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Accuracy of Guided Surgical Template Implant Surgery on Human Cadavers

Conference Paper · July 2010

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 Accuracy of CAD/CAM-guided surgical
template implant surgery on human
cadavers: Part I
Andreas Pettersson, BSc,a Timo Kero, MSc,b Luc Gillot, DDS,c
Bernard Cannas, DDS,d Jenny Fäldt, PhD,e Rikard Söderberg,
PhD,f and Karin Näsström, PhD, DDSg
Karolinska Institute, Huddinge, Sweden; Chalmers University of
Technology, Göteborg, Sweden; Odontological Faculty, University
Paris Descartes, Paris, France

Statement of problem. An optimal method for approaching the clinical surgical situation, when using preoperatively,
virtually planned implant positioning, is to transfer data to a CAD/CAM-guided surgical template with the definitive
position of the implant placed after surgery. The accuracy of CAD/CAM-guided surgeries must be determined to provide
safe treatment.

Purpose. The purpose of this study was to compare the deviation between the position of virtually planned implants
and the position of implants placed with a CAD/CAM-guided surgical template in the mandible and the maxilla in
human cadavers.

Material and methods. Ten maxillae and 7 mandibles, from completely edentulous cadavers, were scanned with CT,
and 145 implants (Brånemark RP Groovy) were planned with software and placed with the aid of a CAD/CAM-guided
surgical template. The preoperative CT scan was matched with the postoperative CT scan using voxel-based registra-
tion. The positions of the virtually planned implants were compared with the actual positions of the implants. Data
were analyzed with a t test (α=.05).

Results. The mean measurement differences between the computer-planned implants and implants placed after sur-
gery for all implants placed were 1.25 mm (95% CI: 1.13-1.36) for the apex, 1.06 mm (95% CI: 0.97-1.16) for the hex,
0.28 mm (95% CI: 0.18-0.38) for the depth deviation, 2.64 degrees (95% CI: 2.41-2.87) for the angular deviation, and
0.71 mm (95% CI: 0.61-0.81 mm) for the translation deviation.

Conclusions. The results demonstrated a statistically significant difference between mandibles and maxillae for the
hex, apex, and depth measurements in the variation between the virtually planned implant positions and the positions
of the implants placed after surgery with a CAD/CAM-guided surgical template. (J Prosthet Dent 2010;103:334-342)

Clinical Implications
A statistically significant difference in measurements was found when comparing
the positions of virtually planned implants to the positions of implants placed with
a CAD/CAM-guided surgical template on human cadavers. These results can be
used to ensure safer patient treatment and to provide a better understanding of the
deviations that can occur in CAD/CAM-guided template surgeries.

a
PhD student, Section for Image and Functional Odontology, Department of Dental Medicine, Karolinska Institute.
b
PhD student, Department of Product and Production Development, Chalmers University of Technology.
c
Clinical Instructor, Laboratory of Anatomy, Odontological Faculty, University Paris Descartes.
d
Clinical Instructor, Laboratory of Anatomy, Odontological Faculty, University Paris Descartes.
e
Senior Scientist, Early Development, Nobel Biocare AB, Göteborg, Sweden.
f
Professor, Head of Department of Product and Production Development, and Director, Wingquist Laboratory, Chalmers Univer-
sity of Technology.
g
Department Chair, Section for Image and Functional Odontology, Department of Dental Medicine, Karolinska Institute.

