Journal of Orthodontics

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Comparison of intraoral and extraoral scanners on

the accuracy of digital model articulation

Jason L. Porter, Caroline K. Carrico, Steven J. Lindauer & Eser Tüfekçi

To cite this article: Jason L. Porter, Caroline K. Carrico, Steven J. Lindauer & Eser Tüfekçi (2018):
Comparison of intraoral and extraoral scanners on the accuracy of digital model articulation,
Journal of Orthodontics, DOI: 10.1080/14653125.2018.1500773

To link to this article: https://doi.org/10.1080/14653125.2018.1500773

Published online: 19 Jul 2018.

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JOURNAL OF ORTHODONTICS
https://doi.org/10.1080/14653125.2018.1500773

Comparison of intraoral and extraoral scanners on the accuracy of digital model

articulation
Jason L. Portera*, Caroline K. Carrico b
, Steven J. Lindauerb and Eser Tüfekçib
a
Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA; bSchool of Dentistry, Virginia
Commonwealth University, Richmond, VA, USA

ABSTRACT ARTICLE HISTORY

Digital dental technology is increasingly becoming an integral part of the modern orthodontic Received 12 February 2018
practice. The accuracy of digitally articulated models is critical when developing orthodontic Accepted 8 July 2018
treatment plans.
Objective: to determine the accuracy of model articulation generated by extraoral and intraoral
scanners.
Design: One extraoral scanner with a wax (EOW) or vinyl polysiloxane bite registration (EOVPS), and
three intraoral digital scanners utilizing confocal static (IOCS), confocal continuous (IOCC), and blue
LED light technologies (IOLED) were used.
Methods: On each scanned image (n = 25 per group), measurements between the maxillary and
mandibular molars and canines were performed and then compared to the gold standard
values. A deviation of ± 0.5 mm from the gold standard value was considered acceptable. The
significance level was kept at 0.05.
Results: IOCS and IOCC were accurate for all six interarch measurements. IOLED and EOVPS groups
produced the next most accurate articulation of the digital models. EOW group resulted in the
least accurate articulation. Also, of the software platforms used, the OrthoCAD™ was found to
be the most accurate system for making measurements on digital casts.
Conclusions: Only the scanners with the confocal imaging technology produced accurately
articulated models. Differences between the scanners may be related to measurement errors
inherent to the technologies employed and the software systems used to process the images.

Introduction
Recent advances in dentistry have made it possible for
clinicians to use in-house intraoral scanners to produce
digital orthodontic study models. The advantages of
using this new technology include reduced cost, less
storage space, and ease of accessibility and transferabil-
ity of the digital images. Furthermore, with the built-in
software in the system, the digital models can be used
to measure important treatment characteristics such as
overbite, overjet, and arch length (Westerlund et al.
2015).
Previous studies reported that digital models are
accurate with regard to most linear measurements
within the arch, and therefore are considered a viable
alternative to physical plaster models (Alcan et al. 2009;
Akyalcin et al. 2013; Mack et al., 2017). A recent systema-
tic review (Rossini et al. 2016) on the diagnostic accuracy
of digital models reported that while some intra-arch
measurements such as crowding are accurate,
parameters that heavily depend on inter-arch relation-
ships have significant errors.
In orthodontics, the information gathered from study
models is an important component of the treatment
planning process. Even though the digital models may
provide an accurate representation of the maxillary and
mandibular arches individually, articulation of the
digital images is critical in the treatment decision-
making process (Greenhill and Basford 1979; Han et al.
1991). A previous study on the use of plaster versus
digital study models in formulating treatment options
indicated disagreement between the groups possibly
due to the errors in the digital articulation (Rheude
et al. 2005).
The importance of accurate articulation is also empha-
sized in the American Board of Orthodontics scoring
guidelines where points are given for discrepancies in
inter-arch measurements such as occlusal contacts,
overjet, and other occlusal relationship. Molar

