The Journal of EVIDENCE-BASED DENTAL PRACTICE

ORIGINAL ARTICLE

CLINICAL FACTORS AFFECTING THE

ACCURACY OF GUIDED IMPLANT SURGERY—
A SYSTEMATIC REVIEW AND META-ANALYSIS

WENJUAN ZHOU, DDS, PhDa,b,c, ZHONGHAO LIU, DDS, PhDa,

LIANSHENG SONG, DDS, MSb, CHIA-LING KUO, PhDd, AND DAVID M. SHAFER, DMDb
a
Department of Implant Dentistry, Yantai Stomatological Hospital, Binzhou Medical University, Yantai, China
b
Division of Oral and Maxillofacial Surgery, UConn School of Dental Medicine, Farmington, CT, USA
c
Division of Conservative Dentistry and Periodontology, Competent Center of Periodontal Research, University Clinic of Dentistry, Medical University of Vienna,
Vienna, Austria
d
CT Institute for Clinical and Translational Science, UConn Health, Farmington, CT, USA

CORRESPONDING AUTHOR: ABSTRACT

Wenjuan Zhou, Division of Oral
and Maxillofacial Surgery, UConn
School of Dental Medicine, 263
Farmington Avenue, Farmington,
CT 06030, USA.
E-mail: zhouwenjuan1004@163.com
KEYWORDS
Dental implants, Computer-assisted,
Guided surgery, Surgical guides,
Accuracy
Conflict of Interest: The authors have
no actual or potential conflicts of
interest.
Received 26 June 2017; accepted
17 July 2017
Objectives
To systematically review the current dental literature regarding clinical accuracy of
guided implant surgery and to analyze the involved clinical factors.
Material and Methods
PubMed and Cochrane Central Register of Controlled Trials were searched. Meta-
analysis and meta-regression analysis were performed. Clinical studies with the
following outcome measurements were included: (1) angle deviation, (2) devia-
tion at the entry point, and (3) deviation at the apex. The involved clinical factors
were further evaluated.
Results
Fourteen clinical studies from 1951 articles initially identified met the inclusion
criteria. Meta-regression analysis revealed a mean deviation at the entry point of
1.25 mm (95% confidence interval [CI]: 1.22-1.29), 1.57 mm (95% CI: 1.53-1.62) at
the apex, and 4.1 in angle (95% CI: 3.97-4.23). A statistically significant differ-
ence (P , .001) was observed in angular deviations between the maxilla and
mandible. Partially guided surgery showed a statistically significant greater de-
viation in angle (P , .001), at the entry point (P , .001), and at the apex (P , .001)
compared with totally guided surgery. The outcome of guided surgery with
flapless approach indicated significantly more accuracy in angle (P , .001), at the
entry point (P , .001), and at apex (P , .001). Significant differences were
observed in angular deviation based on the use of fixation screw (P , .001).

Conclusions
The position of guide, guide fixation, type of guide, and flap approach could
influence the accuracy of computer-aided implant surgery. A totally guided sys-
tem using fixation screws with a flapless protocol demonstrated the greatest
accuracy. Future clinical research should use a standardized measurement tech-
J Evid Base Dent Pract 2018: [28-40] nique for improved accuracy.
1532-3382/$36.00
ª 2017 Elsevier Inc. All INTRODUCTION
rights reserved.
doi: http://dx.doi.org/10.1016/
j.jebdp.2017.07.007 D igital technology has been playing a more and more important role in
dentistry for number of years, one of the most common used digitalized

