RESEARCH AND EDUCATION

Comparative reproducibility analysis of 6 intraoral scanners

used on complex intracoronal preparations
Ji-Man Park, DDS, MSD, PhD,a Ryan Jin-Young Kim, BDS, MSD, PhD,b and Keun-Woo Lee, DDS, MSD, PhDc

Computer-aided design and ABSTRACT

computer-aided manufacturing
Statement of problem. Although studies have reported the trueness and precision of intraoral
(CAD-CAM) technology has scanners (IOSs), studies addressing the accuracy of IOSs in reproducing inlay preparations are
revolutionized workflow in lacking.
dentistry because of its speed,
Purpose. The purpose of this in vitro study was to compare the accuracy of representative IOSs in
convenience, and accuracy.1-4
obtaining digital scans of inlay preparations and to evaluate whether the IOSs had sufficient depth
Accuracy of definitive restora- of field to obtain accurate images of narrow and deep cavity preparations.
tion fabricated in a fully digital
workflow is a crucial factor Material and methods. Digital scans of a bimaxillary typodont with cavity preparations for inlay
5 restorations on the maxillary first premolar, first and second molar, mandibular second premolar, and
determining clinical success.
first molar were obtained using 6 IOSs (CEREC Omnicam, E4D, FastScan, iTero, TRIOS, and Zfx IntraScan).
When the restoration fails to Standard tessellation language (STL) data sets were analyzed using the 3-dimensional analysis software
seat properly in the cavity, more (Geomagic Verify). Color-coded maps were used to compare the magnitude and pattern of general
time needs to be spent for the deviation of the IOSs with those of a reference scan. Each tooth prepared for inlay restoration was
necessary adjustments. If the digitally cut out, and the trueness and precision of each IOS were measured using the
spacer parameters are set at a superimposition technique. Statistical analyses were conducted using statistical software (a=.05).
high value during the CAD Results. The trueness values were lowest with the FastScan (22.1 mm), followed by TRIOS (22.7 mm),
procedure to allow ease of CEREC Omnicam (23.2 mm), iTero (26.8 mm), Zfx IntraScan (36.4 mm), and E4D (46.2 mm). In general,
seating, large internal and mar- the digital scans of more complicated cavity design showed more deviation. Color-coded maps
ginal gaps occur between the showed positive vertical discrepancy with the E4D and negative vertical discrepancy with the Zfx
tooth and restoration. Poor IntraScan, especially on the cavity floor. Regarding precision, the highest value was observed in
the E4D (37.7 mm), while the lowest value was observed with the TRIOS (7.0 mm). However, no
adaptation jeopardizes longevity significant difference was found between teeth with different inlay preparations. Scanning errors
in indirect restorations,6-11 as were more frequently seen in the cervical area.
large discrepancies may lead to
Conclusions. Different IOSs and types of cavity design influenced the accuracy of the digital scans.
clinical complications such as
Scans of more complex cavity geometry generally showed higher deviation. The E4D exhibited the
secondary caries or periodontal most deviation in both trueness and precision, followed by the Zfx IntraScan. The E4D and Zfx
inflammation due to plaque IntraScan appeared to have less depth of field than the others to obtain digital scans for inlay
accumulation.12,13 preparation with different heights. (J Prosthet Dent 2020;123:113-20)
The accuracy of intraoral
scanners (IOSs) has been described, according to the referring to the closeness of agreement between the
definition 5725-1 of the International Organization for arithmetic mean of a large number of test results and the
Standardization14 by using the following terms: trueness, true or accepted reference value and precision, referring

This study was supported by the Yonsei University College of Dentistry (6-2017-0015).
The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.
J.-M.P. and R.J.-Y.K. contributed equally to this article.
a
Clinical Associate Professor, Department of Prosthodontics, Yonsei University, College of Dentistry, Seoul, Republic of Korea.
b
Assistant Professor, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea.
c
Professor, Department of Prosthodontics, Yonsei University, College of Dentistry, Seoul, Republic of Korea.

