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Impact of Surgical Template on the Accuracy of Implant Placement

Article  in  Journal of Prosthodontics · November 2015

DOI: 10.1111/jopr.12407

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Impact of Surgical Template on the Accuracy of Implant
Placement
Liang-wei Xu, PhD,1 Jia You, PhD,1 Jian-xing Zhang, MDS,2 Yun-feng Liu, PhD,1 & Wei Peng, PhD1
1
Key Laboratory of E&M (Zhejiang University of Technology), Ministry of Education & Zhejiang Province, Hangzhou, China
2
Department of Stomatology, Zhejiang People’s Hospital, Hangzhou, China

Keywords
Cone beam computed tomography;
stereolithographic surgical template;
computer-aided manufacturing;
computer-aided implant surgery.
Correspondence
Wei Peng, Key Laboratory of E&M, 18 Chao
Wang Street, Xia Cheng District, Hangzhou,
Zhejiang, China. E-mail: pengwei@zjut.edu.cn
This project was jointly supported by the
National Natural Science Foundation of China
(Grant No. 51375453), the Natural Science
Foundation of Zhejiang Province (Grant No.
LY13E050017), and the Scientific Research
Foundation for the Returned Overseas
Chinese Scholars, State Education Ministry.
The authors have no conflicts of interest to
declare.
Accepted May 21, 2015
Abstract
Purpose: To achieve functional and esthetic results, implants must be placed accu-
rately; however, little information is available regarding the effect of surgical templates
on the accuracy of implant placement. Thus, the aim of this study was to measure the
deviation between actual and planned implant positions, and determine the deviation
caused by the surgical template.
Materials and Methods: Jaws from 16 patients were scanned using cone beam
computed tomography (CBCT). For our study, 53 implants were planned in a virtual
3D environment, of which 35 were inserted in the mandible and 18 in the maxilla. A
stereolithographic (SLA) surgical template was created. A CBCT scan of the surgical
template fitted on a plaster model was performed, and the images obtained were
matched to virtual implant plan images that contained the planned implant position.
The actual implant position was acquired from the registration position of the surgical
template. Deviation between actual and planned implant positions was analyzed.
Results: Mean central deviation at the hex and apex was 0.456 mm and 0.515 mm,
respectively. Mean value of horizontal deviation at the hex was 0.193 mm, horizontal
deviation at the apex was 0.277 mm, vertical deviation at the hex was 0.388 mm,
vertical deviation at the apex was 0.390 mm, and angular deviation was 0.621°.
Conclusion: Our study results revealed a significant deviation between actual and
planned implant positions caused by the surgical template.

doi: 10.1111/jopr.12407

Computer-aided implant technology has been widely used in
dental implant treatment thanks to the development of com-
puted tomography (CT), rapid prototyping (RP), and reverse
engineering (RE).1-3 In the meantime, implant survival rate has
attracted more and more attention.4-6 Surgical templates help
clinicians ensure accuracy of implant position, avoid harm-
ing important anatomical structures such as adjacent roots and
nerves, and take restoration and biomechanics into account.7-9
All considerations regarding implant position and restoration
are reflected in the template; thus, the surgical template is a key
element in computer-aided implant technology.
Computer-guided implant surgery is based on high-
resolution 3D CT scans. Commercially available software
for planning implant position such as SimPlant (Materi-
alise, Leuven, Belgium),10,11 Nobel Guide (NobelBiocare,
Goteborg, Sweden),12,13 or Med 3D (Med3D, Heidelberg,
Germany)14 allow clinicians to interact with CT scan data. The
combination of CT-based treatment planning and computer-
aided design/computer-aided manufacturing (CAD/CAM) of
surgical templates allows clinicians to plan treatment in
advance.15 Procedures such as data acquisition, implant
planning, and fabrication of the surgical template are done
during preoperation. Then, clinicians use the template to
direct the surgical positioning of drills and place the implants
along guide sleeves during surgery. Errors in the final implant
position are difficult to avoid. Errors in computer-guided
implant surgery can be classified in two types: those caused by
the surgical template in preoperation, and those caused by the
operator during surgery.
Some studies have assessed the accuracy of guided surgery
for the transfer of virtual plans to clinical situations,16-21 while
several others have assessed the accuracy of surgical templates
in in vitro studies.12,14,22 These studies analyzed the final error
of computer-guided implant surgery, and they mainly focused
on the deviation between actual and planned implant positions
postsurgery. The final error was due to the combination of
surgical template and operation errors; however, it was difficult
for clinicians judging which was the main factor contributing to

