Journal of Prosthetic Dentistry

Accuracy of markerless registration methods of DICOM and STL files used for computerized surgical guides in mandibles with metal restorations: An in vitro study

Published:November 10, 2022DOI:


      Statement of problem

      Digital imaging and communications in medicine (DICOM) files together with surface scans must be accurately registered in virtual implant planning software programs to match real-life dimensions and ensure correct plan transfer through computer-aided manufactured surgical guides.


      The purpose of this in vitro study was to evaluate the accuracy of 3 different registration methods of DICOM data with and without metal restorations and a metal artifact reduction (MAR) tool for surface scans.

      Material and methods

      Thirteen dentate mandibles were assigned to each group of this study (n=39). Baseplate wax was adapted to the bone surfaces of each mandible, and 5 radiopaque markers were attached. A desktop scanner was used to obtain control scans. The groups of metal-free mandibles (MFM) and mandibles with metal restorations (MRM) were scanned to obtain DICOM data without a MAR tool. Additional DICOM data for the MRM were obtained with the MAR tool (MRM-MAR). Point-based registration (PBR), best-fit registration (BFR), and automatic registration (AR) were used to align standard tessellation language (STL) and DICOM data, and 3 data sets were exported. Radiographic markers on each data set were compared with those on the control scan, and positional deviations were calculated and statistically evaluated with 1-way ANOVA followed by multiple pairwise comparisons, independent samples t test, and 2-way ANOVA (α=.05).


      Within each group, PBR had the lowest deviation values with statistical significance in the MFM and the MRM-MAR groups (P<.001). AR showed failure in the MRM and the MRM-MAR groups. Statistically significant differences were found on comparing the average deviations among the 3 groups for PBR only (P<.001). No association was found between deviation values and the presence or absence of metal restoration, while a positive association was found with the type of registration method (P<.001).


