Received: 4 March 2020 Revised: 22 July 2020 Accepted: 25 August 2020

DOI: 10.1111/cid.12949

ORIGINAL ARTICLE

Comparison of the accuracy of implant position for two-

implants supported fixed dental prosthesis using static and
dynamic computer-assisted implant surgery: A randomized
controlled clinical trial

Paweena Yimarj DDS1 | Keskanya Subbalekha DDS, PhD1 |

Kanit Dhanesuan DDS1 | Kiti Siriwatana DDS1 |
Nikos Mattheos DDS, MASc, PhD2 | Atiphan Pimkhaokham DDS, PhD1

1
Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand
2
Implant Dentistry, Oral Rehabilitation, Faculty
of Dentistry of the University of Hong Kong,
Prince Philip Dental Hospital, Hong Kong,
China
Correspondence
Atiphan Pimkhaokham, Department of Oral
and Maxillofacial Surgery, Faculty of Dentistry,
Chulalongkorn University, 34 Henri Dunant
Road, Wangmai, Patumwan, Bangkok 10330,
Thailand.
Email: atiphan.p@chula.ac.th
Abstract
Background: Computer-assisted implant surgery (CAIS) can facilitate accuracy of sin-
gle implant placement, but little is known with regards to parallelism between multi-
ple implants.
Purpose: To compare the accuracy of position and parallelism of two implants, using
static and dynamic CAIS systems.
Materials and methods: Thirty patients received two implants (60 implants) randomly
allocated to two different CAIS systems. Optimal implant position and absolute paral-
lelism was planned based on preoperative cone beam CT (CBCT). Patients received
implants with a surgical guide (static CAIS, n = 30) or real-time navigation (dynamic
CAIS, n = 30). Implant three-dimensional deviation and parallelism was calculated
after surgery.
Results: The mean 3D deviation in the static and dynamic CAIS group at implant plat-
form were 1.04 ± 0.67 vs 1.24 ± 0.39 mm, at apex were 1.54 ± 0.79 vs
1.58 ± 0.56 mm and angulation were 4.08 ± 1.69 vs 3.78 ± 1.84 , respectively.
The angle deviations between two placed implants (parallelism) in static and dynamic
CAIS groups were 4.32 ± 2.44 and 3.55 ± 2.29 , respectively. There were no sta-
tistically significant differences in all parameters between groups.
Conclusion: Static and dynamic CAIS provides similar accuracy of the 3D implant
position and parallelism between two implants.

KEYWORDS
accuracy, computer-assisted implant surgery, dental implant, parallelism

1 | I N T RO DU CT I O N Conventional implant placement using free-hand surgery based

on 2D radiographic assessment might lead to compromised accuracy
Proper prosthetic-driven three-dimensional implant position is consid- or unfavorable implant positioning especially in complex cases or mul-
ered today a fundamental element for sustainable function and tiple implants, thus increasing the risk for short- or longer-term
esthetic outcome in implant prosthodontics.1 complications.2,3

