Int. J. Oral Maxillofac. Surg.

2023; 52: 264–271

https://doi.org/10.1016/j.ijom.2022.05.009, available online at https://www.sciencedirect.com

Clinical Paper
Dental Implants

S. Jaemsuwan a, S. Arunjaroensuk a,
Comparison of the accuracy of B. Kaboosaya a, K. Subbalekha a,
N. Mattheos b, A. Pimkhaokham a

implant position among freehand a

Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Chulalongkorn

implant placement, static and University, Patumwan, Bangkok, Thailand;

b
Department of Dental Medicine, Karolinska
Institute, Stockholm, Sweden

dynamic computer-assisted
implant surgery in fully
edentulous patients: a non-
randomized prospective study
S. Jaemsuwan, S. Arunjaroensuk, B. Kaboosaya, K. Subbalekha, N. Mattheos, A.
Pimkhaokham: Comparison of the accuracy of implant position among freehand
implant placement, static and dynamic computer-assisted implant surgery in fully
edentulous patients: a non-randomized prospective study. Int. J. Oral Maxillofac.
Surg. 2023; 52: 264–271. © 2022 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Abstract. The optimal implant position is a critical factor for long-term success in
fully edentulous patients. Implants can be placed through conventional freehand,
static computer-assisted implant surgery (CAIS), or dynamic CAIS protocols, but at
present there is very limited clinical evidence on their accuracy in fully edentulous
patients. This study was performed to evaluate the accuracy of implant placement
using three protocols in fully edentulous patients. Thirteen patients received 60
implants with the freehand (n = 20), static CAIS (n = 20), or dynamic CAIS (n = 20)
protocol. Postoperative cone beam computed tomography was utilized to evaluate
the accuracy of implant placement in relation to the planned optimal position. The Keywords: Dental implant; Computer-assisted
data were analysed by ANCOVA followed by Bonferroni analysis. The mean surgery; Surgical navigation; Edentulous jaw;
angular deviation (standard deviation) in the freehand, static CAIS, and dynamic Dimensional measurement accuracy.
CAIS groups was 10.09° (4.64°), 4.98° (2.16°), and 5.75° (2.09°), respectively. The Abbreviations: CAIS; computer-assisted im-
mean three-dimensional deviation (standard deviation) at the implant platform in plant surgery; CBCT; cone beam computed
tomography; DICOM; digital imaging and
the freehand, static CAIS, and dynamic CAIS groups was 3.48 (2.00) mm, 1.40
communications in medicine; ANCOVA; ana-
(0.72) mm, and 1.73 (0.43) mm, while at the implant apex it was 3.60 (2.11) mm, 1.66 lysis of covariance.
(0.61) mm, and 1.86 (0.82) mm, respectively. No difference in terms of accuracy was
found between static and dynamic CAIS; both demonstrated significantly higher Accepted for publication 25 May 2022
accuracy when compared to the freehand protocol in fully edentulous patients. Available online 23 June 2022

0901-5027/520264 + 8 © 2022 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

The placement of multiple implants in
fully edentulous patients presents a
significant challenge for the oral sur-
geon. Tooth loss can result in resorp-
tion of the alveolar ridge, uneven
changes in the patient’s anatomical
structures, and a distortion or lack of
local anatomical reference points,
challenging the ability of the surgeon to
achieve the optimal implant position.1
Thus computer-assisted implant sur-
gery (CAIS) has been proposed for the
planning and placement of implants in
the optimal position.
CAIS systems can be divided into
static and dynamic, based on the tech-
nology and protocols utilized.2,3 Static
CAIS utilizes stereolithographic sur-
gical templates combined with guided
surgery surgical kits, while dynamic
CAIS employs optical tracking tech-
nology to allow the freehand placement
of implants with virtual real-time gui-
dance. In the case where a digital
workflow is not utilized during the
surgical placement but only during the
planning of the implant position, the
implants are placed freehand and the
surgeon uses anatomical landmarks or
measurements to identify the pre-
determined position. Such a protocol is
often mentioned in the literature as
‘freehand’, ‘mental navigation’, or ‘di-
gitally planned–conventionally placed’
implant surgery.4–7 At this point one
has to note that dynamic CAIS would
also qualify as ‘freehand’ implant pla-
cement, as it is not restricted by any
intraoral guidance. However, in con-
trast to conventional freehand place-
ment where the surgeon only uses
anatomical landmarks to determine the
implant position, in dynamic CAIS the
surgeon benefits from real-time feed-
back through a computer screen.
Studies comparing the accuracy of
different CAIS systems have reported
the highest accuracy in patients with
single missing tooth sites, followed by
partially edentulous and lastly fully
edentulous patients.6–10 Unsurprisingly,
Table 1. Inclusion and exclusion criteria for studyenrolment.
