International Orthodontics 2021; 19: 425–432

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Original article
A new technique for testing accuracy and
sensitivity of digital bite registration:
A prospective comparative study

Hasan Camcı, Farhad Salmanpour

Available online: 15 July 2021 Afyonkarahisar Health Science University, Department of Orthodontics,
Afyonkarahisar, Turkey

Correspondence:
Hasan Camcı, Afyonkarahisar Health Science University, Department of Orthodontics,
Afyonkarahisar, Turkey.
[Link]@[Link]

Highlights
 Intraoral scanners (IOS) have become an integral part of orthodontic practice.
 IOS allows to articulate digital models automatically or manually.
 In this study, the accuracy of the IOS device articulation was evaluated using a new 3D method.
 The IOS articulation technique can be used as an alternative to traditional bite registration
methods. However, deviations in the micron level should be considered in sensitive dental
procedures.

Keywords Summary
Intraoral scanner
Interocclusal record Introduction > Intraoral scanners (IOS) use certain algorithms to provide articulations of the upper
Bite registration materials and lower digital models. The study was primarily designed to test the accuracy and sensitivity of
Virtual occlusal record these virtual articulations. The secondary objective was to compare virtual occlusal recording to
Digital workflow traditional methods.
Materials and methods > A total of one hundred and sixty bite registrations (BR) were obtained
from forty class I patients using four different methods. Samples were divided into four groups:
Group 1: BR from wax, Group 2: BR from C type silicone, Group 3: BR from A type silicone, Group 4:
Virtual BR created with Appliance Designer (Copenhagen, Denmark) software from the automati-
cally articulated digital models. Traditional BRs of the first three groups were scanned and
digitalized with IOS (3Shape TRIOS). Group 3 BRs were then taken as a reference and each of
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© 2021 CEO. Published by Elsevier Masson SAS. All rights reserved.
 H. Camcı, F. Salmanpour
Original article

the BRs in Group 1, Group 2, and Group 4 were separately superimposed using Geomagic Control X.
Numeric data such as Mpos (mean of positive deviations), Mneg (Mean of negative deviations),
ITA (In total area), OTA (Out total area) were used in the comparison.
Results > The values for OTA were: Group 1:57.0%, Group 2:28.4%, and Group 4:22.3% respec-
tively. That meant a general deviation in thickness on nearly all of the occlusal registration surfaces.
The Mpos values representing the discrepancy in thickness were Group 1:185.5 m, Group 2:82.7 m,
and Group 4:72.2 m. The surface deviation of Group 1 was significantly different from the other
groups (P < 0.01).
Conclusion > Virtual bite registrations could safely be used as an alternative to conventional BRs.
The performance of wax as a bite registration material was far behind other methods.

