JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Seo and Juodzbalys

Accuracy of Guided Surgery via Stereolithographic Mucosa-

Supported Surgical Guide in Implant Surgery for Edentulous
Patient: a Systematic Review

Cheongbeom Seo1, Gintaras Juodzbalys1

1
Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania.

Corresponding Author:
Cheongbeom Seo
Vytauto pr, LT44352, Kaunas
Lithuania
Phone: +370 68 555279
E-mail: [email protected]

ABSTRACT

Objectives: The purpose of the present study is to systematically review the accuracy of implant placement with mucosa-
supported stereolithographic surgical guide and to find out what factors can influence the accuracy.
Material and Methods: An electronic literature search was performed through the MEDLINE (PubMed) and EMBASE
databases. The articles are including human studies published in English from October 2008 to October, 2017. From the
examination of selected articles, deviations between virtual planning and actual implant placement were analysed regarding
the global apical, global coronal, and angulation position.
Results: A total of 119 articles were reviewed, and 6 of the most relevant articles that are suitable to the criteria were selected.
The present data included 572 implants and 93 patients. The result in the present systematic review shows that mean apical
global deviation ranges from 0.67 (SD 0.34) mm to 2.19 (SD 0.83) mm, mean coronal global deviation ranges from 0.6 (SD
0.25) mm to 1.68 (SD 0.25) mm and mean angular deviation - from 2.6° (SD 1.61°) to 4.67° (SD 2.68°).
Conclusions: It’s clearly shown from most of the examined studies that the mucosa-supported stereolithographic surgical
guide, showed not exceeding in apically 2.19 mm, in coronally 1.68 mm and in angular deviation 4.67°. Surgeons should
be aware of the possible linear and angular deviations of the system. Accuracy can be influenced by bone density, mucosal
thickness, surgical techniques, type of jaw, smoking habits and implant length. Further studies should be performed in order
to find out which jaw can have better accuracy and how the experience can influence the accuracy.

Keywords: computer-assisted surgery; dental implant; dimensional measurement accuracy; edentulous jaw; osseointegration;
review.

Accepted for publication: 26 March 2018

To cite this article:
Seo C, Juodzbalys G.
Accuracy of Guided Surgery via Stereolithographic Mucosa-Supported Surgical Guide in Implant Surgery for Edentulous
Patient: a Systematic Review
J Oral Maxillofac Res 2018;9(1):e1
URL: http://www.ejomr.org/JOMR/archives/2018/1/e1/v9n1e1.pdf
doi: 10.5037/jomr.2018.9101

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JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Seo and Juodzbalys

deviation between the virtual planning and the in vivo

INTRODUCTION position of the implants inserted using computer-aided
implantology [6]. The transfer of the virtual three-
Prosthodontic rehabilitation with endosseous dimensional implant planning to the surgical field
dental implants requires precise implant placement without deviations is unrealistic and it is essential to
for predictable functional, aesthetic and hygienic know the level of accuracy of the method used and
outcomes [1]. In oral rehabilitation with a the conditions which may influence the degree of
traditional surgical approach using osseointegrated accuracy [6].
implants, the surgeon is often obliged to perform A previous study reported greater accuracy in the
essential muco-periosteal detachments in order to edentulous mandible, which has higher bone density,
obtain good visibility of the bone structures [2]. than in edentulous maxilla [7]. However, in another
A stereolithographic surgical template fabricated study, the surgical guide showed higher accuracy in
using computer assisted planning has been recently edentulous maxilla because it covered a larger area
introduced in an effort to improve accuracy of than the edentulous mandible [8].
implant placement [1]. Stereolithography, a rapid To the best of the author’s knowledge, present
prototyping technology, a newer outcome in dentistry study is the first systematic review about accuracy
allows the fabrication of surgical guides from three- of stereolithographic surgical guide implant in
dimensional computer generated models for precise edentulous patient. The purpose of the present study
placement of the implants [3]. The surgical templates is to systematically review the accuracy of implant
fabricated by this technology are preprogramed placement with mucosa-supported stereolithographic
with individual depth, angulations, mesio-distal and surgical guide and to find out what factors could
labiolingual positioning of the implant [3]. Among influence the accuracy.
all available cross-sectional radiography, computed
tomography (CT) has proven to be an effective
diagnostic tool for evaluating bone volume, density, MATERIAL AND METHODS
vital anatomical structures, and most importantly Protocol and registration
in treatment planning and predicting appropriate
implant length, size, and position [1]. CT, when The methods of the analysis and inclusion criteria
coupled with a well-designed radiographic template were specified in advance and documented in a
allows for predictable evaluation of implant sites in protocol. The review was registered in PROSPERO,
relation to available bone, anatomical structures and an international prospective register of systematic
proposed prosthetic tooth positioning [1]. It offers the reviews [9]. The protocol registration number:
opportunity to apply a flapless approach, which on its CRD42018079905, can be accessed through the
own may give extra advantages [4]. Shorter surgery following link:
duration and less discomfort after surgery were https://www.crd.york.ac.uk/prospero/display_record.
recorded when mucosa-supported surgical guides php?ID=CRD42018079905
were used [5]. Therefore, the use of mucosa-supported
stereolithographic surgical guides in edentulous Focus questions
patients will increase along with the demand for
implant-supported restorations in edentulous patients The focus questions were developed according to
[4]. Although with all these advantages, everyone the problem, intervention, comparison, and outcome
must be aware of the fact that there is a variable (PICO) is presented in Table 1.

