TECHNO BYTES

Precision of intraoral digital dental impressions

with iTero and extraoral digitization with the
iTero and a model scanner
Tabea V. Flu€ gge,a Stefan Schlager,b Katja Nelson,c Susanne Nahles,d and Marc C. Metzgere
Freiburg and Berlin, Germany

Introduction: Digital impression devices are used alternatively to conventional impression techniques and
materials. The aims of this study were to evaluate the precision of digital intraoral scanning under clinical
conditions (iTero; Align Technologies, San Jose, Calif) and to compare it with the precision of extraoral
digitization. Methods: One patient received 10 full-arch intraoral scans with the iTero and conventional
impressions with a polyether impression material (Impregum Penta; 3M ESPE, Seefeld, Germany). Stone
cast models manufactured from the impressions were digitized 10 times with an extraoral scanner
(D250; 3Shape, Copenhagen, Denmark) and 10 times with the iTero. Virtual models provided by each
method were roughly aligned, and the model edges were trimmed with cutting planes to create common
borders (Rapidform XOR; Inus Technologies, Seoul, Korea). A second model alignment was then performed
along the closest distances of the surfaces (Artec Studio software; Artec Group, Luxembourg, Luxembourg).
To assess precision, deviations between corresponding models were compared. Repeated intraoral scanning
was evaluated in group 1, repeated extraoral model scanning with the iTero was assessed in group 2,
and repeated model scanning with the D250 was assessed in group 3. Deviations between models were
measured and expressed as maximums, means, medians, and root mean square errors for
quantitative analysis. Color-coded displays of the deviations allowed qualitative visualization of the
deviations. Results: The greatest deviations and therefore the lowest precision were in group 1, with mean
deviations of 50 mm, median deviations of 37 mm, and root mean square errors of 73 mm. Group 2 showed a
higher precision, with mean deviations of 25 mm, median deviations of 18 mm, and root mean square errors of
51 mm. Scanning with the D250 had the highest precision, with mean deviations of 10 mm, median deviations
of 5 mm, and root mean square errors of 20 mm. Intraoral and extraoral scanning with the iTero resulted in de-
viations at the facial surfaces of the anterior teeth and the buccal molar surfaces. Conclusions: Scanning
with the iTero is less accurate than scanning with the D250. Intraoral scanning with the iTero is less accurate
than model scanning with the iTero, suggesting that the intraoral conditions (saliva, limited spacing) contribute
to the inaccuracy of a scan. For treatment planning and manufacturing of tooth-supported appliances, virtual
models created with the iTero can be used. An extended scanning protocol could improve the scanning
results in some regions. (Am J Orthod Dentofacial Orthop 2013;144:471-8)

