computer-aided manufacturing technologies for guided implant

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Requirements on implant planningToday, implant treatment has primarily been improved by immediate loading or reduced heal-ing time [1,2]. These treatment options focus on minimally invasive techniques to reduce the post-surgical trauma and improve the general accep-tance of the complex implant treat ment [3,5]. Routine cases with a large flap preparation showed high postoperative morbidity, with pain and dis-comfort for the patient [6]. This is clinically rel-evant in older patients with compromised general health [7]. Recuperation time should also be as short as possible to permit the patient to return to work quickly. Minimally invasive procedures, such as flapless surgery, require detailed informa-tion about all anatomic structures to avoid injury due to the limited surgical overview [8]. In addi-tion, the final prosthesis must be prepared precisely in order to generate optimal treatment results [9]. Owing to these requirements, treatment planning is very complex, and options that allow short treat-ment times and minimally invasive techniques

have been developed using 3D diagnosis and computer-aided design (CAD)–computer-aided manufacturing (CAM)-guided surgery [10–17]. The use of these techniques must consider the increased effort, due to more intensive treatment appointments and costs.

IndicationsSurgical guides based on 3D diagnosis are used in all indications of oral implants, including single tooth replacement, bridge work and the fixation of complete dentures [18,19]. The radiological load caused by 3D diagnosis is higher than in conven-tional x-ray technique [20]. For the use of advanced radiological imaging techniques, the risks associ-ated with x-ray exposure must be lower than the risk of harming the patient by the surgical treat-ment [21–26]. To protect anatomical structures, such as the mandibular nerve, the foramen men-tale or the sinus floor, surgical guides are used to achieve the optimum position under prosthetic considerations [27,28]. If immediate loading is

Jörg Neugebauer†, Gerhard Stachulla, Lutz Ritter, Timo Dreiseidler, Robert A Mischkowski, Erwin Keeve and Joachim E Zöller†Author for correspondenceUniversity of Cologne, Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 32, 50931 Köln, Germany Tel.: +49 221 478 4700 Fax: +49 221 478 6721 [email protected]

Implant treatment increasingly focuses on the reduction of treatment time and postoperative impairment. The improvement of 3D dental diagnosis by ConeBeam computed tomography allows detailed preparation for the surgical placement of dental implants under prosthetic considerations. While the first generation of implant planning software used high-contrast multislice computed tomography, software that has been specifically designed for ConeBeam computed tomography is now available. Implant placement can be performed using surgical guides or under the control of optical tracking systems. Surgical guides are more commonly used in private office owing to their availability. The accuracy for both techniques is clinically acceptable for achieving implant placement in critical anatomical indications. When using prefabricated superstructures and in flapless surgery, special abutments or an adjusted workflow are still necessary to compensate misfits of between 150 and 600 µm. The proposition to ensure proper implant placement by dentists with limited surgical experience through the use of surgical guides is unlikely to be successful, because there is also a specific learning curve for guided implant placement. Current and future development will continue to decrease the classical laboratory-technician work and will integrate the fabrication of superstructures with virtual treatment planning from the start.

Keywords: 3D diagnosis • complication • flapless procedure • guided implant placement • navigation • prosthetic-driven implant treatment • surgical guide • virtual treatment plan

Computer-aided manufacturing technologies for guided implant placementExpert Rev. Med. Devices 7(1), 113–129 (2010)

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planned, the prosthetic procedure can be prepared with a master cast and performed using a surgical guide [29–32]. If augmentation procedures should be avoided, special implants can be placed in the zygoma or in an angled position next to the sinus or the mental foramen [33–36]. Surgical guides manufactured on the basis of 3D data can also be used for extraoral implants [37].

3D diagnosisComputed tomography has been used for 3D dento–alveolar diag-nosis for about 20 years [38–40]. The 3D radiographic analysis of the remaining teeth and the available bone allows the dentist to gain spatial orientation and estimate bone quality volume prior to implant placement; in addition, a surgical guide is fabricated according to this information [41–48]. To visualize the data, stereolithographic models are produced and the data are processed using special soft-ware [5,49]. CT has the advantage of a good signal-to-noise ratio that even allows the evaluation of soft tissue structures [50,51]. Routine procedures are associated with a relatively high radiation dose, which can be reduced through special parameters to still ensure appropriate diagnostic information [52]. These devices are designed for general diagnostics of the complete body, so that specific parameters for pre-implantological diagnosis must be used for the scan of the upper or lower jaw by general radiologists [20].

The development of ConeBeam computed tomography (CBCT) in 1989 now allows preimplantological diagnosis, without exposure to a high radiological load [20,52–56]. These devices are developed especially for dental–maxillofacial diagnosis and feature a similar design to conventional panoramic x-ray systems [57–61]. The image quality is different in comparison to medical CT, which is known as beam hardening [62]. Artifacts may limit the diagnostic infor-mation due to the larger scattering effects of radiolucent dental restora tion [63]. The low visualization of the soft tissue by the CBCT devices requires indirect imaging via the modification of scan tem-plates with the radio-opaque structures. Due to the specific field of view (FOV) and the adapted software for the diagnosis of the oral cavity, these devices are more cost effective than CT and are even available as dental radiology to dentists in many countries [64].

