IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191

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IP Indian Journal of Orthodontics and Dentofacial Research

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Original Research Article

Comparative evaluation of accuracy, time and patient acceptance between
intraoral scanner and conventional alginate impression technique – An invivo
study
Manasi Jajee1, *, Vishwanath S Patil1 , Basanagouda C Patil1 , Sudha R Halkai1 ,
Jagadish Kadammanavar1 , Munazzah Fatima1
1 Dept. of Orthodontics and Dentofacial Orthopaedics, HKE’s S Nijalingappa Institute of Dental Science & Research,
Kalaburgi, Karnataka, India

ARTICLE INFO ABSTRACT

Article history: Introduction: Orthodontists use various dental records such as dental models or casts for diagnosis and
Received 14-06-2023 treatment planning which includes making of dental impressions and study casts. Conventional alginate
Accepted 07-08-2023 impressions are challenging for the patients with extreme gag reflex, irritation & discomfort. Recently 3D
Available online 08-09-2023 technology has led to development of scanning and digital models, but one major concern has been the
accuracy. So this study was done to compare the accuracy, time and patient acceptance between intraoral
scanner and conventional alginate impression technique.
Keywords:
Materials and Methods: 15 patients were selected. Alginate impressions were made using zhermack
Digital impression
neocolloid. The patients were subjected to digital scanning with Medit i500 intraoral scanner. Procedures
Medit i500 were timed. After the impressions, each patient was asked to complete survey. Tooth width measurements
Conventional impression were made using digital vernier caliper from stone models. In the second method digital images were
Bolton ratio
measured using medit link software. Anterior and overall Bolton ratio was calculated to determine accuracy.
Intraoral scanner
Results: Digital impressions are accurate and comparable to conventional impressions as tooth width
Patient preference measurements did not differ significantly. Conventional impression consumed more time. Patients preferred
digital impressions.
Conclusion: Intraoral scanners are accepted by patients and they have comparable accuracy and time
efficient compared to conventional impression.

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1. Introduction digital impression techniques have continued evolving and

their uses have broadened. Interest in three-dimensional
Impressions have been used in the dentistry since the latter imaging and digital scanning has increased recently. Digital
part of the eighteenth century, and is of great importance in impressions and 3D models have a wide range of application
the practice of dentistry. Throughout the past two centuries, in the dental field and dental specialties. 1
the methods of making dental impressions have greatly
evolved. The 20th century showed remarkable advances Orthodontists use various dental records such as dental
in technology, and digital impressions for use in dentistry models or casts for diagnosis and treatment planning
came about in the 1980’s. In the decades following, which includes making of dental impressions and pouring
study casts. 2 Conventional alginate impression techniques
* Corresponding author. are challenging for the patients with extreme gag reflex,
E-mail address: [email protected] (M. Jajee). irritation & discomfort. 2 It requires stocking of raw