The Journal of Prosthetic Dentistry Pet tersson et al

June 2010
1 Overview of surgical procedure. From left to right: patient
examination; radiographic guide and index; CT/CBCT scan; virtual
planning; surgical template and index; and clinical procedures.
The introduction of dental im-
plants has revolutionized the oral
rehabilitation of completely and par-
tially edentulous patients.1-4 A subse-
quent revolution in implant dentistry
involves the use of 3-dimensional (3-
D) planning programs to assist in ac-
curate placement relative to anatomic
and prosthodontic needs.
The development of 3-D surgi-
cal planning programs, used along
with computerized tomography (CT)
images converted to 3-D models of
clinically relevant data, has made it
possible to mimic the true representa-
tion of the patient’s bone on the com-
puter screen. This concept of implant
treatment planning has been devel-
oped based on 3-D guided surgery, in
which the dentist refers the patient to
the radiologist, who scans the patient
together with a radiographic guide
and a radiographic index. The radio-
graphic guide is scanned separately
after the patient is scanned. The cli-
nician then converts the digital imag-
ing and communications in medicine
(DICOM) files to a 3-D format of the
patient’s bone and prosthesis, aligned
by spherical markers. The clinician
plans the patient treatment in a vir-
tual environment, orders a surgical
template according to the treatment
plan, and the CAD/CAM-guided sur-
gical template makes it possible to
guide the drills and implants during
the surgery. Using this method, the
clinician may avoid potential surgi-
Pet tersson et al
cal mishaps, such as the placement of
implants too close to significant ana-
tomic structures, while optimizing the
eventual prosthetic rehabilitation.
One commercially available soft-
ware used for planning the surgical and
prosthetic phases is NobelGuide (No-
bel Biocare AB, Göteborg, Sweden)5-7
(Fig. 1). This software enables the cli-
nician to transfer planned implant in-
formation and positions in advance of
the actual implant placement. While
implant selection and placement has
always been based on radiological
judgments, usually determined by us-
ing 2-dimensional (2-D) radiographic
images, this new method provides the
clinician with radiological data for all
3 dimensions. After completing the
surgical planning in a virtual environ-
ment, the data specifying the positions
of the implants are used to order the
components required for the surgery
and to manufacture the surgical tem-
plate by rapid prototyping.5,8
Custom-designed hardware com-
ponents, which were developed for
guiding the drills and the implants, are
ordered and delivered to the clinician’s
office. Using the surgical template
and special hardware components,
implants are placed by the surgeon
at a predetermined depth and angle.
The prosthesis is optimized by pros-
thetically driven implant placement.
Studies reporting guided implant
placement with the aid of a CAD/
CAM-guided surgical template have
335
been published, and include validation
results of planned implant positions
as compared to actual positions after
surgery.8-11 The objective of this study
was to compare the deviation between
the positions of virtually planned
implants and the positions of implants
placed with a CAD/CAM-guided sur-
gical template in the mandible and
the maxilla in human cadavers. The
research hypothesis was that there
would be no difference in accuracy
between the virtually planned implant
positions and the actual positions of
the implants placed in the mandible
and maxilla with a CAD/CAM-guid-
ed surgical template. The resulting
information is a first step in validating
the accuracy of CAD/CAM-guided im-
plant surgery.
MATERIAL AND METHODS
Seventeen cadaver jaws (10 max-
illae and 7 mandibles) were used in
the present study. Cadaver jaws were
consecutively collected by the Anato-
my Department, University Paris Des-
cartes (formerly Paris 5 University).
The use of the human-derived mate-
rials was approved by the Laboratory
of Anatomy Department, according
to regulations in France. The criterion
for inclusion was that the experimen-
tal material should be representative
of the clinical situation; thus, each
jaw was intact and completely eden-