28 Volume 18, Number 1


dental technique is digital radiography, which provides
dental professionals potentially a better way of diagnosis
and treatment for dental desease.1-3 In the past several
years, with the introduction of computed tomography (CT)
and 3-dimensional (3D) printing into the field of implant
dentistry, computer-aided design and computer-aided
manufacturing (CAD/CAM) technology brought a great
evolution of novel treatment concepts to dental implant
treatment.4 CT and 3D implant planning software can not
only provide clinicians with 3D information of patient’s
anatomic structures, but also data regarding the patient’s
final prosthesis, these digital data can be combined with
the CAD/CAM technology and further lead to a digital
workflow ending with the production of stereolithographic
(STL) template via a prototyping system.5,6 The STL
template can then be used to guide the position and
direction of certain implants during surgery. By which, the
whole surgical procedure is so called “guided dental
implant surgery.”
According to the consensus statement published in 2009,7
the term “computer-guided surgery” is defined as the use
of a static surgical guide that reproduces the virtual
implant position directly from CT data and does not allow
for intraoperative modification of the implant position. It
has been demonstrated to be an established treatment,6
which reduces the probability of damage to the adjacent
critical structures such as bones, nerves, adjacent tooth
roots, and sinus cavities. The main advantage of guided
surgery is the ability to plan and optimize the implant
position in a restoration-driven placement manner. More-
over, computer-guided technique can help to decrease
postoperative discomfort and allows for immediate func-
tion, as they enable implant placement with minimal surgical
trauma. In addition, this technique offers an alternative to
bone augmentation in situation of severely resorbed alve-
olar ridges, as they facilitate optimal position of implants in
available bones.8-10 However, with the generalization of this
technique, many doubts have risen on its usefulness and
especially the accuracy.11-15
Accuracy in guided implant surgery is defined as matching
the planned position of the implant in the software with the
actual position of the implant in the patient’s mouth.13 It
reflects the accumulation of all deviations from imaging
over the transformation of data into a guide, to the
improper positioning of the latter during surgery,14 and
the different types of errors include error during image
acquisition and data processing, error during surgical
template production, error during template positioning
and movement of the template during drilling, and
mechanical error caused by tolerance of surgical
instruments. All errors, although seldom occurring, can be
cumulative.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
In recent years, several studies have been performed on
different factors affecting the accuracy of guided sur-
gery,16,17 and systematic reviews6,18-20 have evaluated these
studies very well, focusing on the accuracy, clinical advan-
tages, survival rates, complications of computer-guided
surgery, and the influence of using different types of
guide. However, only limited and incomplete data were
provided in clinical trials regarding the accuracy and influ-
ence of relevant clinical factors except for tissue of sup-
port.18 There are still no concerted standard parameters for
the evaluation of deviation, which leads to diversity in
results and, therefore, can hardly provide an effective
indication for the clinical application of guided surgery.
In the present study, we tried to review the current dental
literature, focusing on the clinical accuracy of guided dental
implant surgery, to analyze the involved clinical factors
affecting the accuracy, and tried to find the most appro-
priate method for the evaluation of accuracy.
MATERIALS AND METHODS
Protocol and Registration
This review was registered at the International Prospective
Register of Systematic Reviews (https://www.crd.york.ac.uk/
PROSPERO, registration number 42016050127). It was
conducted in accordance with the guidelines of “Preferred
Reporting Items for Systematic Review and Meta-analysis
Protocols 2015 Statement.”21
Search Strategy for Identification of Studies
Two Internet sources of MEDLINE-PubMed and Cochrane
Central Register of Controlled Trials (CENTRAL) were used
to search for eligible articles (published and online preview)
in English, and this was complemented by a manual search
of the references of all selected full-text articles. Publica-
tions from January 1, 1990, to October 31, 2016,
were searched using the following search strategy:
PubMed: ((((((((((((“Dental Implantation”[Mesh]) OR
“Dental Implants”[Mesh]) AND “Surgery, Computer-Assis-
ted”[Mesh]) OR “Computer-Aided Design”[Mesh]) OR
dental implant navigation) OR digital dentistry) OR guided
dental implant surgery) OR image-guided dental implant
surgery) OR computer-guided dental implant surgery) OR
dental stereo lithography) AND “Dimensional Measurement
Accuracy”[Mesh]) OR dental implant deviation) OR dental
implant precision) OR dental implant accuracy); Cochrane
Central Register of Controlled Trials: dental implantation OR
dental implant and dental navigation OR computer aided
dental implant OR three-dimensional (3D) dental planning
OR 3D dental planning OR computer-assisted dental
implant OR dental stereo lithography OR guided dental
implant placement OR dental surgical template OR dental
guided surgery OR dental surgical guide AND dimensional
March 2018 29
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

