DIGITAL DENTAL

TECHNOLOGIES
Comparison of the Accuracy of Optical Impression
Systems in Three Different Clinical Situations
Maria Doukantzi, Dr Med Dent
Division of Fixed Prosthodontics and Biomaterials, University Clinics of Dental Medicine, University of Geneva,
Geneva, Switzerland.

Philippe Mojon, Dr Med Dent

Division of Fixed Prosthodontics and Biomaterials, Division of Gerodontology and Removable Prosthodontics,
University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland.

Ana Todorovic, Dr Med Dent

Division of Fixed Prosthodontics and Biomaterials, University Clinics of Dental Medicine, University of Geneva,
Geneva, Switzerland; Division of Prosthodontics, Faculty of Dental Medicine, University of Belgrade, Belgrade,
Serbia.

Najla Chebib, Dr Med Dent

Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of
Geneva, Geneva, Switzerland.

Bjarni Elvar Pjetursson, Prof Dr Med Dent, PhD

Division of Fixed Prosthodontics and Biomaterials, University Clinics of Dental Medicine, University of Geneva,
Geneva, Switzerland; Division of Reconstructive Dentistry, Faculty of Odontology, University of Iceland,
Reykjavik, Iceland.

Sabrina Maniewicz, Dr Med Dent

Division of Gerodontology and Removable Prosthodontics, University Clinics of Dental Medicine, University of
Geneva, Geneva, Switzerland.

Irena Sailer, Prof Dr Med Dent

Division of Fixed Prosthodontics and Biomaterials, University Clinics of Dental Medicine, University of Geneva,
Geneva, Switzerland.

Purpose: To investigate the differences in accuracy (ie, trueness and precision) of five different optical
impression systems. Materials and Methods: The accuracy of the following optical impression systems was
tested: (1) CEREC Bluecam (BL); (2) CEREC Omnicam (OM); (3) PlanScan (PL); (4) True Definition Scanner (TD); and
(5) Trios 3 (TR). A standard plastic study model represented a patient with a fully dentate maxilla. Three clinical
situations were simulated: Patient 1 (P1): fully dentate; Patient 2 (P2): anterior partial edentulism (two missing
incisors); and Patient 3 (P3): posterior partial edentulism (missing premolar and molar). The models were scanned
with a reference scanner (IScan D104i), and the digitized models were used as reference for all comparisons.
Then, optical impressions were made for the three clinical scenarios (n = 10 per group). Results: In situation
P1, the TD group provided the highest trueness (median ± SD root mean square: 180.2 ± 46.3 μm). In situation
P2, the highest trueness was found in the TD (97.9 ± 27.6 μm) and TR (105 ± 9.5 μm) groups, and in situation
P3, TR had the highest trueness (P < .05; 76.2 ± 5.6 μm). TR provided the highest precision (P < .05) in all three
clinical situations, with RMS values of 76.7 ± 26 μm for P1, 46.8 ± 14.1 μm for P2, and 39.7 ± 9.1 μm for P3.
Conclusion: Two optical impression systems (TR and TD) were superior to the other tested systems in most of
the measurements. However, none of the tested systems was clearly superior with respect to both trueness and
precision. Int J Prosthodont 2021;34:511–517. doi: 10.11607/ijp.6748

Correspondence to:

D
Dr Irena Sailer
igital impression systems, today known as the intraoral scanner (IOS), were Division of Fixed Prosthodontics
introduced in dentistry in the 1980s. Since Duret’s initial conception of the and Biomaterials
University Clinics for
digital workflow encompassing an optical impression and the completely digital Dental Medicine
development of a single-unit reconstruction, substantial evolution has occurred in University of Geneva, Switzerland
the area of digital dentistry. Nowadays, manufacturers are able to provide the dental Rue Michel – Servet 1
1206 Geneva, Switzerland
community with technology that enables practitioners to take digital impressions even Email: irena.sailer@unige.ch
in more complicated clinical situations, such as in the presence of dental implants or
for carrying out more complex full-arch rehabilitations.1–4 In the last 30 years, digital Submitted October 3, 2019;
accepted July 1, 2020.
dental technology has evolved continuously, with a growing number of manufactur- ©2021 by Quintessence
ers offering new IOS systems.2,5 Optical impression-taking is currently already part of Publishing Co Inc.

