RESEARCH

Accuracy of Different Surgical Guide Designs for Static

Computer-Assisted Implant Surgery: An In Vitro Study
Yu Tsung Wu, DDS1
Panos Papaspyridakos, DDS, MS, PhD1
Kiho Kang, DMD, MS1
Matthew Finkelman, PhD2
Yukio Kudara, RDT, CDT, MDT
Andre B. De Souza, DDS, MSc1*

The aims of this study were to evaluate the effect of (1) the different surgical guide designs and (2) implant placement location on the
accuracy of fully guided implant placement in single edentulous sites using an in vitro study model. Forty-five partially edentulous models
were scanned and divided into 3 groups: group 1, tooth-supported full-arch surgical guide; group 2, 3 different tooth-supported
shortened surgical guides (SSGs); and group 3, tooth-supported full-arch surgical guide with a crossbar. All surgical guides were printed
and used for fully guided implant placement. A total of 180 implants (60 per group) were placed, and scan bodies were positioned on all
models, and postoperative surface scan files (STL) files were obtained. Superimposition of preoperative and postoperative STL files was
performed, and the accuracy of implant position was evaluated. The interaction between group and implant location was statistically
significant for angle, 3D offset at the base, and at the tip (P , .001). The post-hoc tests showed a statistically significantly higher deviation
for group 2 compared to group 3 for all outcomes for implants #4 (P , .05) and #7 (P , .05). There was also a statistically significant
difference in all outcomes between groups 1 and 3 for implant #7 (P , .05). All surgical guide designs presented satisfactory performance
with clinically acceptable levels of deviation. However, SSGs presented higher accuracy for guided implant placement in a single-
edentulous site, whereas a full-arch surgical guide with a crossbar presented superior outcomes when 2 or more guided implants were
placed simultaneously.

Key Words: dental implants, digital workflow, guided implant surgery, accuracy, computer-aided, computed-manufactured

INTRODUCTION sum of errors from data acquisition, digital planning, surgical

guide fabrication, and actual implant placement procedure.7,8

I
mplant therapy is a predictable treatment modality for
Therefore, identifying the source of error is important to
most fully and partially edentulous patients.1–3 However,
increase the predictability of sCAIS.8 A recent ITI consensus
three-dimensional (3D) implant position is one of the most
report based on several systematic reviews concluded that
critical factors for long-term success.4 Malpositioned
there is still a lack of evidence in the literature investigating the
implants are not only more difficult to restore, but are also
source of deviations in every step of the sCAIS.11 The authors
more susceptible to biological (eg, peri-implantitis) and
suggested that the factors within the digital workflow
technical (eg, screw loosening) complications.5,6 In addition,
contributing to the 3D deviations in the actual implant position
in challenging surgical sites with limited bone availability or
from the initial planned position should be investigated
anterior esthetic zone, 3D prosthetically driven implant
individually.11,12
positioning is crucial.
The digital workflow for sCAIS includes acquisition of
Recently, digital technology has been introduced to
intraoral surface scan and cone-beam computerized tomogra-
increase accuracy and facilitate dental treatment. Static
phy, which can be imported into digital implant planning
computer-assisted implant surgery (sCAIS) allows clinicians to
software.13,14 Digital implant planning allows clinicians to
place implants according to the patient’s prosthetic plan.
visualize anatomical structures in 3D aspects and relate the
Recent studies have shown that sCAIS is significantly more
alveolar bone with the prosthetically ideal implant position.
precise than freehand implant placement.7–10
After implant planning, a surgical guide is designed on surface
The actual implant location after placement compared to
scan files (STL file) and is then fabricated by 3D printers or
the initial digitally planned position using sCAIS is dictated by a
milling machines.7 Tooth-supported surgical guides with full
arch coverage are usually designed by default since more
1
Department of Prosthodontics, Tufts University School of Dental abutment teeth seem to provide better stability. However,
Medicine, Boston, Mass, USA. there is still limited evidence in the literature comparing
2
Department of Public Health and Community Service, Tufts University
School of Dental Medicine, Boston, Mass, USA. different surgical guide designs.
* Corresponding author, e-mail: andre.de_souza@tufts.edu Therefore, the aims of this study were to evaluate the effect
https://doi.org/10.1563/aaid-joi-D-21-00055 of (1) different surgical guide designs and (2) implant

