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. 2025 Apr 25;35(5):721–731. doi: 10.1111/jopr.14061

Evaluation of the accuracy of digital workflow for implant‐supported full‐arch fixed dental prostheses using a novel micro‐CT measurement technique

Amira Fouda 1,✉, Chris Wyatt 1, Anthony McCullagh 1, Siddharth R Vora 1, Nancy L Ford 2, Mohamed Gebril 1
PMCID: PMC13247621  PMID: 40285405

Abstract

Purpose

This study aims to evaluate the accuracy of fit of full‐arch implant titanium frameworks fabricated from a fully digital workflow using a novel micro‐CT measurement technique.

Materials and Methods

A 3D‐printed model with four implant analogs was fabricated. A baseline micro‐CT was obtained after placing temporary cylinders on the model. Next, the printed model was scanned with an intraoral scanner (TRIOS 5), and the STL files were used to fabricate 10 titanium frameworks. Each framework was placed back on the model, and another micro‐CT was taken under two conditions: single screw test (SST‐CT) and final fit test (FFT‐CT), and the measurements were compared to the baseline. Framework passivity was evaluated using a single‐screw test (SST) and a screw‐resistance test (SRT). The accuracy of the intraoral scans was assessed by superimposing the 10 scans with a laboratory scan STL to determine if the misfit was due to scanning or milling and designing errors.

Results

None of the frameworks was deemed acceptable using SST‐CT, and only three had an acceptable fit using FFT‐CT. SST and SRT non‐passivity rates were 60% and 80%, respectively. Superimposition analysis revealed that only two intraoral scans used for framework fabrication fell within the acceptable deviation range of 150 microns, suggesting a high tendency for scanning errors and a possible milling or designing error in two samples.

Conclusion

The results show a significant level of misfit. This suggests that the full‐digital workflow for full‐mouth rehabilitation can present some limitations. Due to the rapid advancement in intraoral scanning, further studies are required to validate these findings.

Keywords: CAD‐CAM, complete arch reconstruction, dental implants, dental prosthesis, digital impressions, intraoral scanners, x‐ray microtomography

An implant‐supported fixed full‐arch prosthesis is a well‐established treatment option for edentulous patients. 1 Conventional impressions, particularly open‐tray impressions, provide accurate records 2 , 3 but have limitations, such as relying on operator skills, selected impression material, and technique. 4 Intraoral scanners have become increasingly popular in dentistry, 5 , 6 especially for full‐arch rehabilitations 7 due to their perceived superiority over conventional impressions. 6 Scanners either use confocal microscopy or light triangulations. 8 Light triangulation usually uses laser to measure the distance between the object by analyzing the light reflection of the object, while confocal microscopy focuses on the light beam that passes through a pinhole to increase the optical resolution and the contrast of the desired image. The decision to use either of them usually varies and is based on factors like cost and time; the confocal microscopy is generally more expensive and more time consuming according to the literature. 8 They offer many benefits, such as real‐time visualization, easy and selective repeatability, selective capture of relevant areas, elimination of the need to disinfect impression materials and trays, rapid communication with the laboratory, and data fusion. 6

The literature has identified intraoral scanners’ accuracy using trueness and precision. 9 , 10 Trueness is the closeness of one object to its actual dimension, while precision is the reproducibility between repeated measurements. 9 , 10 A recent systematic review stated that digital impressions provide superior accuracy, fewer errors, and increased patient comfort. 11

Furthermore, a retrospective analysis reported its superiority in scanning full‐arch implants. 12 Studies claiming that the digital impressions demonstrated higher accuracy, fewer errors, and fewer retakes than conventional impressions reinforced this agreement. 13

Multiple factors were reported in the literature that impact the accuracy of the digital impression. For example, scanning edentulous arches is more challenging than scanning dentate arches. 14 Moreover, there are patient‐related factors such as the arch form, soft tissue anatomy, and existing dental restoration, which could also impact the accuracy of the scan. 15 Contrarily, multiple studies have opposed digital scanning for full‐arch impressions; Lyu et al. stated that digital scans have less trueness and are inaccurate in long‐span cases, 16 and others believe that they are insufficient for a full‐arch impression. 17 , 18

