Received: 5 July 2018 Revised: 25 September 2018 Accepted: 23 October 2018

DOI: 10.1111/cid.12705

ORIGINAL ARTICLE

The influence of guided sleeve height, drilling distance,

and drilling key length on the accuracy of static Computer-
Assisted Implant Surgery
Karim El Kholy DDS, MS, DMSc1,2 | Simone F. M. Janner Dr. med. dent.; MAS1 |
Martin Schimmel Dr. med. dent.; MAS3 | Daniel Buser Dr. med. dent1

1
Department of Oral Surgery and
Stomatology, School of Dental Medicine,
University of Bern, Bern, Switzerland
2
Department of Oral Medicine, Infection and
Immunity, School of Dental Medicine, Harvard
University
3
Department of Reconstructive Dentistry and
Gerodontology, School of Dental Medicine,
University of Bern, Bern, Switzerland
Correspondence
Karim El Kholy, Department of Oral Surgery
and Stomatology, School of Dental Medicine,
University of Bern, Freiburgstrasse 7, Bern
3012, Switzerland.
Email: karimelkholy@gmail.com
Abstract
Objective: The aim of this study was to evaluate the effect of guided sleeve height, drilling dis-
tance, and guided key height on accuracy of static Computer-Assisted Implant Surgery (sCAIS).
Materials and Methods: Pre and post-operative positions of implants placed in duplicate dental
models were compared and recorded after placement of implants according to a standardized
treatment planning and execution sCAIS protocol. Guided sleeve heights: 2 mm, 4 mm, 6 mm
and guided key heights: 1 mm and 3 mm were equally randomized in six test groups with vary-
ing implant lengths (10-16 mm) and surgical drilling protocols. The mean crestal and apical
three-dimensional (3D) deviation, as well as the angular deviation were calculated for each
group. Data was analyzed using multivariate analysis ANOVA. P values less than .05 were consid-
ered statistically significant. All P values of post-hoc tests were corrected for multiple testing
using Bonferroni-Holm's adjustment method.
Results: 3D implant positioning accuracy was not significantly affected by the difference in
sleeve height alone or by the implant length alone (P > .05). However, 3D and angular deviation
values became significantly higher as the total drilling distance below the guided sleeve
increased and significantly became lower as the guided key height above the sleeve increased.
18 mm drilling distance resulted in a significantly higher deviation, when compared to 14 mm or
16 mm drilling distances, irrespective of sleeve height or implant length (P < .01). 3 mm key
height resulted in significantly less 3D deviation than 1 mm key height (P < .01).
Conclusion: Decreasing the drilling distance below the guided sleeve, by using shorter sleeve
heights or shorter implants can significantly increase the accuracy of sCAIS.

KEYWORDS

accuracy, computer-aided, computer assisted, dental implants, digital workflow, free drilling
distance, guided surgery, implant, implant surgery, implantology, surgical techniques

1 | I N T RO D UC T I O N when properly planned and executed, can result in a more accurate

The progress of modern implant dentistry based on osseointegration
has revolutionized the rehabilitation of partially and fully edentulous
patients. Well-documented clinical trials have demonstrated favorable
long-term survival and success rates.1–4 A correct, prosthetically
driven, 3D positioning of the implant fixture is believed to play a cru-
cial role for a successful treatment outcome of implant-supported
prostheses.5–8 Static computer assisted implant surgeries (sCAIS),
implant positioning than free handed surgeries.9 The ability to visual-
ize and refine implant positions pre-surgically, using virtual treatment
planning software, has improved early evaluation and optimal implant
positioning in relation to vital anatomical structures, hard and soft tis-
sues, as well as the planned final prosthesis.10 However, the transfer
of the virtually planned implant position, from the planning software
to the patient's mouth is a critical step to reproduce the desired pre-
operatively planned result. The accuracy of a guided implant surgery

Clin Implant Dent Relat Res. 2018;1–7. wileyonlinelibrary.com/journal/cid © 2018 Wiley Periodicals, Inc. 1
2 EL KHOLY ET AL.

