem. A patient 3-dimensional virtual representation aims to facilitate the integration of facial references into treatment
planning or prosthesis design procedures, but the accuracy of the virtual patient representation remains unclear.
Purpose. The purpose of the present observational clinical study was to determine and compare the accuracy (trueness and precision) of a
virtual patient obtained from the superimposition procedures of facial and intraoral digital scans guided by 2 scan body systems.
Material and methods. Ten participants were recruited. An intraoral digital scan was completed (TRIOS 4). Four fiduciary markers were placed in
the glabella (Gb), left (IOL) and right infraorbital canal (IOR), and tip of the nose (TN). Two digitizing procedures were completed: cone beam
computed tomography (CBCT) (i-CAT FLX V-Series) and facial scans (Face Camera Pro Bellus) with 2 different scan body systems: AFT
(ScanBodyFace) and Sat 3D (Sat 3D). For the AFT system, a reference facial scan was obtained, followed by a facial scan with the participant
in the same position as when capturing the CBCT scan. For the Sat 3D system, a reference facial scan was recorded, followed by a facial scan
with the patient in the same position as when capturing the CBCT scan. The patient 3-dimensional representation for each scan body system
was obtained by using a computer program (Matera 2.4). A total of 14 interlandmark distances were measured in the CBCT scan and both 3-
dimensional patient representations. The discrepancies between the CBCT scan (considered the standard) and each 3-dimensional
representation of each patient were used to analyze the data. The Kolmogorov-Smirnov test revealed that trueness and precision values were
not normally distributed (P<.05). A log10 transformation was performed with 1-way repeated-measures MANOVA (a=.05).
Results. The accuracy of the virtual 3-dimensional patient representations obtained by using AFT and Sat 3D systems showed a trueness
ranging from 0.50 to 1.64 mm and a precision ranging from 0.04 to 0.14 mm. The Wilks lambda detected an overall significant difference
in the accuracy values between the AFT and Sat 3D systems (F=3628.041, df=14, P<.001). A significant difference was found in 12 of the
14 interlandmark measurements (P<.05). The AFT system presented significantly higher discrepancy values in Gb-IOL, TN-IOR, IOL-IOR, and
TN-6 (P<.05) than in the Sat 3D system. The Sat 3D system had a significantly higher discrepancy in Gb-TN, TN-IOL, IOL-3, IOL-6, TN-8, TN-
9, TN-11, IOR-11, and IOR-14 (P<.05) than in the AFT system. The Wilcoxon signed-rank test did not detect any significant difference in
the precision values between the AFT and Sat 3D systems (Z=-0.838, P=.402).
Conclusions. The accuracy of the patient 3-dimensional virtual representations obtained using AFT and Sat 3D systems showed trueness
values ranging from 0.50 to 1.64 mm and precision values ranging from 0.04 to 0.14 mm. The AFT system obtained higher trueness than
the Sat 3D system, but both systems showed similar precision values. (J Prosthet Dent 2021;-:---)

For a comprehensive prosthetic treatment plan with a planning elaborated from a 3-dimensional (3D) patient
predictable esthetic result, a comprehensive diagnosis is representation in which all obtained diagnostic data are
required.1-3 However, in the digital era, virtual treatment integrated has become popular.4-7 Like conventional

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Assistant Professor and Assistant Program Director AEGD Residency, College of Dentistry, Department of Comprehensive Dentistry, Texas A&M University, Dallas, Texas;
and Affiliate Faculty Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash; and Researcher at Revilla
Research Center, Madrid, Spain.
b
Associate Professor and Program Director AEGD Residency, Department of Comprehensive Dentistry, College of Dentistry, Texas A&M University, Dallas, Texas.
c
Professor, Oral and Maxillofacial Radiology, Department of Oral and Maxillofacial Radiology, College of Dentistry, Texas A&M University, Dallas, Texas.
d
Assistant Professor Clinical Research and Biostatistics, Eastman Institute of Oral Health, University of Rochester Medical Center, Rochester, N.Y.
e
Professor, Department of Dental Materials Science, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam & Vrije Universiteit, Amsterdam, The
Netherlands.
f
Professor and Head, Division of Dental Biomaterials, Clinic for Reconstructive Dentistry, Center for Dental and Oral Medicine, University of Zürich, Zürich, Switzerland.