The accuracy of the digital impression is crucial because of its impact on the passivity of the final framework. The passivity of the framework is an essential element for successful rehabilitation. 19 , 20 , 21 Passive fit is defined as the relative looseness or tightness of the implant and the prosthetic element affecting the forces and movement of the connected components following assembly. 22 Passivity could also be defined as precision that does not cause complications over the long term in the restoration. 23 Vertical misfits up to 100 µm and horizontal misfits up to 345 µm could be tolerated without negative outcomes. 24 Many complications are associated with a lack of framework passivity, 21 , 24 , 25 , 26 including repeated screw loosening, chipping of the prosthetic material, and potential implant failure. 27 Finite element analyses have shown that misfits increase the stress on the prosthetic components and the surrounding bone. 28 , 29 Therefore, it's crucial to have an acceptable fit to ensure overall stability and prevent biological complications. 30 , 31 , 32 , 33

The acceptable misfit level is smaller than 150 µm, according to Kan et al., 34 and 100 µm according to Katsoulis et al. 21 and Jemt et al. 35 Many techniques can be used to evaluate the framework misfit, such as single‐screw test (Sheffield test), 34 alternative finger pressure, 36 saliva extrusion test, 37 direct vision and tactile sensation, 38 screw resistance test, 35 optical scan analysis, 39 and radiographs. 40 , 41 , 42 Micro‐computed tomography (micro‐CT) provides a high‐resolution three‐dimensional image of a small object without distortion. 43 It has been used extensively to compare and detect internal and marginal fit of dental crowns. 44 It can also be utilized to assess the misfit by checking the presence of micro‐gaps between the implant and the sleeve interface in short‐span restorations. 45

Despite the advancement in digital intraoral scanning, there remains a significant debate in the literature regarding its accuracy for full‐arch rehabilitations. 11 , 13 , 16 Some studies evaluated the accuracy of digital impressions by evaluating the passivity of the verification jigs. 46 , 47 Assessing the accuracy of titanium frameworks through micro‐CT analysis has not previously been implemented for full‐mouth rehabilitation as existing literature focuses on short‐span restorations. 45 This study evaluates the accuracy of fit of full‐arch implant frameworks fabricated from a fully digital workflow using high‐resolution micro‐CT.

MATERIALS AND METHODS

Model fabrication

A 3D‐printed edentulous mandibular model with gingival mask was designed using 3Shape (3shape Dental System, Copenhagen K, Denmark) and printed using resin material for the model and gingival mask (Keymodel/KeyMask, KeyPrint, Keystone Industries GmbH, Singen, Germany) (Figures 1a and 2a,b). Four implant analogs with multi‐base abutments were secured in the model (ELOS analog for printed models, PMA, MUA4501, Elos Medtech, Goteborg, Sweden). Next, four temporary cylinders (Multibase EV, Temporary Cylinder, Dentsply Sirona, Charlotte, NC, USA) were hand‐tightened to the multi‐base abutments (Figure 1b). Baseline micro‐CT measurements were performed using a  μ100 CT cabinet micro‐CT scanner (Scanco Medical AG, Brüttisellen Switzerland) with a beam energy of 90 kVp and a tube current of 200 µA filtered by 0.1 mm Cu. The resultant images were reconstructed with an isotropic voxel spacing of 36.8 microns.

FIGURE 1.

FIGURE 1

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(a) The printed model; (b) Temporary abutments attached to the multi‐base abutments for baseline measurements; (c) Scan bodies hand tightened to the multi‐base abutments and scanning protocol using BLO scanning pattern; (d) Framework design using EXOCAD software; (e) Placing the titanium framework for SST‐CT; (f) Placing the titanium framework for FFT‐CT. SST‐CT, single screw test; FFT‐CT, final fit test

FIGURE 2.

FIGURE 2

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(a) The printed model with the implant analogs; (b) Removable printed soft tissues; (c) Tightening the screw at the most distal abutment in the single screw test; (d) The milled titanium frameworks; (e) Observing the marginal discrepancy after removing the soft tissues.