is defined as the deviation between the planned and final position of

an implant.9 Although, the accuracy of sCAIS has witnessed an overall
improvement in the last decade, the variables that result in increased
inaccuracies, and sometimes the failure of guided surgery, are still
largely unknown. As the popularity of the sCAIS increases, the respon-
sible introduction of it's broad application requires a knowledge of
common variables and decision-making points during treatment plan-
ning and execution. Errors during data acquisition, data transfer, data
processing, treatment planning, guide design and production, as well FIGURE 1 Sample of the study-model used

as surgical execution might all contribute to increased deviations from

the three digitally generated datasets. One investigator performed all
the virtually planned implant position.11–18 The variables encountered
the virtual planning of implant surgeries (KEK). Sleeve heights (2 mm,
during the treatment-planning step by itself are numerous. With dif-
4 mm, 6 mm) and guided key heights (1 mm and 3 mm) were randomly
ferent software and hardware emerging every year from multiple
assigned to different guided implant preparation protocols. The surgical
manufacturers, it is important to focus on basic engineering concepts
drilling protocols were produced using different combinations of sleeve
involved in the processing, planning and execution of these proce-
and key heights and distributed equally between the six groups.
dures in order to be able to establish basic principles that can help cli-
nicians achieve a more reproducible and predictable outcome.
1. Group 1a: implants placed using a combination of 2 mm sleeve
While clinical studies are important to evaluate the clinical effi-
height and 1 mm key height. (n = 20).
ciency and efficacy of developed treatment protocols, the refinement
2. Group 1b: implants placed using a combination of 2 mm sleeve
of technology and procedures often requires the return to lab-testing
height and 3 mm key height. (n = 20).
to isolate the numerous variables introduced along the process to sur-
3. Group 2a: implants placed using a combination of 4 mm sleeve
gical execution. For example, conducting a clinical trial to investigate
height and 1 mm key height. (n = 20).
the effect of different guided sleeve heights on sCAIS accuracy would
4. Group 2b: implants placed using a combination of 4 mm sleeve
be impractical due to the difficulty of applying firm standardization cri-
height and 3 mm key height. (n = 20).
teria on numerous clinical variables, such as bone quality, clinical
5. Group 3a: implants placed using a combination of 6 mm sleeve
access, guide design and support and presence or absence of simulta-
height and 1 mm key height. (n = 20).
neous grafting procedures. Therefore, we have elected to conduct this
6. Group 3b: implants placed using a combination of 6 mm sleeve
study using an in vitro model, that would eliminate the above variables
height and 3 mm key height. (n = 20).
and enable us to control additional digital workflow variables encoun-
tered during the steps of data transfer, treatment planning, guide
Furthermore, the free-drilling-distance (FDD), defined as the lin-
design, guide fabrication and surgical execution. We postulate that
ear measurement from the bottom of the guided sleeve to the tip of
the variables encountered in the above steps can significantly impact
the surgical drill (bottom of the osteotomy), was calculated for each
the accuracy of sCAIS. We hypothesize that the control of these vari-
group (Figure 2). Implants were therefore further classified according
ables would improve the predictability and accuracy of treatment out-
to the FDD length used during their osteotomy preparation protocol
comes. Notably, drill guidance and drill related deviations have been
into 14 mm, 16 mm, and 18 mm groups.
shown to have a significant impact on the accuracy of implant place-
19 Surgical guides were designed using the same software (coDiag-
ment. Nevertheless, the effect of the different components involved
nostiX) and 3D printed using the Rapid Shape P30 printer (Rapid
in the drill guidance process is still poorly understood. Consequently,
Shape GmbH, Heimsheim, Germany). All guides were produced from
this study specifically aims to investigate the effect of sleeve height,
SHERAprint-sg transparent resin (SHERA Werkstoff-Technologie
drilling distance and drilling key height on the accuracy of dental
GmbH & Co KG, Lemförde, Germany). Material thickness was set to
implants placed with a sCAIS approach.
(3 mm) and guide to teeth offset value to (0.15 mm). Guides were
visually checked for fit by each operator and minor adjustments, to
2 | MATERIALS AND METHODS the outer surface but not the inside surface of the guide were permit-
ted in order to assure full access of the surgical handpiece. All sCAIS
This study was conducted in 30 duplicate acrylic models (Bonemodels, procedures were performed by two experienced operators (KE and
Castellon, Spain) simulating human bone with 6 potential sites for SJ). Sequential drilling of all osteotomies was performed according to
implant placement corresponding to FDI positions 12, 15, 21, 23, manufacturer's recommendations. 4.1 × 10mm and 4.1 × 16 mm
25, and 26 (Figure 1). bone level implants (Straumann Ag, Basel, Switzerland) were placed
Each model was scanned using 3shape intraoral scanner (3shape, using guided-portable-adaptors, a handpiece and finished by torque
Copenhagen, Denmark) and a cone-beam computed tomography wrench if necessary. Corresponding scan bodies were then hand tight-
(J. Morita Corp, Osaka, Japan) was taken. A digital waxup of the missing ened and post-operative digital impressions were taken using 3shape
teeth and digital treatment planning including correct 3D implant posi- intraoral optical scanner. Standard tessellation language (STL) files
tioning was then performed on a dedicated software (coDiagnostiX, were then imported into coDiagnostiX software containing the previ-
Dental Wings Inc, Montreal, Canada) after importing and matching of ous digital plan. Treatment evaluation feature was used to compare
EL KHOLY ET AL. 3