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 Digital Dental Technologies
the daily clinical procedures of many dentists, and the
IOS is an integral part of the equipment of the modern
dental office.5
The use of 3D cameras offers many advantages over
conventional impressions using elastomeric impression
materials, both for the patient and the dentist.6 Indeed,
several studies have demonstrated a higher efficiency of
the digital process compared to the conventional one.7,8
In addition, IOS systems may be an additional asset for
patient communication, as they provide an intraoral
image immediately visible on a screen and can assist
in diagnosis and treatment planning. They may also
facilitate the everyday life of the practitioner by offering
the possibility of easily erasing and repeating a specific
part of an impression, by controlling the final result of a
preparation or restoration with analysis tools, or by easily
storing patient data. Finally, the risk of cross-infection
with the laboratory is eliminated with the use of optical
impressions, and a better collaboration between the
clinician and the technician can be established thanks
to facilitated communication.2
IOS systems and the associated CAD/CAM techniques
have changed the workflow process in restorative den-
tistry, nowadays called the “digital workflow.” In this
new digital workflow, a 3D camera is used to capture the
intraoral situation—namely the tooth surfaces, as well as
the surrounding soft tissues. A 3D digital model of the
patient’s arch is thus directly created, thereby eliminating
the need for a physical model for the manufacturing of
a restoration.9 Through the use of a virtual model and
a CAD/CAM software, chairside single-unit restorations
may be achieved in a single session. In more complex
cases where a physical working model is needed, the
latter can be fabricated from the virtual file using rapid
prototyping technology.10–12
In restorative dentistry, an accurate impression
remains a crucial factor for the production of a
well-fitting restoration.13 It is therefore necessary to
determine the reliability of the IOS systems available
on the market. The accuracy of an impression method
is described by the combination of two measures:
trueness and precision (ISO 5725).14 Trueness is the
comparison between each impression tested and the
original geometry, thus representing the proximity
of the impression to the real geometry. Precision de-
scribes the differences between the impressions within
a test group and represents reproducibility; ie, the
frequency with which the same impression is achieved
with the same outcome.12,14
To date, impression-taking with elastomeric impression
materials remains the gold standard.13 Numerous in vitro
studies have compared the accuracy of conventional elas-
tomeric impressions to that of digital impressions,15–17
proving the performance of an IOS is compatible with
clinical requirements.6,17,18
512 The International Journal of Prosthodontics
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In recent years, dental manufacturers have introduced
many new IOS systems, and practitioners’ interest in
optical impression systems has increased. Different IOS
systems, design software, and milling machines are in-
troduced to the dental market every year. In this new
era of digital dentistry, where the clinical lives of dentists
and dental technicians are constantly changing, many
questions remain unanswered. It is therefore essential
to assess whether differences in accuracy exist among
the new digital impression devices, and if so, which ones
are the most accurate.
Therefore, the objective of this in vitro study was to
evaluate the differences in accuracy (ie, trueness and
precision) of five different digital impression systems. The
null hypothesis was that all digital impression systems
are equally accurate and that there are no statistically
significant differences in accuracy when used in different
clinical situations.
MATERIALS AND METHODS
In the present study, five optical impression systems
were evaluated, and their accuracy was compared to a
well-established reference scanner recommended for
high-accuracy scanning of dental models (IScan D104i,
Imetric).19
Validation of the Reference Scanner
The accuracy of the laboratory scanner selected as the
reference scanner for this study was evaluated by using
it to scan a reference object for which the precise dimen-
sions were known and provided by the manufacturer
(Brick 2 × 4, Lego).
For the assessment of precision, the Lego brick was
scanned 10 times, and the 10 obtained data files were
saved in standard tessellation language (STL) format. A
dedicated 3D inspection software (Geomagic Control X,
3D Systems) was used to compare the 10 STIL files by
pairs. The 3D comparison was performed by superim-
posing each pair of STL data files (n = 45 comparisons)
according to the best fit method, where all possible
orientations are calculated and the one with the best
volume/object-to-object combination is selected. The
3D differences for each point of the two surfaces were
calculated, and the root mean square (RMS), used to
represent the difference between the two scans, was
computed by the software with the following formula:
n (x1i – x2i)2
i=1
n
The trueness of the reference scanner was evaluated
using an analysis software (OraCheck, Cyfex) to measure
the length of the Lego brick on the scans. The average
 Doukantzi et al