F
a
Resident, Division of Oral and Maxillofacial Surgery, University Medical Center,
Freiburg, Germany. or the introduction of computer-aided design and
b
Research fellow, Biological Anthropology, University Medical Center, Freiburg, computer-aided manufacturing technologies in
Germany. dentistry, virtual models of teeth are required.
c
Professor, Division of Oral and Maxillofacial Surgery, University Medical Center,
Freiburg, Germany. Digital processes are applied for prosthetic-driven
d
Associate professor, Division of Oral and Maxillofacial Surgery, Charite Campus backward planning of implant surgery,1,2 orthodontic
Virchow, Berlin, Germany.
e
measurements, and treatment planning3-6 combined
Associate professor, Division of Oral and Maxillofacial Surgery, University Med-
ical Center, Freiburg, Germany. with surgical planning.7 Data acquired by intraoral
All authors have completed and submitted the ICMJE Form for Disclosure of scanning, computed tomography, cone-beam computed
Potential Conflicts of Interest, and none were reported. tomography, and extraoral surface scanning can be
Reprint requests to: Tabea V. Fl€ ugge, Division of Oral and Maxillofacial Surgery,
University Medical Center Freiburg, Hugstetter Str 55, 79106 Freiburg, Germany; fused.1,2,7
e-mail, tabea.viktoria.fluegge@uniklinik-freiburg.de. For the acquisition of digital images of teeth,
Submitted, November 2012; revised and accepted, April 2013. different procedures have been described: digitization
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists. of plaster casts,3,5,8-12 digitization of impressions,8,13
http://dx.doi.org/10.1016/j.ajodo.2013.04.017 and intraoral digital impressions.13,14 The accuracy
471
472
Fig 1. Synopsis of model manufacturing and virtual model generation.
of the different image acquisition methods and
systems has been examined with extraoral
reference models.9,12,15-18 However, to date, no studies
concerning the practical application and precision of
digital scanning in vivo have been done.
Digital work flow has been proposed to improve treat-
ment planning, give higher efficiency, and allow new
methods of production and new treatment concepts.19-21
Data storage and reproducibility are facilitated,9,19 and
treatment documentation and communication between
professionals as well as between dentists and patients
have become more convenient.22
Currently, there are a few major digital impression
devices: iTero (Align Technologies, San Jose, Calif),
Lava COS (3M ESPE, Seefeld, Germany), and Trios
(3Shape, Copenhagen, Denmark) for image acquisition;
and CEREC AC (Sirona, Bensheim, Germany) and E4D
(D4D Technologies, Richardson, Tex) for digital imaging
and in-office manufacturing.14 Excluding the iTero and
the Trios, all scanning devices need drying and
powdering of intraoral surfaces (CEREC, E4D, Lava
COS). This limits their practicability and accuracy
because powder application can add to the measuring
error.23 With all devices mentioned, digital impressions
are acquired without contact to the gingival tissues.
The precision of intraoral and extraoral scanning
with the iTero as well as extraoral scanning with a model
scanner was examined in this study.
MATERIAL AND METHODS
Impressions were acquired according to the study
protocol that was approved by the ethics committee of
the medical faculty of Freiburg University, after we
received written consent from the study participant.
One participant with a Class I occlusion and full denti-
tion was examined.
In-vivo (intraoral) scans (group 1) and ex-vivo
(extraoral) scans of 1 patient and the patient’s models
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Fl€
ugge et al
were made with 2 laser scanners (group 2, iTero; group
3, D250; Fig 1).
According to the study protocol, the data acquisition
for group 1 was based on 10 intraoral scans with the
iTero of the maxilla and the mandible of 1 patient
(n 5 20).
For groups 2 and 3, a unique model was used. The
model fabrication for the extraoral scans was performed
as follows.
Using the same patient as in group 1, polyether im-
pressions of the maxilla and the mandible were taken us-
ing a monophase polyether material (Impregum Penta;
3M ESPE) and stainless steel impression trays
(M1W-Rim-Lock; M1W Dental, B€ udingen, Germany).
The impressions were disinfected and poured with type
IV stone (picodent U 180; Picodent, Wipperf€ urth,
Germany) after a setting time of 4 hours. The first
impression was used for the production of the stone
casts, independently of the subjective assessment of
the quality. One stone cast of the maxilla and 1 stone
cast of the mandible were made.
The stone casts were scanned with the iTero using the
same scanning protocol as for the intraoral scans. The
scans of each stone cast model (maxilla and mandible)
were repeated 10 times and produced the data set for
group 2 (n 5 20).
The virtual models for group 3 (n 5 20) were
collected by repeated scanning (10 times) of the stone
casts with a model scanner (D250).
All scans with the iTero were recorded by the same
examiner (T.V.F.) in a predetermined order. Scanning
started with the most distal tooth in the third quadrant
continuing to the anterior teeth (Figs 2 and 3). Next,
the fourth quadrant was scanned, again beginning
with the most distal tooth. Scanning of the maxilla
started with the most distal tooth in the first quadrant
and ended at the central incisor. The second quadrant
was recorded starting with the most distal tooth. Each
tooth was scanned from its buccal and lingual sides by
Fl€
ugge et al
Fig 2. Intraoral scanning and the iTero-rendered stereolithographic model of the scanned jaw.
Fig 3. Extraoral scanning of a stone cast and the iTero-rendered stereolithographic model of the cast.
placing the camera at an angle of 45 to the tooth axis.
Images of each tooth showed neighboring parts of adja-
cent teeth. These served to overlap the pictures to create
a model of the whole arch from single images. All models
were exported in a Standard Tesselation Language (STL;
3D Systems, Rock Hill, SC) format and were used for
evaluation, independently of the subjective assessment.
For digitization, the stone casts were placed into
the D250 scanner next to a laser source and 2 high-
resolution cameras. During the scanning process, the
platform moves the model; therefore, the laser reaches
the model from multiple angles. Light planes are
projected onto the model, and the cameras capture their
reflections from the surface (Fig 4).
The principle of triangulation was used for the
creation of a 3-dimensional model, available as a stereo-
lithographic data set.
All stereolithographic data sets of 1 dental arch and 1
scanning method (n 5 10) were imported in a common
coordinate system and aligned by a procedure with the
closest distance between 2 surfaces (Rapidform XOR;
Inus Technologies, Seoul, South Korea). The models
were orientated toward the occlusal plane to fit a view
American Journal of Orthodontics and Dentofacial Orthopedics
473
for drawing the cutting planes. A first cutting plane
running through the deepest point of the gingival sulcus
of the canines and the second molars in the maxilla and
the canines and the first molars in the mandible was
created. A second cutting plane was created running
through the transverse fissure of both second molars.
All surfaces were cut with the common cutting planes
to create equal basal and posterior borders (Fig 5).
For quantitative analysis of precision, deviations be-
tween the vertices of the surfaces were measured. Operated
scan data were imported into Artec Studio software
(version 0.7.3.39; Artec Group, Luxembourg, Luxembourg)
to perform a pairwise rigid body registration. Correspond-
ing models for each comparison were roughly aligned
manually and then registered onto another using the
implemented surface mapping algorithm.
Deviations between aligned models were analyzed
using the software package Morpho, version 0.25 (based
on R; created by Stefan Schlager, Freiburg, Germany).24
To estimate the differences between the surfaces, each
vertex on the test surface was projected to the closest
point on the corresponding control surface, and the
Euclidean distance was recorded. The model rendered
September 2013  Vol 144  Issue 3
474 Fl€
ugge et al

