Stefan Vandeweghe Accuracy of digital impressions of

Valentin Vervack
Melissa Dierens
multiple dental implants: an in vitro
Hugo De Bruyn study

Authors’ affiliations:
Stefan Vandeweghe, Valentin Vervack, Hugo De
Bruyn, Department of Periodontology, Oral
Implantology, Removable and Implant Prosthetics,
Dental School, Faculty of Medicine and Health
Sciences, Ghent University, Ghent, Belgium
Melissa Dierens, Oral and Maxillofacial Imaging
Unit, Dental School, University Hospital Ghent,
Ghent, Belgium
Hugo De Bruyn, Department of Prosthodontics,
Malm€ o University, Malm€o, Sweden
Corresponding author:
Stefan Vandeweghe, DDS, PhD
Department of Periodontology, Oral Implantology,
Removable and Implant Prosthetics
University Hospital Ghent
De Pintelaan 185, Poli 8
9000 Ghent
Belgium
Tel.: +32 9 332 59 22
Fax: +32 9 332 15 26
e-mail: stefan.vandeweghe@ugent.be
Key words: dental implant, digital impression, edentulous, intra-oral scan
Abstract
Introduction: Studies demonstrated that the accuracy of intra-oral scanners can be compared with
conventional impressions for most indications. However, little is known about their applicability to
take impressions of multiple implants.
Aim: The aim of this study was to evaluate the accuracy of four intra-oral scanners when applied
for implant impressions in the edentulous jaw.
Material and methods: An acrylic mandibular cast containing six external connection implants
(region 36, 34, 32, 42, 44 and 46) with PEEK scanbodies was scanned using four intra-oral scanners:
the Lava C.O.S. and the 3M True Definition, Cerec Omnicam and 3Shape Trios. Each model was
scanned 10 times with every intra-oral scanner. As a reference, a highly accurate laboratory scanner
(104i, Imetric, Courgenay, Switzerland) was used. The scans were imported into metrology software
(Geomagic Qualify 12) for analyses. Accuracy was measured in terms of trueness (comparing test
and reference) and precision (determining the deviation between different test scans). Mann–
Whitney U-test and Wilcoxon signed rank test were used to detect statistically significant
differences in trueness and precision respectively.
Results: The mean trueness was 0.112 mm for Lava COS, 0.035 mm for 3M TrueDef, 0.028 mm for
Trios and 0.061 mm for Cerec Omnicam. There was no statistically significant difference between
3M TrueDef and Trios (P = 0.262). Cerec Omnicam was less accurate than 3M TrueDef (P = 0.013)
and Trios (P = 0.005), but more accurate compared to Lava COS (P = 0.007). Lava COS was also less
accurate compared to 3M TrueDef (P = 0.005) and Trios (P = 0.005).The mean precision was
0.066 mm for Lava COS, 0.030 mm for 3M TrueDef, 0.033 mm for Trios and 0.059 mm for Cerec
Omnicam. There was no statistically significant difference between 3M TrueDef and Trios
(P = 0.119). Cerec Omnicam was less accurate compared to 3M TrueDef (P < 0.001) and Trios
(P < 0.001), but no difference was found with Lava COS (P = 0.169). Lava COS was also less accurate
compared to 3M TrueDef (P < 0.001) and Trios (P < 0.001).
Conclusions: Based on the findings of this in vitro study, the 3M True Definition and Trios scanner
demonstrated the highest accuracy. The Lava COS was found not suitable for taking implant
impressions for a cross-arch bridge in the edentulous jaw.

The introduction of CAD/CAM has simplified
and improved the workflow of fixed prosthetic
dentistry. Although many studies demonstrate
a significant improvement in the accuracy of
CAD/CAM compared to conventional cast
frameworks (Karl & Holst 2012), a significant
error is still present. In the conventional work-
flow, half of the misfit is introduced during the
impression procedure and production of the
stone cast, while the other half occurs while
manufacturing the prosthesis (Schneider et al.
Date: 2001; Heckmann et al. 2004). Although cad-
Accepted 20 March 2016
cam improved the accuracy of the latter, the
To cite this article: initial step in the workflow, taking an impres-
Vandeweghe S, Vervack V, Dierens M, De Bruyn H. Accuracy
of digital impressions of multiple dental implants: an in vitro sion and pouring the cast, remained the same.
study.
Making a digital impression by means of
Clin. Oral Impl. Res. 00, 2016, 1–6
doi: 10.1111/clr.12853 an intra-oral scanner may help to overcome
these errors. The virtual model used by the
cad software is almost immediately created
using the data of the intra-oral scanner. As
there is no need for a stone cast or a conven-
tional impression, the dimensional errors
that take place during these procedures can
be avoided (Johnson & Craig 1985; Millstein
1992). Theoretically, this could improve the
accuracy and fit of the final prosthesis.
Although passive fit is difficult to describe
(Heckmann et al. 2004), Jemt & Lie (1995)
defined it as an accuracy level that does not
cause any long-term clinical complications.
According to the authors, discrepancies up to
150 lm were acceptable. For implant-sup-
ported reconstructions, the level of fit is even
more important compared to teeth-supported

