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Computer-aided manufactu ring technologies for guided implant placement
Article    in  Expert R eview of Medic al De vices · Januar y 2010
DOI: 10.1586/ erd.09.61  · Sour ce: PubMed
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Joer g Neug ebauer
Univ ersity of Cologne
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Lutz Ritt er
Univ ersity of Cologne
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Timo Dr eiseidler
Dreifaltigk eits-Krank enhaus Wesseling
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Erwin K eeve
Charit é Univ ersitätsmedizin Berlin
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113
Review
www.expert-reviews.com ISSN 1743-4440 © 2010 Expert Reviews Ltd 10.1586/ERD.09.61 Requirements on implant planning
Today, implant treatment has primarily been
improved by immediate loading or reduced heal –
ing time [1,2]. These treatment options focus on
minimally invasive techniques to reduce the post –
surgical trauma and improve the general accep –
tance of the complex implant treat ment [3,5].
Routine cases with a large flap preparation showed
high postoperative morbidity, with pain and dis –
comfort for the patient [6]. This is clinically rel –
evant in older patients with compromised general
health [7]. Recuperation time should also be as
short as possible to permit the patient to return
to work quickly. Minimally invasive procedures,
such as flapless surgery, require detailed informa –
tion about all anatomic structures to avoid injury
due to the limited surgical overview [8]. In addi –
tion, the final prosthesis must be prepared precisely
in order to generate optimal treatment results [9].
Owing to these requirements, treatment planning
is very complex, and options that allow short treat –
ment times and minimally invasive techniques have been developed using 3D diagnosis and
computer-aided design (CAD)–computer-aided
manufacturing (CAM)-guided surgery [10–17] .
The use of these techniques must consider the
increased effort, due to more intensive treatment
appointments and costs.
Indications
Surgical guides based on 3D diagnosis are used in
all indications of oral implants, including single
tooth replacement, bridge work and the fixation
of complete dentures [18,19]. The radiological load
caused by 3D diagnosis is higher than in conven –
tional x-ray technique [20]. For the use of advanced
radiological imaging techniques, the risks associ –
ated with x-ray exposure must be lower than the
risk of harming the patient by the surgical treat –
ment [21–26] . To protect anatomical structures,
such as the mandibular nerve, the foramen men –
tale or the sinus floor, surgical guides are used to
achieve the optimum position under prosthetic
considerations [27,28] . If immediate loading is Jörg Neugebauer†,
Gerhard Stachulla,
Lutz Ritter, Timo
Dreiseidler, Robert
A Mischkowski,
Erwin Keeve and
Joachim E Zöller
†Author for correspondence
University of Cologne,
Interdisciplinary Outpatient
Department for Oral Surgery
and Implantology, Kerpener
Straße 32, 50931 Köln, Germany
Tel.: +49 221 478 4700
Fax: +49 221 478 6721
Joerg.neugebauer@uk-koeln.deImplant treatment increasingly focuses on the reduction of treatment time and postoperative
impairment. The improvement of 3D dental diagnosis by ConeBeam computed tomography
allows detailed preparation for the surgical placement of dental implants under prosthetic
considerations. While the first generation of implant planning software used high-contrast
multislice computed tomography, software that has been specifically designed for ConeBeam
computed tomography is now available. Implant placement can be performed using surgical
guides or under the control of optical tracking systems. Surgical guides are more commonly
used in private office owing to their availability. The accuracy for both techniques is clinically
acceptable for achieving implant placement in critical anatomical indications. When using
prefabricated superstructures and in flapless surgery, special abutments or an adjusted workflow
are still necessary to compensate misfits of between 150 and 600 µm. The proposition to ensure
proper implant placement by dentists with limited surgical experience through the use of surgical
guides is unlikely to be successful, because there is also a specific learning curve for guided
implant placement. Current and future development will continue to decrease the classical
laboratory-technician work and will integrate the fabrication of superstructures with virtual
treatment planning from the start.
Keywords : 3D diagnosis • complication • flapless procedure • guided implant placement • navigation
• prosthetic – driven implant treatment • surgical guide • virtual treatment planComputer-aided
manufacturing technologies
for guided implant placement
Expert Rev. Med. Devices 7(1), 113–129 (2010)
For reprint orders, please contact reprints@expert-reviews.com

Expert Rev. Med. Devices 7(1), (2010) 114
Review Neugebauer, Stachulla, Ritter et al.
planned, the prosthetic procedure can be prepared with a master
cast and performed using a surgical guide [29–32] . If augmentation
procedures should be avoided, special implants can be placed in
the zygoma or in an angled position next to the sinus or the mental
foramen [33–36] . Surgical guides manufactured on the basis of 3D
data can also be used for extraoral implants [37].
3D diagnosis
Computed tomography has been used for 3D dento–alveolar diag –
nosis for about 20 years [38–40] . The 3D radiographic analysis of the
remaining teeth and the available bone allows the dentist to gain
spatial orientation and estimate bone quality volume prior to implant
placement; in addition, a surgical guide is fabricated according to
this information [41–48] . To visualize the data, stereolithographic
models are produced and the data are processed using special soft –
ware [5,49]. CT has the advantage of a good signal-to-noise ratio that
even allows the evaluation of soft tissue structures [50,51]. Routine
procedures are associated with a relatively high radiation dose, which
can be reduced through special parameters to still ensure appropriate
diagnostic information [52]. These devices are designed for general
diagnostics of the complete body, so that specific parameters for pre-
implantological diagnosis must be used for the scan of the upper or
lower jaw by general radiologists [20].