To reconstruct the 3D model, data acquisition is performed by a digital 2D x-ray detector. Data acquisition is influenced by the data transfer rate, and the size and modulation of the detector, which affect the volume, resolution and image quality of the scan [51]. Due to the low radiation dose, image-intensifier systems are still beneficial regarding size and resolution, especially in regard to the scanned FOV [20,50,51]. Multiple devices for CBCT are currently available [65,662]. The FOV varies between 3 × 5 and 20 × 28 cm. For implant planning, a FOV of at least 12 × 8 cm seems to be necessary to include the fiducial markers of the scanning tem-plates [67,68]. In terms of the accuracy of guided implant placement, CBCT generates high-resolution isotropic volumetric data with high geometric accuracy [20,69,70].

Data transferUntil now, most of the planning software and companies offer-ing surgical guides have required radiological data transfer by the Digital Imaging and Communications in Medicine (DICOM)

protocol [71,72]. This is quite often a time-consuming process, because the data must be converted to perform the 3D render-ing that is necessary for the 3D visualization of the anatomi-cal structures and the prosthetic setup [73]. The low contrast of CBCT scans is an especially difficult issue in various planning programs because the structures cannot be determined as easily as in standard high-contrast CT [51,64,74]. Since CBCT is now developed in cooperation with dental companies that also supply products other than radiological devices, implant planning soft-ware is available on the same interface as radiological diagnostics (e.g., Galileos Implant, Galileos, Sirona, DigiGuide Mini Dental Implant [MDI], ILUMA and 3-m Imtec). One integrated system is already available in which the diagnosis can be made directly after scanning the patient and implant planning does not require further data transfer. This system also allows the direct fabrication of the surgical guide, so that the data transfer times are reduced to a minimum (Galileos Implant, Galileos and Sirona) [67].

Planning softwareWhen CT was first used for preimplantological diagnosis, soft-ware was already available to simulate implant placement for bet-ter orientation during surgery [43,75,76]. This simulation allows the determination of the bone available for implant placement under surgical aspects. The final goal for an implant placement is the incorporation of a prosthetic superstructure [77]. This requires a simulation of the expected prosthetic outcome at the time the 3D diagnosis is made [78–80]. For optimal results, implant plan-ning can be performed under prosthetic considerations by adding the prosthetic information to the scan via the simulation of the later crown shape or the axis of the abutment implant [81–84]. To visualize the prosthetic outcome, a wax up is transferred to a barium-sulfate resin, so that the contours become visible in the radiological scan [85]. If only the axes of the abutments need to be visualized, gutta-percha points can alternatively be used in the axis of the planned crowns.

Available softwareThe first program on the market with international recognition was SimPlant by Columbia Scientific, which is now distributed by Materialize Dental, Leuven, Belgium [43]. This open system can be used with about 388 implant systems made by 78 companies. Modifications of this software are also available for several compa-nies and implant systems, especially with instruments for guided surgery. Recently, a number of programs for implant planning have been developed (Table 1) [13,76,86–90].

3D renderingFor the spatial orientation of the implants in the oral cavity, it is important to perform a 3D rendering after the DICOM import of the radiological data [91]. This process may be very complex for data generated by CB technology, since programs were histori-cally developed based on high-contrast CT, with a low number of slices [92]. A few companies recently developed their software especially for the requirements of the image quality of low-contrast CBCT [69]. Depending on the philosophy of the program, the user

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interface is more graphically or more technically oriented [13]. The information to modify the visual impression is the same for both software technologies; they just use different workflows. The sur-face model of the bone or the scanned prosthesis can also be used for the fabrication of the surgical guides [15,93–95].

FiducialsDepending on the further surgical guide manufacturing process, fiducials may be required at the beginning of the planning process. These fiducials are necessary during scanning for transferring the orientation of the patient to the planning software and later on

for guide fabrication. Planning systems that process the data on rapid prototyping machines do not require these fiducials, because the surface model of the anatomical structures is used for guide fabrication. However, if a scan template is modified by a CAD–CAM milling technique, fiducials are necessary even for guide production. Scan templates can be very simple prefabricated parts or specific bite plates with fiducials on a high-precision and con-nector surface for the production of the surgical guide. During the radiological scan, these fiducials should not be placed in an area where metal scattering may reduce image quality. Failure of the software to detect the fiducials requires a further scan.

Table 1. Implant planning software.

Software platform (former names) Available software modification Distributor

10 DR implant 10 DR Seoul, South Korea

Artma virtual implant Eurodoc, Vienna, Austria

Blue Sky Plan Blue Sky Bio, Grayslake, IL, USA

coDiagnostiX coDiagnostiXSKYplanX

IVS Solutions, Chemnitz, GermanyBredent, Senden, Germany

CTV (PraxisSoft) M+K Dental, Kahla, Germany

DenX Image Guided Implantology Image Navigation, Jerusalem, Israel

DentalVox (Era Scientific) Biosfera, Rimini, Italy

DentalSlice Bioparts, Brasília, Brasil

DDent plus I AlloVision, Greenville, SC, USA

DigiGuide MDI Imtec, Ardmore, OK, USA

Easy Guide (CAD implant, Praxim) Keystone Dental, Drilllington, MA, USA

Implant Location System Tactile Technologies, Rehovot, Israel

InVivoDental Anatomage, San Jose, CA, USA

Implant3D (Stent CAD)

Implant3DImpla 3D Navi

Media Lab, La Spezia, ItalySchütz Dental, Rosbach, Germany

Implanner Dolphin Imaging, Chatsworth, CA, USA

Implant3D(med3D)

