Dohiem et al.

BMC Oral Health (2022) 22:486 BMC Oral Health

https://doi.org/10.1186/s12903-022-02505-7

RESEARCH Open Access

Digital assessment of the accuracy of implant

impression techniques in free end saddle
partially edentulous patients. A controlled
clinical trial
Mohamed M. Dohiem1, Medhat Sameh Abdelaziz5*, Mohamed Farouk Abdalla2,3 and Aya Mohamed Fawzy4

Abstract
Objectives This in vivo study aims to assess the accuracy of the digital intraoral implant impression technique, the
conventional closed-tray impression technique, and open-tray impression techniques in a standardized method of
data segmentation along with the best-fit algorithm to overcome the inconsistency of results of previous studies
regarding implant impression techniques.
Materials and methods Sixteen implants were placed in eight patients. Each patient has undergone four impression
techniques: direct intraoral scanning of the stock abutment, intraoral scanning using a scan body, conventional closed
tray impression technique, and the conventional open tray impression technique. The conventional impressions
were poured into stone casts with analogues and stock abutments and scanned using a desktop scanner. In intraoral
scanning of the scan body, computer-aided design software was used for the replacement of the scan body with
a custom-made abutment that is identical to the stock abutment, allowing comparison with the other impression
techniques. The deviation in implant position between the groups was measured using special 3D inspection and
metrology software. Statistical comparisons were carried out between the studied groups using a one-way analysis of
variance (ANOVA) test.
Results The total deviation between groups was compared to the reference group represented by the intraoral
scanning of the abutment. The total deviation was statistically significantly different (P = 0.000) among the different
studied groups. The mean deviation was recorded as 21.45 ± 3.3 μm, 40.04 ± 4.1 μm, and 47.79 ± 4.6 μm for the
intraoral scanning of the scan body, the conventional closed, and open tray, respectively.
Conclusion For implant impressions in partially edentulous patients, intraoral oral scanning using a scan body
significantly improves scanning and overall accuracy. Regarding conventional impressions, the closed-tray impression
techniques showed more accuracy than conventional open-tray impressions.

*Correspondence:
Medhat Sameh Abdelaziz
[email protected]; [email protected]
Full list of author information is available at the end of the article

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 2 of 9

Clinical relevance Intraoral digital implant impression using scan body offers more accuracy than conventional
implant impression techniques for recording posterior implant position in free-end saddle partially edentulous
patients.
Keywords Accuracy, Implants, Digital impression, Partially edentulous, Scan body, Custom abutment

