journal of dentistry 35 (2007) 903908

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Direct mechanical data acquisition of dental impressions for the manufacturing of CAD/CAM restorations
Sebastian Quaas *, Heike Rudolph, Ralph G. Luthardt
University Ulm, Department of Dentistry, Prosthetic Dentistry and Materials Sciences, Albert-Einstein-Allee 11, 89070 Ulm, Germany

article info
Article history: Received 17 June 2007 Received in revised form 23 August 2007 Accepted 27 August 2007

abstract
Objectives: The basic prerequisite for the production of dental restorations by means of CAD/ CAM technologies is the data acquisition (digitization). Currently, two methods are available, i.e. the extraoral digitization of master casts and the direct intraoral data acquisition. However, it seems to be benecial to immediately digitize impressions directly at the dental ofce in order to combine the high precision of mechanical digitizing methods and to shorten the production process. The aim of this study was to investigate the measurement uncertainty (2s) and the

Keywords: One-step-impression Computer aided analysis Mechanical measurement Touch-probe-scanner Digitizing Data acquisition Dental restoration CAD/CAM

three-dimensional accuracy of the immediate tactile in-ofce digitization of dental impressions and of the mechanical digitizing of ceramic master dies using a high-precision touchprobe digitizer. Methods: The experimental set-up consisted of ceramic master dies representing tooth 13 and 36 as well as their identical virtual models (CAD models). Fifteen one-step putty-wash impressions were taken from each tooth. The impressions as well as the ceramic master dies were digitized applying a standardized procedure. The datasets were aligned to the corresponding CAD models; then, a computer-aided three-dimensional analysis was performed. Results: The digitizing of the dental impressions showed a measurement uncertainty of 5.8, mean positive deviations between 27 and 28 mm, and mean negative deviations between 21 and 31 mm. The digitizing of the ceramic master dies showed a measurement uncertainty of 2.8, mean positive deviations between 7.7 and 9.1 mm, and mean negative deviations between 8.5 and 8.8 mm. Conclusion: Mechanical digitizers show a very low measurement uncertainty and a high precision. The immediate tactile in-ofce digitization of impressions cannot be recommended as adequate data acquisition method for CAD/CAM restorations. It is recommendable to digitize clinical sites extraorally, i.e. after taking an impression and fabricating a model cast thereof. # 2007 Elsevier Ltd. All rights reserved.

1.

Introduction

When using computer-aided technologies for the production of dental restorations, the minimum requirements are to digitize the abutment teeth. The digitizing accuracy is a major

factor, which has an inuence on the t of xed restorations.1,2 Currently, the data acquisition is either performed directly in the patients mouth (intraoral) or indirectly after taking an impression and fabricating a master cast (extraoral). Regardless of the digitizing mode applied, clinical parameters, e.g.

* Corresponding author. Tel.: +49 731 500 64245; fax: +49 731 500 64203. E-mail address: sebastian.quaas@uniklinik-ulm.de (S. Quaas). 0300-5712/$ see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2007.08.008

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saliva, blood, movements of the patient, might affect the reproduction of teeth.37 Intraoral digitization allows the dental-care provider to directly obtain the data from the prepared teeth. Thus, taking an impression and fabricating a cast model are no longer necessary.8 Titanium dioxide or magnesium oxide powder has to be applied to the glossy, lucent tooth surfaces in order to avoid reections and to create a measurable surface. The powder layer applied to the tooth surface results in an additional thickness of 1385 mm.9 An in vitro study showed a higher accuracy of the extraoral digitization with impression taking and model fabrication than in case of the intraoral digitization.10 Prior to the extraoral digitization, an impression of the clinical situation has to be taken. The impression technique as well as the properties of the impression material used may affect the tting precision of xed restorations as well. The fabrication of a master cast compensates for volumetric changes of the impression material to a certain extent.11,12 However, the fabrication of a master cast is a time-consuming and error-prone method that requires the presence of or collaboration with a dental laboratory. Master casts can be digitized extraorally either with optical or with mechanical tools.13 The optical digitization allows a fast and wearless high-resolution data acquisition.14 As a disadvantage, however, shadowing effects limit the use of the extraoral optical digitization method. Multiple measurements combined with the alignment of partial measurements are necessary in order to compensate for such effects. In principle, mechanical digitizers are mainly used for the data acquisition of cavities or negative moulds15,16 such as the silicone impression of a tooth. The reproduction of small-sized structures is restricted by the diameter and the design of the probe tip.2 Measurement errors in case of mechanical digitizing are mainly caused by the geometry of the measuring objects2,17,18 and were said to be comparable to those of the extraoral digitization with optical tools.2,14,1720 Persson et al. found maximum shape-related errors of +/10 mm with the contact probe device of the Procera system. It is difcult to mechanically digitize soft and exible materials due to possible surface damages or object deformation caused by the touch of the probe15 even if the dental-care provider applies only a gentle contact force. High contact pressures might injure the surface of the objects to be measured.2 The immediate tactile in-ofce digitization of impressions seems to be benecial as it combines the high precision of mechanical digitizing methods and a shortened production process. Studies about the measurement uncertainty of mechanical digitizers are rare, and studies investigating the measurement uncertainty of the direct digitization of dental impressions, check-bites or inner surfaces of crowns were not even found at all. The aim of this study was to investigate the three-dimensional (3D) accuracy and the measurement uncertainty (2s) of the immediate tactile in-ofce digitization of dental impressions compared to the mechanical digitization of ceramic master dies by means of a high-precision touch-probe digitizer. In this study, the hypothesis that the 3D accuracy of immediate tactile in-ofce digitization of dental impressions can compete with the accuracy gained by the mechanical digitizing of ceramic master dies was examined.