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Clinical Implications
The virtual patient obtained by the superimposition
of facial and intraoral scans guided by scan bodies
might facilitate the 3-dimensional representation;
however, diagnostic trial restorations are still
recommended.
methods, diagnostic data are obtained from photographs
or facial scans, digital diagnostic casts, and a virtual
diagnostic waxing by using a computer-aided design
(CAD) software program.8-10 Additional digital informa-
tion such as from cone beam computed tomography
(CBCT) scans can be also integrated.11-13
A technique has been reported for superimposing a
patient’s facial and intraoral digital scans guided by scan
bodies.14-17 Effective superimposition of digital data is the
key to obtaining accurate clinical representations, which
might influence the accuracy of the treatment planning
procedures. However, the accuracy of 3D virtual repre-
sentations remains unclear.
The relationship between the technology used by the
intraoral scanner (IOS) systems and the accuracy of its
acquisition procedure has been reported,18-28 as well as
factors that could impact digital scan accuracy.29 These
factors include the handling and learning curve,30,31
calibration,32 scanning protocol,33-35 ambient lighting
conditions,36-40 surface characteristics,41-44 mobile tis-
sue,45 and presence of saliva.30,46,47 Digital scanning
provides a clinically acceptable alternative to conven-
tional impression making for the fabrication of tooth-
and implant-supported crowns and short-span fixed
dental prostheses.18-28
Previous studies have evaluated the accuracy of
different facial scanning technologies.48-57 The reports of
earlier studies have shown deviation values close to 1
mm,48-53 but a discrepancy of up to 2 mm has been
considered clinically acceptable.54 Dental studies that
compared the discrepancies between the measurements
obtained on a CBCT scan and the measurements calcu-
lated on a patient 3D representation captured by using a
facial scanner are sparse.58,59 An average discrepancy
between the CBCT scan and 3D facial representation
surfaces has been reported to range between 0.60 and
26.94 mm.58,59 However, the authors are unaware of a
previous study evaluating the accuracy of a patient 3D
representation.
The purpose of the present clinical study was to
determine and compare the accuracy (trueness and pre-
cision) of the patient 3D representation obtained from
the superimposition procedures between the facial and
intraoral digital scans guided by 2 different scan body
systems. The null hypothesis was that no difference
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 1. Representative intraoral digital scan recorded by using
intraoral scanner (TRIOS 4; 3Shape A/S).
would be found in the accuracy (trueness and precision)
of a patient 3D representation guided by 2 different scan
body systems.
MATERIAL AND METHODS
Ten complete maxillary dentate participants receiving a
dental implant treatment in the mandible were recruited
in the Health Science Center Building of the College of
Dentistry at Texas A&M University (IRB2019-0191). In-
clusion criteria included being older than 18 years of age,
English and Spanish speakers, completely dentate in the
maxilla from the first left molar to the first right molar or
with only 1 posterior maxillary tooth missing from the
first left molar to the first right molar, partially dentate in
the mandible but with stable occlusion, without a history
of systemic or local conditions contraindicative to implant
placement, without temporomandibular joint disease,
and without a drug history that could affect bone re-
modeling. Exclusion criteria included pregnancy, in-
dividuals with physical disabilities, prisoners, individuals
with psychiatric disorders, and individuals with a history
of facial scar tissue, lip incompetence, previous facial
trauma, maxillofacial surgery, and metal ceramic pros-
theses on the maxillary anterior teeth.
An intraoral examination was completed by a pros-
thodontist (M.R.L.), and an intraoral digital scan was
obtained by using an IOS (TRIOS 4; 3Shape A/S) as per
the manufacturer’s protocol (Fig. 1). The scan was ob-
tained by positioning each participant in a dental chair in
a room with no windows. The unit light was turned off,
and only the ceiling light was used.37,39 The ambient
lighting with a luminosity of 1000 lux was measured by
using a meter (LX1330B Light Meter; Dr. Meter Digital
Illuminance).37,39 A prosthodontist (M.R.L.) with 10 years
of experience using IOSs recorded all the scans as per the
manufacturer’s recommended protocol. A standard
tessellation language (STL) file STLIOS was obtained.
Revilla-León et al
- 2021 3

