RESEARCH AND EDUCATION

Accuracy and precision of 3D-printed implant surgical guides

with different implant systems: An in vitro study
Matthew Yeung, DDS,a Aous Abdulmajeed, BDS, PhD,b Caroline K. Carrico, PhD,c
George R. Deeb, DDS, MD,d and Sompop Bencharit, DDS, MS, PhDe

ABSTRACT
Statement of problem. Implant guided surgery systems promise implant placement accuracy and precision beyond straightforward nonguided
surgery. Recently introduced in-office stereolithography systems allow clinicians to produce implant surgical guides themselves. However,
different implant designs and osteotomy preparation protocols may produce accuracy and precision differences among the different implant systems.
Purpose. The purpose of this in vitro study was to measure the accuracy and precision of 3 implant systems, Tapered Internal implant system
(BioHorizons) (BH), NobelReplace Conical (Nobel Biocare) (NB), and Tapered Screw-Vent (Zimmer Biomet) (ZB) when in-office fabricated surgical
guides were used.
Material and methods. A cone beam computed tomography (CBCT) data set of an unidentified patient missing a maxillary right central incisor and
intraoral scans of the same patient were used as a model. A software program (3Shape Implant Studio) was used to plan the implant treatment with
the 3 implant systems. Three implant surgical guides were fabricated by using a 3D printer (Form 2), and 30 casts were printed. A total of 10 implants
for each system were placed in the dental casts by using the manufacturer’s recommended guided surgery protocols. After implant placement,
postoperative CBCT images were made. The CBCT cast and implant images were superimposed onto the treatment-planning image. The
implant positions, mesiodistal, labiopalatal, and vertical, as well as implant angulations were measured in the labiolingual and mesiodistal planes.
The displacements from the planning in each dimension were recorded. ANOVA with the Tukey adjusted post hoc pairwise comparisons were
used to examine the accuracy and precision of the 3 implant systems (a=.05).
Results. The overall implant displacements were −0.02 ±0.13 mm mesially (M), 0.07 ±0.14 mm distally (D), 0.43 ±0.57 mm labially (L), and 1.26
±0.80 mm palatally (P); 1.20 ±3.01 mm vertically in the mesiodistal dimension (VMD); 0.69 ±2.03 mm vertically in the labiopalatal dimension
(VLP); 1.69 ±1.02 degrees in mesiodistal angulation (AMD); and 1.56 ±0.92 degrees in labiopalatal angulation (ALP). Statistically significant
differences (ANOVA) were found in M (P=.026), P (P=.001), VMD (P=.009), AMD (P=.001), and ALP (P=.001). ZB showed the most
displacements in the M and vertical dimensions and the least displacements in the P angulation (P<.05), suggesting statistically significant
differences among the M, VMD, VLP, AMD, and ALP. NB had the most M variation. ZB had the least P deviation. NB had the fewest
vertical dimension variations but the most angulation variations.
Conclusions. Dimensional and angulation displacements of guided implant systems by in-office 3D-printed fabrication were within clinically
acceptable limits: <0.1 mm in M-D, 0.5 to 1 mm in L-P, and 1 to 2 degrees in angulation. However, the vertical displacement can be as much as
2 to 3 mm. Different implant guided surgery systems have strengths and weaknesses as revealed in the dimensional and angulation implant
displacements. (J Prosthet Dent 2020;123:821-8)

S.B. is a lecturer for Zimmer Biomet Institute; his research was partly supported by Zimmer Biomet; lectures for Formlabs and 3Shape. BioHorizon, Nobel Biocare, and
Zimmer Biomet provided implant fixtures used for this study. Supported in part through the American Association of Dental Research Student Fellowship and the Virginia
Commonwealth University A.D. Williams Dental Student Research Fellowship (to M.Y. under the supervision of S.B.).
a
Former doctoral student, Department of General Practice, School of Dentistry, Virginia Commonwealth University, Richmond, Va.
b
Assistant Professor and Director of Biomaterials, Department of General Practice, School of Dentistry, Virginia Commonwealth University, Richmond, Va.
c
Assistant Professor, Department of Oral Health Promotion and Community Outreach, School of Dentistry, Virginia Commonwealth University, Richmond, Va; and Assistant
Professor, Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Va.
d
Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond, Va.
e
Associate Professor and Director of Digital Dentistry Technologies, Department of General Practice and Department of Oral & Maxillofacial Surgery, School of Dentistry, Virginia
Commonwealth University, Richmond, Va; and Associate Professor, Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, Va.

