Periodontology 2000, Vol. 66, 2014, 228–246 © 2014 John Wiley & Sons A/S.

& Sons A/S. Published by John Wiley & Sons Ltd

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Guided surgery: accuracy and

efficacy
MARJOLEIN VERCRUYSSEN, MARGARETA HULTIN, NELE VAN ASSCHE,
KRISTER SVENSSON, IGNACE NAERT & MARC QUIRYNEN

Preoperative three-dimensional planning has gained used in craniomaxillofacial surgery. Despite the fact
popularity because of the introduction of cone beam that some clinical and accuracy studies are available,
computed tomography. Different concepts of three- dynamic systems currently have a very limited indica-
dimensional planning, such as computer-guided tion in implant dentistry and are not in widespread use
(static) surgery and computer-navigated (dynamic) as a result of the initial high costs. Computer-navigated
surgery, have been proposed to transfer virtual digital surgery systems are not included in the current review.
planning from a personal computer to the surgical Using three-dimensional planning software, the
field (42). In computer-guided (static) surgery, a static surgeon can, after consulting with the dentist to pro-
surgical guide is used that transfers the virtual vide a template representing the planned prosthesis,
implant position from computed tomography datato properly position implants in a virtual reality. When
the surgical site. These guides are produced by com- the planned prosthesis is incorporated into these
puter-aided design/computer-assisted manufacture computed tomography images, the planning can take
technologies, such as stereolithography, or manually into account both the jawbone anatomy and the
in a dental laboratory, using mechanical positioning planned superstructure. This should improve biome-
devices or drilling machines (42, 73, 78, 80). During chanics and esthetics. Moreover, it may optimize the
computer-navigated surgery, the position of the sur- mutual interaction between the ‘surgical’ and the
gical instruments in the surgical area is constantly prosthetic teams. Precise preoperative planning has
displayed on a screen with a three-dimensional image made it possible to implement immediate loading in
of the patient. In this way, the system allows real-time a relatively predictive manner and hence reduce the
transfer of the preoperative planning and visual feed- treatment time and increase comfort for the patient.
back on the screen (16, 67, 82). In the review of Jung Furthermore, when combined with flapless surgery, it
et al. (42), a statistically significant higher mean pre- is presumed that postoperative patient morbidity and
cision was found in favor of dynamic systems com- discomfort may also be reduced. As a result, implant
pared with the static surgical guides. However this placement may develop from difficult toward simple
difference could be explained by the fact that there surgery and from stress toward relative comfort, for
are more preclinical studies on accuracy for the both the patient and the surgeon.
dynamic systems and more clinical studies for the The limits of the use of static guided surgery are set
static systems. In contrast to dynamic guidance, the by the maximum deviation observed between plan-
‘static’ guidance via surgical templates does not allow ning and postoperative outcome. Deviations may
changes to be made to the surgical plan at the time of reflect the sum of all errors occurring from imaging to
surgery. However, the bur sleeves of the templates the transformation of data into a guide, to the impro-
permit rigidly guided and highly controllable drilling, per positioning of the latter during surgery. Thus, all
which may be an advantage in areas where irregular errors, although seldom occurring, can be cumula-
bone is present. Furthermore, the intraoperative set- tive. Much attention will be paid to the latter aspect.
up of a navigation system is not required, and there Indeed, when blind surgery is performed, as during a
are no time constraints and potential inconvenience flapless approach, this is very relevant. Critical
of intraoperative registration and tracking. Intraoper- anatomical structures, such as the mandibular canal
ative optical navigation devices are more frequently or mental foramen, must be avoided at all costs to