THE JOURNAL OF PROSTHETIC DENTISTRY 113

114 Volume 123 Issue 1

manufacturer using precision processing were used to

Clinical Implications eliminate procedural errors in cavity preparation. The
Inaccurate digital scans may contribute to clinically type and position of the cavity preparations were as
follows: occlusal preparation on the maxillary first pre-
relevant discrepancies between the tooth and
molar, mesio-occlusal preparation on the maxillary first
definitive restoration. Clinicians should be aware
molar (MxFM) and maxillary second molars (MxSM),
that the accuracy of digital scans varies, depending
mesio-occluso-distal cavity with a lingual cusp reduction
on the tooth preparation and type of IOS used.
preparation on the mandibular second premolar (MnSP),
and bucco-occlusal preparation on the mandibular first
molar (MnFM) (Fig. 1). After the ideal initial tooth
to agreement between test results. During the fabrication
arrangement was established, none of the teeth were
of CAD-CAM restorations, an error may be introduced in
removed from or added to the master model, and no
the digital scanning procedure with an IOS. Some studies
external forces were applied during the experiment. All
have suggested that digital scans should not be used to
experiments were carried out at 23 ±1  C and 50 ±5%
digitize complete or edentulous arches because of
relative humidity.
distortion.15-19 However, others have reported that dig-
A desktop scanner (Sensable S3; MEDIT) was used to
ital scans acquired using IOSs have better accuracy than
obtain the reference standard tessellation language (STL)
conventional silicone impressions for both single and
data set of the master model. This scanner system had a
multiple-tooth scans.5,20-30 Nonetheless, some clinicians
camera resolution of 1.4 megapixels with an accuracy of
remain skeptical about intraoral digital scanning, and
±0.01 mm. The high capacity (140×140×100 mm) of the
also, the purchasing and managing cost of such digital
scanner system allows scanning of complete-arch casts.
scanning systems remains high.31 In the conventional
In the present study, 6 IOSs were used: the CEREC
indirect restoration procedure, any minor undercuts in
Omnicam (Dentsply Sirona), E4D (D4D Technologies),
the tooth preparation can be addressed by the dental
FastScan (IOS Technologies), iTero (Cadent), TRIOS
laboratory technician. Such undercuts are processed by
(3Shape), and Zfx IntraScan (Zfx GmbH) (Table 1). The
software in CAD-CAM restorations. Studies have shown
accuracy of the IOSs was compared in 2 categories: data
that more accurate scanner readings can be obtained if
capture mode, which compared individual images (E4D,
the scanned surface is smooth and regular.29,32
FastScan, and iTero) with video sequences (CEREC
Deviations in the digital scan are smallest when the
Omnicam, TRIOS, and Zfx IntraScan) and data capture
camera of the IOS is positioned perpendicular to the
principle, which compared accuracy among active trian-
surface being scanned, and the magnitude of deviation
gulation (CEREC Omnicam, FastScan), confocal micro-
increases with the degree of tilt of the camera away from
scopy (iTero, TRIOS, and Zfx IntraScan), and optical
the perpendicular plane.33 However, clinicians must
coherence tomography (E4D). The scanning procedure
manipulate IOSs at various angles and positions relative
was repeated 5 times with each scanner, according to the
to the teeth to adequately acquire a digital scan of an
manufacturers’ instructions.
area. The IOS, being an optical device, has a limited
Inspection software (Geomagic Verify v4.1.0.0.; 3D
depth of field that may vary depending on the system.34
Systems) was used to obtain the trueness and precision
In addition, soft and hard tissues may cause scanning
values of the IOSs. The digital models were modified to
interference.35
remove parts not relevant for measurement, leaving only
The performance of IOSs has been compared by
the teeth with cavity preparations: maxillary first pre-
evaluating the adaptation of the fabricated restora-
molar, MxFM, MxSM, MnSP, and MnFM. The STL data
tion,5,20,22,25-27 and studies have addressed the influence
set of each tooth from each IOS was superimposed onto
of tooth geometry on the accuracy of the IOSs.34-37
the reference data set of the corresponding tooth, which
However, information regarding the effects of cavity
was itself obtained using the reference scanner and a
design on digital scan acquisition by IOSs is sparse. The
best-fit algorithm to evaluate the trueness of the IOS.
purpose of this in vitro study was to investigate the
Color-coded maps were used to observe the magnitude
reproducibility of digital scans of various complex inlay
and pattern of deviation between the reference scanner
preparations using 6 IOSs. The null hypothesis was that
and the digital models acquired by each IOS. To evaluate
no difference would be found in trueness or precision
the precision of the IOSs, the STL data sets from the
among the different cavity types or among the IOSs.
same scanner were superimposed.
Statistical analyses were conducted using statistical
MATERIAL AND METHODS
software (IBM SPSS Statistics, v20.0; IBM Corp) (a=.05).
A typodont with various inlay preparations served as the As the data were not normally distributed, as indicated
master model. Artificial teeth (A50H-Set; J. Morita by the Kolmogorov-Smirnov test, the median trueness
Europe GmbH) that had been prepared by the and precision values of the IOSs, as well as the data

THE JOURNAL OF PROSTHETIC DENTISTRY Park et al

January 2020 115

Figure 1. A, Maxillary master model. B, Mandibular master model. C, Occlusal inlay preparation on maxillary first premolar. D, Mesio-occlusal inlay
preparation on maxillary first molar. E, Mesio-occlusal inlay preparation on maxillary second molar. F, Mesio-occluso-distal inlay preparation with lingual
cusp reduction on mandibular second premolar. G, Bucco-occlusal inlay preparation on mandibular first molar. H-L, Representative digitized model
obtained by reference scanner corresponding to master model. H, Maxillary first premolar. I, Maxillary first molar. J, Maxillary second molar. K,
Mandibular second premolar. L, Mandibular first molar.