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Vandeweghe et al
Accuracy of digital implant impressions
prostheses. Dental implants have a reduced
mobility which only exists because of the
flexibility of the bone (Kim et al. 2005). The
absence of a periodontal ligament prevents
the implant from adapting to the ill-fitting
framework, and as a consequence, stress will
be induced in the implant and framework
(Bacchi et al. 2013). Combined with an
increase in occlusal loading (Hammerle et al.
1995), it is not surprising that the complica-
tion rate is higher for implant restorations
compared to tooth-born restorations (Good-
acre et al. 2003).
Several laboratory investigations have eval-
uated the accuracy of intra-oral scanners.
Ender & Mehl (2011) compared the accuracy
of the Lava COS and Cerec Bluecam intra-oral
scanners with a conventional polyether
impression and found that the accuracy of the
digital impressions was better. Similarly,
Guth et al. (2013) compared the accuracy of
the traditional CAD/CAM workflow with
intra-oral scanning and found the highest
accuracy for the latter. However, most studies
evaluating the accuracy of intra-oral scanners
focus on tooth-supported restorations or eval-
uate only the data output of the digitizers.
Making digital impressions of dental
implants requires the use of scanbodies,
which are easy to capture as most of the object
is located supragingivally. On the other hand,
the accuracy will also depend on the fit of
these scanbodies on the implants. Stimmel-
mayr et al. (2012) reported an average discrep-
ancy in the fit of the scanbodies of 39 lm on
the original implants and only 11 lm on the
implant analogues. Consequently, one could
assume that laboratory scanning of the stone
cast would lead to fewer errors. Another
aspect of the implant workflow that may
cause small deviations in accuracy is the
matching of the virtual scan body from the
cad software’s library on the virtual model. If
the original scan lacks quality, this may result
in an incorrect matching of the scan body and
an error in the position of the analogue in the
virtual model.
Scanning an edentulous jaw may be chal-
lenging due to the lack of anatomical land-
marks and the fact that all scanbodies are
identical. Andriessen et al. (2014) experienced
several problems when scanning two
implants in the edentulous mandible because
the intra-oral scanner had difficulties to
make a distinction between both implants.
As a result, the majority of scans were use-
less.
The inter-implant distance also seems to
affect the accuracy. A longer scanning dis-
tance resulted in an increased error. Implant
2 | Clin. Oral Impl. Res. 0, 2016 / 1–6
angulation did not affect the accuracy (Gime-
nez et al. 2014).
The aim of this study was to evaluate the
accuracy of various intra-oral scanners when
used for implant impressions in the edentu-
lous jaw.
Material and methods
Study protocol
Six regular dental implants with an external
hex connection (IBT, Southern Implantsâ,
Irene, South Africa) were placed in an acrylic
model of the edentulous mandible at the posi-
tion of the 1st molar, 1st premolar and lateral
incisor (Fig. 1). Inter-scan body distance and
angulation are depicted in Table 1. Six cus-
tom-made intra-oral scanbodies in PEEK
(=polyether ether ketone) (Proscan, Zonhoven,
Belgium) were connected to the implants and
tightened by hand to approximately 10Ncm.
The model was scanned with a highly
accurate optical digitizer (104i, Imetric, Cour-
genay, Switzerland) and a 3D image was cre-
ated and exported as an open-format STL file.
Similarly, the model was scanned 15 times by
each intra-oral scanner according to the manu-
facturer’s recommendation. The five first scans
were not used for analyses, to avoid inaccuracies
caused by a learning curve. The remaining scans
were exported to an open file format (STL, Ply).
For the Lava COS and 3M TrueDef, these files
could be downloaded directly from the cloud,
while for the 3Shape Trios and Cerec Omnicam,
the data needed to be imported into additional
software (Exocad, Darmstadt, Germany) to
allow creation of an open STL fi
Intra-oral scanners
The LavaTM Chairside Oral Scanner (Lava
COS) was launched in 2008 by 3MTMESPE
(Seefeld, Germany) and is based on the princi-
ple of active wavefront sampling with struc-
tured light projection. It allows data
capturing in a video sequence and models the
data in real time. Light powder dusting of the
dental arch is necessary to locate reference
points for the scanner.
In 2012, the Lava COS was replaced by the
3MTM True Definition (3M TrueDef) scanner
(3MTMESPE), which is an upgraded version of
the Lava COS, with updated software and an
improved wand with a larger focus depth. It
also uses light powder dusting.
The Cerec Omnicam (Sirona, Long Island
City, NY, USA) is based on the concept of
active triangulation and uses a white light to
project a pattern on the object. It captures
data continuously in colour, without the
need for contrast spraying.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
The Trios scanner (3Shape, Copenhagen,
Denmark) is based on confocal microscopy
and continuously captures 2D images from
different positions to create a 3D surface.
The recent version captures in colour and
does not use contrast spraying.
Data analyses
All scans were imported into metrology soft-
ware (Geomagic Qualify 12, 3D Systems,
Rock Hill, SC, USA) for data analyses (Fig. 2).
The CAD file of the scan body was aligned
to the six scanbodies, using a best-fit algo-
rithm with the tolerance set at 1 lm. Next,
the six aligned scanbodies were saved as a
new file. This allowed to compare only the
scanbodies, thereby excluding all other irrele-
vant parts of the model.
As defined by Ender & Mehl (2011), accu-
racy consists of two parameters: trueness
describes how close a test scan resembles the
scan taken by a reference scanner, while pre-
cision describes how much the various test
scans differ from each other.
For this study, the trueness was evaluated
by comparing the various test scans obtained
from the intra-oral scanner with the reference
scan from the Imetric 104i. Precision was
evaluated by comparing the scans from each
intra-oral scanner with one another. The pri-
mary outcome is thus to evaluate the accu-
racy, in terms of trueness and precision, at
the level of the implant scanbodies.
Test and reference scans were superim-
posed and aligned, using a best-fit algorithm
with the tolerance set at 0.001 lm. Then, a
3D comparison was done, thereby calculating
the absolute mean deviation from the mean
positive and negative deviation. The trueness
was based on 10 comparisons per scanner,
while the precision was calculated from 45
comparisons.
Statistics
Statistics were performed using SPSS v 20
(IBMâ, Armonk, NY, USA) with the level of
significance set at P = 0.05. Differences in
trueness and precision were first evaluated
using Friedman’s 2-way ANOVA test. Post
hoc analyses to identify significant differ-
ences in trueness and precision in between
the different intra-oral scanners were done
using Wilcoxon signed rank test.
Results
Mean values for trueness and precision are
based on the pooled findings for all six scan-
bodies analysed. Friedman’s test detected
 Vandeweghe et al
Accuracy of digital implant impressions