Table 1. Digitizing procedures performed on each participant

FS Scan
Characteristics CBCT Scan AFT System Sat 3D System
Intraoral digitizing Intraoral digital scan using intraoral scanner (TRIOS 4;
procedures 3Shape A/S)
Facial digitizing CBCT Facial scanner (Face Camera Pro
procedures File format: Bellus; Bellus 3D).
DICOM files File format: OBJ file
Extraoral markers 4 Fiducial markers located on glabella (Gb), left (IOL) and
right infraorbital canal (IOR), and tip of nose (TN).
Extraoral scan body Not applicable Scan Body Face Not applicable
(AFT Dental
System)
Intraoral scan body Scan Body Intraoral scan
Mouth (AFT body (Sat 3D;
Dental Sat 3D)
System)

CBCT, cone beam computed tomography; DICOM, Digital Imaging and Communications
in Medicine; FS, facial scanner; OBJ, geometry definition file.

Subsequently, 4 extraoral radiopaque markers (Den-

talMark 1.0mm; SureMark) were placed on the partici-
pant’s face in the following positions: glabella (Gb), left
(LIO) and right infraorbital canal (RIO), and tip of the
nose (TN). The markers were maintained in the same
position during all the acquisition procedures. Two
digitizing methods, namely a CBCT and a facial scanner
method, were then performed consecutively on all par-
ticipants (Table 1). The sequence of the digitizing pro-
cedures was randomized by using a shuffled deck of
cards.
A CBCT scan with a voxel size of 125 mm, a slice Figure 2. Representative cone beam computed tomography scan. A,
thickness of 200 mm, and a 17×23-cm field of view was Hard tissues. B, Soft tissues.

made (i-CAT FLX V-Series; KaVo Kerr) from the superior

border of the orbit to the lower border of the mandible. A
standard imaging protocol was used. Participants were
positioned in the CBCT unit by using a head strap with
the midsagittal plane coincident with the midline of the
field of view, which extended from the frontal bone to the
level of the third or fourth cervical vertebrae. Laser
positioning lights were used to confirm the head posi-
tion. The occlusal plane was oriented parallel to the x-axis
with the teeth in intercuspation and the patient occluding
on a cotton roll with the lips closed. These procedures
were performed by an experienced operator. The effective
dose was approximately 69.2 mSv. The Digital Imaging
and Communications in Medicine (DICOM) files of each
participant were exported (Fig. 2).
For the FS acquisition, facial scans were obtained by
using 2 different scan bodies, the AFT system (ScanBo-
dyTeeth and ScanBodyFace; AFT Dental System) and the
Sat 3D system (Sat 3D; Sat 3D) (Table 1). The facial scans
were obtained by using a facial scanner (Face Camera Pro
Bellus; Bellus3D) connected to a tablet computer (Hua-
wei MediaPad M3; Huawei) and controlled by a specific
software program (Face Camera App; Bellus3D). The
order of the scan body systems was randomized by using
a shuffled deck of cards. The facial scan was calibrated
before each acquisition procedure as per the manufac-
turer’s recommendations. Furthermore, participants were
seated in an adjustable chair between 30 and 45 cm from
the scanner in a room with no windows. The lighting
intensity was 1000 lux (LX1330B Light Meter; Dr. Meter
Digital Illuminance), and the color temperature was
4100K.57 The scanning procedures were obtained in
high-definition mode. All the digitizing procedures were
performed by the same prosthodontist (M.R.L.), who had
3 years of previous experience handling the selected facial
scanner.
For the AFT system, 2 facial scans were captured, a
reference and maximum intercuspation (MIP) scans. An
extraoral scan body (ScanBodyFace; AFT Dental System)
was positioned on the participant’s forehead and main-
tained there during the facial scanning procedures. In
addition, an intraoral scan body (ScanBodyMouth; AFT
Dental System) was positioned in the participant’s mouth
and stabilized by using high- and low-viscosity polyvinyl
siloxane impression material (Virtual Putty Regular
Setting; Ivoclar Vivadent AG). For the reference scan,
both scan bodies were maintained, and the facial scan
was recorded as per the manufacturer’s instructions. For
the MIP scan, the intraoral scan body was removed, and