The development of ConeBeam computed tomography (CBCT)
in 1989 now allows preimplantological diagnosis, without exposure
to a high radiological load [20,52–56] . These devices are developed
especially for dental–maxillofacial diagnosis and feature a similar
design to conventional panoramic x-ray systems [57–61] . The image
quality is different in comparison to medical CT, which is known
as beam hardening [62]. Artifacts may limit the diagnostic infor –
mation due to the larger scattering effects of radiolucent dental
restora tion [63]. The low visualization of the soft tissue by the CBCT
devices requires indirect imaging via the modification of scan tem –
plates with the radio-opaque structures. Due to the specific field
of view (FOV) and the adapted software for the diagnosis of the
oral cavity, these devices are more cost effective than CT and are
even available as dental radiology to dentists in many countries [64].
To reconstruct the 3D model, data acquisition is performed by a
digital 2D x-ray detector. Data acquisition is influenced by the data
transfer rate, and the size and modulation of the detector, which
affect the volume, resolution and image quality of the scan [51].
Due to the low radiation dose, image-intensifier systems are still
beneficial regarding size and resolution, especially in regard to the
scanned FOV [20,50,51] . Multiple devices for CBCT are currently
available [65,662] . The FOV varies between 3 × 5 and 20 × 28 cm.
For implant planning, a FOV of at least 12 × 8 cm seems to be
necessary to include the fiducial markers of the scanning tem –
plates [67,68] . In terms of the accuracy of guided implant placement,
CBCT generates high-resolution isotropic volumetric data with
high geometric accuracy [20,69,70] .
Data transfer
Until now, most of the planning software and companies offer –
ing surgical guides have required radiological data transfer by the
Digital Imaging and Communications in Medicine (DICOM) protocol [71,72] . This is quite often a time-consuming process,
because the data must be converted to perform the 3D render –
ing that is necessary for the 3D visualization of the anatomi –
cal structures and the prosthetic setup [73]. The low contrast of
CBCT scans is an especially difficult issue in various planning
programs because the structures cannot be determined as easily
as in standard high-contrast CT [51,64,74] . Since CBCT is now
developed in cooperation with dental companies that also supply
products other than radiological devices, implant planning soft –
ware is available on the same interface as radiological diagnostics
(e.g., Galileos Implant, Galileos, Sirona, DigiGuide Mini Dental
Implant [MDI], ILUMA and 3-m Imtec). One integrated system
is already available in which the diagnosis can be made directly
after scanning the patient and implant planning does not require
further data transfer. This system also allows the direct fabrication
of the surgical guide, so that the data transfer times are reduced
to a minimum (Galileos Implant, Galileos and Sirona) [67].
Planning software
When CT was first used for preimplantological diagnosis, soft –
ware was already available to simulate implant placement for bet –
ter orientation during surgery [43,75,76] . This simulation allows the
determination of the bone available for implant placement under
surgical aspects. The final goal for an implant placement is the
incorporation of a prosthetic superstructure [77]. This requires a
simulation of the expected prosthetic outcome at the time the
3D diagnosis is made [78–80] . For optimal results, implant plan –
ning can be performed under prosthetic considerations by adding
the prosthetic information to the scan via the simulation of the
later crown shape or the axis of the abutment implant [81–84] .
To visualize the prosthetic outcome, a wax up is transferred to a
barium-sulfate resin, so that the contours become visible in the
radiological scan [85]. If only the axes of the abutments need to
be visualized, gutta-percha points can alternatively be used in the
axis of the planned crowns.
Available software
The first program on the market with international recognition
was SimPlant by Columbia Scientific, which is now distributed by
Materialize Dental, Leuven, Belgium [43]. This open system can
be used with about 388 implant systems made by 78 companies.
Modifications of this software are also available for several compa –
nies and implant systems, especially with instruments for guided
surgery. Recently, a number of programs for implant planning
have been developed (Table 1) [13,76,86–90] .
3D rendering
For the spatial orientation of the implants in the oral cavity, it is
important to perform a 3D rendering after the DICOM import
of the radiological data [91]. This process may be very complex for
data generated by CB technology, since programs were histori –
cally developed based on high-contrast CT, with a low number
of slices [92]. A few companies recently developed their software
especially for the requirements of the image quality of low-contrast
CBCT [69]. Depending on the philosophy of the program, the user

www.expert-reviews.com 115
Review Computer-aided manufacturing technologies for guided implant placement
interface is more graphically or more technically oriented [13]. The
information to modify the visual impression is the same for both
software technologies; they just use different workflows. The sur –
face model of the bone or the scanned prosthesis can also be used
for the fabrication of the surgical guides [15,93–95] .
Fiducials
Depending on the further surgical guide manufacturing process,
fiducials may be required at the beginning of the planning process.
These fiducials are necessary during scanning for transferring the
orientation of the patient to the planning software and later on for guide fabrication. Planning systems that process the data on
rapid prototyping machines do not require these fiducials, because
the surface model of the anatomical structures is used for guide
fabrication. However, if a scan template is modified by a CAD–
CAM milling technique, fiducials are necessary even for guide
production. Scan templates can be very simple prefabricated parts
or specific bite plates with fiducials on a high-precision and con –
nector surface for the production of the surgical guide. During the
radiological scan, these fiducials should not be placed in an area
where metal scattering may reduce image quality. Failure of the
software to detect the fiducials requires a further scan. Table 1. Implant planning software.