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Templates for Implant Placement Accuracy Xu et al

the final error, which prevented improving accuracy. In addition, Table 1 Distance deviation
the operational error cannot be controlled if the analysis of
Distance deviation (mm)
deviation is made postsurgery.
This study focuses on the impact of the surgical template 95% 95%
on guided surgery, without taking into account surgery. The Variable Mean Min Max SD CI LL CI UL p
aim of this study was to measure the deviation between actual
and planned implant positions, and to determine the deviation cdh 0.456 0.094 0.888 0.222 0.522 0.641 <0.001
caused by the surgical template. cda 0.515 0.069 0.919 0.233 0.572 0.713 <0.001
hdh 0.193 0.030 0.454 0.123 0.190 0.262 <0.001
hda 0.277 0.031 0.597 0.190 0.271 0.393 <0.001
Materials and methods vdh 0.388 0.080 0.906 0.238 0.323 0.453 <0.001
Data acquisition vda 0.390 0.090 0.908 0.236 0.465 0.583 <0.001

All patients included in the study provided informed consent
prior to the start of the study. In addition, the study protocol
was approved by the Ethics Committee at Zhejiang People’s
Hospital (China).
Sixteen adults (eight men, eight women; average age =
41 years) were included in this study. Before treatment, all pa-
tients got a CBCT scan (Kavo 3D exam i), and a 3D model was
reconstructed from the scan images (Fig 1A). We used the fol-
lowing operation and reconstruction parameters in the scanner:
8 mA, 120 kV, scanning time 8 seconds, and scan thickness 0.25
mm. Data were saved in Digital Imaging and Communications
in Medicine (DICOM) 3.0 format. Clinicians prepared dental
models by taking impressions using silicone rubber impression
material (DMG, Bielefeld, Germany), and filling the impres-
sions with plaster to create models (Fig 1B). Each plaster model
was then scanned using 3D laser scanning equipment (DM700;
3Shape, Copenhagen, Denmark). Digital plaster models were
exported as standard triangle language (STL) format files
(Fig 1C).
Surgical plan and template fabrication
Jaw data were processed using 6D implant planning software
(6D-dental, Hangzhou, China). Then, clinicians reconstructed
3D jaw models, and specified the planned implant positions
(Figs 1A,D). Digital plaster models were imported into the
software and registered with the jaw model. Then, surgical
templates for implants were calculated using the software and
exported to STL format (Fig 1E). Surgical templates were fab-
ricated from the exported data using stereolithography (SLA)
(Fig 1F). After CAD data were transferred to an RP model-
ing machine (Connex350; Objet, Rehovot, Israel), templates
were fabricated using UV-cured acrylic-based resin material
(MED610; Objet) in 16-μm layers. The final surgical tem-
plates were fitted and trimmed to the plaster models by the
same dental technician (Fig 2A).
Registration and acquisition of actual implant
position
Immediately after the final surgical template was completed,
a CBCT scan of the template fitted to the plaster model was
taken (Fig 2B). Digital and jaw models were matched in a
coordinate system using corresponding voxels from the two
data sets. Once data sets were aligned, the actual position of
the surgical template could be confirmed (Fig 2C). The actual
implant position and guide sleeve were coaxial. Meanwhile, the
distance from the hex of the actual implant to the surface of the
Positive value for vertical deviation indicates that the actual implant site was
higher than the planned position.
cda, central deviation at apex; cdh, central deviation at hex; hda, horizontal
deviation at apex; hdh, horizontal deviation at hex; LL, lower level; UL, upper
level; vda, vertical deviation at apex; vdh, vertical deviation at hex.
guide sleeve could be calculated. Therefore, the actual implant
position was recorded according to the actual guide sleeve of
the surgical template (Fig 2D). Then, the deviation between
the actual and planned positions could be analyzed presurgery
(Figs 2E,F).
Accuracy assessment
Linear and angular discrepancies between actual and planned
implant positions were analyzed. The Euclidean distance was
measured at the hex and apex of the implant, and the angle
of axis deviation was also calculated. Seven parameters (i.e.,
cdh, cda, hdh, hda, vdh, vda, and ad) were used to describe
the deviation (Fig 3). Hex refers to the center of the prosthetic
connection of the implant, while apex refers to the tip of the
implant.
Statistical analysis
Data were statistically analyzed using SPSS software (v.11.0;
SPSS Inc., Chicago, IL). Results were analyzed using t-test for
deviations between actual and planned implants. Deviations
were summarized using minimum, maximum, mean, standard
deviation, and the corresponding 95% confidence intervals. All
tests were two-sided, and α = 0.05 was considered statisti-
cally significant. A post hoc power analysis was performed to
determine the minimum adequate sample size.
Results
There were 53 implants planned in the 6D software, and no
templates were fractured in this study. All CBCT scans of
the surgical template fitted on the plaster model were per-
formed by the same operator. There were significant differ-
ences in all outcome variables (i.e., cdh, cda, hdh, hda, vdh,
vda, and ad) between the actual and planned implant positions
(Tables 1 and 2). Our statistical analysis was limited to the as-
sessment of discrepancies in these seven parameters since they
were the most important to achieve optimal clinical results
without complications. Central deviation at the hex and apex
between actual and planned implants was almost constant with
a mean of 0.456 mm and 0.515 mm, respectively. Mean value