Introduction Conventional implant impressions can be classi-

The most important step in the fabrication of an implant- fied as closed or open-tray impression techniques. The
supported prosthesis with long-term success is to accu- open-tray impression technique utilizes a tray with an
rately transfer the 3D implant position from the patient’s open window for unscrewing the impression copings to
mouth to the master cast or prosthesis design software be removed as one unit with the impression, while the
[1, 2]. Inaccurate transfer of the implant position results closed-tray impression technique utilizes an impression
in a poor fit of the prosthesis with biomechanical com- transfer that remains on the implants while the tray is
plications such as bone loss and screw loosening [3, 4]. removed from the mouth. This transfer is later removed
Many factors affect the implant position on the master from the implant and repositioned into the impression [5,
cast, such as the impression technique, impression mate- 16]. The closed tray impression technique is indicated in
rial, tray type, and dental stone manipulation during cast limited inter-arch space situations or where inaccessible
pouring, which are unavoidable human and materials- posterior implants are present. The conventional impres-
related factors [3, 5]. sions could be digitized using desktop optical scanners
With the advancement of computer-aided design and [5].
computer-aided manufacturing (CAD-CAM) technol- To date, different articles have investigated the accu-
ogy, there are direct and indirect approaches for implant racy of digital implant impression techniques. Tomita et
prosthetics digital workflow [6]. The indirect work- al. [17] reported that the use of an intraoral digital scan
flow involves making a conventional implant impres- for a complete arch impression was more accurate than
sion which is then digitized by using an optical desktop a conventional impression, in agreement with Arcuri et
scanner, while the direct workflow creates a digital scan al. and Alikhasi et al. [18, 19]. On the other hand, Seo and
directly from the patient’s mouth using an intraoral scan- Kim [3] highlighted how the accuracy of digital implant
ner, and scan bodies [6, 7]. impression decreases in the case of full arch scanning
Direct digital implant impression has several advan- in comparison with conventional impression. How-
tages over conventional impression techniques, including ever, even if different in vitro studies showed promising
reduced chairside time and increased patient acceptance. results, in vivo studies are currently scarce. etc.
[8] It reduces the possible distortion of an impression It was reported that clinical data regarding digital and
during impression making and cast pouring [1]. It also conventional impressions are sparse, and there is a need
eliminates some procedures related to conventional for valid clinical data on the accuracy of implant impres-
impressions, such as tray selection, pouring of the cast, sions as most of the previous studies are in-vitro stud-
transportation to the laboratory, and cast storage, as all ies, particularly for partially edentulous arches [2, 4].
the data is stored virtually [8–10]. The intraoral scanning Therefore, the primary purpose of this in vivo study was
procedure is very suitable for patients having problems to compare the accuracy between the digital intraoral
with conventional impression techniques, such as gag implant impression technique, the conventional closed-
reflex or allergy to the impression material [11–13]. tray impression technique, and the open-tray impression
For making a direct digital implant impression, a scan technique. The null hypothesis was that conventional
body is screwed onto the implant, then an optical intra- closed-tray and open-tray implant impression techniques
oral scanner (IOS) is used to capture the scan body’s 3D have similar accuracy to digital intraoral scans using a
position [10, 14, 15]. A specific digital library compatible scan body for partially edentulous arches.
with each scan body and implant commercial brand is
used for virtually determining the exact implant position Materials and methods
using superimposition, and a best-fit algorithm [8, 14]. The present study followed the Declaration of Helsinki
The conventional implant transfers the implant posi- for the ethical principles of medical research involving
tion to the master cast using a rigid tray, an impression human subjects and was approved by the research eth-
coping, and elastomeric material [3]. Several conven- ics committee of Future University (FUE-REC (7)/2-
tional implant impression techniques were proposed for 2021). The study was registered on clinicaltrials.gov with
enhancing the accuracy of implant impressions, by splint- registration number NCT04908618. first registered on
ing impression copings and modifying tray design [3]. 1/6/2021. Eight male patients with free-end saddle par-
tially edentulous mandibles, with ages ranging from 30

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 3 of 9

to 50, were selected from the outpatient clinic of the

Department of Prosthodontics at Future University
Faculty of Oral and Dental Medicine (FUE). The inclu-
sion criteria were patients with missing first and second
mandibular molars and a full set of maxillary dentitions
with appropriate inter-arch space. All patients have ade-
quate bone width and length for implant placement. All
patients were free from any debilitating diseases such as
bone diseases, diabetes mellitus, or any other diseases
that affect dental implant osteointegration.

Implant placement
A prosthetically driven implant placement was imple-
mented using a computer-guided flapless surgical pro-
tocol. Each patient was scanned using a Cone-Beam
Computed Tomography x-ray machine (PaX-i3D Green;
VATECH) to obtain a Digital Imaging and Communica-
tion in Medicine (DICOM) file. Intraoral scanning of
the working arch, the opposing arch, and bite registra-
tion was performed using (MEDIT i700; MEDIT Corp)
to create a standard tessellation language (STL) file of the
patient arches.
After the virtual setting of missing teeth using (Exo-
cad, Dental CAD software), and superimposition of the
patient’s DICOM & STL files using (Real guide 5.0 soft-
ware 3DIEMME), the surgical guides were created.
Two dental implants, 4 mm in diameter and 10 mm in
length (Internal hex, conical connection tapered dental
implant, IS-II active, Neo Biotech.) were placed in the
posterior area of the first and second mandibular molars
Fig. 1 Conventional implant impression techniques. (a) closed tray im-
in each patient according to prosthetically driven implant
pression technique. (b) open tray impression technique
placement using the surgical guide with copious irriga-
tion. After 6 months, loading of the healing abutments
was carried out over the implants for 2 weeks. All the a low-expansion type IV dental stone (Zhermack Elite)
surgical procedures for implant placement were per- with an appropriate water/powder ratio according to the
formed by one experienced implantologist. manufacturer’s instructions (Fig. 1a).