Intraoral scanning and accuracy

A scan body (Astra Tech Implant, Dentsply Sirona, Charlotte, USA) was manually attached to each multi‐base abutment using hand tightening (Figure 1c). The TRIOS 5 (3Shape, Copenhagen, Denmark) was used for intraoral scanning. First, the model without the scan bodies was scanned (soft‐tissue scan), following which the scan bodies were attached and re‐scanned using the BLO protocol (buccal‐lingual‐occlusal) (Figure 1c) since this scanning pattern has good precision and trueness in capturing complex geometries of full‐arch implant cases, as it ensures accurate detailed and accurate digital impression according to the literature. 48 Gomez‐Polo, et al. found that the Buccal‐Lingual‐Occlusal (BLO) scanning pattern had better trueness and precision when compared to other scanning patterns, particularly in full‐arch mandibular and maxillary implant scan as it showed low deviation when compared to the Zigzag (ZZ) method which had the lowest accuracy. The study also explained that the BLO provided consistent and reproducible results and achieved great balance between the scanning speed and the data acquisition. The Circumference (C) pattern had the shortest scanning time, but the BLO still performed better. The BLO also provided less impact from operator variability as some scanning patterns like Zigzag (ZZ) and Occlusal‐buccal‐lingual (OBL) may introduce more errors due to inconsistent hand movement and difficulty in maintaining proper scanning patterns. 48 As proposed by Papspyridakos et al., 49 20 trial scans were first performed for calibration, and another 10 scans were performed for framework fabrication. To test the scanning error, the same model with scan bodies attached was scanned using a high‐accuracy laboratory scanner (E4 lab scanner, 3Shape, A/S Copenhagen, Denmark) with a reported accuracy of 4 µm.

All scans were transferred into the Medit Link software (Medit Link v 2.4.4; Medit, Seoul, Republic of Korea) for data analysis. The laboratory‐scanned STL file (control) was superimposed with each intraoral scan STL using selected area features within the software (Figure 3a,b), ensuring that all scans were in the same morpho‐space (Figure 3c). To eliminate irrelevant areas of the scan, the model base and the soft tissues were erased, keeping only the scan bodies (Figure 3d,e). The software outputs RMS values in the form of heatmaps, which indicate the difference between the laboratory scan and each intraoral scan. A visual tolerance of 100 microns was applied when displaying the heat maps (Figure 3e). To ensure that the superimposition step did not introduce significant errors, the above steps were repeated for each scan twice, and the difference in the RMS values was calculated. An average RMS error value of 0.0055 was obtained (Figure 7a), suggesting that the superimposition methodology was highly accurate.

FIGURE 3.

FIGURE 3

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Superimposition analysis; (a) Superimposing the models using the selected area feature; (b) The models after superimposition; (c) Setting the XYZ coordinates to zero; (d) Erasing the model, soft tissues, and any irrelevant areas; (e) The heat map for each framework.

FIGURE 7.

FIGURE 7

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(a) Box plot for superimposition error calculation, (b) Bar chart representing mean RMS values at each scan, (c) Box plot representing the distribution of RMA values with reference line at the clinically acceptable discrepancy (red line), (d) mean RMS values at each implant location.

Framework Fit Tests

Ten frameworks were designed using Exocad (Exocad Dental CAD2.2, Exocad GmbH, Darmstadt, Germany) (Figures 1d and 2d) using each of the 10 STL scan files. They were milled using titanium Grade 5 in the form of a 10 mm milling desk using a Zirkonzahn M1 heavy‐duty milling machine (Zirkonzahn, Italy) (Figure 2d). The frameworks were initially checked for passive fit with alternate finger pressure and verified not to interfere with the model at the gingival aspect.

For objective fit assessment, each framework was scanned twice using the specimen micro‐CT with the aforementioned parameters. For the first scan, the single screw test was simulated (SST‐CT), where only the terminal implant's prosthetic screw was hand‐tightened on the multi‐base abutment (Figure 1e). The second micro‐CT scan was performed on the model where all the screws were hand‐tightened (Figure 1f), simulating the final fit test (FFT‐CT). The gap between the abutment and the temporary cylinder was measured using Microview software (Parallax Innovations, Canada). 50 The average fit was calculated as follows: (a) Internal fit by extending three lines along the multi‐base abutment and measuring the distance on both sides of the abutment (total = 12 per implant) (Figure 4b,e); (b) Marginal fit by extending lines around the margins of the 2D micro‐CT image (total = 8 per implant) (Figure 4c). Hence, the total locations for baseline, SST‐CT, and FFT‐CT measurements are 48, 480, and 480, respectively, for internal fit, and 32, 320, and 320 for marginal fit.