Introduction mouth when the teeth are in the maximum intercuspal position
With technological advances, orthodontic applications have (MIP) or digital models could be manually aligned in the IOS
become increasingly digital and traditional impression techni- device software. In the manual method, the IOR taken from the
ques have been replaced by intra-oral scanners (IOS) [1–3]. patient by conventional methods is scanned and used as a
Digital models have many advantages such as increasing patient reference. In the direct method, the right and left buccal areas
satisfaction, an easy revision of missing scanning parts, reducing are scanned while the teeth are in the MIP. The general way of
chair time, and enabling the production of customized remov- the direct method is an algorithm which performs the initial
able and fixed appliances [4,5]. preliminary alignment followed by a least squared numerical
In addition to good aesthetics, a good function is also aimed in match, often supplemented by measurements of the nearest
orthodontic treatment [6]. Effective chewing functions and main- iterative points between them [17].
taining the health of the temporomandibular joint are only The aim of this study is to test the accuracy of the IOS device's
possible with good occlusion [7]. In order to achieve a good occlusal bite identification by comparing virtual bite registration
occlusion and function at the end of orthodontic treatment, it is (VBR) with traditional bite registration. There are a limited
very important that the occlusal relationship between the upper number of studies in the literature testing the accuracy of
and lower teeth is properly registered in the diagnostic model. interocclusal recordings of IOS devices [18–22]. While some of
Indeed, treatment plans are quite different for patients with the these studies compared the occlusal bite recording accuracy of
same degree of crowding but different occlusal relationships. An the various devices, only a few compared the traditional tech-
error during the bite registration process might cause undesired niques with the digital method. However, in these studies, we
conditions, such as incorrect tooth extraction or incorrect treat- detected that the bite registrations were not evaluated with all
ment planning. This can appear, however, not only because of its surfaces as a whole. For instance; Edher et al. made compar-
human error but also because of the structural properties of the isons by defining sites of close proximity and sites of clearance
bite registration materials (BRM) [8]. Today, qualitative and using shimstock foil and the transillumination [19]. Wong et al.
quantitative indicators are used to record occlusal relations. tested the interocclusal recording performance of three different
Qualitative indicators (BRMs) are: dental wax, acrylic resin, metal intraoral scanning devices by measuring the 3D distance
oxide pates (zinc oxide-eugenol) and elastomeric materials [9]. between certain reference points [22]. Solaberrieta et al. also
An ideal BRM should have the following characteristics [10–12]: used contact points to identify the requirements for accurate
 precise recording of the incisal and occlusal teeth surfaces; virtual occlusal recordings [23]. In our research, the occlusal
 dimensional stability after setting; recording accuracy of the IOS device was tested by a three-
 easy usage and easy verification; dimensional evaluation of all contact surfaces.
 compatibility of tissues etc. Do virtual occlusal recordings taken with IOS devices accurately
Silicone-based BRMs have been reported to be more reliable mimic the patient's occlusion? Or what are their sensitivity in the
than other qualitative occlusal indicators [13]. Some authors reproduction of the IOR? In view of the preliminary information
have also suggested that they should be the gold standard [14]. presented above, our study was designed to provide answers to
Photo Occlusion Technique, T-Scan (Tekscan, South Boston, MA, both of these questions. The primary aim of the study was to
USA) and Dental Prescale are some of the frequently used determine the accuracy and sensitivity of an occlusal bite
quantitative occlusal indicators [15,16]. Today, IOS devices are obtained with an intraoral scan device. The secondary objective
capable of identifying and recording interocclusal relationships. was to compare virtual occlusal recording to traditional
Interocclusal registration (IOR) could be recorded directly in the methods.
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A new technique for testing accuracy and sensitivity of digital bite registration: A prospective comparative study