Table 1. Intraoral scanners investigated

Light Necessity
System Manufacturer Scanner Technology Source Acquisition Method of Coating
CEREC Omnicam Dentsply Sirona Active triangulation with strip light projection Light Video sequence None
E4D dentist (initial version) E4D Technologies Optical coherence tomography Laser Individual image Occasional
FastScan IOS Technologies, Inc Active triangulation and Scheimpflug principle Laser Individual image Yes
iTero (1st generation) Align Technology Inc Parallel confocal microscopy Red laser Individual image None
TRIOS (2nd generation) 3Shape A/S Confocal microscopy Light Video sequence None
Zfx IntraScan Zfx GmbH Confocal microscopy and Moiree effect detection Laser Video sequence None

capture principle values, were analyzed using a Kruskal-
Wallis test. For the post hoc test, the dependent variable
was converted into the rank variable, and 1-way ANOVA
was conducted, followed by multiple comparisons of the
rank variable by the Tukey honestly significant difference
test.
RESULTS
The median trueness values were in descending order:
E4D (46.2 mm), Zfx IntraScan (36.4 mm), iTero (26.8 mm),
CEREC Omnicam (23.2 mm), TRIOS (22.7 mm), and
FastScan (22.1 mm). The trueness values of the CEREC
Omnicam, FastScan, and TRIOS did not differ signifi-
cantly, but these scanners did show significantly lower
trueness values than the iTero, E4D, and Zfx IntraScan,
except between the CEREC Omnicam and iTero; the E4D
exhibited significantly higher trueness value than the Zfx
IntraScan, which showed significantly higher trueness
value than the iTero (P<.05) (Table 2; Fig. 2). Among the
cavity types, the smallest deviations were found in the
MxSM with the mesio-occlusal inlay preparation (22.3
mm) and in the MnFM with the bucco-occlusal inlay
preparation (25.2 mm). These values were significantly

Park et al THE JOURNAL OF PROSTHETIC DENTISTRY

116 Volume 123 Issue 1

Table 2. Comparison of trueness among intraoral scanners depending on tooth position and cavity design
MxFP MxFM MxSM MnSP MnFM
Variable N Median (Q1-Q3) Total df Chi-Square P
CEREC Omnicam 5 21.9 (19.2-29.0) 28.7 (28.2-29.2) 18.6 (18.4-19.9) 27.1 (26.4-32.3) 22.6 (22.1-24.0) 23.2 CD (20.5-28.7) 4 16.541 .002
E4D 5 50.1 (46.0-61.7) 44.1 (38.2-53.9) 50.6 (37.7-56.3) 40.2 (38.0-44.3) 46.2 (43.7-48.7) 46.2 A (42.5-51.0) 4 6.628 .157
FastScan 5 22.1 (20.8-27.3) 21.6 (19.9-24.5) 18.7 (16.4-23.4) 24.5 (22.1-25.4) 24.8 (21.2-25.2) 22.1 D (20.5-25.1) 4 5.271 .261
iTero 5 25.3 (21.5-28.6) 24.4 (22.8-30.9) 23.6 (20.1-29.8) 34.9 (34.6-35.4) 30.6 (26.9-32.9) 26.8 C (23.5-34.3) 4 12.374 .015
TRIOS 5 20.3 (18.5-21.0) 24.4 (23.5-25.0) 14.3 (13.7-16.3) 30.7 (29.1-30.9) 23.2 (22.1-24.9) 22.7 D (18.5-25.4) 4 22.116 <.001
Zfx IntraScan 5 40.3 (32.8-41.1) 38.9 (36.4-50.2) 35.8 (30.2-36.3) 34.3 (30.9-45.5) 33.5 (25.4-42.8) 36.4 B (91.0-41.1) 4 4.416 .353
Total 26.0 ab (20.8-40.4) 28.2 ab (24.0-37.3) 22.3 b (17.4-34.4) 31.2 a (27.1-36.0) 25.2 ab (22.6-36.1) 27.0 (22.3-36.0)
df 5 5 5 5 5
Chi-square 21.842 23.725 24.114 23.208 18.598
P .001 <.001 <.001 <.001 .002

df, degrees of freedom; MnFM, mandibular first molar with bucco-occlusal cavity; MnSP, mandibular second premolar with mesio-occluso-distal cavity and lingual cusp reduction; MxFP,
maxillary first premolar with occlusal cavity; MxFM, maxillary first molar with mesio-occlusal cavity; MxSM, maxillary second molar with mesio-occlusal cavity; P, P-value by Kruskal-Wallis test.
Different uppercase letters within same column indicate statistical difference between IOSs; different lowercase letters within same row indicate statistical difference among cavity designs
(multiple comparison by Tukey honestly significant difference test) (P<.05).