CONTACT Eser Tüfekçi etufekci@vcu.edu Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, PO Box 980566, Rich-
mond, VA 23298-0566, USA
*Current affilation: Orthodontics at Bridgetower, Meridian, ID
© 2018 British Orthodontic Society
2 J. L. PORTER ET AL.
classification, overbite, overjet, and canine classification
rely on correctly articulated models. Therefore, accuracy
is not only important in the assessment of intra-arch
measurements such as crowding and tooth-size discre-
pancy but also in the determination of inter-maxillary
relationship.
The intraoral scanning systems available on the
market are based on different technologies. Parallel con-
focal laser and optical technology uses a laser beam that
is projected on dental hard and surrounding soft tissues.
The reflected beam is led through a filter so that the
image that lies in the focal point of the lens is projected
on the sensor. By hovering the lens over the dental
tissues, structures are tomographically sliced. The slices
are then stitched together to create a complete picture
which is termed ‘a point and stitch reconstruction.’
Another system available is three-dimensional (3D) in
motion video technology with pulsating visible blue
light. In this case, active wavefront sampling is used for
data collection. Since dental structures present reflective
surfaces, to avoid the dispersion of light, a thin layer of
powder coating is needed to capture a true reproduction
of the oral structures (Mangano et al. 2017)
Regardless the differences between the technologies
they use, digital scanners are considered good alterna-
tives to plaster models. However, there is little scientific
evidence exploring the accuracy of model articulation.
Furthermore, most of the previous work on the accuracy
of articulation focused on the inter-occlusal recording
materials (Santoro et al. 2003; Quimby et al. 2004;
Stevens et al. 2006; Dalstra and Melsen 2009; Sweeney
et al. 2015). Therefore, the purpose of this study was to
determine the accuracy of model articulation generated
by extra-oral (EO) and intra-oral (IO) scanners.
Materials and Methods
In this study, an EO model scanner (Ortho Insight 3D,
Motion View Software, Chattanooga, TN), two confocal
(IOcs: iTero® 2.9 and IOCC: iTero® Element, Align Technol-
ogy Inc., San Jose, CA) and one 3D in motion blue LED
Figure 1. Example of indentations on cast.
light (IOLED:3 M™ True Definition, 3M ESPE, St Paul,
MN) intra-oral digital scanners were used. The study
design was similar to the experiment performed in a pre-
vious study by Sweeney et al. (2015). Initially, an alginate
impression of a plastic typodont (005–000; American
Orthodontics, Sheboygan, WI) was produced. Sub-
sequently, maxillary and mandibular models were
made using Fujirock plaster (GC America, Alsip, IL)
according to the manufacturer’s instructions. These
plaster models served as master models as they are
still considered as the gold standard for orthodontic
measurements and diagnosis (Fleming et al. 2011).
On the plaster models, bur marks of two different sizes
(No.4 and No.2) were made on the buccal surfaces near
the gingival margins of the maxillary and mandibular
first molars, canines, and central incisors (Figure 1).
Since the smaller indentations produced by the No. 2
round bur were successfully captured by all scanners,
these points were used because of possibility of less vari-
ation in point selection during measurements.
The gold standard values were obtained on the
plaster models that were previously mounted in a
semi-adjustable articulator (Whipmix, Louisville, KY) in
the maximum intercuspal position (Figure 2). Six
different inter-arch measurements were performed:
upper right first molar (UR6) to the lower right first
molar (LR6), upper right canine (UR3) to the lower right
canine (UL3), upper right central incisor (UR1) to the
lower right central incisor (LR1), upper left first molar
(UL6) to the lower right left first molar (LL6), upper left
canine (UL3) to the lower left canine (LL3), upper left
central incisor (UL1) to the lower left central incisor
(LL1). Digital calipers (Fowler High Precision USA,
Newton, MA) were used to measure the distance
between corresponding indentations pairs. Each inter-
arch measurement was repeated 25 times, and the
mean distance for each of the six different indentation
pairs was used as the gold standard. A schematic of
the study design is shown in Figure 3.
For the EO scanner, two different articulations were
generated using either a vinyl polysiloxane (VPS)