FIGURE 2 Free drilling distance versus osteotomy depth calculation in sCAIS. A, Free drilling distance = drill length − (sleeve length + guided
key height). Osteotomy depth = drill length − (sleeve length + guided key height + sleeve height). Osteotomy depth = implant length. B, Sleeve
height: Distance from the apical border of the sleeve to the implant shoulder

pre-planned to post-surgical implant positions. Virtually planned and the groups in 3D deviation or angular deviation values (P > .05). How-
postoperative implant STL files were superimposed using the same ever, 3D deviation measurements at the crest and apex of the implant
occlusal/incisal surfaces of teeth as a reference. Angular and 3D devi- were significantly influenced by the FDD (P < .01; Figure 5). Increas-
ation at implant crest and implant apex were measured (Figure 3). ing the FDD led to a significant reduction in the accuracy of sCAIS.
The difference in 3D deviation values between the 18 mm group was
2.1 | Statistical analysis
The statistical analysis was performed with the software package R,
Version 3.4.4 (R Core Team 2013. R: A language and environment for
statistical computing. R Foundation for Statistical Computing, Vienna,
Austria. URL http://www.R-project.org). Data was exported to an
excel sheet and analyzed using multivariate analysis of variance
(ANOVA) between group means. P values less than .05 were considered
statistically significant. All P values of post-hoc tests were corrected
for multiple testing using Bonferroni-Holm's adjustment method.

3 | RESULTS

The results of the measurements and statistical analyses are summa-

rized in Tables 1–3 and Figures 4–7.
The results of the multivariate analysis demonstrated significant
effects of the drilling distance (p < .01) and the drilling key length
(p < .01). On the other hand, the guided sleeve height and implant fix-
ture length did not show a significant effect on the outcome (P < .05).
There were no significant interactions between any two or three fac-
tors. Following these results from the multivariate ANOVA post-hoc
tests were performed to compare different drilling distances and dif-
ferent key lengths.

4 | S L E E V E H E I G H T A ND F R E E D R I L L I N G
DISTANCE

As shown in Figure 4, Comparisons between groups with different

sleeve heights as an individual variable were not significant for any of FIGURE 3 Deviation measurements evaluated
4 EL KHOLY ET AL.