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 Guided surgery

prevent neurological complications. The preoperative

radiological determination of the distances between
anatomical landmarks can lack precision (15), and
this constitutes a serious risk, especially in the case of
blind surgery. Significant variations can be observed
within the systems working with surgical guides (e.g.
for example, the guidance of the drills in the surgical
templates). Some use different templates with sleeves
with increasing diameter for one patient. Others
apply removable sleeves in one single template (with
removable sleeve inserts or sleeves on drills). Some
systems have specially designed drills or drill stops to
allow depth control, whereas others have indication
lines on the drills. After preparation of the implant os-
Fig. 1. Accuracy is expressed by the following parameters:
teotomy, some systems allow guided placement of
a deviation at the entry point of the implant or cavity (indi-
the implant, whereas for other systems the template cated by letter a); deviation at the apex of the implant or
has to be removed before implant insertion. These cavity (indicated by the letter b); deviation of the axis of
are only some examples illustrating how difficult it is the cavity or implant (indicated by the symbol alpha);
to interpret and compare individual studies. The sys- deviation in height/depth (indicated by the letter y) and
the horizontal/lateral deviation (x).
tematic reviews of Jung and co-workers (42) and
Schneider and co-workers (67), who reviewed both 0.5 (range: 0.1–1.2) mm and 0.8 (range: 0.1–2.7) mm
accuracy and clinical efficacy, concluded that differing at the entry point and 0.5 (range: 0.1–1.3) mm and 1.1
levels and quantity of evidence were available for com- (range: 0.2–3.6) mm at the apex (46,59).
puter-assisted implant placement and that future
research should be directed to increase the number of
Findings
clinical studies with longer observation periods and to
improve the systems in terms of accuracy and efficacy. Data from a recent systematic review (73) revealed an
This review aims to provide an overview of the overall mean deviation, at the entry point, of 1.0 mm
accuracy of the procedure and also to give an over- (standard error = 0.12 mm; 95% confidence interval:
view of the efficacy of static guided surgery. The data 0.8–1.2); range: 0–6.5 mm. The corresponding data at
from two recent systematic reviews (37, 73) are the apex were 1.2 mm (standard error = 0.1 mm; 95%
discussed in this paper. confidence interval: 1.0–1.6); range: 0–6.9 mm. The
overall mean angulation was 3.8° (standard error =
0.3°, 95% confidence interval: 3.2–4.4); range: 0.0–
Accuracy 24.9°. The overall mean vertical deviation (based on
five studies) was 0.5 mm (standard error = 0.1 mm,
95% confidence interval: 0.2–0.7), with a maximum
Definition
ranging from 2.3 to 4.2 mm. This review included 19
Accuracy is defined as matching the position of the articles, which reported on accuracy. Of these studies,
planned implant in the software with the actual posi- two were model based, five were on human cadavers
tion of the implant in the mouth of the patient. The and 12 were on patients. Four to 54 patients were
accuracy of the implant or the osteotomy site is included in each study, giving a total of 279 patients
mostly expressed by four parameters (Fig. 1): deviation overall. The accuracy of 10 different static image-
at the entry point; deviation at the apex; deviation guided systems has been reported (Table 1). Large
of the long axis; and deviation in height/depth. deviations were found to occur. The total deviation is
Matching of the planned with the placed implant the cumulative number of deviations that can occur
position can be based on a second (cone beam) com- at each step (80, 82). These deviations may be consid-
puted tomography scan (allowing matching between ered as very large, but an in-vivo randomized clinical
preoperative planning and postoperative implant trial comparing guided surgery with mental naviga-
positions) or via ‘model matching’ (by comparing tion (with or without any type of surgical template) is
pre- and postoperative models of the treated jaw) currently not available. Two in-vitro studies on acrylic
(43). The mean deviations for model and computed models (53, 65) compared deviations for mental
tomography matching are quite similar: respectively, navigation with deviations for guided surgery, and a

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 Table 1. Comparison of the accuracy of 10 different static image-guided systems

230
Study Study No. of Site Support System Template No. of Pins Implant Error entry (mm) Error apex (mm) Error angle Error depth
design implants templates guided (°) (mm)

Mean SD Mean SD Mean SD Mean SD

Vercruyssen et al.

Arisan In vivo 279 Maxilla and Aytasarim Safe Stereolithography

et al. (6) mandible SurgiGuide

Bone Aytasarim Safe Stereolithography 3 0 No 1.70 0.52 1.99 0.64 5.00 1.66

Bone SurgiGuide Stereolithography 3 0 No 1.56 0.25 1.86 0.40 4.73 1.28

Mucosa Aytasarim Safe Stereolithography 1 3 No 1.24 0.51 1.40 0.47 4.23 0.72

Mucosa SurgiGuide Stereolithography 1 3 Yes 0.70 0.13 0.76 0.15 2.90 0.39

Tooth involved Aytasarim Safe Stereolithography 1 0 No 1.31 0.59 1.62 0.54 3.50 1.38

Tooth involved SurgiGuide Stereolithography 1 0 Yes 0.81 0.33 1.01 0.40 3.39 0.84

Behneke In vivo 132 Maxilla and Tooth involved Med3D Laboratory 1 0 Sometimes 0.28 0.42 1.94
et al. (12) mandible

87 Maxilla 0.32 0.53 2.02

45 Mandible 0.32 0.42 2.25

24 0.21 0.28 1.49

Cassetta In vivo 227 Maxilla and Tooth involved, Stereolithography

et al. (18) mandible mucosa, bone
116 SurgiGuide Stereolithography 3 0 No 1.47 0.68 1.83 1.03 5.09 3.7 0.98 0.71

57 Safe SurgiGuide Stereolithography 1 Yes Yes 1.49 0.63 1.9 0.83 3.93 2.34 0.85 0.63

54 Safe SurgiGuide Stereolithography 1 0 Yes 1.55 0.59 2.05 0.89 5.46 3.38 0.63 0.43

D´haese In vivo 77 Maxilla Mucosa Facilitate Stereolithography 1 >4 Yes 0.91 0.44 1.13 0.52 2.60 1.61
et al. (24)

Di Giacomo In vivo 21 Mandible and Tooth involved, SurgiGuide Stereolithography 3 0 No 1.45 1.42 2.99 1.77 7.25 2.67
et al. (25) maxilla bone

Di Giacomo In vivo 60 Maxilla and Mucosa SinterStationHiQ Stereolithography 1 2 No 1.35 0.65 1.79 1.01 6.53 4.31
et al. (26) mandible