Impression techniques Open-tray impression technique

Each patient has undergone four impression techniques, Open tray impression copings were screwed over the
including: implants with a tightening torque of 20 Ncm as recom-
mended by the manufacturer. A bitewing radiograph of
Closed tray impression technique the implant is used to confirm that the impression cop-
The healing abutments were removed and the closed tray ings are correctly seated. The impression copings were
short impression copings were screwed over the implants splinted using dental floss and Dura-lay.
with a tightening torque of 20 Ncm as recommended by A custom hard tray with open holes over the copings
the manufacturer. A bitewing radiograph of the implant was used to make a one-step impression using Putty
is used to eliminate the possibility of a gap between the and a light body rubber base after applying tray adhe-
coping and the implant. sive 10 min before the impression making. After setting
A one-step impression technique using hard, stock tray, the impression material, the impression copings were
and putty and light body rubber base (polyvinyl silox- unscrewed and the tray was removed from the mouth.
ane, Zhermack Elite HD+) was made. The implant ana- The implant analogues were screwed into the impres-
logues were screwed into the impression coping, then sion coping, and the impression was poured into a low-
the impression coping-analog assembly was positioned expansion type IV dental stone (Fig. 1b).
into the impression. The impression was poured using

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 4 of 9

of the scan bodies and surrounding structures on the

software.
A dental computer-aided design (CAD) software (Exo-
cad Dental CAD) was used to fabricate the digital model.
Using the best-fit algorithm and a scan body from the
digital software library, the exact implant position was
determined [20–22], and custom abutments identical
to the abutments used in all the other impression tech-
niques were loaded onto the implant (Fig. 2a–b).
For all four studied groups, the scanning protocol was
performed in a continuous pattern, starting from the
posterior teeth on one side, passing through the anterior
teeth, and ending at the stock abutments/scan bodies on
the other side. The scan was done over the occlusal sur-
face first, followed by the lingual surface, and ended with
the labial and vestibular sides of the teeth. For any miss-
ing data, a smooth vertical rotation of the scanner head
was made over the defective part of the scanning [23, 24].
The scans were done by one experienced operator
in around 5 min for each scan, and then the scans were
exported as an STL file.

The digital comparison of accuracy between implant

impression techniques
Using special 3D inspection and metrology soft-
ware (Geomagic Control X; 3D systems), the intraoral
scanning of the stock abutments tightened over the
implants was set as a reference model for all upcoming
comparisons.
3D segmentation of the model was carried out to split
Fig. 2 Intraoral scanning of scan body. (a) implant position determination
the model into 2 parts: teeth and abutments. The teeth
using the superimposition of the scan body from the digital library. (b)
digital designing of custom abutments over the implants part is used for superimposition between the models
using the best-fit algorithm, while the abutments part
To digitize the conventional impressions I and II, the is used for 3D comparison of accuracy and deviation in
stock abutments were screwed with a tightening torque micrometers (Fig. 3a–b).
of 20 Ncm as recommended by the manufacturer on the The 3D comparison was carried out between the stud-
analogs, followed by digital scanning using an intraoral ied groups, and the root mean square (RMS) values
scanner (MEDIT i700; MEDIT Corp) after being pow- representing the total deviation were collected for each
dered with a homogenous layer of spray (3 M high-reso- group (Fig. 4a–c) (video 1). The RMS value represents
lution scanning spray). the deviation between the data by squaring the distance
between the compared data points, divided by the num-
Intraoral scanning of stock abutments ber of data points, which is automatically calculated by
Stock abutments identical to those used in conventional the software [10, 25].
impressions were torqued in place intraorally at 20 Ncm, Horizontal split sections are made in all the models at
followed by the application of a homogenous layer of the same Z plane for measuring the distance between the
optical scanning powder, and scanned with the MEDIT abutments of the superimposed models using the desk
I700 intraoral scanner, producing a digital representation contact method (software tool) (Fig. 5a–c) (video 1).
of the abutments directly on the software.
Statistical methodology
Intraoral scanning using scan bodies Data were collected and entered into the computer using
Nonmetallic, cylindrical with flattened side scan bodies SPSS (Statistical Package for Social Science) statistical
of 17.1 mm in length (Neo Biotech IS scan body) were analysis program (ver. 25). Kolmogorov-Smirnov test of
screwed onto the implants intraorally with a tightening normality revealed no significance in the distribution of
torque of 20 Ncm, producing a digital representation the variables, so the parametric statistics were adopted.