Figure 2. Model articulation obtained on the semi-adjustable
articulator.
(EOVPS) (Regisil®, Dentsply Sirona, York, PA) or articulation
wax (EOW, Coprwax™, Heraeus Kulzer, LLC, South Bend,
IN). VPS material or the softened wax were applied to the
occlusal surfaces of the mandibular dentition and the
articulator was closed until the teeth were contacting
in maximum intercuspation. A 1000-g weight was
placed on top of the articulator for both groups to
prevent expansion of the occlusion registration material.
Each bite registration was scanned with the extraoral
laser surface scanner within 10 min of setting. The digi-
tized bite registrations were utilized to articulate the
Figure 3. Groups investigated – Each group (n = 25) was further divided into two subgroups (subgroup 1, n = 13 scans and subgroup 2,
n = 12 scans). Operator 1 performed and recorded all measurements for subgroup 1 and operator 2 performed and recorded all
measurements for subgroup 2
JOURNAL OF ORTHODONTICS 3
maxillary and mandibular digital models using the
Motion View software (Motion View, Chattanooga, TN)
to identify the teeth on both the bite registrations and
the models. A best-fit surface-matching algorithm fit
the maxillary model to the upper surface of the bite
registration and the mandibular model to the lower
surface.
The IO scanner protocol followed the specific manu-
facturer’s instructions. During the scanning of the bite,
a 1000-g weight was placed on top of the articulator to
maintain models in maximum intercuspation.
The occlusion resulting from the extra- and intra- oral
scanners were not modified and once all the digital
images were generated in occlusion for all groups
(each, n = 25), the models were further randomly
assigned to two subgroups. Measurements for sub-
group 1 (n = 13) and subgroup 2 (n = 12) were per-
formed and recorded by operator 1 and operator 2,
respectively.
For each digital model, the distance between corre-
sponding interarch markers was measured using the
applicable software for each scanner. The Ortho
Insight 3D software version 6.0.7044 (Motion View Soft-
ware, Chattanooga, TN) was used to analyze models
produced using the Ortho Insight 3D laser surface
scanner. OrthoCAD™ version 5.4.0.403 (Align Technol-
ogy San Jose, CA) was used to analyze models produced
using the iTero® and iTero® Element scanners. To
analyze models produced with the 3M True Definition
scanner, MeshLab version 1.3.4 (MeshLab Visual Com-
puting Lab – Italian National Research Council – CNR)
was used.
4 J. L. PORTER ET AL.

Using the UR6 to UR3 distance as a reference line
(control), the software systems corresponding to
specific scanners were also evaluated for their accuracy
by comparing the measurements to the gold standard
values to determine any inherent measurement error
within a specific computer programme.
All measurements were carried out by two operators
who were blinded to the purpose of the study were
trained and calibrated prior to the start of the investi-
gation. The intra-rater reproducibility and reliability was
determined by measuring twenty-five randomly selected
scans twice within one month. The inter-rater reliability
was assessed by comparing the measurements carried
on identical twenty-five digital models by the two
operators.
Statistical analysis
The intra- and inter- rater reliability showed excellent
agreement (Table 1). Digital scanners and their associ-
ated software systems were evaluated using two-one
sided equivalence testing (TOST). According to the Amer-
ican Board of Orthodontics objective grading system, a
0.5 mm of difference for occlusal relationship between
plaster and digital models are considered not to be clini-
cally significant (Okunami et al., 2007). Therefore, in this
study for the evaluation of articulation accuracy, the
equivalence bounds were set to 0.5 mm above and
below the gold standard measurement. A significance
level of 0.05 and SAS EG v.6.1 were used for all analyses.
Power Analysis
A post hoc power analysis was completed in nQuery
Advisor v.7.0 to assess the sample size. With 25 scans, a
two group design will have 91% power to reject the
null hypotheses that the observed difference is more
than 0.5 mm in either direction (greater or smaller). The
power analysis was completed based on the average
difference from the typodont across the 3 scanners and
all 6 measures.
Results
All experimental groups reported at least three inter-arch
measurements that were within the clinically equivalent
range of ±0.5 mm of the gold standard (Table 2, Figures 4
and 5). Of the scanners tested, only the iTero® (IOCS) and
iTero® Element (IOCC) produced articulated models with
all interarch measurements within the acceptable
range. The 3MTM scanner (IOLED) and the Regisil® bite
registration used with the extraoral Ortho Insight 3D
scanner (EOVPS) produced four of the six interarch
measurements within the acceptable range. The Copr-
waxTM bite registration used with the extraoral scanner
(EOW) produced only three of the six interarch measure-
ments in the acceptable range. Using Fisher’s Exact chi-
squared test, the number of correct measuremetns did
not differ significantly among the 5 methods (p =
0.1804).
Descriptive statistics indicated that all groups exhib-
ited some variability to a degree with the Coprwax ™
group (EOW) showing the largest standard deviation in
every inter-arch measurement (Table 3).
The three software systems resulted in measurements
that were within the 0.5 mm equivalence bounds and
were not statistically significantly different (Table 4).
The equivalence bounds were the narrowest for the
OrthoCAD™ software platform. indicating more pre-
cision in measurement.

Table 1. Summary of intra and inter-rater reliability.