measurement accuracy OR dental implant deviation OR
dental implant precision OR dental implant accuracy.
Studies Selection and Data Extraction
For inclusion in this study, the articles were selected ac-
cording to the following criteria: (1) articles published in
English; (2) clinical cohort studies; (3) the article title is
related to the question, that is, studies reporting on the
accuracy of static guided implant surgery performed in the
partially or complete edentulous jaw; (4) studies in which
quantitative results are provided (only studies providing
exact information on the amount and direction of implant or
osteotomy deviations were included); and (5) studies with a
minimum sample size of 10. To evaluate the deviation, at
least the following parameters should have been observed:
deviation at the entry point, deviation at the apex, and
deviation of the axis.
Articles were additionally rejected after full-text analysis in
the following situations: (1) expert opinions or literature re-
views; (2) reports of techniques; (3) case series; (4) implants
installed in areas of bone augmentation; (5) studies with
zygomatic implants, pterygoid implants, or mini-implants for
orthodontic purposes; and (6) studies using CT for implant
planning without applying CAD/CAM surgical guide during
surgery (mental navigation).
less than 5% was deemed statistically significant. All the
meta-regression analyses were performed using R 3.3.1. For
the comparison of other involved clinical factors, meta-
analysis was conducted using Review Manager, version 5.0
(The Nordic Cochrane Center, Denmark). Heterogeneity
between studies was assessed with the I2 statistics ($50%)
and Cochran’s Q test (P ,.001/95% confidence interval [CI]).
P values and 95% CIs were calculated for each variable of
interest. The level of significance was set at P # .05.
RESULTS
The initial search yielded 1743 titles from PubMed and 208
from the Cochrane Central Register of Controlled Trials.
After reviewing the abstract, 1906 were excluded and 45
were considered for further full-text screening. Finally, 14
articles (6 retrospective studies and 8 prospective studies)
were included in this systematic review (Figure 1). The
characteristics of the included articles are presented in
Table 1; the review did not include studies with smokers
and patients with periodontal disease or other systemic
diseases to avoid selection bias. The risk of bias
assessment showed that most observational studies
included in this systematic review received 8-10 stars,
which indicates a medium-level methodological quality,

Two reviewers retrieved the data independently and dis-

cussed with a third reviewer for the final selection of Figure 1. Flow diagram of articles retrieved from
included studies. Except for the deviation of guided sur- databases.
gery; age, radiology method (CT or cone beam CT (CBCT)),
position of guide (maxilla or mandible), fixation of guide
(with or without fixation screw), type of guide (totally/fully
guided or partially guided), and flap method (open flap or
flapless) were further considered to be factors that would
influence the accuracy of the outcome.

For the assessment of bias risk in included studies, the

adapted Newcastle-Ottawa Scale was used according to 2
previous systematic reviews.18,22 In brief, a maximum of 13
stars could be assigned for each included study; studies with
10-12 points indicated high methodological quality, 7-9
points indicated medium-level methodological quality, and u

others were considered as studies with low methodological

quality.

Statistical Analysis
The results of different studies were combined by meta-
analysis assuming a random-effects model. Subgroup
comparisons, for example, age groups and radiation
methods, were performed in the framework of mixed-effects
meta-regression. An omnibus test was used to test if there is
mean difference between groups. If the result was signifi-
cant, all possible pairwise comparisons were conducted with
multiple testing adjustment by Tukey’s method. A P value

30 Volume 18, Number 1

 Table 1. Characteristics of studies included for qualitative analysis.
Global Global Lateral Lateral Depth Depth
Angle deviation deviation deviation deviation deviation deviation
deviation coronal apical coronal apical coronal apical
Type of Type of
(degree) (mm) (mm) (mm) (mm) (mm) (mm)
Mean Edentulism guide flap Fix screw
Patients/no. age (no. of Jaw (no. Guide (no. of (no. of (no. of
Study Design Rx of implants (y) implants) of implants) system implants) implants) implants) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Ozan Retrospective CT 30/110 47 Fully; partially Max. (58); Stent Total Flapless (60); N (110) 4.10 2.30 1.11 0.70 1.41 0.90 – – – – – – – –
et al., 2009 Mand. (52) CAD flap(50)

Cassetta Retrospective CT 10/111 54 Fully (94); Max. (68); SimPlant Total Flapless (93); Y (67); N (44) 4.68 2.98 1.52 0.61 1.97 0.86 1.20 0.63 – –
et al., 2011 partially (17) Mand. (43) flap(18)

Cassetta Retrospective CT 12/129 55 Fully (112); Max. (78); SimPlant Total Flapless (111); Y (75); 4.78 2.89 1.57 0.63 2.06 0.88 1.23 0.60 – –
et al., 2013 partially (17) Mand. (51) flap (18) N (54)

