Karin I.

Dahlmo, BS, CDTa

Matts Andersson, LDS, Odont Dr/PhDb
On a New Method to Assess the Martin Gellerstedt, PhDc
Accuracy of a CAD Program Stig Karlsson, LDS, Odont Dr/PhDd

Purpose: This study was initiated with the purpose of developing and evaluating a system
for measuring the magnitude of the variation between a computer-aided design (CAD)
object created on the computer screen and a replicated object produced by computer-
aided manufacturing (CAM). Materials and Methods: Controlled geometric forms, a square
and a cone, were designed in a CAD program, and measuring distances were selected.
The CAD data were transmitted to CAM data, and objects were produced. The CAD/CAM
process was the Procera system, and the holder system permitted the objects to be ground
into cross sections, similar to the visualization in the CAD program. Five objects of each
shape were produced and measured by two operators two times. Three operators
measured one of the objects 30 times. Results: Observed values were greater than the true
value. For all objects, the systematic error was at most 15.5 µm. Interoperator difference
was small. The variation because of measurement error was greater for the square object
compared to the cone. However, the variation because of object was higher for the cone
object than for the square. The total standard deviation was 7.7 µm. Thus, the total random
error caused by object variation and measurement error was in approximately 95% of all
measurements less than 15 µm. Conclusion: There are no differences in the measurement
data derived from this method and actual measurement data from an object created by the
computer-aided dental design program. The method has high validity and reliability, ie,
high accuracy. Int J Prosthodont 2001;14:276–283.