Inclusion criteria
• Fully edentulous arch
• Requiring at least two implants for restoration
• Adequate bone volume for primary implant placement
• Mouth opening of at least 30 mm
• Anatomically suitable for all three protocols:
(a) Freehand implant placement
(b) Static CAIS
(c) Dynamic CAIS
• Having an interim denture for the planning process
Accuracy of implant position with three protocols
the fully edentulous group presents with
the least accurate implant positions. The
anatomy might be a challenge for non-
guided freehand placement due to the
absence of reproducible reference points.
Challenges also exist for CAIS systems,
as the absence of teeth might complicate
the stabilization of the surgical guide and
reduce the precision of digital diagnostic
procedures such as intraoral scanning.
Although studies have reported the
accuracy of implant position with in-
dividual CAIS systems in edentulous
patients,11,12 there is a lack of com-
parative studies where different CAIS
and freehand placement protocols have
been compared within an identical
process and surgical setup. With the
increasing application of immediate
protocols in fully edentulous patients,
the accuracy of implant placement can
become a determining factor of success.
The aim of this non-randomized
prospective study was to investigate the
accuracy of implant position when
using conventional freehand, static
CAIS, and dynamic CAIS protocols for
the placement of implants in fully
edentulous patients.
Materials and methods
This non-randomized prospective study
was approved by the Human Research
Ethics Committee of the Faculty of
Dentistry Chulalongkorn University
(HREC-DCU 2018–083) and is regis-
tered in the Thai Clinical Trials Registry
database (TCTR20190125002).
Patients
Fully edentulous patients presenting to
the Department of Oral and
Maxillofacial Surgery, Faculty of
Dentistry, Chulalongkorn University
between June 2017 and April 2020 for
implant rehabilitation, who fulfilled the
eligibility criteria listed in Table 1, were
invited to participate in the study.
Exclusion criteria
• Systemic condition that might impair osseointegration
• Existing clinical or radiographic pathology in the jaw bone
• Refusal to sign a consent form
265
The sample size estimation was con-
ducted based on the mean deviations
reported by Vercruyssen et al.,6 who re-
ported both freehand and static CAIS
groups, and Block et al.,10 who reported
freehand and fully guided dynamic
CAIS groups; these studies measured
three-dimensional (3D) deviation, which
was also performed in the present study.
The mean implant deviation (standard
deviation (SD)) in the freehand, static
CAIS, and dynamic CAIS groups was
2.06 (1.64) mm, 0.63 (0.54) mm, and 0.82
(0.52) mm, respectively. A significance
level (α) of 0.05 and power (1 − β) of
0.95 were used for the calculation of the
sample size in G*Power software (ver-
sion 3.1.9.2; Heinrich-Heine-Universität
Düsseldorf, Germany). The required
number of implants per group was de-
termined to be 14.
Waitlisted edentulous patients who
fulfilled the eligibility criteria were ex-
amined sequentially and allocated to one
of three cohorts: freehand, static CAIS,
and dynamic CAIS. The aim was to
reach a number of 20 implants in each
cohort, for analysis of deviation at the
implant level. Patients were allocated to
the treatment protocol sequentially after
enrolment, with the aim of ensuring an
equal number of implants in each group,
as the analysis of accuracy was to be
conducted at the implant level. Therefore,
for this allocation, the number of im-
plants each patient required was the pri-
mary consideration, while patient and
clinician preferences were not requested,
registered, or considered.
For patients with well-fitting den-
tures, these were duplicated and used
for planning in the freehand and CAIS
groups. If dentures were ill-fitting or
not suitable for use, new ones were
made prior to planning.
Cone beam computed tomography
scanning process
Preoperative and postoperative cone
beam computed tomography (CBCT)
266 Jaemsuwan et al.
Fig. 1. The digital workflow in each group.
data were acquired in Digital Imaging
and Communications in Medicine
(DICOM) format by means of a 3D
Accuitomo 170 scanner (J. Morita Inc.,
Kyoto, Japan) under the supervision of
one experienced oral radiologist. The
machine was set at 5 mA, 90 kV,
0.25 × 0.25 × 0.25 mm voxel size, and
10 × 10 cm field of view.
For the patients in the freehand and
static CAIS groups, well-fitting dupli-
cate dentures were seated on the bare
edentulous ridge in the freehand group
and on mini implants in the static CAIS
group, with gutta-percha markers, to
assist in planning the implant location
and to verify the prosthetic restoration
by dual scan technique in
coDiagnostiX software (Dental Wings,
Montreal, Canada); this protocol has
been published previously.5
For the patients in the dynamic
CAIS group, the duplicate denture
(with the gutta-percha markers) was
attached to the alveolar ridge through
an occlusal guide appliance (fiducial
markers, Implant Real-time Imaging
System IRIS 100; EPED Inc.,
Kaohsiung City, Taiwan), which had to
be fixed on mini implants (S-mini ball
type; Neobiotech, Seoul, South Korea)
in the jaw during the CBCT scanning
process. This was used as the registra-
tion stent, containing four radiopaque
fiducial markers.