FIGURE 4.

FIGURE 4

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(a) Illustration of the different types of misfits that were observed in the micro‐CT analysis. (b) Perfect fit, (c) Vertical misfit, (d) Horizontal misfit, (e) Combination of vertical and horizontal misfit, (f) Angular misfit.

For subjective fit assessment, each framework was evaluated using the single‐screw test (SST) and screw‐resistance tests (SRT) by two blinded, experienced prosthodontists after removing the gingival mask (Figure 2a–c,e). For the SST, one screw was tightened at the terminal abutment, and the discrepancy was checked on the contralateral side 34 (Figure 2c,e). For the SRT, the screws that are close to the midline were tightened first and stopped when the initial resistance was observed, and the screw was tightened again for another half turn; a misfit is considered when more than half a turn is needed to achieve the desired prosthesis seating. 35

Statistical analysis

Quantitative data underwent normality testing via Kolmogorov–Smirnov and Shapiro–Wilk tests. Internal and marginal fit data were non‐parametric, while RMS values were parametric. Data were summed as median, range, mean, and standard deviation. Non‐parametric data comparisons for baseline, SST, and FFT utilized Friedman's and Dunn's tests. For parametric data, a paired t‐test was employed (IBM SPSS Statistics, Version 29.0). The sample size was based on previous studies with similar experimental designs. 3 , 16 , 51 , 52 , 53

RESULTS

Framework fit assessment

Based on the micro‐CT views, the following fits were observed: (a) Perfect fit (Figure 4b), (b) Vertical misfit where the discrepancy was noted at the margins (Figure 4c), (c) Horizontal misfit (Figure 4d), when the discrepancy was noted at the internal gap, and no discrepancy was noted at the marginal gap, (d) A combination of both vertical and horizontal misfits (Figure 4e), and (e) An angular misfit (Figure 4f). This is proposed as the new classification of misfit (Table 1).

TABLE 1.

The new classification of misfit.

Perfect fit (Figure 4b) No observable discrepancies
Vertical misfit (Figure 4c) Discrepancies noted at the margins
Horizontal misfit (Figure 4d) Discrepancies noted at the internal gap, with no discrepancies at the marginal gap
Combined vertical and horizontal misfits (Figure 4e) Discrepancies noted both vertically at the margins and horizontally at the internal gap
Angular misfit (Figure 4f) Discrepancies observed in the angular positioning of the components
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The Internal Fit showed no significant difference between baseline and SST‐CT, but FFT‐CT showed significantly lower discrepancies than baseline measurements (Dunn's Test, P < 0.05, Figure 5a). The Marginal Fit showed significant differences among baseline, SST‐CT, and FFT‐CT (P < 0.001). Pairwise comparisons using Dunn's test showed the highest discrepancy in SST‐CT, followed by FFT‐CT compared to baseline (Figure 5b). To evaluate the distribution of discrepancies in each framework, the marginal fit was assessed via SST‐CT and FFT‐CT. Figure 6a,b shows that every framework had some locations where the fit was above the acceptability threshold, which was set at up to 150 microns following Kan et al. who concluded that prosthetic complications could happen after exceeding this limit. 34 Subjective, SST, and SRT non‐passivity rates were 60% and 80%, respectively, as assessed by two blinded experts. These tests were known to assess the accuracy of passivity assessment in implant‐supported frameworks. 54

FIGURE 5.

FIGURE 5

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(a) Internal discrepancy at baseline, SST‐CT, FFT‐CT, (b) Marginal discrepancy at baseline, SST‐CT, FFT‐CT (circles and stars represent outliers).SST‐CT, single screw test; FFT‐CT, final fit test

FIGURE 6.

FIGURE 6

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(a) Box plot of the marginal discrepancy across different frameworks in a single screw test (SST‐CT), (b) Box plot of the marginal discrepancy across different frameworks in final fit test (FFT‐CT).