D uring the past decade, computer-aided de-

sign/manufacturing (CAD/CAM), which are well-
known processes in the industrial world, have found
their way into dentistry. Interest in this designing and
manufacturing process occurred because of its po-
tential as an alternative to the lost-wax technique that
has been used for many decades for fabricating den-
tal restorations. A number of reports in the literature
in recent years detail the CAD/CAM methods that
have been used in dentistry.1–15 Equally impressive is
aManager, Procera Technical Support, Nobel Biocare, Göteborg,
Sweden.
bManager, Procera Research and Development, Nobel Biocare,
Göteborg, Sweden.
c Statistician, University of Trollhättan/Uddevalla, Uddevalla,
Sweden.
d Professor, Department of Prosthetic Dentistry and Dental
Materials Science, Göteborg University, Sweden.
Reprint requests: Ms Karin Dahlmo, Nobel Biocare, PO Box 5190,
S-402 26 Göteborg, Sweden. Fax: + 46 (31) 163152. e-mail:
karin.dahlmo@.nobelbiocare.se
The International Journal of Prosthodontics
the number of articles reporting on the clinical suc-
cess and the improved characteristics of restorations
fabricated by these CAD/CAM methods.16–26
CAD/CAM systems have the potential for three
sources of variation. The first source is the measure-
ment accuracy of the device used in recording the con-
tours of the die and the transfer of the ascii data files
to the computer. The second source of variation is the
ability of the computer software to modify the data in
designing the restoration. The software must be able
to transfer to the manufacturing facility accurate in-
formation that will result in the production of a restora-
tion that is a replica of what was created on the com-
puter screen. The third source of variation involves the
manufacturing process itself and the precision of the
machinery used to fabricate the restoration.
Understanding and measuring the sources of vari-
ation, and the effect of each on the accuracy and pre-
cision of the CAD/CAM system in use, is extremely
important to the success of any dental restorations
produced by these systems, and ultimately the
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 Dahlmo et al
healthcare of the patient. Major errors resulting from
any one of these error sources would eliminate this
technical approach as an option in dental treatment.
Variations between the contours of the original
die and the visualization of the data on the computer
screen, and variations between the die and the man-
ufactured restoration, have been reported.15,20–22,27
However, none of the systems available have re-
ported on the variations between a design created on
the computer screen and the design produced at the
manufacturing facility.
In industrial applications, the CAD/CAM process
usually involves robotic mechanisms to produce mul-
tiple components of the same size and dimensions
that can easily be inspected for accuracy using a
quality-control measurement system. In dentistry,
however, comparing the CAD object with the actual
object produced by a CAM protocol is very difficult.
This lack of supporting documentation is under-
standable because all investigations dealing with the
determination of CAD/CAM variations require a sys-
tem of measuring the variation. Such measurements
are absolutely essential to determine if the object
produced at the manufacturing facility is exactly the
same as the object designed on the computer. No
such measurement systems have been reported.
Therefore, this study was initiated with the purpose
of developing and evaluating a system for measuring
the magnitude of the variation between the CAD die
or object created on the computer screen and a repli-
cated die or object produced by the CAM. The hy-
pothesis for this investigation was that there are no dif-
ferences in the measurement data derived from this
new method and the actual measurement data from
specific sites on an object created by the computer-
aided dental design (CADD) software; the accuracy,
ie, the validity and reliability, of this method is high.
Materials and Methods
This study used the CAD/CAM method of the Procera
system (Nobel Biocare). The recording process in
this system uses a mechanical scanner with a contact
probe. The collected data are transferred to the com-
puter as ascii files. These files can be projected onto
the computer screen as two-dimensional cross sec-
tions through the long axis of the die. Cross sections
are available for every degree around the vertical
axis of the die. The prosthetic reconstruction is de-
signed using a specially developed CADD software
program.
Each tooth form has multiple irregularities and geo-
metric configurations that are unique for that tooth.
Therefore, it is extremely difficult to measure these
tooth forms as they appear on the computer screen and
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New Method to Assess Accuracy of CAD
then compare these data to measurements of the ac-
tual object produced by the CAM process.
A far more practical approach to determine if dif-
ferences exist between the computer screen mea-
surements and the actual measurement data from
the produced object is to use computer-generated
forms of specific designs. A controlled geometric
form will provide specific positions for measurement