Table 1. PICO table

Edentulous patients who underwent surgical implant placement using stereolithographic mucosa-supported surgical
Population (P)
guide method.
Intervention (I) Implant placement with stereolithographic mucosa-supported surgical guide
Comparator or
Comparison of planned implant position with actual implant position after surgical implant placement
control group (C)
Deviation (distance in mm) between virtual planning and actual implant surgical placement according to global apical,
Outcomes (O)
global coronal, and angulation position
Does stereolithographic mucosa-supported surgical guide ensure accurate enough implant placement?
Focus questions What factors could affect the accuracy of implant placement with mucosa-supported stereolithographic surgical
guide?

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Types of publications surgical guide method.

The review included studies on human published in Inclusion and exclusion criteria
the English language.
Inclusion criteria for the selection were:
Types of studies • Human studies analysing accuracy of surgical
dental implant placement into edentulous jaw
The review included all human prospective studies, using stereolithographic mucosa-supported
retrospective studies and a randomized controlled surgical guide.
pilot study published between October 2008 and • Surgical implant placement accuracy was
October 2017, that reported on accuracy of surgical evaluated according to global deviation which is
dental implant placement into edentulous jaw using defined as the three-dimensional distance between
stereolithographic mucosa-supported surgical guide. the coronal and apical centres of the planned and
placed implants.
Information sources Exclusion criteria for the selection were:
• In vitro studies using mucosa-supported surgical
Information sources were PubMed/Medline and guide implant system.
EMBASE databases. • Studies that placing implants using mucosa-
supported surgical guide implant system was done
Literature search strategy to partial-edentulous jaw.
• Studies that placing implants was done by using
To identify the relevant studies, a detailed electronic tooth-supported surgical guide.
search was carried out according to PRISMA • Studies that placing implants was done by using
bone-supported surgical guide.
guidelines [10] within a PubMed/Medline and
EMBASE databases using different combinations of
Sequential search strategy
the following keywords: “Implant”, “Surgical guide”,
“Edentulous”, “Accuracy”, and “Stereolithographic”.
The selected articles were subjected independently to
The search details are as followed: implant [All
clear inclusion and exclusion criteria. The reviewer
Fields] AND (“surgical procedures, operative”
resolved the ambiguous point by taking advice
[MeSH Terms] OR (“surgical” [All Fields] AND
from an experienced senior reviewer. Following
“procedures”[All Fields] AND “operative” [All
the initial literature search, all articles were chosen
Fields]) OR “operative surgical procedures” [All according title relevancy, considering the exclusion
Fields] OR “surgical” [All Fields]) AND guide [All criteria. Following, studies were excluded based on
Fields] AND (“mouth, edentulous” [MeSH Terms] irrelevant data obtained from the abstracts. The final
OR (“mouth” [All Fields] AND “edentulous” [All stage of screening involved reading the full texts
Fields]) OR “edentulous mouth” [All Fields] OR and confirming each study’s eligibility based on the
“edentulous” [All Fields]) AND accuracy [All Fields] inclusion criteria.
AND stereolithographic [All Fields]. The search
was performed only for English articles which were Data collection process
published from October 2007 to October 2016.
Data were independently extracted from articles in the
Selection of studies form of variables according to the aim and themes of
the present review as listed shown below.
The resulting articles were independently subjected
to clarify inclusion and exclusion criteria by two Data items
reviewers. First titles and abstracts were screened and
finally full reports were obtained for all the studies The following data were obtained from the included
that were deemed eligible for inclusion in this paper articles:
(Figure 1). • “Author(s)” - revealed the author.
• “Year of publication” - revealed the year of
Population publication.
• “Patients” - describes the patients who were
Edentulous patients who underwent surgical implant treated by mucosa-supported surgical guide
placement using stereolithographic mucosa-supported implant system.