Clin Implant Dent Relat Res. 2020;1–7. wileyonlinelibrary.com/journal/cid © 2020 Wiley Periodicals LLC 1
2 YIMARJ ET AL.
Computer-assisted implant surgery (CAIS) was introduced in response
to the need for increased precision and accuracy, mainly including two
approaches: the static and the dynamic. Both approaches are based on
three-dimensional image reconstruction and planning of virtual implant
placement in the optimal position.4,5 Then the virtually planned implant
position is transferred to the real surgical sites by means of a custom-made
guided surgery template in the case of static CAIS or through a real-time
tracking and guidance of the surgical drill in dynamic CAIS systems.6-8
Both static and dynamic CAIS systems come with different potential
and limitations, although they are both based on a virtually planned opti-
mal implant position. Static CAIS systems would not allow the surgeon
direct visual contact with the working surgical site and intraoperative
change from the planned position is difficult. The patient's mouth open-
ing, availability of teeth, teeth position, or mobility might be important
practical parameters that can influence the ability to place and stabilize a
surgical guide, in particular concerning posterior surgical sites.9 On the
other hand, dynamic CAIS systems might present with tracking registra-
tion error (TRE), although such errors can be noted and corrected with
recalibration. Nevertheless, the registration process is technically sensi-
tivity and requires time. To such limitations one could add the necessary
learning curve of the surgeon and the high cost of the machine.10,11
Several studies have documented improved accuracy for static or
dynamic CAIS as compared to free hand surgery, with the majority of
clinical studies however having evaluated only single implant place-
ment.7,8,12-14 Although studying single implant clinical scenario would be
an essential proof of principle, the truth is that the cases where increased
accuracy is required are mainly concerning complex reconstructions with
multiple implants, especially where implant parallelism is required. A fixed
dental prosthesis supported by two or more implants would add to the
surgical complexity with the element of implant parallelism or relative
angulation, something especially important in the light of sustainable
prosthesis design and modern immediate loading protocols.
At present however, there are no clinical studies investigating the
effects of static or dynamic CAIS on the parallelism of multiple
implants. Thus, the aim of this randomized clinical trial was to com-
pare the accuracy of implant position, as well as the parallelism
between two implants placed with either static or dynamic CAIS to
support a fixed dental prosthesis in partially edentulous patients.
2 | MATERIALS AND METHODS
This study was a randomized controlled clinical trial, approved by the
Human Research Ethics Committee of the Faculty of Dentistry,
Chulalongkorn University (HREC-DCU 2018-082) and registered at
the Thai Clinical Trials Registry (TCTR20181224002).
2.1 | Population
Sample size calculation was conducted by means of statistical soft-
ware (G*Power software, version 3.1) using Mann-Whitney U test
with 95% of study power and significance level (α) set at .05. Previous
studies on the 3D deviation of implants utilizing similar protocol have
identified the appropriate sample to be of 30 pairs of implants.7,8 The
outcomes of two previous studies comparing deviation between
planned and actual implant position at platform, apex, and angle with
static and dynamic CAIS systems were utilized for the sample calcula-
tion Beneke et al15 and Block et al.11 Based on the outcomes of these
studies on 3D deviation at platform (0.21 ± 0.16 and 1.37 ± 0.55 mm),
at apex (0.32 ± 0.34 and 1.56 ± 0.69 mm), and angle (1.35 ± 1.11
and 3.62 ± 2.73 ), respectively, the minimum sample size require-
ment for each of the three outcomes was 10, 14, and 46 implants,
respectively. Angular deviation between two implants is a novel
parameter in this study that has not been studied before, and thus the
power calculation can only indirectly be possible.
Patients 20 years or older with an edentulous space requiring a
fixed dental prosthesis supported by two implant fixtures and who
had the respective teeth been extracted since at least 3 months, had
adequate bone volume for primary stability (with or without a simulta-
neous guided bone regeneration procedure) were invited to partici-
pate in the study. Patients were included only if the prosthesis was to
be supported by two neighboring implants (two missing teeth) or a
3-unit bridge (three missing teeth). Patients were excluded if they
presented with uncontrolled systemic disease, conditions, or medica-
tion which could affect to dental implant treatment, clinical or radio-
graphic signs of any pathology in the jaw bone, increased mobility of
adjacent teeth, or with current use of orthodontic appliances.
Patients were then randomly allocated into two groups: static
CAIS group (n = 30) and dynamic CAIS group (n = 30) by block ran-
domization (6 per block).
2.2 | Cone beam CT scanning protocol
All patients received a cone beam CT (CBCT) radiographic examina-
tion with a 3D Accuitomo 170 machine (J.Morita Inc, Kyoto, Japan).
The patients in the dynamic CAIS group in particular, received the
CBCT examination wearing a custom-made vacuum stent attached to
an occlusal device with the radiopaque fiducial markers, used as refer-
ence points to the patient's jaw, as required by the dynamic CAIS pro-
tocol (IRIS-100; EPED Inc, Kaohsiung, Taiwan). After the CBCT, the
vacuum stent was kept for later use at the time of the surgery.
2.3 | Computer-assisted implant planning
The DICOM (digital imaging and communications in medicine) files from
CBCT were imported into the coDiagnostiX software, version 9.7 (Dental
Wings Inc, GmbH, Germany) for static CAIS group and in the Iris-100 soft-
ware (EPED Inc) for dynamic CAIS group. Both software allow the virtual
placement of the implant in the optimal 3D restorative driven position.
For static CAIS group in particular, STL file from model scanning (D900L
scanner, 3Shape, Copenhagen, Denmark) was imported and merged with
the DICOM file to create the proper position based on the restorative and
biologic driven concepts.
YIMARJ ET AL. 3