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2581-9356/© 2023 Innovative Publication, All rights reserved. 183
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materials as well as storage space for the plaster a way that minimises patient discomfort. It functions with
models. 3 Plaster models are subject to loss, fracture, and the Medit Link programme. The scanning is powder free
degradation. 4 Current interest in 3D technology has led to which is more comfortable for the patients. The Medit link
development of scanning and digital models. Digital casts application saves the scan in various formats like OBJ, STL
has numerous advantages such as more efficient storage, or PLY so it can be used with the software that supports
data retrieval, transferability, decreased processing time. these formats.
In 1999, digital models were first made accessible in Conventional methods of impression taking uses
orthodontics. These models were made by scanning plaster impression materials which are dimensionally stable such
casts made from impressions. 5 Diagnostic measurements as alginate or agar. Zhermack neocolloid Alginate is used
have usually been made on plaster dental casts. 3D digital for this study which has high thixotropy, accuracy in the
dental models can be used now. 6 Digital models can be reproduction of details and a dimensional stability from
used in orthodontics for analysis of teeth and occlusion, 48 to 120 hours. It has become essential for assessing
treatment simulation, appliance design and production, and the reliability of tooth size-arch length discrepancy
assess the treatment effects. 1 No significant differences measurements performed on digital impressions and
were found in the assessments of linear interarch, overjet, compare the measurements with those obtained from plaster
overbite, and arch-length measurements obtained from these models by means of traditional methods. So a comparison
digital 3D models and their corresponding plaster models between the digital and conventional method is done in this
on comparison. 7 The most critical requirement for a digital study.
model system in orthodontics is its diagnostic precision. 8 Patient acceptance was checked using a questionnaire.
With the development of digital impression and their Various types of surveys can be utilized for psychometric
reported advantages, one major concern has been the measurements, and the most commonly used measurement
accuracy. Since the introduction of 3-dimensional scanning scales are the Likert scale and visual analog scale (VAS),
in dentistry, a number of dental and orthodontic providers both of which have been found to be reliable. The Likert
have started making digital scanners and thorough software scale provides multiple pre-determined categories for the
analysis programmes that perform a wide range of tasks. 9 subject to select, such as “strongly agree, agree, neutral,
These functions simplify procedures such as dental analysis disagree, and strongly disagree.” It is measured with ordinal
and diagnosis, occlusal setups, and treatment predictions. numbers, where each answer choice is assigned a nominal
The digital software also offers new procedures, such as the value. 12 Improvement of patients’ satisfaction can result in
ability to overlay models at different time points, allowing increase in patient compliance. This is especially true in
visualization of tooth movements and treatment outcomes. patients who may have fear or anxiety related to healthcare.
Due to the limited data and controversial findings from
Various manufacturing companies have been producing
studies examining patients’ opinions of intraoral scans,
intraoral scanners. Each scanning system is advantageous to
more information is needed to evaluate patient satisfaction
practitioners in one or the other way, including size of wand,
and preference for different impression types. So this
use of powder, scanning method, ability to capture colour
study was done to compare the accuracy, time and patient
and record full mouth scan, ease of using software, device
acceptance between intraoral scanner and conventional
portability, time required for scanning and compactness of
alginate impression technique.
scanner. 9,10
The intraoral scanners differ in method of image
2. Materials and Methods
acquisition, as well as in unit size, speed and weight.
Image acquisition techniques such as triangulation, active 2.1. Instruments and materials that will be used
wavefront sampling (AWS), parallel confocal system,
1. Equipment
accordion fringe interferometry (AFI), three-dimensional
in-motion video, telecentric system and IOS fast scan (a) Medit i500 intraoral scanner(Medit Corp., Seoul,
have been introduced. Examples of currently marketed Korea).
intraoral scanning systems include the iTero Element (b) Digital vernier caliper (Oleander).
(Align Technology, San Jose, CA), TRIOS 3 (3Shape (c) Stopwatch
A/S, Copenhagen, Denmark), True Definition (3M ESPE,
St. Paul, MN), Cerec AC OmniCam (Sirona Dental 2. Materials
Systems, Bensheim, Germany), CS3600 (Carestream (a) Alginate impression material (Neocolloid
Health, Rochester, NY), and PlanScan (Planmeca/E4D Zhermack, Badia Polesine, Italy)
Technologies, Richardson, TX) and Medit. 11 (b) Dental stone (Orthokal, Kalabhai Karson Pvt.
In this study Medit i500 scanner is used for digital Ltd., India)
impression technique. To acquire 3D images triangulation (c) Rubber bowl
technology is used. The operator can move the scanner in (d) Alginate mixing spatula
 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191 185

(e) Impression trays was used to record tooth widths from the stone models
(Orthokal, Kalabhai Karson Pvt Ltd., India). The second
2.2. Method method of measurement involves using tools in Medit
link software (Figure 8). Tooth widths were measured by
2.2.1. Inclusion criteria selecting maximum mesiodistal diameter of each crown. An
1. Patients with age range between 15-50 years. anterior and an overall Bolton ratio was calculated. In this
2. Patients with full complement of permanent teeth from study, validity is considered to be the extent to which the
first molar to contralateral first molar in both the jaws. measurements from digital system agreed with the caliper
3. No missing or heavily restored teeth. measurements. Measurements made with caliper are taken
4. No remaining deciduous teeth, no supernumerary to be the true values. Accuracy was judged as the closeness
teeth. of the digital values to the caliper measurements which was
5. No teeth with large carious lesions or enamel defects. assessed by measuring anterior and overall Bolton ratio.
that would affect the mesiodistal morphology of crown.