TABLE 1 Multivariate analysis results

a) Results for the outcome “3D Deviation at Crest.”
Factor DF* Sum of squares Mean square F value P value
Guided sleeve height 2 0.0171 0.0085 0.5541 .5818
Free drilling distance 2 5.9599 2.9800 193.3216 <.0001
Drilling key length 1 0.5530 0.5530 35.8725 <.0001
Implant length 1 0.0005 0.0005 0.0318 .8600
Guided sleeve height: Drilling distance 4 0.0214 0.0053 0.3467 .8437
Guided sleeve height: Drilling key length 2 0.0209 0.0105 0.6790 .5166
Drilling distance: Drilling key length 2 0.0025 0.0013 0.0810 .9225
Guided sleeve height: Implant length 2 0.0398 0.0200 1.2914 .2933
Drilling distance: Implant length 2 0.0211 0.0106 0.6875 .5134
Drilling key length: Implant length 1 0.0000 0.0001 0.0030 .9567
Guided sleeve height: Drilling distance: Drilling key length 4 0.0057 0.0014 0.0931 .9837
Guided sleeve height: Drilling distance: Implant length 4 0.0115 0.0029 0.1873 .9427
Guided sleeve height: Drilling key length: Implant length 2 0.0205 0.0102 0.6645 .5238
Drilling distance: Drilling key length: Implant length 2 0.361 0.0180 1.1702 .3274
Guided sleeve height: Drilling distance: Drilling key length: 4 0.0450 0.0113 0.7300 .5803
Implant length
b) Results for the outcome “3D deviation at base.”
Factor DF* Sum of squares Mean square F value P value
Guided sleeve height 2 0.0062 0.0031 0.9801 .3898
Free drilling distance 2 0.7275 0.3638 114.4955 <.0001
Drilling key length 1 0.1092 0.1092 34.3795 <.0001
Implant length 1 0.0012 0.0012 0.3884 .5390
Guided sleeve height: Drilling distance 4 0.0039 0.0010 0.3093 .8689
Guided sleeve height: Drilling key length 2 0.0007 0.0004 0.1165 .8906
Drilling distance: Drilling key length 2 0.0070 0.0035 1.1066 .3470
Guided sleeve height: Implant length 2 0.0074 0.0037 1.1670 .3283
Drilling distance: Implant length 2 0.0142 0.0071 2.2341 .1289
Drilling key length: Implant length 1 0.0000 0.0000 0.0028 .9586
Guided sleeve height: Drilling distance: Drilling key length 4 0.0094 0.0024 0.7429 .5722
Guided sleeve height: Drilling distance: Implant length 4 0.0006 0.0001 0.0437 .9961
Guided sleeve height: Drilling key length: Implant length 2 0.0013 0.0007 0.2032 .8175
Drilling distance: Drilling key length: Implant length 2 0.0008 0.0004 0.1295 .8792
Guided sleeve height: Drilling distance: Drilling key length: Implant 4 0.0029 0.0008 0.2345 .9162
length
c) Results for the outcome “angular deviation.”
Factor DF* Sum of squares Mean square F value P value
Guided sleeve height 2 0.0796 0.0398 0.4482 .6440
Free drilling distance 2 6.6943 3.3472 37.7146 <.0001
Drilling key length 1 6.2727 6.2727 70.6779 <.0001
Implant length 1 0.1105 0.1105 1.2451 .2755
Guided sleeve height: Drilling distance 4 0.3364 0.0841 0.9475 .4539
Guided sleeve height: Drilling key length 2 0.1416 0.0708 0.7976 .4620
Drilling distance: Drilling key length 2 0.2454 0.1227 1.3828 .2702
Guided sleeve height: Implant length 2 0.0972 0.0486 0.5477 .5832
Drilling distance: Implant length 2 0.4925 0.2463 2.7749 .0824
Drilling key length: Implant length 1 0.1600 0.1600 1.8025 .1920
Guided sleeve height: Drilling distance: Drilling key length 4 0.4404 0.1101 1.2406 .3204
Guided sleeve height: Drilling distance: Implant length 4 0.3487 0.0872 0.9823 .4358
Guided sleeve height: Drilling key length: Implant length 2 0.0558 0.0279 0.3143 .7332
Drilling distance: Drilling key length: Implant length 2 0.1983 0.0991 1.1169 .3437
Guided sleeve height: Drilling distance: Drilling key length: Implant 4 0.2240 0.0560 0.6309 .6452
length