Software platform (former names) Available software modification Distributor
10 DR implant 10 DR Seoul, South Korea
Artma virtual implant Eurodoc, Vienna, Austria
Blue Sky Plan Blue Sky Bio, Grayslake, IL, USA
coDiagnostiX coDiagnostiX
SKYplanXIVS Solutions, Chemnitz, Germany
Bredent, Senden, Germany
CTV (PraxisSoft) M+K Dental, Kahla, Germany
DenX Image Guided Implantology Image Navigation, Jerusalem, Israel
DentalVox (Era Scientific) Biosfera, Rimini, Italy
DentalSlice Bioparts, Brasília, Brasil
DDent plus I AlloVision, Greenville, SC, USA
DigiGuide MDI Imtec, Ardmore, OK, USA
Easy Guide (CAD implant, Praxim) Keystone Dental, Drilllington, MA, USA
Implant Location System Tactile Technologies, Rehovot, Israel
InVivoDental Anatomage, San Jose, CA, USA
Implant3D
(Stent CAD)Implant3D
Impla 3D NaviMedia Lab, La Spezia, Italy
Schütz Dental, Rosbach, Germany
Implanner Dolphin Imaging, Chatsworth, CA, USA
Implant3D
(med3D)Implant3D
CeHa Implant
IGS Monitormed3D, Heidelberg, Germany
C. Hafner, Pforzheim, Germany
2ingis, Brussels, Belgium
Implametric 3dent, Valencia, Spain
Nobel Guide (Litorim, Cath. Uni.
Leuven, Belgium)
(Oralim, Medicim)Nobel Biocare, Göteborg, Sweden
Robodent RoboDent, Garching, Germany
Simplant (surgicase) Simplant/Surgiguide
Facilitate
ExpertEaseMaterialize, Leuven, Belgium
Astratech, Mölndal, Sweden
Dentsply Friadent, Mannheim, Germany
Scan2guide Scan2Guide
ImplantMasterIdent, Foster, CA, USA
Various
Sicat Implant Sicat Implant
Galileos ImplantSicat, Bonn, Germany
Sirona, Bensheim, Germany
Virtual implant placement (Implant Logic) BioHorizons, Birmingham, AL, USA
Visit Research Project, University Vienna, Austria
CAD: Computer-aided design; MDI: Mini Dental Implant.

Expert Rev. Med. Devices 7(1), (2010) 116
Review Neugebauer, Stachulla, Ritter et al.
Planning interface
Dental diagnosis and implant planning are based on the inspec –
tion of the panoramic radiograph [91]. Due to the 3D nature of the
model, the panoramic reconstruction has to be calculated by the
software [69]. This can be performed automatically by the software,
with an optimization option, or an individual panoramic curve
has to be placed in the 3D model. This panoramic reconstruction
then provides spatial information for implant placement. Each
of the planning programs has a library with at least the implant
bodies of the manufacturing company, but most of the programs
are designed as open software with a large number of implant
suppliers and corresponding implant systems (Table 1). From this
library, the implants are available as 3D models, which allow
virtual placement of the planned implants next to the anatomi –
cal structures and other planned implants. Some programs also
permit the placement of virtual abutments, either custom-made
or belonging to the library of the implant bodies [96]. Therefore,
the planned treatment can be simulated, not only under surgical
but also under prosthetic aspects [97–99] . For prosthetic purposes,
radio-opaque visualization delivers information about angulations and exact positioning. The double-scan procedure was developed
especially for CBCT scans; it permits overlaying the scan of the
radiological template on the scan with the patient and the radio –
logical template, which offers the opportunity for easier segmen –
tation [12,100] . This requires fiducials in the scan template so that
both scans can be properly oriented to each other [73]. This concept
was first available with NobelGuide, but is now also offered for
other systems (e.g., SimPlant).
Documentation
After finalizing the plan, it can be documented through various
printouts or by online publication, so that the planning result
can be discussed with the referring dentist and the corresponding
laboratory technician [67]. Finally, the surgical guide is ordered.
Surgical guides
In the beginnings of 3D-planning, the transfer of implant posi –
tions from the planning software was not standardized and had
to be done individually by the user [101,102] . Today, most of the
software suppliers also offer the option of transferring the data to
a guide fabrication or optical tracking system (Table 2) [13,89,103–105] .
Depending on the manufacturing process of surgical guides,
they can be fixed on remaining teeth or abutments, the soft tis –
sue, auxiliary implants or directly onto the bone [13,15] . So far,
bone-supported surgical guides could only be produced by the
rapid prototyping or 3D-printing procedures because they use the
virtual surface model of the bone to generate a surgical guide that
can then be placed directly onto the bone after preparation of the
mucoperiosteal flap [106]. This is used mainly for the completely
edentulous jaw, where no additional abutments, teeth or auxil –
iary implants can be placed [107]. An alternative approach is the
fixation of the surgical guide by anchor pins, which stabilize the
surgical guide in the jaw with specific screws [35,94] . The position
of the anchor pins is also determined by the planning software to
prevent collision of the planned implant sides and deviations of
the surgical guide from the optimal position [108,109] .
The other fixation techniques are available for all production
types because the surface of the teeth or abutments, or even of
the soft tissue can be transferred through modification of the scan
template or by the rendering of the anatomical surface models.
Handling completely soft tissue-borne surgical guides is difficult
because the orientation in the mouth changes after the flap is
raised, and the fixation is not necessarily in the same position
during the scan and during surgery [110].
Variation of sleeves
In addition to the fixation, drill guidance differs in the various
designs of surgical guides. Initially, only sleeves for the pilot drill
or multiple surgical guides with different sleeve diameters were
available for identifying the proper axis [111]. To achieve high
accuracy, additional sleeve designs are now also available [93]. In
the sleeve-in-sleeve concept, multiple sleeves are placed to properly
orient the implant drills with increasing diameters. A few com –
panies have already developed special surgical kits to even allow
guided implant placement with one master sleeve.Table 2. Technology of navigated
implant placement.