Journal of Oral Implantology 351

Different Guide Designs for Static Computer-Assisted Implant Surgery
FIGURE 1. (a) Partially edentulous models used in the study and (b) example of a model with fully guided implants placed with scan bodies.
placement location on the 3D accuracy of guided implant
placement in single edentulous sites. The null hypotheses of
this study were that in fully guided implant surgery, there is no
difference in the angle and 3D offset at the base and tip using
different surgical guide designs and in different implant
locations.
MATERIALS AND METHODS
Forty-five partially edentulous acrylic models (15 per group)
with missing teeth #4, #7, #9, and #14 (Models Plus LLC,
Kingsford Heights, IN) were used in this study (Figure 1). All
acrylic models were labeled and digitally scanned with an
intraoral scanner (TRIOS 3, 3-Shape, Copenhagen, Denmark),
and acquired STL files were imported into digital implant
planning software (CoDiagnostiX, DentalWings, Montreal,
Canada) for each sample. Digital implant planning was
performed for each sample, using an implant with a 4.1
diameter and 10 mm in length (Bone Level Tapered RC,
Straumann AG, Basel, Switzerland) for all 4 different sites. At the
mesiodistal aspect, the implants were positioned centrally and
buccolingually. The implants were positioned in the central
fossa, and apicocoronally, the implants were positioned 2 mm
apical to the proposed mucosal margin. All implant planning
was performed by an experienced operator.
After a similar implant planning for all study models, a
computer-assisted design of surgical guides was performed
using the same implant planning software (coDiagnostiX,
DentalWings) based on the planned position of the implant.
For each group, a different surgical guide was designed (Figure
1). For group 1, a tooth-supported full-arch surgical guide
(FASG) covering 8 teeth was designed; for group 2, three
different tooth-supported shortened surgical guides (SSG)
supported by four teeth each were designed; and for group
3, a tooth-supported full-arch surgical guide with a crossbar
(FASGC) covering 8 teeth was designed (Figure 2). All surgical
guide designs were planned with a cylindrical sleeve 5 mm in
diameter and 6 mm in length from the implant shoulder (H6).
352 Vol. XLVIII / No. Five / 2022
Therefore, all drills and handle lengths were similar for all the
studied groups.
A total of 75 surgical guides were designed (15 for group 1,
FASG; 45 for group 2, SSG; and 15 for group 3, FASGC). The
offset to set the clearance between the surgical guide and the
tooth contact surface was established at 50 lm. The surgical
guide wall thickness was established at 3 mm, and inspection
windows on teeth #3, #6, #8, and #11 were placed to check
surgical guide seating. All surgical guides were planned to be
positioned 458 in the center of the printing tray and printed in
polyurethane using a 3D printing machine (Varseo S, BEGO,
Germany). All surgical guides were printed by an experienced
technician (Figure 2). After 3D printing, stainless steel sleeves
(T-sleeve, Ø 5 mm, H 5 mm, Straumann, Basel, Switzerland)
were secured.
All models were inserted into the simulation head in a
preclinical setting for clinical procedures. Fitting of the surgical
guide was checked, and fully guided implant placement was
performed after sequential drilling osteotomies according to
the manufacturer. All implants were placed with an insertion
torque between 30 and 50 Ncm. A total of 180 implants were
placed in all 45 studied models. After implant placement, scan
bodies (CARES RC Mono Scanbody, D 4.8 mm, H 10 mm, PEEK,
Straumann) were placed on all models with 10 Ncm torque
(Figure 1). All models were scanned with a desktop scanner
(CARES 7 lab scanner, DentalWings). Acquired STL files were
imported into the implant planning software (coDiagnostiX,
DentalWings) and superimposed with the initial STL file of the
same model using 4 specific landmarks (Figure 3). Accuracy of
all implants was checked by comparing the initial plan with the
final implant position. The outcomes of this study were angular
deviation (in degrees), 3D offset at base (implant platform), and
tip (implant apex) deviation (in millimeters), all of which were
measured (Figure 4).
Power calculations were conducted using the software
nQuery Advisor (v. 7.0). According to study results of El Khouly
et al,15 the anticipated variance in the group indicates that the
angular deviation was 0.7, with a within-group standard
 Wu et al