22 Maxilla 1.51 0.62 1.86 1.07 8.54 4.2

38 Mandible 1.26 0.66 1.75 0.99 5.37 3.98

Dreiseidler In vitro 54 Maxilla and Tooth involved Laboratory

et al. (27) mandible

24 NobelGuide 1 0 Yes 0.22 0.10 0.34 0.15 1.10 0.51 0.25 0.20

30 SICAT 1 0 0.15 0.12 0.40 0.12 1.18 0.55

 Table 1. (Continued)

Study Study No. of Site Support System Template No. of Pins Implant Error entry (mm) Error apex (mm) Error angle Error depth
design implants templates guided (°) (mm)

Mean SD Mean SD Mean SD Mean SD

Ersoy In vivo 94 Maxilla and Ay-Design Stereolithography >1 Not applicable No 1.22 0.85 1.51 1.00 4.90 2.36
et al. (29) mandible

23 Mucosa 1.10 0.70 1.70 1.00 4.90 2.20

45 Bone 1.30 1.00 1.60 1.50 5.10 2.70

26 Tooth involved 1.10 0.60 1.30 0.70 4.40 1.60

48 Maxilla 1.04 0.56 1.57 0.97 5.31 0.36

46 Mandible 1.42 1.05 1.44 1.03 4.44 0.31

Ozan In vivo 110 Maxilla and Tooth involved, Ay-Design Stereolithography >1 0 No 1.10 0.70 1.41 0.90 4.10 2.30
et al. (56) mandible mucosa, bone

58 Maxilla 0.95 0.50 1.41 1.00 4.85 2.40

52 Mandible 1.28 0.90 1.40 0.90 3.32 1.90

30 Tooth involved 0.87 0.40 0.95 0.60 2.91 1.30

50 Bone 1.28 0.90 1.57 0.90 4.63 2.60

30 Mucosa 1.06 0.60 1.60 1.00 4.51 2.10

Pettersson Ex vivo 145 Maxilla and Mucosa NobelGuide Stereolithography 1 3–5 Yes 0.39 0.59
et al. (58) mandible

78 Maxilla 0.83 0.57 0.96 0.50 2.02 0.66

67 Mandible 1.05 0.47 1.24 0.58 2.46 0.67

Pettersson In vivo 139 Maxilla and Mucosa NobelGuide Stereolithography 1 Yes Yes 0.80 1.09 2.26 0.15
et al. (59) mandible

89 Maxilla 0.80 1.05 2.31 0.06

50 Mandible 0.80 1.15 2.16 0.29

Ruppin Ex vivo ~60 Mandible Bone SurgiGuide Stereolithography 3 0 No 1.50 0.80 NA 7.90 5.00
et al. (62)

Sarment In vitro 50 Mandible Epoxy SurgiGuide Laboratory 3 Osteotomies 0.90 0.50 1.00 0.60 4.50 2.00
et al. (65)

Valente In vivo 89 Maxilla and Tooth involved, SurgiGuide Stereolithography 3 Not No 1.40 1.30 1.60 1.20 7.90 4.70 1.00 1.00
et al. (70) mandible mucosa, bone applicable
Guided surgery

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Vercruyssen et al.

Table 1. (Continued)

Study Study No. of Site Support System Template No. of Pins Implant Error entry (mm) Error apex (mm) Error angle Error depth
design implants templates guided (°) (mm)

Mean SD Mean SD Mean SD Mean SD

Van Assche Ex vivo 12 Maxilla and Tooth involved NobelGuide Stereolithography 1 0 or 1 Yes 1.10 0.70 1.20 0.70 1.80 0.80
et al. (71) mandible

Van Assche In vivo 19 Maxilla and Tooth involved NobelGuide Stereolithography 1 0 or 1 Yes 0.60 0.30 0.90 0.40 2.20 1.10
et al. (72) mandible

van Steenberghe Ex vivo 10 Maxilla Mucosa NobelGuide Stereolithography 1 0 Yes 0.80 0.30 0.90 0.30 1.80 1.00
et al. (76)

Vasak In vivo 79 Maxilla and Tooth involved NobelGuide Stereolithography 1 Yes Yes 0.46 BL 0.35 BL, 0.70 BL, 0.49 BL, 3.53 1.77 0.52 0.42
et al. (77) mandible mucosa 0.43 MD 0.32 MD 0.59 MD 0.44 MD

Mucosa 0.49 BL, 0.64 BL, 3.50 0.60

0.46 MD 0.62 MD

Tooth involved 0.37 BL, 0.88 BL, 3.70 0.37

0.35 MD 0.49 MD

Maxilla 0.47 BL, 0.70 BL, 3.55 0.57

0.45 MD 0.59 MD

Mandible 0.41 BL, 0.70 BL, 3.68 0.34

0.36 MD 0.57 MD

Widmann Ex vivo 51 Maxilla and Three screws Easy Taxis Aiming Laboratory 1 3 Yes 1.10 0.60 1.20 0.70 2.80 2.10
et al. (81) mandible Device

This table is adapted from the systematic review of Van Assche et al. (73). The first line of each study represents the overall data. If data are mentioned for subgroups. they are in the lines below. Pins, fixation pins; System, guiding sys-
tem. BL, bucolingual; MD, mesiodistal.
 Guided surgery

significant improvement was observed in favor of

guided surgery for all deviations. The angular devia-
tions were 4.5° and 8.0° (65) in the first study and 4.2°
and 10.4° in the second, for guided surgery and men-
tal navigation, respectively (53). An in-vivo pilot study
confirmed the higher accuracy of guided surgery (79).