Brand Fabrication Technology
Artma Local Optical tracking
Blue Sky Plan Central/Local 3D-printing
coDiagnostiX Local Mechanical
Optical tracking
DenX Image-
Guided SurgeryLocal Optical tracking
DentalVox Central CAM-milling
DentalSlice Central Stereolithography
DDent plus I Local Mechanical
Easy Guide Central CAM-milling
Implant Location
SystemCentral CAM temperature-forming
Implametric Central Stereolithography
Implant3D Local Mechanical
Implant3D (med3D) Local Mechanical
Optical tracking
Nobel Guide Central Stereolithography
Robodent Local Optical tracking
Scan2guide Central Rapid manufacturing
technology
Sicat Implant Central CAM-milling
Simplant Central Stereolithography
Visit Local Optical tracking
VIP Pilog
Compu -GuideCentral CAM-milling
CAM: Computer-aided manufacture; VIP: Virtual Implant Placement.

www.expert-reviews.com 117
Review Computer-aided manufacturing technologies for guided implant placement
Guide production
Today, surgical guides can be produced
by the local laboratory technician or den –
tist using special mechanical positioning
devices, or in a centralized facility with vari –
ous types of CAD–CAM techno logy [22].
The decentralized or local fabrication uses
software that provides the user with an
information sheet with the coordinates of
a positioning device to modify the position
of the master cast and the scan template
(Figure 1) [13,14,112] . The correct position of
the implant axis can be simulated and a
parallel milling system is used to place the
surgical sleeve [92]. The process of fixation
on a milling system is quite precise, in the
range of navigation systems [113]. To avoid
an increase of deviation through the various
production steps, direct fixation of the sleeve
is preferred [113].
For the systems with centralized fabrica –
tion, planning is performed on a standard
PC, and the data are then transferred to
the production center, which fabricates
surgical guides according to the data from
the planning software (Figure 2). The surgical guides were initially
produced mainly by stereolithography, utilizing the previously
mentioned surface models. Particularly for larger surgical guides,
this technology is associated with high cost and production time.
Current developments are examining the concept of modifying
the radiological tem plates [114]. Since the fit is checked prior to the
CT scan, a precise fit can also be expected after the placement of
the sleeves, and there is no further need for adjustments [8].
A new concept is the use of 3D printing to generate 3D models
and surgical guides, which can also be used for local fabrication
in dental laboratories or dental offices.
Guided implant placement
For guided implant placement, most systems offer the option of
placing the master sleeve in a specific position, so that the implant
drills with a stop function allow exact vertical preparation. Three
concepts for drill guidance are currently available (Table 3).
One is working with drills that feature a fixed sleeve to ensure
guidance in the master sleeve of the surgical guide. The drawback
of this system is that guidance is only provided if the master sleeve
is in contact with the sleeve part of the drill. Especially in long
implants, multiple changes of the drills are necessary because the
initial preparation is performed with a short drill to achieve a
guided preparation. The advantage of this system is that a mini –
mum of mobile parts are used for the surgical preparation. Another
approach uses small holders that are also oriented in the master
sleeve of the surgical guides. The drills of the implant kit are
placed through these holders. A further design features sleeves that
are mobile on the drills, so that the final drill length can be used
(Figure 3). After the preparation of the implant site, instruments are also available for guided implant placement. If a flapless procedure
is used, this is especially important for achieving the correct verti –
cal orientation of the implants [92,115–117] . This process should also
allow the use of prefabricated computerized numerical control-
milled superstructures for immediate loading with a minimally
invasive and time-effective treatment [16,31,32,108,118] .
Optical tracking
Next to surgical guides, intraoperative navigation by optical track –
ing is another option to make use of 3D imaging and the transfer
of data to the surgical environment [13,119–127] . Preparation of the
surgery is similar to the surgical guide process, without the final
fabrication of a surgical guide. The navigation systems are avail –
able for general surgery, with specific adaptations for dentoalveolar
surgery [120,128–130] , or as specific devices for dental implant place –
ment [13,121–123,130–133] . The technical set-up is reduced, so that
large devices are not always necessary (Table 4) [134].
Dental implant optical tracking systems need the fiducials that
were used during the radiological scan as reference points for the
registration of the instruments [129]. The accuracy of the optical
tracking systems depends on the reliability and the precision of
detection of these fiducials [135]. At the reference point, an optical
system is mounted, so that the infrared camera can control for the
position of the patient in relation to the instruments. This enables
the surgeon to check the position of the drill on the control moni –
tor relative to the patient and the reconstructed model according
to the preoperative planning. The use of implant optical tracking
systems is also superior to general navigation systems in general
indications, such as cancer resection [120]. Since the drills are not
guided by sleeves, there is more freedom for the instrument during
A B
C D E
Figure 1. (A) Fixed restoration in maxilla by support of mechanical guide fabrication
Software interface of planning software (Implant3D, med3D Heidelberg, Germany).
(B) Intraoperative view of a surgical guide that was made by modification of the
radiological stent. (C) Control sheet to evaluate the achieved axis. (D) Panoramic
radiograph after prosthetic delivery. (E) Control of implant-borne bridges or splinted
crowns 2 years after delivery.

Expert Rev. Med. Devices 7(1), (2010) 118
Review Neugebauer, Stachulla, Ritter et al.
implant placement, and the procedure is still controlled in difficult
anatomical indications including cancer reconstruction and high
atrophy [136].
Accuracy
The accuracy of guided implant placement with surgical guides
or optical tracking has been evaluated by in vitro and clinical
studies [989,104] .
In vitro surgical guides
In in vitro studies, the accuracy of the surgical guides and the
implant placement has already been found to be limited by the
accuracy of the various process steps [137]. For a good prosthetic
outcome, it is important that the crestal position is not changed, as described by various studies by the precision of the entry point [86].