data from both the screen and the same locations on
the form produced by the CAM process. For such a
measurement method, the test objects created on the
computer screen must be well-defined geometric
forms.
In turn, the computer software must be able to
generate a cross section vertically through the long
axis of the computer-generated object and display the
cross section as a 2-D profile on the computer screen.
Similarly, the object produced by the CAM would
need to be sectioned in a way that would create the
exact same vertical profile as the one viewed on the
computer screen. From these two 2-D profiles, it
would then be possible to select specific locations for
measurements and comparisons of any measurement
differences between the screen object and the actual
object.
Creating the Computer Object
The Procera CADD program was used to generate the
test objects for this study, and simple geometric forms,
a square and cone, were selected and created in the
CADD program. The objects could be projected on
the computer screen in cross sections vertically
through the center of each object. A specific cross-
section view was selected as a measuring site show-
ing a 180- to 0-degree profile.
Measurement locations (height 1, 2, and 3) were
selected for computer measurements of the CADD-
generated objects, and to establish the CADD value
a special CADD tool, a z reference line, was used.
With the superior surface of the objects being zero,
the line was positioned vertically on the various se-
lected locations, and the distances, or CADD values,
automatically appeared on the computer screen as
numeric figures. The CADD values for the cone were
A = 8,200 µm (1,500 µm from top), and B = 8,500
µm (3,000 µm from top); and for the square C =
8,000 µm (3,000 µm from top) (Fig 1).
Creating the Machined Object
The CADD data from the square and the cone were
transmitted as CAM data for the manufacturing
process, and a Procera milling machine was used to
create the objects. Titanium was selected as the
277 The International Journal of Prosthodontics
 New Method to Assess Accuracy of CAD
A
B C
180° 0°
Milling tool
Titanium rod
Reference stop
Guide pin
180°
milling material. A titanium rod was fixed in a ma-
chining holder device used in the normal CAM pro-
duction process. This holder was designed with a ro-
tational reference and a guide pin. When placing the
holder into the milling machine, the holder was ad-
justed to locate the guide pin to the machining ref-
erence stop, 180 degrees ahead of where the milling
process started, ie, where the first data point around
the vertical axis of the rod would be produced (Fig
2). This adjustment was calibrated to an accuracy of
± 0.05 degrees. When the adjustment was com-
pleted, a machine tool milled the titanium blank
into a square and a cone form around the vertical
axis of the holder.
The International Journal of Prosthodontics
Dahlmo et al
Fig 1 Measurement locations
A, B, and C on the CADD-gener-
ated objects; the cone, left, and
the square, right.
180° 0°
Fig 2 Holder with the milling
material (a titanium rod) placed in
the milling machine and adjusted
to locate the guide pin (the rota-
tional reference) to the machining
reference stop, ie, 180 degrees
from where the milling process
started.
Holder
Machine milling chuck
0°
Measuring the CAM Object
A computer numeric controlled (CNC) milling ma-
chine (Dynamyte 2800) equipped with the same type
of mounting device as the Procera milling machine
was used to grind the machined objects to the cross
section of 180 to 0 degrees. The position of the
mounting device was defined in the control system
of the CNC milling machine, and when positioning
the holder into the CNC, the guide pin was adjusted
to correspond to the cross section of 180 to 0 degrees
in the CAD program. The square and the cone were
then ground through the center of the position to the
cross section of 180 to 0 degrees (Fig 3).
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 Dahlmo et al
Fig 3 Holder with the milled ob-
ject positioned into a mounting
device on the CNC milling ma-
chine and cut to the cross section
of 180 to 0 degrees.
Reference stop
Fixture
A measuring microscope (Nikon SMZ-U), a con-
nected video camera (Sony Color Videoprint
Mavigraph), and a coordinate table with micrometer
gauges (Mitutoyo) were used for the measurement of
the machined objects (Fig 4). An image-analysis system
(Boeckeler VIA 100) and a fiberoptic system (Heim LQ
1600) were used in the measurement procedure. On
the coordinate table, a mounting device permitted the
placement of the holder with the cross-sectioned ob-
jects parallel to the table. In this way, profiles from the
square and the cone could be recorded and visualized
on the video screen. The mounting device allowed for
alignment and fastening of the holder onto the coor-
dinate table so that the vertical axis of the holder cor-
responded to the Y axis on the coordinate table. To
view a profile showing the selected cross section from
180 to 0 degrees, the guide pin was oriented to the ref-
erence stop on the mounting device in a relationship
that corresponded to the first data or milling point (0
degrees) in the rotation. The first step in measuring was
to determine the zero point on the video screen, the su-