Possible sources of error

Radiographic technique. Preoperative planning can

be performed via multislice computed tomography or
cone beam computed tomography (38, 39, 49, 57),
with the latter offering imaging at low dose and rela-
tively lower costs. Poeschl et al. (60) compared the Fig. 2. Example of movement of the patient during the
accuracy of multislice computed tomography with scan. The blue arrow on the three-dimensional model of
that of cone beam computed tomography in image- the jaw shows a clear step, indicating that the patient has
guided surgery in an in-vitro model study. Acrylic moved their head in a vertical manner.
mandibular models with four precise metal reference
markers were scanned using multislice computed longer cylindrical in shape. This could be explained
tomography and cone beam computed tomography. by minor movements during scanning. Pettersson et al.
First of all, the distances between the fixed reference (59) emphasized that such movements are not always
markers were measured using a three-axis drilling visible on the three-dimensional images. Furthermore,
machine; then, they were measured for multislice the automatic superimposing procedure of gutta-per-
computed tomography and cone beam computed cha markers (visible on the patient’s cone beam com-
tomography, applying different software systems. No puted tomography data and the prosthesis cone beam
statistically significant difference was found between computed tomography data in the event that a dual
multislice computed tomography and cone beam scan had been performed) sometimes proceeded
computed tomography. The difference between the without any notification of errors. The ‘movement’
mean value overall and the reference was 0.4 mm for factor has a significant influence on the final accu-
multislice computed tomography and 0.5 mm for racy. However, this statistically significant difference
cone beam computed tomography. Arisan et al. (5) may not be clinically relevant.
compared the accuracy of multislice computed
tomography with that of cone beam computed Position of the scan prosthesis. The correct position-
tomography in a clinical study. Similar deviation val- ing of the scan prosthesis, in particular in cases where
ues were found for multislice computed tomography the scan prosthesis is transferred into the surgical
and cone beam computed tomography: respectively, guide, is extremely important. Therefore, an index is
0.8 (standard deviation = 0.3) mm and 0.8 (standard strongly recommended to position and stabilize the
deviation = 0.3) mm at the entry point, 0.8 (standard template in the mouth of the patient during the scan-
deviation = 0.3) mm and 0.9 (standard deviation = ning process (Fig. 3). Optimal fit of the scan prosthesis
0.3) mm at the apex and 3.3 (standard deviation = 0.4)° with the patient’s soft tissue is crucial. This can be con-
and 3.5 (standard deviation = 0.4)° for angulation. trolled using the software to determine whether air is
visible between the scan prosthesis and the soft tissues
Patient’s movement. The image quality of the (cone (Fig. 4A). If the scan prosthesis does not fit well, the
beam) computed tomography scan can impede the following problems should be anticipated: incorrect
system’s accuracy if motion or metal artifacts are position of the teeth in relation to the jawbone; incor-
present (27). Metal artifacts can result from metal- rect planning of the implant positions; poor fit of the
dense tooth restorations, and motion artifacts may surgical guide, resulting in instability of the guide; and
result from patient movement (owing to lack of com- incorrect position of the surgical guide, resulting in
pliance or inappropriate fixation during the radiologi- inaccuracy. Furthermore, it is also important that the
cal investigation) (Fig. 2). Pettersson et al. (59) scan prosthesis has sufficient thickness (Fig. 4B).
observed, during the matching procedure, that in
some cases the segmented implants from the follow- Surgical guide production. The production of the
up cone beam computed tomography scan were no surgical guide can be subdivided into two main