Implant3DCeHa ImplantIGS Monitor

med3D, Heidelberg, GermanyC. Hafner, Pforzheim, Germany2ingis, Brussels, Belgium

Implametric 3dent, Valencia, Spain

Nobel Guide (Litorim, Cath. Uni. Leuven, Belgium)(Oralim, Medicim)

Nobel Biocare, Göteborg, Sweden

Robodent RoboDent, Garching, Germany

Simplant (surgicase) Simplant/SurgiguideFacilitateExpertEase

Materialize, Leuven, BelgiumAstratech, Mölndal, SwedenDentsply Friadent, Mannheim, Germany

Scan2guide Scan2GuideImplantMaster

Ident, Foster, CA, USAVarious

Sicat Implant Sicat ImplantGalileos Implant

Sicat, Bonn, GermanySirona, Bensheim, Germany

Virtual implant placement (Implant Logic) BioHorizons, Birmingham, AL, USA

Visit Research Project, University Vienna, Austria

CAD: Computer-aided design; MDI: Mini Dental Implant.



Planning interfaceDental diagnosis and implant planning are based on the inspec-tion of the panoramic radiograph [91]. Due to the 3D nature of the model, the panoramic reconstruction has to be calculated by the software [69]. This can be performed automatically by the software, with an optimization option, or an individual panoramic curve has to be placed in the 3D model. This panoramic reconstruction then provides spatial information for implant placement. Each of the planning programs has a library with at least the implant bodies of the manufacturing company, but most of the programs are designed as open software with a large number of implant suppliers and corresponding implant systems (Table 1). From this library, the implants are available as 3D models, which allow virtual placement of the planned implants next to the anatomi-cal structures and other planned implants. Some programs also permit the placement of virtual abutments, either custom-made or belonging to the library of the implant bodies [96]. Therefore, the planned treatment can be simulated, not only under surgical but also under prosthetic aspects [97–99]. For prosthetic purposes, radio-opaque visualization delivers information about angulations

and exact positioning. The double-scan procedure was developed especially for CBCT scans; it permits overlaying the scan of the radiological template on the scan with the patient and the radio-logical template, which offers the opportunity for easier segmen-tation [12,100]. This requires fiducials in the scan template so that both scans can be properly oriented to each other [73]. This concept was first available with NobelGuide, but is now also offered for other systems (e.g., SimPlant).

DocumentationAfter finalizing the plan, it can be documented through various printouts or by online publication, so that the planning result can be discussed with the referring dentist and the corresponding laboratory technician [67]. Finally, the surgical guide is ordered.

Surgical guidesIn the beginnings of 3D-planning, the transfer of implant posi-tions from the planning software was not standardized and had to be done individually by the user [101,102]. Today, most of the software suppliers also offer the option of transferring the data to a guide fabrication or optical tracking system (Table 2) [13,89,103–105].

Depending on the manufacturing process of surgical guides, they can be fixed on remaining teeth or abutments, the soft tis-sue, auxiliary implants or directly onto the bone [13,15]. So far, bone-supported surgical guides could only be produced by the rapid prototyping or 3D-printing procedures because they use the virtual surface model of the bone to generate a surgical guide that can then be placed directly onto the bone after preparation of the mucoperiosteal flap [106]. This is used mainly for the completely edentulous jaw, where no additional abutments, teeth or auxil-iary implants can be placed [107]. An alternative approach is the fixation of the surgical guide by anchor pins, which stabilize the surgical guide in the jaw with specific screws [35,94]. The position of the anchor pins is also determined by the planning software to prevent collision of the planned implant sides and deviations of the surgical guide from the optimal position [108,109].

The other fixation techniques are available for all production types because the surface of the teeth or abutments, or even of the soft tissue can be transferred through modification of the scan template or by the rendering of the anatomical surface models. Handling completely soft tissue-borne surgical guides is difficult because the orientation in the mouth changes after the flap is raised, and the fixation is not necessarily in the same position during the scan and during surgery [110].

Variation of sleevesIn addition to the fixation, drill guidance differs in the various designs of surgical guides. Initially, only sleeves for the pilot drill or multiple surgical guides with different sleeve diameters were available for identifying the proper axis [111]. To achieve high accuracy, additional sleeve designs are now also available [93]. In the sleeve-in-sleeve concept, multiple sleeves are placed to properly orient the implant drills with increasing diameters. A few com-panies have already developed special surgical kits to even allow guided implant placement with one master sleeve.

Table 2. Technology of navigated implant placement.

Brand Fabrication Technology

Artma Local Optical tracking

Blue Sky Plan Central/Local 3D-printing

coDiagnostiX Local MechanicalOptical tracking

DenX Image-Guided Surgery

Local Optical tracking

DentalVox Central CAM-milling

DentalSlice Central Stereolithography

DDent plus I Local Mechanical

Easy Guide Central CAM-milling

Implant Location System

Central CAM temperature-forming

Implametric Central Stereolithography

Implant3D Local Mechanical

Implant3D (med3D) Local MechanicalOptical tracking

Nobel Guide Central Stereolithography

Robodent Local Optical tracking

Scan2guide Central Rapid manufacturing technology

Sicat Implant Central CAM-milling

Simplant Central Stereolithography

Visit Local Optical tracking

VIP Pilog Compu-Guide

Central CAM-milling

CAM: Computer-aided manufacture; VIP: Virtual Implant Placement.