perior surface of the square and cone, respectively, for
the control unit in the analyzing system. From this
zero point, the measurement distances A, B, and C
were identified for the control unit on the video screen.
Study Design
Two experiments were performed during this study.
The manufacturing process, grinding process, and
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New Method to Assess Accuracy of CAD
Object
Holder
Guide pin
180°
the measurement procedure were all performed using
a standardized protocol. An individual experienced
in the operation of the CAM system performed the ma-
chining of the two objects. Individuals trained in its
use operated the measurement equipment. During the
measuring procedure, the distance coordinate value
that would have normally appeared on the screen was
hidden to the operator. The reason for blinding the op-
erator to this value was to eliminate any bias on the
part of the operator, who would be performing the
measurements of the same object several times. In ad-
dition, the numeric values of the CADD-generated ob-
jects were unknown to the operators.
In experiment 1, five samples of the square and the
cone were milled, ground (to produce the cross-sec-
tional view), and measured. All objects were mea-
sured independently by two operators. Each opera-
tor measured each object on two different occasions.
During each measurement session the object was
repositioned, and thus the total measuring proce-
dure was repeated. A total of 20 measurements on
each geometric shape were performed. This experi-
mental protocol provided information about the dif-
ference between the measured objects and the nom-
inal value (CADD value), interoperator difference
(difference between operators), variability between
objects (cross-sectional views), and intraoperator
variability (differences between independent mea-
surements performed on the same object by the same
operator, also called measurement error).
279 The International Journal of Prosthodontics
 New Method to Assess Accuracy of CAD
Video head
Measuring
microscope
Guide pin
Holder
Object
Reference stop
In experiment 2, one cone was measured by three
independent operators. Each operator performed 30
independent measurements. For each measurement
the object was repositioned, and thus the total mea-
suring procedure was repeated. This experimental
protocol provided information about the difference
between the measured object and the nominal value
(CADD value), the difference between the three op-
erators, and the measurement error (a more precise
estimate than in the first experiment).
Statistical Analysis
In the first experiment, a two-way analysis of variance
(ANOVA) was used. The objects were considered as
a random sample from the manufacturing and grind-
ing process. Thus, differences between objects (cross-
sectional views) were considered as a random factor
in the model. The possible difference between oper-
ators was treated as a fixed factor in the model. The
model also contained a random error, interpreted as
the measurement error (intraoperator variability). The
objective of this analysis was to separate and estimate
the different sources of variation and to estimate the
eventual difference between the two operators.
In the second experiment, a one-way ANOVA was
used, also with the eventual differences between op-
erators as a fixed factor. The objective in the analy-
sis was to estimate the different sources of variation
and possible differences between operators.
The International Journal of Prosthodontics
Dahlmo et al
Fig 4 Holder with the cross-sec-
tioned object placed in a mount-
Video screen ing device on the measurement
coordinate table with the guide
pin oriented to the reference stop.
Profiles from the object are visu-
alized on the video screen, and
the measurement locations can
be identified for the control unit on
the video screen.
180° 0°
V block
Coordinate table
Results
All mean distance values for the three locations in ex-
periment 1 were greater than the CADD values (Table
1). For the square, C, the mean distance value was
15.5 µm greater than the CADD value. For the cone,
there was also a systematic error; the total mean
value for A and B was 4.2 µm and 7.0 µm greater than
the CADD value, respectively.
In experiment 2, including only one object, the sys-
tematic error was negative; the mean for all three op-
erators was less than the CADD value (Table 2). The
mean measured for location A differed from the CADD
value by only 7.0 µm and for location B by only 6.6 µm.
The difference between the two operators from
experiment 1 and between the three operators from
experiment 2 was at most 7.2 µm (Tables 3 and 4).
The estimates of standard deviation (SD) by differ-
ent sources of variation (experiment 1) gave at most
a total variation of 7.7 µm (Table 5). The estimates of
SD caused by measurement error were smaller in ex-
periment 2 (3.1 µm).
Discussion
The overall focus of this project was to develop a
measurement system that is accurate and reliable
and could be used to compare on-screen data or
measurements of an object created by the CADD
software to actual measurement data collected from
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 Dahlmo et al New Method to Assess Accuracy of CAD