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Figure 3. Representative digitizing procedures of FS-AFT group. A,
Reference facial. B, Maximum intercuspation scan. C, Digitized intraoral
scan body.
2 cotton rolls were position between the maxillary and
mandibular arches of the participant, who was asked to
maintain them in position in MIP with the lips sealed. A
facial scan of the participant was then obtained, and the
cotton rolls were removed. Two geometry definition
(OBJ) files were exported, one corresponding to the
reference scan (OBJREF file) and another corresponding to
the MIP scan (OBJMIP file) (Fig. 3). The intraoral scan
body was digitized with a laboratory scanner (D2000
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Figure 4. Representative digitizing procedures of FS-Sat 3D group. A,
Reference facial. B, Maximum intercuspation scan. C, Digitized intraoral
scan body.
Scanner; 3Shape A/S) as per the recommendations of the
manufacturer (Fig. 3). The scanner had been previously
calibrated by following the manufacturer’s instructions.
An STLSB file was obtained.
For the Sat 3D system, 2 facial scans, reference and
MIP scans, were completed. An intraoral scan body (Sat
3D; Sat 3D) was positioned in the participant’s mouth
and stabilized with high- and low-viscosity polyvinyl
siloxane impression material (Virtual Putty Regular
Revilla-León et al
- 2021 5

Table 2. Measurement procedures completed on each participant described by Revilla-León et al.14 Then, the same inter-
Measurements Superimposition landmark measurements were recorded (Fig. 6). Each
Group Procedures 14 Interlandmark Measurements
measurement was obtained 3 times, and the mean was
CBCT group Not applicable 6 facial measurements
FS-AFT group Iterative closest  Gb-TN computed. Similarly, for the Sat 3D system measure-
point technique  Gb-IOR ments (FS-Sat 3D group), the STLIOS, OBJREF, OBJMIP,
FS-Sat 3D  Gb-IOL
group between facial
and intraoral  TN-IOR and STLSB files were imported into the same dental CAD
digital scans14  TN-IOL software program. The alignment procedures were per-
 IOR-IOL
8 dentofacial measurements formed as previously described by Revilla-León et al.14
 IOR-3: IOR-cusp of maxillary first When the superimposition was completed, the same
right molar
 IOR-6: IOR-cusp of maxillary right interlandmark measurements were recorded (Fig. 7).
canine Each measurement was obtained 3 times, and the mean
 TN-6: TN-buccal cusp of maxillary
right canine was computed.
 TN-8: TN-mesial incisal edge of For each participant, the facial and dentofacial inter-
maxillary right central incisor
 TN-9: TN-mesial incisal edge of landmark measurement discrepancies between the CBCT
maxillary left central incisor and FS-AFT group and between the CBCT and FS-Sat
 TN-11: TN-buccal cusp of maxillary
right canine 3D group were calculated and used to analyze the data.
 IOL-11: IOL-cusp of maxillary left Trueness was defined as the average absolute discrep-
canine
 IOR-14: IOL-cusp of the maxillary ancy between the interlandmark distances measured on
first left molar the CBTC and on the 3D patient representations, while
CBCT, cone beam computed tomography; FS, facial scanner; Gb, glabella; IOL, left precision was defined as the interlandmark measurement
infraorbital canal; IOR, right infraorbital canal; TN, tip of nose; 3, Maxillary right first
molar; 6, Maxillary right canine; 8, Maxillary right central incisor; 9, Maxillary left central discrepancies between the CBCT and the virtual 3D pa-
incisor; 11, Maxillary left canine; 14, Maxillary left first molar. tient representations.37,39,57,60
The Kolmogorov-Smirnov test revealed that the
trueness and precision mean values for most of the
Setting; Ivoclar Vivadent AG). The reference scan was
interlandmark measurement discrepancies for both scan
obtained as per the manufacturer’s instructions. For the
body systems were not normally distributed (P<.05). The
MIP scan, the intraoral scan body was removed, and 2
Levene test showed a lack of homogeneity of variance for
cotton rolls were positioned between the maxillary and
some of the interlandmark measurement discrepancies
mandibular arches of the participant, who was asked to
(P>.05). For the data violating normality and homoge-
maintain them in MIP position with the lips sealed, and a
neity of variance assumptions, a log10 transformation was
new facial scan was recorded. Two OBJ files were
performed to assess the trueness differences of the
exported (OBJREF and OBJMIP files) (Fig. 4). The intraoral
FS-AFT and FS-Sat 3D groups with 1-way repeated-
scan body was digitized by using the same scanner
measures MANOVA, considering all 14 interlandmark
(D2000 Scanner; 3Shape A/S) as per the manufacturer’s
trueness measurements a composite outcome. The Wilks
recommendations (Fig. 4). The scanner was previously
lambda and pairwise comparison tests were used to
calibrated by following the manufacturer’s instructions.
analyze the data. The Wilcoxon signed-rank test was
An STLSB file was obtained. After all the digitizing pro-
used to compare the precision mean values between the
cedures were completed, the facial markers were
FS-AFT and FS-Sat 3D groups. Data were analyzed by
removed.
using a statistical program (IBM SPSS Statistics for
Interlandmark measurements were obtained from the
Windows, v25; IBM Corp).
CBCT scan and from both 3D representations obtained
by using both scan body systems (Table 2). All the
RESULTS
measurements were performed by the same prostho-
dontist (M.R.L.), who had 6 years of previous experience The interlandmark measurement means and standard
handling the CAD dental software program (Matera 2.4; deviation discrepancies obtained between the CBCT and
exocad GmbH). For the CBCT measurements (CBCT the FS groups are provided in Table 3. The accuracy
group), the DICOM files were imported into a dental of the virtual 3D patient representations obtained by
CAD software program (Matera 2.4; exocad GmbH) to using the AFT and Sat 3D systems showed a trueness
perform the facial and dentofacial interlandmark mea- value ranging from 0.50 to 1.64 mm and a precision value
surements (Table 2) (Fig. 5). Each measurement was ranging from 0.04 to 0.14 mm (Fig. 8).
obtained 3 times, and the mean was computed. The Wilks lambda test detected an overall significant
For the AFT system measurements (FS-AFT group), difference in the accuracy values between the FS-AFT
the STLIOS, OBJREF, OBJMIP, and STLSB files were im- and FS-Sat 3D groups (F=3628.041, df=14, P<.001).
ported into the same dental software program. The su- Pairwise comparison showed a significant difference
perimposition procedures were performed as previously between FS-AFT and FS-Sat 3D groups in 12 of the 14