Vieira Retrospective CBCT 14/62 – Fully (62) Max.; Mand. Dental Total Flapless (62) Y (62) 1.89 0.46 1.79 0.81 2.21 1.50 – – – – – – – –
et al., 2013 Slice

Farley et Prospective CBCT 10/Oct 42 Single (10) Max. (3); iDent Total Flapless (10) – 3.68 2.19 1.45 0.60 1.82 0.60 0.63 0.37 1.11 0.71 21.20 0.70 21.24 0.68
al., 2013 Mand. (7)

Cassetta Retrospective CT 20/227 55 Fully (182); Max. (135); SimPlant Total (111); Flapless (187); Y (111); 4.82 3.14 1.50 0.63 1.92 0.91 1.35 0.68 – – – –
et al., 2013a partially (45) Mand. (92) partial(116) flap (40) N (116)

Arisan Prospective CT/CBCT 11/102 – Fully (102) Max. (64); SimPlant Total Flapless (102) Y (102) 3.38 1.11 0.78 0.32 0.83 0.33 – – – – – – – –
et al., 2013 Mand. (44)

Lee Retrospective CT 48/102 52.9 Fully (17); Max. (62); OnDemand 3D Total (102) Flap (102) Y (102) 3.80 3.24 1.09 1.10 1.56 1.48 0.72 0.75 1.23 1.25 0.66 0.95 0.69 1.03
et al., 2013 partially (85) Mand. (40)

The Journal of EVIDENCE-BASED DENTAL PRACTICE

Ersoy Prospective CT 21/94 43 Fully (65); partially Max. (48); Stent CAD Total (94) Flapless (41); – 4.90 2.36 1.22 0.85 1.51 1.00 – – – – – – – –
et al., 2008 (20); single (9) Mand. (46) flap (53)

Arisan Prospective CBCT 54/279 48.4 Fully; – Stent CAD Total (29); Flapless; flap – 3.96 1.05 1.22 0.39 1.44 0.43 – – – – – – – –
et al., 2010 partially SimPlant partial (30)

Di Giacomo Prospective CBCT 12/60 60.3 Fully (60) Max. (22); NTT Partial (60) Flapless (60) Y (60) 6.53 4.31 1.35 0.65 1.79 1.01 – – – – – – – –
et al., 2011 Mand. (38)

Stubinger Prospective CT 10/44 62.5 Fully (44) – Astra Tech AB Total (44) Flap (44) Y (44) 2.39 0.97 0.71 0.399 0.77 0.382 0.43 0.297 0.52 0.273 – –
et al., 2014

Vasak Prospective CT 16/79 58 Fully; Max.; Mand. Nobel Biocare Total (79) Y (79) 3.53 1.77 0.46 0.35 0.70 0.49 – – – – 0.53 0.38 0.52 0.42
et al., 2011 partially
March 2018

Verhamme Prospective CBCT 30/104 – Fully (104) Max. (104) Nobel Biocare Total (104) Flapless (104) Y (64); 2.819 – 1.368 – 1.587 – 0.60 – 0.751 – – – 0.843 –
et al., 2015 N (40)