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Clinical Implications
Each implant guided surgical system has strengths
and weaknesses that clinicians must learn to
accommodate. In general, limited mesiodistal and
labiopalatal dimensional and angulation
displacements are expected in guided surgery.
However, clinicians should be careful with the
vertical depth of implant placement and should
check the depth of the osteotomy before placing an
implant. Clinicians should recognize the range of
implant deviation upon placement of the system
used; therefore, clinicians should be trained in each
implant system to compensate for these possible
deviations.
The recent introduction of in-office stereolithographic 3D
printers has popularized their clinical applications,
especially for guided implant surgery. Their use has
reduced the cost of surgical guides and provides direct
access for clinicians throughout the workflow, from
intraoral scanning to implant treatment planning, surgi-
cal implant placement, restorative design, and fabrica-
tion.1-3 Guided implant surgery promises improved
placement accuracy and precision compared with con-
ventional nonguided implant surgery.4-13 Moreover,
guided surgery allows conservative flapless surgery and
therefore limits surgical complications.6,14-16
Guided implant surgery has been reported to be more
accurate and precise than conventional surgical guides or
free-hand implant placement.2,9-11,17,18 However, most
of these studies compared only within the same implant
surgical system. Information comparing the precision and
accuracy of different guided implant surgery systems is
lacking.9,10,18 Different drill designs, sizes, protocols, as
well as implant fixture designs may influence the effec-
tiveness of each guided implant system. More impor-
tantly, as clinicians are moving toward in-office implant
guide fabrication for guided surgery, information is
required on how different implant systems may behave
in terms of accuracy and precision when in-office ster-
eolithographic fabrication is used.
The main objectives of this study were to define the
range of dimensional and angulation deviations of
implant placements from the planned implant positions,
referred to as placement accuracy; to define the variables
in the range of implant placement deviations, referred to
as placement precision; and to give clinical recommen-
dations for improving guided implant surgery for 3
commonly used implant systems. The accuracy of implant
placement is most often referred to as the mean implant
deviation, comparing the actual implant placement with
the planned implant position. The precision of implant
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 123 Issue 6
placement is referred to as the variation or variance of
implant deviation.5,6 The research hypothesis was that
each implant-guided system would have its own unique
implant deviations, and therefore, implant dimensional
and angulation deviations would be specific to each sys-
tem. Specifically, the accuracy and the precision would be
different among different implant surgical systems when
in-office 3D printing was used in guide fabrication.
Defining the specific strengths and weaknesses of implant
systems through implant deviations would allow better
clinical recommendations for improving in-office implant
guide fabrication, implant guided surgery, implant pros-
thetic design, and implant treatment outcome.
MATERIAL AND METHODS
Three implant systems were chosen: Tapered Internal
implant system (BioHorizons, BH), NobelReplace
Conical (Nobel Biocare, NB), and Tapered Screw-Vent
(Zimmer Biomet, ZB). A cone beam computed tomog-
raphy (CBCT) data set and intraoral scans obtained from
the implant clinic database of an unidentified patient
missing a maxillary right central incisor were used. The
CBCT scans were obtained by using the following pro-
tocol: i-CAT FLX V10 (Imaging Sciences International
LLC) with standard implant scan parameters (16 cm in
depth, 10 cm in height, 0.3-mm voxel size, 8.9-second
scan time, 3.7-second exposure time, 120 kVP, 5 mA,
and 501.3 mGy/cm2).5 The intraoral scans were made by
using the TRIOS Intraoral Scanner (3Shape A/S). By
using the CBCT and intraoral scans, the implant treat-
ment planning to replace the maxillary right central
incisor was carried out by using the Implant Studio 2017
(3Shape A/S). Three treatment plans were made by using
a BH (4.6×12 mm), NB (4.3×13 mm), or ZB (3.7×13 mm)
implant. The implant positions were approximately the
same in terms of positioning and angulation, but with
slightly differences in implant fixture lengths and widths.
The protocol for fabricating the dental cast and sur-
gical guide is similar to those of previous studies.4,5 The
intraoral scan was imported into a software program
(Dental System v2017; 3Shape A/S), in which the dental
cast and surgical guide were designed.4 The cast was
exported in the standard tessellation language (STL)
format and was used to print 30 dental casts (Form 2;
Formlabs) (Fig. 1). Dental Model resin (Formlabs) was
used to print at a resolution of 0.1 mm, lying flat on the
base without the fabrication of printing supports. The
cast was later used for implant placement. Three implant