Intraoral scanning accuracy

Since all the frameworks had below‐expected values for marginal and internal fit, intraoral scans were evaluated as one potential source for this discrepancy. Heatmaps showing the superimposition of intraoral scan device outputs on the laboratory scan output (control) showed significant areas of high deviations (Figure 3e). The average RMS values for most scans exceeded clinically acceptable thresholds of 150 microns, 55 indicating the mean RMS for all scans was not within acceptable discrepancy levels (Figure 7c), and when evaluated individually, only two of them fell within the acceptable range (Figure 7b). No significant differences were seen when assessing the deviation in anterior and posterior implants (scan bodies) (Figure 7d) (t‐test, P = 0.902, Effect size = 0.032).

DISCUSSION

To the authors' knowledge, this is the first study to analyze the accuracy of fit of a full‐arch titanium framework fabricated from a fully digital workflow using micro‐CT analysis. The results of this study show a significant non‐passivity rate from both the objective (SST‐CT, FFT‐CT) and subjective evaluations (SST and SRT tests). Notably, scanning errors were identified in most of the frameworks, while a potential designing or milling error was noted in two cases.

Titanium frameworks were chosen because they are rigid, and it was hypothesized that they would identify the prosthetic misfit more effectively than verification jigs made of non‐rigid resin. 22

A titanium framework should be manufactured to have even contact with the prosthetic components without developing any stresses before functional loading. 45 Therefore, the accuracy of the milled titanium frameworks secured onto the model was evaluated by measuring both the marginal and internal gaps between the superstructure and the multiunit abutment.

This study showed a statistically significant difference in the internal fit between Baseline SST‐CT and FFT‐CT. This is consistent with the findings of Jemt et al., who observed that most of the distortion occurred in the horizontal plane when they compared milled titanium frameworks with casted prostheses. 54 The marginal gap at the FFT‐CT was less than at the SST‐CT, and this is expected as tightening all the screws will always attempt to reduce the marginal gap due to the superstructure elastic deformation. However, this doesn't eliminate the non‐passivity problem. 45 The subjective SST and SRT tests showed a low passivity rate; clinically assessing the clinical fit is usually difficult, especially with subgingival margins. 34 , 36

The result of this study differs from Mizumoto et al., who claimed that digital scanning shows a comparable or even better accuracy than conventional impressions for full‐arch situations. 56 In addition, many studies support that digital impressions have a high success rate when compared to conventional impressions. 11 , 13 , 49 , 57 , 58 Other authors reported inconclusive outcomes. Rutkunas et al. concluded that there is no statistical difference in passivity between the digitally and conventionally fabricated restorations and that implant angulation is the main challenge in both workflows. 59 Furthermore, Pera et al., compared the milled full‐arch framework accuracy from both digital and conventional workflows and found that the digital and analog impressions produced frameworks with a similar clinical fit and passivity by the Sheffield test and the radiographic analysis. 60

The results of the present study are consistent with those of Andriessen et al., who observed an inter‐implant distance error of more than 100 µm when intraoral scanning was utilized. They concluded that the resulting error is too large to fabricate a well‐fitted framework in edentulous mandibles. 17 Another study with a similar outcome was done by Lyu et al., 16 who indicated that digital scanning resulted in poorer trueness and precision than the conventional splinted open‐tray impression technique. In addition, Zingari et al. 61 also showed a similar outcome, as they believed that the intraoral scanners showed many errors as they either overestimated or underestimated the scan bodies' linear and axial measurements.

Moreover, Shaikh et al. stated that the conventional impression is more accurate for implant‐supported prostheses and that the digital scanning that uses optical triangulation has better accuracy than the one that uses ultrafast optical scanning and confocal microscopy. 3 This could be linked to our study, which also used a digital scanner that uses a confocal microscopy scanner. Uribarri et al. also confirmed that scanning angulation error is usually higher in the superstructure with more than three implants when intraoral scanners were used. 45 They also mentioned that marginal and internal discrepancies are due to scanning and milling errors, respectively, which is consistent with our study outcome. 45

In the study by Uribarri et al., 45 the analysis of milling error was significantly related to the marginal and internal fit of the CAD‐CAM frameworks. They specifically mentioned that the milling error can lead to an increase in marginal and internal discrepancies, which could lead to the formation of microgaps at the implant and the framework interface. They suggested critical review and adjustment in the milling and designing process used in the digital fabrication of the frameworks.