tulous. A pilot project was first under-
taken using 3 jaws to define the pro-
tocols and methods to be used in the
main phase of the study.
A radiographic guide that recorded
the soft tissue geometry and the future
occlusal scheme was fabricated for each
of the edentulous residual ridges. The
radiographic guide was equivalent to
the conventional prosthesis for patients
and was fabricated by a dental labora-
tory technician with clear acrylic resin
(ProBase Cold; Ivoclar Vivadent AG,
Schaan, Lichtenstein) and contained
6-10 gutta-percha spherical markers
with a diameter of 1.5 mm and a depth
of 1 mm (Roeko Guttapercha Points
GT; Coltène/Whaledent GmbH, Lan-
336
genau, Germany). The markers al-
lowed matching of the radiographic
guide with the aid of the markers to
the patient volume from the CT scan
and created a 3-D virtual model in
dedicated software. A radiographic
index was produced before the first
CT scan of the patient (Regisil; Dent-
sply Caulk, Milford, Del). The radio-
graphic guide was positioned onto
the edentulous residual ridge, togeth-
er with the radiographic index, and
rubber bands were used to fixate the
jaws. The cadaver jaw was then fixed
to a plastic box with foam and im-
aged with a CT scanner (SOMATOM
Sensation 10; Siemens AG, Erlangen,
Germany). The CT scans were per-
formed using a 0-degree gantry tilt,
120 kV, 80 mAs, a slice width of 0.75
mm, and a reconstruction increment
of 0.5 mm. A second CT scan was
then performed of the radiographic
guide alone, with the same settings
as for the previous scan. The data
was exported from the CT scanner
by the radiologist and provided elec-
tronically. The resulting DICOM files
were converted with software (Proc-
era Software Clinical Design Premi-
um, version 1.5; Nobel Biocare AB)
to form a 3-D virtual model of the
matched bone and the radiographic
guide. The DICOM files were loaded
into the software’s CT-scan file con-
verter application, and the files for
the bone and prosthesis were se-
lected. The prosthesis and bone were
matched as the gutta-percha markers
were found and registered from the 2
2 A, Virtually planned implant position. B, Actual placement of implants after dissection.
The Journal of Prosthetic Dentistry
separate scans. The software eventu-
ally created a single file containing the
3-D shape of the radiographic guide
and bone combined.
To maximize the number of im-
plants in the study to be compared,
a surgical plan was developed with
a maximum number of implants
(Brånemark System MK III Groovy
RP; Nobel Biocare AB) in each jaw.
Some of the implants were to be used
to evaluate guiding in complex areas,
such as close to the mandibular canal,
incisive canal, or cortex. The planning
software implant coordinates were
exported to CAD design software
(Procera Software Clinical Design
Premium, version 1.5; Nobel Biocare
AB). CAD/CAM-guided surgical tem-
plates, which use specifically designed
sleeves to guide the drills and the im-
plants during surgical placement,
were ordered, together with clinically
relevant components, from Nobel
Biocare AB.
All implants were placed in the ca-
daver jaws using a CAD/CAM-guided
surgical template and according to the
treatment plan. The surgical protocol
has been described previously.5-7 The
surgical protocol also included infor-
mation on the drilling sequence, torque
value, and details on the placement of
each implant. The drilling sequence for
the cadaver surgeries simulated the ac-
tual clinical situation.
During the implant placement
procedure, only visual guidance,
provided by the soft tissue in con-
tact with the intaglio surface of the
Volume 103 Issue 6
surgical template, and manual pres-
sure were used while positioning the
anchor pins (Guided Anchor Pin, di-
ameter 1.5 mm; Nobel Biocare AB).
The anchor pins were placed to secure
the position of the surgical template
to the bone and soft tissue. Three to
5 anchor pins were placed in each jaw
during this procedure.
With the aid of an attached tem-
plate abutment, the first implant was
placed to secure the position of the
surgical template. The implant was
attached to the surgical template us-
ing a template abutment (Guided
Template Abutment Brånemark Sys-
tem RP; Nobel Biocare AB) which
connected to the implant and en-
gaged in the sleeve of the CAD/CAM-