Trueness Precision Trueness Precision

CEREC
CD * C MxFP ab * * a
Omnicam
Intraoral Scanner

E4D A A
MxFM ab a
FastScan D B
Tooth

MxSM b a
iTero C C
*
MnSP a a
TRIOS D D
Zfx MnFM ab a
B A
IntraScan

0 20 40 60 80 0 50 100 150 µm 0 20 40 60 80 0 50 100 150 µm

Deviation Deviation
Figure 2. Overall trueness and precision of each intraoral scanner. Figure 3. Trueness and precision of each intraoral scanner for each tooth
Different letters on right of each diagram indicate statistical difference type. Different letters on right of each diagram indicate statistical difference
between groups (multiple comparison by Tukey honestly significant between groups (multiple comparison by Tukey honestly significant
difference test) (P<.05). difference test) (P<.05). MnFM, mandibular first molar with bucco-occlusal
cavity; MnSP, mandibular second premolar with mesio-occluso-distal cavity
smaller than those of the MnSP with an onlay prepara- and lingual cusp reduction; MxFP, maxillary first premolar with occlusal
tion (31.2 mm) (Table 2; Fig. 3). In the comparison be- cavity; MxFM, maxillary first molar with mesio-occlusal cavity; MxSM,
tween data capture principles, optical coherence tomog- maxillary second molar with mesio-occlusal cavity.
raphy showed significantly higher trueness value and
active triangulation, significantly lower trueness value,
regardless of the cavity type. The E4D showed a positive
than systems that used the confocal microscopy principle
deviation, whereas the digital casts obtained by the Zfx
(P<.05). Video sequence data capture showed greater
IntraScan presented a negative deviation. All IOSs pro-
trueness value than individual image data capture (P<.05)
duced occasional scanning errors in the cervical area,
(Table 3).
such as voids and irregularities (dimples and nodules),
Regarding precision, significant differences were
especially around the box areas of the cavities. Scanning
found among all the IOSs; the E4D exhibited the highest
errors were more marked and frequent in the E4D
value (37.7 mm), followed by the Zfx IntraScan (34.2 mm),
(Fig. 5).
FastScan (20.0 mm), iTero (12.0 mm), CEREC Omnicam
(9.4 mm), and TRIOS (7.0 mm) (P<.05) (Table 4; Fig. 2).
DISCUSSION
The cavity types did not affect the precision of the overall
IOSs (P>.05). To date, the accuracy of IOSs has been evaluated
The representative deviation patterns of the digital for intraoral digital scans of single tooth scans,23,24,29
casts of each tooth are presented in Figure 4. All IOSs multiple-tooth scans,24,28,30 complete arches,16-19,35 and
tested showed a similar deviation pattern, except for the edentulous jaws.15 The present study primarily evaluated
E4D and Zfx IntraScan, which showed noticeable devi- the performance of various IOSs by individually
ation, especially around the intracoronal cavities, comparing their trueness and precision in obtaining a