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Pubmed/MEDLINE, EMBASE data base advanced search

-Search terms: ”implant”, “surgical guide”, ”edentulous”,
”accuracy”, ”stereolithographic”;
Identification

-Journal categories: dental journals;

-Publication dates: October 2008 - October 2017;
-Species: Humans;
-Languages: English;
-Abstract able;
(n = 119)

Records screened after

duplication removal
Screening

(n = 114)
Duplicated and not
Filtered relevance title and abstracts
were excluded
(n = 103)
Abstracts were screened
according to title relevancy
(n = 16)
Authors could not be
Filtered contacted for eligibility
Eligibility

(n = 1)

Full-text articles assessed

for eligibility
(n = 15)
-Lack of information (n = 2)
-Not relevant result (n = 2)
Filtered -Patient data is not clear (n = 1)
-Data is combined with partial
edentulous arch (n = 4)
Articles included
(n = 6)
Included

Patients Implants
(n = 93) (n = 572)

Figure 1. PRISMA flow diagram.

• “Implant number” - indicates the implant numbers Risk of bias assessment

which were placed by mucosa-supported surgical
guide implant system to patient. The risk of bias assessment was conducted using
• “Jaw” - describes the jaw of patient that were Cochrane Risk of Bias Tool [11] for randomized
placed implant by using mucosa-supported clinical trial and The Newcastle-Ottawa Scale: Cohort
surgical guide implant system. Studies [12] for nonrandomized included studies
• “Smoking habit” - relevant to smoking habit.
independently.
• “Surgical technique” - indicates surgical technique
that clinician is using fixation screw to fix surgical
template. Synthesis of results
• “Deviation according to global apical, global
coronal, and angulation” - indicates deviation Relevant data of interest on the previously stated
of placed implant which were placed by using variables were collected and organised into
mucosa-supported surgical guide implant system. table.

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Statistical analysis post- graduate training in periodontology. They all