value obtained from the 10 scans was compared to the Table 1   Tested Intraoral Scanners and Their
exact dimensions provided directly by the manufacturer. Characteristics
Surface Scanning technology
Scanner preparation principle
Reference Models
The chosen reference model for the experiment was a Cerec Bluecam Powder Triangulation/single image
(Dentsply Sirona)
standard plastic study model (ANA-4V, Frasaco) used to
represent a maxillary dental arch. Three clinical situations Cerec Omnicam None Triangulation/continuous
(Dentsply Sirona) images
were simulated by modifying the configuration of the
PlanScan None Triangulation/continuous
dentition on the study model. A clinical situation of a (Planmeca) images
patient with a full arch was simulated by using the model
True Definition Powder Active wavefront
in its fully dentate state (Patient 1 [P1]). Two clinical situa- (3M ESPE) Sampling/continuous
tions of patients presenting with partial edentulism were images
created by removing specific teeth on the study model. Trios 3 (3Shape) None Confocal microscopy
An anterior gap situation was simulated by removing Laser/continuous images
adjacent lateral and central incisors, creating a two-unit
anterior gap (Patient 2 [P2]), while a two-unit poste-
rior gap was created by removing an adjacent second
premolar and first molar (Patient 3 [P3]). The reference thereafter superimposed using the best fit method. The
model was scanned for each of the situations with the 3D differences were calculated, and the RMS was used
laboratory reference scanner, and the scan data were to evaluate the compliance of the tested superimposed
saved in STL format (REF 1–3, respectively). data.

Tested Intraoral Scanners Analysis of Accuracy

Five commonly used optical impression systems present-
ing with different characteristics were selected for this
in vitro study (Table 1): (1) Cerec Bluecam (BL; Dentsply
Sirona); (2) Cerec Omnicam (OM; Dentsply Sirona); (3)
PlanScan (PL; Planmeca); (4) True Definition (TD; 3M
ESPE); and (5) Trios 3 (TR; 3Shape).
Digital Impressions
The three simulated patient situations were scanned
using the five selected IOS systems, starting with P1, fol-
lowed by P2, and then P3. The digital impressions were
taken according to each manufacturer’s instructions
concerning scanning path strategy as well as surface
preparation. Ten digital impressions were made (n = 10)
for each model (P1–3) with each IOS system. All models
were first scanned using the three systems that did not
require surface preparation: OM, TR, and PL. The models
were prepared thereafter using a matting powder (Cerec
Optispray, Dentsply Sirona) before scanning with the BL,
then prepared with a dusting powder (High Resolution
Scanning Spray, 3M ESPE) before use of the TD. The
scan data were directly exported from the acquisition
unit (OM, BL, TR, PL) or sent for postprocessing (TD) and
then exported in STL format. All impressions were made
by a single operator (M.D.) after training in the use of
all the IOS systems.
Scan File Preparation for Comparisons
The obtained STL data from the 10 scans of each model
using the five IOS systems were analyzed with a 3D
inspection software (Geomagic Control X) by means of
3D comparison. The STL data of the tested groups were
The trueness (ISO 5725-1) of each IOS system was as-
sessed by comparing the digital impressions to the actual
original geometry of the model, meaning that all of the
STL data (n = 10) from each tested group (BL, OM, PL,
TD, and TR; in P1–P3) were superimposed with the cor-
responding reference scans made with the laboratory
scanner (REF 1–3).
The precision of the IOS systems was evaluated by
comparing the digital impressions within each test
group in each simulated situation, meaning the STL data
(n = 10) for every tested group and situation (BL, OM,
PL, TD, and TR; in P1–P3) were superimposed among
themselves.
Statistical Analyses
Nonparametric distribution was confirmed using
Kolmogorov-Smirnov test. All comparisons were there-
fore performed using Kruskal-Wallis test followed by
Dunn-Bonferroni adjusted post hoc test to show homog-
enous subsets based on rank. The significance level was
set at P < .05. Statistical analysis was performed using
SPSS statistical software version 22.0 (IBM).
RESULTS
Accuracy of the Reference Scanner
The 10 STL data files of the Lego brick scans were su-
perimposed and compared in pairs, resulting in a total
of 45 comparisons. The average value for precision over
the 45 comparisons was 22.8 ± 17.5 μm.
The average length of the bricks measured on the
10 STL data files was 1.0 ± 3.7 μm larger than the