Original article
 posterior or anterior open bite;
Material and Methods
 prosthetic restoration.
Definitions of groups
IORs were collected using four different methods, three con-
The ethics approval for our research was obtained from the
ventional bite registration methods, and one virtual bite regis-
Afyonkarahisar Health Science University Clinical Research Ethics
tration for each patient. A total of 160 IORs of 40 patients were
Committee (ID:2020-91). In the power analysis to determine
divided into four groups.
sample size, it revealed that at least 40 patients were required
for each group in order to obtain sufficient statistical power
(a = 0.05, and 1-b = 0.80, effect size h2 = 0.265) [18]. Forty
patients with class I malocclusion were included in the study. Three traditional Bite Registration Methods
Class II and class III patients were excluded from the study due to The three qualitative indicators (BRMs) used in our research
the possibility of undesirable anterior thickness (particularly in were as follows: Group 1: Dental wax (red base plate), Group 2:
the canine region) of the occlusal records. Thus, the results of the Zetaplus C-type silicone (Zhermack, BadiaPolesine, Italy), Group
study were not negatively influenced by these uncontrolled 3: Occlufast Rock A-type silicone (Zhermack, BadiaPolesine,
thicknesses. The mean of Little's irregularity index scores was Italy). In all three IOR acquisition procedures, the patients were
2.88 in the mandible and 3.04 in the maxilla. Informed consent asked to close their mouths in the maximum intercuspal posi-
forms were received from all patients. Inclusion criteria for the tion and all teeth were air-dried before the materials were
study was as follows: inserted. In Group 1, the wax was kept in a hot water bath
 permanent dentition; before placing it in the patient's mouth. After obtaining the IOR,
 complete eruption of all teeth and contact with the antagonist; the wax was cooled by air spray for 1–2 min, then removed from
 2–3 mm overjet. the mouth. The IORs obtained with C-type silicone and Occlufast
Patients with any of the following conditions were excluded Rock were removed from the mouth after the complete setting
from the study: of the materials. The IORs considered to be imperfect were
 functional deviation; reproduced. The criteria used to recognize the imperfection
 general or single-tooth posterior cross-bite; modality were: inadequate margin detail, thin walls, internal
 single-tooth anterior cross-bite; bubbles, marginal tears, drags and pulls. However, in total, only
 polydiastema; four IORs (two in Group 2 and two in Group 3) were required to
 missing teeth; reproduce. After ensuring that all three IORs were perfect, each
 partially erupted or unerupted teeth; was first air-dried, then scanned by an IOS device, and converted
 buccally positioned canine; to a 3D digital IOR in the STL format (figure 1).

Figure 1
Digitalized BRs. G1: Wax, G2: C-type silicone, G3: A-type silicone, G4: Virtual BR
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Figure 2
Steps (from A to F) of VBR creation. A: An arch-shaped line was formed, extending from the distal of the right second molar to the
distal of the left second molar, B: The software generated a shell covering all of the upper tooth surfaces using the line as a
reference, C: The lower jaw was articulated with the upper jaw, D: The imprints of the lower teeth were created in the shell, E:
Frontal view of VBR, F: The area to be assessed was selected

Construction of the Virtual Bite Registration (VBR) silicone) were used as a reference in all three-dimensional
First, all the teeth were air-dried, then the lower and upper superimpositions. This group was used as a reference because
digital models of the patients were obtained using the 3Shape of its superiority to other materials [24] and advantages of type
TRIOS device (Copenhagen, Denmark). The left and right buccal A silicone such as excellent dimensional stability, adequate tear
areas were scanned when the teeth were in MIP to record the strength, good working and setting time, extremely high accu-
IOR of the digital models. The models were automatically artic- racy, minimal distortion removal, dimensionally stable even
ulated by the device. The articulation result was compared with after one week [25]. The following steps were performed in
the intraoral teeth relationship so its accuracy was verified. three-dimensional superimposition process of the reference
Incorrect IORs were renewed. Precisely aligned models were IORs (figure 3):
imported into the Appliance Designer (Copenhagen, Denmark)  the reference IOR was superimposed with the other IORs

software. The VBRs (Group 4) were generated using the follow- separately using the local best fit (LBF) algorithm. The LBF
ing steps (figure 2): algorithm was easy to use because the selection of two
 the upper teeth were covered with a virtual bar; objects that want to be overlapped was adequate. The pro-
 while looking at the model from the occlusal view, virtual bar gram automatically achieved maximum surface contact;
edges were reshaped according to the borders of the teeth;  the software eventually transformed the deviation between

 the models were brought into articulation and imprints of the overlapping surfaces into both qualitative (color histogram)
upper and lower teeth were created on the virtual bar; and quantitative data;
 the VBR was saved in an STL format and exported.  the uncontrollable thickness of the excess part of the IORs,

especially in the anterior region, could have negatively

Superimposition Process of the Reference IORs affected the results. Thus, only contact regions from the first
The four (3 traditional and 1 virtual) three-dimensional digital molar to canine were selected bilaterally to eliminate
IORs were transferred to the Geomagic Control X (Geomagic; unwanted thickness. The numerical data of these regions were
Morrisville, USA) software. Group 3 IORs (Occlufast Rock, type A evaluated.
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A new technique for testing accuracy and sensitivity of digital bite registration: A prospective comparative study