guided surgical template to secure the
position after tightening the screw. A
second implant was placed to fix the
second template abutment. In some
situations in which posterior im-
plants were placed, a third template
abutment was placed to stabilize the
surgical template in the best possible
manner. Standard components were
used during the surgical procedure,
according to the NobelGuide pro-
tocol.5,6,7 A total of 145 Brånemark
Groovy RP implants were placed,
67 implants in the mandible and 78
in the maxilla. Immediately after the
surgical phase was completed, a post-
operative CT scan of the jaw was per-
formed with the same settings as for
the preoperative scans. In addition,
a dissection of some jaws was per-
formed to view the anatomy and the
Pet tersson et al
June 2010
position of the implant in comparison
to the planned position (Fig. 2).
The postoperative CT scan was
matched against the preoperative CT
scan using a 3-D voxel-based match-
ing method, as previously described.13
The 2 different data sets from the
pre- and postoperative CT scans were
registered into a single coordinate
system by calculation of mutual infor-
mation between the corresponding
voxels in the 2 data sets. The voxel-
based software searched for corre-
sponding gray values between the 2
data sets and aligned them. With the
aligned data sets, the actual positions
of the implants could be compared
with the virtually planned positions.
Linear and angular discrepancies be-
tween the planned and actual posi-
tions of each implant were analyzed in
3-D. The Euclidean distance between
the planned and actual implant po-
sition was measured at the center of
the apex and center of the hex of the
implant. The apex refers to the tip of
the implant and the hex refers to the
center of the prosthetic connection
of the implant. The angular deviation
between the main axes of the planned
and actual implant positions was
computed as well. The matching and
calculation procedure used was simi-
lar to that previously described.8,9,12,13
Statistical calculations were per-
formed using statistical software (SAS
Enterprise 4; SAS Institute, Inc, Cary,
NC). Calculations were further repro-
duced using a second statistical pro-
gram (STATISTICA 7.0; StatSoft, Inc,
Tulsa, Okla) to verify results. Devia-
tion apex, deviation hex, translation
deviation, and angle deviation were
log (e) transformed to have approxi-
mately normal distributed data for
use in the statistical analyses. To test
for deviation equal to zero, a 1-sam-
ple t test was used. Deviations were
summarized using median, minimum,
maximum, mean, and standard devia-
tion and the corresponding 95% con-
fidence interval. Differences between
the mandible and maxilla were tested
using the 2-sample t test. All tests
were 2-sided, and α=.05 was consid-
ered as statistically significant.
RESULTS
The differences between the man-
dible and maxilla were statistically
significant for apex, hex, and depth
deviation (Table I). The differences
between the virtually planned im-
plants and the actual positions of the
implants were statistically significant
for all 5 outcome variables: apex, hex,
depth, translation deviation, and an-
337
gle (Tables II, III, and IV).
A box plot analysis was used to
show the deviations in the mandible
and maxilla; the differences between
the mandible and the maxilla are il-
lustrated for the deviation between
the planned implant compared to the
placed implant in the apex, hex, an-
gle, depth, and translation measure-
ments, in different panels (Fig. 3).
The translation deviation graph
illustrates the parallel deviation be-
tween the virtually planned implant
and the implant placed after surgery
(Fig. 4). The translation error differ-
ence between placed implants (green-
blue color) and the planned implants
(gray implants with threads) can
be observed by visualizing the seg-
mented implants placed after surgery
and the virtually planned implants
after matching (Fig. 5). The great-
est random variation observed in the
data was observed in the mandible
“3Mand,” with the maximum de-
viation (Table II). All implants were
positioned in the same direction in
terms of the repositioning error. The
maximum range deviations for both
the mandible and maxilla occurred in
the same cadaver head (3Mand and
13Max) (Table II).