Table 1 Mean A, B, and C Distance Values with Corresponding CADD Values for
Experiment 1

CADD Total Mean values for individual objects, in order

Distance value (µm) mean (µm) Minimum Maximum

A (cone) 8200 8204.2 8198.0 8201.0 8204.0 8204.3 8213.5

B (cone) 8500 8507.0 8498.3 8501.8 8507.5 8512.5 8515.0
C (square) 8000 8015.5 8010.5 8014.5 8015.5 8017.5 8019.5

Table 2 Mean A and B Distance Values with Corresponding CADD Values for
Experiment 2

CADD Total By operator

Distance value (µm) mean (µm) Minimum Median Maximum

A (cone) 8200 8193.0 8190.6 8192.8 8195.6

B (cone) 8500 8493.4 8490.6 8492.7 8496.9

specific locations on the object manufactured from Table 3 True Mean Difference Between the Two
the CADD program. Producing measurement values Operators for Experiment 1
that are extremely close to the CADD value for the Estimated 95% confidence
manufactured objects created by the CADD program Distance differences (µm) interval
will demonstrate that the measurement method is
A (cone) 6.9 3.1–10.7
accurate and that the CADD is also able to produce B (cone) 7.2 3.7–10.7
accurate on-screen measurement values. C (square) 1.0 –5.1–7.1
Experiment 1 provided information about the vari-
ation in five samples produced for each of the
shapes. Data from this experiment also provided in- Table 4 True Mean Difference Between the Operators
formation about the intraoperator variability (mea- for Experiment 2
surement error). In Table 1, all mean distance values Estimated 95% confidence
for all three locations were greater than the CADD Distance differences (µm) interval
values; the fact that the mean distance value is
A (cone)
greater for the square might indicate an error in the Operator 1 vs 2 2.2 0.6–3.8
process of grinding into the selected cross section. Operator 1 vs 3 5.0 3.4–6.6
If the cross section is incorrectly produced, the value Operator 2 vs 3 2.8 1.2–4.4
B (cone)
of distance C will increase because of its squared Operator 1 vs 2 2.1 0.9–3.3
shape. Also included in the squared range was the Operator 1 vs 3 6.3 5.1–7.4
production error, which was found in an earlier in- Operator 2 vs 3 4.1 3.0–5.3
vestigation.15 Interoperator variability was analyzed
by ANOVA in both experiments. In Tables 3 and 4,
the analyses of interoperator variability are pre- Table 5 Estimates of Standard Deviation (SD) by
sented; because the confidence interval in all cases Different Sources of Variation for Experiment 1
did not contain the zero, all differences were statis-
SD of variation
tically significant (5% level of significance). because of SD of variation
However, the difference was at most estimated to be measurement because of SD of total
7.2 µm. The estimated difference between operators Distance error (µm) objects (µm) variation (µm)
was smallest for the squared shape. Because both op- A (cone) 3.9 5.4 6.8
erators performed the same number of observations, B (cone) 3.6 6.8 7.7
a difference of 7.2 µm means that one operator’s C (square) 6.3 1.1 6.5
mean value was 3.6 µm greater than the average (in
this case 8507.0 µm according to Table 1) and the
other operator’s mean value was 3.6 µm less than the various location distances for the two objects. One
average. The small confidence intervals indicated can conclude from the data that different operators
that little measurement difference occurred between can use this method with small differences, ie, high
the two operators when they were measuring the interoperative reliability.
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 New Method to Assess Accuracy of CAD
Both experiments were performed with replicates,
ie, several independent measurements on the same ob-
ject performed by the same operator. This provides the
opportunity to estimate the intraoperator variability
by experiment. Furthermore, because the first experi-
ment also contained several different objects, it also
provided the opportunity to estimate variation caused
by objects (cross-sectional views). Estimates of varia-
tion in terms of SD from different sources are pre-
sented in Table 5; the total variation was nearly the
same for both shapes. The SD for the cone was only
slightly higher. For the square, most of the variation was
because of measurement error. For the cone, the SD
for the measurement error was smaller than the SD be-
cause of objects.
The most pessimistic interpretation is that the total
systematic error on the two shapes could be 15.5 µm
(greatest systematic error) plus 3.6 µm (the operator
with the greatest systematic error), which gives a
“worst-case systematic error” of 19.1 µm. In the total
systematic difference from the CADD value, the op-
erator error was the smallest part. Nevertheless, analy-
sis of the reasons for operator differences could pro-
vide a means to calibrate operators and decrease
differences.
The other part of the systematic difference could be
because of the grinding process and/or measurement
process. This difference could be reduced by analy-
ses and refined processes. However, a total system-
atic difference of at most 19.1 µm must be considered
acceptable. Thus, the validity is acceptable.
When comparing the two operators performing
measurements on the three distances, the estimated
difference between the two operators was at most 7.2
µm. Although this difference is statistically significant,
it is from a practical point of view a small value. Thus,
the interoperator reliability, even in the worst case,
could be considered acceptable. Nevertheless, it may
be possible to reduce this difference.
The variability, in terms of SD, because of random-
ness, ie, intraoperator variability and differences be-
tween objects, was at most 7.7 µm. A standard devia-
tion of 7.7 µm means that differences from the CADD
value because of randomness will be lower than 7.7 µm
in 68% of all cases; in 95% of all cases, the difference
because of randomness will be lower than 15.4 µm.
Observe that the random difference should be added
to the systematic difference. The size of the systematic
difference depends on which object is to be measured
and by which operator (earlier estimated to be at most
approximately 19 µm). Regarding the squared shape,
most of the variability was because of intraoperator
error. Regarding the conical shape, variability because
of differences between objects was a little higher than
intraoperator variability. It seems reasonable that the
The International Journal of Prosthodontics
Dahlmo et al
variability because of differences between objects was
higher for the conical shape than for the square. This
is because the conical shape is more complex and the
distance value A and B is dependent on the height.
The variability because of intraoperator variability
could actually be improved. It is rather easy and not
that time consuming to take replicates and use the
mean value. For instance, by using four measure-
ments instead of one, the intraoperator variability is
reduced by 50%. The intraoperator variability and
variability because of differences between objects is
rather small and could be regarded as acceptable.
Thus, the reliability is acceptable.
Conclusions
Under the assumption that the manufacturing process
was without systematic error, the measuring method
(ie, grinding and measuring) gave a positive system-
atic error, ie, observed values were greater than the
true value. For all objects and geometric shapes, the
systematic error was at most 15.5 µm. The estimated
difference between operators, interoperator differ-
ence, was so small that it is of no relevance. The vari-
ation because of measurement error, intraoperator
variability, was slightly lower in the second experi-
ment, and it was greater for the square object com-
pared to the cone. However, the variation because of
objects was higher for the cone object than for the
square. The total standard deviation was only 7.7 µm.
Thus, the total random error caused by object varia-
tion and measurement error was in approximately
two thirds of all measurements lower than 8 µm. In ap-
proximately 95% of all measurements, the random
error will be lower than 15 µm. Within the limitations
of this investigation, it can be concluded that:
1. There are no differences in the measurement data
derived from this new method and actual mea-
surement data from specific sites on an object cre-
ated by the CADD program. The method has high
validity and reliability, ie, high accuracy.
2. The new measurement method provides an exact
measure to determine the capabilities of the on-
screen designing process of the Procera CAD/
CAM system. The method can be used when de-
termining the clinical acceptability of dental
restorations.
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FORM WITHOUT WRITTEN PERMISSION
FROM THE PUBLISHER.
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Literature Abstract