Guide productionToday, surgical guides can be produced by the local laboratory technician or den-tist using special mechanical positioning devices, or in a centralized facility with vari-ous types of CAD–CAM techno logy [22]. The decentralized or local fabrication uses software that provides the user with an information sheet with the coordinates of a positioning device to modify the position of the master cast and the scan template (Figure 1) [13,14,112]. The correct position of the implant axis can be simulated and a parallel milling system is used to place the surgical sleeve [92]. The process of fixation on a milling system is quite precise, in the range of navigation systems [113]. To avoid an increase of deviation through the various production steps, direct fixation of the sleeve is preferred [113].

For the systems with centralized fabrica-tion, planning is performed on a standard PC, and the data are then transferred to the production center, which fabricates surgical guides according to the data from the planning software (Figure 2). The surgical guides were initially produced mainly by stereolithography, utilizing the previously mentioned surface models. Particularly for larger surgical guides, this technology is associated with high cost and production time. Current developments are examining the concept of modifying the radiological tem plates [114]. Since the fit is checked prior to the CT scan, a precise fit can also be expected after the placement of the sleeves, and there is no further need for adjustments [8].

A new concept is the use of 3D printing to generate 3D models and surgical guides, which can also be used for local fabrication in dental laboratories or dental offices.

Guided implant placementFor guided implant placement, most systems offer the option of placing the master sleeve in a specific position, so that the implant drills with a stop function allow exact vertical preparation. Three concepts for drill guidance are currently available (Table 3).

One is working with drills that feature a fixed sleeve to ensure guidance in the master sleeve of the surgical guide. The drawback of this system is that guidance is only provided if the master sleeve is in contact with the sleeve part of the drill. Especially in long implants, multiple changes of the drills are necessary because the initial preparation is performed with a short drill to achieve a guided preparation. The advantage of this system is that a mini-mum of mobile parts are used for the surgical preparation. Another approach uses small holders that are also oriented in the master sleeve of the surgical guides. The drills of the implant kit are placed through these holders. A further design features sleeves that are mobile on the drills, so that the final drill length can be used (Figure 3). After the preparation of the implant site, instruments are

also available for guided implant placement. If a flapless procedure is used, this is especially important for achieving the correct verti-cal orientation of the implants [92,115–117]. This process should also allow the use of prefabricated computerized numerical control-milled superstructures for immediate loading with a minimally invasive and time-effective treatment [16,31,32,108,118].

Optical trackingNext to surgical guides, intraoperative navigation by optical track-ing is another option to make use of 3D imaging and the transfer of data to the surgical environment [13,119–127]. Preparation of the surgery is similar to the surgical guide process, without the final fabrication of a surgical guide. The navigation systems are avail-able for general surgery, with specific adaptations for dentoalveolar surgery [120,128–130], or as specific devices for dental implant place-ment [13,121–123,130–133]. The technical set-up is reduced, so that large devices are not always necessary (Table 4) [134].

Dental implant optical tracking systems need the fiducials that were used during the radiological scan as reference points for the registration of the instruments [129]. The accuracy of the optical tracking systems depends on the reliability and the precision of detection of these fiducials [135]. At the reference point, an optical system is mounted, so that the infrared camera can control for the position of the patient in relation to the instruments. This enables the surgeon to check the position of the drill on the control moni-tor relative to the patient and the reconstructed model according to the preoperative planning. The use of implant optical tracking systems is also superior to general navigation systems in general indications, such as cancer resection [120]. Since the drills are not guided by sleeves, there is more freedom for the instrument during

A B

C D E

Figure 1. (A) Fixed restoration in maxilla by support of mechanical guide fabrication Software interface of planning software (Implant3D, med3D Heidelberg, Germany). (B) Intraoperative view of a surgical guide that was made by modification of the radiological stent. (C) Control sheet to evaluate the achieved axis. (D) Panoramic radiograph after prosthetic delivery. (E) Control of implant-borne bridges or splinted crowns 2 years after delivery.



implant placement, and the procedure is still controlled in difficult anatomical indications including cancer reconstruction and high atrophy [136].

AccuracyThe accuracy of guided implant placement with surgical guides or optical tracking has been evaluated by in vitro and clinical studies [989,104].

In vitro surgical guidesIn in vitro studies, the accuracy of the surgical guides and the implant placement has already been found to be limited by the accuracy of the various process steps [137]. For a good prosthetic outcome, it is important that the crestal position is not changed, as

described by various studies by the precision of the entry point [86]. The angulation and the exact orientation for the later placement of the abutments are measured by the apical positioning, respectively. The mean values for the crestal positions range from 0.15 ± 0.12 to 1.5 ± 0.8 mm. The apical deviation always shows larger mean values, from 0.4 ± 0.12 to 2.0 ± 0.7 mm [11,122,137–142]. In the risk assessment of the use of these guides, the maximum values, especially at the apex, are important. Owing to a horizontal or vertical deviation of up to 1.86 [137] or 2.7 mm [138], anatomical structures may be harmed. A security distance of at least 1 mm is recommended based on the results of additional in vitro studies [143].

The use of additional sleeves reduces the freedom of motion for the following drills and does not lead to an increase of the metrical deviations of the system [138,141].

The systems with a master sleeve and additional tools or sleeves allow a precise preparation of the implants and even the seating of the implant through the surgical guide, so that high precision can be achieved [141]. A limiting factor is the size of the master sleeve because it could lead to difficulties during manufacturing due to insufficient space between several implants, if small-diameter implants are used. Some companies provide systems with two kinds of sleeves, which increases the number of drills or additional sleeves [93].