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 5 of 9

Fig. 3 Segmentation of the scanned model into teeth and abutments. (a) Fig. 4 3D deviation of different implant impression techniques. (a) 3D de-
the scanned model is composed of multiple segments. (b) segmenting viation of intraoral scanning with scan body. (b) 3D deviation of closed tray
the model into teeth to be used for best-fit superimposition and abut- impression technique. (c) 3D deviation of open tray impression technique
ments used for 3D comparison
deviation between each of the studied groups. Intraoral
The mean and standard deviation were used to describe scanning of the scan body group showed the best accu-
the data. Comparisons were carried out between more racy when compared to the control group, while the con-
than two independent, normally distributed subgroups ventional open tray impression group showed the lowest
using a one-way Analysis of Variance (ANOVA) test. level of accuracy. Tables 1 and 2.
Post-hoc multiple comparisons were done using the Bon- The distances measured between the superimposed
ferroni method. An alpha level was set at 5% with a sig- abutments at the horizontal cross-section revealed sta-
nificance level of 95%. tistically significant (p = 0.006) differences between the
groups investigated. The post-hoc comparison showed
Results a statistically insignificant difference between intraoral
The trueness of the different implant impression tech- scanning of the scan body and the closed tray impres-
niques was shown by the mean and standard deviation sion technique. (p = 0.629). The conventional open tray
of the root mean square values. Intraoral scanning of the impression group showed the lowest level of accuracy
scan body and conventional closed and open tray impres- at the horizontal cross-section measurements recording
sions were compared to intraoral scanning of the stock (267.5 ± 21.213 μm) (Tables 1 and 2).
abutment. The mean values of total deviation for the
studied groups were 21.45 ± 3.3 μm, 40.04 ± 4.1 μm, and Discussion
47.79 ± 4.6 μm respectively (Fig. 6). Passive fit is a very important factor for the success of
The total deviation was statistically significantly dif- any implant-supported prosthesis. For this reason, an
ferent among the three studied groups (p = 0.000). The accurate impression free from distortion is very criti-
post-hoc comparison showed a statistically significant cal [8, 26]. In a systematic review, Ting-Shu S and Jian