THE JOURNAL OF PROSTHETIC DENTISTRY Park et al

January 2020
Table 3. Comparison of trueness by data capture principle and mode
Variable N Median (Q1-Q3)
Data capture principle
Confocal microscopy 75
Triangulation 50
Optical coherence tomography 25
Total
Chi-square
P <.001
Data capture mode
Individual images 75
Video sequence 75
Total
P .049
P, P-value by Kruskal-Wallis test. Different letters indicate statistical difference among
groups (multiple comparison by Tukey honestly significant difference test) (P<.05).
digital scan of a master model with different cavity types
designed for inlay restoration. There were significant
differences in the trueness and precision values of the 6
IOSs, leading to rejection of the null hypothesis. The
order of trueness and precision of the IOSs corroborated
a previous study, which evaluated the accuracy of IOSs in
the digitization of a complete arch.35 The present study
indicated that the E4D performs less accurately than the
other IOSs, followed by the Zfx IntraScan, irrespective of
the type of cavity being scanned.
The success of a restoration is affected by the amount
of discrepancy between the tooth and the restora-
tion.6-8,12,13 As a CAD-CAM restoration is milled from a
digital cast obtained by optical scanning, any deviation
from the real structure precludes fabrication of a well-
fitting restoration. In the present study, color-coded
maps obtained using each IOS were compared with
those obtained using the reference scanner to visualize
the pattern and amount of deviation of each scanner’s
digital scans. Such color-coded maps have been used in
previous studies to evaluate complete-arch digital
scans.16,17 These studies showed a general deviation pattern
for the whole arch. Specifically, IOSs become less accurate
as the length of the scanning arch increases because regis-
tration errors accumulate.37 Therefore, long span digital
scans cannot objectively compare the effects of various
cavity designs on each individual tooth. An increase in the
length of scanning arch has been shown to impair the
accuracy of the digital scan because of an accumulation of
errors in the registration of overlapping images.
In the present study, digital casts were analyzed after
precise isolation of each individual tooth, thus elimi-
nating any inherent deviation associated with arch
distortion due to long span scanning. Notably, intra-
coronal cavity preparations showed distinct deviation in
the E4D and Zfx IntraScan: the E4D with a positive de-
viation (shown in red) and the Zfx IntraScan with a
negative deviation (shown in blue on the color-coded
map). However, both IOSs showed the opposite
Park et al
117
deviation at the unprepared tooth surfaces. The absolute
deviation may exceed 100 mm, as the range of the color-
coded map was set from −100 mm to +100 mm. Thus, it
29.2 B (22.9-34.9) seems that neither IOS can detect the complex geome-
22.6 C (20.6-26.3)
tries of the inlay preparations with sufficient accuracy. If
46.2 A (42.5-51.0)
restorations were fabricated from the digitized casts, the
27.1 (22.3-36.0)
E4D would lead to a thinner restoration, increasing the
63.578
risk of fracture and leaving a large interfacial discrepancy.
This space would be filled with a thicker layer of cement,
26.8 B (22.9-42.8)
which could compromise restoration retention.11 In
27.1 A (21.7-34.3) addition, greater shrinkage stress generated during
27.1 (22.3-36.0) polymerization by the increased amount of resin cement
may cause debonding at the interface between the tooth
and the cement. Interfacial debonding may cause post-
operative sensitivity, especially upon mastication, mar-
ginal discoloration, and secondary caries,9 principle
reasons for restoration failure.10 Unlike the E4D, resto-
rations fabricated with the Zfx IntraScan would be ill-
fitting and have premature contact with the opposing
tooth. For this reason, more time would likely be spent
on occlusal adjustment of the restorationdunless the
spacer parameter was adjusted.
Noticeable scanning deficiencies or defects, such as
voids or irregularities, were observed toward the cervical
area, particularly in the digital casts acquired using the
E4D. Inaccuracy in the registration of areas being scan-
ned in the E4D was consistent with that reported in the
study by Nedelcu and Persson,23 who reported that the
E4D lacked clearly defined transition areas, showing the
largest deviation and greater amount of noise. The Zfx
IntraScan tended toward inadequate patching of uncap-
tured areas, even though the distortion was smaller than
that of the E4D. It may be that the E4D and Zfx IntraScan
have an insufficient depth of field and are, thus, unable to
capture all the surfaces of different heights in sharp focus.
In contrast, the overall accuracy of the FastScan was not
significantly affected, even though it presented unscan-
ned areas, perhaps because it possesses better software.
Regarding the influence of the cavity types on repro-
ducibility, the overall effect of cavity types on trueness
differed significantly, while there was no significant differ-
ence in the precision values. The master model had different
cavity types, including occlusal cavity, proximal or buccal box
cavity with an occlusal extension, and an onlay cavity outline
with proximal boxes and cusp reduction, in the order of the
complexity of the geometric features. Typically, deviation
occurred more frequently and at greater magnitude when
scanning a more complex cavity. Besides the type of scanner
system, limited scanning angle and restricted access are
considered as factors that influence the accuracy of
IOSs.23,31 The digital models of the MnSP, which had a
complicated onlay preparation, showed significantly greater
deviation from the reference cast than those of the other
teeth. However, there was a tendency, although not sta-
tistically significant, for the occlusal cavity to show higher
THE JOURNAL OF PROSTHETIC DENTISTRY
118 Volume 123 Issue 1