Fig 4. Scanning of a plaster cast with the D250 and rendered stereolithographic model of the cast.

Fig 5. Stereolithographic data set obtained from scan-

ning with reference planes (reference planes 1 to 3) for
cutting, displayed with Rapidform XOR.

from the first scan served as the control surface for the
consecutively acquired models in each group.

Statistical analysis
Further statistical analysis was performed with
the software R.25 For testing differences between
the groups’ distributions of averaged distances, the
Kolmogorov-Smirnov test—a distribution free and
nonparametric procedure—was applied. The level of
significance was set at 0.05.
For the assessment of error, maximum, mean, and
median deviations were calculated for each group based
on the averaged errors of each observation. The
distances between the vertices of the corresponding
models were displayed with color maps, so that areas
of high and low agreement could be identified.
RESULTS
In group 1, the virtual models, rendered from serial
intraoral scans of the maxilla and the mandible with
the iTero, were compared. The mean deviation was
50 mm (median, 37 mm). Deviations in the maxilla were
Fig 6. Colored presentation of the deviations between
surfaces in group 1.
on average 57 mm (median, 43 mm); the mandible
deviated on average 43 mm (median, 31 mm). Maximum
deviations were on average 1.137 mm in the maxilla and
717 mm in the mandible. Deviations of the mandible
were significantly lower than deviations in the maxilla.
Deviations between models are displayed in Figure 6.
The highest deviations were observed at the palatal
borders, the facial surfaces of the anterior teeth, and the
molars on both sides of the maxilla. In the mandible, the
highest deviations were at the buccal side of the molars
and the facial side of the anterior teeth. There were also
deviations above average in the interdental spaces.