In vivo surgical guidesClinical investigations have only been published by a few authors [33,110,144]. Older studies report variations at the crestal position of between 1.45 ± 1.42 and 1.51 mm, and at the apex of 2.99 ± 1.77 and 3.07 mm [33,144]. Bone-supported surgical guides showed very high deviations of up to 4.5 mm crestally and 7.1 mm at the apex [144], which were explained by the design not hav-ing been adjusted. Current studies show improved values for the surgical guides. A comparison study of the various support types – tooth-, mucosa- and bone-supported – showed no significant difference in deviation of the crestal position, with average values of 0.87 ± 0.4, 1.06 ± 0.6 and 1.28 ± 0.9 mm, respectively. For the deviation from the planned apical position, a significant differ-ence between tooth-supported guides (0.95 ± 0.6 mm), mucosa-supported guides (1.6 ± 1.0 mm; p = 0.014) and bone-supported guides (1.57 ± 0.9 mm; p = 0.003) was found. There was no significant difference between the bone- and mucosa-supported guides for the apical position [110].

In vitro optical trackingFor the vector vision system (BrainLAB, Hainstetten, Germany), deviations from the upper implant reference point were 0.95 ± 0.25 mm, and those from the apical reference point were 0.97 ± 0.34 mm in vitro [145]. For the demanding positioning of implants next to the sinus floor, a deviation of the implant tip of 0.11 ± 0.22 mm was achieved. In this in vitro study, 13 out of 60 preparations (21.6%) showed a perforation of the sinus floor, with an average depth of 0.24 mm [146]. A similar result was found in the comparison between navigated implant placement and con-ventional procedure for the placement in the posterior mandible near the mandibular canal [147].

A B

C D

E F

G

Figure 2. (A) Workflow for minimal implant placement in maxilla to avoid larger augmentation procedure, check of wax-up. (B) Check of exact position of radiological stent with reference for planning software and separated BaSO4-teeth. (C) Planning report after virtual placement of four implants (Sicat Implant, Sicat, Bonn, Germany). (D) Placement of surgical guide manufactured by CNC-milling (Sicat, Bonn, Germany). (E) Implant side preparation prior to sinus cavity with an inclination of 38°. (F) Postoperative radiological control without any signs of implant contact to the sinus cavity. (G) Final fixed bridge in maxilla prior to start of treatment in the mandible.



An experimental study on minipigs showed a deviation of less than 0.5 mm in all directions for a specific implant-designed tracking system [148]. For the use of the rela-tively long zygomatic implants, an overall precision of 1.5 ± 1.1 mm could be simulated with a variation of 0.1–4.9 mm [136]. In the alveolar process, deviation values in compari-son to the vestibular bone were found to be 0.55 ± 0.31 mm at the crest of the implant and 1.44 ± 0.79 mm at the apex when using the Visit system [149]. The use of a head-mounted display with this system improved the val-ues, resulting in deviations of 0.58 ± 0.4 and 0.79 ± 0.71 mm, respectively [150]. A com-parison study for Robodent and IGI DenX versus manual implant placement showed a deviation at the apex of 0.60 ± 0.20 mm (maximum: 0.92) for Robodent, 0.94 ± 0.40 mm (maximum: 1.88) for IGI DenX, and 1.89 ± 0.80 mm (maximum: 2.95) for manual placement [151]. These results were also supported by a comparative examina-tion of two navigation systems with a surgi-cal guide system [122] and in the comparison of an optical tracking system with manual placement [152].

In vivo optical trackingThe control of the clinical placement of navigated implants showed similar results as guided implant placement, with a devia-tion at the crestal part of 1.0 ± 0.5 and 1.3 ± 0.9 mm at the apex of the implant [153]. Further studies show an average deviation of 0.7 ± 0.3 mm at the lingual position for the crestal and apical position in the Visit system [154], and 0.7 ± 0.5 mm for the crestal and 1.2 ± 0.8 mm for the apical position when using a general navigation system [155]. For this pilot study on 20 edentulous patients, navigated flapless implant placement was found to be a predictable and safe procedure in cases with wide, regular mandibular ridges. The technique was less accurate, more complicated and more time consuming in areas with irregular bone [154,155]. Data showing low deviation for the difficult placement of zygomatic implants are now available, with a crestal deviation of 1.36 ± 0.59 mm and an apical deviation of 1.57 ± 0.59 mm [156].

AdvantagesThe advantage of the surgical guides is mainly derived from a pre-cise knowledge of the anatomical findings and optimal preparation of the surgery without the risk of intraoperative changes of the protocol [157,158]. They are a prerequisite for the flapless procedures, for implant placement in difficult anatomical positions and in case of tilted implant positions chosen to avoid more invasive grafting

procedures [62,115,159,160]. In immediate loading, it is always dif-ficult for the laboratory-technician to provide the superstructure in a very short period of time after the implant placement. Detailed preoperative planning allows the laboratory-technician to work ahead to shorten these processing times [118].

Follow-up studies show that the parameters indicating long-term success, such as peri-implant bone resorption, are in the same range as in conventional procedures [161]. In summary, guided implant placement using 3D diagnostics reduces patient morbid-ity and the complication rate [30,162]. Data for the comparison of the implant outcome for both techniques are limited. One study showed that the use of surgical guides (1.31%) seems to have a lower failure rate than optical tracking systems (2.96%) [13].