Implant planning process
An experienced prosthodontist planned
the prosthetic restoration for all pa-
tients. The implant position was
planned during the digital workflow
(Fig. 1) by one experienced operator,
following the guidelines set by Buser
et al.13 The Straumann implant system
(Institut Straumann AG, Basel, Swit-
zerland) was selected from the implant
libraries of each software for the pur-
pose of virtual planning. Implants of
the appropriate type and size were
chosen and placed in positions corre-
sponding to the prosthetic plan, the
bone morphology, and anatomical
limitations in the multiplanar re-
construction image.
Freehand and static CAIS groups
For the freehand and static CAIS
groups, the preoperative DICOM files
were imported into implant planning
software coDiagnostiX version 9.7
(Dental Wings). The DICOM files from
CBCT were converted into 3D images
to show the detail necessary to locate
the implant positions. In addition, ex-
traoral scanning of stone cast models
(D900L scanner; 3Shape, Copenhagen,
Denmark) was performed to generate
stereolithography (STL) files. The files
were transferred into the planning
software, representing the soft tissue of
the edentulous ridges. These STL files
were merged with the DICOM files to
achieve accurate virtual planning and
to generate the digital drilling guides,
which were then printed to produce the
surgical guides for the static CAIS
group. For the freehand group, a vir-
tual image was used during the surgery
in order to place the implants con-
ventionally.
Dynamic CAIS group
For the dynamic CAIS group, the pre-
operative DICOM files were imported
into the implant planning software
IRIS 100 (EPED Inc.), which was also
utilized for real-time navigation in the
implant bed preparation and implant
insertion.
Surgical protocol
All surgeries were performed under local
anaesthesia in the clinic of the
Department of Oral and Maxillofacial
Surgery. All 60 implants were placed by
one oral and maxillofacial surgeon who
has experience of more than 100 sur-
geries with each of the freehand, static
CAIS, and dynamic CAIS protocols.
Implant placement was conducted after
raising a full thickness mucoperiosteal
flap in all cases.
Freehand group
The 3D virtual image of the planned
implant positions was reviewed prior to
surgery. All implant osteotomies were
positioned based on the surgeon’s inter-
pretation of the anatomical landmarks
and intraoperative measurements corre-
sponding to the virtual plan. The osteo-
tomies were prepared and the implants
were placed using the freehand method.
Static CAIS
Three mini implants (S-mini ball type;
Neobiotech) were placed on each eden-
tulous arch prior to the surgery. The 3D-
printed surgical guide that was created
from the denture scan (soft tissue-sup-
ported template) was placed on the mini
implants and its position was verified by
means of a bite index taken from the
denture occlusion. Upon verification of
the correct position, three holes were
drilled in the alveolar ridge indicating the
positions of three fixative pins. After the
full thickness mucoperiosteal flap was
raised, the guide was fixed into the bone
with the fixative pins, using the three
drilled holes as reference points. The
Straumann Guided Surgery system was
used to drill the surgical sites and install
the implants with a fully guided protocol.

Dynamic CAIS
As in the static CAIS group, three mini
implants (S-mini ball type; Neobiotech)
were placed on each edentulous arch
serving as reference points, and the re-
gistration stent was fixed on the mini
implants during the registration pro-
cess. An infrared tracking camera was
set to detect the movement of the hand-
piece and registration stent (sensors)
and to verify the hand-piece and drill
orientation. The fiducial markers were
used to identify the position of the pa-
tient during the registration process,
corresponding to the preoperative
DICOM files. After the registration
process was completed, the positioning
of the osteotomies, preparation of the
implant beds, and implant placement
were conducted by means of real-time
navigation. The navigation screen dis-
played in real time the chosen virtual
drills projected on the anatomy as dis-
played in the CBCT, providing in-
formation about the relative position
and angle of the drills in relation to the
optimal planned position. The surgeon
placed all implants under the guidance
of the navigation system.
Postoperative care and scanning
Postoperative instructions were given
to the patients. Antibiotics (amoxicillin
1 g twice a day for 5 days) and analgesic
drugs (mefenamic acid 500 mg three
times a day for 5 days) were prescribed.
All postoperative CBCT scans were
taken 1 week after surgery, with the
same settings as the preoperative ones.
Furthermore, in the dynamic CAIS
Table 2. Demographic and clinical characteristics of the study patients.