surgical guide designs, one for each implant system, were
exported into a software program (PreForm; Formlabs) in
the STL format. The casts were oriented, and appropriate
structural printing supports were designed. The guides
were printed in resin (Dental SG; Formlabs) at a reso-
lution of 0.05 mm.1,4 After the guides had been printed,
Yeung et al
June 2020
Figure 1. Study workflow. CBCT, cone beam computed tomography. *Length of drill refers to depth of osteotomy preparation.
the print supports were removed. The guides were then
rinsed twice in isopropanol and air-dried, and the sur-
gical guide tubes were placed. Finally, the surgical guides
were postprocessed by light-polymerization for 1 hour
and sterilized in an autoclave.1,4,5 For each implant sys-
tem, 10 dental casts and 10 implants were used. The
same surgical guide and implant surgical kit were used
for each system to control the variations of guide fitting
and drills. The implants were placed based on the
manufacturer’s recommendation. All osteotomy sites
were prepared through surgical guides. The osteotomes
were evaluated for depth and width before implant
placement. Then, BH and NB implants were placed
through the surgical guide, while ZB implants were
placed after the removal of the surgical guide. Figure 1
illustrates the workflow used in the study. Post-
operative CBCT scans were made by using a post-
operative scanning protocol similar to that of a previous
study.5
The dimensions and angulations of the implant po-
sition were determined in the mesiodistal and labiopa-
latal planes, similar to previous studies.4,5,7 The distances
between the most cervical part of the planned implant
Yeung et al
823
and the closest adjacent natural tooth root surfaces
mesially and distally were recorded as M and D,
respectively. The distances between the most cervical
part of the planned implant and the outer surface dental
cast labially and palatially were recorded as L and P,
respectively. The vertical distance between the most
cervical part of the implant and the soft tissue in the
mesiodistal and labiopalatal planes was recorded as VMD
and VLP, respectively. The mesiodistal implant angula-
tion in relation to the left maxillary central incisor and the
labiopalatal implant angulation in relation to the palatal
plane of the cast were recorded as AMD and ALP,
respectively, (Fig. 2).
Similar to the preoperative measurement, the post-
operative positions of the placed implants were measured
by using a previous published protocol.4,5,7 The post-
operative CBCT scans were superimposed onto the plan-
ned implant position. The implant positions, mesiodistally,
labiopalatally, and vertically, as well as the implant angu-
lations in the labiopalatal and mesiodistal planes were
measured and compared with the planned positions. The
differences between the planned and placed implant po-
sitions in each dimension and at each angulation were
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Figure 2. Measurements for planned and placed implant positions. A, Measurements for BH. B, Measurements for NB. C, Measurements for ZB.
BH, BioHorizons; NB, Nobel Biocare; ZB, Zimmer Biomet.
recorded. Accuracy of implant placement refers to the
mean implant placement deviations. To examine the dif-
ferences in the accuracy among the implant systems,
ANOVA (a=.05) was used. In the cases of unequal vari-
ance, the Welch ANOVA was used. If a statistically sig-
nificant difference was found based on ANOVA, post hoc
pairwise comparisons were used to compare the differ-
ences in accuracy of each pair of implant systems. All post
hoc pairwise comparisons were performed by using the
Tukey adjusted P values to account for multiple compari-
sons. To examine the precision of each implant system, the
Levene test for differences in variance was used to examine
a pair of implant systems in each dimension and at each
angulation.
RESULTS
The overall implant displacements were −0.02 ±0.13
mm mesially (M), 0.07 ±0.14 mm distally (D), 0.43
±0.57 mm labially (L), and 1.26 ±0.80 mm palatally (P);
1.20 ±3.01 mm vertically in the mesiodistal dimension
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Volume 123 Issue 6
(VMD); 0.69 ±2.03 mm vertically in the labiopalatal
dimension (VLP); 1.69 ±1.02 degrees in mesiodistal
angulation (AMD); and 1.56 ±0.92 degrees in labio-
palatal angulation (ALP). Table 1 demonstrates the
mean, standard deviation, range, minimum (Min), Q1
(first quartile), Q3 (third quartile), and maximum (Max)
values for each implant system, as well as the P values.
Figure 3 demonstrates the box plots of each dimension
and angulation deviation overall and for each implant
system.
In terms of accuracy, referring to the deviations from
the planned implant position, there were statistically
significant differences (ANOVA) in M (P=.026), P
(P<.001), VMD (P<.001), AMD (P<.001), and ALP
(P<.001). In the M dimension, ZB showed the most
displacements, while no statistically significant differ-
ences were found in NB and BH. In the vertical dis-
placements (VMD and VLP), ZB showed statistically
higher displacements than NB and BH. In the angulation
displacements, ZB showed the fewest displacements in P
(0.56 ±0.57 mm), AMD (0.83 ±0.28 mm), and ALP (0.77
Yeung et al
June 2020 825