Original article
Figure 3
Selection of entire occlusal surface area. Only the numerical data of the selected region were compared between the groups

Surface deviations resulting from the overlapping were qualita- not included in the assessment because the uncontrollable
tively demonstrated by colour histogram (figure 4). The colour thickness of the impression materials in this region could
codes had the following meanings: green; perfectly aligned adversely affect the results of the study.
areas, red; positively positioned areas (PPA) relative to the
reference model, blue; negatively positioned areas (NPA). Geo- Statistical Analysis of the Data
magic Control X automatically converts surface deviations into Mean values and standard deviations of all parameters were
quantitative data. The numerical data provided by the software determined using the SPSS 22.0 package program (SPSS Inc,
were Mpos (mean of the positively positioned red areas, i.e. Chicago, III). Kruskal-Wallis and post hoc Tamhane tests were
thicker areas than the reference), Mneg (mean of the negatively used to compare the data between the groups.
positioned blue areas, i.e. thinner areas than the reference), ITA
(the ratio of the perfectly matching green area to the total area),
OTA (the ratio of the sum of the red and blue areas to the total Results
area), PPA (positively positioned red areas, i.e. thicker areas The distribution of the Mpos value among the groups was Group
than the reference.) and NPA (negatively positioned blue areas, 1: 185.5  105.3 m, Group 2: 82.7  35.8 m and Group 4: 72.2
i.e. thinner areas than the reference). The sum of PPA and NPA  23.9 m. The difference between Group 1 and the other groups
gives the OTA value, in other words, while OTA describes the was statistically significant (P < 0.001) (table I). The Mneg value
total deviation as a percentage, the PPA and NPA values repre- showed a similar distribution among the groups (P < 0.001).
sent the negative or positive distribution of the total deviation. The meaning of Mpos refers to those areas positively positioned
In the overlaps only data were used from the areas between the relative to the reference. This meant that, in some regions of
first molar and the canine. Both the occlusion on the right and IORs, waxes (Group 1) were slightly thicker than C-type silicones
the occlusion on the left were assessed. The anterior region was and VBRs (Group 2 and 4).

Figure 4
Colour map of superimpositions for one side of bite registrations. The colour codes had the following meanings: green; perfectly
aligned areas, red; positively positioned areas (PPA) relative to the reference model, blue; negatively positioned areas (NPA)
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TABLE I
Mean values of the parameters and comparison of findings among groups.

Mpos (m) Mneg (m) ITA(%) OTA(%) PPA(%) NPA(%)

Mean W SDs Mean W SDs Mean W SDs Mean W SDs Mean W SDs Mean W SDs

Group 1 185.5  105.3a 183.8  96.8a 42.9  18.8a 57.0  18.8a 31.9  14.9a 25.1  13.3a

Group 2 82.7  35.8b 80.0  32.6b 71.5  16.0b 28.4  16.0b 16.0  13.9b 12.4  10.0b

Group 4 72.2  23.9b 76.0  30.8b 77.6  10.5b 22.3  10.5b 7.8  7.1c 14.4  9.5b

Total 113.4  82.9 113.3  79.0 64.0  21.6 35.9  21.6 18.5  15.9 17.3  12.3
P = 0.00 P = 0.00 P = 0.00 P = 0.00 P = 0.00 P = 0.00

In each column, different superscripts (a,b,c) indicate statistically significant difference between groups (P < .05). (unit: m (micrometer) and % (percentage)).