Freehand group
Patients 6 4
Implants 20
Sex
Male 3 3
Female 3 1
Implant diameter
3.3 mm 1 0
4.1 mm 18
4.8 mm 1 6
Implant length
≤10 mm 17
>10 mm 3 5
Jaw
Maxilla 10
Mandible 10
Position
Anterior 12
Posterior 8 8
CAIS, computer-assisted implant surgery.
Accuracy of implant position with three protocols
group, the registration stent was fixed
accurately in the same position.
Data collection
The deviation of the placed implant
position from the planned position was
determined by superimposition of the
preoperative CBCT scan with the vir-
tual plan and the postoperative CBCT
scan. The postoperative DICOM files
were transferred to the corresponding
planning software of each group. For
the freehand and static CAIS groups,
the data were measured in
coDiagnostiX software version 9.7
(Dental Wings) using surface-based re-
gistration. In the dynamic CAIS group,
the data were measured in IRIS 100
software (EPED Inc.) using marker-
based registration.
The postoperative CBCT scan was
converted into 3D images to show the
actual implant position. The virtually
placed implant was superimposed ac-
curately on the actual implant image in
order to give software recognition of
the placed implant position. The de-
viation between the placed and planned
implant was calculated automatically
by the planning software. The deviation
in the implant position was described as
follows: (1) 3D deviation at the implant
platform, defined as the linear dis-
placement between the planned and
placed implant (in millimetres) as
measured at the centre of the implant
platform; (2) 3D deviation at the im-
plant apex, defined as the linear dis-
placement between the planned and
placed implant (in millimetres) as
measured at the centre of the implant
Static CAIS group
20
14
15
8 12
12
12
267
apex; (3) deviation of the implant axis,
defined as the deviation in degrees (°)
between the planned and placed im-
plant axis line; (4) parallelism, defined
as the angular deviation between two
implants that were planned to be par-
allel. Due to the complex anatomy and
variations in the alveolar ridge mor-
phology, parallelism of all implants is
not possible or possibly even desired.
Instead, when the anatomy and pros-
thetic planning allowed for a pair of
implants to be planned for placement in
parallel, this was marked and the par-
allelism of these specific pairs was
controlled after placement, as described
by Yimarj et al.14
Statistical analysis
IBM SPSS Statistics version 22 (IBM
Corp., Armonk, NY, USA) was used
for the statistical analysis, with a 95%
level of confidence. A P-value less than
0.05 was considered statistically sig-
nificant. The implant deviation among
the three systems was analysed by
analysis of covariance (ANCOVA)
followed by Bonferroni post-hoc ana-
lysis, where the covariate is the inter-
dependence of the sample due to
implants clustered within a participant.
Results
A total of 60 implants placed in 13
patients were included in the analysis.
The mean age (SD) of the patients was
66 (6.73) years (range 51–75 years). The
distribution of the implants among the
three cohorts can be seen in Table 2.
Dynamic CAIS group
3
20
3
0
3
11
6
14
6
8
9
11
268 Jaemsuwan et al.
Table 3. Comparison of the angular deviation, 3D deviation at the platform, and 3D deviation at the apex among the three systems.
Groups
Deviation Freehand
Mean (SD) (n = 20)
A B
Angular deviation 10.09 (4.64)
A B
3D deviation at 3.48 (2.00)
platform
3D deviation at apex 3.60 (2.11)A
ANCOVA, analysis of covariance; 3D, three-dimensional; CI, confidence interval; SD, standard deviation.
The same superscripted uppercase letter indicates no statistically significant difference between the groups, analysed by ANCOVA
followed by Bonferroni post-hoc analysis (P > 0.05).
The mean angular deviation (SD)
between planned and placed implants
in the freehand, static CAIS, and dy-
namic CAIS groups was 10.09° (4.64°),
4.98° (2.16°), and 5.75° (2.09°), respec-
tively. In the freehand group, the mean
3D deviation (SD) at the implant plat-
form and apex was 3.48 (2.00) mm and
3.60 (2.11) mm, respectively. The mean
3D deviation (SD) at the implant plat-
form and apex in the static CAIS group
was 1.40 (0.72) mm and 1.66 (0.61) mm,
while in the dynamic CAIS group it was
1.73 (0.43) mm and 1.86 (0.82) mm,
respectively (Table 3).
After adjustment for the inter-
dependence of the sample using
ANCOVA, there were statistically sig-
nificant differences in mean angular
deviation (F(2,56) = 10.156,
P < 0.001), mean 3D deviation at the
platform (F(2,56) = 8.567, P = 0.001),
and mean 3D deviation at the apex (F
(2,56) = 6.289, P = 0.003) between the
groups. Bonferroni post-hoc analyses
were performed and confirmed statisti-
cally significant differences in angular
deviation, 3D deviation at the implant
platform, and 3D deviation at the im-
plant apex between the freehand and
static CAIS groups (P < 0.001,
P = 0.001, and P = 0.004, respectively)
and between the freehand and dynamic
CAIS groups (P = 0.001, P = 0.004, and
P = 0.011, respectively). No statistically
significant difference was found be-
tween the static CAIS and dynamic
CAIS groups.