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Fl€
ugge et al
Fig 7. Colored presentation of the deviations between
surfaces in group 2.
Fig 9. Colored scale for the deviations shown in Figures 6, 7, and 8 (mm).
In group 2, the virtual models acquired with the
repeated scans of the stone casts with the iTero were
compared. Deviations from the test surface were on
average 25 mm (median, 18 mm). The maxillae had a
mean deviation of 30 mm (median, 18 mm), whereas the
mandibles had a mean deviation of 21 mm (median, 17
mm). The color-coded deviations are depicted in Figure 7.
The highest deviations in the maxilla were found at
the facial surfaces of the anterior teeth in the left maxilla
and at the palatal borders of the models. The maximum
deviation was 1.79 mm in the maxilla. The mandible had
lower deviations and a homogenous distribution with
above-average values in the molar region and the
gingival sulcus. The maximum deviation averaged
423 mm. Deviations in the mandible were significantly
lower than in the maxilla.
In group 3, the deviations between the virtual models
rendered from repeated model scanning with the
D250 were compared. Models deviated on average
American Journal of Orthodontics and Dentofacial Orthopedics
475
Fig 8. Colored presentation of the deviations between
surfaces in group 3.
10 mm (median, 6 mm). Average deviations were 11 mm
in the maxilla and 9 mm in the mandible. The maximum
deviation was 460 mm for the maxilla and the mandible.
The color-coded values of the deviations are shown in
Figure 8.
Deviations in group 3 were lower than deviations in
groups 1 and 2. The areas of deviations showed similar
patterns in the maxilla and the mandible. The inter-
dental spaces had the greatest deviations between the
virtual models. Deviations in the mandible were signif-
icantly lower than those in the maxilla. The color scale
(Fig 9) shows the deviations in Figures 6, 7, and 8. The
mean deviations in all groups are displayed in the
Table.
The Kolmogorov-Smirnov test showed that the
overall deviations were significantly different for every
method.
In Figure 10, the boxplot diagram shows the
distribution of the deviations for all methods.
September 2013  Vol 144  Issue 3
476
Table. Mean deviation of each method (mm)
iTero intraoral iTero extraoral D250
Mean deviation 50 25 10
DISCUSSION
The reason for the use of intraoral digital impression
systems is adequate accuracy and precision compared
with conventional techniques and extraoral digitization
of stone casts. Ender and Mehl18 defined accuracy as a
deviation from the original object and precision as the
accuracy of repeated measurements.
The precision of intraoral scanning was evaluated in
this study and compared with extraoral digitization of
stone casts with the iTero and a model scanner (D250).
The accuracy of the different work flows to create a vir-
tual model was not our objective. The systematic errors
caused by impression taking and model manufacturing
are neither included nor relevant for the present data.
Polyether-based stone casts served as an extraoral
reference. All scans were conducted with the same
model. Scanning with the model scanner D250 has a
different image acquisition technique compared with
intraoral scanners. The model is continuously captured
with the projection of laser planes and the recording of
their reflections. With all intraoral scanning techniques,
image acquisition is done incrementally. The iTero
system produces single images of every tooth, which
are assembled for a virtual model of the whole jaw.
This process, called stitching, might produce a system-
atic error.26 Mehl et al27 found lower accuracy of
quadrant digitization compared to single-tooth
digitization with the CEREC system. Because the stitch-
ing algorithm of the iTero system is unknown, its
contribution to the error in precision cannot be
explained. However, lower precision of the iTero
compared with the D250 was observed in this study.
Loss of information at model edges, especially in the
maxilla, was observed with the iTero system. This
resulted in high deviation values. According to the
scanning protocol, a fixed number of pictures is acquired
of every tooth. The image section of the camera covers
the tooth and, depending on its anatomy, a variable
portion of the gingiva. The scans show that the image
acquisition of the marginal gingiva could not be
precisely reproduced in the maxilla. An extended
protocol, resulting in a longer scanning time, might be
necessary to obtain complete information.
The facial surfaces of the anterior teeth were
imprecisely captured with the iTero in intraoral and
extraoral digitizations (Figs 6 and 7). Although they
appear to be easily accessible with the scanning wand,
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Fl€