Table 1. Implant placement deviations and statistical analyses

Tukey Adjusted Post Hoc Pairwise
Comparisons, P*
Dimension (mm)/Angulation ( ) Implant System Mean SD Range Min Max ANOVA (P)* BH-NB BH-ZB NB-ZB
M BH 0.06 0.09 0.30 -0.12 0.18 .026 t test .210 .021 .503
NB -0.03 0.18 0.54 -0.29 0.25
ZB -0.09 0.06 0.18 -0.16 0.02
D BH 0.05 0.16 0.49 -0.18 0.31 .663 t test N/A N/A N/A
NB 0.10 0.12 0.37 -0.12 0.25
ZB 0.05 0.14 0.42 -0.20 0.22
L BH 0.37 0.50 1.52 -0.49 1.03 .076 t test N/A N/A N/A
NB 0.74 0.68 1.90 -0.23 1.67
ZB 0.18 0.39 1.28 -0.45 0.83
P BH 1.62 0.47 1.37 0.76 2.13 .001 t test .462 <.001 .003
NB 1.59 0.85 1.85 0.47 2.32
ZB 0.56 0.57 1.70 -0.40 1.30
VMD BH -0.21 3.93 12.60 -8.48 4.12 .009 t test .339 .01 <.001
NB 0.35 1.34 4.48 -2.55 1.93
ZB 3.46 1.83 5.80 -0.51 5.29
VLP BH -0.12 2.18 7.46 -4.69 2.77 .258 t test N/A N/A N/A
NB 0.81 1.10 4.17 -0.87 3.30
ZB 1.38 2.46 7.00 -2.28 4.72
AMD BH 1.84 0.34 1.07 1.42 2.49 .001 t test .116 <.001 .003
NB 2.39 1.33 3.21 0.61 3.82
ZB 0.83 0.28 0.86 0.42 1.28
ALP BH 1.86 0.33 1.03 1.45 2.48 .001 t test .324 <.001 .005
NB 2.05 1.22 3.16 0.55 3.71
ZB 0.77 0.26 0.71 0.48 1.19
*Statistically significant P values shown in bold.

±0.26 mm), with statistically significant difference (See P
values in Table 1).
In terms of precision, referring to the consistency of
displacement or the least variation in deviations, the
Levene tests for differences in variance (a=.05) suggested
statistically significant differences in the M, P, VMD,
VLP, AMD, and ALP. ZB and BH had statistically fewer
variations in M than NB. ZB had statistically fewer vari-
ations in the P deviation than BH and NB. NB and ZB
had statistically fewer variations in VMD. NB had sta-
tistically significantly fewer variations than BH and ZB in
VLP. NB, however, had statistically more variations in the
angulations (AMD and ALP).
DISCUSSION
The results support the research hypothesis that when an
in-office stereolithographic fabricated guide is used, each
implant guided surgery system has unique strengths and
weaknesses. Overall, guided implant surgery performed
by using in-office 3D-printed guides has a similar range
of accuracy and precision as previous studies.4,5 Note that
the vertical depth of placement in this study could induce
an error of approximately 3 mm or more in some sys-
tems. The M dimension has the highest accuracy,
approximately 0.1 mm in BH and ZB and approximately
0.2 mm in NB. The D dimension also has similar
accuracy, approximately 0.1 to 0.3 mm. While there was a
statistically significant difference in M displacement
among the 3 implant systems, the displacement values
were in the range of those of other studies and likely to
have little clinical significance.4,5,13 In the L dimension,
all implants displaced slightly labially, reflecting a clinical
situation of limited labial or buccal bone. Clinicians
should pay attention to this trend of labial or buccal
displacement when performing flapless surgery.
Angulation of the drill and other techniques such as
bone tapping have been suggested to limit labial or buccal
directional and angulation displacements.19-22 The ZB
system showed the least P displacement. This may be
related to the way the implant was placed and the size of
the implant fixture and threads. With the BH and NB
systems, the implant fixtures were placed through the
guide, making it more difficult to lean on the palatal bone
and keep the implant fixture palatally. In addition, the sizes
of the NB fixture and threads were much larger than the
osteotomy sites. In the ZB situation, after the osteotomy
site had been completely prepared (through the surgical
guide), the implant fixture was placed without the guide,
and clinicians could then direct the fixture against the
palatal bone. Therefore, clinicians should pay particular
attention to placement of the implant when fully guided
surgery is performed and try to keep the implant fixture
engaged with the palatal bone or perform bone tapping.4,23

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826 Volume 123 Issue 6

0.