FIGURE 2. Photograph of studied groups: group 1, FASG—full-arch surgical guide supported by 4 abutment teeth, 8 teeth; group 2, SSG—
shortened surgical guide supported by 4 abutment teeth; and group 3, FASGC—full-arch surgical guide supported by 4 abutment teeth, 8
teeth, with a crossbar.

deviation of 1.58. Based on these anticipated values, a sample outcome variable. Descriptive statistics (mean, standard devi-
size of n ¼ 15 per group was sufficient to achieve power greater ation, minimum, and maximum) were calculated by group and
than 99% to differentiate between groups with a type I error subgroup (where the term ‘‘subgroup’’ refers to the implant
rate of a ¼ 0.05. A separate analysis was conducted for each numbers #4, #7, #9, or #14). Statistical analysis was then

FIGURE 3. Image of preoperative and postoperative models’ superimposition using 5 fixed reference areas for implant placement
evaluation.

Journal of Oral Implantology 353

Different Guide Designs for Static Computer-Assisted Implant Surgery

to assess the simple main effects, that is, a separate comparison

of groups was conducted for each subgroup, and a separate
comparison of subgroups was conducted for each group. The
comparison of groups within each subgroup was performed
using one-way ANOVA (with Tukey’s HSD used in post-hoc
tests). The comparison of subgroups within each group was
performed via repeated-measures ANOVA due to the afore-
mentioned presence of 4 implants per model, with the
Bonferroni correction used in post-hoc tests. The data were
examined for normality using graphical methods (histograms
and quantile–quantile plots) and were found to be approxi-
mately normally distributed. The significance level was set at a
¼ 0.05, with the exception of tests in which the Bonferroni
correction was used (in which case the significance level was
set at a ¼ 0.05/6 ’ 0.0083). SPSS v. 26 software (SPSS Inc. IBM
Corp, Chicago, IL) was used for the analysis. All statistical
analyses, methodologies, and results were reviewed by an
independent statistician.

RESULTS

All implants were placed uneventfully. The overall mean and

FIGURE 4. Schematic drawing demonstrating the 3 measurements
analyzed in the study: 3D offset at base (implant shoulder), 3D
offset at tip (implant apex), and angular deviation.
conducted via mixed analysis of variance (ANOVA) to account
for the presence of four implants per model, which resulted in a
between-model factor of ‘‘group’’ and a within-model factor of
‘‘subgroup.’’ In each mixed ANOVA (ie, for each outcome
variable), the interaction between group and subgroup was
found to be statistically significant (P , .001). Therefore, per
standard statistical practice,16 additional tests were performed
standard deviation angle were 2.91 6 1.488, 2.86 6 1.338, and
2.54 6 1.118 for groups 1, 2, and 3, respectively. The overall
mean and standard deviation for 3D offset at base were 0.63 6
0.21, 0.55 6 0.22, and 0.48 6 0.18 mm for groups 1, 2 and 3,
respectively. The overall mean and standard deviation for 3D
offset at tip were 1.08 6 0.44, 1.01 6 0.44, and 0.85 6 0.33 mm
for groups 1, 2 and 3, respectively.
Table 1 presents the results of the angular deviation by
group and subgroup. In the analyses of simple main effects,
there was a statistically significant difference between the
groups for implants #4, #7, and #14 (P , .05), but not for
implant #9 (P ¼ .238). Post-hoc tests showed a statistically
significantly higher deviation for group 2 compared to group 3
for implants #4 (P ¼ .016) and #7 (P , .001) and statistically
significantly higher deviation for group 3 compared to group 2
for implant #14 (P ¼ .025). There was also a statistically
significantly higher level of deviation for group 1 compared to
group 3 for implant #7 (P ¼ .005). The within-group
comparisons of angular deviations between the different
implants demonstrated no statistically significant difference in