2.

Materials and methods

The experimental set-up allowing the evaluation of every step of the CAD/CAM process chain by means of an established procedure4,12,13,21 consisted of virtual CAD surface models (reference models) and ceramic master dies of the prepared teeth 13 (upper right canine) and 36 (lower left rst molar) (Fig. 1).12 The ceramic master dies were made out of alumina zirconia ceramics (HITK Hermsdorfer Institut fu r Technische Keramik, Hermsdorf/Thuringia, Germany). They were digitized mechanically (Triclone 90, Renishaw plc, Gloucestershire, GB), and CAD surface models were created as reference (ce.novation V1.0, ILMCAD, Ilmenau, Germany). In order to validate the conformance of the CAD surface models with the ceramic master dies, a second digitizing system was used. The ceramic master dies were optically digitized with the hiScanm (IVB GmbH, Jena, Germany; Fraunhofer IOF, Jena, Germany; Hint-ELs GmbH, Griesheim, Germany).12 In this study, a probe diameter of 1.0 mm and a contact force of 0.5 N were used for the mechanical digitization. In preliminary tests, measurement procedures for the digitization of positive and negative moulds were tested. For the comparable digitization of positives and negatives, a radial measurement procedure was chosen in order to acquire a sufcient number of measurement points (approx. 30,000) within an acceptable time (max. 60 min). In this procedure, the measurement object was digitized with star-shaped movements. Each ceramic master die was digitized three times applying the same parameters (step-over: 0.1 mm, scanning speed: 250 mm/min, maximum probe deection: 0.3 mm, chordal tolerance: 0.01 mm) in order to determine the measurement uncertainty. A temporary crown and bridge material (Luxatemp, DMG, Hamburg, Germany) was used to create an articial gingiva simulating the gingival sulcus (Fig. 2). The width and depth of this gingival sulcus were measured with a slide gauge. The measurement results are shown in Table 1. Fifteen visually perfect impressions each were taken of the ceramic master dies 13 and 36 with the one-step putty-wash method (Dimension Penta H/Garant L; 3M ESPE AG, Seefeld, Germany). In order to create a subgingival nishing line, articial gingiva was adapted at the ceramic master dies. For all impressions, unperforated, individualized mandibular stock trays were used. Each tray was prepared with acrylic resin (KALLOCRYL CPGM, SPEIKO, Muenster, Germany) to dene four separate sections. In general, the impressions were measured mechanically 4.5 h after having taken the impression (Triclone 90, Renishaw plc, Gloucestershire, GB).12 After the calibration of the measurement device with a calibration gauge, the impressions were xed on the object table. Each impression was digitized only once in order to prevent getting different results caused by volumetric changes of the impression material or by harming the impressions surface during probing. After transferring all datasets acquired optically and mechanically (point clouds of the measured surface) to the CAD analysis software Surfacer (V.10.6, SDRC Imageware, Ann Arbor, MI, USA), the datasets measured were processed according to a procedure given by Luthardt et al.4 and aligned to the CAD surface model. In this context, alignment means to

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Fig. 1 The experimental set-up including the virtual CAD surface model (as reference model) and an identical ceramic master die of the prepared tooth.

superimpose the 3D datasets in a three-dimensional system of coordinates according to mathematical correlation calculations.12,20 For each of such alignments, the root mean square deviation (RMS error) was calculated,22 and the optimum coordinate transformation was computed (Surfacer, V.10.6, SDRC Imageware, Ann Arbor, MI, USA) for the alignment with the best t. The measurement points beyond the nishing line were cut off and, thus, excluded from the analysis. The threedimensional deviations between each single point of the datasets measured and the CAD surface models were calculated (Surfacer). The results are indicated by the positive and negative deviations (maximum, mean and standard deviation) and by a color-coded representation of the threedimensional deviations (qualitative analysis).