2.2.2. Exclusion criteria

1. Patients with history of mental, emotional or
developmental disabilities, cleft lip or palate or other
craniofacial anomalies, epilepsy, seizures or chronic
use of anticonvulsants.
2. Patient with missing and heavily restored teeth
3. Patients with deciduous teeth and supernumerary teeth
4. Patients with large carious lesions and enamel defects
which affects the mesiodistal morphology of crown.

2.2.3. Procedure
The patients were selected based on the inclusion and
exclusion criteria. Informed consent was obtained. All
patients underwent oral prophylaxis.
Two procedures were done on each patient as follows:

1. Conventional alginate impression (Neocolloid

Zhermack, Badia Polesine, Italy). Fig. 1: Alginate impression material (Neocolloid Zhermack, Badia
Polesine, Italy)
2. Digital impression with intraoral scanner (Medit i500,
Medit Corp., Seoul, Korea).

All the materials needed to perform the procedures was

organized before seating the patient (Figures 1 and 2).
Upper and lower alginate impression (Figure 3) were made
with neocolloid impression material (Neocolloid Zhermack,
Badia Polesine, Italy).
The impressions were poured in dental stone (Orthokal,
Kalabhai Karson Pvt Ltd., India) to obtain study models
(Figures 4 and 6). Base pouring was done with dental
plaster.
The intraoral scan was performed with Medit i500
intraoral scanner (Medit Corp., Seoul, Korea). Full arch
scanning was done (Figure 7). The second and third molar
were included in the scan, when present. The scan was
opened in Medit link software and digital image was
obtained (Figure 8). Timing was recorded for both the
procedures. While taking the alginate impression time was
recorded from tray selection till impression removal. After
the clinical procedure, each patient was asked to complete Fig. 2: Materials required for impression
the specifically designed survey. For the first method of
measurement (Figure 5), a digital vernier caliper (Oleander)
186 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191

Fig. 3: Upper and lower alginate impressions (Neocolloid

Zhermack, Badia Polesine, Italy)

Fig. 6: Study models

Fig. 7: Medit i500 intraoral scanner (Medit Corp., Seoul, Korea)

Fig. 4: Type III dental stone (Orthokal, Kalabhai Karson Pvt. Ltd,)
India)

Fig. 8: Intraoral scan images with tooth width measurements

3. Results
Data was entered into Microsoft Excel spreadsheet and
was checked for any discrepancies. Summarized data was
presented using Tables and Graphs. The data was analysed
by SPSS (21.0 version). Shapiro Wilk test was used to check
which all variables were following normal distribution. Data
was normally distributed therefore, bivariate analyses were
Fig. 5: Digital vernier caliper (Oleander) performed using the parametric tests i.e Independent t test.
For finding the association between categorical variables,
Chi square test was used. Level of statistical significance
 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191 187