TABLE 1
Results for the angle deviation (in degrees; n ¼ 15 per group)
1 2 3

FASG* SSG FASGC

Group
Implant Mean 6 SD Min Max Mean 6 SD Min Max Mean 6 SD Min Max P**
4 3.00 6 1.68 0.30 6.30 3.27 6 1.09 1.00 5.00 2.01 6 0.46 1.30 3.10 .015
7 3.35 6 1.28 1.20 5.10 3.79 6 1.40 1.40 7.20 1.84 6 1.04 0.50 4.00 ,.001`
9 2.79 6 1.62 1.10 5.90 2.19 6 0.73 0.90 3.70 2.77 6 0.55 1.92 3.60 .238
14 2.51 6 1.33 0.80 5.40 2.23 6 1.34 0.30 5.20 3.53 6 1.28 1.08 6.10 .024§

*FASG indicates full-arch surgical guide; SSG, shortened surgical guides; FASGC, full-arch surgical guide with a crossbar.
**P values corresponding to between-group analysis.
In the post-hoc tests, there was a statistically significant difference between groups 2 and 3 (P ¼ .016).
`In the post-hoc tests, there were statistically significant differences between groups 2 and 3 (P , .001) and between groups 1 and 3 (P ¼ .005).
§In the post-hoc tests, there was a statistically significant difference between groups 2 and 3 (P ¼ .025).

354 Vol. XLVIII / No. Five / 2022

 Wu et al

TABLE 2
Results for the 3D offset at base (in mm; n ¼ 15 per group)
1 2 3
FASG* SSG FASGC
Group
Implant Mean 6 SD Min Max Mean 6 SD Min Max Mean 6 SD Min Max P**
4 0.60 6 0.23 0.30 1.08 0.66 6 0.20 0.31 1.03 0.45 6 0.15 0.21 0.76 .015
7 0.66 6 0.14 0.36 0.89 0.66 6 0.22 0.33 1.18 0.37 6 0.15 0.13 0.59 ,.001`
9 0.67 6 0.19 0.35 0.93 0.43 6 0.18 0.09 0.85 0.51 6 0.13 0.31 0.72 .001§
14 0.60 6 0.26 0.20 1.21 0.46 6 0.16 0.25 0.83 0.60 6 0.19 0.29 1.10 .122

*FASG indicates full-arch surgical guide; SSG, shortened surgical guides; FASGC, full-arch surgical guide with a crossbar.
**P values corresponding to between-group analysis.
In the post-hoc tests, there was a statistically significant difference between groups 2 and 3 (P ¼ .014).
`In the post-hoc tests, there were statistically significant differences between groups 2 and 3 (P , .001) and between groups 1 and 3 (P , .001).
§In the post-hoc tests, there were statistically significant differences between groups 1 and 2 (P ¼ .001) and between groups 1 and 3 (P ¼ .038).

group 1. For group 2, there was a statistically significant
difference between the implants (P , .001). Post-hoc tests
showed a statistically significant difference between implants
#4 and #9 (P ¼ .0079) and #7 and #9 (P ¼ .003). For group 3,
there was a statistically significant difference between the
implants (P , .001). Post-hoc tests showed a statistically
significant difference between implants #4 and #9 (P , .001), #4
and #14 (P ¼ .001), #7 and #9 (P ¼ .003), and #7 and #14 (P ,
.001).
Regarding the 3D offset at the base, Table 2 provides the
results by group and subgroup. In the analyses of the simple
main effects, there was a statistically significant difference
between groups for implants #4, #7, and #9 (P , .05), but not
for implant #14 (P ¼ .122). Post-hoc tests demonstrated a
statistically significant difference between groups 2 and 3 for
implant #4 (P ¼ .014) and #7 (P ,.001), with higher levels of
deviation for group 2 compared to group 3. There was also a
statistically significantly higher level of deviation for group 1
compared to group 2 for implant #9 (P ¼ .011). The within-
group comparisons of 3D offset at the base between different
implants demonstrated no statistically significant difference for
group 1 (P ¼ .503). For group 2, there was a statistically
significant difference between the implants (P , .001). Post-hoc
tests showed a statistically significant difference between
implants #4 and #9 (P , .001), #4 and #14 (P ¼ .0079), and #7
and #9 (P ¼ .001). For group 3, there was a statistically
significant difference between the implants (P ¼ .002). Post-hoc
tests showed a statistically significant difference between
implants #7 and #14 (P ¼ .005).
Table 3 shows the results for the 3D offset at the tip by
group and subgroup. In the analyses of the simple main effects,
there was a statistically significant difference between groups
for implants #4, #7, and #9 (P , .05), but not for implant #14 (P
¼ .106). Post-hoc tests demonstrated a statistically significant
difference between groups 2 and 3 for implant #4 (P ¼ .015) and
#7 (P , .001), with higher levels of deviation for group 2
compared to group 3. There was also a statistically significantly
higher level of deviation for group 1 compared to group 2 for
implants #7 (P , .001) and #9 (P ¼ .011). The within-group
comparisons of 3D offset at the tip between different implants
demonstrated no statistically significant difference in group 1 (P
¼ .377). For group 2, there was a statistically significant
difference between the implants (P , .001). Post-hoc tests
showed a statistically significant difference between implants
#4 and #9 (P , .001) and #7 and #9 (P ¼ .001). For group 3, there
was a statistically significant difference between the implants (P
, .001). Post-hoc tests showed a statistically significant
difference between implants #4 and #14 (P ¼ .002), #7 and #9
(P , .001), and #7 and #14 (P , .001).