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 Digital Dental Technologies

Table 2   Comparison of Trueness (μm) of the Five Tested Intraoral and a total of 225 comparisons for
Scanning Systems each scanner group from which the
Scanner P1: Complete arch P2: Anterior gap P3: Posterior gap measurements for precision were
Cerec Omnicam 374.5 ± 41.5b 186.4 ± 26.5b 165.8 ± 25.5b subsequently calculated (Table 3
Trios 3 325.3 ± 82.7b 105 ± 9.5a 76.2 ± 5.6a and Fig 3).
The IOS system showing the high-
PlanScan 345.3 ± 53.4b 274.2 ± 79b 266.5 ± 50.1c
est precision was TR, and this was
Cerec Bluecam 347 ± 149.2b 226.5 ± 408.6b 246.3 ± 310b
the case in all of the tested situa-
True Definition 180.2 ± 46.3a 97.9 ± 27.6a 125.6 ± 37b tions (RMS: P1 = 76.7 ± 26 μm; P2 =
Data are reported as the median ± SD root mean square. Different superscript letters represent a 46.8 ± 14.1 μm; P3 = 39.7 ± 9.1 μm;
significant difference (P < .05; a < b < c < d) between both rows and columns.
P < .05). The lowest precision in the
situation with a complete arch (P1)
was found for PL (191.2 ± 60.3 μm;
Scan
1.5 P < .05). Both BL and PL showed the
P1
P2 lowest precision in the models mim-
P3 icking anterior and posterior gaps
(RMS: BL/P2 = 100.2 ± 213.2 μm;
1.0
PL /P2 = 175.6 ± 98.9 μm; BL /
RMS (µm)

* P3 = 90.3 ± 136.9 μm; PL /P3 =

108.9 ± 39.1 μm; P < .05).
0.5
DISCUSSION

The purpose of this in vitro study was

0 to evaluate the accuracy (ie, trueness
OM1 TR1 PL1 BL1 TD1 OM2 TR2 PL2 BL2 TD2 OM3 TR3 PL3 BL3 TD3
and precision) of five digital intraoral
impression systems in complete-arch
impressions of three different clinical
Fig 1   Comparison of trueness of all IOS systems. P1 = complete arch; P2 = anterior gap;
P3 = posterior gap; OM = Cerec Omnicam; TR = Trios 3; PL = PlanScan; BL = Cerec Bluecam;
scenarios.
TD = True Definition. This study revealed significant
differences in the accuracy of the
intraoral impression systems used
to obtain the complete-arch digital
dimensions provided by the manufacturer. This difference was not statisti- impressions. While one system (TR)
cally significant. was significantly better than all the
others with respect to precision in all
Trueness of the Tested IOS Systems clinical scenarios, the trueness of the
Each model (P1–P3) was scanned 10 times with each IOS system, resulting systems differed between fully den-
in a total of 150 digital impressions, which were subsequently compared tate situations and partially dentate
to the corresponding reference scans (REF 1–3) to calculate the trueness situations (anterior/posterior gap). In
(Table 2 and Fig 1). the P1 scenario, TD was significantly
In the situation of a fully dentate arch (P1), the lowest RMS value, and better in terms of trueness than all
therefore the highest trueness, was found for TD, with a median ± SD RMS the other tested groups, whereas in
value of 180.2 ± 46.3 μm (P < .05). For the model simulating an anterior the P2 and P3 scenarios, TR achieved
gap (P2), the highest values of trueness were measured in the TD and TR better trueness values. On the con-
groups, with RMS values of 97.9 ± 27.6 μm and 105 ± 9.5 μm, respectively. trary, PL was found to be inferior to
The TD and TR groups were not statistically different from each other, but the other systems for both aspects
were significantly different from the other groups (P < .05). Finally, in the of accuracy in all three clinical sce-
situation with a posterior gap (P3), the highest trueness was found for TR narios. Consequently, on the basis
(RMS = 76.2 ± 5.6 μm; P < .05), whereas PL showed the lowest trueness of the present findings, the null hy-
(RMS = 266.5 ± 50.1 μm; Fig 2). pothesis was rejected.
Several previous studies have
Precision of the Tested IOS Systems investigated the accuracy of com-
All 10 STL files for each situation (P1–P3) were compared within each plete-arch impressions obtained by
scanner group, resulting in 45 superimpositions per group per situation, intraoral impression systems. Renne