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Xu et al
Figure 1 Data acquisition and surgical plan. (A) Mandibular digital model. (B) Plaster model. (C) Digital plaster model. (D) Planned implant position. (E)
Surgical template created with the software. (F) Surgical template.
Table 2 Angular deviation
Angular deviation (degrees)
Variable Mean Min Max SD 95% CI LL 95% CI UL
ad 0.621 0.062 1.870 0.446 0.498 0.744
ad, angular deviation; LL: lower level; UL: upper level.
of horizontal deviation at the hex was 0.193 mm, horizontal
deviation at the apex was 0.277 mm, vertical deviation at the
hex was 0.388 mm, vertical deviation at the apex was 0.390
mm, and angular deviation was 0.621°.
Discussion
Computer-aided template guided technology offers clinicians
another way to address the final position of implants prior to
surgery and prosthetic work. This technology also allows clin-
icians to collaborate in the planning stage and combine their
knowledge; however, with new advancements there may be
limitations and risks, so it is important to understand how this
technique works, and how accurate the surgical template is.
Previous studies evaluated the clinical deviation between ac-
tual and planned implant positions postsurgery.16-21 Data from
the second CT scan of patients performed after surgery were
processed, and jaw reconstruction was registered to CT data
obtained presurgery, while deviation of the actual and planned
implant positions was analyzed. Schneider et al7 searched 3120
relevant articles and found that 8 articles met the inclusion cri-
Journal of Prosthodontics 00 (2015) 1–6 
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Templates for Implant Placement Accuracy
teria regarding accuracy, while 10 met the criteria for clinical
performance. These authors found that the mean deviation was
1.07 mm (95% CI: 0.76 to 1.22 mm) at the hex, and 1.63 mm
p (95% CI: 1.26 to 2 mm) at the apex. The mean vertical error
was 0.43 mm (95% CI: 0.12 to 0.74 mm). This is the final
<0.001 accumulated error when fitting virtual surgical plans to surgi-
cal templates. This error can arise during acquisition of CBCT
scans, from the interpolation of the software used for planning,
the processes used to create surgical templates, the fit and place-
ment of the template on the patient, or the operator. The final
error in implant position can be divided into two parts: error
accumulated on the surgical template, and error caused by oper-
ation. Errors caused by surgical template or the operator would
lead to a deviation of the actual implant position from the ideal
implant position. In fact, even if the clinician drills along the
template sleeve completely, the planned implant position may
change after the manufacture of the surgical template. Several
studies have shown that implant survival increased with the ex-
perience of the operator.23-26 Cushen et al25 found that the level
of experience of the operator placing the implants contributes
to the accuracy of implant placement; operators more experi-
enced with surgical templates placed more implants accurately.
However, little information regarding the effect of the surgical
template on implant placement accuracy is available.
Our study evaluated the deviation between actual and planned
implant positions, caused by the surgical template, regardless of
clinical operation or experience. We found a significant differ-
ence in the accuracy of implant placement based on the surgical
template. Compared to clinical results, the error caused by the
surgical template was smaller. Pettersson et al15 found that the
3
Templates for Implant Placement Accuracy Xu et al

Figure 2 Method used to analyze deviation. (A) Surgical template fitted on the plaster model. (B) Reconstruction of the template fitted on plaster
model from the CBCT images. (C) The reconstructed model was matched with the mandible. (D) Actual implant position. (E) Actual and planned
implant positions in the mandible. (F) Deviation between the actual and planned implant position.