The two implants were planned in perfect parallelism and 0 angle
deviation between the two implants was confirmed by the respective
planning software. Patients for whom optimal parallelism of the
implants was not possible or desired due to local anatomic conditions
(eg, angle or dimensions of neighboring roots) were excluded from the
study. After completion of the planning for the static CAIS group, the
design of the digital surgical template was sent to a certified
manufacturing dental laboratory to produce a stereolithographic surgi-
cal guide (VisiJet MP200, VisiJet M3 Stone Plast; 3D Systems, Inc,
Rock Hill, South Carolina).
2.4 | Surgical procedures
All surgeries were performed by one surgeon, specialist in Depart-
ment of Oral and Maxillofacial Surgery (OMFS) and experienced with
the use of both static and dynamic CAIS.
2.5 | Implant placement with static CAIS
Before the initiation of the surgery, the fit and stability of the surgical
guide was verified in the patient's mouth. A fully guided surgical proto-
col was utilized. Implant bed preparation was conducted according to
the guided surgery protocol of Straumann system, while the respective
fixtures (Straumann, Institute Straumann AG, Basel, Switzerland) were
inserted through the sleeves of the surgical template.
inserted in patient's mouth during the second CBCT scan and was
then transferred to the IRIS-100 software (EPED Inc) for superimposi-
tion with the preoperative virtual planning. The 3D position deviation
and the angle deviation between the placed and the planned implant
position was automatically calculated by the coDiagnostiX for static
CAIS group and Iris-100 software for dynamic CAIS group.
Two outcomes were then measured:
1. The deviation of the actual implant position as compared to the
planned one. Three measurements were conducted to express
this outcome: 3D deviation at implant shoulder, 3D deviation at
implant apex, and angle deviation of implant axis. Each of the
three measurements was averaged for each patient (two
implants) and the respective results represented the patient level
(Figure 1).
2. The parallelism between the two placed dental implants in each
patient. The axis of the implant was defined as the line which
crosses the center of the implant shoulder and the center of the
implant apex. The angle of the axes of the two implants was mea-
sured to assess parallelism. One of the implants was defined as ref-
erence and then the deviation of the angle of the second implant
axis as compared to the axis of the reference implant was calcu-
lated (Figure 2).

2.6 | Implant placement with dynamic CAIS

Prior to surgery, the registration procedure was performed to deter-

mine the location and orientation of the handpiece in relation to the
patient's anatomic landmarks. Two tracking sensors were connected
with the vacuum stent in the patient's mouth. A registration probe
was placed on the handpiece which then was tracked by the infrared
camera for four predetermined markers positioned on the vacuum
stent. Implant bed preparation and implant placement were performed
F I G U R E 1 The 3D deviation of the planned and placed implant
under real-time visual guidance through the navigation system. The
position at platform, apex, and angle deviation of the axis
position of the drill and the planned implant position were projected
on the data from the CBCT and displayed on the screen in real time
during the surgery.

2.7 | Accuracy measurement

After implant placement, all patients received a second CBCT scan

with the same settings as previously. For the static CAIS group, super-
imposition of pre- and postoperative CBCT images was conducted, in
order to evaluate the deviation between planned and actual implant
position via the respective function of the co-DiagnostiX software
(Dental wings Inc, Montreal, California). For the dynamic CAIS group, F I G U R E 2 The angle deviation between the axis of the two
the same registration stent that contain four fiducials marker was placed implants in each patient
4 YIMARJ ET AL.

TABLE 1 The 3D deviation of the planned and placed implant position at platform, apex, and angle deviation of the axis

Group Static CAIS (n = 30) Dynamic CAIS (n = 30) P-value (Mann-Whitney U test)
Deviation at platform (mm), mean ± SD 1.04 ± 0.67 1.24 ± 0.39 .11
Deviation at apex (mm), mean ± SD 1.54 ± 0.79 1.58 ± 0.56 .57

Angle deviation ( ), mean ± SD 4.08 ± 1.69 3.78 ± 1.84 .64

Abbreviations: CAIS, computer-assisted implant surgery; SD, standard deviation.

T A B L E 2 The angle deviation

Static CAIS Dynamic P-value
between the axis of the two placed
Group (n = 30) CAIS (n = 30) (independent t-test)
implants in each patient
Angle deviation between the axis 4.32 ± 2.44 3.55 ± 2.29 .39
of the two placed implants ( ),
mean ± SD

Abbreviations: CAIS, computer-assisted implant surgery; SD, standard deviation.

F I G U R E 3 The deviation at implant platform in mesiodistal and F I G U R E 5 The deviation at implant platform in buccolingual and
buccolingual direction apicocoronal direction

2.8 | Statistical analysis

All data were calculated under IBM SPSS Statistics software (version
24; SPSS Inc, Chicago, Illinois). The normality of data distribution were
calculated using Kolmogorov-Smirnov test, mean 3D deviation at
implant shoulder, apex, and angle deviation at axis between the actual
and the planned position were found to have a non-normal distribu-
tion, therefore Mann-Whitney U test was used for the analysis. Mean
angle deviations of axis between two implants (parallelism) in each
patient were compared using independent t-test. P-value <.05 was
considered as statistically significant.