The angulation and the exact orientation for the later placement of
the abutments are measured by the apical positioning, respectively.
The mean values for the crestal positions range from 0.15 ± 0.12 to
1.5 ± 0.8 mm. The apical deviation always shows larger mean values,
from 0.4 ± 0.12 to 2.0 ± 0.7 mm [11,122,137–142] . In the risk assessment
of the use of these guides, the maximum values, especially at the
apex, are important. Owing to a horizontal or vertical deviation
of up to 1.86 [137] or 2.7 mm [138], anatomical structures may be
harmed. A security distance of at least 1 mm is recommended based
on the results of additional in vitro studies [143].
The use of additional sleeves reduces the freedom of motion for
the following drills and does not lead to an increase of the metrical
deviations of the system [138,141] .
The systems with a master sleeve and additional tools or sleeves
allow a precise preparation of the implants and even the seating of
the implant through the surgical guide, so that high precision can
be achieved [141]. A limiting factor is the size of the master sleeve
because it could lead to difficulties during manufacturing due
to insufficient space between several implants, if small-diameter
implants are used. Some companies provide systems with two
kinds of sleeves, which increases the number of drills or additional
sleeves [93].
In vivo surgical guides
Clinical investigations have only been published by a few
authors [33,110,144] . Older studies report variations at the crestal
position of between 1.45 ± 1.42 and 1.51 mm, and at the apex of
2.99 ± 1.77 and 3.07 mm [33,144] . Bone-supported surgical guides
showed very high deviations of up to 4.5 mm crestally and 7.1 mm
at the apex [144], which were explained by the design not hav –
ing been adjusted. Current studies show improved values for the
surgical guides. A comparison study of the various support types
– tooth-, mucosa- and bone-supported – showed no significant
difference in deviation of the crestal position, with average values
of 0.87 ± 0.4, 1.06 ± 0.6 and 1.28 ± 0.9 mm, respectively. For the
deviation from the planned apical position, a significant differ –
ence between tooth-supported guides (0.95 ± 0.6 mm), mucosa-
supported guides (1.6 ± 1.0 mm; p = 0.014) and bone-supported
guides (1.57 ± 0.9 mm; p = 0.003) was found. There was no
significant difference between the bone- and mucosa-supported
guides for the apical position [110].
In vitro optical tracking
For the vector vision system (BrainLAB, Hainstetten, Germany),
deviations from the upper implant reference point were
0.95 ± 0.25 mm, and those from the apical reference point were
0.97 ± 0.34 mm in vitro [145]. For the demanding positioning of
implants next to the sinus floor, a deviation of the implant tip of
0.11 ± 0.22 mm was achieved. In this in vitro study, 13 out of 60
preparations (21.6%) showed a perforation of the sinus floor, with
an average depth of 0.24 mm [146]. A similar result was found in
the comparison between navigated implant placement and con –
ventional procedure for the placement in the posterior mandible
near the mandibular canal [147].
A B
C D
E F
G
Figure 2. (A) Workflow for minimal implant placement in maxilla
to avoid larger augmentation procedure, check of wax-up.
(B) Check of exact position of radiological stent with reference
for planning software and separated BaSO4-teeth. (C) Planning
report after virtual placement of four implants (Sicat Implant,
Sicat, Bonn, Germany). (D) Placement of surgical guide
manufactured by CNC-milling (Sicat, Bonn, Germany). (E) Implant
side preparation prior to sinus cavity with an inclination of 38°.
(F) Postoperative radiological control without any signs of implant
contact to the sinus cavity. (G) Final fixed bridge in maxilla prior
to start of treatment in the mandible.

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Review Computer-aided manufacturing technologies for guided implant placement
An experimental study on minipigs
showed a deviation of less than 0.5 mm in
all directions for a specific implant-designed
tracking system [148]. For the use of the rela –
tively long zygomatic implants, an overall
precision of 1.5 ± 1.1 mm could be simulated
with a variation of 0.1–4.9 mm [136]. In the
alveolar process, deviation values in compari –
son to the vestibular bone were found to be
0.55 ± 0.31 mm at the crest of the implant and
1.44 ± 0.79 mm at the apex when using the
Visit system [149]. The use of a head-mounted
display with this system improved the val –
ues, resulting in deviations of 0.58 ± 0.4 and
0.79 ± 0.71 mm, respectively [150]. A com –
parison study for Robodent and IGI DenX
versus manual implant placement showed
a deviation at the apex of 0.60 ± 0.20 mm
(maximum: 0.92) for Robodent, 0.94 ± 0.40
mm (maximum: 1.88) for IGI DenX, and
1.89 ± 0.80 mm (maximum: 2.95) for
manual placement [151]. These results were
also supported by a comparative examina –
tion of two navigation systems with a surgi –
cal guide system [122] and in the comparison
of an optical tracking system with manual
placement [152].
In vivo optical tracking
The control of the clinical placement of
navigated implants showed similar results
as guided implant placement, with a devia –
tion at the crestal part of 1.0 ± 0.5 and
1.3 ± 0.9 mm at the apex of the implant [153].
Further studies show an average deviation
of 0.7 ± 0.3 mm at the lingual position
for the crestal and apical position in the Visit system [154], and
0.7 ± 0.5 mm for the crestal and 1.2 ± 0.8 mm for the apical
position when using a general navigation system [155]. For this
pilot study on 20 edentulous patients, navigated flapless implant
placement was found to be a predictable and safe procedure in
cases with wide, regular mandibular ridges. The technique was
less accurate, more complicated and more time consuming in areas
with irregular bone [154,155] . Data showing low deviation for the
difficult placement of zygomatic implants are now available, with
a crestal deviation of 1.36 ± 0.59 mm and an apical deviation of
1.57 ± 0.59 mm [156].