Figure 3 Assessment of the deviation between actual and planned im- horizontal deviation at hex, hda = horizontal deviation at apex, cdh =
plant positions. (A) Central and horizontal deviations at the hex and apex. central deviation at hex, cda = central deviation at apex, vdh = vertical
(B) This schematic shows the vertical and angular deviations. (hp = hex deviation at hex, vda = vertical deviation at apex, ad = angular deviation).
planned, ap = apex planned, ha = hex actual, aa = apex actual, hdh =

mean deviation at the hex was 0.80 mm, and the mean value
at the apex was 1.09 mm, while Cassetta et al10 found that
the mean deviation at the hex and apex were 1.47 mm and
1.83 mm, respectively. Meanwhile, Di Giacomo et al11 found
that the mean horizontal deviation at the hex was 1.45 mm, and
the mean horizontal deviation at the apex was 2.99 mm. Ozan
et al27 found 1.28 mm of horizontal deviation at the implant
hex, and 1.57 mm of horizontal deviation at the apex. Dreisei-
dler et al28 found that the horizontal error at the implant hex
was 0.217 mm, and 0.343 mm at the apex. In our study, central

4 Journal of Prosthodontics 00 (2015) 1–6 

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Xu et al Templates for Implant Placement Accuracy

Figure 4 Box plots showing the median, quartile, and extreme value of the deviation of the implants. (A) Central deviation at the hex and apex. (B)
Horizontal deviation at the hex and apex. (C) Vertical deviation at the hex and apex. (D) Angular deviation.

mean values at the hex (0.456 mm) and apex (0.515 mm) were
much smaller than the final deviation after surgery. Horizon-
tal mean values at the hex (0.193 mm) and at the apex (0.277
mm) were also smaller than in the studies mentioned above.
Central or horizontal deviations were much larger at the apex
of the implant, which was consistent with clinical results (Fig
4A,B). Vertical deviations at the hex (0.388 mm) and at the apex
(0.390 mm) were almost equal (Fig 4C). Meanwhile, mean
value of vertical deviation was positive, showing that the actual
implant position was higher than the planned position. In ad-
dition, the angular deviation showed that the axis deviation of
the actual and planned implants did not exceed 0.8° (Fig 4D).
Angular (0.621°) and vertical (0.39 mm) deviations were also
smaller than the corresponding deviations in the clinical studies
mentioned above.
Our results provide a better understanding of possible de-
viations of the surgical template when performing computer-
guided implant surgery. Compared to the analysis of implant
accuracy postsurgery, clinicians can have an idea of the tem-
plate error presurgery; thus, they can adjust the implant position
during the operation. Our study provided a way to test the qual-
ity of the template and control the risks of computer-aided
implant surgery. Our results can also be useful for clinicians for
the improvement of this specific treatment method.
Limitations of our study include that it was an in vitro in-
vestigation performed under controlled conditions, and a small
number of surgical templates were used. We did not examine
other technical errors that can occur during the performance of
CBCT scans or reconstruction of CBCT data and registration
during analysis. Future additional studies are needed to gain
insight on the various conditions affecting surgical templates to
reduce the error of these factors.
Conclusion
Using CBCT scans and planning software, deviation be-
tween the actual and planned implant positions was analyzed

Journal of Prosthodontics 00 (2015) 1–6 

C 2015 by the American College of Prosthodontists 5
Templates for Implant Placement Accuracy
presurgery. The results of this in vitro investigation revealed a
significant deviation caused by the surgical template.
Acknowledgments
The authors want to express their appreciation to Hangzhou 6D
Dental Company for supplying test data and appliances.
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C 2015 by the American College of Prosthodontists