The European Journal of Orthodontics Advance Access published February 27, 2015

European Journal of Orthodontics, 2015, 1–5

doi:10.1093/ejo/cjv001

Original article

Reliability and validity of measurements on

digital study models and plaster models
Ralph Philip Reuschl*,†, Wieland Heuer**,***,†, Meike Stiesch**,
Daniela Wenzel**** and Marc Philipp Dittmer*****,******
Departments of *Orthodontics and **Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical
School, ***Private Practice, Detmold, ****Department of Biometry and *****Centre for Dental, Oral and Maxillofacial
Medicine, Hannover Medical School, Germany,******Private Practice, Sarstedt

Correspondence to: Marc Philipp Dittmer, Edith-Weyde-Str. 7, 31157 Sarstedt, Germany. E-mail: marc@drdittmer.de

† These authors contributed equally to the success of this study.

Summary
Objective:  To compare manual plaster cast and digitized model analysis for accuracy and efficiency.
Material and methods:  Nineteen plaster models of orthodontic patients in permanent dentition
were analyzed by two calibrated examiners. Analyses were performed with a diagnostic calliper
and computer-assisted analysis after digitization of the plaster models. The reliability and efficiency
of different examiners and methods were compared statistically using a mixed model.
Results:  Statistically significant differences were found for comparisons of all 28 teeth (P < 0.001),
mandibular intermolar width (IMW, P = 0.0453), and overjet (P < 0.001 to P = 0.0329). Single-tooth
measurements tended to have larger values when measured manually and the SD was between
0.06 and 1.33 mm. Digital analyses gave significantly higher values for mandibular IMW and
overjet. Less time was needed for digital measurements.
Conclusion:  Clinical significance of the differences between the methods compared did not appear
significant. 3D laser-scanned plaster model analysis appears to be an adequate, reliable, and time
saving alternative to analogue model analysis using a calliper.

Introduction plaster models with a calliper. Measurements with OrthoCad models

Impression taking and plaster model production are established
methods in dentistry and plaster models serve as basis for documenta-
tion and diagnosis. In orthodontics, model analysis is used routinely
and is a key factor to treatment planning and review of orthodon-
tic progress. In recent years, digitalization techniques in dentistry
have advanced and methods to digitalize plaster models into 3D vir-
tual models have been established. In 1999, Align Technology Inc.
(San Jose, California, USA) introduced OrthoCad, which is a digi-
tal model service, based on a proprietary scanning process of plas-
ter models (1). Three years later, GeoDigm Corp. (Falcon Heights,
Minnesota, USA) introduced ‘emodels’, a digitalization service for
plaster models using non-destructive laser scanning (1). Several stud-
ies have been performed to compare digital model analyses with the
so-called ‘gold standard’, which means the manual measurement of
(2–4) or emodels (5–7) seem to be generally as precise and reliable
as measurements made with plaster models. However, before 3D
data are available, plaster models or the original impressions have
to be sent to the provider and this is not cost efficient. For this rea-
son, desktop laser scanners were developed to transfer the scanning
process into practice or in-house laboratory. The reliability of these
desktop scanners, e. g. those of 3Shape (Copenhagen, Denmark), has
been evaluated by various authors, who found that digital models
obtained by 3Shape scanners are reliable for measurements and the
evaluation of dental arch relationships (8–10). However, the ana-
lytical software (Orthoanalyzer; 3Shape) of this system has not
been tested yet. Besides the general advantages of virtual models,
e.g. less storage space, lower costs, instant accessibility, and trans-
fer anywhere in the world for instant referral or consultation (11),
Orthoanalyzer software offers a workflow for a step-by-step analysis

© The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
1
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2 European Journal of Orthodontics, 2015