Advantages
The advantage of the surgical guides is mainly derived from a pre –
cise knowledge of the anatomical findings and optimal preparation
of the surgery without the risk of intraoperative changes of the
protocol [157,158] . They are a prerequisite for the flapless procedures,
for implant placement in difficult anatomical positions and in case
of tilted implant positions chosen to avoid more invasive grafting procedures [62,115,159,160] . In immediate loading, it is always dif –
ficult for the laboratory-technician to provide the superstructure in
a very short period of time after the implant placement. Detailed
preoperative planning allows the laboratory-technician to work
ahead to shorten these processing times [118].
Follow-up studies show that the parameters indicating long-
term success, such as peri-implant bone resorption, are in the same
range as in conventional procedures [161]. In summary, guided
implant placement using 3D diagnostics reduces patient morbid –
ity and the complication rate [30,162] . Data for the comparison of
the implant outcome for both techniques are limited. One study
showed that the use of surgical guides (1.31%) seems to have a
lower failure rate than optical tracking systems (2.96%) [13].
Limitations
Possible failure reasons may include poor resolution of the 3D
radiological image, which is influenced by the design of the
device and by artifacts. In particular, multiple prosthetic res –
torations made from metal or zirconium oxide ceramics lead Table 3. Implant systems with instruments for guided surgery.
Implant company System Surgical guide Guidance by Guidance for
Astratech, Mölndal,
SwedenFacilitate Simplant
SICATDrill
Positioning
HandleAll drills and
implants
BioHorizons,
Birmingham, AL, USAPilog
Compu -GuidePilog
Compu -GuideMultiple
sleevesPilot drills
Biomet 3i, Palm
Beach Gardens,
FL, USANavigator Simplant
SICATDrill
Positioning
HandleAll drills and
implants
Bredent, Senden,
GermanySKYplanX SKYplanX Sleeve in
sleeveAll drills and
implants
Camlog, Wimsheim,
GermanyCamlog Guide coDiagnostiX
med3D
SICAT
SimplantIntegrated
sleeve on drillAll drills and
implants
Dentsply Friadent,
Mannheim, GermanyExpertEase coDiagnostiX
med3D
Sicat
SimplantMounted
sleeve on drillAll drills and
implant
Imtec, Ardmore,
OK, USADigiGuide MDI DigiGuide MDI Drills
Keystone Dental,
Drilllington, MA, USAEasy Guide Easy Guide Sleeve Drills
Nobel Biocare,
Göteborg, SwedenNobel Guide Nobel Guide Drill
Positioning
HandleAll drills and
implants
Straumann, Basel,
SwitzerlandGuided
SurgerycoDiagnostiX
med3D
Scan2Guide
SICAT
SimplantDrill
Positioning
HandleAll drills and
implants
Various Safe System Simplant Mouted sleeve
in guideAll drills and
implants

Expert Rev. Med. Devices 7(1), (2010) 120
Review Neugebauer, Stachulla, Ritter et al.
to difficulties in evaluation of these 3D data due to so-called
metal scattering. In addition, movement artifacts may result in
incorrect metric information, as determined by several in vitro
studies [163,164] .
Surgical guides planned with a reduced security distance to
the anatomical structures or in an area with limited available
bone were found to be associated with risk; deviations of these
surgical guides may harm anatomical structures, or reduced cov –
erage of the implant with bone may result, thus increasing the
failure rate [165]. The use of these surgical guides demands that
the user is familiar with implant treatment; minimization of surgical trauma requires that the surgeon can still estimate the
local findings to protect these structures and achieve an implant
placement, which fulfills the prosthetic requirements [165–167] .
The results of the accuracy testing showed that deviation
increases if the base of the guide and the position of the sleeve
are at larger distances to the entrance point of the bone [168]. In
case of thick soft tissue, bone-anchored surgical guides or optical
tracking systems may be favorable.
The previously cited range of accuracy is not acceptable for
prosthetic restoration, as this requires an accuracy of 0.02 mm.
One potential way of compensating for this inaccuracy is to use
A B C
D E F
G H I
Figure 3. (A) Guided implant placement with ExpertEase: planning of implant position with implants and available abutments (Simplant
12, Materialise, Leuven, Belgium). (B) Sterelithgraphic model of atrophic edentulous maxilla (Materialise, Leuven, Belgium).
(C) Stereolithographic surgical guide with master sleeve (Expertease, FRIADENT, Mannheim, Germany). (D) Soft-tissue preparation of
bone-anchored surgical guide. (E–G) Implant preparation, placement and control by surgical guide. (H) Final restoration with
bar-supported superstructure in atrophic maxilla with regional grafting procedures. (I) Radiological control by panoramic image of
consolidated sinus floor.

www.expert-reviews.com 121
Review Computer-aided manufacturing technologies for guided implant placement
abutments with a spacer and a resilient
part as guided abutments [108]. It has been
reported that this technique has a high suc –
cess rate (98.9%) for nonsmoking patients
when providing restorations for edentulous
patients by expanding abutments within 1 h,
using a prefabricated fixed prosthesis [109].
Other authors report a high complication
rate with early failures, such as impossibil –
ity to seat the planned implant, unexpected
osseous findings, and an implant failure
rate of 9%. The prosthetic outcome was
also compromised by early complications,
including loosening of the prosthesis, speech
problems and bilateral cheek biting. Late
complications included loosening of screws,
fracture of the prosthesis and pressure sensi –
tivity during chewing [165]. Fractures of the
surgical guide were also reported, as were
misfits between abutment and fixtures, and the need for extensive
occlusion adjustments. In terms of implant success with these com –
plications, a survival rate of only 89% was reported in the maximum
observation period of 44 months [169]. As known from standard
treatment planning, flapless surgery requires special training and
involves a learning curve to achieve optimum results [170].