CAD, computer-aided design; CT, computer tomography; CBCT, cone beam computer tomography; Max., maxilla; Mand., mandible; SD, standard deviation.
31
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
and 4 studies had high-level methodological quality
(Figure 2).
Meta-regression analysis revealed an overall (14 studies, n 5
1513 implants) mean deviation at the entry point of 1.25 mm
(95% CI: 1.22-1.29), 1.57 mm (95% CI: 1.53-1.62) at the apex,
and the mean angular deviation is 4.1 (95% CI: 3.97-4.23).
Seven studies (n 5 727 implants) reported a mean lateral
error at the entry point of 1.05 mm (95% CI: 1.00-1.09),
whereas the mean apical lateral deviation (4 studies, n 5 260
implants) was 0.91 mm (95% CI: 0.81-1.02). The mean depth
deviation was 0.64 mm (95% CI: 0.53-0.74) at the entry point
(3 studies, n 5 191 implants) and 1.24 mm (95% CI: 1.16-
1.32) at the apex (4 studies, n 5 295).
Effect of Age on the Accuracy of Guided Surgery
Data on patients’ age were retrieved from 11 studies. Three
age groups were created: 40-50 years (4 studies, n 5 493
implants); 50-60 years (5 studies, n 5 648 implants); and 60
years or older (2 studies, n 5 104 implants).
The mean angular deviation was 4.15 (95% CI: 3.62-4.67)
for the 40- to 50-year group, 4.32 (95% CI: 3.78-4.87) for
the 50- to 60-year group, and 4.43 (95% CI: 0.37-8.48) for
the 60 years or older group. The mean deviation at the entry
point for the 3 age groups was 1.21 mm (95% CI: 1.15-1.26),
1.23 mm (95% CI: 0.81-1.64), and 1.03 mm (95% CI: 0.40-
1.65), respectively, and their corresponding mean apical
Figure 2. Risk of bias of included studies. Stars were assigned to respective study, 10 studies received 8-10 stars that
indicated a medium-level methodological quality, and 4 studies with more than 10 stars had high-level methodological
quality.
32 Volume 18, Number 1
errors were 1.47 mm (95% CI: 1.40-1.53), 1.64 mm (95% CI:
1.14-2.14), and 1.27 mm (95% CI: 0.27-2.27).
P values from the omnibus test associated with age for
angular deviation, deviation at the entry point, and devia-
tion at the apex were 0.975, 0.789, and 0.658, respectively.
None of the P values are statistically significant, which im-
plies that there is no significant difference between age
groups for the 3 deviations.
Effect of Radiology Methods on the Accuracy of
Guided Surgery
For the influence of radiology techniques, 9 studies (n 5 946
implants) used CT for the guided surgery, whereas 6 studies
(n 5 567 implants) used CBCT. The mean angular deviation
was 4.02 (95% CI: 3.45-4.59) for the CT group and 3.86
(95% CI: 2.41-5.30) for the CBCT group. For deviation at the
entry point, the CT group revealed a mean error of 1.10 mm
(95% CI: 0.84-1.36), whereas the CBCT group presented a
mean error of 1.31 mm (95% CI: 0.99-1.63). The mean de-
viation at the apex was 1.59 mm (95% CI: 1.52-1.66) and
1.54 mm (95% CI: 1.48-1.60), respectively, for CT and CBCT
groups.
The study of Arisan et al.23 had both CT and CBCT data. We
conducted sensitivity analysis by including both data and
excluding the CT data. The omnibus test P values for
angular deviation, deviation at the entry point, and apical
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 3. Deviation stratified by the guide position (maxilla vs mandible): (A) angular deviation; (B) deviation at the
entry point; and (C) deviation at the apex.