Despite following a specific scanning protocol (BLO) 48 and using one of the superior intraoral scanners on the market, this study's outcome showed a high tendency for scanning errors. Comparing this outcome with other studies’ outcomes is challenging due to many variables, such as different scanning devices and protocols. 62 , 63 Moreover, many factors could affect the accuracy of the intraoral scanners, such as implant position, angulation, and inter‐implant distance. 18 , 64

Scan body design and material, operator experience, and scanning strategies can affect the scanning accuracy. 15 , 18 Some authors believe that digital scans have to be used with assistive devices, 65 , 66 as they claim that these devices could improve the accuracy of digital scans, especially in angulated implant situations. 65 , 66 Using fiducial markers in the maxilla 67 and fixation pins in the mandible could enhance the scanning quality. 68 Other authors believe that splinting scan bodies could improve accuracy; 66 , 69 these previous findings are indirectly consistent with the findings of our study regarding digital scanning.

Few studies mentioned the need for verification jigs for full‐arch rehabilitation using a digital workflow. Sinada et al. 46 assessed the use of digitally designed and milled verification jigs from the photogrammetry data acquisition and declared that their use improves the accuracy of the digital workflow. 46 Moreover, Negreiros et al. used a conventional verification jig in the digital workflow and claimed that this hybrid approach effectively improves the digital workflow outcome. 70 Finally, Ercoli et al. assessed the passivity of implant full‐arch prostheses with and without verification jigs. They concluded that when verification jigs were used, all the frameworks had a passive fit, and when no verification jigs were used, only two frameworks fit passively. Their study concluded that the fabrication of the verification jig is essential for fixed implant‐supported prostheses. 71 The data from our study supports the notion that including verification jigs in these workflows can improve passivity.

The future of intraoral scanning shows promising results in the literature, 72 with the expected advancement in technology leading to greater accuracy and reliability. As software algorithms and hardware continue to evolve, these scanners will likely become more accurate and easier to use and will probably have enhanced error detection and correction capabilities.

Even with the effort to mimic the soft tissues using the gingival mask, one limitation of this study is its in vitro nature as it does not fully replicate the dynamic clinical environment. As saliva and tongue mobility are absent, the tests performed here simulate only certain factors in clinical workflows; patient‐specific biomechanics are not accounted for in this model. However, one can only assume that if the laboratory‐based tests yield poor fits, clinical tests may provide similar, if not worse outcomes. Additionally, only scanning errors were tested as a potential source for framework misfit. Milling errors can be another source of lack of passivity and follow‐up studies are planned to assess this in the future.

CONCLUSION

None of the 10 frameworks evaluated using SST‐CT were acceptable compared to the clinically acceptable misfit level. In the FFT‐CT analysis, three frameworks were considered to have an acceptable fit. The non‐passivity rate was 60% and 80% for the single‐screw and screw‐resistance tests, respectively. For superimposition analysis, only two frameworks fell within the acceptable level of deviation, suggesting a scanning error in most of the frameworks and a potential milling error in two of them. To improve the reliability of the digital workflow, it's advisable to incorporate a verification jig step before the final fabrication of the framework. This step is crucial to confirm the accuracy of the digital scan.

The data suggests that titanium frameworks fabricated using digital workflows do not have acceptable clinical misfit level, as evaluated using objective micro‐CT analysis. The subjective clinical non‐passivity rate was comparably poor. Furthermore, the data suggests that scanning errors using contemporary intraoral scanners may be significant sources in the misfit of frameworks. Further research could explore the different scanning protocols and new scanners, and software enhancement may minimize these errors in the future. Based on these findings, it is recommended that the digital scan be supplemented with additional verification steps, such as using a verification jig, before proceeding with the framework fabrication.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ACKNOWLEDGMENTS

The project was funded by UBC startup funds, Msc Project (Research supervisor: Dr. Mohamed Gebril). We would like to thank Dr. Jolanta Aleksejuniene for her valuable statistical consultation, and Dr. Faraj Edher for granting us access to the intraoral scanner.

Fouda A, Wyatt C, McCullagh A, Vora SR, Ford NL, Gebril M. Evaluation of the accuracy of digital workflow for implant‐supported full‐arch fixed dental prostheses using a novel micro‐CT measurement technique. J Prosthodont. 2026;35:721–731. 10.1111/jopr.14061

This research was awarded 3rd place in the 2024 ACP John J. Sharry Research Competition.

DATA AVAILABILITY STATEMENT

Data sharing is accepted

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