Another option is to prepare the superstructure according to
the surgical guide but then to compensate the inaccuracy between
the planned and reached position through gluing, cementing or
laser-welding the superstructure after fixation of the components
in the mouth of the patient [171–173] .
Recent developments
The actual workflow for producing surgical guides is quite com –
plex, because several patient appointments and waiting periods are
necessary to prepare the prosthetic setup, do the radiological exam,
produce the surgical guide and finally place the implant. This is
not only time consuming for the patient but it is also work inten –
sive and generates cost [90]. Various options are being developed
to optimize this workflow. Digital technology has tremendously
improved conventional laboratory work in recent years [174]. Digital
impression techniques have been available for more than 20 years
as single-shot impressions [175,176] and are now also offered with
video capturing [176]. To optimize precision, the most accurate
techniques should be used, such as the high-frequency blue-light
technique [177]. The high-frequency light features high-precision
transfer without noise, because there is no need for summarizing
multiple frames. This allows a digital wax up for planning after
the radiological scan instead of the cost-intensive preparation of
barium sulfate teeth as the scan reference (Figure 4). With this
technique, at least one step could be eliminated [10].
Production costs and the likelihood of errors in the surgical
guides depend on the production process. Central CAD-CAM
technologies such as stereolithography or computerized numeri –
cal control-milling stations require a high investment but deliver
products with a high predictability. Computerized numerical control-milling stations for fabrication of superstructures are
more and more common in dentistry and can be used in the
local dental laboratory or even in the dental office with clini –
cally acceptable precision [178,179] . These systems can also produce
surgical guides to shorten the process [180].
Discussion
Today, implant placement can be considered a routine proce –
dure in a dental office, but the further developments require
very detailed planning and the ability to transfer this planning
information to the surgical procedure.
Three-dimensional diagnosis can be an advantage for the patient,
especially when minimally invasive techniques are used [181].
Detailed planning can also provide the option of immediate loading
to achieve a higher level of satisfaction for the patient [32,162,169,182] .
A 3D diagnosis is the basis for the use of 3D planning. At the
beginning of modern implantology, only CT was available. Studies
based on CT imaging generate 3D data, but the resolution of CT
imaging is nonisotropic, delivering limited spatial image resolu –
tion in at least one axis [183]. Today, CBCT is most often used for
pre-implantological 3D diagnosis [184–189] . It allows torsion-free,
metrically correct implant planning under consideration of the
anatomical structures with a low radiological dose [20,53,190] .
The workflow for the preparation of the patient for 3D diagno –
sis exhibits few variations based on the implant and surgical guide
design that is used. This area has the most development potential
in terms of shortening the preparation and treatment times. The
predictability for the precision is always higher for technical sys –
tems compared with manually adjusted systems. However, the
required cost-intensive hardware is a disadvantage, especially in
countries with low wages for manual labor.
Guided implant placement using surgical guides with modi –
fied surgical instruments promise the highest degree of accuracy,
which is currently not in the required range for the complica –
tion-free incorporation of prefabricated prostheses for immediate
loading [165,166,169] .Table 4. Commercialized navigation systems for guided
implant placement.
System Distributed by Concept
Artma Eurodoc Telemedizin Anwendung,
Vienna, AustriaImplant placement
DenX Image-Guided
ImplantologyImage Navigation, Jerusalem, Israel Implant placement
IVS coDiagnostiX IVS Solutions, Chemnitz, Germany Implant placement
LandmarX , Medtronic Xomed, Jacksonville, FL, USA ENT surgery
Mona dent (Med3D) Mona-X, Dortmund, Germany Implant placement
Robodent RoboDent, Garching, Germany Implant placement
SMN Zeiss,Oberkochen Germany General surgery
StealthStation S7 Medtronic Navigation, Louisville, CO, USA General surgery
vv2 brainlab BrainLAB, Hainstetten, Germany General surgery
ENT: Ear, nose and throat; SMN: Surgical Microscope Navigator.

Expert Rev. Med. Devices 7(1), (2010) 122
Review Neugebauer, Stachulla, Ritter et al.
The clinical use of surgical guides in the posterior area requires
additional skills and experience due to the more complex design,
especially of the master sleeves. For the atraumatic treatment of
the bone, it is important to avoid overheating; this requires careful
preparation due to the limited access of coolant solution in the
externally irrigated drills [165,191] .
Expert commentary
In the past, prosthetic dentistry involved the use of the remaining
teeth for the fixation of a superstructure on natural abutments
using conventional laboratory technician work. Limitations
included the distribution of the residual abutments, which could
pose problems in placing a fixed restoration, and the need to
grind healthy teeth to carry any kind of superstructure. Today,
dental implants are used for the replacement of single teeth, for
the complete reconstruction in the partially edentulous jaw, and for the stabilization and fixation of complete dentures. The use
of endosseous implants allows the restoration of the dentition
with the same functionality as the root of the former teeth [1].
This requires an exact treatment plan for implant placement
in the available bone under consideration of the anatomical
findings, the prosthetic requirements and the patient’s medical
history [3,103] . The correct implant position should be planned
prior to surgery, and tools should be available to achieve the
optimum position [192].
Dentists are grinding teeth to shape abutments for remov –
able or fixed prosthetic work. Preparing an implant site requires
preparation into the bone, which is a different technique than
tooth grinding. Instead of the ablative preparation for a crown,
the receptor sites for a dental implant must be prepared into the
bone. This can present difficulties because the bone structure
is not visible prior to the surgery and the position of the tip of
A B C
D E F G
H I J K
Figure 4. (A) Reconstruction with virtual prosthetic setup: failing implants due to peri-implantitis and near tooth position in left
mandible. (B) Large defect after explantation and removal of first bicuspid. (C) Soft tissue situation after reconstruction by hip graft.