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 6 of 9

abutments’ positional relationship with the elimination

of the errors related to different impression materials
and techniques [28, 29]. In a study by Natsubori R, it was
concluded that Scan powder improves the accuracy in
stock abutment scanning, especially in cases of multiple
implants [29]. For this reason, the intraoral scanning of
implant abutments was set as a reference for all the com-
parisons in the present study.
IOS scanning of movable tissues such as the tongue
and frenum leads to inaccurate results. On the contrary,
a better scan is achieved of soft tissue with little or no
movement, such as the attached gingiva [11]. For this
reason, movable tissues such as the frenum cannot be
used as a landmark for superimposition and compari-
son between different impression techniques; otherwise,
false results in evaluating accuracy will occur [11]. The
segmentation method used in this study along with the
best-fit algorithm guarantee standardization of research
results by neglecting any irrelevant data in the compari-
son, such as soft tissue, which may affect the results of
the previous studies.
Accuracy is defined by two factors: trueness and pre-
cision. Trueness refers to how close the test scan data is
to the reference scan [8, 10, 30]. The best fit alignment
method is used to evaluate the accuracy of different digi-
tal impressions by scanning either closed or open tray
stone cast using a desktop scanner to fabricate a digital
model, which was the best fit aligned over the digital
models obtained from scanning intraorally using IOS. It
was reported that the best-fit alignment method is suit-
Fig. 5 Horizontal split sections in the compared abutments. (a, b) Hori-
able for the evaluation of accuracy in one quadrant [3,
zontal split sections are made in all the models at the same Z plane. (c)
measuring the distance between the abutments of the superimposed 31, 32]. This algorithm minimizes the global distances
models using the disk contact method between the test and reference data, and the deviation
between the data is measured using the root-mean-
S concluded that digital scans are clinically satisfactory square error [6]. The further the test data was from the
when compared to conventional impression techniques reference, the greater the root mean square and the devi-
in the fabrication of tooth or implant-supported fixed ation [30].
partial dentures [27]. Introducing intraoral optical scan- In our study, a one-step polyvinyl siloxane impression
ners (IOSs) into implant prosthodontics has many ben- technique using putty and light rubber base was used for
efits, such as the elimination of tray selection, impression recording closed-tray and open-tray impression tech-
disinfection, and delivery to the dental laboratory. It niques. Polyvinyl Siloxane impression material is more
also decreases impression distortion during making or accurate compared with polyether impressions in record-
on removal from a patient’s mouth, as well as improves ing implants in a partially edentulous arch [33].
patient comfort and acceptance. Moreover, digital scans In a study by Ajioka H et al., it was reported that an
can be stored electronically as digital information [15, optical impression has a smaller error concerning the
27]. angulation between implants compared to a conventional
Kim JE et al. evaluated the accuracy of intraoral scan- impression [13]. The results of our study emphasize these
ning of stock abutments and reported that intraoral findings as the least mean deviations were in the intraoral
scanning of stock abutments is an accurate method to scanning of the scan body group (21.45 ± 3.3) µm com-
fabricate implant-supported prostheses as the stock pared with the conventional open tray and closed tray
abutment doesn’t require repeated removal as most groups.
impression copings and scan body which could affect The findings of the present study showed that the
the impression accuracy [25]. It was also reported that closed tray impression technique was more accurate
the intraoral scanners can precisely record the stock compared to the open tray impression technique, which

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 7 of 9

Fig. 6 Bar chart comparing the accuracy of the intraoral scanner with scan body Vs. conventional closed and open tray implant impression techniques

Table 1 One-way ANOVA test comparisons between the three Table 2 Post hoc multiple comparisons between the three
different implant impression techniques different implant impression techniques
Different Digital im- Conven- Conventional P Different impression techniques P value P value
impression pression with tional open-tray value Total Distance between
techniques intraoral scan closed-tray impression deviation abutments in the
body impression (R.M.S.) horizontal plane
Mean ± SD 21.45 ± 3.3 40.04 ± 4.1 47.79 ± 4.6 0.000* Digital impression Convention- 0.000* 0.629 NS
Total deviation with intraoral scan al closed-tray
in micro-meter body impression
represented by Digital impression Convention- 0.000* 0.006*
Root Mean with intraoral scan al open-tray
Square (RMS) body impression
Mean ± SD 225 ± 0.27.774 236 ± 23.261 267.5 ± 21.213 0.006* Conventional closed- Convention- 0.003* 0.044*
The distance tray impression al open-tray
in micro-meter impression
between the *: Statistically significant (p < 0.05)
abutments at NS: Statistically not significant (p>0.05)
the horizontal
plane
*: Statistically significant (p < 0.05)
The less deviation in the closed tray impression tech-
NS: Statistically not significant (p>0.05)
nique coincides with Parameshwari G’s findings, which
carried out an in-vitro study comparing different implant
can be attributed to its simplicity, and the closed tray impression techniques for partially edentulous patients
impression copings ideal for single and multiple implants [33]. It also coincides with Balouch et al., who carried
impression in patients with inadequate mouth open- out an in-vitro study comparing the accuracy between
ing for access to the screws retaining the pick- up type the closed tray and open tray impression techniques
impression copings with the impression in place, also in in 15° angled implants and concluded that the closed
patients with limited inter arch space, the tendency to tray is more accurate than the open tray technique [35].
gag, and implants placed in the inaccessible posterior Another in-vitro study by Sabouhi M et al. examined the
region of the mouth [34]. The greater accuracy of the effect of impression techniques and impression coping
closed tray impression technique could also be due to the on the accuracy of impressions and reported that closed-
fact that the path of removal of the impression along with tray impression coping provides a more accurate impres-
the impression copings in the open tray impression tech- sion compared to the other coping designs [26].
nique which cause deformation of the impression mate- On the contrary, after an in-vitro study, Izadi A et
rial which will not be fully recovered [14]. al. reported that the open tray impression technique