The three-dimensional geometric deviations between the datasets measured and the CAD surface model were statistically analyzed by means of the repeated measure analysis with one within factor (tooth types: canine, molar) and a global signicance level of 0.05 (SPSS 12.0, SPSS Inc., Chicago, IL, USA).

3.

Results

The digitization of the ceramic master dies showed a mean RMS error of 20.7 mm (S.D. 1.8). Table 2 shows the calculated positive and negative deviations between the datasets gained by digitizing the ceramic master dies and the reference CAD surface model as well as the measurement uncertainty. The 3D accuracy of the ceramic master dies, which was tested with an optical digitizing system, showed mean

Table 1 Widths and depths of the artificial gingival sulcus Tooth

13

Sulcus widths (mm)

Oral Vestibular Mesial Distal Oral Vestibular Mesial Distal 0.2 0.5 1.5 0.2 0.5 0.8 0.5 0.4

Sulcus depths (mm)

Oral Vestibular Mesial Distal Oral Vestibular Mesial Distal 1.2 1.1 0.5 1.0 1.0 2.0 0.5 0.8

36

Fig. 2 A sleeve out of temporary crown and bridge material simulates the gingival sulcus.

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journal of dentistry 35 (2007) 903908

Table 2 Deviations between the datasets gained from digitizing the ceramic master dies and the reference CAD surface models as well as the calculated measurement uncertainty (2s) Tooth N Ceramic master dies Mean (mm)
Positive deviations Canine (13) Molar (36) Negative deviations Canine (13) Molar (36) 3 3 9.1 7.7

Table 4 P-values of the RMS error and the mean positive and negative deviations with regard to the tooth shape (canine, molar) N
RMS error Variances are equal Variances are unequal Mean positive deviations Variances are equal Variances are unequal Mean negative deviations Variances are equal Variances are unequal 15 15

T-value
1.300 1.300

P-value
0.204 0.204

2s
3.0 3.26

15 15

0.843 0.843

0.406 0.406

3 3

8.5 8.8

3.4 1.6

15 15

10.802 10.802

0.000 0.000

positive deviations of 5.4 mm (S.D. 7.2) and mean negative deviations of 5.8 mm (S.D. 7.0) for the canine and mean positive deviations of 7.5 mm (S.D. 6.9) and mean negative deviations of 11.2 mm (S.D. 11.2) for the molar. The RMS error of the digitized impressions resulted in nearly identical values of the two ceramic master dies, i.e. 30.7 mm (S.D. 1.2) in case of the canine and 30.0 mm (S.D. 1.4) in case of the molar. Table 3 illustrates the mean positive and mean negative deviations between the measured datasets gathered by digitizing the impressions and their corresponding CAD surface models. Measurement uncertainties for the digitalization of the impressions resulted between 3.6 and 7.2. Regarding the digitized impressions of the canine, the average maximum deviations amounted to 158.7 mm and 186.0 mm and 17.3 mm and 199.2 mm regarding the digitized impressions of the molar. The statistical analysis showed no signicance for the RMS error (P = 0.204) and the mean positive deviations (P = 0.406) regarding the tooth shape, while the tooth shape played a signicant role for the mean negative deviations (P 0.000) (Table 4). The qualitative analysis of the deviations between impression and CAD surface model resulted in reduced point clouds with circularly enlarged areas of the prepared teeth. In the color-coded representation of the threedimensional deviations, the edges of the point cloud of the molar appeared reduced. Large negative deviations were noticed in the areas of the nishing line and of the edges. Discrepancies of up to 208 mm between the CAD surface model and the measured dataset of the impressions were found in these areas (Fig. 3).

4.

