Our objective was to investigate the influence of various image artifacts on three-dimensional chamfer matching. A number of artificial and natural artifacts (for instance, as a model for CT-MR matching) were introduced or suppressed in pairs of pelvic CT scans, and a perturbation study was used to determine reliability and accuracy in a well known ground truth situation. In general, chamfer matching is extremely robust against missing data, low resolution, and poor segmentation of the images. In the presence of artifacts, minimization of the average distance outperformed minimization of the root-mean-square distance. Outliers in the scan from which the point list is obtained must be avoided. For example, rotation of the femurs reduces CT-CT registration accuracy by 1-2 mm. The robustness of chamfer matching is confirmed by a limited perturbation study of CT-MR registration for the pelvic region. In conclusion, chamfer matching is extremely accurate and reliable if outliers are avoided in the scan from which the point list is derived, and the average distance is used as a cost function.