3 | RE SU LT S

Fifteen patients (mean age 60; 2 males, 13 females) received

F I G U R E 4 The deviation at implant platform in mesiodistal and 30 implants with static CAIS, while another 15 patients (mean age 60;
apicocoronal direction 5 males, 10 females) received the same amount of implants with
YIMARJ ET AL.
F I G U R E 6 The deviation at implant apex in mesiodistal and
buccolingual direction
F I G U R E 7 The deviation at implant apex in mesiodistal and
apicocoronal direction
dynamic CAIS. All implants were posterior and 56 were involved in
prosthesis supported by two neighboring implants (static 28, dynamic
28), while 4 implants (static 2, dynamic 2) were supporting 3-unit
bridges.
The mean 3D deviations of the planned and placed implant posi-
tions at platform and apex in static vs dynamic CAIS group were
1.04 ± 0.67 vs 1.24 ± 0.39 mm and 1.54 ± 0.79 vs 1.58 ± 0.56 mm,
respectively. Similarly, the angular deviation between planed and
placed position with static vs dynamic CAIS groups were
   
4.08 ± 1.69 vs and 3.78 ± 1.84 , respectively (Table 1). The mean
angular deviations between the axis of two placed dental implants
(parallelism) in static vs dynamic CAIS groups were 4.32 ± 2.44 vs
3.55 ± 2.29 , respectively. There were no statistically significant dif-
ferences in all parameters between groups (Table 2).
Moreover, when comparing the implant deviation at
mesiodistal, buccolingual, and apicocoronal directions, significant
5
F I G U R E 8 The deviation at implant apex in buccolingual and
apicocoronal direction
differences were found. Deviation at platform was significantly
more toward the lingual direction (P = .03) while at the apex signifi-
cantly more toward the distal direction (P = .03) in dynamic CAIS
more than static CAIS. No significant difference in the other direc-
tions was found. The deviation to each direction of all implants is
presented in Figures 3 to 8.
4 | DI SCU SSION
Both static and dynamic CAIS have been documented to help clini-
cians in achieving a favorable and accurate implant positioning, which
is a prerequisite for successful implant therapy and can facilitate a sus-
tainable prosthetic restoration.
Although optimal parallelism of multiple implants has been report-
edly a critical factor to strive for when supporting the same prosthesis,
such an outcome has been frequently compromised by operator, tech-
nique, or anatomic difficulties. Static CAIS, utilizing a surgical guide
might in this aspect differ to dynamic CAIS, which in essence remains
a “freehand” surgical placement. Nevertheless, this randomized con-
trolled trial did not find any significant differences in terms of parallel-
ism outcomes between the two techniques. All parameters from both
groups were in a range of likely values when compared to the previ-
ous studies.7,11,16-19 Moreover, the deviations observed in this study
were smaller than those reported in in vitro studies, such as the study
by Ruppin et al20 on three different CAIS systems, who reported mean
platform deviation of less than 1.5 mm and mean angular deviation of
less than were 8.1 in partially and fully edentulous human cadaver
mandibles. Similarly, Somogyi-Gnass et al21 reported mean deviations
static and dynamic CAIS at platform and apex less than 1.91 and
1.14 mm, respectively, and mean angular deviation less than 4.2 , with
no significant differences to be found. Kaewsiri et al7 reported mean
implant deviations at platform and apex in static CAIS group of 0.97
and 1.28 mm, respectively, while in dynamic CAIS group were 1.05
6 YIMARJ ET AL.
and 1.29 mm, respectively, with no statistically significant difference.
Similarly, angular deviation in static and dynamic CAIS groups were
  7
2.84 and 3.06 , respectively. In systematic reviews and meta-
analyses that reported the accuracy of CAIS systems in clinical studies,
the deviation was less than 1.22 and 1.45 mm at platform and apex,
respectively, and angular deviation less than 4.06 .17,22-24 However,
these systematic reviews included various study designs, with differ-
ent objectives and the collective results are not easy to extrapolate in
clinical situations. The present study investigated a very specific clini-
cal scenario, that is, two fixtures supporting one fixed dental prosthe-
sis in all cases. Albeit a simple form of a multiunit Faculty of Dentistry,
Chulalongkorn University (FDP), this is the first attempt to study the
operator's ability to achieve parallelism with static and dynamic CAIS.
Conducted with the above selection criteria and under a strict ran-
domized controlled trial setup, this study presented a more complex
scenario than the great majority of similar clinical studies, which
report outcomes of CAIS in single tooth space.
When analyzing the deviation at platform and apex in mesiodistal,
buccolingual, and apicocoronal directions, the results showed some