Table I. Summary statistics for tests between mandible and maxilla. Numbers of implants: 67 for
mandible and 78 for maxilla. Deviations in millimeters. Note: Negative value for depth deviation in-
dicates that implant did not reach planned position. Positive value indicates that implant was placed
deeper than planned position. LL: lower level, UL: upper level
Mandible Maxilla
Range Range
95% CI 95% CI 95% CI 95% CI
Variable Mean Min Max SD LL UL Mean Min Max SD LL UL P

Depth 0.48 –0.07 1.46 0.52 0.36 0.61 0.1 –0.03 1.61 0.60 0.03 0.24 <.001

Apex 1.24 0.13 3.63 0.58 1.08 1.43 0.96 0.12 2.43 0.50 0.86 1.08 .01

Hex 1.05 0.41 3.13 0.47 0.94 1.18 0.83 0.07 2.78 0.57 0.73 0.94 .01

Angle 2.46 0.26 7.44 0.67 2.09 2.9 2.02 0.08 5.38 0.66 1.74 2.34 .08

Translation 0.49 0.01 2.87 1.12 0.37 0.64 0.45 0.00 2.24 1.07 0.35 0.57 .63

Pet tersson et al
338 Volume 103 Issue 6

Table II. Summary of total deviations at the apex and hex and per cadaver and jaw type. Devia-
tions in millimeters. LL: lower level, UL: upper level
Cadaver Deviation Apex Deviation Hex
Number
of 95% CI 95% CI 95% CI 95% CI
Implants Median Mean SD LL UL P Median Mean SD LL UL P

1Mand 9 1.17 1.07 0.46 0.77 1.17 .001 0.69 0.71 0.16 0.61 0.74 .001
2Mand 9 0.96 1.03 0.36 0.79 1.11 .001 0.95 0.79 0.27 0.61 0.85 .001
3Mand 11 3.14 2.52 1.16 1.83 2.73 .001 2.46 2.19 0.90 1.66 2.35 .001
4Mand 11 1.6 1.47 0.84 0.97 1.62 .001 1.36 1.26 0.41 1.02 1.33 .001
5Mand 8 1.47 1.60 0.56 1.21 1.74 .001 1.18 1.81 0.09 1.75 1.83 .001
6Mand 11 1.16 1.32 0.54 1.00 1.42 .001 0.91 0.92 0.28 0.75 0.97 .001
7Mand 8 0.87 0.91 0.24 0.74 0.97 .001 1.06 1.04 0.21 0.89 1.09 .001
8Max 8 1.17 1.15 0.23 0.99 1.20 .001 0.91 0.99 0.20 0.85 1.03 .001
9Max 6 0.51 0.55 0.19 0.40 0.61 .001 0.54 0.56 0.19 0.41 0.62 .001
10Max 8 1.13 1.07 0.42 0.78 1.17 .001 0.85 0.81 0.19 0.68 0.86 .001
11Max 8 1.02 0.97 0.33 0.74 1.05 .001 0.66 0.62 0.15 0.51 0.65 .001
12Max 10 1.00 1.01 0.22 0.88 1.06 .001 0.57 0.57 0.25 0.42 0.62 .001
13Max 8 1.00 1.30 0.64 0.86 1.46 .001 1.78 1.90 0.62 1.47 2.05 .001
14Max 8 0.67 0.67 0.22 0.52 0.73 .001 0.86 0.81 0.14 0.71 0.84 .001
15Max 6 1.26 1.32 0.52 0.90 1.49 .002 0.95 1.10 0.35 0.82 1.21 .001
16Max 9 1.38 1.46 0.30 1.27 1.53 .001 1.46 1.48 0.12 1.40 1.50 .001
17Max 7 1.30 1.07 0.50 0.70 1.21 .001 0.79 0.67 0.37 0.40 0.77 .001
Total 145 1.12 1.25 0.68 1.13 1.36 <.001 0.93 1.06 0.58 0.97 1.16 <.001

Table III. Summary of total depth and translation deviations and per cadaver and jaw type. Deviations in milli-
meters. Note: Negative value for depth deviation indicates that implant did not reach planned position. Positive
value indicates that implant was placed deeper than planned position. LL: lower level, UL: upper level
Cadaver Deviation Depth Translation Deviation
Number
of 95% CI 95% CI 95% CI 95% CI
Implants Median Mean SD LL UL P Median Mean SD LL UL P