233
Vercruyssen et al.

cal template can also influence the inaccuracy

(Fig. 6A). This is even more so when several consecu-
tive guides are used for drills with increasing diameter
(2, 4). Arisan et al. (4) reported that their consecutive
bone-supported guides frequently moved spontane-
ously away from the alveolar bone during drilling.
This was seen especially in dense bone areas with a
thin alveolar crest. However, even when one guide
was used and fixed by fixation pins they occasionally
found that fixation screws were loosened and
required tightening. Therefore, one must check
whether the guide remains stable in the correct posi-
tion during the drilling process. Figure 6B shows an
ideal distribution of fixation pins, with the distal pins
Fig. 3. Scan prosthesis with gutta-percha markers and
behind the most posterior implant position. Further-
index to stabilize the guide during the scanning procedure.
more, it is recommended that the most posterior pins
approaches: stereolithography; and laboratory produc- are tightened before the anterior pins; because of the
tion (for the latter the scan prosthesis is transferred undercutting of the jaw in the front region, there is a
into a surgical guide) (78). The overall deviation during risk of tilting the surgical guide when the anterior pins
the production of a stereolithographic guide is are tightened first. Another study (20) reported on a
<0.25 mm (Fig. 5) (14, 64, 69). This deviation might method to enhance the stabilization of the guide
occur during one of the following three steps: the using a combination of bone–tooth supported guides.
(cone beam) computed tomography scan for acquisi- Via laser scanning, detailed dentition information
tion of anatomical data of the patient; the image seg- was obtained, which is more accurate than the denti-
mentation using dedicated software packages tion information retrieved from the three-dimen-
combined with data processing; and the building of sional skull model reconstructed from computed
the model itself, using one of several available rapid tomography images. The laser-scanned dentition
prototyping technologies (68). Production of the guide model was then superimposed on the computed
in the laboratory can be executed manually with the tomography model, to serve as the basis for a more
aid of a coordinate transfer apparatus or with the accurate three-dimensional model and resulting ste-
computer numerical control milling machine (11, 27, reolithographic guide, which is supported by both
28). The deviation of the latter is <0.5 mm (27). This tooth and bone. One publication (24) evaluated the
overall deviation is also the sum of three steps: image interimplant deviation within a patient to investigate
quality of the (cone beam) computed tomography whether the deviation is related to malpositioning of
scan; the production of the scan prosthesis; and the the surgical guide or to individual malpositioning of
production accuracy of the device, which transfers the implants. They observed that the mean deviation
the planned implant positions to the corresponding was substantially different from the interimplant
drill sleeve positions in the scan prosthesis. deviation (1.3 mm vs. 0.3 mm for apical inaccuracy).
These results indicate that the inaccuracy is mainly
Positioning and stabilization of the surgical tem- determined by the mispositioning of the surgical
plate. The positioning and stabilization of the surgi- guide. Future studies should look to both aspects.

A B

Fig. 4. (A) Cross-sectional image in

the planning software. The blue
arrow indicates the air between the
radiographic guide and the mucosa.
(B) Three-dimensional model of the
jaw and the scan prosthesis. The
blue arrows indicate insufficient
thickness of the prosthesis.

234
 Guided surgery

example, the mean deviation at entry was 1.04 mm in

thick mucosa (i.e. as seen in smokers) compared with
0.80 mm in thin mucosa (i.e. as seen in nonsmokers)
(23). Another study (77) observed that an increase of
1 mm in the buccal mucosa thickness resulted in an
increase of the buccolingual deviation of 0.41 mm.

Learning curve. The literature is not consistent on

whether a learning curve is important; one clinical
trial observed a learning curve (77), whereas two
other studies did not (18, 70).

Jaw position. There is an inconsistency in the obser-

vations comparing the data of the maxilla with the
Fig. 5. Example of a stereolithographic guide (courtesy of
mandible. Some publications reported no differences
Materialise Dentalâ).
(6, 11, 26, 29), whereas others observed less deviation
for the mandible (59, 77).
Tolerance of the drills. The tolerance of the drills
within the drill guide and/or keys, as reported in two Computer-assisted implant system. Because of the
in-vitro studies (47, 74), underlines the importance of heterogeneity in study designs included in the sys-
the position of the drill within the guide. The maximal tematic review (73), comparison of different static
deviation of the drill within the surgical guide can computer-assisted implant systems (Ay-Designâ,
reach a maximum horizontal deviation of 1.3 mm at Aytasarimâ, EasyTaxisâ, SinterStationHiQâ, Surgi-
the implant shoulder and 2.4 mm at the apex for a Guideâ, Safe SurgiGuideâ, SICATâ, Med3Dâ, Nobel-
13-mm implant. A maximum deviation in angulation Guideâ and Facilitateâ) was impossible. Each guiding
of 5.2° was observed (47). The latter is specific for system has its advantages and disadvantages. More
each guiding system. This can also explain a deviation randomized studies are needed, using the same study
of the implants to the right for right-handed surgeons design in a large population of patients, in order to
or to the mesial (especially for more distal implants). calculate deviations for equivalent subgroups (same
Data on these phenomena are limited. Di Giacomo surgeon, same guiding device, same scanning proce-
et al. (26), as well as Vasak et al. (77), found signifi- dure and same matching procedure).
cantly lower deviations for anterior implants com-
pared with posterior implants. However, there are, of
Recommendations
course, other explanations for this deviation. Horwitz
et al. (36) observed that attrition of sleeves and drills, To postulate recommendations for increasing accu-
after longer use, are a contributing factor. racy, it is important to be aware that deviations reflect
the sum of all errors occurring from imaging to the
Mucosal thickness. The mucosal thickness (depending transformation of data into a guide, to the improper
on the biotype or related to smoking) can influence the positioning of the latter during surgery. As a first step
accuracy of mucosa-supported templates (23, 77). For it is important to take a correct scan of an immobi-

A B

Fig. 6. (A) Example of a surgical guide with the surgical index, which will stabilize the guide during fixation on the underly-
ing bone. (B) Implant planning in software. Three fixation screws are planned (and are well distributed); one at the midline
and two posterior of the last implant position.