March 2018 33
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
deviation were 0.738, 0.336, and 0.508 when including both
data and were 0.654, 0.460, and 0.689 when excluding the
CT data. Both gave consistent results and suggested that
there is no significant difference in the accuracy between
CT and CBCT.
Effect of the Guide Position
Four studies (3 prospective studies and 1 retrospective study;
n 5 274 implants) were reviewed for comparing the accuracy
of guided surgery performed on the maxillary or mandible
jaw. Statistically significant differences (P , .001) were found
in the mean angular deviation between maxillary and
mandible positions (MD: 0.89 [95% CI: 0.76-1.03]; Figure 3A).
The global meta-analysis showed no statistical significance
(P 5.06) in coronal accuracy when comparing the maxilla and
mandible positions (MD: 20.17 [95% CI: 20.34 to 0.00];
Figure 3B), whereas differences in apical error between
maxillae and mandibles were also not statistically significant
(P 5 .8) (MD: 0.03 [95% CI: 20.20 to 0.27]; Figure 3C).
Influence of Guide Type (Totally Guide vs. Partially
Guide)
Only 2 studies (1 prospective and 1 retrospective study; n 5
215 implants) reported data comparison of totally and
partially guided surgery protocols. The results of the pro-
spective study showed that the angular deviation was
significantly greater (P ,.001) in the partially guided surgery
group, whereas the retrospective study showed no statistical
difference (P 5 .35) in angular deviation when comparing
the partially guided with totally guided surgery. Global
meta-analysis indicated statistically greater accuracy
(P , .001) in angle in the totally guided surgery group than
the partially guided surgery group (MD: 21.16 [95%
CI: 21.40 to 20.92]; Figure 4A). As for the deviation at the
entry point and apex, the results showed significant greater
error (P , .001) in the partially guided surgery group
(MD: 20.53 [95% CI: 20.61 to 20.45] and MD: 20.65
[95% CI: 20.75 to 20.56], respectively) (Figure 4B-C).
Effect of Flap Approach
Three studies (2 prospective studies and 1 retrospective
study, n 5 190 implants) compared the effect of open-flap
or flapless approach on the accuracy of guided surgery.
A statistically significant greater reduction (P ,.001) in angle
deviation (MD: 1.20 [95% CI: 0.90-1.50]) (Figure 5A) and
coronal deviation (MD: 0.55 [95% CI: 0.45-0.65])
(Figure 5B) was reported in the guided surgery group with
a flapless approach. For deviation at the apex, the
outcome of the subgroup with retrospective study showed
no statistical difference between flap and flapless groups
(P 5 .07); however, the global analysis showed that the
flapless group had significantly more accuracy (P , .001)
than the open-flap group (MD: 0.66 [95% CI: 0.54-0.79])
(Figure 5C).
34 Volume 18, Number 1
Influence of the Guide Fixation
To evaluate the influence of fixation on accuracy, only 2
retrospective studies (n 5 132 implants) were included.
Significant differences (P , .001) were observed in the de-
viation of angle based on the use of fixation screw
(MD: 21.30 [95% CI: 21.94 to 20.66]) (Figure 6A). No
statistically differences were seen between fixed and
unfixed guides in coronal deviation (P 5 .88) and apical
deviation (P 5 .93) (Figure 6B-C).
DISCUSSION
In this systematic review of the literature, the accuracy of
guided implant surgery and the involved clinical factors
were evaluated. At the time of this review, 4 other publica-
tions6,18-20 had reviewed literature regarding the accuracy;
however, only limited and incomplete data were provided on
clinical trials. In this meta-analysis, in addition to evaluation of
the overall deviation of guided surgery, a comprehensive
comparison of involved clinical factors was also performed to
see whether these factors could influence the accuracy of the
position of implants inserted with STL guides. The involved
factors included age, radiology method, the position of
guide (maxilla or mandible),24-27 type of guide (totally or
partially guided),28,29 flap approach (open flap or flap-
less),25,27,28 and guide fixation (use of fixation screw or
not).29,30 The effect of the type of tissue support has been
well evaluated in another review,18 so we did not repeat the
same work on the type of tissue support.
In addition, during study selection, we found that the pa-
rameters used in clinical studies for evaluating deviation were
diverse. Some of the studies reported 2D deviations with or
without lateral and depth parameters, whereas other studies
used 3D measurement. Some studies evaluated lateral and
depth errors both coronally and apically, whereas others
included data only at the entry point or at the apex. More-
over, calculation of these parameters was different. To stan-
dardize the measurement, only studies with data of at least
global angular, coronal, and apical deviations were included;
lateral and depth deviations at the entry point and the apex
was reviewed separately. According to some plausible and
straightforward measurement of deviation,20,31 global devi-
ation was defined as the distance between the coronal/apical
centers of the planned and placed implants, and angular
deviation was calculated as the 3D angle between the lon-
gitudinal axes of both. Depth deviation was the coronal/
apical vertical distance between the planned and placed
implants, and lateral deviation was the coronal/apical hori-
zontal distance between the planned and placed implants.
These should be taken into account as consensus parameters
in further studies to standardize the research work.
The results in this meta-analysis showed a mean deviation at
the entry point of 1.25 mm, at the apex of 1.57 mm, and
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 4. Deviation stratified by the guide type (totally guided vs partially guided): (A) angular deviation; (B) deviation
at the entry point; and (C) deviation at the apex. CI, confidence interval; Max., maxilla; Mand., mandible; SD, standard
deviation.

angle of 4.1 . Meanwhile, the lateral coronal deviation 0.91 mm. Coronal/apical depth deviation26,33,35,36 was
retrieved from 7 studies26,29,30,32-35 was 1.05 mm, and 0.64 mm/1.24 mm. These results agree with previous review
lateral apical deviation retrieved from 4 studies26,33-35 was studies, which indicated that although guided implant

March 2018 35
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 5. Deviation stratified by the flap approach (flap vs flapless): (A) angular deviation; (B) deviation at the entry
point; and (C) deviation at the apex. CI, confidence interval; Max., maxilla; Mand., mandible; SD, standard deviation.