Results of the multivariate analysis for each outcome: 3D deviation at crest, 3D deviation at base and angular deviation is presented. The free drilling dis-
tance and the key height had a significant impact on all three outcomes (P < .0001).
*DF, Degrees of Freedom.
EL KHOLY ET AL. 5

TABLE 2 Deviation measurements in relation to the drilling distance height on the accuracy of sCAIS. Choices of sleeve height, drill length
apical to the sleeve (free drilling distance) and guided key height are often made separately by the clinician or
3D deviation 3D deviation generated randomly by the planning software. However, if we exam-
Distance
at crest at apex Angular deviation ine the sCAIS process as a continuous connected operation, we will
bellow the
sleeve (FDD) Mean SD Mean SD Mean SD clearly find that the above choices have a direct influence on the pro-
14 mm 0.494 0.142 0.344 0.078 1.855 0.322 duction of the intra-surgical drilling protocol and therefore, the rela-
16 mm 0.838 0.121 0.418 0.051 2.570 0.409 tionship between both variables and their collective impact on the
18 mm 1.264 0.163 0.606 0.063 2.615 0.571
surgical execution and resultant accuracy should be considered.
The results of this in vitro investigation demonstrate that the accu-
TABLE 3 Deviation measurements in relation to the drilling key
racy of sCAIS is directly related to the free drilling distance apical to the
height above the sleeve
guided sleeve and inversely related to the guided key height used above
3D deviation 3D deviation the sleeve. We introduce the significance of evaluating the total FDD
Distance above
at crest at apex Angular deviation
the sleeve used in each sCAIS protocol. The findings are consistent with long estab-
(key height) Mean SD Mean SD Mean SD
lished engineering principles that an increase in drilling length is associ-
1 mm 0.961 0.345 0.498 0.117 2.680 0.458
ated with an increase in lateral vibration and chattering. As an example,
3 mm 0.769 0.328 0.413 0.126 2.033 0.442
in a previous study Schneider et al.17 demonstrated that drill lateral
movement, resulting from tolerance of surgical instruments can be
statistically significant, when compared with the 16 mm (P < .01) and
reduced by decreasing the drill length and increasing the key height
14 mm (P < .01) groups. Angular deviations were significant (P < .05)
above the sleeve. Whether this surgical tolerance and lateral movement
only between the 18 mm and the 14 mm groups (P < .01), but insig-
would translate into a significant deviation in a clinical scenario has not
nificant between the 16 mm and 18 mm groups (P = 0.750) (Figure 7).
been established. The present study takes one-step further to under-
These findings demonstrate that an increase in FDD can lead to sig-
standing the potential clinical impact. Our results demonstrate that the
nificantly higher 3D deviation values in implants placed using sCAIS.
increased drilling distance beyond the guiding sleeve can indeed result in
a significant 3D and angular deviation at both the implant crest and apex.
5 | D RI LL I N G K E Y H E I G H T Choi et al.20 suggested that making the drill guiding channel longer, can
reduce angular deviation values in dental implants. We here isolated the
The mean 3D deviation at the crest of the implant, caused by a 1 mm variable of the free drilling distance existing below the guided sleeve as
drilling key was significantly higher at implant crest (P < .01) and implant being an influential factor. Our data did not find a significant impact of
apex (P < .01; FIGURES 6 and 7). Angular deviations were also statisti- the drill length or the guided sleeve height, when evaluated as individual
cally significant between the two key height groups (P < .01). These variables. It was the drilling distance resulting from the combination of
results suggest that the guided key height was inversely proportional to these two values and the drilling key height that was found to have sig-

the 3D and angular deviation values. In other words, as the distance nificant impact on accuracy. In other words, using a 24 mm drill with a

above the guided sleeve increases, because of the length of the drilling 2 mm sleeve height is expected to result in a longer FDD and conse-

key height, the 3D and angular deviation values decrease.
6 | DISCUSSION
This is the first study to the best of our knowledge that examines the
direct influence of sleeve height, drilling distance, and guided key
quently an increased 3D deviation, when compared to using a 20 mm
drill with a 6 mm sleeve height. Our finding that increasing the drilling
key height had an inverse effect on the accuracy of dental implants might
be due to the fact that an increase in the drilling key height would result
in a longer guiding channel through the drilling key. Cassetta et al.13 pre-
viously suggested that tolerance of surgical instruments might produce
angular deviations in implants placed with sCAIS. In the present study,