235
Vercruyssen et al.

lized patient with an optimally fitted scan prosthesis. factors – such as the definition of prosthesis survival,
During the surgical procedure it is essential to place whether immediate or delayed loading was imple-
and fixate the surgical guide properly. For the latter it mented and whether temporary or permanent pros-
is strongly recommended to use fixation pins, and, if theses were evaluated – and hence direct comparison
possible, to use one surgical guide in combination with the conventional technique can be difficult. The
with sleeves of increasing internal diameter. During computer-guided implant concept, in combination
the drilling process, one has to be aware that a certain with immediate loading (Figs. 7A-D), is marketed as
tolerance of the drills exists and that one has to easy, safe and predictable. However, several compli-
check that the correct direction is followed during cations or unexpected events were reported, as
the entire drilling sequence. Concerning the com- described in Table 2, as were fracture of the surgical
puter-assisted implant systems, no recommenda- guide (Fig. 8), dehiscences (31) and soft-tissue lacera-
tions can be given. In a randomized prospective tion (26). Misfit of the temporary prosthesis was the
study from our center (79) no difference could be most common prosthetic complication, caused by
found between two guiding systems (Materialise inaccurate placement of the implants (Fig. 9A). After
Universalâ and FacilitateTM) in patients edentulous placement of the temporary prosthesis the most
in the maxilla or mandible. common complication was prosthesis fracture
(Fig. 9B). It seems obvious that guided surgery, espe-
cially in combination with immediate loading, cannot
Efficacy be regarded as easier than conventional techniques.

Clinical protocol
Definition
Flapless surgery has gained interest since several
To determine the efficacy of guided implant articles showed that raising a flap leads to bone
placement, the implant survival or success rate and resorption (30, 34, 83). Via a flapless approach the
the prosthesis survival rate following guided place- periosteum and blood supply to the bone remain
ment should be compared with that following con- intact (10, 17) (Figs. 10A and 10B). Three studies
ventional implant placement. Furthermore, different compared guided flapless surgery with conventional
clinical protocols, such as flapless surgery, can also open flap surgery and reported on patient-centered
contribute to the efficacy of guided surgery. outcomes (4, 32, 55). These studies demonstrated a
statistically significant reduction in immediate post-
Findings operative pain, use of analgesics, swelling, edema,
hematoma, hemorrhage and trismus, for flapless sur-
Implant survival or success rate
gery. One of these studies (4) also compared guided
Several studies presenting prospective observational flapless surgery with guided open flap surgery and
data on the clinical performance of guided implant demonstrated a consistently better outcome for the
placement were identified (37). However, most of flapless approach. These results are supported by the
these studies had an observational period of <2 years good scores for patient comfort and satisfaction
(see Table 2) and only one study (63) had a follow-up reported by several observational studies on guided
period of up to 5 years. For these studies one can flapless surgery (1, 54, 75). A prolonged oral surgical
envisage survival rates comparable with those for con- intervention may increase postoperative pain and
ventional implant treatment. Also, lower success rates discomfort for the patient (66). One of the above-
have been observed for smokers treated with guided mentioned controlled studies reported that the dura-
surgery (3, 7, 8, 41). For example, a cohort study (63) tion of the treatment with flapless guided surgery was
reported cumulative survival rates of 81.2% and 98.9% less than half (24 min) of that needed for open flap
for smokers and nonsmokers, respectively. The latter guided surgery and/or conventional surgery (4). This
was confirmed in a prospective clinical study of D’ha- observation is supported by Komiyama et al. (45)
ese et al. (22), in which patients were treated with who reported that the duration of the flapless guided
flapless guided surgery in the maxilla (implant sur- surgical intervention, including immediate recon-
vival = 69.2% in smokers vs. 98.7% in nonsmokers). struction (Teeth-in-an-Hour concept; Nobel Biocare
AB, Gothenburg, Sweden), took 30–45 min. Thus, the
Prosthesis survival rates
time factor may indeed be part of the explanation of
The prosthesis survival rates ranged widely (from 62% why less pain and discomfort was reported by
to 100%) (see Table 3), probably as a result of several patients after flapless guided surgery. Even if the

236
 Table 2. Prospective observational data on the clinical performance of guided implant placement

Study Study design Follow-up System Complications at guided implant placement Complications after guided placement
period
(months) Reason No. of Reason No. of No. of Reason
prosthetic implant prosthetic
events failures events

Abad-Gallegos Retrospective Not Nobel Guide Lack of primary Not reported Lack of passive 10 Not Screw loosening.
et al. (1) observational reported stablility. Limited fit. Implant reported Fracture of
oral aperture pain. Change prosthesis or
to angulated teeth
abutment
Arisan et al. (4) Prospective 2–4 Aytasarim classic, Fracture of bone- Not applicable 5 Not
comparative* Simplant-SAFE supported surgical applicable
guides
Barter (9) Prospective Mean = 49 coDiagnostiX Not reported 1 Not
observational and GonyX reported
Berdougo Retrospective 12–48 EasyGuide and Not reported 10 Not
et al. (13) comparative* CAD Implant reported
system
Cassetta Retrospective Not SimPlant Safe Uncontrolled removal Not applicable Not Not
et al. (19) observational applicable of gingiva. Alteration applicable applicable
of external hexagon.
Laceration. Template
breakage. Limited
implant stability
Danza et al. (21) Retrospective 1–41 Implant 3D and Not reported 0 Not
comparative* (mean = 14) Ray-Set reported
D´haese (22) Prospective 12 Astra Facilitate Misplacement owing 0 13 3 Esthetic reasons.
observational to misfabrication of Prosthesis
surgical guide fracture
Di Giacomo Prospective 30 Implant Viewer Pulling of soft tissue. 1 Midline 1 1 Prosthesis
et al. (26) observational 1.9 and Insertion of wider deviation fracture
Rhinoceros 4.0 implants than
planned. Instability.
Pain
Fortin et al. (32) Randomized Not CAD implant Not reported Not Not
control trial* applicable system reported reported
Fortin et al. (33) Prospective 48 EasyGuide Implant lost before Not applicable 0 Not
observational loading reported
Guided surgery