significant differences. At the platform level placement with dynamic
CAIS resulted in more deviation toward the lingual direction in the
buccolingual axis. At the apex placement with dynamic CAIS pres-
ented with more deviation to the distal direction in the mesiodistal
axis. No significant difference was found in any other direction. This
observation might be a result of some influence of the field of vision
or the surgeon, as placement under dynamic CAIS is still conducted
under direct vision and manual control. Nevertheless, there was no
evidence that such an effect had any impact in the overall clinical out-
comes in terms of accuracy.
The need for parallelism of two implants which support a fixed
dental prosthesis is well established. Parallelism will allow a similar
path of insertion of the prosthesis for both implants, thus allowing
screw retention with a more simple design, better contour and a
prosthesis that directs the forces along the long axis of the implant
25
fixtures. In the absence of such parallelism, the clinician needs to
utilize more complex prosthetic manipulation such as multiple, cus-
tomized or angled abutments, cement retention, angled screw
channels and more. Such restorations might increase complexity,
costs but also risks for technical and biological complications. The
often compromised emergence profile of angled abutments and
the risks of cement rests have been reported to increase the preva-
lence of peri-implant tissue inflammation.26,27 Furthermore, com-
promise of the biomechanics of the prosthesis-implant complex
due to occlusal forces no longer being directed down the long axis
of the implant could increase stresses on the prosthesis compo-
nents, the implants, and the bone28 predisposing among others to
29
risk of prosthesis or abutment screw loosening. Kao et al
reported that cortical bone stress elicited by implant placement
and loading stress increased proportionately with the angle of the
abutment.
The present study, being the first to compare the ability of
static and dynamic CAIS to support parallelism of the implants
placed, showed no significant difference between the two
techniques. Implant fixtures require an angled abutment when
inserted at an angle greater than 12 .31 Both CAIS systems provide
an accurate implant placement and could assist efficiently the sur-
geon to achieve adequate parallelism of the implants, with less than
4.35 deviation.
Several factors have been reported to influence the extent of
deviation from the planned implant position when utilizing static and
dynamic CAIS.4,13,15,32-35 In static CAIS, most common limitations or
potential sources of error include fracture or misfit of the surgical
guide and patients with limited mouth opening. In dynamic CAIS, com-
mon limitations and errors include TRE, or limitations related to the
learning curve of using the navigation system. The surgical guides uti-
lized in this study were tooth-support under fully guided protocol.
Dynamic CAIS protocol utilized a registration method by means of
four radiopaque fiducial markers attached to an occlusal stent. All sur-
geries were performed by one experienced specialist surgeon. In the
future, upcoming advanced digital technologies such as augmented
reality (AR) may be used in conjunction with the CAIS and navigation
systems, which may further increase accuracy and effectiveness/effi-
ciency. Furthermore, future research should address more complex
scenario of implant placement, as for example the use of CAIS in fully
edentulous patients.
5 | CONC LU SION
Static and dynamic CAIS systems appear to achieve similar clinical
outcomes when placing in vivo two implants not only with regards to
deviation from the optimal implant position but also with regards to
implant parallelism. Both static and dynamic CAIS can be indicated for
placing multiple implants supporting the same prosthesis, with the
choice being rather directed by the surgeon's preferences, patient's
anatomic conditions and inherent indications and limitations of each
system.
CONFLIC T OF INT ER E ST
The authors declare no potential conflict of interest.
DATA AVAILABILITY STAT EMEN T
The data sets used and/or analyzed during the current study are avail-
able from the corresponding author on reasonable request
OR CID
Keskanya Subbalekha https://orcid.org/0000-0002-1570-2289
Nikos Mattheos https://orcid.org/0000-0001-7358-7496
Atiphan Pimkhaokham https://orcid.org/0000-0002-0170-243X
30
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How to cite this article: Yimarj P, Subbalekha K, Dhanesuan K,
Siriwatana K, Mattheos N, Pimkhaokham A. Comparison of
the accuracy of implant position for two-implants supported
fixed dental prosthesis using static and dynamic computer-
assisted implant surgery: A randomized controlled clinical trial.
Clin Implant Dent Relat Res. 2020;1–7. https://doi.org/10.
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