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 Doukantzi et al

et al evaluated the accuracy of seven

digital scanners in an in vitro study,
including the TR, which was found
to provide the best combination of
speed, trueness, and precision for
complete-arch scans.20 These find- Omnicam Trios 3 PlanScan
ings are in accordance with the
results of the present study. In a re-
cently published study, the accuracy
of nine IOS systems was evaluated,21
and similar trends as in the present
study were reported. The trueness
and precision of the complete-arch
Bluecam True
scans made with three of the scan- Definition
ners (TR, TD, and OM) were bet- a
ter than the ones made with the
other tested scanners.21 Similar to
the present study, TR presented the
best outcomes for both accuracy
parameters.21
Despite the general similarity in
the performance of the scanners Omnicam Trios 3 Planscan
between these studies, there are
differences in the absolute values
reported. Although to date a thresh-
old for clinically acceptable accuracy
has not yet been defined, in many
studies, the trueness and precision
values were below 150 μm, which
would seem to be clinically accept- Bluecam True
b Definition
able. In the present study, the RMS
values of trueness were found to be
significantly higher, especially in the
fully dentate scenario (P1).
A direct comparison with other
published results is difficult to un-
dertake due to the presence of
variations in study designs. Not only Omnicam Trios PlanScan
does the handling of the data via the
analysis software differ among the
studies, but so does the interpreta-
tion of divergences after superimpo-
sition and the 3D comparison.17 In
some studies, 20% of the measured
points (outliers) were excluded from
Bluecam True
the analysis,17 while in other stud- Definition
ies, a trimming of the virtual model c
with the elimination of artifacts and/ Fig 2   3D comparison of trueness of all IOS systems. (a) P1 (full arch). (b) P2 (anterior gap).
or the gingival area was performed (c) P3 (posterior gap).
before the 3D comparison.15 In the
present study, the virtual soft tis-
sues were not eliminated from the
3D comparison, which could explain
the differences in the values when
compared to those of other studies.

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 Digital Dental Technologies

Table 3   Comparison of Precision of the Five Tested Intraoral Scanning of the reference scanner used was an
Systems imperative precondition to this study,
Scanner P1: Complete arch P2: Anterior gap P3: Posterior gap and the value of trueness < 10 μm
Cerec Omnicam 122.7 ± 54.1b 62 ± 25.5b 64.6 ± 21.3b was consistent with previous re-
Trios 3 76.7 ± 26a 46.8 ± 14.1a 39.7 ± 9.1a ports.19,24,25 The revealed accuracy
of the reference scanner in this in
PlanScan 191.2 ± 60.3d 175.6 ± 98.9d 108.9 ± 39.1c
vitro study enhances the accurate
Cerec Bluecam 111.8 ± 28.6b 100.2 ± 213.2d 90.3 ± 136.9c
results of all 3D comparisons of the
True Definition 153.3 ± 85.2c 86.6 ± 46c 71.2 ± 32.2b tested groups.
Data are reported as the median ± SD root mean square. Different superscript letters represent a Digital intraoral impression sys-
significant difference (P < .05; a < b < c < d) between both rows and columns.
tems continue to develop rapidly.
The accuracy of these new systems
will remain a key factor for the pro-
Scan duction of adequately fitting restora-
P1 tions in restorative dentistry. Up to
P2 today, no system seems superior to
303 384
P3
.60
404
the others in all clinical scenarios. All
systems have advantages and limita-
RMS2 (µm)

tions, and further research is needed,

.40 including standardized test methods
to evaluate and compare the differ-
430
137 341
ent intraoral impression systems.
.20 46 61 125 265
435