Six implant pairs in each of the
freehand group (four patients) and
static CAIS group (two patients), and
four implant pairs in the dynamic CAIS
group (two patients) were planned for
parallel placement and thus were se-
lected for the assessment of parallelism
after placement. The mean angular de-
viation (SD) between the two parallel
planned implants was 4.43° (1.71°),
2.53° (1.67°), and 5.34° (4.12°),
Mean difference (95% CI) P-value
Static Dynamic
(n = 20) (n = 20) Freehand vs static
B
4.98 (2.16) 5.75 (2.09) 5.32 (2.29, 8.36)
P < 0.001
B
1.40 (0.72) 1.73 (0.43) 1.93 (0.74, 3.11)
P = 0.001
1.66 (0.61)B 1.86 (0.82)B 1.74 (0.46, 3.02)
P = 0.004
respectively, with no statistically sig-
nificant difference between the groups.
Discussion
The results of this study demonstrated
a higher implant deviation in edentu-
lous patients when compared to the
deviation reported previously for single
tooth7–9 and partially edentulous
spaces.14 Nevertheless, the implant po-
sition in the static and dynamic CAIS
groups demonstrated greater accuracy
than that in the freehand group. The
outcomes of this study showed greater
deviation than has been reported in
previous in vitro and cadaver stu-
dies,15–19 which might be indicative of
how the clinical condition can affect
accuracy.20,21 The clinical results,
however, remain well within the range
of acceptable deviation,11 and the out-
comes in both CAIS groups, which did
not differ significantly from each other,
were significantly superior to the out-
comes in the freehand implant place-
ment group.
Precision with freehand implant pla-
cement or non-guided freehand place-
ment relies on the experience of the
surgeon for identifying and achieving
the planned position of the implant.
According to Block et al.,10 dynamic
CAIS systems might require a ‘learning
curve’ for the oral surgeon in order to
achieve increased accuracy, while Va-
lente et al.22 mentioned that human
error has a limited role in static CAIS
systems. In this study, all surgeries were
performed by a single specialist op-
erator, who has long experience in
freehand implant placement protocols,
but also has accumulated significant
experience (more than 100 cases) with
both static and dynamic CAIS. Hence
the influence of surgeon experience on
the results was expected to be minimal,
but one could anticipate deviations in
Freehand vs dynamic Static vs dynamic
4.54 (1.56, 7.53) − 0.78 (−3.30, 1.73)
P = 0.001 P = 1.000
1.60 (0.43, 2.77) − 0.33 (−1.31, 0.65)
P = 0.004 P = 1.000
1.56 (0.29, 2.82) − 0.19 (−1.25, 0.87)
P = 0.011 P = 1.000
the case of freehand and CAIS surgery
being performed by less experienced or
multiple operators.
Some studies have used the freehand
protocol as the control for full arch
implant placement, but very few clinical
studies have compared a freehand
group with dynamic and static CAIS
systems in the fully edentulous condi-
tion. Vercruyssen et al.6 compared the
implant position between freehand
(mental navigation) and static CAIS
groups in 60 fully edentulous patients,
reporting the highest deviation in the
vertical direction (depth) in the static
CAIS group, while the freehand group
showed larger deviations for all ob-
served variables. However, they per-
formed a two-dimensional analysis of
the variables, hence the results are not
directly comparable with those of the
3D analysis in the present study.
Smitkarn et al.7 showed superior ac-
curacy with static CAIS compared to
the freehand group (mental CAIS) for
implant placement in a single tooth
space. Similarly, Aydemir and Arisan,23
in a split-mouth randomized controlled
trial, showed less linear deviation in the
dynamic CAIS group when compared
to the freehand group for single im-
plant placement in the posterior max-
illa. In the present study with fully
edentulous patients, the deviations were
shown to be higher in all aspects when
compared with the above single-im-
plant studies.