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Figure 5. Representative facial and dentofacial interlandmark measurement obtained in CBCT group by using dental software program (Matera 2.4;
exocad GmbH). A, Gb-IOR facial inter-landmark measurement. B, IOR-3 dentofacial inter-landmark measurement. CBCT, cone beam computed
tomography; Gb, glabella; IOR, right infraorbital canal; 3, maxillary right first molar.

Figure 6. Representative dentofacial interlandmark measurement obtained in FS-AFT group using a dental software program (Matera 2.4; exocad
GmbH). A, Dentofacial IOR-3 interlandmark measurement. B, Detailed of IOR-3 interlandmark measurement. IOR, right infraorbital canal; 3, maxillary
right first molar.

Figure 7. Representative dentofacial interlandmark measurement obtained in FS-Sat 3D group using a dental software program (Matera 2.4; exocad
GmbH). A, Dentofacial IOR-3 inter-landmark measurement. B, Detailed of the IOR-3 interlandmark measurement. IOR, right infraorbital canal; 3, maxillary
right first molar.

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Table 3. Descriptive statistics for facial and dentofacial interlandmark Facial and Dento-Facial Inter-Landmark Measurements (mm)
measurements obtained in FS-AFT and FS-Sat 3D groups (mm) 2.00
FS-AFT Group FS-Sat 3D Group
Interlandmark 95% 95% 95% 95%
Measurement Mean Lower CL Upper CL Mean Lower CL Upper CL 1.50
Gb-TN 50.17 48.98 51.36 50.14 48.96 51.33

Median (mm)
Gb-IOR 68.48 67.46 69.51 68.48 67.45 69.50
Gb-IOL 67.08 65.80 68.35 67.10 65.83 68.37 1.00
TN-IOR 66.74 65.70 67.78 66.77 65.73 67.82
TN-IOL 65.47 64.06 66.87 65.46 64.06 66.86
IOL-IOR 91.92 91.00 92.84 91.94 91.03 92.86 0.50
IOR-3 40.52 39.75 41.30 40.40 39.62 41.18
IOR-6 46.92 46.30 47.53 46.91 46.29 47.53
0.00
TN-6 58.46 57.34 59.59 58.61 57.48 59.74