had a limited surgical experience in implant therapy
No meta-analyses could be performed due to the (30 - 80 implants placed). They had placed implants
heterogeneity between the studies (different study strictly series of steps (preparation of scan prosthesis,
designs, control groups, and observation periods). scanning procedure, pre-surgical planning, surgery,
Parametric data were expressed as mean and standard accuracy analysis) from November 2011 to January
deviation (M [SD]). 2014. Procedures were approved under supervision
of experienced surgeons. For example, in pre-surgical
RESULTS planning procedure, pre-surgical planning was
Study selection confirmed by both of experienced periodontologist
and prosthodontist. They both used same treatment
Total of 119 publications were retrieved and 16 and accuracy analysis protocol. The result showed that
articles were reviewed in fully. Initial exclusion for inexperienced group, the mean apical deviation
was done by duplication and not relevant titles was 1.102 (0.531) mm, mean coronal deviation was
and abstracts. Among them, six publications 0.871 (0.495) mm, mean angular deviation was 2.788°
were selected for the purpose of the systematic (1.475°). However for experienced group, the result
review. One publication was unable to screen. of mean apical deviation was 1.598 (0.701) mm,
According to inclusion and exclusion criteria, mean coronal deviation was 1.384 (0.643) mm, and
finally six publications were included, in which mean angular deviation was 2.705° (1.358°). Only in
have had evaluated a total of 572 implants from 93 angulation, the inexperienced group scored less than
patients. the experienced clinician [4]. The conclusion of the
article implies that the surgical experience had no
Exclusion of studies major impact on accuracy of implant placement and
inaccuracy was mainly resulted from mal positioning
Exclusion of articles are as followed: articles [1,13] of the guide.
that lack of information of deviation, articles [14,15] Similar pilot study was taken place in 2017 by
with not relevant result and article that patient data is Cassetta et al. [23], the aim of this research was to
not clear [16]. Articles [17-20] that data is combined compare the accuracy between group of experienced
with partial edentulous arch. surgeons (expert in computer-guided implantology)
and group of inexperienced surgeons (none the less
Risk of bias within studies expert in standard implantology). Ten of healthy
edentulous (maxilla and mandible) patients were
The risk of bias that indicated within this article enrolled, then divided into two different groups.
is collected and organised in Table 2 and Table Group I was comprised of experienced surgeons
3. Table 2 shows evaluation of the risk of bias who had experienced in placing at least 500 implants
for nonrandomized included studies, using The using computer-guided implantology. Group II
Newcastle-Ottawa Scale: Cohort Studies Tool was comprised of inexperienced surgeons who had
[12]. Two studies [4,5] were evaluated with score no experience of computer-guided implantology,
6 and three [6,21,22] with score 7. The risk of but at least 500 were implanted inserted using
bias assessment for randomized clinical trial [23] conventional implantology. Unlike study of Van
conducted using Cochrane Risk of Bias Tool [11] et al. [4], the result came out to be very different.
revealed low risk study judgement. For inexperienced group, the mean apical deviation
was 1.02 (0.44) mm, mean coronal deviation was
Study characteristics 0.75 (0.18) mm, mean angulation was 3.07° (2.7°).
For experienced group, the mean apical deviation
Van et al. [4] compared accuracy of surgical dental was 0.67 (0.34) mm, mean coronal deviation was
implant placement into edentulous jaw using 0.6 (0.25) mm, mean angular deviation was 3.21°
stereolithographic mucosa-supported surgical guide (1.57°). The inexperienced group had performed
by surgeons who do not have experience in guided better only in terms of the angular deviation results
surgery and surgeons who were experienced (Table [23]. Perhaps there had been difference in result
4). Experienced surgeons data were retrieved for between Cassetta et al. [23] and Van et al. [4].
comparison from Vercruyssen et al. [24] study. The The result of Cassetta et al. [23] had some limits
group of surgeons who did not have experience in though in which a pilot study was performed
surgical guide were those who followed a 3-year for a few patients only giving less creditability.

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Table 2. Evaluation of the risk of bias for nonrandomized included studies, using Table 3. The risk of bias assessment for randomized clinical trial [24] conducted using Cochrane Risk of Bias
The Newcastle-Ottawa Scale: Cohort Studies Tool [12] Tool [11]

Studies Selection Comparability Outcome Total score Blinding of

Random Blinding of Incomplete
Van et al. [4] 6 Year of Allocation participant’s Selective Other
★★★ ★ ★★ Study
publication
sequence
concealment and
outcomes outcome
reporting bias
Ochi et al. [5] 6 generation assessment data
★★★★ ★ ★ personnel
Cassetta et al. [6] ★★★★ ★ ★★ 7 Cassetta et al.
2017 + + + + + + +
Cassetta et al. [21] 7 [23]
★★★★ ★ ★★
D’haese et al. [22] ★★★ ★ ★★★ 7 + = low risk; ? = unclear risk; - = high risk.