(Schneider et al. 2001; Heckmann et al.

Fig. 1. The study model represented an edentulous jaw with six external connection implants. The intraoral scan-
bodies were made in PEEK (polyether ether ketone).
Table 1. Overview of the distance and angle between the adjacent implant scanbodies
Scan body 46–44 44–42
Angle 0.57° 1.65°
Distance, mm 9.51 6.61
Fig. 2. The metrology software produces a colour-map, demonstrating the size of the deviations between test and
reference through different colours.
significant differences for trueness (P < 0.001)
and precision (P < 0.001).
Trueness
The mean trueness was 0.112 mm (SD 0.025,
range 0.084–0.174) for Lava COS, 0.035 mm
(SD 0.012, range 0.023–0.061) for 3M True-
Def, 0.028 mm (SD 0.007, range 0.021–0.044)
for 3Shape Trios and 0.061 mm (SD 0.023,
range 0.029–0.099) for Cerec Omnicam.
There was no statistically significant differ-
ence between 3M TrueDef and 3Shape Trios
(P = 0.262). Cerec Omnicam was less accu-
rate than 3M TrueDef (P = 0.013) and 3Shape
Trios (P = 0.005) but more accurate compared
to Lava COS (P = 0.007). Lava COS was also
less accurate compared to 3M TrueDef
(P = 0.005) and 3Shape Trios (P = 0.005)
(Figs 3 and 4).
Precision
The mean precision was 0.066 mm (SD
0.025, range 0.001–0.132) for Lava COS,
0.030 mm (SD 0.011, range 0.013–0.054) for
3M TrueDef, 0.033 mm (SD 0.012, range
0.005–0.057) for 3Shape Trios and 0.059 mm
(SD 0.024, range 0.009–0.115) for Cerec
42–32 32–34
4.62° 4.79°
10.28 7.28
Omnicam. There was no statistical signifi-
cant difference between 3M TrueDef and
3Shape Trios (P = 0.119). Cerec Omnicam
was less accurate compared to 3M TrueDef
(P < 0.001) and 3Shape Trios (P < 0.001), but
no difference was found with Lava COS
(P = 0.169). Lava COS was also less accurate
compared to the 3M TrueDef (P < 0.001) and
3Shape Trios (P < 0.001) (Fig. 3).
Discussion
A good fitting prosthesis is important to
avoid complications and assure the longevity
of the construction. However, this is not easy
to achieve. The application of CAD/CAM in
dentistry has improved the accuracy of the
frameworks, when compared to the conven-
tional casted frames (de Franca et al. 2015).
Despite this improvement, implant-supported
frameworks still have demonstrated micro-
gaps up to 38 lm, depending on the span of
the construction (Katsoulis et al. 2015).
The remaining misfit is largely caused by
errors that occur during the impression tak-
ing and the production of the stone cast
2004). To eliminate these errors, the concept
of digital impressions was introduced.
When evaluating the fit of a tooth-sup-
ported crown, digital impressions resulted in
a better fit compared to conventional impres-
sions and stone casts for single crowns (Syrek
et al. 2010; Ng et al. 2014) as well as for
fixed partial dentures (Almeida e Silva et al.
2014; Svanborg et al. 2014). Although digital
impressions clearly improved the framework
fit of tooth-born restorations, its final accu-
racy will still vary, depending on the shape of
the preparations and the span of the frame-
34–36 work.
Little research was done on the use of
4.22°
5.70 intra-oral scanners for the full arch. Using a
full-arch model containing 14 tooth prepara-
tions, Patzelt et al. (2014) tested the accuracy
of four intra-oral scanners. The mean true-
ness was between 38 and 332.9 lm, while
the precision ranged from 37.9 to 99.1 lm.
The authors concluded that only one intra-
oral scanner (Lava C.O.S.) could be recom-
mended for use in the edentulous jaw. Ender
& Mehl (2015) evaluated several conventional
impression materials and intra-oral scanners.
The digital impressions of a full arch had a