Static CAIS systems have been as-
sessed in previous clinical studies on
edentulous patients.11,12,20,24–27 Some
clinical studies have shown somewhat
larger 3D deviations at the implant
platform and apex as compared to the
present study,24,25,27 others have shown
comparable results,12,20 while Ver-
hamme et al.26 reported smaller devia-
tions than in this study. In a systematic
review of static CAIS in fully edentu-
lous patients, Marliere et al.11 reported

mean 3D deviation of the implant
platform, apex, and angle to be in the
range of 0.17–2.17 mm, 0.77–2.86 mm,
and 1.85–8.4°, respectively, with the
results of the present study falling
within these ranges.11
There is no available clinical study so
far that has performed a 3D assessment
to investigate the accuracy of dynamic
CAIS systems in fully edentulous pa-
tients. One in vitro study investigating
the accuracy of guided implant place-
ment using a dynamic CAIS system in a
fully edentulous model, found devia-
tions somewhat smaller than those ob-
served in the present clinical study.19
Mini implants were used in all pa-
tients in the dynamic and static CAIS
groups for consistency, although this
might not be essentially a standard
procedure. The mini implants are in-
dicated in static surgery to support the
surgical guide. Likewise, in the dynamic
group, mini implants were used in order
to facilitate the pre- and postoperative
CBCT scanning, planning, registration,
and navigation process. The systematic
review of Tahmaseb et al.2 also stated
that the accuracy of mini implant-sup-
ported guides was higher than that of
other types of support. Mucosa-sup-
ported guides could be displaced by
swelling of the soft tissue due to an-
aesthesia injections,28 or by resilience of
the mucosa, which might lead to in-
accuracies in the final implant posi-
tion.20,29 Such indications did not exist
in the freehand group, although the
placement of mini implants in these
patients might have facilitated accuracy
by serving as reference points. The
placement of mini implants in conven-
tional freehand protocols for the pur-
pose of serving as reference points is
neither recommended nor practiced at
present. Therefore, although the place-
ment of mini implants in the freehand
group could potentially have improved
the comparative nature of the study in
terms of accuracy, it would have de-
creased the relevance to currently
practiced protocols and might even
have introduced ethical problems.
In the present study, the selection of
the protocol was mainly directed by the
need to ensure an equal number of
implants in each group, in order to
serve the analysis for accuracy, which
was conducted at the implant level.
Thus, after fulfilling the inclusion cri-
terion of suitability for all three
Accuracy of implant position with three protocols
protocols, the main determinant was
the number of implants each patient
required. In clinical terms, however,
factors other than the accuracy of im-
plant position could also influence the
decision between the three protocols,
such as anatomical limitations, mouth
opening and access for surgical instru-
ments and drills, and patient conditions
such as pharyngeal reflex. Furthermore,
the ability to modify the osteotomy or
implant position during the surgery, as
is possible in freehand and navigation
surgery, might be an important de-
terminant aside from accuracy, espe-
cially in cases with a complex surgical
anatomy or unexpected conditions.
Bone density and mucosal thickness
can influence the accuracy of implant
placement.30 In the present study all
patients were deemed to be suitable for
all three protocols prior to enrolment,
so as to reduce any bias in the cohort
allocation as much as possible.
Cost-effectiveness might be another
important determinant. However this
encompasses many parameters, as each
protocol has different initial investment
costs and consumables. The learning
curve, duration of the procedures,
maintenance/upgrade costs, and even
patient experience would need to be
accounted for in order to better un-
derstand cost-effectiveness implica-
tions. Although the patients were not
charged any differently for static and
dynamic CAIS in this study, in market
terms the freehand implant placement
would have been the most affordable,
followed by static CAIS and dynamic
CAIS. Although no analysis was at-
tempted for the duration of the surgery,
freehand implant surgeries were in
general shorter, as the two CAIS sys-
tems utilized more time-consuming de-
vices such as fixed surgical guides and
tracking devices. At this point again,
the experience of the surgeon with each
protocol might have a significant
impact.
The results of this study should be
interpreted under the limitations of the
sample size, patient allocation, and
protocol. The analysis of accuracy was
conducted at the implant level, as in
previous studies,23 and thus a sample
with equal numbers of implants in each
cohort was pursued. This way a rela-
tively large number of implants were
analysed in three equal cohorts, ac-
counting in the statistical analysis for
269
the clustering effect of the patients. The
study did not find a significant differ-
ence in terms of accuracy between static
and dynamic CAIS, although a trend
could be suggested. It is likely that a
difference between the two CAIS pro-
tocols exists, albeit of much smaller
proportion when compared to the dif-
ference between freehand and CAIS.
To further investigate such a hypoth-
esis, a much larger sample size might be
required.
In this study, three common proto-
cols of implant placement were com-
pared, as they are currently practiced.
This might have introduced some dif-
ferences with a potential influence on
the outcomes, such as for example the
use of mini implants, which was not
indicated in the freehand protocol.
Nevertheless, the clinical relevance of
the conclusions with currently practiced
procedures was deemed more im-
portant than a theoretically optimal
comparative design. On the basis of this
study, it is concluded that static and
dynamic CAIS achieved similar accu-
racy of implant placement, while free-
hand implant placement resulted in
significantly higher 3D and angle de-
viations.