Table 4. Characteristics of included studies

Deviation Deviation Deviation

Deviation
Apical Coronal according to according to
Implant Guide Smoking Surgical Ang according to jaw
Study Patient Rx Jaw deviation deviation Dev surgical technique smoking habit
no. system habit technique (°) (mean [SD])
(mm) (mm) (mean [SD]) (mean [SD])
Mean (SD) Maxilla Mandible Fixed Non-fixed Yes No
Maxilla
Van et al. [4] 16 75 Simplant CBCT and - Fixed 1.1 (0.53) 0.87 (0.5) 2.79 (1.47) - - - - - - -
mandible
Ochi et al. [5] 15 30 Nobelbiocare CBCT Mandible - Fixed 1.08 (0.47) 0.89 (0.44) - - - - - - - -
Fixed (8)/ - - 2.11 (0.75) 2.22 (0.91) 2.28 (0.84) 2.04 (0.79) 2.11 (0.75)
Cassetta et al. Yes (6)/
11 95 Simplant CT Maxilla non-fixed 2.15 (0.81) 1.65 (0.56) 4.62 (2.74) - - 1.66 (0.57 1.64 (0.56) 1.8 (0.51) 1.52 (0.58 1.66 (0.57)
[6] no (5)
(3) - - 4.1 (2.43) 5.44 (3.02) 4.41 (3) 4.79 (2.52) 4.1 (2.43)
AD
2.12 (0.78) 2.25 (0.88) 2.09 (0.75) 2.26 (0.89) 2.27 (0.83) 2.08 (0.8)
(mm)
Maxilla Fixed (18)/
Cassetta et al. Yes (14)/ CD
28 225 Simplant CT and non-fixed 2.19 (0.83) 1.68 (0.6) 4.67 (2.68) 1.68 (0.51) 1.64 (0.71) 1.66 (0.58) 1.68 (0.6) 1.83 (0.58) 1.54 (0.56)
[21] no (14) (mm)
mandible (10)
Ang
4.36 (2.9) 5.46 (2.03) 4.09 (2.4) 5.62 (2.8) 4.5 (2.87) 4.92 (2.52)
(°)
D’haese et al. Astra Tech Yes (5)/
13 77 CT Maxilla Fixed 1.13 (0.52) 0.91 (0.44) 2.6 (1.61) - - - - - - -
[22] AB no (8)
5
37 Maxilla 0.67 (0.34) 0.6 (0.25) 3.21 (1.57) - - - - - - -
Cassetta et al. exp
3Diemme CT and No Fixed
[23] 5
33 mandible 1.02 (0.44) 0.75 (0.18) 3.07 (2.7) - - - - - - -
inexp

Ang = angulation; Dev = deviation; exp = inexperienced; inexp = inexperienced; Rx = radiological technique; CT = computer topography; CBCT = cone-beam computer topography; SD = standard deviation;
AD = apical deviation; CD = coronal deviation.