was set at p-value less than 0.05. More number of subjects among whom digital scanning was
As per the results obtained, the mean value for ABR done said that their appointment for the impression did not
was found to be 78.63 and 78.78 for alginate and digital last long.Table 7
impression respectively which is not statistically significant Significant difference was seen in the perception
(p=0.89;Table 1). The mean for OBR was 93.65 and regarding stress for the appointment when subjects were
93.72 for alginate and digital impression, which is again asked between alginate impression or digital scanning.
statistically not significant (p=0.94; Table 1). The result More number of subjects among whom digital scanning was
shows no significant difference between the Bolton ratio done said that they had no stress.Table 8
calculated by both the methods as p>0.05. Overall perception score was found to be significantly
Work time analysis for the digital and the conventional more in digital scanning group favouring the digital
impression procedures revealed a significantly reduced impression.Table 9
mean chair time for the digital workflow of 3.39 min
compared with the conventional approach with 7.46 min 4. Discussion
(p=0.001; Table 2). In Tables 3, 4, 5, 6, 7 and 8,
Analysis of tooth size differences is necessary for both
the calculated mean results are presented related to
orthodontic diagnosis and treatment planning. It has even
treatment time, patients’ comfort level, anxiety, gag reflex,
been referred to as the seventh key of occlusion and
queasiness, ease of breathe and possible stress during
is regarded as the important variable, particularly in the
impression procedures. In general, significant differences
anterior segment. Bolton was the first to identify the precise
[P < 0.05] were evident for all six questions’ pairings,
ratios of the mesiodistal width that exist between the
always favouring the digital technique over the conventional
maxillary and the mandibular dentition from canine to
approach (Tables 3, 4, 5, 6, 7 and 8). One additional
canine and from first molar to first molar in order to achieve
question regarding overall perception was given. Again,
an ideal occlusion in 1958. Earlier authors such as Neff,
analysis demonstrated mean satisfaction scores with a trend
Ballard, and Lundstrom had made attempts to quantify this
favoring the digital impression for the defined categories:
relationship. 2
with overall mean value of 25.53 (P =0.001).
According to Bolton the purpose of the tooth size
No significant difference was seen in the Anterior and
discrepancy ratio as a diagnostic aid is “to gain insight
overall Bolton ratio of the impression taken from digital
into the function and esthetic outcome of a given case
scanning or alginate impression as p>0.05.
without the use of keslings diagnostic setup”. Though
Time taken was found to be significantly more when Bolton’s analysis is considered as the gold standard for
impression was taken from alginate impression technique predicting interarch tooth size discrepancies, this study
as p<0.05.Table 2 aims in comparing the validity of the values between
Significant difference was seen in the perception of two methods namely vernier calipers and digital software
gag reflex when subjects were asked between alginate measurements. 2
impression or digital scanning. More number of subjects In the present study 15 patients between 15-50 years of
among whom digital scanning was done said that they did age were selected. One set of alginate impression was made.
not feel gag reflex.Table 3 Digital models were obtained by using Medit i500 intraoral
Significant difference was seen in the perception of scanner (Medit Corp., Seoul, Korea) and the digital values
queasiness when subjects were asked between alginate were attained using medit link software (Figures 7 and 8).
impression or digital scanning. More number of subjects Linear measurements of each tooth (mesiodistal width) were
among whom digital scanning was done said that they did calculated in the study models using digital vernier caliper
not feel queasiness. Table 4 (Oleander; Figure 5).
Significant difference was seen in the perception Caliper measurements were recognised as the gold
regarding easy breathe when subjects were asked between standard to which other measuring methods were compared,
alginate impression or digital scanning. More number of according to Jennifer Asquith et al. Shellart et colleagues
subjects among whom digital scanning was done said that used vernier calipers and needle point dividers to calculate
they had easy breathe.Table 5 the Bolton’s analysis values. To avoid a parallelex mistake,
Significant difference was seen in the perception a digital vernier caliper was employed in place of a vernier
regarding comfort feeling when subjects were asked caliper. 13 This study evaluated the validity of the Medit i500
between alginate impression or digital scanning. More intraoral scanner and its associated software in measuring
number of subjects among whom digital scanning was done mesiodistal widths and determining Bolton’s ratios.
said that they felt comfortable.Table 6 To compare the two groups, chi square test was used
Significant difference was seen in the perception and P value was calculated to find the significance level.
regarding appointment for the impression when subjects There was no statistically significant difference between
were asked between alginate impression or digital scanning. the Bolton ratios from the digital method and the caliper
188 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191

Table 1: Intergroup comparison of Anterior and overall Bolton ratio

N Mean Std. Std. Error P value
Deviation Mean
Anterior Bolton ratio Alginate impression 15 78.6300 3.02560 .78121
0.897
(ABR) Digital scanning 15 78.7847 3.44411 .88927
Overall Bolton ratio Alginate impression 15 93.6547 2.54449 .65698
0.947
(OBR) Digital scanning 15 93.7273 2.70937 .69956

Table 2: Intergroup comparison of time taken

N Mean Std. Deviation Std. Error Mean
Alginate impression 15 7:46:40.00 0:15:20.528 0:03:57.679
Time taken
Digital scanning 15 3:39:36.00 0:45:19.435 0:11:42.155
P value 0.001