Table 4. Comparison of precision among intraoral scanners depending on tooth position with various inlay preparations
MxFP MxFM MxSM MnSP MnFM
Variable N Median (Q1-Q3) Total df Chi-Square P
CEREC Omnicam 10 14.1 (7.8-18.2) 10.1 (8.9-10.9) 8.7 (7.6-10.1) 8.8 (8.0-14.3) 9.2 (8.7-9.9) 9.4 C (8.3-11.5) 4 6.723 .151
E4D 10 43.2 (33.4-106.5) 36.6 (30.8-62.7) 40.7 (36.0-78.5) 31.6 (22.1-56.1) 34.7 (28.6-78.0) 37.7 A (30.8-67.1) 4 4.844 .304
FastScan 10 23.8 (20.5-25.3) 20.9 (19.4-24.5) 26.4 (19.6-35.9) 18.2 (14.4-23.5) 15.7 (13.9-20.0) 20.5 B (17.0-25.1) 4 15.109 .004
iTero 10 13.4 (11.3-13.8) 16.2 (12.0-22.8) 13.8 (11.5-16.3) 9.9 (7.9-12.5) 9.3 (7.3-9.5) 12.0 C (9.5-13.9) 4 25.997 <.001
TRIOS 10 7.5 (6.2-9.3) 7.7 (5.7-10.9) 7.0 (5.9-12.7) 6.0 (5.1-10.0) 5.2 (4.4-11.3) 7.0 D (5.4-10.4) 4 3.063 .547
Zfx IntraScan 10 34.2 (27.6-35.2) 37.7 (32.9-43.6) 32.3 (23.9-34.2) 42.1 (31.0-49.7) 35.3 (26.1-46.0) 34.2 A (28.2-40.9) 4 8.320 .081
Total 18.4 a (10.3-33.0) 19.7 a (10.4-30.9) 15.7 a (9.8-34.2) 14.4 a (8.9-28.9) 12.3 a (9.0-28.4) 15.7 (9.5-31.0)
df 5 5 5 5 5
Chi-square 44.705 44.659 42.714 47.783 47.197
P <.001 <.001 <.001 <.001 <.001

df, degrees of freedom; MnFM, mandibular first molar with bucco-occlusal cavity; MnSP, mandibular second premolar with mesio-occluso-distal cavity and lingual cusp reduction; MxFP,
maxillary first premolar with occlusal cavity; MxFM, maxillary first molar with mesio-occlusal cavity; MxSM, maxillary second molar with mesio-occlusal cavity; P, P-value by Kruskal-Wallis test.
Different uppercase letters within same column indicate statistical difference between IOSs; different lowercase letters within same row indicate statistical difference among cavity designs
(multiple comparison by Tukey honestly significant difference test) (P<.05).

Figure 4. Deviation between digital casts acquired by each intraoral scanner and reference scanner. Range of deviation color coded from −100 mm
(blue) to +100 mm (red). MnFM, mandibular first molar with bucco-occlusal cavity; MnSP, mandibular second premolar with mesio-occluso-distal cavity
and lingual cusp reduction; MxFP, maxillary first premolar with occlusal cavity; MxFM, maxillary first molar with mesio-occlusal cavity; MxSM, maxillary
second molar with mesio-occlusal cavity.

trueness values than the box cavity. The occlusal cavity was
not as deep as the box cavity, but the narrower width of the
occlusal cavity may be perhaps related to an increased de-
viation during scanning procedure. The overall trueness was
better when scanning the mesio-occlusal inlay preparation
on the MxSM, even though there was a relatively deep and
narrow proximal box cavity. The trueness values of the
digital models of the MxFM were greater than those of the
digital models of the MxSM, even though both had a similar
cavity design, perhaps because, with the MxSM, the buc-
colingual dimension of the proximal box cavity was wider
and thus provided more room for scanning the internal