36 Volume 18, Number 1

 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 6. Deviation stratified by the fixation method (fixed vs unfixed): (A) angular deviation; (B) deviation at the entry
point; and (C) deviation at the apex. CI, confidence interval; Max., maxilla; Mand., mandible; SD, standard deviation.

surgery has many advantages, the possible deviation errors
with this technique that might cause damage to adjacent
anatomic structures or lead to restoration misfit are not
negligible.
As we mentioned earlier, the deviation errors accumulate
from every step of the procedure, so the involved clinical
factors must be considered. Some authors17 reported
smoking as an influencing factor, and others37 reported
surgeon experience as an influencing factor.
Factors such as CT scan method, guide position, type of
guide, and so on were also reported in the
literature.12,16,27,38,39 In this systematic review, we
summarized these clinical factors, and several important
findings were observed.
First, guided surgery performed on the mandible has a more
angular accuracy than on the maxilla. Based on our daily
practice, the possible explanation might be the bone
anatomy and bone density; the structure of the mandible is
straight with an arcuate shape, whereas the shape of maxilla
is a circular curve, which restrains the angulation control. In
addition, the mandible bone is denser. Another important
finding was that the totally guided procedure was more
precise than the partially guided procedure, which is
because with the partially guided procedure, implants were
inserted manually, thus leading to a greater error than im-
plants inserted with a guide. Comparing the accuracy of
guided surgery between the flapless and open-flap ap-
proaches, the results indicated that a flapless approach is
more accurate than an open-flap approach. This can be

March 2018 37
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
explained by the fact that guided surgery required a more
extensive flap than conventional surgery did18;
repositioning of the guide during surgery is more difficult
because of the possible interference of the reflected
tissue.40,41 Finally, a guide with fixation screws showed
greater reduction in angular deviation than a guide
without fixation screws. The stability of STL template could
be the explanation; a fixed surgical guide is more accurate
than manual pressure or freehand placement to position
the surgical guide.42
Regarding the effects of age and the radiology method,
the meta-regressive analysis observed that age has no
significant influence on accuracy. This result rejected our
previous hypothesis that guided surgery performed on
younger patients has greater accuracy because of high
bone quality; dense bone cannot affect the angular devi-
ation, regardless of the implant placement method.39 A
possible explanation is that the subjects included in this
study were at their middle age or older, in which stage
individuals achieve peak bone mass, and after that, bone
loss became more rapid than bone formation.
Comparison of CT and CBCT revealed no significant
difference for the influence on accuracy, which coincided
with the results of the only study reporting on deviation
comparison between CT- and CBCT-derived STL
guides.23 Other factors such as smoking habit, the
surgeon’s experience, surgery site in arch, guide system,
and implant length were not analyzed in this review; the
reason is that not enough eligible studies focusing on
these factors were available. This fact reminds us of
including these factors in further studies.
As to the quality of included studies and potential bias, only
prospective and retrospective clinical studies were included
in this meta-analysis considering our daily clinical practice.
Each study was analyzed using the Newcastle-Ottawa Scale
to evaluate methodological quality, which showed moder-
ate to high quality. To avoid or minimize possible selection
bias, a standard protocol was employed, and exact inclusion
and exclusion criteria were defined. In addition, the data
from prospective and retrospective studies were analyzed
separately in subgroups. Significant heterogeneity was
observed when comparing some of the involved clinical
factors. Possible explanations are as follows: the study de-
signs were different, the included patients were diverse, and
there were clinical variations. After sensibility analysis, one
study26 including only 10 subjects with single missing tooth
was recognized, but with low sensitive to the overall results.
One obvious limitation of this review is the limited number
of included studies, which impacts the results of this meta-
analysis. These limitations remind us that additional clinical
studies on accuracy are still needed to provide guideline for
clinical work.
38 Volume 18, Number 1
CONCLUSION
It can be concluded that the position of guide (maxilla or
mandible), guide fixation (use of fixation screw or not), type
of guide (totally or partially guided), and flap approach
(open flap or flapless) influence the accuracy of computer-
aided implant surgery. Totally guided systems using fixed
screws with a flapless approach had greater accuracy. To
minimize the cumulative errors, clinicians can make a totally
guided system with fixed screws as the first choice in daily
practice, which can be made better with a flapless
approach. Future clinical research work should be directed
to use a standardized measurement for accuracy and to
control all involved factors to improve the accuracy of
guided implant surgery.
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