LimitationsPossible failure reasons may include poor resolution of the 3D radiological image, which is influenced by the design of the device and by artifacts. In particular, multiple prosthetic res-torations made from metal or zirconium oxide ceramics lead

Table 3. Implant systems with instruments for guided surgery.

Implant company System Surgical guide Guidance by Guidance for

Astratech, Mölndal, Sweden

Facilitate SimplantSICAT

Drill Positioning Handle

All drills and implants

BioHorizons, Birmingham, AL, USA

Pilog Compu-Guide

Pilog Compu-Guide

Multiple sleeves

Pilot drills

Biomet 3i, Palm Beach Gardens, FL, USA

Navigator SimplantSICAT



Bredent, Senden, Germany

SKYplanX SKYplanX Sleeve in sleeve


Camlog, Wimsheim, Germany

Camlog Guide coDiagnostiXmed3DSICATSimplant

Integrated sleeve on drill


Dentsply Friadent, Mannheim, Germany

ExpertEase coDiagnostiXmed3DSicatSimplant

Mounted sleeve on drill

All drills and implant

Imtec, Ardmore, OK, USA

DigiGuide MDI DigiGuide MDI Drills

Keystone Dental, Drilllington, MA, USA

Easy Guide Easy Guide Sleeve Drills

Nobel Biocare, Göteborg, Sweden

Nobel Guide Nobel Guide Drill Positioning Handle


Straumann, Basel, Switzerland

Guided Surgery

coDiagnostiXmed3DScan2GuideSICATSimplant



Various Safe System Simplant Mouted sleeve in guide




to difficulties in evaluation of these 3D data due to so-called metal scattering. In addition, movement artifacts may result in incorrect metric information, as determined by several in vitro studies [163,164].

Surgical guides planned with a reduced security distance to the anatomical structures or in an area with limited available bone were found to be associated with risk; deviations of these surgical guides may harm anatomical structures, or reduced cov-erage of the implant with bone may result, thus increasing the failure rate [165]. The use of these surgical guides demands that the user is familiar with implant treatment; minimization of

surgical trauma requires that the surgeon can still estimate the local findings to protect these structures and achieve an implant placement, which fulfills the prosthetic requirements [165–167].

The results of the accuracy testing showed that deviation increases if the base of the guide and the position of the sleeve are at larger distances to the entrance point of the bone [168]. In case of thick soft tissue, bone-anchored surgical guides or optical tracking systems may be favorable.

The previously cited range of accuracy is not acceptable for prosthetic restoration, as this requires an accuracy of 0.02 mm. One potential way of compensating for this inaccuracy is to use

A B C

D E F

G H I

Figure 3. (A) Guided implant placement with ExpertEase: planning of implant position with implants and available abutments (Simplant 12, Materialise, Leuven, Belgium). (B) Sterelithgraphic model of atrophic edentulous maxilla (Materialise, Leuven, Belgium). (C) Stereolithographic surgical guide with master sleeve (Expertease, FRIADENT, Mannheim, Germany). (D) Soft-tissue preparation of bone-anchored surgical guide. (E–G) Implant preparation, placement and control by surgical guide. (H) Final restoration with bar-supported superstructure in atrophic maxilla with regional grafting procedures. (I) Radiological control by panoramic image of consolidated sinus floor.



abutments with a spacer and a resilient part as guided abutments [108]. It has been reported that this technique has a high suc-cess rate (98.9%) for nonsmoking patients when providing restorations for edentulous patients by expanding abutments within 1 h, using a prefabricated fixed prosthesis [109]. Other authors report a high complication rate with early failures, such as impossibil-ity to seat the planned implant, unexpected osseous findings, and an implant failure rate of 9%. The prosthetic outcome was also compromised by early complications, including loosening of the prosthesis, speech problems and bilateral cheek biting. Late complications included loosening of screws, fracture of the prosthesis and pressure sensi-tivity during chewing [165]. Fractures of the surgical guide were also reported, as were misfits between abutment and fixtures, and the need for extensive occlusion adjustments. In terms of implant success with these com-plications, a survival rate of only 89% was reported in the maximum observation period of 44 months [169]. As known from standard treatment planning, flapless surgery requires special training and involves a learning curve to achieve optimum results [170].

Another option is to prepare the superstructure according to the surgical guide but then to compensate the inaccuracy between the planned and reached position through gluing, cementing or laser-welding the superstructure after fixation of the components in the mouth of the patient [171–173].

Recent developmentsThe actual workflow for producing surgical guides is quite com-plex, because several patient appointments and waiting periods are necessary to prepare the prosthetic setup, do the radiological exam, produce the surgical guide and finally place the implant. This is not only time consuming for the patient but it is also work inten-sive and generates cost [90]. Various options are being developed to optimize this workflow. Digital technology has tremendously improved conventional laboratory work in recent years [174]. Digital impression techniques have been available for more than 20 years as single-shot impressions [175,176] and are now also offered with video capturing [176]. To optimize precision, the most accurate techniques should be used, such as the high-frequency blue-light technique [177]. The high-frequency light features high-precision transfer without noise, because there is no need for summarizing multiple frames. This allows a digital wax up for planning after the radiological scan instead of the cost-intensive preparation of barium sulfate teeth as the scan reference (Figure 4). With this technique, at least one step could be eliminated [10].