trueness between 29 and 45 lm and a preci-
sion ranging from 19 to 63 lm, which was
not significantly better than the conventional
impressions. The authors stated that the
intra-oral scans demonstrated more local
deviations and their accuracy depended lar-
gely on the scanning technique. Su & Sun
(2016) evaluated the precision of the Trios
scanner and compared it with a laboratory
scanner. Not only was the precision signifi-
cantly lower for the intra-oral scanner, the
deviation also increased with number of
teeth scanned.
Digital implant impressions may be even
more challenging. Scanning a single implant
can be done with high predictability, as was
shown in several studies and case reports
(Lee & Gallucci 2013; Lin et al. 2013; Abdel-
Azim et al. 2014; Joda et al. 2014). When
using a monolithic restoration, a complete
digital workflow is possible as the abutment
and crown are virtually designed and manu-
factured in their final shape (Joda & Bragger
2014). However, when scanning multiple
implants in an edentulous jaw, some difficul-
ties may arise. As multiple, identical scan-
bodies are used, it may be difficult for the
intra-oral scanner to distinguish one from
another and thus identify the correct location
in the jaw. Intra-oral scanners that work with
a photosystem may paste images of different
scanbodies on top of each other (Andriessen

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2016 / 1–6
Vandeweghe et al
Accuracy of digital implant impressions

Fig. 3. Boxplot representing the overall trueness and precision for the different scanners.

Fig. 4. Graph representing the mean trueness at every implant location for the different scanners.

4 | Clin. Oral Impl. Res. 0, 2016 / 1–6 © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

et al. 2014). Gimenez et al. (2015) scanned
six implants in the edentulous jaw, using the
Cerec Bluecam intra-oral scanner. Although
the first quadrant could be captured quite
accurately, the trueness significantly wors-
ened when also the second quadrant was
recorded. Papaspyridakos et al. (2015) com-
pared a digital impression system (Trios) with
several conventional (polyether splinted and
non-splinted) impression techniques for the
registration of five implants in the edentu-
lous mandible. The authors found no signifi-
cant differences between the digital and
conventional impression method and con-
cluded that digital impressions could be used
for implant impressions in the edentulous
jaw. The mean deviation for the Trios intra-
oral scanner was 19.18 lm, which is lower
than the values observed in our study. This
can be explained by differences in the num-
ber of implants, a different implant connec-
tion or a different design and fit of the scan
body. Stimmelmayr et al. (2012) reported a
significant difference in scan body fit
between the actual original implants and lab-
oratory analogues, in favour of the latter. In
the study by Papaspyridakos et al. (2015),
conventional extra-oral scan bodies were
used, which were significantly longer than
the ones used in our study. As was reported
by Fluegge et al. (2015), the precision will
decrease when shorter and smaller (intra-oral)
scanbodies are used.
The largest discrepancies were found at the
extremities of the model, being the scanbod-
ies located at position 36 and 46. As these
are the endpoints of our scanned surface, all
errors will occur somewhere in between and
thus lead to a maximal error at one of the
endpoints. van der Meer et al. (2012) reported
an increase in distance error over the length
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