237
 Table 2. (Continued)

238
Study Study design Follow-up System Complications at guided implant placement Complications after guided placement
period
(months) Reason No. of Reason No. of No. of Reason
prosthetic implant prosthetic
Vercruyssen et al.

events failures events

Gillot et al. (35) Prospective 12–51 Nobel Guide Guide difficult to 1 Major occlusal 4 11 Fractures of
observational insert. Absence of adjustment resin. Prosthetic
primary stability required for screw loosening
one patient
Johansson Prospective 12 Nobel Guide Misfit of occlusal 15 Problems getting 2 1 Prosthesis
et al. (40) observational index. Misfit of the the prosthesis remade using
surgical guide. in the exact standard
Problems installing position. Major abutments
the implants occlusal owing to
adjustments difficulties in
maintaining
adequate oral
hygiene
Katsoulis Prospective 3 Nobel Guide Not applicable Not Not
et al. (43) comparative* reported reported

Komiyama Prospective 6–44 Nobel Guide Fracture of surgical 8 Misfit of 19 Three Prosthesis had to
et al. (45) observational (mean ≥ 15) template prosthesis. prostheses be removed
Major occlusal owing to
adjustments implant loss
Komiyama Prospective >12 Nobel Guide Not applicable Not Not
et al. (44) observational (mean = 19) applicable applicable

Lindeboom & Randomized 1 Nobel Guide Not applicable Not Not

van Wijk (48) control trial reported reported

Malo et al. (50) Prospective 6–21 Nobel Guide Not reported 2 10

observational (mean = 13)
Meloni et al. (51) Retrospective 18 Nobel Guide Fracture of surgical 2 Temporary 2 2 Fracture of the
observational template prosthesis did temporary
not fit at time prosthesis
of placement
 Table 2. (Continued)

Study Study design Follow-up System Complications at guided implant placement Complications after guided placement
period
(months) Reason No. of Reason No. of No. of Reason
prosthetic implant prosthetic
events failures events

Merli et al. (52) Prospective 8 Nobel Guide Fracture of surgical 4 Prosthesis did 2 5 Fracture of
observational guide. Lost implant not fit at time temporary
because primary of placement prosthesis.
stability could not Prosthetic screw
be achieved loosening.
Fracture of
porcelain
coating of
permanent
prosthesis
Nikzad & Prospective 12 Simplant, Not applicable 2 2 Fixtures lost. No
Azari (54) observational SurgiGuide seating of
prosthesis
Nkenke et al. (55) Prospective 12 NobelGuide Not reported 0 Not reported
comparative*
Pomares (61) Retrospective 12 NobelGuide Fracture of surgical 3 Misfit of 4 8 Fracture of
observational template temporary temporary
prosthesis prosthesis
Sanna et al. (63) Prospective 6–60 NobelGuide Not reported 9 Not reported
observational (mean = 26)
van Steenberghe Prospective 12 NobelGuide 2 Prosthetic misfit. 0 3 Occlusal material
et al. (75) observational Midline fracture.
deviation Prosthetic screw
loosening
Yong & Prospective Mean = 27 NobelGuide Too deep placement 2 Incomplete 7 12 Speech problem.
Moy (84) observational of one implant seating of Bilateral
which was removed prosthesis cheekbiting.
(failure) owing to bony Fracture of
interference prosthesis.
Heavy occlusal
wear. Screw
loosening
This table was adapted from the systematic review of Hultin & Svensson (37)
*Control group included conventional open flap surgery.
Guided surgery

239
 Table 3. Prosthesis survival rates

240
Study Survival rate Other outcome

Immediate/Delayed loading Implants Prosthesis Follow-up

period
With guided Without guided With guided Without guided With guided Without guided (months)
Vercruyssen et al.

placement placement placement (%) placement placement (%) placement

Barter (9) Not reported Not reported 98 Not applicable 100 Not applicable Mean = 49

Berdougo Not reported Not reported 96 99% Not reported Not reported 12–48
et al. (13)*

Danza et al. (21)* Immediate Immediate loading/ 100 96% Not reported Not reported 1–41
loading/ Delayed loading (mean = 14)
Delayed
loading
D’haese Immediate Not applicable 89 Not applicable 62† Not applicable 12 99% implant survival rate in
et al. (22) loading/ nonsmokers and 74% in
Delayed smokers. Smoking and
loading immediate loading in
combination in edentulous
maxillae increased implant loss
Di Giacomo Immediate Not applicable 96 Not applicable 92 Not applicable 30
et al. (26) loading