Production costs and the likelihood of errors in the surgical guides depend on the production process. Central CAD-CAM technologies such as stereolithography or computerized numeri-cal control-milling stations require a high investment but deliver products with a high predictability. Computerized numerical

control-milling stations for fabrication of superstructures are more and more common in dentistry and can be used in the local dental laboratory or even in the dental office with clini-cally acceptable precision [178,179]. These systems can also produce surgical guides to shorten the process [180].

DiscussionToday, implant placement can be considered a routine proce-dure in a dental office, but the further developments require very detailed planning and the ability to transfer this planning information to the surgical procedure.

Three-dimensional diagnosis can be an advantage for the patient, especially when minimally invasive techniques are used [181]. Detailed planning can also provide the option of immediate loading to achieve a higher level of satisfaction for the patient [32,162,169,182]. A 3D diagnosis is the basis for the use of 3D planning. At the beginning of modern implantology, only CT was available. Studies based on CT imaging generate 3D data, but the resolution of CT imaging is nonisotropic, delivering limited spatial image resolu-tion in at least one axis [183]. Today, CBCT is most often used for pre-implantological 3D diagnosis [184–189]. It allows torsion-free, metrically correct implant planning under consideration of the anatomical structures with a low radiological dose [20,53,190].

The workflow for the preparation of the patient for 3D diagno-sis exhibits few variations based on the implant and surgical guide design that is used. This area has the most development potential in terms of shortening the preparation and treatment times. The predictability for the precision is always higher for technical sys-tems compared with manually adjusted systems. However, the required cost-intensive hardware is a disadvantage, especially in countries with low wages for manual labor.

Guided implant placement using surgical guides with modi-fied surgical instruments promise the highest degree of accuracy, which is currently not in the required range for the complica-tion-free incorporation of prefabricated prostheses for immediate loading [165,166,169].

Table 4. Commercialized navigation systems for guided implant placement.

System Distributed by Concept

Artma Eurodoc Telemedizin Anwendung, Vienna, Austria

Implant placement

DenX Image-Guided Implantology

Image Navigation, Jerusalem, Israel Implant placement

IVS coDiagnostiX IVS Solutions, Chemnitz, Germany Implant placement

LandmarX , Medtronic Xomed, Jacksonville, FL, USA ENT surgery

Mona dent (Med3D) Mona-X, Dortmund, Germany Implant placement

Robodent RoboDent, Garching, Germany Implant placement

SMN Zeiss,Oberkochen Germany General surgery

StealthStation S7 Medtronic Navigation, Louisville, CO, USA General surgery

vv2 brainlab BrainLAB, Hainstetten, Germany General surgery

ENT: Ear, nose and throat; SMN: Surgical Microscope Navigator.



The clinical use of surgical guides in the posterior area requires additional skills and experience due to the more complex design, especially of the master sleeves. For the atraumatic treatment of the bone, it is important to avoid overheating; this requires careful preparation due to the limited access of coolant solution in the externally irrigated drills [165,191].

Expert commentaryIn the past, prosthetic dentistry involved the use of the remaining teeth for the fixation of a superstructure on natural abutments using conventional laboratory technician work. Limitations included the distribution of the residual abutments, which could pose problems in placing a fixed restoration, and the need to grind healthy teeth to carry any kind of superstructure. Today, dental implants are used for the replacement of single teeth, for the complete reconstruction in the partially edentulous jaw, and

for the stabilization and fixation of complete dentures. The use of endosseous implants allows the restoration of the dentition with the same functionality as the root of the former teeth [1]. This requires an exact treatment plan for implant placement in the available bone under consideration of the anatomical findings, the prosthetic requirements and the patient’s medical history [3,103]. The correct implant position should be planned prior to surgery, and tools should be available to achieve the optimum position [192].

Dentists are grinding teeth to shape abutments for remov-able or fixed prosthetic work. Preparing an implant site requires preparation into the bone, which is a different technique than tooth grinding. Instead of the ablative preparation for a crown, the receptor sites for a dental implant must be prepared into the bone. This can present difficulties because the bone structure is not visible prior to the surgery and the position of the tip of

A B C

D E F G

H I J K

Figure 4. (A) Reconstruction with virtual prosthetic setup: failing implants due to peri-implantitis and near tooth position in left mandible. (B) Large defect after explantation and removal of first bicuspid. (C) Soft tissue situation after reconstruction by hip graft. (D) Virtual setup of prosthetic goal with CAD-CAM software (Cerec 3D, Sirona, Bensheim). (E) Planning with merged virtual set up (Sirona Implant, Sirona, Bensheim). (F–H) Implant site preparation after hip graft with surgical guide for 2-mm pilot drill. (I) Implant placement after further preparation. (J) Final superstructure with splinted crowns. (K) Radiological control after treatment of left mandible.



the drill is not under the surgeon’s visible control. Anatomical variations may be found [193] and detailed metrical analysis is not always possible with routine imaging procedures [194]. Classic dental implant treatment is based on 2D radiological diagnosis and the visual inspection of the oral cavity with high predict-ability [91]. This workflow does not deliver information about the spatial orientation around the teeth or about the edentulous part of the alveolar crest [69].