39 231 309
CONCLUSIONS
0
OM1 TR1 PL1 BL1 TD1 OM2 TR2 PL2 BL2 TD2 OM3 TR3 PL3 BL3 TD3 From the results of the present in
vitro study, the following conclusions
can be drawn:
Fig 3  Comparison of precision of all IOS systems. OM = Cerec Omnicam; TR = Trios 3;
PL = PlanScan; BL = Cerec Bluecam; TD = True Definition. • In situations with anterior or
posterior gaps, TR exhibited the
highest accuracy, followed by
OM and TD.
• In fully dentate situations, TD
Additionally, a significant difference was found among the three clinical provided the highest trueness;
scenarios, with P1 showing higher values than P2 or P3 in terms of trueness. however, not the highest
In many studies, there are typical deviation patterns in complete-arch scans precision.
across the incisal edges of the anterior teeth and the buccal surfaces of mo- • TR provided the highest
lars, indicating a slight distortion of the posterior teeth. In the two scenarios precision in all three clinical
with partial edentulism, P2 in the anterior area and P3 in the posterior area, situations.
better results were found, which could be explained by the elimination of • PL showed the most inferior
the areas where most errors occur. Another possible explanation could be accuracy in all three clinical
the learning curve of the operator, as the scanning process started with the situations.
full-arch scenario in this study. In an in vivo study, Ender et al demonstrated • None of the tested systems
that the precision of conventional impressions was similar to or better than exhibited superior accuracy in all
the digital scans of BL, OM, TD, TR, iTero 3D scanner (Invisalign), and Lava tested clinical situations.
COS (3M ESPE), with the digital impression groups of TR and OM reaching
the same high-precision levels as conventional impression groups.22,23 The ACKNOWLEDGMENTS
results of the present study are in agreement with previous studies reporting
values of precision < 90 μm for the TR group in all clinical scenarios—which The present study was supported by the Uni-
was significantly better than the other groups—followed by the OM and versity of Geneva with the tested scanners.
The study was not financially supported by
TD groups.22,23
any companies. The authors report no con-
All of the comparisons in the present in vitro study were undertaken af- flicts of interest.
ter the digitization of a master model with a laboratory 3D scanner (IScan
D104i), which is recommended for high-accuracy scanning.19 The validation

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 Doukantzi et al

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Literature Abstract

Role of Thin Gingival Phenotype and Inadequate Keratinized Mucosa Width (< 2 mm) as Risk Indicators for Peri-implantitis and
Peri-implant Mucositis
There is growing evidence on the impact of thin gingival phenotype (TnP) and inadequate keratinized mucosa width (KMW < 2 mm) around
dental implants on peri-implant health. This study investigated the role of TnP and inadequate KMW as risk indicators for peri-implantitis
and -mucositis and on dental patient-reported outcomes. A total of 63 patients with 193 implants (mean follow-up of 6.9 ± 3.7 years)
were given a clinical and radiographic examination and a questionnaire to assess patient awareness of food impaction and pain/discomfort.
Chi-square tests and regression analysis for clustered data were used to compare outcomes. Implants with TnP had a statistically higher
prevalence of peri-implantitis (27.1% vs 11.3%; PR, 3.32; 95% CI, 1.64–6.72; P = .001) peri-implant mucositis (42.7% vs 33%; PR, 1.8;
95% CI, 1.12–2.9; P = .016), and pain/discomfort during oral hygiene (25% vs 5%; PR, 3.7; 95% CI, 1.06–12.96; P = 0.044) than thick
phenotype. Implants with inadequate KMW had a statistically higher prevalence of peri-implantitis (24.1% vs 17%; PR, 1.87; 95% CI,
1.07–3.25; P = .027) and peri-implant mucositis (46.6% vs 34.1%; PR, 1.53; 95% CI, 1–2.33; P = 0.05) and pain/discomfort during oral
hygiene (28% vs 10%; PR, 2.37; 95% CI, 1.1–5.1; P = .027) than with adequate KMW. TnP was strongly associated with inadequate KMW
(PR = 3.18; 95% CI, 1.69–6.04; P < .001). Conclusion: TnP and inadequate KMW (< 2 mm) may be significant risk indicators for peri-
implant disease and pain/discomfort during brushing.
Gharpure AS, Latimer JM, Aljofi FE, Kahng JH, Daubert DM. J Periodontol 2021 [epub ahead of print April 15]. References: 48. Reprints: Diane
Daubert, ddaubert@uw.edu —Carlo Ercoli, USA

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