Funding
This study received financial support
from the 90th Anniversary of
Chulalongkorn University, Rachadapisek
Sompote Fund.
Ethical approval
The clinical protocol of this study was
approved by the Ethics Committee of
the Faculty of Dentistry,
Chulalongkorn University, Bangkok,
Thailand (Reference No. 094/2018;
Study Code HREC-DCU 2018–083).
Acknowledgements. The authors would
like to thank Dr Paweena Yimarj,
Assistant Prof. Phonkit Sinpitaksakul,
Assistant Prof. Soranun Chantarangsu,
and Prof. Mansuang Arksornnukit for
their input and contributions to this
study.
Competing interests
None.
270 Jaemsuwan et al.
Patient consent
Not required.
Appendix A. Supporting
information
Supplementary data associated with
this article can be found in the online
version at doi:10.1016/j.ijom.2022.
05.009.
References
1. Henry PJ. A review of guidelines for im-
plant rehabilitation of the edentulous
maxilla. J Prosthet Dent 2002;87:281–8.
2. Tahmaseb A, Wismeijer D, Coucke W,
Derksen W. Computer technology appli-
cations in surgical implant dentistry: a
systematic review. Int J Oral Maxillofac
Implants 2014;29:25–42.
3. Jung RE, Schneider D, Ganeles J,
Wismeijer D, Zwahlen M, Hämmerle CH,
Tahmaseb A. Computer technology ap-
plications in surgical implant dentistry: a
systematic review. Int J Oral Maxillofac
Implants 2009;24(Suppl):92–109.
4. Gillot L, Cannas B, Friberg B, Vrielinck
L, Rohner D, Pettersson A. Accuracy of
virtually planned and conventionally
placed implants in edentulous cadaver
maxillae and mandibles: a preliminary
report. J Prosthet Dent 2014;112:798–804.
5. Vercruyssen M, Cox C, Coucke W, Naert
I, Jacobs R, Quirynen M. A randomized
clinical trial comparing guided implant
surgery (bone‐ or mucosa‐supported)
with mental navigation or the use of a
pilot‐drill template. J Clin Periodontol
2014;41:717–23.
6. Vercruyssen M, Coucke W, Naert I,
Jacobs R, Teughels W, Quirynen M.
Depth and lateral deviations in guided
implant surgery: an RCT comparing
guided surgery with mental navigation or
the use of a pilot‐drill template. Clin Oral
Implants Res 2015;26:1315–20.
7. Smitkarn P, Subbalekha K, Mattheos N,
Pimkhaokham A. The accuracy of single-
tooth implants placed using fully digital-
guided surgery and freehand implant
surgery. J Clin Periodontol 2019;
46:949–57.
8. Kaewsiri D, Panmekiate S, Subbalekha
K, Mattheos N, Pimkhaokham A. The
accuracy of static vs. dynamic computer-
assisted implant surgery in single tooth
space: a randomized controlled trial. Clin
Oral Implants Res 2019;30:505–14.
9. Kiatkroekkrai P, Takolpuckdee C,
Subbalekha K, Mattheos N,
Pimkhaokham A. Accuracy of implant
position when placed using static com-
puter-assisted implant surgical guides
manufactured with two different optical
scanning techniques: a randomized clin-
ical trial. Int J Oral Maxillofac Surg 2020;
49:377–83.
10. Block MS, Emery RW, Lank K, Ryan J.
Implant placement accuracy using dy-
namic navigation. Int J Oral Maxillofac
Implants 2017;32:92–9.
11. Marliere DAA, Demetrio MS, Picinini
LS, Oliveira RG, Netto H. Accuracy of
computer-guided surgery for dental im-
plant placement in fully edentulous pa-
tients: a systematic review. Eur J Dent
2018;12:153–60.
12. Vinci R, Manacorda M, Abundo R,
Lucchina AG, Scarano A, Crocetta C,
Muzio LL, Gherlone EF, Mastrangelo F.
Accuracy of edentulous computer-aided
implant surgery as compared to virtual
planning: a retrospective multicenter
study. J Clin Med 2020;9:774.
13. Buser D, Martin W, Belser UC.
Optimizing esthetics for implant restora-
tions in the anterior maxilla: anatomic
and surgical considerations. Int J Oral
Maxillofac Implants 2004;19:43–61.
14. Yimarj P, Subbalekha K, Dhanesuan K,
Siriwatana K, Mattheos N,
Pimkhaokham A. Comparison of the
accuracy of implant position for two-im-
plants supported fixed dental prosthesis
using static and dynamic computer-as-
sisted implant surgery: a randomized
controlled clinical trial. Clin Implant Dent
Relat Res 2020;22:672–8.