1Mand 9 0.43 0.45 0.13 0.37 0.48 .001 0.49 0.56 0.36 0.32 0.64 .002
2Mand 9 0.55 0.6 0.27 0.42 0.66 .001 0.60 0.57 0.29 0.38 0.63 .001
3Mand 11 0.66 0.64 0.34 0.44 0.70 .001 1.43 1.52 0.81 1.04 1.66 .001
4Mand 11 0.84 0.57 0.78 0.11 0.71 .036 0.66 0.97 0.82 0.49 1.12 .003
5Mand 8 0.66 0.35 0.72 –0.15 0.53 .212 0.25 0.40 0.52 0.04 0.53 .066
6Mand 11 0.33 0.13 0.63 –0.24 0.24 .509 0.57 0.75 0.71 0.33 0.88 .006
7Mand 8 0.69 0.67 0.17 0.55 0.71 .001 0.44 0.39 0.18 0.27 0.43 .001
8Max 8 0.70 0.65 0.43 0.36 0.76 .003 0.35 0.38 0.32 0.16 0.46 .011
9Max 6 –0.21 –0.19 0.10 –0.27 –0.15 .007 0.35 0.40 0.16 0.27 0.45 .002
10Max 8 0.32 0.32 0.16 0.21 0.36 .001 0.16 0.18 0.15 0.08 0.22 .010
11Max 8 0.39 0.33 0.19 0.20 0.38 .002 0.57 0.60 0.28 0.41 0.67 .001
12Max 10 0.31 0.35 0.19 0.23 0.39 .001 0.43 0.50 0.29 0.32 0.56 .001
13Max 8 0.70 0.88 0.40 0.60 0.97 .001 0.80 1.08 0.59 0.67 1.23 .001
14Max 8 –0.54 –0.41 0.40 –0.69 –0.31 .022 0.43 0.46 0.22 0.30 0.51 .001
15Max 6 –0.2 –0.29 0.23 –0.47 –0.21 .026 0.93 1.01 0.49 0.61 1.17 .004
16Max 9 –0.92 –0.92 0.28 –1.10 –0.86 .001 1.28 1.29 0.24 1.14 1.35 .001
17Max 7 0.15 0.20 0.27 0.01 0.28 .089 0.80 0.60 0.51 0.22 0.74 .022
Total 145 0.39 0.28 0.59 0.18 0.38 <.001 0.56 0.71 0.59 0.61 0.81 <.001

The Journal of Prosthetic Dentistry Pet tersson et al

June 2010 339

Table IV. Summary of total angular deviations and per cadaver

and jaw type. Deviations in degrees. LL: lower level, UL: upper level
Cadaver Angle Deviation
Number
of 95% CI 95% CI
Implants Median Mean SD LL UL P

1Mand 9 2.54 2.82 1.54 1.81 3.16 .001

2Mand 9 2.29 2.20 1.46 1.25 2.52 .002
3Mand 11 2.62 2.66 1.20 1.95 2.87 .001
4Mand 11 4.02 4.40 1.98 3.23 4.75 .001
5Mand 8 2.67 2.71 1.70 1.53 3.13 .003
6Mand 11 3.39 3.40 1.50 2.51 3.67 .001
7Mand 8 2.24 2.04 0.84 1.46 2.25 .001
8Max 8 1.60 1.84 1.18 1.02 2.13 .003
9Max 6 1.34 1.39 0.38 1.09 1.52 .001
10Max 8 2.26 2.01 1.27 1.13 2.32 .003
11Max 8 2.12 2.47 1.14 1.67 2.75 .001
12Max 10 2.64 2.67 0.67 2.26 2.80 .001
13Max 8 4.61 4.29 0.92 3.65 4.51 .001
14Max 8 2.74 2.66 0.68 2.18 2.82 .001
15Max 6 1.72 1.82 1.00 1.02 2.14 .007
16Max 9 2.05 1.88 0.70 1.42 2.03 .001
17Max 7 2.44 2.22 0.97 1.49 2.49 .001
Total 145 2.48 2.64 1.42 2.41 2.87 <.001

Deviation Apex Deviation Hex Angle Deviation

7
6
5
4
*
*
3 *
*
* *
* *
*
2 * * *
1
0 1.06
1.16 1.02 0.87 2.68 2.31
–1
–2
Translation Deviation Deviation Depth Mandible Maxilla