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Cassetta et al. [23] concluded in his article that of the radiographic guide and surgical guide during
inexperienced group’s resulting in higher coronal and surgery.
apical deviation were due to the error from position. D’haese et al. [22] performed a prospective
Cassetta et al. [6,21] analysed factors that can study on the accuracy of mucosally supported
influence the accuracy of mucosa supported surgical stereolithographic surgical guide in fully edentulous
guide technique. In the article [21], the author maxilla. Seventy eight implants were installed in 13
compared the results of accuracy according to surgical edentulous maxilla, and 77 implants were analysed
technique, jaw, and smoking habits. Also, author among 78 implants. One of the implant was lost
took measurement of mucosal thickness to find out shortly after the insertion due to abscess formation
the relation between mucosal thickness and smoking which caused by remnants of impression material.
habits. According to the result, accuracy of implant The result showed that mean global coronal deviation
insertion using a mucosa-supported stereolithographic of 0.91 (0.44) mm, mean global apical deviation of
surgical guide in completely edentulous patients was 1.13 (0.52) mm, and mean angular deviation of 2.6°
mainly affected by variable factors such as surgical (1.61°). And the study included result of differences in
technique, jaw, and smoking habits. The result also coronal and apical inter implant position, comparing
showed that a high level of accuracy was obtained the virtual distance with the in vivo inter implant
when fixed mucosa-supported stereolithographic distance after surgery on a patient level. The result
surgical guides were used in the maxilla. This was showed that the mean coronal deviation of 0.18
most likely attributable to the fact that fixation screws (0.15) mm mean apical deviation was 0.33 (0.28) mm
and greater surface support reduced any possible which was substantially lower than the global coronal
displacement of the guide during surgery [21]. In and apical deviation. The significant difference was
addition, the mucosal thickness also affected accuracy, observed when comparing the global apical deviation
thicker the mucosa, higher the deviation values were. of short and long implants. Shorter implants (8 mm)
Similar research was done by Cassetta et al. [6], showed mean global coronal deviation lower than
but this study was constricted to only maxilla. It is 0.75 mm while longer implants (15 mm) showed
interesting to know that study showed a significant about 1 mm. It was similar in mean global apical
difference when comparing the global coronal deviation as well; shorter implants (8 mm) showed
deviations among smokers and non-smokers. less than 1mm while longer implants (15 mm)
Ochi et al. [5] in their study discussed more precisely showed more than 1.75 mm. Shorter implants showed
factors that could affect accuracy of implant significantly lower apical deviations compared to that
placement with mucosa-supported stereolithographic of longer ones. Author found that optimal positioning
surgical guides in edentulous mandibles. The study of the fixation screws and support and stability of
covered both of the model and the patient study and the guide on the mucosa are very important issue to
yet only the patient study was used for this research obtain better accuracy.
after considering inclusion and exclusion criteria:
30 implants were placed among the 15 patients,
global deviation in the neck was 0.89 (0.44) mm DISCUSSION
and for the apex, it was 1.08 (0.47) mm. According
to Spearman’s rank correlation coefficients for each In the current systematic review, mucosa-supported
deviation and bone density, mucosal thickness, and stereolithographic surgical guide’s accuracy and
area of supporting mucosa, had showed that there factors which could affect guided surgery were
were significant negative correlations between assessed.
bone density and depth deviations at the implant In order to evaluate the accuracy of placing implant
neck and apex. Author assumed that when surgical using mucosa-supported stereolithographic surgical
guides were used, the implants tended to be placed guide, as a parameter, the global deviation is defined
more superficially. Closer to the planned position as the three-dimensional distance between the coronal
when they were deeply inserted on lower density and apical centres of the planned and placed implants
bone sites. Also there was a significant positive (Figure 2). The angular deviation is calculated as the
correlation between mucosal thickness and the global three-dimensional angle between the longitudinal axes
deviation at implant apex. Study had showed that of both. In Van et al. [4], other deviation values were
increased mucosal thickness led to higher global included which are as follows: apical depth, coronal
deviation at the implant apex. This was due to depth, bucco-lingual, mesio-distal. In D’haese et al.
thick mucosa causing movement of the guide and [22] study inter implant deviation was included. But
resulting in positional discrepancy between CT scan in order to standardize the results, it was omitted.

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the positioning error between experienced and