TABLE 3
Results for 3D offset at tip (in mm; n ¼ 15 per group)
1 2 3
FASG** SSG FASGC
Group
Implant Mean 6 SD Min Max Mean 6 SD Min Max Mean 6 SD Min Max P**
4 1.06 6 0.55 0.17 2.14 1.19 6 0.38 0.52 1.81 0.77 6 0.16 0.51 1.02 .017
7 1.19 6 0.33 0.48 1.66 1.29 6 0.47 0.55 2.42 0.55 6 0.29 0.11 1.15 ,.001`
9 1.11 6 0.44 0.59 1.78 0.76 6 0.28 0.31 1.39 0.94 6 0.16 0.68 1.13 .015§
14 0.96 6 0.44 0.46 1.83 0.81 6 0.40 0.25 1.72 1.13 6 0.35 0.62 1.76 .106

*FASG indicates full-arch surgical guide; SSG, shortened surgical guides; FASGC, full-arch surgical guide with a crossbar.
**P values corresponding to between-group analysis.
In the post-hoc tests, there was a statistically significant difference between groups 2 and 3 (P ¼ .015).
`In the post-hoc tests, there were statistically significant differences between groups 2 and 3 (P , .001) and between groups 1 and 3 (P , .001).
§In the post-hoc tests, there was a statistically significant difference between groups 1 and 2 (P ¼ .011).