7
6
5
4
3 *
2 *
* * *
*
1
0
0.56 0.56 *
–1 *
0.55
0.21
–2
Mandible Maxilla Mandible Maxilla
3 Box plot of deviations in mandible and maxilla. Angle deviations are in degrees, all other deviations
are in millimeters. Note: Length of box corresponds to interquartile range. Horizontal line and numbers
within box correspond to median. Plus sign indicates mean. Crosses indicate outliers.
Pet tersson et al
340 Volume 103 Issue 6

28

24

Number of Implants
20

16

12

0
0 0.1 0.3 0.5 0.7 0.9 1.1 1.3 1.5 1.7 1.9 2.5 3.0
Translational Deviation
4 Histogram of translational deviation. Measurements in millimeters.

5 Translation deviation. Figure from 3Mand (Table III), with largest error in group. Planned
implants are gray with threads. Postoperative implants are blue-green color. Note all im-
plants are positioned in parallel direction after surgery compared to planned position.

DISCUSSION
Based upon the results of this
study, the research hypothesis cannot
be accepted, as there was a statisti-
cally significant difference between
the results of the mandible and the
maxilla for depth deviation, apex, and
hex, with the greater variation regis-
tered in the mandible. One explana-
tion for the variation could be that
the surgical template in the mandible
is less stable, as it covers a smaller
area compared to the maxilla. The
results demonstrated a significant
difference between the virtually
planned implants and the actually
placed implants for all 5 variables,
apex, hex, depth, translation devia-
tion, and angle. However, although
the values were statistically significant,
The Journal of Prosthetic Dentistry
it was not clear whether the results are
clinically significant.
CAD/CAM-guided implant surgery
offers the clinician another method
to ensure accurate and prosthetically
driven implant placement. As with
most new advancements, there may
be limitations and risks. While the
most accurate assessments will come
from clinical use, this study on cadav-
ers might add valuable information
about the accuracy of guided surgery.
The present study provides informa-
tion about the results of the specific
treatment performed, with limita-
tions such as the disadvantage of not
using the surgical index. The results
could be used to improve instructions
to clinicians and enable clinicians to
provide safer patient treatment. In a
review article including results from
8 published studies, Schneider et al11
presented results with a mean devia-
tion at the hex of 1.07 mm (95% CI:
0.76-1.22 mm) and a mean deviation
at the apex of 1.63 mm (95% CI: 1.26-
2 mm). The present study presents a
mean deviation at the hex of 1.06 mm
(95% CI: 0.97-1.16 mm) and a mean
deviation at the apex of 1.25 mm
(95% CI: 1.13-1.36 mm) and, thus,
demonstrates similar or better results.
The positioning of the radiograph-
ic guide calls for the patient to occlude
onto a radiographic index and radio-
graphic guide during the imaging pro-
cedure. In this study, the radiographic
guides could not be positioned in the
conventional manner. The guides had
to be manually placed with the help of
rubber bands. This method produced
a risk of positioning the radiographic
Pet tersson et al
June 2010
guide in a less than ideal manner. In
12 out of 17 cadaver jaws, a space
was visible between the soft tissue
and radiographic guide.
The traditional clinical procedure
to position the CAD/CAM-guided
surgical template onto the registered
position of the radiographic guide
could, for obvious reasons, not be
performed, due to the inability to
make an occlusal registration. There-
fore, the surgeon manually placed the
CAD/CAM-guided surgical template,
which may have resulted in less accu-
rate positioning of the implants.
Implant planning was performed
in an experimental manner, placing
as many implants as possible with
regard to the anatomical situation,
considering the availability of the
bone volume and the technical limi-
tations within the system. The limita-
tion of determining the position for
the radiographic guide and surgical
template in the experimental model
introduced errors that should not be
present clinically.
To preserve the specimens, each
cadaver was frozen and then thawed
up to 4 times, which may have caused
dehydration and a change in the size
and shape of the soft tissue. These
alterations of the soft tissue probably
caused minor changes in the posi-
tioning of the radiographic guide and
surgical template from the planned
positioning. In an attempt to mimic