Gb TN
Gb R
TN OL
TN R
IO OL
R

IO 3
6
-6
-8

TN 9
IO 1
IO 1
14
R-
R-

-
-1
1
-IO

-IO

IO

TN
TN
TN

L-
L-
-

-I

-I
TN-8 50.47 49.52 51.41 50.21 49.26 51.15

IO
Gb

L-
TN-9 49.50 48.84 50.15 49.47 48.82 50.13
TN-11 56.62 55.84 57.41 56.34 55.56 57.13
Landmark Measurement
IOL-11 45.51 45.09 45.94 45.40 44.98 45.83
Group AFT group SAT group
IOL-14 39.56 38.97 40.15 39.43 38.83 40.02

FS, facial scanner; Gb, glabella; IOL, left infraorbital canal; IOR, right infraorbital canal; Figure 8. Facial and dentofacial interlandmark measurements.
TN, tip of nose; 3, maxillary right first molar; 6, maxillary right canine; 8, maxillary right
central incisor; 9, maxillary left central incisor; 11, maxillary left canine; 14, maxillary left
first molar. Table 4. Descriptive statistics for facial and dentofacial interlandmark
measurement discrepancies obtained between CBCT and each of FS
groups (AFT and Sat 3D groups) (mm)
interlandmark measurement discrepancies (P<.05). No FS-AFT Group FS-Sat 3D Group
significant differences were found in the Gb-IOR and Mean ±standard Mean ±Standard
IOL-6 interlandmark measurement discrepancies be- Interlandmark Deviation (Trueness Deviation (Trueness
Measurements ±precision) ±precision)
tween the FS-AFT and FS-Sat 3D groups (P>.05). The Gb-TN 0.65 ±0.04 0.67 ±0.04
FS-AFT group presented significantly higher discrepancy Gb-IOR 0.69 ±0.04 0.69 ±0.04
values in 4 interlandmarks measurements, namely Gb- Gb-IOL 0.87 ±0.04 0.85 ±0.04
IOL, TN-IOR, IOL-IOR, and TN-6 (P<.05), while the TN-IOR 0.83 ±0.04 0.80 ±0.04
FS-Sat 3D group had a significantly higher discrepancy in TN-IOL 0.95 ±0.04 0.96 ±0.04
8 interlandmark measurements, namely Gb-TN, TN- IOL-IOR 0.61 ±0.06 0.59 ±0.05
IOL, IOL-3, IOL-6, TN-8, TN-9, TN-11, IOR-11, and IOL-3 0.50 ±0.05 0.62 ±0.04
IOR-14 (P<.05). The Wilcoxon signed-rank test did not IOL-6 0.76 ±0.05 0.76 ±0.05
detect any significant difference in the precision values TN-6 0.93 ±0.04 0.78 ±0.05
between the FS-AFT and FS-Sat 3D groups (Z=-0.838, TN-8 0.88 ±0.09 1.14 ±0.07

P=.402) (Table 4). TN-9 1.16 ±0.05 1.18 ±0.05

DISCUSSION
Significant differences were found for the trueness of the
3D patient representations obtained with the AFT and
Sat 3D systems, but no significant differences were found
for the precision of the virtual patient visualization
guided by either of the scan body systems. Therefore, the
null hypothesis was partially rejected. The research
question concerned the reliability of the patient 3D vir-
tual representation obtained by the superimposition of
the facial and intraoral digital scans. The objective of the
present clinical study was to analyze the accuracy of
the first step of a digital workflow, which includes the
acquisition of the patient 3D virtual representation.
Based on the results obtained, the patient 3D virtual
representations showed a trueness value ranging from
0.50 to 1.64 mm and a precision value ranging from 0.04
to 0.14 mm. Although clinical reports have shown the
TN-11 1.04 ±0.05 1.32 ±0.05
IOR-11 1.12 ±0.05 1.23 ±0.05
IOR-14 1.51 ±0.14 1.64 ±0.09
Gb, glabella; TN, tip of nose; IOR, right infraorbital canal; IOL, left infraorbital canal; 3,
maxillary right first molar; 6, maxillary right canine; 8, maxillary right central incisor; 9,
maxillary left central incisor; 11, maxillary left canine; 14, maxillary left first molar.
reliability of the virtual patient representation obtained
by the superimposition methods of facial and intraoral
scans guided by scan bodies,14-17 further studies are
needed to determine the clinically acceptable range for
which the virtual patient provides an accurate represen-
tation for treatment planning procedures or prosthesis
design. The authors are unaware of previous studies that
have analyzed the accuracy of virtual patients; therefore,
comparisons could not be made.
In the present study, the interlandmark distances
were measured from the CBCT scan and 3D virtual
representations. The measurements obtained from the