UR6-LR6 UR3-LR3 UR1-LR1 UL6-LL6 UL3-LL3 UL1-LL1
mm ± SD mm ± SD mm ± SD mm ± SD mm ± SD mm ± SD
Intra Initial (5.4 ± 0.2) (10.8 ± 0.2) (10.3 ± 0.1) (5.7 ± 0.2) (8.3 ± 0.1) (9.6 ± 0.2)
Repeat (5.5 ± 0.2) (10.9 ± 0.2) (10.3 ± 0.2) (5.7 ± 0.2) (8.4 ± 0.2) (9.7 ± 0.2)
Inter Operator 1 (5.2 ± 0.2) (10.6 ± 0.1) (10.1 ± 0.2) (5.4 ± 0.2) (8.2 ± 0.1) (9.6 ± 0.3)
Operator 2 (5.2 ± 0.2) (10.4 ± 0.2) (10.0 ± 0.2) (5.2 ± 0.1) (8.1 ± 0.2) (9.3 ± 0.2)

Table 2. Difference from gold standard (mm) and TOST equivalence bounds.
90% CL Mean on Difference from Gold Standard (mm)
EOW EOPVS IOCS IOCC IOLED
UR6-LR6 (0.41, 0.87) (0.33, 0.61) (0.2, 0.3) (0.13, 0.32) (0.28, 0.43)
UR3-LR3 (0.07, 0.52) (0.29, 0.43) (0.31, 0.4) (0.09, 0.4) (0.48, 0.56)
UR1-LR1 (−0.2, 0.38) (0.12, 0.24) (0.16, 0.24) (0.02, 017) (0.25, 0.33)
UL6-LL6 (0.14, 0.66) (0.57, 0.73) (0.39, 0.48) (0.19, 0.39) (0.44, 0.59)
UL3-LL3 (−0.21, 0.31) (0.15, 0.25) (0.19, 0.27) (0.07, 0.18) (0.35, 0.43)
UL1-LL1 (−0.36, 0.26) (0.09, 0.24) (0.11, 0.2) (0.02, 016) (0.23, 0.29)
*Items in bold are statistically equivalent within ±0.5 mm of gold standard measurements based on TOST with a significance level of P < 0.05.

Figure 4. Difference from gold standard (mm) and TOST Equivalence Bounds. Each bar represents the 90% (i.e. 1-2α) Confidence Inter-
val on Mean Difference from Gold Standard. Those that fall within the TOST equivalence bounds at 0.5 mm from the gold standard are
deemed equivalent to the gold standard.
Discussion
Hayashi et al. (2015) reported that using standard refer-
ence points decreases the random measurement errors
associated with identifying landmarks. Therefore, in this
study, instead of measuring overjet and overbite, the
standardized marks on specific teeth were used to evalu-
ate accuracy.
The confocal imaging based scanners, namely iTero®
(IOCs) and the iTero® Element (IOCC), produced the most
accurate results overall with all six interarch measure-
ments within the pre-selected equivalence bounds
(Table 2). Both scanners produced reliable digitally
articulated models although the iTero® scanner showed
less variability than the iTero® Element scanner (Table 3).
Despite both the iTero® and iTero® Element intraoral
scanners use the confocal imaging technology; they
differ in the image acquisition characteristics (Baheti
et al. 2015). While the iTero® Element captures data in
a continuous confocal mode, the iTero® acquires
images in a static confocal mode. Since the bite regis-
tration procedure is same for both scanners, the slight
increase in variability for the iTero® Element scanner
may be attributed to the motion that is introduced
during the image acquisition.
JOURNAL OF ORTHODONTICS 5
Previous Studies
The 3M™ True Definition scanner (IOLED) that uses blue
LED light technology (Baheti et al. 2015) produced con-
sistent, reproducible results (Table 3). However, the
assessments were accurate only in four of the six inter-
arch measurement categories (Table 2). It is possible
that both the scanner to acquire images and the soft-
ware to articulate the maxillary and mandibular arches
play a role in the accuracy of the occlusion. When
using blue LED light technology scanners, a powder
needs to be used for image capturing. Although consist-
ing of fine particles, the powder could adversely affect
the articulation or the software used may not accurately
mesh all scans together. 3M™True Definition does not
recommend any specific software to view the models
produced on their scanner. It is possible that other soft-
wares could result in more accurate occlusions. To fully
determine the impact of the software on the accuracy
of digital images obtained by this scanner, different soft-
ware systems should be used to evaluate the accuracy of
the generated digital articulations.
The VPS bite registration provided a more accurate
articulation compared to wax registration when used
with the Ortho Insight 3D® laser surface scanner (Table
6 J. L. PORTER ET AL.

Figure 5. Bland Altman plots of difference in molar, canine, and incisor tooth measurements for the scanners against the gold standard.

2). The Regisil® bite registration also resulted in less varia- attributed to the thin aluminum sheet in the middle of
bility when compared to the Coprwax ™ bite registration the wax that may have prevented the models from
as shown by smaller standard deviations (Table 3). The closing completely. Incomplete or deviated bite closure
inaccurate bite registration with Coprwax ™ could be may therefore have resulted in less producible and

Table 3. Mean and standard deviation of each measurement by method.