Discussion

In this investigation, the quality of the alignment of the datasets was inuenced by several process variables (measurement uncertainty of the digitizer, errors with regard to the impression); it worsens the better the datasets are matching each another.14,20 For the quantitative and qualitative analyses of the

Table 3 Deviations between the datasets taken from the impressions of the ceramic master dies and the reference CAD surface models as well as the calculated measurement uncertainty (2s) Tooth N Digitized impressions Mean (mm)
Positive deviations Canine (13) Molar (36) Negative deviations Canine (13) Molar (36) 15 15 28.1 27.1

2s
7.2 6.0

15 15

30.6 20.6

6.2 3.6

Fig. 3 (a and b) Large discrepancies between the CAD surface model and the data taken from the impressions were found in the area of the finishing line. (a) Silicone impression of the molar 36. The frame indicates the area with very thin light material without being supported by the putty. (b) The same area in the color-coded representation of the three-dimensional deviations in mm; negative deviations in blue, positive deviations in red.

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accuracy of the digitized impressions that, alignment of datasets measured is required that best ts the reference CAD surface model. An RMS error of less than 10 mm is considered as excellent t, whereas an RMS error of more than 50 mm denotes a poor t.23 Outliers, data points beyond the nishing line, and several scattered points were deleted manually and, thus, remained unconsidered.4 Such points would have increased the RMS error and induced direction dependence during the alignment process. In regard to the handling, digitizing the impressions was more difcult than digitizing the prepared teeth. A correct orientation of the impression in the digitizer is necessary to avoid undercuts and missing data. Persson et al. reported digitizing errors similar to the mean positive and negative deviations that were found in the present study for the digitizing process of prepared teeth.2,18 If comparing the results indicated in Tables 2 and 3, the measurement uncertainty of the immediate tactile in-ofce digitization of dental impressions differs signicantly from the digitization of ceramic master dies. Therefore, the hypothesis that the 3D accuracy and the measurement uncertainty (2s) of the immediate tactile in-ofce digitization of dental impressions can compete with the mechanical digitizing of ceramic master dies is falsied. The considerably lower accuracy of the immediate tactile in-ofce digitization probably comes from errors caused by the one-step puttywash impression as well as from effects associated with the digitizing of exible materials (in this case: polyvinylsiloxane). Other data found in current literature proved that a mean deviation of about 10 mm occurs when taking impressions and fabricating master casts.12,24 Thus, the immediate tactile inofce digitizing of dental impressions causes an additional error compared to the conventional procedure. The mean positive 3D deviations between the two tooth shapes showed only small differences, whereas the mean negative deviations between the CAD surface model and the digitized impressions differed signicantly (Table 4). The qualitative analysis of color-coded graphs showed an elongation and a slightly reduced width of the impressions of the ceramic master dies. Also other authors reported of similar three-dimensional changes due to the one-step putty-wash impression technique.4,5,25,26 Large discrepancies between the CAD surface model and the data taken from the impressions were calculated in the areas of the nishing line and of the occlusal or incisal edges, respectively. Very thin light material layers, which are not supported by the putty, were mainly found in the area of the nishing line (Fig. 3a). The rigid articial sulcus also means a limitation since it cannot be treated with a retraction cord as it is possible in the clinical soft tissue management. Thus, small tear-offs are unavoidable (Fig. 3a). However, the areas of the nishing line where most of the tear-offs occurred deformed less during the measurement process (Fig. 4). In spite of the low contact forces of 0.5 N, the area of the nishing line showed strong contact deviations. Compared to the CAD surface model, the qualitative analysis of the digitized nishing line presented smaller discrepancies in the area where the articial sulcus had its largest width and where it, therefore, was more resistant to the touch-probe force. Especially in the area of the nishing line, it seems that the width of the sulcus and, thus, the thickness of the

Fig. 4 A thin layer of impression material offers insufficient resistance against the contact pressure applied with the probe of the mechanical digitizer.

impression material have an inuence on the quality of the data acquisition when immediately digitizing dental impressions directly at the dental ofce. A thin layer of impression material offers insufcient resistance against the contact pressure of the probe of the mechanical digitizer (Fig. 4). Edges with a radius that is smaller than the radius of the probe tip cannot be digitized accurately. Hence, the deviations at the occlusal and incisal edges probably occurred due to a mismatch between the probe tip and the negative shape of the abutment tooth (mould/impression) to be measured.

5.

Conclusions

Mechanical digitizing cannot be recommended for the direct digitizing of dental impressions. The three-dimensional geometry changes of the tooth shape would be clinically acceptable. However, large discrepancies between the CAD surface model and the data taken from the impressions were found in the area of the nishing line. Therefore, it is recommendable to extraorally digitize clinical sites after taking an impression and fabricating a model cast.

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