THE JOURNAL OF PROSTHETIC DENTISTRY Park et al

January 2020
Figure 5. Representative digital cast showing frequently observed imperfect surfaces in dotted outlines.
cavity surfaces. As the trueness values were relatively low
when scanning the teeth with the proximal box, the depth of
field of the IOSs appeared to be adequate at the given cavity
heights.
Regarding the data capture principle, the IOSs that
used active triangulation were significantly more accurate
than those that used other scanning principles, while
optical coherence tomography showing the least accuracy
in reproducing the master model. However, it may not be
possible to extrapolate these data because the E4D was
the only IOS in the present study that used optical
coherence tomography. Moreover, even though the
TRIOS, which uses confocal microscopy, exhibited the
best accuracy in terms of both trueness and precision,
the overall accuracy of confocal microscopy was affected
because the second least accurate IOSdthe Zfx
IntraScandoperates at a similar data capture principle.
Therefore, the present study was inconclusive regarding
which scanning principle is the most effective, because
the IOSs used different data acquisition technologies and
different types of data processing software.
Studies have reported that the accuracy of IOSs
is comparable or superior to conventional silicone im-
pressions, except in the case of complete-arch
impression.5,17-22,25-29 In this regard, superimposition
Park et al
119
has been used to compare the accuracy of digital scan-
ning with that of conventional impressions. To obtain a
digital cast using conventional impressions, stone casts
of a reference complete-arch model were scanned.19
However, tears or distortion in the undercuts of con-
ventional impression materials, particularly at the inter-
proximal embrasures, can result in a distorted stone cast.
In addition, dimensional change in the stone is inevitable
during setting. To minimize bias related to measurement
error caused by these distortions, conventional impres-
sion material was not included in this study. An in vitro
reference model was scanned to solely examine variables
related to the types of cavity and IOSs.
This in vitro study has limitations because the accu-
racy of the IOSs may be influenced by patient factors,
such as obstacles to ideal positioning of the scanners due
to patient movement, limited mouth opening, and
interference by the tongue, lips, and cheeks. Further-
more, the effects of blood, saliva, and crevicular fluid
were not considered. In addition, operator skills and
experience may affect clinical outcomes. A valid com-
parison could not be made since the authors are unaware
of studies that reported the influence of different types of
preparations on the accuracy of IOS. In future studies,
cavity depth should be varied to provide a better
THE JOURNAL OF PROSTHETIC DENTISTRY
120
understanding of the limitations of the IOSs with regard
to depth of field, and the same teeth used with different
cavity types for a direct comparison of the effect of the
cavity types on the accuracy.
Despite the limitation of the small sample size, the
present study demonstrated the general trend of the
accuracy of IOSs with various inlay cavity designs.
Therefore, it could serve as the basis for further
comparative evaluation to determine whether IOS ac-
curacy can be affected by the location of a cavity. Future
studies could measure specific points of interestdfor
example, along the margin and internal surfaces.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. Different IOSs and types of cavity design influenced
the accuracy of the digital scans (P<.05).
2. Scans of more complex cavity geometry generally
showed higher deviation (P<.05).
3. The E4D exhibited the most deviation in both trueness
and precision, followed by the Zfx IntraScan. The E4D
and Zfx IntraScan appeared to have less depth of field
to obtain digital scans for inlay preparation with
different heights than the others (P<.05).
REFERENCES
1. Gjelvold B, Chrcanovic BR, Korduner EK, Collin-Bagewitz I, Kisch J. Intraoral
digital impression technique compared to conventional impression tech-
nique. A randomized clinical trial. J Prosthodont 2016;25:282-7.
2. Park JM, Kim J, Shim JS. Review of computer-assisted implant surgeries:
navigation surgery system vs. computer-guided implant template vs. robot.
Implantology 2018;22:50-68.
3. Lim JH, Park JM, Kim M, Heo SJ, Myung JY. Comparison of digital intraoral
scanner reproducibility and image trueness considering repetitive experience.
J Prosthet Dent 2018;119:225-32.
4. Kim J, Park JM, Kim M, Heo SJ, Shin IH, Kim M. Comparison of experience curves
between two 3-dimensional intraoral scanners. J Prosthet Dent 2016;116:221-30.
5. Rodiger M, Heinitz A, Burgers R, Rinke S. Fitting accuracy of zirconia single
crowns produced via digital and conventional impressions-a clinical
comparative study. Clin Oral Investig 2017;21:579-87.
6. Keshvad A, Hooshmand T, Asefzadeh F, Khalilinejad F, Alihemmati M, Van
Noort R. Marginal gap, internal fit, and fracture load of leucite-reinforced
ceramic inlays fabricated by CEREC inLab and hot-pressed techniques.
J Prosthodont 2011;20:535-40.
7. Schaefer O, Decker M, Wittstock F, Kuepper H, Guentsch A. Impact of digital
impression techniques on the adaption of ceramic partial crowns in vitro.
J Dent 2014;42:677-83.
8. Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture.
Review of the clinical survival of direct and indirect restorations in posterior
teeth of the permanent dentition. Oper Dent 2004;29:481-508.