      PBR had the highest accuracy level compared with AR and BFR methods. An increase in the number of calculations resulted in more deviation values. The MAR tool had a positive effect on PBR in mandibles with metal restorations.
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        • Scherer M.D.
        Presurgical implant-site assessment and restoratively driven digital planning.
        Dent Clin North Am. 2014; 58: 561-595
        • Mora M.A.
        • Chenin D.L.
        • Arce R.M.
        Software tools and surgical guides in dental-implant-guided surgery.
        Dent Clin North Am. 2014; 58: 597-626
        • Chan H.L.
        • Misch K.
        • Wang H.L.
        Dental imaging in implant treatment planning.
        Implant Dent. 2010; 19: 288-298
        • Worthington P.
        • Rubenstein J.
        • Hatcher D.C.
        The role of cone-beam computed tomography in the planning and placement of implants.
        J Am Dent Assoc. 2010; 141: 19S-24S
        • De Kok I.J.
        • Thalji G.
        • Bryington M.
        • Cooper L.F.
        Radiographic stents: integrating treatment planning and implant placement.
        Dent Clin North Am. 2014; 58: 181-192
        • Ganz S.D.
        Three-Dimensional imaging and guided surgery for dental implants.
        Dent Clin North Am. 2015; 59: 265-290
        • Naziri E.
        • Schramm A.
        • Wilde F.
        Accuracy of computer-assisted implant placement with insertion templates.
        GMS Interdiscip Plast Reconstr Surg DGPW. 2016; 5: Doc15
        • Ersoy A.E.
        • Turkyilmaz I.
        • Ozan O.
        • McGlumphy E.A.
        Reliability of implant placement with stereolithographic surgical guides generated from computed tomography: clinical data from 94 implants.
        J Periodontol. 2008; 79: 1339-1345
        • Katsoulis J.
        • Pazera P.
        • Mericske-Stern R.
        Prosthetically driven, computer-guided implant planning for the edentulous maxilla: a model study.
        Clin Implant Dent Relat Res. 2009; 11: 238-245
        • Ozan O.
        • Turkyilmaz I.
        • Ersoy A.E.
        • McGlumphy E.A.
        • Rosenstiel S.F.
        Clinical accuracy of 3 different types of computed tomography-derived stereolithographic surgical guides in implant placement.
        J Oral Maxillofac Surg. 2009; 67: 394-401
        • Behneke A.
        • Burwinkel M.
        • Behneke N.
        Factors influencing transfer accuracy of cone beam CT-derived template-based implant placement.
        Clin Oral Implants Res. 2012; 23: 416-423
        • Flügge T.
        • Derksen W.
        • te Poel J.
        • Hassan B.
        • Nelson K.
        • Wismeijer D.
        Registration of cone beam computed tomography data and intraoral surface scans–a prerequisite for guided implant surgery with CAD/CAM drilling guides.
        Clin Oral Implants Res. 2017; 28: 1113-1118
        • Van Assche N.
        • Quirynen M.
        Tolerance within a surgical guide.
        Clin Oral Implants Res. 2010; 21: 455-458
        • Cassetta M.
        • Di Mambro A.
        • Giansanti M.
        • Stefanelli L.V.
        • Barbato E.
        How does an error in positioning the template affect the accuracy of implants inserted using a single fixed mucosa-supported stereolithographic surgical guide?.
        Int J Oral Maxillofac Surg. 2014; 43: 85-92
        • Vercruyssen M.
        • Cox C.
        • Coucke W.
        • Naert I.
        • Jacobs R.
        • Quirynen M.
        A randomized clinical trial comparing guided implant surgery (bone- or mucosa-supported) with mental navigation or the use of a pilot-drill template.
        J Clin Periodontol. 2014; 41: 717-723
        • Vercruyssen M.
        • Fortin T.
        • Widmann G.
        • Jacobs R.
        • Quirynen M.
        Different techniques of static/dynamic guided implant surgery: modalities and indications.
        Periodontol 2000. 2014; 66: 214-227
        • Raico Gallardo Y.N.
        • da Silva-Olivio I.R.T.
        • Mukai E.
        • Morimoto S.
        • Sesma N.
        • Cordaro L.
        Accuracy comparison of guided surgery for dental implants according to the tissue of support: a systematic review and meta-analysis.
        Clin Oral Implants Res. 2017; 28: 602-612
        • Swennen G.R.J.
        • Barth E.L.
        • Eulzer C.
        • Schutyser F.
        The use of a new 3D splint and double CT scan procedure to obtain an accurate anatomic virtual augmented model of the skull.
        Int J Oral Maxillofac Surg. 2007; 36: 146-152
        • Bornstein M.
        • Scarfe W.
        • Vaughn V.
        • Jacobs R.
        Cone beam computed tomography in implant dentistry: a systematic review focusing on guidelines, indications, and radiation dose risks.
        Int J Oral Maxillofac Implants. 2014; 29: 55-77
        • Ku J.K.
        • Lee J.
        • Lee H.J.
        • Yun P.Y.
        • Kim Y.K.
        Accuracy of dental implant placement with computer-guided surgery: a retrospective cohort study.
        BMC Oral Health. 2022; 22: 1-10
        • Flügge T.V.
        • Nelson K.
        • Schmelzeisen R.
        • Metzger M.C.
        Three-dimensional plotting and printing of an implant drilling guide: simplifying guided implant surgery.
        J Oral Maxillofac Surg. 2013; 71: 1340-1346
        • Birkfellner W.
        • Solar P.
        • Gahleitner A.
        • et al.
        In-vitro assessment of a registration protocol for image guided implant dentistry.
        Clin Oral Implants Res. 2001; 12: 69-78
        • Nkenke E.
        • Zachow S.
        • Benz M.
        • et al.
        Fusion of computed tomography data and optical 3D images of the dentition for streak artefact correction in the simulation of orthognathic surgery.
        Dentomaxillofac Radiol. 2004; 33: 226-232
        • Swennen G.R.J.
        • Mommaerts M.Y.
        • Abeloos J.
        • et al.
        The use of a wax bite wafer and a double computed tomography scan procedure to obtain a three-dimensional augmented virtual skull model.
        J Craniofac Surg. 2007; 18: 533-539
        • Plooij J.M.
        • Maal T.J.J.
        • Haers P.
        • Borstlap W.A.
        • Kuijpers-Jagtman A.M.
        • Bergé S.J.