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Figure 9. A, Scattering effect of radiopaque marker placed on tip of nose with measurement point located on center of marker. B, Gabella marker on
virtual 3D patient representation and measurement point located on center of marker. 3D, 3-dimensional.
CBCT scan included the distortion from the CBCT digi-
tizing procedures; therefore, if a different CBCT unit was
used, differences would be expected. Furthermore,
measurement inaccuracies might be anticipated because
of the scattering effect of the radiopaque markers. The
accuracy of the virtual patient representation represented
the distortion accumulation from the multiple digitizing
and merging procedures completed, and the inaccuracies
of the interlandmark location measurements including
the location of the marker on the facial scans and
anatomic dental marks (Fig. 9).
The mean ±SD facial interlandmark measurement dis-
crepancies between the CBCT and the FS group varied from
0.59 ±0.05 mm to 0.95 ±0.04 mm. The facial interlandmark
measurements were significantly different between the FS-
AFT and FS-Sat 3D groups, except for 1 interlandmark
measurement. These results might be caused by skin
movements that displaced the radiopaque markers. The
head strap of the CBCT unit, the forehead extraoral scan
body of the AFT system, and the lack of extraoral scan body
required on the Sat 3D system might have caused minimal
skin movement differences among the groups.
The dentofacial interlandmark measurement dis-
crepancies showed higher inconsistencies compared with
the facial interlandmark measurement discrepancies. The
mean ±SD dentofacial interlandmark measurement dis-
crepancies varied from 0.50 ±0.05 mm to 1.64 ±0.09 mm.
Overall, the Sat 3D system led to significantly higher
discrepancies with the dentofacial interlandmark mea-
surements. This finding might be explained by the scan
body design variations, such as the number and color of
the scan bodies (blue and red for the AFT system and
white for the Sat 3D system), shape, and dimensions of
the intraoral scan bodies.
Discrepancies of both the AFT and Sat 3D systems
appeared to increase from the patient’s right to the pa-
tient’s left. The interpretation of this result is difficult. The
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- Issue -
linear interlandmark measurements were calculated on a
3D representation; therefore, the higher discrepancy on a
linear dentofacial measurement may be caused by a
different position of the landmarks on the x-, y-, and z-
axis.
A previous study evaluated the accuracy of the same
facial scanner by comparing interlandmark distances
measured manually and digitally on the facial repre-
sentations.57 The authors reported a trueness mean
value of 0.91 mm and a precision mean value of 0.32
mm. Even so, the accuracy values reported for the facial
scanner used can be considered in the clinically
acceptable range.54 Digitizing procedures performed
with a different facial scanner might increase or
decrease the discrepancies obtained in the present
clinical investigation.
The alignment protocol accomplished in the present
study requires overcoming a learning curve that in-
cludes handling the digitizing devices and performing
the CAD processes. In the present investigation, all the
digitizing and alignment procedures were performed by
an experience prosthodontist. Limitations of the present
study included the unique digitizing procedures and
scan body systems tested or restricted patient dental
conditions. Further studies varying the facial scanner
and IOS, scan body design, alignment technique, and
different intraoral conditions such as partially or
completely edentulous patients or those presenting
malocclusion are needed to evaluate the accuracy of
virtual representations.
CONCLUSIONS
Based on the results of the present clinical study, the
following conclusions were drawn:
1. The accuracy of the patient 3D virtual representation
obtained using AFT and Sat 3D systems showed
Revilla-León et al
- 2021
trueness values ranging from 0.50 to 1.64 mm and
precision values ranging from 0.04 to 0.14 mm.
2. The AFT system obtained higher trueness compared
with the Sat 3D system, but both systems showed
similar precision.
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Corresponding author:
Dr Marta Revilla-León
3302 Gaston Ave
Room 713, Dallas, TX 75246.
Email: revillaleon@tamu.edu
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.02.023
Revilla-León et al