Table 3: Perception regarding gag reflex

q1
Total
Strongly Disagree Neutral Agree Strongly
disagree agree
Alginate N 3 9 1 1 1 15
impression % 20.0% 60.0% 6.7% 6.7% 6.7% 100.0%
Group
Digital scanning N 0 0 0 9 6 15
% 0.0% 0.0% 0.0% 60.0% 40.0% 100.0%
N 3 9 1 10 7 30
Total
% 10.0% 30.0% 3.3% 33.3% 23.3% 100.0%
P value 0.001

Table 4: Perception regarding Queasiness

q2
Total
Strongly Disagree Neutral Agree Strongly
disagree agree
Alginate N 1 4 8 1 1 15
impression % 6.7% 26.7% 53.3% 6.7% 6.7% 100.0%
Group
Digital N 0 0 1 8 6 15
scanning % 0.0% 0.0% 6.7% 53.3% 40.0% 100.0%
N 1 4 9 9 7 30
Total
% 3.3% 13.3% 30.0% 30.0% 23.3% 100.0%
P value 0.001

Table 5: Perception regarding easy breathe

q3
Total
Disagree Neutral Agree Strongly
agree
Alginate N 4 7 3 1 15
impression % 26.7% 46.7% 20.0% 6.7% 100.0%
Group
Digital N 0 1 7 7 15
scanning % 0.0% 6.7% 46.7% 46.7% 100.0%
N 4 8 10 8 30
Total
% 13.3% 26.7% 33.3% 26.7% 100.0%
P value 0.002
 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191 189

Table 6: Perception regarding comfort feeling

q4
Total
Strongly Disagree Neutral Agree Strongly
disagree agree
Alginate N 2 3 8 1 1 15
impression % 13.3% 20.0% 53.3% 6.7% 6.7% 100.0%
Group
Digital N 0 0 4 6 5 15
scanning % 0.0% 0.0% 26.7% 40.0% 33.3% 100.0%
N 2 3 12 7 6 30
Total
% 6.7% 10.0% 40.0% 23.3% 20.0% 100.0%
P value 0.014

Table 7: Perception regarding appointment for the impression

q5
Total
Disagree Neutral Agree Strongly
agree
Alginate N 3 6 3 3 15
impression % 20.0% 40.0% 20.0% 20.0% 100.0%
Group
Digital N 0 2 9 4 15
scanning % 0.0% 13.3% 60.0% 26.7% 100.0%
N 3 8 12 7 30
Total
% 10.0% 26.7% 40.0% 23.3% 100.0%
P value 0.043

Table 8: Perception regarding stress for the appointment

q6
Total
Strongly Disagree Neutral Agree Strongly
disagree agree
Alginate N 1 7 1 3 3 15
impression % 6.7% 46.7% 6.7% 20.0% 20.0% 100.0%
Group
Digital N 0 1 0 9 5 15
scanning % 0.0% 6.7% 0.0% 60.0% 33.3% 100.0%
N 1 8 1 12 8 30
Total
% 3.3% 26.7% 3.3% 40.0% 26.7% 100.0%
P value 0.040

Table 9: Intergroup comparison of overall perception

N Mean Std. Deviation Std. Error Mean
Alginate impression 15 17.2000 5.22631 1.34943
Digital scanning 15 25.5333 2.94877 .76137
P value 0.001

measurements obtained from alginate group. The tooth information from plaster models that are converted to digital
widths obtained from the alginate impression showed files is very accurate. The digital models obtained from that
slightly increased values in comparison with the medit link intraoral scanner eliminate the inherent problem of model
software values (Table 1). storage. They also have potential benefits such as: Instant
accessibility of 3D information without need for retrieval
Dental cast analysis plays a vital role in clinical
of plaster model from storage area, ability to perform
orthodontic practice for both diagnosis as well as for
accurate treatment planning and diagnostic set ups for
predicting and assessment of the treatment outcome.
various orthodontic cases, virtual images can be transferred
According to the literature review there are no universal
anywhere in the world for referral and consultations. 7
standard for defining the accuracy of a study model. 7
Orthodontists are now exposed to new tools as a The present study compared the validity of intraoral
result of technological advancements, which aid in more dental scanner; impression material retrieved study models.
precise diagnosis and treatment planning. The diagnostic The result of this study showed that the tooth width
190 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191