of the models, followed by a tool for a diagnostic or therapeutic set- measurements were performed. In-process magnification or zoom-
up. This set-up can be divided into substeps according to the amount ing in the desired model area was allowed, in order to give maximal
of tooth movement. The resultant virtual models can then be plotted resolution.
via additive methods or milled via subtractive manufacturing meth- Calibration of both examiners was achieved by collaboration
ods and then be used for the production of orthodontic auxiliaries in two sample cases. Measurements were directly compared and
or appliances. discussed until final definition. After the two examiners had been
Because of the advantages and the development of fast and trained and calibrated, a standardized workflow was established
accurate intraoral scanners, it is foreseeable that virtual models will for the manual and digital measurements to assure that the quality
replace plaster models in the medium term. Accordingly, the soft- and time courses were similar for the two types of measurement.
ware for virtual model analysis will become more important and Each model set was measured 3 times at intervals of 3 days by the
should deliver results that are at least as reliable and valid as those 2 examiners.
from plaster model analysis. Hence, the aim of this study was to The following parameters were included:
compare traditional manual model analysis with an orthodontic cal-
liper with the virtual model analysis of digitalized plaster models. 1. Tooth widths were measured for teeth 17–27 and 37–47. The
marks were the contact points between neighbouring teeth or the
Inter- and intra-individual reproducibility was also evaluated. The
greatest mesiodistal diameter.
following hypothesis was formulated: digital model analysis is as
2. Upper jaw transversal width between palatal cusps of first molars
reliable and measurements obtained are equally reliable compared
(Max. IMW, i.e. intermolar width) and of canines (Max. ICW, i.e.
to manual model analysis.
intercanine width).
3. Lower jaw transversal width between central fossae of first molars
(Mand. IMW) and of the canine cuspids (Mand. ICW).
Materials and methods 4. Overjet, measured from the mesiobuccal surface of the lower inci-
Pre-treatment plaster model sets of 20 patients were randomly sor to the mesiobuccal surface of the upper incisor parallel to the
selected from patients seeking orthodontic treatment in the Hannover occlusal plane. The maximum distance detected was used (Over-
Medical School postgraduate program ‘Master of Science in Lingual jet).
Orthodontics’. All plaster models were made in the same laboratory, 5. Overbite, measured from incisor edge to incisor edge in a 90° angle
with similar time intervals from impression taking to model pro- to the occlusal plane. The maximum distance detected was used
duction. The criteria for inclusion were a fully erupted permanent (Overbite); see also Figures 1 and 2.
dentition, similar shape of the models—with a base parallel to the 6. Midline discrepancy was measured from the contact point of the
occlusal plane—and full integrity of the model: cracked or damaged upper central incisors to the contact point of the lower central inci-
models were not used. Furthermore, models with bonded retainers, sors (Midline Discrepancy).
appliances, attachments, or prostheses were excluded. After applying 7. Duration of time to take above measurements (Time Needed).
these criteria, 19 models remained in the pool of cases. The patients’
Distances were measured in millimetres (mm) and time was doc-
ages ranged between 15 and 47  years; 9 male and 10 female vol-
umented in seconds. Manual model analysis was performed with
unteers had Class I (11 patients), Class II (6 patients), and Class III
a diagnostic calliper (‘Zürcher Model’, Smile Dental®, D, article
malocclusions (2 patients). Eleven of those 19 patients had also
number: 06-0075) to an accuracy of one tenth (1/10) of a mm. No
slight crowding in the anterior region.
magnification was used for manual model analysis. All data were
Using G-Power (G-Power 3.1.9.2, Franz Faul, University of Kiel,
recorded in a standardized document to guarantee similar work-
Kiel, Germany), power and sample sizes were calculated. Power
flows. Model number and trial were documented. Digital values
calculation for the digital and manual value groups of single-tooth
were saved to an accuracy of one hundredth (1/100) of a mm, as
measurements revealed that a sample size of 7 would have a power
this is a standard feature of the software. No post-measurement
of 95 per cent to detect difference in means of 2 mm (e.g. a first
rounding was operated.
condition mean [µ1] of 9.92 mm [±0.13 mm] and a second condition
Documented data were captured in a Microsoft Excel™ 2007
mean [µ2] of 7.92 mm [±1.33 mm]). Furthermore, power calculation
file and processed for descriptive statistics. Further statistical analy-
for the single-tooth values of the inter-examiner groups revealed that
sis with the aid of a mixed model was performed by the procedure
a sample size of 18 would have a power of 80 per cent to detect
implemented in SAS™ 9.3.
difference in means of 0.19 mm (e.g. a first condition mean [µ1] of
5.79 mm [±0.19 mm] and a second condition mean [µ2] of 5.6 mm
[±0.2 mm]).
Each model set was anonymized with a number and then digi-
talized using a 3D laser scanning system with two cameras with 5.0
megapixels each (D800; 3Shapedental, Copenhagen, Denmark).
The accuracy of this scanner is given by the manufacturer as 15
microns. After separate scanning of the upper and lower jaw plas-
ter model, a bite scan was performed in the wax-bite position, in
order to ensure identical bites in the virtual and plaster model sets.
The output format used for calculating the model was an open
standard STL file of about 22–25 MB for each set of plaster mod-
els. The collected data were saved as STL files and imported to
Orthoanalyzer software (Build: 1.2.2.2; 3Shapedental) for further
editing. To establish identical preconditions, the virtual model sets