Fortin et al. (33) Delayed Not applicable 98 Not applicable Not reported Not applicable 48
loading
Gillot et al. (35) Immediate Not applicable 98 Not applicable 100 Not applicable 12–51 Removal and replacement of
loading adjustable abutments used in
the temporary prosthesis was
unpleasant for the patients
Johansson Immediate Not applicable 99 Not applicable 96 Not applicable 12 Mean marginal bone loss of
et al. (40) loading 1.3 mm; 19% of the subjects
had > 2 mm bone loss;
mucosal inflammation was
present in 23% of probed sites
Komiyama Immediate Not applicable 89 Not applicable 84 Not applicable 6–44 Bleeding on probing = 82%
et al. (45) loading (mean ≥ 15) (16–100%). Bone loss was
more common when
pressure-like mucosal ulcers
were detected under the
prosthesis
 Table 3. (Continued)

Study Survival rate Other outcome

Immediate/Delayed loading Implants Prosthesis Follow-up

period
With guided Without guided With guided Without guided With guided Without guided (months)
placement placement placement (%) placement placement (%) placement

Malo et al. (50) Immediate Not applicable 98 Not applicable Not reported Not applicable 6–21 21% of all measured sites at
loading (mean = 13) 6 months and 28% at
12 months had > 2 mm
radiographic bone loss
Meloni et al. (51) Immediate Not applicable 98 Not applicable 87‡ Not applicable 18 Mean marginal bone loss of
loading 1.6 mm after 18 months
Nikzad et al. (54) Delayed Not applicable 96 Not applicable Not reported Not applicable 12 Mean pain score on visual
loading analog scale at follow-up
was within the range for
little or no pain
Nkenke et al. (55)* Immediate Immediate loading 100 100% 100 100% 12 Guided surgery generated
loading less postoperative pain
and swelling compared
with open flap surgery
Pomares (61) Immediate Not applicable 98 Not applicable 100 Not applicable 12
loading
Sanna et al. (63) Immediate Not applicable 95 Not applicable Not reported Not applicable 6–60 Mean marginal bone loss
loading (mean = 26) of 2.6 mm in smokers and
1.2 mm in nonsmokers
van Steenberghe Immediate Not applicable 100 Not applicable 100 Not applicable 12 Mean marginal bone loss of
et al. (75) loading 1.2 mm mesial and 1.1 mm
distal
Yong and Moy (84) Immediate Not applicable 91 Not applicable Not reported Not applicable Mean = 27
loading
Outcome was determined in studies using static guided systems and with a mean follow-up of ≥ 12 months. This table was adapted from the systematic review of Hultin and Svensson (37).
*Control group included conventional open flap surgery.
†
Survival rate reported on temporary prosthesis for the immediately loaded cases.
‡
Survival rate reported on temporary prostheses.
Guided surgery

241
Vercruyssen et al.

A B

C D

Fig. 7. (A–D) Clinical case of a patient treated with flapless guided surgery and immediately restored with a temporary
partial bridge.

for use in frail patients. However, again, very limited

information is available. Horwitz et al. (36) described
the use of flapless guided implant placement in an
irradiated cancer patient and showed good results
after 2 years. In the study by Barter (9), six patients
were treated with flapless guided surgery to avoid sec-
ondary exposure of previously grafted sites. The
implant survival rate was 98% and all prostheses were
still in use after 4 years.

Cost effectiveness
Fig. 8. Example of a fracture of the surgical guide (cour-
The cost effectiveness of different guided surgery pro-
€ rn Klinge).
tesy of Prof. Bjo
tocols is difficult to judge as no information on this
duration of the surgical intervention is shorter with parameter could be found in the scientific literature.
flapless guided surgery compared with conventional An interesting clinical question is whether these tech-
techniques, it seems that much more time has to be niques can be used as an alternative to bone augmen-
invested in the preoperative planning. The flapless tation. Unfortunately, only one article addresses this
guided implant placement technique allows the sur- question. Fortin et al. (33) used the guided technique
geon to install the implants with minimal surgical in partially edentulous patients with severely
trauma to the bone and associated soft tissues. As resorbed maxillae and reported a 98% implant
such, these techniques may be particularly attractive survival rate after 4 years.

A B

Fig. 9. (A) Misfit of the prefabricated

prosthesis. (B) Radiographs showing
the misfit of the prefabricated
prosthesis.

242
 Guided surgery

A B

Fig. 10. Clinical picture of flapless

surgery in the maxilla after removal
of the guide (A) and after placement
of the abutments (B).

5. Arisan V, Karabuda ZC, Pisßkin B, Ozdemir T. Conven-

Conclusion tional multi-slice computed tomography (CT) and cone-
beam CT (CBCT) for computer-aided implant placement.
Different computer-assisted implant placement proce- part II: reliability of mucosa-supported stereolitho-
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one has to accept a certain inaccuracy of 2.0 mm,
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