0. 0.

0. 0.
mm

0 0.

mm
–0. 0

–0. –0.

–0. –0.
Overall BioHorizon Nobel Zimmer Overall BioHorizon Nobel Zimmer
M A D B

2 2

1. 1.5

1 1

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mm

0. 0.5

0 0

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Overall BioHorizon Nobel Zimmer Overall BioHorizon Nobel Zimmer
L C P D
10 6

4
5
2
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mm

0 0

–2
–5
–4

–10 –6
Overall BioHorizon Nobel Zimmer Overall BioHorizon Nobel Zimmer
VMD E VLP F
4
4

3
3
Degree
Degree

2
2

1 1

0 0
Overall BioHorizon Nobel Zimmer Overall BioHorizon Nobel Zimmer
AMD G ALP H
Figure 3. Box plots for dimensional and angulation implant deviations showing first and third quartile box plots and maximal and minimal values. A, M.
B, D. C, L. D, P. E, VMD. F, VLP. G, AMD. H, ALP. ALP, angulation in labiopalatal dimension; AMD, angulation in mesiodistal direction; D, distal; L, labial;
M, mesial; P, palatal; VLP, vertical in labiopalatal dimension; VMD, vertical in mesiodistal direction.

THE JOURNAL OF PROSTHETIC DENTISTRY Yeung et al

June 2020
While ZB performs well in most dimensions
compared with other systems, the partially guided pro-
tocol, preparing for an osteotomy with the surgical guide
but placing the implant without the surgical guide, leads
to a lack of vertical control, and, therefore, the ZB implant
displacement can be more than 3 mm. While the
manufacturer recommends placing the implant without
the guide, a previous study suggests fully guiding ZB
implants through the guide to provide better vertical
accuracy clinically.5 In terms of angulation deviation, ZB
systems demonstrated the least angulation deviation,
which may be a result of less deviation from thin labial
bone and angulation at placement similar to that of the P
displacement. However, the overall angulation deviations
of all 3 systems were consistent with those of previous
studies.4,5
In terms of precision, NB appeared to have the
highest variability, which may be the result of the vertical
stopper used in the guide system and the larger size of
the implant fixture and threads than the osteotomy site.
While BH and ZB osteotomy preparations are performed
by using the entire drill length, the NB system uses a
stopper that may result in less precision.
This in vitro study has limitations similar to those of
previous work.4 First, the fitting of the guide and dental
casts may not be the same as in the patient’s mouth.
Clinically, there may be some minor movements of nat-
ural teeth and soft tissue. However, previous in vitro and
in vivo studies4,5 demonstrated that the range of implant
deviations in resin 3D-printed models4 was similar to that
in humans.5 Second, the nature of drill deviations when
drilling through a homogenous polymethyl methacrylate
may be different from that when drilling through non-
homogenous alveolar bone. Third, the dental casts used
in this study did not have soft tissue. Thus, some de-
viations of the implant fixture may occur as a result of lack
of soft tissue in the cervical portion of the implant fixture.
Finally, the implant systems chosen were of different
widths and lengths, and direct comparison of these im-
plants may not reflect a side-by-side comparison but only
a general overview of the system. The influence of
different drills used in guided surgery may be observed
when performing trephination-based implant guided
surgery which can standardize the initial osteotomy site,
except for the final implant drill that is specific to each
implant system.24 In addition to these limitations, the
deviations themselves were assumed to be independent
and were all analyzed individually. There may be inherent
correlations among the deviations that were not consid-
ered in this analysis. Future studies should include anal-
ysis of implant deviations in humans with different
locations in the mouth, different types of bone, as well as
different implant systemespecific deviations when a uni-
versal implant guided system such as trephination-based
implant guided surgery is used.
Yeung et al
827
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. When guide fabrication is performed in office by
using a desktop stereolithographic printer, clinicians
should recognize the limitations of the guide, such
as the guide fit and depth of placement.
2. When performing fully or partially guided surgery,
clinicians need to be aware of potential vertical and
palatal displacements.
3. When a long drill is used with a surgical stopper,
clinicians should recognize that the implant place-
ment may have less precision and that the fit of all
surgical components is essential during osteotomy
preparation.
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Corresponding author:
Dr Sompop Bencharit
Department of General Practice
School of Dentistry
Virginia Commonwealth University
520 N 12th Street, Richmond, VA 23298-0566
Email: sbencharit@vcu.edu
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.05.027
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