The values for OTA were: Group 1: 57.0%, Group 2: 28.4%, and translucent nature of the material. In the study of Edher et al.,
Group 4: 22.3% respectively. A considerable surface deviation the transillumination technique was used to compare the accu-
between the reference IOR (Group 3) and wax IORs was found racy of virtual interocclusal recording with traditional techniques
when assessing the OTA parameter. Group 2 and Group 4 OTA [19]. In their research, only sites of close proximity and sites of
values were relatively acceptable. This finding revealed the clearance on silicone were detected and compared with the
presence of a general discrepancy in thickness on almost all contact areas of virtual digital models. Botsford et al. tested the
surfaces of the occlusal records. However, if we look at the accuracy of virtual occlusal recording, using special software to
magnitude of these thickness variations between the groups, assess the location and size (circumference) of the canine and
this quantity corresponds to the Mpos and Mneg value, which molar teeth occlusal contact areas [18]. However, different
was 70–80 m on average. The OTA value of Group 1 showed a location and size of contact points on the same digital models
statistically significant difference compared to the other two can be seen in different software, because each software brings
groups (P < 0.001). the models in MIP with its own unique algorithm. Furthermore,
In evaluating the results of this research two components of the Montero et al. reported that IOS devices are unreliable for
OTA value, PPA and NPA, were critical. Indeed, these values determining the occlusal contact area [30]. Park et al. evaluated
indicate the direction of the difference in thickness (positively, i. the occlusal recording success of five different devices using the
e., thicker or negatively, i.e., thinner) between the reference 3D overlap and reported deviations of up to 440 m in the
BRM (Group 3) and the experimental groups. The distribution of performance of the devices [21]. Similarly, Wong et al. observed
PPA values between the groups was as follows: Group 1: 31.9%, deviations up to 579 m in bite registration performance of three
Group 2: 16.0%, and Group 4: 7.8%. The thickness deviation in different devices [22]. According to Cheolmin et al., the mount-
the positive direction (PPA) among test groups was statistically ing accuracy of digital models is influenced by image processing
significant (P < 0.001). Compared to the reference, the occlusal algorithms and software versions, especially for complete arch
recordings obtained in the test groups also contained thinner scans [31].
(NPA) regions. However, only Group 1 showed statistically sig- Our results revealed that there was an average deviation of 70-
nificant differences from other groups. 80 m (Mpos and Mneg) between the reference group and the
study groups. However, Solaberrieta et al. used another method
Discussion to research the accuracy of virtual occlusal recording. In this
In many literature studies, silicone has been reported to be more study, using articulated papers, the contact points on the plaster
successful and reliable in revealing occlusal contacts than other model were compared with the virtual contact points [20]. The
impression materials [26–28]. Specifically, type A silicone allows authors analysed the findings using reverse engineering soft-
for proper and comfortable closing of the mandible prior to ware and detected an average of 69 m deviation. Deviations of
setting. It also maintains its dimensional stability after setting up to 95 m were detected in another study, using transamination
[29]. The transillumination method is accepted as a standard and shimstock [16]. These findings were consistent with the
technique for comparing silicone with other BRM [14,19]. The Mpos and Mneg values obtained in our study.
light transmittance of a material is related to its physical struc- In our view, it is an incomplete approach to analyse a bite
ture as well as its thickness. The qualification of the occlusal registration only according to the occlusal contact points. A bite
contacts in the transillumination method is associated with the registration is much more than occlusal contact points. Indeed,
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A new technique for testing accuracy and sensitivity of digital bite registration: A prospective comparative study