15. Viegas VN, Dutra V, Pagnoncelli RM, de
Oliveira MG. Transference of virtual
planning and planning over biomedical
prototypes for dental implant placement
using guided surgery. Clin Oral Implants
Res 2010;21:290–5.
16. Widmann G, Zangerl A, Keiler M,
Stoffner R, Bale R, Puelacher W.
Flapless implant surgery in the edentu-
lous jaw based on three fixed intraoral
reference points and image-guided sur-
gical templates: accuracy in human ca-
davers. Clin Oral Implants Res 2010;
21:835–41.
17. Noharet R, Pettersson A, Bourgeois D.
Accuracy of implant placement in the
posterior maxilla as related to 2 types of
surgical guides: a pilot study in the
human cadaver. J Prosthet Dent 2014;
112:526–32.
18. Jorba-Garcia A, Figueiredo R, Gonzalez-
Barnadas A, Camps-Font O, Valmaseda-
Castellon E. Accuracy and the role of
experience in dynamic computer guided
dental implant surgery: an in-vitro study.
Med Oral Patol Oral Cir Bucal 2019;
24:e76–83.
19. Pellegrino G, Bellini P, Cavallini PF,
Ferri A, Zacchino A, Taraschi V,
Marchetti C, Consolo U. Dynamic navi-
gation in dental implantology: the influ-
ence of surgical experience on implant
placement accuracy and operating time.
An in vitro study. Int J Environ Res
Public Health 2020;17:2153.
20. Ersoy AE, Turkyilmaz I, Ozan O,
McGlumphy EA. Reliability of implant
placement with stereolithographic sur-
gical guides generated from computed
tomography: clinical data from 94 im-
plants. J Periodontol 2008;79:1339–45.
21. Emery RW, Merritt SA, Lank K, Gibbs
JD. Accuracy of dynamic navigation for
dental implant placement—model-based
evaluation. J Oral Implantol 2016;
42:399–405.
22. Valente F, Schiroli G, Sbrenna A.
Accuracy of computer-aided oral implant
surgery: a clinical and radiographic
study. Int J Oral Maxillofac Implants
2009;24:234–42.
23. Aydemir CA, Arisan V. Accuracy of
dental implant placement via dynamic
navigation or the freehand method: a
split-mouth randomized controlled clin-
ical trial. Clin Oral Implants Res 2020;
31:255–63.
24. Cassetta M, Pompa G, Di Carlo S,
Piccoli L, Pacifici A, Pacifici L. The in-
fluence of smoking and surgical technique
on the accuracy of mucosa-supported
stereolithographic surgical guide in com-
plete edentulous upper jaws. Eur Rev
Med Pharmacol Sci 2012;16:1546–53.
25. Vieira DM, Sotto-Maior BS, Barros CA,
Reis ES, Francischone CE. Clinical ac-
curacy of flapless computer-guided sur-
gery for implant placement in edentulous
arches. Int J Oral Maxillofac Implants
2013;28:1347–51.
26. Verhamme LM, Meijer GJ, Boumans T,
Haan AF, Bergé SJ, Maal TJ. A clinically
relevant accuracy study of computer‐-
planned implant placement in the eden-
tulous maxilla using mucosa‐supported
surgical templates. Clin Implant Dent
Relat Res 2015;17:343–52.
27. Chmielewski K, Ryncarz W, Yüksel O,
Goncalves P, Baek KW, Cok S, Dard M.
Image analysis of immediate full-arch
prosthetic rehabilitations guided by a
 Accuracy of implant position with three protocols 271

digital workflow: assessment of the dis-
crepancy between planning and execu-
tion. Int J Implant Dent 2019;5:26.
28. Sun Y, Luebbers HT, Agbaje JO,
Schepers S, Politis C, Van Slycke S,
Vrielinck L. Accuracy of dental implant
placement using CBCT-derived mucosa-
supported stereolithographic template.
Clin Implant Dent Relat Res 2015;
17:862–70.
29. Geng W, Liu C, Su Y, Li J, Zhou Y.
Accuracy of different types of computer-
aided design/computer-aided manu-
facturing surgical guides for dental im-
plant placement. Int J Clin Exp Med
2015;8:8442–9.
30. Seo C, Juodzbalys G. Accuracy of guided
surgery via stereolithographic mucosa-
supported surgical guide in implant sur-
gery for edentulous patient: a systematic
review. J Oral Maxillofac Res 2018;9:e1.
Correspondence to: Department of Oral
and Maxillofacial Surgery
Faculty of Dentistry
Chulalongkorn University
34 Henri Dunant Road
Wangmai
Patumwan
Bangkok 10330
Thailand. Fax: +66 2218 8581.
E-mail: atiphan.p@chula.ac.th