were oriented in the OrthoAnalyzer to the occlusal plane before Figure 1.  Typical screenshot of a virtual model during analysis of the overbite.
R. P. Reuschl et al.
Figure  2.  Photo taken analogue to the screenshot of Figure  1 showing a
typical overbite measurement of the manual analysis.
The null hypothesis was defined as no difference between the
manual and digital methods and between evaluators. Standard devi-
ation, mean, and coefficient of variation were calculated for each
patient, examiner, and method, yielding four different sample groups
for each patient. Intra-examiner and inter-examiner data were evalu-
ated for the different methods. Means and standard deviation data
were presented in scatter plot graphs to depict inter- and intra-exam-
iner correlation.
P values were calculated for each measured parameter. P <0.05
was taken as statistically significant, corresponding to rejection of
the null hypothesis. P values were presented in a separate table, in
order to emphasize statistically significant parameters.
Results
Comparison of tooth widths
The overall comparison between the manual and digital meth-
ods shows that some results differed significantly (P  <  0.001, see
Table  1). There was significant difference in inter- examiner vari-
ation (P  <  0.001). There was a significant effect of the examiners
in the manual method (P  <  0.001), but not in the digital method
(P  =  0.228). The mean values for tooth width from the manual
method were larger than the values from the digital method (0.1–
2.5 mm). Examiner 2 gave larger values than Examiner 1 for either
method. The standard deviation was significantly higher in molar
regions, but only for the digital method. The standard deviations
of the width measurements were similar for the two methods. The
SE of all combinations ranged from 0.0163 to 0.023 mm. With the
digital method, both examiners found remarkably low values with
tooth 27, which were almost 20 per cent lower than with the manual
method, thus leading to a high overall standard deviation.
Comparison of transversal measurements (Max.
IMW, Max. ICW, Mand. IMW, and Mand. ICW)
The transverse measurements were not significantly influenced by
examiner or method, with the exception of a single value: Examiner
1 found significantly higher values for the mandibular IMW with
manual measurements than with digital ones (P = 0.0453). The SE
for the combined measurements was 0.1824 mm.
Comparison of overjet
The overall comparison found statistically significant differences
between the examiners (P  <  0.001) and method of measurement
3
(P = 0.0002) (see Table 1). There were striking differences between
the two examiners with respect to the mean values in the manual
measurements (3.68 versus 5.11 mm). Furthermore, there were sta-
tistically significant differences between the digital results for exam-
iner one and his manual results (P < 0.001), as well as to both the
manual (P  <  0.001) and digital (P  <  0.001) results for Examiner
2. There were also significant differences between the digital results
for Examiner 2 and the manual results for Examiner 1 (P = 0.0329).
Comparison of overbite values
For overbite, there were no statistically significant differences with
respect to method of measurement or examiner (Table 1).
Midline
For midline, there were no statistically significant differences with
respect to method of measurement or examiner (Table 1).
Comparison of time needed for measurements
Time needed for analyses was statistically significant influenced by
the method (P  <  0.0001). Digital trials were 75–92 seconds faster
than manual trials. A  minimum time needed for digital measure-
ments was 4:29 minutes, the maximum time was 10:54 minutes,
whereas manual measurements took between 6:24 and 9:56 min-
utes. Thus, the bandwidth of time needed to complete a trial was
lower for the manual method. Comparing the two examiners, no
significance was detected (P = 0.2370). Both examiners showed the
same mean value of 6:17 minutes for digital measurements.
Discussion
The trend to virtual models in orthodontics is clear and different
software programs are available to perform virtual model analyses.
Several studies have compared different model analysis software
programs and the conventional manual analysis (10, 12–14). In
these studies, scanner and software were not provided by a single
manufacturer, which makes the workflow from scanning to analysis
more demanding. A  simple workflow is available with the 3Shape
system, which offers an intraoral scanner or extraoral laser scanning
boxes as well as an analysis tool with the Orthoanalyzer software.
To the best of the authors’ knowledge, no study has evaluated the
Orthoanalyzer software yet. In the present study, this software was
compared for the first time with the manual analyses with a cal-
liper. The number of samples needed to give conclusive results was
determined by a review of current literature and proofed by a power
analysis. Watanabe et  al. (15), Leifert et  al. (16), Zilberman et  al.
(17), and Asquith et  al. (18) selected between 10 and 25 models.
According to the results of these studies, 19 models were calculated
as an adequate number of samples.
Various options are available to obtain the data set for a full dental
arch. The direct intraoral scanning method is already available and
seems to have sufficient reliability for diagnostic purposes (19, 20) but
is still not routinely used in dental practice. Furthermore, scanning
conventional impressions directly by either computed tomography or
with lasers has the advantage that it eliminates plaster models but
has the potential disadvantage that correct bite registration can be
challenging to achieve. The third and most common method for digi-
talization of dental arches is the scanning of plaster models by various
scanning techniques (e. g.  laser scanning, structured-light scanning)
(21, 22). With a scan in the wax-bite position, a high correlation can
be assumed between the plaster model set and the virtual model set.
In the current study, a laser scanning method was therefore applied.
 4 European Journal of Orthodontics, 2015