UL1-LL1 UL3-LL3 UL6-LL6 UR1-LR1 UR3-LR3 UR6-LR6
mm ± SD mm ± SD mm ± SD mm ± SD mm ± SD mm ± SD
Gold Standard 9.5 ± 0.32 8.1 ± 0.16 5.3 ± 0.18 10.1 ± 0.19 10.5 ± 0.17 5.2 ± 0.19
EOW 9.5 ± 0.9 8.2 ± 0.76 5.7 ± 0.75 10.2 ± 0.85 10.8 ± 0.66 5.8 ± 0.66
EOPVS 9.7 ± 0.22 8.3 ± 0.15 6 ± 0.23 10.3 ± 0.18 10.9 ± 0.2 5.7 ± 0.41
IOCS 9.7 ± 0.18 8.3 ± 0.17 5.7 ± 0.17 10.3 ± 0.16 10.9 ± 0.19 5.5 ± 0.20
IOCC 9.6 ± 0.2 8.2 ± 0.16 5.6 ± 0.29 10.2 ± 0.22 10.7 ± 0.44 5.4 ± 0.27
IOLED 9.8 ± 0.09 8.5 ± 0.12 5.8 ± 0.22 10.4 ± 0.11 11 ± 0.11 5.6 ± 0.22

Table 4. Equivalence of scanner software programmes used in
the study.
90%CL Mean
Software (0.05 Significance Level Equivalence Test)
Motion View (−0.21, −0.16) Equivalent
MeshLab (0.20, 0.28) Equivalent
OrthoCAD™ (−0.07, 0.05) Equivalent
accurate articulation. Although the distortion of the wax
due to temperature change may also have a factor on
the bite accuracy, this is unlikely to have occurred in
this study due to the well-controlled handling of the
Coprwax ™ during the testing. Another possible expla-
nation for the difference in articulation accuracy
between bite registrations could be due to the ability
of the laser in the extraoral scanner reading the VPS
material in a more accurate manner than the wax. The
software system used may also affect the accuracy of
the model articulation. The Ortho Insight 3D® laser
surface scanner groups may both show some slight inac-
curacies when compared with the gold standard due to
the ability of its software to mesh the acquired image.
Strength and Limitations
Although the three software systems were within the
equivalent bounds, there were slight differences
among them (Table 4). The OrthoCAD™ software was
shown to produce more accurate representations of
the scan than the other softwares tested in this study.
Both the iTero® and iTero® Element scanners were
found to generate the most accurate digital articulations,
and they both use the OrthoCAD™ software. Therefore,
differences between the scanners may be attributed to
measurement errors inherent to the technologies
employed and the software systems used to process
the images. Therefore, the results of this study should
be interpreted with caution because it was not possible
to use the same software to evaluate the accuracy of
the scanners. Another limitation of the study is that the
accuracy of the scanners was evaluated by measuring
points in the vertical dimension only.
Future Studies
In future studies, the accuracy should be evaluated by
using reference points in all dimensions. Further investi-
gations are required to develop standardized and com-
parable methods to evaluate the accuracy of the
intraoral scanners. Overall, within the limits of this
study, it may be concluded that orthodontic digital
models can be used as the new gold standard instead
the plaster models (Fleming et al. 2011; Sakar et al. 2017).
JOURNAL OF ORTHODONTICS 7
Conclusions
. The intraoral scanners that use confocal imaging tech-
nology and OrthoCAD™ software platform (The
iTero® and the iTero® Element) was equivalent to typo-
dont for all 6 interarch measurements, while the
remaining were equivalent for 3–4 of the 6.
. The intraoral scanner with the blue LED light technol-
ogy (3M™ True Definition) and the extraoral scanner
with Regisil® bite registration (Ortho Insight 3D®) gen-
erated the next most accurate articulation of the
digital models (4 of the 6 measurements).
. The extraoral scanner with Coprwax ™ bite regis-
tration (The Ortho Insight 3D®) resulted in the least
accurate articulation of the digital models (3 of the 6
measurements).
Acknowledgment
We thank Davey MacDonald, Al Long, and Hunter Lee for their
help during the data collection for this research project. Dr.
Jason Porter carried out the study. Dr. Eser Tufekci and Dr.
Steven Lindauer provided guidance with the study design
and interpretation of the results. Dr. Carrico performed the stat-
istical analyses.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Caroline K. Carrico http://orcid.org/0000-0001-9521-9854
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