9. Ferracane JL. Developing a more complete understanding of stresses produced
in dental composites during polymerization. Dent Mater 2005;21:36-42.
10. Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons
for failure. J Adhes Dent 2001;3:45-64.
11. Wiskott HW, Belser UC, Scherrer SS. The effect of film thickness and surface
texture on the resistance of cemented extracoronal restorations to lateral
fatigue loading. Int J Prosthodont 1999;12:255-62.
12. Addi S, Hedayati-Khams A, Poya A, Sjogren G. Interface gap size of
manually and CAD/CAM-manufactured ceramic inlays/onlays in vitro. J Dent
2002;30:53-8.
13. Kois JC. The restorative-periodontal interface: biological parameters.
Periodontol 2000 1996;11:29-38.
14. International Organization of Standardization. ISO 5725-1. Accuracy (true-
ness and precision) of measurement methods and results. Part 1: General
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 123 Issue 1
principles and definitions. Geneva: ISO; 1994. Available at: https://www.iso.
org/obp/ui/#iso:std:iso:5725:-1:ed-1:v1:en.
15. Patzelt SB, Vonau S, Stampf S, Att W. Assessing the feasibility and accuracy
of digitizing edentulous jaws. J Am Dent Assoc 2013;144:914-20.
16. Patzelt SB, Emmanouilidi A, Stampf S, Strub JR, Att W. Accuracy of full-arch
scans using intraoral scanners. Clin Oral Investig 2014;18:1687-94.
17. Ender A, Mehl A. Accuracy of complete-arch dental impressions: a new
method of measuring trueness and precision. J Prosthet Dent 2013;109:121-8.
18. Ender A, Attin T, Mehl A. In vivo precision of conventional and digital
methods of obtaining complete-arch dental impressions. J Prosthet Dent
2016;115:313-20.
19. Ender A, Mehl A. In-vitro evaluation of the accuracy of conventional and
digital methods of obtaining full-arch dental impressions. Quintessence Int
2015;46:9-17.
20. Su TS, Sun J. Comparison of marginal and internal fit of 3-unit ceramic fixed
dental prostheses made with either a conventional or digital impression.
J Prosthet Dent 2016;116:362-7.
21. Shembesh M, Ali A, Finkelman M, Weber HP, Zandparsa R. An in vitro
comparison of the marginal adaptation accuracy of CAD/CAM restorations
using different impression systems. J Prosthodont 2017;26:581-6.
22. Abdel-Azim T, Rogers K, Elathamna E, Zandinejad A, Metz M, Morton D.
Comparison of the marginal fit of lithium disilicate crowns fabricated with
CAD/CAM technology by using conventional impressions and two intraoral
digital scanners. J Prosthet Dent 2015;114:554-9.
23. Nedelcu RG, Persson AS. Scanning accuracy and precision in 4 intraoral
scanners: an in vitro comparison based on 3-dimensional analysis. J Prosthet
Dent 2014;112:1461-71.
24. Mehl A, Ender A, Mormann W, Attin T. Accuracy testing of a new intraoral
3D camera. Int J Comput Dent 2009;12:11-28.
25. Pradies G, Zarauz C, Valverde A, Ferreiroa A, Martinez-Rus F. Clinical
evaluation comparing the fit of all-ceramic crowns obtained from silicone and
digital intraoral impressions based on wavefront sampling technology. J Dent
2015;43:201-8.
26. Sakornwimon N, Leevailoj C. Clinical marginal fit of zirconia crowns and
patients’ preferences for impression techniques using intraoral digital scanner
versus polyvinyl siloxane material. J Prosthet Dent 2017;118:386-91.
27. Seelbach P, Brueckel C, Wostmann B. Accuracy of digital and conventional
impression techniques and workflow. Clin Oral Investig 2013;17:1759-64.
28. Guth JF, Runkel C, Beuer F, Stimmelmayr M, Edelhoff D, Keul C. Accuracy of
five intraoral scanners compared to indirect digitalization. Clin Oral Investig
2017;21:1445-55.
29. Gonzalez de Villaumbrosia P, Martinez-Rus F, Garcia-Orejas A, Salido MP,
Pradies G. In vitro comparison of the accuracy (trueness and precision) of six
extraoral dental scanners with different scanning technologies. J Prosthet
Dent 2016;116:543-50.e1.
30. Ender A, Zimmermann M, Attin T, Mehl A. In vivo precision of conventional
and digital methods for obtaining quadrant dental impressions. Clin Oral
Investig 2016;20:1495-504.
31. Mangano F, Gandolfi A, Luongo G, Logozzo S. Intraoral scanners in
dentistry: a review of the current literature. BMC Oral Health 2017;17:149.
32. Rudolph H, Luthardt RG, Walter MH. Computer-aided analysis of the in-
fluence of digitizing and surfacing on the accuracy in dental CAD/CAM
technology. Comput Biol Med 2007;37:579-87.
33. Kurz M, Attin T, Mehl A. Influence of material surface on the scanning error
of a powder-free 3D measuring system. Clin Oral Investig 2015;19:2035-43.
34. Park JM. Comparative analysis on reproducibility among 5 intraoral scanners:
sectional analysis according to restoration type and preparation outline form.
J Adv Prosthodont 2016;8:354-62.
35. Kim RJ, Park JM, Shim JS. Accuracy of 9 intraoral scanners for complete-arch
image acquisition: qualitative and quantitative evaluation. J Prosthet Dent
2018;120:895-903.e1.
36. Bohner LOL, De Luca Canto G, Marcio BS, Lagana DC, Sesma N, Tortamano
Neto P. Computer-aided analysis of digital dental impressions obtained from
intraoral and extraoral scanners. J Prosthet Dent 2017;118:617-23.
37. Carbajal Mejia JB, Wakabayashi K, Nakamura T, Yatani H. Influence of
abutment tooth geometry on the accuracy of conventional and digital
methods of obtaining dental impressions. J Prosthet Dent 2017;118:392-9.
Corresponding author:
Dr Keun-Woo Lee
Department of Prosthodontics
Yonsei University, College of Dentistry
50-1 Yonsei-ro, Seodaemun-gu, Seoul
REPUBLIC OF KOREA
Email: kwlee@yuhs.ac
Acknowledgments
The authors thank Pf. Im Hee Shin for providing statistical analysis for this study.
Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2018.10.025
Park et al