Table 1.  P values, lower and upper limit of the 95% confidence interval for all combinations: comparison of all 28 teeth (Comp. all 28 teeth), maxillary intermolar width (Comp. Max. IMW), As model analysis is a routine procedure in an orthodontic prac-
maxillary intercanine width (Comp. Max. ICW), mandibular intermolar width (Comp. Mand. IMW), mandibular intercanine width (Comp. Mand. ICW), overjet (Comp. Overjet), overbite (Comp.

−0.1764 0.1209
−0.1425 0.1548

−0.2769 0.1436

−0.3108 0.1097

−0.2318 0.1886

−0.2441 0.1764

−0.1651 0.2553

−0.1313 0.2892
Upper
tice and commonly performed with plaster casts, we deliberately
chose a diagnostic analogue calliper (Zürcher Model) to conduct our

Lower
measurements. This is less accurate than a digital calliper, although

Discrepancy
Midline these differences are not clinically significant and diagnostic ana-
logue callipers are widely used. Nevertheless, the advantages offered
Upper P value

−0.00306 0.3653 0.7135

−0.2353 0.1331 0.9352

0.1938 0.5325

−0.09488 0.4261 0.3469

0.3905 0.8398

−0.02821 0.4928 0.7511

−0.06383 0.4572 0.6728

0.2249 0.4599
Comp.

by the software included standard features like zoom, turn, and tilt
of the models as well as the accuracy grade (1/100 mm).
Defining the correct landmark is a decisive issue when look-
ing at reliability and intra- and inter-examiner validity. Standard
−0.3272

−0.1305

−0.2961
Lower

deviations in molar regions increased significantly, but only for the

digital method. This might be caused by difficulties in identifying
Overbite

P value

−0.9572 0.1311 0.0002 −0.6639 −0.2082 0.0539

−0.4193 0.669 <0.0001 −1.0147 −0.5591 0.5847

−0.5836 0.9555 <0.0001 −1.7555 −1.1112 0.6144

−1.1215 0.4176 <0.0001 −1.4046 −0.7603 0.2114

−1.0578 0.4813 <0.0001 −1.5451 −0.9008 0.3263

0.0802

0.5325 0.1381

0.1816 0.7878
Comp.

tooth margins. Problems in setting correct landmarks on digital

models have been reported by other authors (5, 23–26). Hunter and

0.02871 0.673
Upper

Priest (26) also found significantly larger values for posterior teeth
but reported a reduction in variation as the technique was refined.
0.1994 −0.1118

0.3908 −0.4627
Lower

Dalstra and Melsen (23) concur with these findings and suggest that
there is a learning curve, especially for digital measurements, that
0.0329
Overjet

Upper P value
Comp.

would lead to minor deviations as the examiner becomes familiar

with the technique. Although explicit emphasis was put on calibra-
−1.3074 0.2316

−1.2438 0.2953

−0.7059 0.8332

tion of both examiners, there is evidence that Examiner 1 was not

able to reproduce landmarks as precisely during digital trials as
Lower

Examiner 2 or as the manual trials. Another possible explanation for

variations and large standard deviations is the technique of digitali-
Mand. ICW

zation. Undercuts of models, especially in approximate regions, can

P value

0.03584 0.1360
0.2278 0.6515

0.6342

−0.7269 −0.00779 0.3683

0.4610

0.1697

0.2258

0.8705
Comp.

lead to scan shadows and thus to inaccuracy (15).