The relationship between cigarette smoking and dental implant failure.

This article presents the results of a retrospective clinical study that shows the effect of to-
bacco on implant treatment. The records of 56 implant patients of a single surgeon were re-
viewed. A total of 187 Brånemark (Nobel Biocare) endosseous dental implants had been
placed over a 4-year period for removable and single- or multiple-unit fixed prostheses. A stan-
dard data sheet was used to collect information including patient gender, age, medical and
dental history, status regarding smoking, intraoral location of each implant, reason for failure,
and bone type at the placement site, ie, grafted or natural bone. A Chi-squared test was used
to compare implant failure rates in smokers and nonsmokers by whole mouth and by specific
location. This study demonstrated a significant association between implant failure rates and
cigarette smoking, with failure rates of 17% in smokers compared to 7% in nonsmokers.
Implant length was also shown to be a significant factor, with shorter implants (≤ 10 mm) being
more susceptible to failure in smokers. It was concluded that these results concur with many
other studies of the topic, and many surgeons have recommended a complete, if only short-
term, cessation of smoking in the perioperative period for implant placement. Smoking should
be considered a relative contraindication to implant placement when planning treatment.

Wallace RH. Eur J Prosthodont Restorative Dent 2001;8:103–106. References: 23. Reprints: Dr Robert H.
Wallace, Senior House Officer, Department of Restorative Dentistry, Newcastle Dental Hospital, Richardson
Road, Newcastle-upon-Tyne NE2 4AZ, United Kingdom. Fax: + 0191 2275149—AW

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