ugge et al
the steep-angled anterior surface might require
additional scans from different angles, as Mehl et al27
have already suggested for steep areas.
The imprecise digitization of the molar areas with the
iTero in extraoral use was more pronounced for intraoral
use. This might be caused by the complex angled
surfaces of the molars and the undercut surfaces of
the neighboring teeth. This theory is supported by
Rudolph et al,15 who used different methods for
digitization of an extraoral reference model to show
that tooth shape was a dominating factor for precision
and that large deviations occurred in areas with strong
changes of curvature. The precision of extraoral model
scanning with the D250 was not lower in areas of high
curvature and undercuts. The continuous image
acquisition with laser planes captures all areas of the
model precisely, except for interdental spaces, that
accounted for the overall imprecision. The deviations
of the group 3 models were on average 10 mm. This
agrees with the study of Persson et al.28
Despite the identical scanning protocol, the precision
for extraoral scanning with the iTero (25 mm) was higher
than for intraoral scanning with the iTero (50 mm). This
might be due to patient movement, limited intraoral
space, intraoral humidity, and saliva flow. High
deviations in intraoral scans of the molar areas indicate
that patient-related factors had a strong influence on
scanning quality. In comparison, the reduced values
obtained with the extraoral iTero scanning might result
from greater freedom of placement of the scanning
wand next to the model teeth.
Numerous in-vitro studies have shown that prerequi-
sites for clinical use of intraoral and extraoral scanning
devices are met.9,12,15-17 However, the precision of
scanning devices under intraoral conditions has not
been documented to date. This study shows that the
iTero system in vivo and ex vivo can be used to
create virtual models for diagnostics and treatment
planning in orthodontics. To manufacture orthodontic
appliances on the basis of the virtual models, not only
the scanning process but also the production process
must be considered. Computer-aided design and
computer-aided manufacturing on the basis of virtual
models created with data from the iTero intraoral scans
are accompanied by inaccuracies, especially when the
depiction of facial surfaces of anterior teeth and molars
or marginal soft tissues is important for the appliance
(eg, aligners, customized brackets). Extraoral scanning
techniques show higher precision and therefore allow
higher accuracy of applicances built with computer-
aided design and computer-aided manufacturing. How-
ever, the inaccuracies of the impression must be added
to all laser scanning data acquired ex vivo.
Fl€
ugge et al
Fig 10. Boxplot of the deviations for every method (outliers are hidden).
We showed that intraoral scanning with the iTero was
less precise than extraoral scanning and digitization with
the D250, which is still the most precise digitization
method currently available. The precision of the intraoral
iTero scan is similar to the values documented in the
literature with conventional polyether impressions
(61.3 6 17.9 mm) for reproduction of the intraoral
situation. The in-vitro precision for the CEREC
(30.9 6 7.1 mm) was comparable with that of the
iTero under extraoral conditions (25 mm) in our study.18
The in-vitro precision of the Lava-COS system
(60.1 6 31.3 mm) was lower than the in-vitro and
in-vivo precision of the iTero.18 With CEREC and iTero,
the images are recorded in a static position relative to
the tooth, whereas the Lava COS captures images while
the scanning wand is constantly moving; this might
result in lower precision for this technique.
Our results indicate that the positions of teeth and
their surfaces can be reproduced in a virtual model,
but soft-tissue reproduction was imprecise.
The image acquisition technique of the iTero does
not require the application of a scanning powder. The
precision of the iTero might be higher compared with
the CEREC and the Lava-COS, since powder application,
necessary for these systems, produces a layer of variable
thickness.23
CONCLUSIONS
Intraoral scanning with the iTero is less precise than
model scanning with it. Therefore, patient-related
factors influence the scanning process. Scanning of the
maxilla is less accurate than scanning of the mandible.
An extended scanning protocol might improve the
scanning results in the maxilla. Because of its technical
American Journal of Orthodontics and Dentofacial Orthopedics
477
features, extraoral scanning has the highest precision.
For treatment planning and manufacturing of tooth-
supported appliances, virtual models created with the
iTero can be used.
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