Single-tooth measurements are claimed to be highly precise and
0.1841

0.1147

0.1676

0.2901

reliable. As our data show, measurements with an analogue calli-

0.482
Upper

per have better reliability than digital measurements. Analogue data

−0.4727
−0.2807

−0.6045

−0.5515

−0.2371

reveal a smaller standard deviation for teeth in the posterior area

−0.533

−0.429
Lower

(lowest SD 0.06 mm at tooth 34 and 42), whereas the front teeth

Comp. Mand.

show larger standard deviations (0.25 mm at tooth 12). In contrast,

digital measurements are highly reproducible in the front area, up
14.3594 0.0453
P value

8.8267 0.0918
9.5564 0.8374

15.1224 0.3372

−0.03265 15.2677 0.1808

6.8416 0.2938

7.7499 0.7036

8.4478 0.5027
IMW

to the premolar region (lowest SD 0.1 mm at tooth 44), but show

less accuracy in the molar region (highest SD 1.3 mm at tooth 27).
Upper

Tooth 27 showed very high standard deviations throughout using

the digital method, possibly indicating an inbuilt error within the
Dig., digital; Man., manual. Bold values represent statistically significant results (P ≤ 0.05).
−1.2061

−0.2382

−0.9409

−8.3073

−7.3991

−6.6313
−1.942
Lower

software or in the handling of the software by the examiners. Data of

manual measurements show the highest standard error for maxillary
Max. ICW

ICW (SE 2.73–3.89 mm), although this does not mean statistically

Upper P value

−0.1129 0.745 0.2089

−0.459 0.3989 0.1276

−0.7084 0.5049 0.0575

0.0853

−0.3207 0.8926 0.0510

−0.2605 0.9528 0.8489

−0.2189 0.9943 0.9636

0.6482 0.8125
Comp.

significance. Moreover, digital measurements of mandibular ICW

and especially overjet were comparatively inaccurate and tended to
−0.3622 0.851
Overbite), midline discrepancy (Comp. Midline discrepancy).

be larger than manual results. Asquith and McIntyre (8) defined sys-
tematic errors of more than 0.5 mm for single-tooth measurements
−0.565
Lower

and overjet or measurements with more than 5 per cent discrepancy

Comp. Max.

from reference marks as clinically unacceptable. The results of the

P value

0.3125 0.1478
−0.08452 0.8901

0.07279 0.7412

0.4279

0.3537

0.2619

0.2090

0.8926

present study suggest that except for the variation on 27, the soft-
IMW

ware delivered reliable results and should be able to replace plaster

cast analysis. Nevertheless validity of digital results are more critical
0.4697

0.2093

0.1816

−0.2155
0.442
Upper

than manual measurements as the quality of the digitalization pro-

cess and interpretation of anatomic structures and predefined con-
−0.01734

0.09152
0.2488
<0.0001 −0.1482

0.3797

0.1193

0.3519

<0.0001 −0.3054
Lower

tact points lead to higher standard deviations. Furthermore, there is

a risk of making type 1 error when several measurements are made
Comp. all

<0.0001

<0.0001

<0.0001

<0.0001

<0.0001
0.2279
28 teeth

with both methods.

P value

Time taken to measure digital models was significantly lower

Dig. Examiner 1 versus Dig.

than the manual method (P ≤ 0.0001). This is a decisive criterion for

Method of measurement

Man. Examiner 1 versus

Dig. Examiner 1 versus

Dig. Examiner 1 versus

Dig. Examiner 2 versus

Dig. Examiner 2 versus

choosing a procedure for daily routine in an orthodontic practice.

Examiner 1 versus Ex-

The potential time saving can nearly be 2 minutes per model.

Man. Examiner 1

Man. Examiner 2

Man. Examiner 1

Man. Examiner 2

Man. Examiner 2

While the difference in time to analyze models digitally or manu-

Examiner 2

ally was significant, there was little inter-examiner variation, particu-

aminer 2

larly for digital models: both examiners took 6:17 minutes, whereas
R. P. Reuschl et al.
analogue measurements took 7:32 minutes for Examiner 1 and 7:49
minutes for Examiner 2.
Conclusion
3D laser-scanned plaster model analysis appears to be an adequate
and reliable alternative to the conventional method of model analy-
sis with an analogue calliper and it appears to be more efficient. In
spite of hard and software bias in determining the correct landmark,
digital model analysis should be accurate enough for treatment plan-
ning. Discrepancies in individual tooth diameters and linear meas-
urements were not clinically significant for most values.
Software advantages, such as embedded calculation of required
data, can be used to optimize efficiency in orthodontic workflows.
Further emphasis should be placed on improving efficiency and
efficacy of digital analysis; this should help practitioners to use digi-
tal techniques in an optimal manner during their daily work.
Acknowledgements
The plaster models used in the present study were provided by the Department of
Orthodontics, Hannover Medical School, (Head: Prof. Schwestka-Polly), whose
support is gratefully acknowledged. The Orthoanalyzer Software was made
available by 3Shape, whose support is also gratefully acknowledged.
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