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Dohiem et al. BMC Oral Health (2022) 22:486 Page 8 of 9

Authors contributions
provides more accurate impressions compared to other 1. M. M. Dohiem (article approval, operator in all the practical work,
impression techniques [36]. In an in-vitro study com- manuscript Writing-concept).
paring the accuracy of different impression techniques 2. M. S. Abd El Aziz (corresponding Author, operator in all the practical work,
writing of the manuscript-design- interpretation -statistics-data collection-
in partially edentulous patients by Marghalani A et al., it software- article approval).
was reported that there was no difference between open- 3. M. Farouk: concept- design-interpretation.
tray and closed-tray techniques [15]. Concerning the 4. A. M. Fawzy: manuscript Writing- interpretation- article approval)

inconsistent results on the accuracy of either the open Funding

tray or closed tray method, it appears that the measure- This research did not receive any specific grant from funding agencies in the
ment method and superimposition have a great effect on public, commercial, or not-for-profit sectors.
Open access funding provided by The Science, Technology & Innovation
the result [8], there for the segmentation method used in Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank
the present study can overcome this problem. (EKB).
Even though the total deviation between the three
Data availability
implant impression techniques was statistically signifi- All data generated or analyzed during the current study are included in this
cant, these deviations were clinically insignificant as they published article and its additional files.
were below the reported deviation for clinically accept-
able fit (below 200 μm) [2, 15, 37, 38]. Declarations
The limitations of this study include in vivo compari-
Ethics approval and consent to participants
son of different implant impression techniques in full The present study followed the Declaration of Helsinki for the ethical
arch cases and completely edentulous patients, which can principles of medical research involving human subjects and was approved by
represent a challenge in the intraoral scanning impres- the research ethics committee of Future University (FUE-REC (7)/2-2021).

sion technique. The comparison between implant level Informed consent

and abutment level impression techniques is also consid- Informed consent was obtained from all subjects and/or their legal guardians.
ered a limitation of this study. This study compares dif-
Consent for publication
ferent implant impression techniques in free-end saddle Not Applicable.
partially edentulous cases. The different implant impres-
sion techniques in bonded posterior or anterior partially Conflict of interest
The authors declare that they have no conflict of interest.
edentulous patients are also considered a limitation
of this study. It is recommended to utilize the adopted Clinical trial registration
methodology in this study in a large sample size, compar- study was registered on clinicaltrials.gov with registration number
NCT04908618.
ing the mandibular and maxillary partially edentulous
patients’ different implant impression techniques for dif- Author details
1
ferent implant placement positions. Faculty of Oral and Dental Medicine, Zagazig University, El-Zagazig
University, Sharqia, Egypt
2
Faculty of Oral and Dental Medicine, Prosthodontics Department, Cairo
Conclusion University, Cairo, Egypt
3
1. Intraoral oral scanning and scan body significantly Faculty of Dentistry, Galala University, Suez, Egypt
4
Faculty of Oral and Dental Medicine, Future University in Egypt, Cairo,
improve implant impression accuracy. Egypt
2. Closed-tray implant impression technique is more 5
Faculty of Oral and Dental Medicine, Future University in Egypt, Fifth
accurate than the open-tray impression technique in Settlement, End of 90 street, New Cairo, Cairo, Egypt

partially edentulous patients.

Received: 3 June 2022 / Accepted: 11 October 2022
3. The introduced method in this research of data
segmentation along with the best-fit algorithm
has the ability to standardize the measurements
regarding implant impression accuracy. References
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Acknowledgements on the transfer accuracy of conventional and digital implant impres-
The authors thank professor Hussien El Charkawi (head of the prosthodontics sions using a new reference key-based method. Clin Oral Implants Res.
department) for his valuable advice throughout conducting this research. 2021;32:460–9.

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