Five-year viewToday, surgical guides are mainly produced on a software plat-form designed for CT technology. Owing to the lower radiologi-cal exposure of CBCTs, the contrast in the DICOM transfer is reduced, so it is necessary to develop a new software platform that is focused on the use of CB data. The labor-intensive process involving several appointments to prepare the patient, not only with the radiological scan but also for the temporary restora-tion, will involve less classic laboratory-technician work and more

CAD–CAM technology systems. For the planning and design of the superstructure, software will be available in the form of ‘expert systems’ to shorten the user interface time with the soft-ware when determining the size and position of the implants and the shape of the superstructure [195]. This will finally lead to the local production of surgical guides, even by the dentist, owing to the available CAD–CAM milling stations [180].

Furthermore, these systems can be used not only by experts to achieve the optimum results, but also for education purposes for the complex implant prosthetic treatment in virtual reality [196].

Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Medical computed tomography (CT) and cone-beam CT are delivering detailed information for 3D-planning of implant placement.

• 3D planning software is available in various designs with simple or advanced planning options.

• 3D planning requires a more intense workflow to simulate the prosthetic outcome already at the beginning of the treatment.

• Surgical guides can be manufactured locally with mechanical devices or centrally with computer-aided manufacturing (CAM) technology such as stereolithography, CNC-milling or 3D-printing.

• Surgical guides produced by computer-aided design-CAM technology allow a minimally invasive treatment with the protection of sensitive anatomical structures in difficult indications.

• Optical tracking systems seem to be more accurate and have more flexibility during surgery but require more training for the staff.

• Various implant companies offer instruments that allow a guided implant site preparation and implant placement.

• Clinical data on the outcome of immediate restorations with prefabricated superstructures using guided implant placement are controversial.

• Further research projects are ongoing to simplify the workflow by optimizing knowledge-based systems and to more intensively use computer-aided design-CAM-technology in dental implant treatment.

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• Criticalreviewoftheclinicalrelevanceoftheachievedprecisionofsurgicalguides.

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• Interestingstudyforthecomparisonofvarioustechniques.

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114 Widmann G, Widmann R, Widmann E et al. Use of a surgical navigation system for CT-guided template production. Int. J. Oral Maxillofac. Implants 1, 72–78 (2007).

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124 Weihe S, Kruse C, Franz E-P et al. A new planning and navigation system for dental implantology – evaluation of ergonomic aspects and accuracy. Int. J. CARS 1, 421–423 (2006).

125 Birkfellner W, Huber K, Larson A et al. A modular software system for computer-aided surgery and its first application in oral implantology. IEEE Trans. Med. Imaging 6, 616–620 (2000).

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135 Freysinger W, Truppe MJ, Gunkel, AR et al. A full 3D-navigation system in a suitcase. Comput. Aided Surg. 2, 85–93 (2001).

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•• Criticalreviewoftheclinicalrelevanceoftheachievedprecisionofsurgicalguides.

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• Investigationofanewsystemwithbestresultsforsurgicalguidesatthemoment.



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147 Gaggl A, Schultes G. Assessment of accuracy of navigated implant placement in the maxilla. Int. J. Oral Maxillofac. Implants 2, 263–270 (2002).

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• Interestingstudyshowingthelimitationsofnavigatedsurgeryindifficultindication.

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153 Kramer FJ, Baethge C, Swennen G et al. Navigated vs. conventional implant insertion for maxillary single tooth replacement. Clin. Oral Implants Res. 1, 60–68 (2005).

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• Presentationofanewintra-oraldeviceforopticalimpression.

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•• Presentationofexpertsystemtosupportthedecisiononimplantplacement.

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Affiliations• Priv.-Doz. Dr. med. dent. Jörg Neugebauer

University to Cologne, Consultant at Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 32, 50931 Köln, Germany Tel.: +49 221 478 4700 Fax: +49 221 478 6721 [email protected]

• Gerhard Stachulla, CDT Implant and 3D Planning Center, Augsburger Straße 26, 86444 Affing-Mühlhausen, Germany Tel.: +49 170 205 4821 Fax: +49 820 7959 9355 [email protected]

• Dr. med. Lutz Ritter University to Cologne, Department for Craniomaxillofacial and Plastic Surgery, Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 62, 50931 Köln, Germany Tel.: +49 221 478 5771 Fax: +49 221 478 5774 [email protected]

• Dr. med. Dr. med. dent. Timo Dreiseidler University to Cologne, Department for Craniomaxillofacial and Plastic Surgery, Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 62, 50931 Köln, Germany Tel.: +49 221 478 5771 Fax: +49 221 478 5774 [email protected]

• Priv.-Doz. Dr. med. Dr. med. dent. Robert A Mischkowski, University to Cologne, Consultant at Department for Craniomaxillofacial and Plastic Surgery, Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 62, 50931 Köln, Germany Tel.: +49 221 478 5771 Fax: +49 221 478 5774 [email protected]

• Univ.-Prof. Dr. Erwin Keeve Professor and Director at the Berlin Centre of Mechatronic Medical Technology, Charité Universitätsmedizin Berlin Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany Tel.: +49 304 5055 5132 [email protected]

• Univ.-Prof. Dr. med. Dr. med. dent. Joachim E Zöller Professor, University to Cologne, Head of Department for Craniomaxillofacial and Plastic Surgery, Interdisciplinary Outpatient Department for Oral Surgery and Implantology, Kerpener Straße 62, 50931 Köln, Germany Tel.: +49 221 478 5771 Fax: +49 221 478 5774 [email protected]

computer-aided manufacturing technologies for guided implant

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