replication by both methods showed a reliable value impressions were still the preferred model acquisition
(Table 1). In a study by Ursus R Schimer et al they method with respect to chair time and patient acceptance. 2
evaluated the accuracy and reliability of computer aided This was contradictory as we found that digital impressions
space analysis. They compared 3D orthodontic dental casts are less timing consuming with comparable accuracy
with photocopies of stone models and found that dental and are accepted by patients compared to conventional
casts cannot be accurately reproduced on photocopies hence impression technique (Tables 2 and 9).
accurate space analysis from photocopies is not possible. 14
In another study done by Kazuo Hayashi et al they studied 5. Limitations
the accuracy and reliability of Sure Smile Ora Scanner
with Vivid910 Scanner and R700 scanner. They found all While the study revealed some significant differences
these scanners are sufficiently accurate when compared with in patient satisfaction regarding digital and alginate
gold standard and there was no significant difference in the impressions, the limitations of this study should be
reliability between all these comparisons. 15 recognized. As mentioned above, the lack of even
distribution for age and previous impression experience
The study also included investigating patients’ among groups are confounding variables that could affect
perceptions regarding the scanner, and relative chairside the subjects’ responses. Finally, as with all research
time requirements for different impression methods. involving surveys and questionnaires, the inherent issue of
Limited studies evaluating the use and patient perception response bias is present.
of intraoral scanners in the orthodontic field have also been Further studies should analyze whether or not there could
completed, with differing results. 2,16,17 Vasudevan et al be age-related differences among patients’ perceptions.
found that 77% of patients preferred intraoral scans over Further studies with wider sample and comparing different
alginate impressions. Grünheid et al found that 73.3% of age groups should be performed in order to deeply
patients preferred alginate impressions over intraoral scans. investigate those aspects. The method described to check
Burhardt et al found that young patients preferred digital accuracy in this study is time-consuming and requires
impression techniques over alginate impressions. The training, and may give rise to operator related errors.
studies listed above used scanners that required teeth to be
coated with a layer of titanium dioxide powder. Burhardt’s
6. Scope for the Study
study investigated the impact of the titanium dioxide
powder and found that over 60-70% of subjects reported 1. Additional research would be needed to confirm above
noticing the powder. 9 The scanners used in the present findings and to determine the perception considering
study do not use titanium dioxide powder, and patients the age groups.
were comfortable during scanning procedure without any 2. Further research with large number of samples can be
gag reflex (Tables 3 and 6) and they did not feel stressed done to obtain more accuracy.
(Table 8). 3. Other methods to check accuracy can be used which
All patients answered a comparative questionnaire consumes less time.
between the two techniques. The results showed that 4. Comparison can be done by including more number of
digital impressions are more efficient than conventional intraoral scanners.
impression, and have been preferred by 100% of the patients
in this study (Table 9). Therefore, the study concludes that 7. Conclusion
the total treatment time during the conventional impression
Within the limits of the present investigation, the following
technique is longer when compared to the digital system
conclusions can be drawn:
(Table 2). The results are in accordance with the study done
by Maria Francesca Sfondrini et al. 18 Digital impressions 1. No significant difference was seen in the Anterior
used for prosthodontic and restorative means have been and overall Bolton ratio of the impression taken
studied, and recent data suggest that patients prefer digital from digital scanning or alginate impression.
impressions to conventional polyether techniques. 17 Digital impressions are accurate and comparable
In a study by Ulf Schepke et al the digital impression to conventional impressions.
proved to be a more efficient technique when the total 2. Digital impressions resulted to be faster than alginate
time of treatment was evaluated; the digital system required impressions.
fewer reps, which helped reduce the final treatment time; 3. The overall patients’ acceptance of digital impression
the difficulty of the technique was less for digital than techniques was significantly higher than that of
conventional impression when performed by inexperienced conventional impression techniques. Medit i500
operators. 17 This is in accordance with the present study. intraoral scanner scored a better value in terms of
According to study by Thorsten Grunheid et al (2014) comfort, gag reflex breathing difficulty and stress for
despite the high accuracy of chairside oral scanners, alginate appointment.
 Jajee et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(3):183–191 191

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