Original article
the relation between the upper and lower models is associated occlusal contact points and sites of close proximity has been
with all three directions of space. Yaw, pitch, and roll rotation of stated to be superior to other approaches [19]. Unlike the
the upper or lower models could have an impact on the occlusal transillumination method, our new approach enables us to
contact points and the sites of close proximity. Since the man- evaluate three-dimensionally not only the contact points but
ufacturers know this condition, they offer users the opportunity also the entire occlusal relationship. The only drawback of our
to manually re-orient virtual articulator models via specific technique was the need for each IOR to be digitized. The process
software. Therefore, scanning as large fields as possible in both was time-consuming and sensitive.
the right and left buccal segments is recommended in order to Bite force generated by patients could be a confounding factor in
prevent possible rotations of the models [32,33]. the three-dimensional comparison of bite registration methods.
The imitation and reflection of reality could sometimes be Gurdsapsri et al. reported that different levels of clenching
difficult for virtual occlusal recordings. For instance, contact increased the posterior occlusal contact areas but did not affect
points that appear in conventional impression materials as a the anterior contacts [37]. In an in vitro study conducted by
thin film layer are observed in virtual registration as a perfora- Krahenbuhl et al., they placed a 49N load on the articulated
tion. This is one of the reasons why micron (m) level deviations models to achieve maximum contact between the antagonist
exist between conventional and virtual bite registration. As a teeth and to ensure that the BRM materials polymerized under
result of the inability for imitation of the reality, it could be seen the same occlusal force [38]. In an in vivo study, standardization
in the patient's mouth during clinical application that a pros- of occlusal force could be quite difficult. Therefore, many similar
thetic restoration produced from virtual bite registration does in vivo studies have not been able to standardize the occlusal
not contact the antagonist teeth. However, some of the force [18,39]. All participants were instructed to bite in the MIP
researchers reported that this problem could be solved by position in all recordings, but their bite force could not be
certain modifications in the software algorithm [17]. Wong measured quantitatively. The results of this in vivo study were
et al. stated that various IOS systems cause different interoc- clinically more relevant, but the fact that the complete stan-
clusal distortion rates [22]. In a study in which Porter et al. dardization of the bite force of the participants could not be
assessed the efficiency of intraoral and extraoral scanners in the achieved quantitatively was the limitation of our study. Addi-
digital model articulation, they reported that only devices using tionally, no test-retest was performed for the new technique
confocal imaging technology correctly articulated the models used in this study. Therefore, additional studies are required for
[34]. In a study comparing traditional and digital bite registra- the technique's validation.
tions, Ries et al. suggested that digital interocclusal registrations
showed higher accuracy [35].
Conclusion
Aside from the deformation of wax materials outside the Virtual bite registrations could safely be used as an alternative to
mouth, it may generate resistance during the lower jaw closure. conventional BRs.
This can affect the sensitivity and accuracy of the bite registra- The performance of wax as a bite registration material was far
tion [24]. In order to eliminate such undesirable factors, all behind other methods.
traditional bite registrations were scanned and digitalized
Ethics approval: this study was approved by Afyonkarahisar Health
shortly after they were obtained by a single experienced Sciences University Clinical Research Ethics Committee.
researcher. Patients whose wax registration had been deformed
Consent for publication: written consent for publication was obtained
during the digitalization were excluded from the study. The from each participant.
results of our study have shown that the use of wax for occlusal
registration was cost-effective but less reliable than other tech- Availability of data and materials: data and materials are available at the
Orthodontic Department in the Faculty of Dentistry, Afyonkarahisar Health
niques. The surface deflection was on average 180 m and this Sciences University.
was approximately twice higher than the other groups.
In previous studies, when certain standards are met, the virtual Funding: not applicable.

registrations were stated to be accurate [32,33,36]. In our study, Authors' contributions: H.C. and F.S. created the conception/design of the
a more sensitive and more holistic method was used than work, and wrote the article. H.C. and F.S. performed experimental
procedure of the study. HC also created the conception/design of the
previous studies, and not only the contact points but also
work and did a critical revision of the article. All authors read and
proximities of all occlusal surfaces were evaluated. Neverthe- approved the final manuscript.
less, our findings that the VBR was as reliable as traditional IORs
Disclosure of interest: the authors declare that they have no competing
were consistent with the results of previous studies. This was an interest.
indicator of the accuracy of our new bite registration evaluation
technique. Transillumination technique in the determination of
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tome 19 > n83 > September 2021