the clinical setting as closely as pos-
sible, formaldehyde was not used.
Another issue was the flexibility of the
soft tissue in the cadavers, which might
add further variation to the results.
All of these minor differences be-
tween a living patient’s tissue and the
cadaver tissue may have contributed
to the errors in implant placement, in
comparison to the planned implant
positions. One cadaver in the present
study demonstrated the maximum
errors for both the mandible and the
maxilla (Fig. 5). This indicates that
the radiographic guide and surgical
template were likely malpositioned.
When reviewing the variation be-
tween the planned and the placed
Pet tersson et al
implants in the mandible (3Mand)
visually (Fig. 5), it appeared that a
parallel movement (translation) oc-
curred with the placed implants com-
pared to the planned implants. Mal-
positioning of the radiographic guide
and the surgical template might re-
sult in errors, such as rotation and
misplacement. additional research is
required to obtain more information
about the deviation from misplace-
ments of the radiographic guide and
the surgical template.
In this study, the variations be-
tween the virtually planned implants
and the implants placed after sur-
gery were compared using matching
methods similar to those presented
in a study by Van Assche et al.9 This
study 9 was performed on formalin-
treated cadavers and presented re-
sults with a range of 0.3-2.3 mm with
a mean value of 1.1 mm for the hex
and a range of 0.7-2.4 mm with a
mean value of 2.0 mm for the apex.
The current study presented results
with a range of 0.07-3.13 mm and a
mean value of 1.06 mm for the hex
and a range of 0.12-3.63 mm with a
mean value of 1.25 mm for the apex.
One reason for the differences be-
tween this study and the study by
Van Assche may be the number of ex-
perimental surgeries performed and
included in each of the different stud-
ies. The study by Van Assche includ-
ed only 4 subjects and 12 implants,
while this study included 17 subjects
and 145 implants. Another reason
might be that tooth-supported CAD/
CAM surgical templates were used in
the study by Van Assche, while in the
current study, only completely eden-
tulous CAD/CAM surgical templates
were used. Tooth-supported CAD/
CAM surgical templates are prob-
ably more stable compared to those
for totally edentulous subjects, add-
ing a possible disadvantage when ex-
cluding the surgical index and, thus,
causing larger deviations. The current
study presents the variation obtained
in completely edentulous specimens
that were frozen and thawed, and
without the option of using a surgi-
341
cal index. The results could be used
to provide a better understanding of
possible deviations that could occur
when performing CAD/CAM-guided
surgeries. This information can also
be useful for clinicians, in improving
this specific treatment method.
In future studies, if positioning
and repositioning errors are reduced,
the results will depend on the surgical
system limitations and errors, as well
as on variations between surgeons.
Additional studies are needed to learn
more about the various conditions af-
fecting virtual planning and guided
surgery, and how accurate CAD/
CAM-guided surgery is compared to
the freehand placement of implants.
CONCLUSIONS
Within the limitations of this
study, the results demonstrate a sta-
tistically significant difference be-
tween mandibles and maxillae for the
hex, apex, and depth measurements
between the virtually planned implant
positions and the positions of the
implants placed after surgery with a
CAD/CAM-guided surgical template
on human cadavers.
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Volume 103 Issue 6
Corresponding author:
Mr Andreas Pettersson
Karolinska Institute
Section for Image and Functional Odontology
Department of Dental Medicine
Alfred Nobels Allé 8
Box 4064
SE-14104 Huddinge
SWEDEN
Fax: +46 87795301
E-mail: andreas.pettersson@ki.se
Acknowledgments
The authors thank Matts Andersson for his
contribution of ideas throughout the study,
the department of Early Development at
Nobel Biocare AB, Göteborg, Sweden, for their
support of this study, and Filip Schutyser for
his expertise in 3-D software design and func-
tion and the matching process. The authors
also thank Prof Jean-François Gaudy for his
support and continuous help during the study
at the Laboratory of Anatomy, Odontologi-
cal Faculty, University Paris Descartes, Paris,
France.

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