FIGURE 4 3D deviation in relation to the sleeve height. Evaluating the impact of sleeve height as an individual variable on the 3D deviation
values revealed no significant impact or direct correlation between sleeves of different heights and the 3D deviation values of the implants
inserted with sCAIS (P > .05)
6 EL KHOLY ET AL.

FIGURE 5 3D deviation in relation to the drilling distance apical to the FDD. Evaluation of the 3D deviation values in relation to the FDD
revealed that the 3D deviation values significantly increased as the FDD increased

FIGURE 6 3D deviation in relation to the guided key height. Evaluation of 3D deviation values in relation to the key height and the
corresponding created distance above the sleeve revealed that the 3D deviation values decreased as the distance above the sleeve, created by
the use of longer drilling keys, was increased. These differences were significant at the crest and the apex of implants

we standardized this tolerance as much as possible by using identical
instruments, produced by the same manufacturer, to drill osteotomies of
measurably equal dimensions. Other factors that can potentially affect
accuracy, such as guide thickness, guide to teeth offset, guided sleeve to
guide offset and guide material were controlled as best as possible by
standardizing treatment planning and production parameters.
The formulas presented in Figure 2 take into consideration the
number of variables involved in determining the FDD. For example,
the placement of a 10 mm implant can be accomplished by different
drilling protocols, involving multiple combinations of sleeve heights,
drill lengths and drilling key heights. Given that the sleeve length is
often constant (5 mm), the clinician might use:

FIGURE 7 Angular deviation in relation to the FDD and guided key height. Evaluation of angular deviation values in relation to the drilling
distance apical to the sleeve and to the key height and the corresponding created distance above the sleeve revealed that the angular deviation
values decreased as the distance above the sleeve, created by the use of longer drilling keys, was increased. These differences were significant at
the crest and the apex of implants
EL KHOLY ET AL.
1. A 24 mm long drill, a 6 mm sleeve height and a 3 mm drilling key
height
or
2. A 20 mm long drill, a 2 mm sleeve height and a 3 mm drilling key
height.
Both the above drilling protocols would result in an osteotomy
with the same depth of 10 mm.
Our findings indicate that, whenever possible, it is recommended
to choose the option that results in the minimum amount of FDD to
minimize the deviation between the virtually planned and post-
operative implant positions. Choosing a surgical protocol that involves
a shorter drill, lower sleeve height and longer drill key can have a more
favorable outcome on the accuracy of sCAIS procedures.
Often this choice is limited because of the sleeve height being
dictated by soft and hard tissue interferences. On the other hand,
reducing sleeve height and drill length has a potential clinical advan-
tage in patients with limited mouth openings, especially in posterior
implant locations. However, in clinical situations where multiple com-
binations of guided instruments are possible, the final surgical proto-
col should be chosen with the above results in mind.
7 | CO NC LUSIO N
Our results indicate that minimizing the free drilling distance, apical
to the guided sleeve and increasing the length of the guided key
height above the sleeve can increase the accuracy of sCAIS proce-
dures. The choice of guided sleeve height, implant length and appro-
priate drilling protocol should not be viewed as individual decisions.
Instead, they should be collectively evaluated to optimize sCAIS
outcomes.
CONF LICT OF IN TE RE ST
The study was funded by a grant to KEK through the Foundation of
Dental Research and Education. The authors report no conflict of
interest.
ORCID
Karim El Kholy https://orcid.org/0000-0002-6426-1774
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How to cite this article: El Kholy K, Janner SFM,
Schimmel M, Buser D. The influence of guided sleeve height,
drilling distance, and drilling key length on the accuracy of
static Computer-Assisted Implant Surgery. Clin Implant Dent
Relat Res. 2018;1–7. https://doi.org/10.1111/cid.12705