inexperienced group. In the aspect of how the
experience could affect the accuracy, this present
review included limited number of studies. Therefore,
a further research study should be conducted.
a The factors retrieved from independent studies that
could influence the accuracy of mucosa-supported
stereolithographic surgical guides suggested are as
follows: (1) bone density, (2) mucosal thickness, (3)
surgical techniques, (4) the jaw, (5) smoking habits,
α and (6) implant length.
Ochi et al. [5] suggested that there was negative
correlations between bone density and depth
b deviations. Of the 30 implants placed, 21 were placed
Placed
more superficially and 9 were placed more deeply, yet
Planned there was depth control of the drills. It can be assumed
that when surgical guides are used, the implants tend
to be placed more superficially than planned and they
Figure 2. Three-dimensional evaluation of planned and placed
implant positions. come close to the planned position when inserted
a = global apical; α = angle; b = global coronal. more deeply at bone sites with lower bone density [5].
Also, Ochi et al. [5] suggested that there is positive
The result in the present systematic review showed correlation between mucosal thickness and the global
that mean apical global deviation was from 0.67 deviation at the implant apex implied that an increased
(0.34) mm to 2.19 (0.83) mm, mean coronal global mucosal thickness led to higher global deviation at the
deviation was from 0.6 (0.25) mm to 1.68 (0.25) mm implant apex. As the mucosal thickness gets thicker,
and mean angular deviation was from 2.6° (1.61°) the global deviation at the apex would increase. This
to 4.67° (2.68°). According to current data, apical suggestion is supported by Cassetta et al. [6,21]
deviation was higher than coronal deviation. It can be studies. Authors [6,21] had found that smokers tends
explained by the fact that implant guidance is optimal to have more deviation than non-smokers and this was
in the coronal part of the prepared osteotomies because smokers had a significantly thick mucosal
because of the limited effect of the angular deviation biotype compared to nonsmokers. Cassetta et al.
on the global deviation, which increases at a larger [6,21] also suggested that surgical technique affected
distance, that is, further into the bone [22]. accuracy, as the fixed surgical guides provided a
Guided surgery could be very helpful for those higher level of accuracy. This was a result of the
of surgeons who do not have much of surgical reduced possibility of displacement of the guide.
experience of dental implant treatment. Van et al. D’haese et al. [22] demonstrated that control of the
[4] made a study about how possibly experience of proper fit of the surgical guide was achieved by
placing implant could affect the accuracy of guided optimal positioning of the fixation screws and this
surgery via mucosa-supported stereolithographic would decrease the value of deviation. In the Cassetta
surgical guide. According to current data, only in et al. [21] study, mandible may allow a greater
angulation, the inexperienced group scored less possibility of guide displacement than maxilla since
than that of the experienced surgeon’s. And author the reduced area of support. D’haese et al. [22] found
had concluded that surgical experience had no that statistically significant difference was found when
major influence on accuracy of implant placement comparing the global apical deviation of short versus
and malpositioning of the guide was the main long implants, as implant length got longer, the global
factor of inaccuracy. This result could be achieved apical deviation got bigger. This could have clinical
from each step in the procedures for planning and consequences when more implants are installed in
surgery were done under supervision of trained anatomically compromised regions [22]. There were
surgeons. In contrast, Cassetta et al. [23] had their also more factors could influence the deviation of
randomized controlled pilot study demonstrated that mucosa-supported stereolithographic surgical guide.
the inexperienced group performed better only in However these factors needed to be carefully studied
the angular deviation results. And experienced group further to find correlation with deviation. Virtual
showed better accuracy in global apical, coronal dental implant operation planning and template-
deviation. The major difference was observed in guided surgery has gained attention as a method

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of improving the predictability of dental implant

placement. Nokar et al. [25] determined and compared CONCLUSIONS
the accuracy of an advanced surgical template
based on computer-aided design/computer-assisted It’s clearly shown from most of the examined studies
manufacture (CAD/CAM) with the conventional that the mucosa-supported stereolithographic surgical
surgical template. It is interesting to note, that the guide, showed not exceeding in apically 2.19 mm, in
average differences between the planned and actual coronally 1.68 mm and in angular deviation 4.67°.
entry points in the mesiodistal and buccolingual Surgeons should be aware of the possible linear
directions, lengths, and angles of the implants and and angular deviations of the system. Accuracy can
the osteotomy showed a considerable reduction in be influenced by bone density, mucosal thickness,
the CAD/CAM group versus the conventional group surgical techniques, type of jaw, smoking habits and
(P < 0.005). Authors concluded that the accuracy of implant length. Further studies should be performed in
implant placement was improved using an innovative order to find out which jaw can have better accuracy
CAD/CAM surgical template. However implant and how the experience can influence the accuracy.
position depend on the individual anatomy of the
jaws and the ability to place the CAD/CAM-guided
surgical template in the proper position [26]. Zhou ACKNOWLEDGMENTS AND DISCLOSURE
et al. [27] compared how radiology method could STATEMENTS
affect the accuracy of guided surgery in his systematic
review and meta-analysis. Based on his study The authors confirm that this article content has no
result, he concluded that there is no such significant conflict of interest with any financial organization
difference in the accuracy between CT and CBCT. regarding the material discussed in the article.

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To cite this article:

Seo C, Juodzbalys G.
Accuracy of Guided Surgery via Stereolithographic Mucosa-Supported Surgical Guide in Implant Surgery for Edentulous
Patient: a Systematic Review
J Oral Maxillofac Res 2018;9(1):e1
URL: http://www.ejomr.org/JOMR/archives/2018/1/e1/v9n1e1.pdf
doi: 10.5037/jomr.2018.9101

Copyright © Seo C, Juodzbalys G. Published in the JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
(http://www.ejomr.org), 31 March 2018.
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