        Digital three-dimensional image fusion processes for planning and evaluating orthodontics and orthognathic surgery. A systematic review.
        Int J Oral Maxillofac Surg. 2011; 40: 341-352
        • Akyalcin S.
        • Cozad B.E.
        • English J.D.
        • Colville C.D.
        • Laman S.
        Diagnostic accuracy of impression-free digital models.
        Am J Orthod Dentofacial Orthop. 2013; 144: 916-922
        • Rhee Y.K.
        • Huh Y.H.
        • Cho L.R.
        • Park C.J.
        Comparison of intraoral scanning and conventional impression techniques using 3-dimensional superimposition.
        J Adv Prosthodont. 2015; 7: 460-467
        • Lanis A.
        • Alvarez del Canto O.
        The combination of digital surface scanners and cone beam computed tomography technology for guided implant surgery using 3shape implant studio software: a case history report.
        Int J Prosthodont. 2015; 28: 169-178
        • Tahmaseb A.
        • Wu V.
        • Wismeijer D.
        • Coucke W.
        • Evans C.
        The accuracy of static computer-aided implant surgery: a systematic review and meta-analysis.
        Clin Oral Implants Res. 2018; 29: 416-435
        • Macchi A.
        • Carrafiello G.
        • Cacciafesta V.
        • Norcini A.
        Three-dimensional digital modeling and setup.
        Am J Orthod Dentofac Orthop. 2006; 129: 605-610
        • Guo H.
        • Zhou J.
        • Bai Y.
        • Li S.
        A three-dimensional setup model with dental roots.
        J Clin Orthod. 2011; 45: 209-216
        • Lee R.J.
        • Pham J.
        • Choy M.
        • et al.
        Monitoring of typodont root movement via crown superimposition of single cone-beam computed tomography and consecutive intraoral scans.
        Am J Orthod Dentofac Orthop. 2014; 145: 399-409
        • Yilmaz B.
        Incorporating digital scans of diagnostic casts into computed tomography for virtual implant treatment planning.
        J Prosthet Dent. 2015; 114: 178-181
        • Dada K.
        • Pariente L.
        • Daas M.
        Strategic extraction protocol: use of an image-fusion stereolithographic guide for immediate implant placement.
        J Prosthet Dent. 2016; 116: 652-656
        • Joda T.
        • Bragger U.
        • Gallucci G.
        Systematic literature review of digital three-dimensional superimposition techniques to create virtual dental patients.
        Int J Oral Maxillofac Implants. 2015; 30: 330-337
        • Noh H.
        • Nabha W.
        • Cho J.H.
        • Hwang H.S.
        Registration accuracy in the integration of laser-scanned dental images into maxillofacial cone-beam computed tomography images.
        Am J Orthod Dentofac Orthop. 2011; 140: 585-591
        • Kang S.H.
        • Lee J.W.
        • Lim S.H.
        • Kim Y.H.
        • Kim M.K.
        Dental image replacement on cone beam computed tomography with three-dimensional optical scanning of a dental cast, occlusal bite, or bite tray impression.
        Int J Oral Maxillofac Surg. 2014; 43: 1293-1301
        • Kim B.C.
        • Lee C.E.
        • Park W.
        • et al.
        Integration accuracy of digital dental models and 3-dimensional computerized tomography images by sequential point- and surface-based markerless registration.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: 370-378
        • Ritter L.
        • Reiz S.D.
        • Rothamel D.
        • et al.
        Registration accuracy of three-dimensional surface and cone beam computed tomography data for virtual implant planning.
        Clin Oral Implants Res. 2012; 23: 447-452
        • Lin H.H.
        • Chiang W.C.
        • Lo L.J.
        • Sheng-Pin Hsu S.
        • Wang C.H.
        • Wan S.Y.
        Artifact-resistant superimposition of digital dental models and cone-beam computed tomography images.
        J Oral Maxillofac Surg. 2013; 71: 1933-1947
        • Widmann G.
        • Berggren J.P.M.
        • Fischer B.
        • et al.
        Accuracy of image-fusion stereolithographic guides: mapping CT data with three-dimensional optical surface scanning.
        Clin Implant Dent Relat Res. 2015; 17: e736-e744
        • Shu Su T.
        • Sun J.
        Comparison of repeatability between intraoral digital scanner and extraoral digital scanner: an in-vitro study.
        J Prosthodont Res. 2015; 59: 236-242
        • Queiroz P.M.
        • Santaella G.M.
        • da Paz T.D.J.
        • Freitas D.Q.
        Evaluation of a metal artefact reduction tool on different positions of a metal object in the FOV.
        Dentomaxillofac Radiol. 2017; 4620160366
        • Sheikhi M.
        • Behfarnia P.
        • Mostajabi M.
        • Nasri N.
        The efficacy of metal artifact reduction (MAR) algorithm in cone-beam computed tomography on the diagnostic accuracy of fenestration and dehiscence around dental implants.
        J Periodontol. 2020; 91: 209-214
        • Di Giacomo G.A.P.
        • Cury P.R.
        • de Araujo N.S.
        • Sendyk W.R.
        • Sendyk C.L.
        Clinical application of stereolithographic surgical guides for implant placement: preliminary results.
        J Periodontol. 2005; 76: 503-507
        • Tahmaseb A.
        • Wismeijer D.
        • Coucke W.
        • Derksen W.
        Computer technology applications in surgical implant dentistry: a systematic review.
        Int J Oral Maxillofac Implants. 2014; 29: 25-42
        • Jamjoom F.Z.
        • Kim D.G.
        • McGlumphy E.A.
        • Lee D.J.
        • Yilmaz B.
        Positional accuracy of a prosthetic treatment plan incorporated into a cone beam computed tomography scan using surface scan registration.
        J Prosthet Dent. 2018; 120: 367-374
        • Faul F.
        • Erdfelder E.
        • Lang A.G.
        • Buchner A.
        G∗Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Moudi E.
        • Haghanifar S.
        • Johari M.
        • Gholinia H.
        • Ghanbarabadi M.
        Evaluation of the cone-beam computed tomography accuracy in measuring soft tissue thickness in different areas of the jaws.
        J Indian Soc Periodontol. 2019; 23: 334-338
        • Koo T.K.
        • Li M.Y.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        J Chiropr Med. 2016; 15: 155-163