Journal of Oral Implantology 355

Different Guide Designs for Static Computer-Assisted Implant Surgery
DISCUSSION
This study investigated the effect of different surgical guide
designs and implant locations on the accuracy of guided
implant placement. The findings of the present study showed
that all surgical guide designs presented satisfactory perfor-
mance with clinically acceptable levels of deviation. However,
the overall results demonstrated superior outcomes of FASGC
compared to other groups when 2 or more guided implants
were placed. In contrast, SSG presented higher accuracy for
guided implants in a single-edentulous space. In this study,
there was a significant difference between implant locations,
particularly in group 2, in which multiple SSGs were used. It
seemed that the surgical guides on 4 abutment teeth designed
for a single-tooth edentulous surgical site are more accurate
than those designed for two single-tooth edentulous surgical
sites.
Although sCAIS has presented higher accuracy than
freehand implant placement,17,18 several manufacturing and
clinical factors could potentially influence its accuracy, since the
accuracy of guided implant surgery is a sum of errors within the
process, from data acquisition to printing or milling the surgical
guide.10,19 Several site-related or patient-related factors could
also influence its accuracy, such as timing of implant
placement, patient’s mouth opening, and tolerance to surgical
instruments. In this in vitro study, several factors were
controlled; however, 3D implant deviation could still be
generated from other factors such as (1) intraoral scanners
and laboratory scanner, (2) 3D printer, (3) bending effect of
surgical guide, (4) height of metal sleeves, (5) thickness of soft
tissue, and (6) clinician expertise.
Although digital impressions have demonstrated compara-
ble accuracy to conventional impressions,20,21 Ender et al22
found that a quadrant digital impression showed higher
accuracy than full-arch digital impressions. However, it is
unknown if the accuracy of the implant placement is higher
when using a quadrant digital impression for single implant
placement compared to full-arch digital impression. This study
demonstrated that SSGs presented superior results for single-
guided implant placement. Therefore, if there are plans for SSG
to be used with digital impression, a shortened-arch intraoral
scanning could be used to potentially improve its accuracy.
Nonetheless, an offset between the surgical guide and intraoral
surface scan is required for computer-aided design-computer-
aided manufacturing (CAD–CAM) surgical guides to compen-
sate for errors from data acquisition and/or impression.
The findings of the present study are in partial disagree-
ment with the results of another in vitro study. The effects of
the different surgical guide designs (full arch, 4-teeth, 3-teeth,
or 2-teeth) supported by teeth were compared in another in
vitro study.15 Acrylic bone models were used, and each study
model included 3 single-tooth gap situations. All models were
scanned, and digital treatment planning, including correct 3D
implant positioning, was performed. Surgical guides were
designed and produced with standardized design, production
variables, and material. The authors found significantly more
deviation for surgical guides using 3-teeth or 2-teeth compared
to 4-teeth or full-arch. However, they did not find a statistically
significant difference between the 4-teeth and full-arch surgical
guides. These results are incongruent with the results of the
356 Vol. XLVIII / No. Five / 2022
present study, where FASG presented higher 3D deviation
compared to SSG (supported by 4 teeth) for single implant
placement. On the other hand, when more than 1 guided
implant placement is planned, FASGC (supported by 8 teeth
with cross bars) presented superior outcomes. The present in
vitro study, however, presents some significant differences
compared to the in vitro study of Kholy et al,15 such as (1) type
of surgery (flap versus flapless), (2) 3D printer, (3) implant
macrodesign, and (4) postoperative scanning.
There are several factors that could influence the design
and fabrication of a surgical guide, such as material thickness,
extension, number of edentulous spaces, number of teeth
supporting the guide, and type of 3D printer and material
used.23–25 The surgical guide length seems to have an effect on
the accuracy of the guided implant placement, particularly in
those cases where multiple edentulous spaces are present. It
seems that longer surgical guides with multiple edentulous
spaces tend to bend more easily when forces from osteotomy
and implant placement are applied. This could explain the
higher accuracy of implant placement using FASGC for multiple
edentulous spaces found in this study. Thus, the cross bar can
potentially prevent some of the bending effects in such clinical
scenarios. To our knowledge, this is the first study to consider
the bending effect of a surgical guide and its influence on the
accuracy of guided implant placement. Therefore, more studies
with different designs are required to prove this concept. It
should also be emphasized that different printing materials
have different levels of rigidity,26 which could also influence the
bending effect.
This study has several limitations, such as (1) the acrylic
model could generate different outcomes compared to
different alveolar bone conditions; (2) only 3 surgical guide
designs were compared; (3) only one distance (6 mm) from the
sleeve position to the implant shoulder was used because of
the thickness of soft tissue; and (4) only flapless surgery was
performed. Most of these limitations are due to the nature of
this in vitro study design; therefore, further clinical studies are
needed to compare different surgical guide designs to confirm
results of the present study.
CONCLUSION
All surgical guide designs presented satisfactory performance
with clinically acceptable levels of implant deviation. FASGC
presented higher accuracy when 2 or more guided implants
were placed. In single-edentulous spaces, the SSG presented
higher accuracy. Further research on different patterns of
partially edentulous ridges, different designs of surgical guides,
and different implant designs should be investigated to provide
more information for clinicians to design reliable surgical
guides in a more cost-effective manner.
ABBREVIATIONS
FASG: full-arch surgical guide
FASGC: full-arch surgical guide with crossbar
sCAIS: static computer-assisted implant surgery
SSG: shortened-arch surgical guide

ACKNOWLEDGMENTS
The authors acknowledge the American Academy of Implant
Dentistry Foundation (AAIDF) for sponsoring this research with
AAIDF Research Grant.
NOTE
The authors do not have any financial interest in the companies
whose materials are included in this article and declare no
potential conflicts of interest with the publication of this article.
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