(D) Virtual setup of prosthetic goal with CAD-CAM software (Cerec 3D, Sirona, Bensheim). (E) Planning with merged virtual set up
(Sirona Implant, Sirona, Bensheim). (F–H) Implant site preparation after hip graft with surgical guide for 2-mm pilot drill. (I) Implant
placement after further preparation. (J) Final superstructure with splinted crowns. (K) Radiological control after treatment of
left mandible.

www.expert-reviews.com 123
Review Computer-aided manufacturing technologies for guided implant placement
the drill is not under the surgeon’s visible control. Anatomical
variations may be found [193] and detailed metrical analysis is not
always possible with routine imaging procedures [194]. Classic
dental implant treatment is based on 2D radiological diagnosis
and the visual inspection of the oral cavity with high predict –
ability [91]. This workflow does not deliver information about the
spatial orientation around the teeth or about the edentulous part
of the alveolar crest [69].
Five-year view
Today, surgical guides are mainly produced on a software plat –
form designed for CT technology. Owing to the lower radiologi –
cal exposure of CBCTs, the contrast in the DICOM transfer is
reduced, so it is necessary to develop a new software platform
that is focused on the use of CB data. The labor-intensive process
involving several appointments to prepare the patient, not only
with the radiological scan but also for the temporary restora –
tion, will involve less classic laboratory-technician work and more CAD–CAM technology systems. For the planning and design
of the superstructure, software will be available in the form of
‘expert systems’ to shorten the user interface time with the soft –
ware when determining the size and position of the implants and
the shape of the superstructure [195]. This will finally lead to the
local production of surgical guides, even by the dentist, owing to
the available CAD–CAM milling stations [180].
Furthermore, these systems can be used not only by experts to
achieve the optimum results, but also for education purposes for
the complex implant prosthetic treatment in virtual reality [196].
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Medical computed tomography (CT) and cone-beam CT are delivering detailed information for 3D-planning of implant placement.
• 3D planning software is available in various designs with simple or advanced planning options.
• 3D planning requires a more intense workflow to simulate the prosthetic outcome already at the beginning of the treatment.
• Surgical guides can be manufactured locally with mechanical devices or centrally with computer-aided manufacturing (CAM)
technology such as stereolithography, CNC-milling or 3D-printing.
• Surgical guides produced by computer-aided design-CAM technology allow a minimally invasive treatment with the protection of
sensitive anatomical structures in difficult indications.
• Optical tracking systems seem to be more accurate and have more flexibility during surgery but require more training for the staff.
• Various implant companies offer instruments that allow a guided implant site preparation and implant placement.
• Clinical data on the outcome of immediate restorations with prefabricated superstructures using guided implant placement
are controversial.
• Further research projects are ongoing to simplify the workflow by optimizing knowledge-based systems and to more intensively use
computer-aided design-CAM-technology in dental implant treatment.
References
Papers of special note have been highlighted as:
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Affiliations
• Priv.-Doz. Dr. med. dent. Jörg Neugebauer
University to Cologne, Consultant at
Interdisciplinary Outpatient Department
for Oral Surgery and Implantology,
Kerpener Straße 32, 50931 Köln, Germany
Tel.: +49 221 478 4700
Fax: +49 221 478 6721
joerg.neugebauer@uk-koeln.de• Gerhard Stachulla, CDT
Implant and 3D Planning Center,
Augsburger Straße 26, 86444 Affing-
Mühlhausen, Germany
Tel.: +49 170 205 4821
Fax: +49 820 7959 9355
gerhard@stachulla.de
• Dr. med. Lutz Ritter
University to Cologne, Department for
Craniomaxillofacial and Plastic Surgery,
Interdisciplinary Outpatient Department
for Oral Surgery and Implantology,
Kerpener Straße 62, 50931 Köln, Germany
Tel.: +49 221 478 5771
Fax: +49 221 478 5774
lutz.ritter@uk-koeln.de
• Dr. med. Dr. med. dent. Timo Dreiseidler
University to Cologne, Department for
Craniomaxillofacial and Plastic Surgery,
Interdisciplinary Outpatient Department
for Oral Surgery and Implantology,
Kerpener Straße 62, 50931 Köln, Germany
Tel.: +49 221 478 5771
Fax: +49 221 478 5774
timo.dreiseider@uk-koeln.de
• Priv.-Doz. Dr. med. Dr. med. dent. Robert
A Mischkowski,
University to Cologne, Consultant at
Department for Craniomaxillofacial and
Plastic Surgery, Interdisciplinary
Outpatient Department for Oral Surgery
and Implantology, Kerpener Straße 62,
50931 Köln, Germany
Tel.: +49 221 478 5771
Fax: +49 221 478 5774
r.mischkowski@uni-koeln.de
• Univ.-Prof. Dr. Erwin Keeve
Professor and Director at the Berlin Centre
of Mechatronic Medical Technology,
Charité Universitätsmedizin Berlin
Campus Virchow-Klinikum,
Augustenburger Platz 1,
13353 Berlin, Germany
Tel.: +49 304 5055 5132
keeve@charite.de
• Univ.-Prof. Dr. med. Dr. med. dent.
Joachim E Zöller
Professor, University to Cologne, Head of
Department for Craniomaxillofacial and
Plastic Surgery, Interdisciplinary
Outpatient Department for Oral Surgery
and Implantology, Kerpener Straße 62,
50931 Köln, Germany
Tel.: +49 221 478 5771
Fax: +49 221 478 5774
zoeller@uni-koeln.de
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