Accuracy of Navigation-Guided Dental Implant Placement

with Screw Versus Hand Template Fixation

in the Edentulous Mandible
Philipp Kauffmann, MD, DMD1/Anna Rau, MD2/Wilfried Engelke, MD, DMD, PhD3/
Markus Troeltzsch, MD, DMD1/Phillip Brockmeyer, MD, DMD1/
Lauer-Saridakis Dagmar, DMD4/Robert Cordesmeyer, MD, DMD1

Purpose: Preoperative planning of the implant position as part of a coordinated prosthetic and surgical
concept is becoming increasingly important regarding function and esthetics. The aim of this study was to
investigate the transmission accuracy of template fixation during surgery in edentulous arches with hand
fixation in comparison to intermediary screw fixation. Materials and Methods: Preoperatively, 10 implant
positions were planned using computed tomography (CT) with the system med3D for implant placement
in four mandible models of the Goettingen study model, using a prosthetic diagnostic template. A total of
40 implant insertions were created. For every 20 insertions, the template was temporarily fixed with three
screws and compared with the insertion using a hand-fixed template. The precision of the transmission
was evaluated with and without screw fixation by re-evaluating the preimplant planning with additional CT
scanning of the respective models. Results: Compared with the hand-fixed procedure (HFG) in the model
situation, there were no significant differences between the deviations of planned and final implant position
in the screw-fixed group (FG). According to the study results, the fixed procedure leads to less depth deviation
and lateral error of the implant base in relation to the HFG. Within both groups, there were significant
differences between the radial deviation tendencies from the implant base to the implant apex (P = .033 for
FG and P = .001 for HFG). Conclusion: The use of CT-based implant planning succeeds in fixed and hand-
fixed surgical procedures with high precision in the atrophic, edentulous mandible model. According to the
results of this study, in cases demanding high depth precision, screw-fixation of the template can be helpful.
Int J Oral Maxillofac Implants 2018;33:383–388. doi: 10.11607/jomi.5784

Keywords: dental implants, navigation-guided dental implant, template fixation

In the last decades, the use of dental implants has

been established in daily practice, leading to increas-
ing demands in esthetics and function.1,2 Therefore,
complex cases in the implant supply have become
an ever-increasing challenge for the implantologist.1
The optimal implant placement will no longer be
1 Assistant Professor, Department of Maxillofacial Surgery,
Georg August University, Göttingen, Germany.
2 Assistant Professor, Department of Anaesthesiology, Georg
August University, Göttingen, Germany.
3 Professor, Department of Maxillofacial Surgery, Georg August
University, Göttingen, Germany.
4Researcher, Dental Practice, Braunschweig, Germany.
Correspondence to: Dr Philipp Kauffmann, Robert-Koch-Strasse
40, 37075 Göttingen, Germany. Fax: 0049(0)551-398312.
Email: philipp.kauffmann@med.uni-goettingen.de
©2018 by Quintessence Publishing Co Inc.
judged solely by bone quality, but also by the planned
prosthetic restoration and its best functional and es-
thetic results.3,4 Therefore, a detailed, combined pre-
operative planning and prosthetic-surgical concept
seems to take on increasing value. In this respect,
three-dimensional (3D) imaging has been proven to be
extremely helpful.1–3,5–8 The use of implant planning
software, individually milled surgical guides, and com-
puter-assisted surgery have been established in pre-
operative planning.1,5,7,9–14 However, the transfer of 3D
data to the surgical situation remains challenging.15,16
Custom-made drilling templates provide a way to ad-
vance the transfer of the virtually planned implant po-
sition to the operation area. The transmission accuracy
is also a critical aspect of these systems. The aim of this
study was to determine the transmission accuracy of
surgical guides in edentulous arches with hand fixation
and surgical guides with intermediary screw fixation.

The International Journal of Oral & Maxillofacial Implants 383

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Kauffmann et al
a b
c d
e f
MATERIALS AND METHODS
To simulate an authentic situation for edentulous patients,
four edentulous mandible models (GOS Mandibula Type
1; patent nr: EP0822531 A1) from Goettingen Surgical Sim-
ulation Systems were used.17 The GOS Mandibula Type 1
model is supplied as a slightly atrophic mandible. The
model is produced as standard with the bone quality D II.
These jaw models properly replicate the anatomical
structures as compact and cancellous bone. A mucosa
mask represents the resilient mucosa.17 Ten titanium
screw implants (L10 mm, Ø 3.75 mm) made by Bego
Semados S (Bego) were inserted. A total of 40 implants
were placed in four models. The digital planning of
the implant position was carried out with the program
Implant3D (Implant3D). The models were scanned by
computed tomography (CT) (Aquilion, Toshiba), which
is equipped with a 512 × 12-pixel matrix and a special
scan protocol for dental implants. A spiral scan of 0.5-mm
slice thickness was conducted for ultra-high-resolution
images with a voxel size of 0.033 mm.
384 Volume 33, Number 2, 2018
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Fig 1  Matching library program. (a, b)
2D–3D reconstruction. (c, d) Axial view. (e,
f) Sagittal view. (a, c, e) Inverse planning by
superposing the radiopaque implants in the
post CT scan (blue scheme), (b, d, f) including
the implant position in the preplanning CT
scan (orange scheme).
Fig 2  (Below) Illustration of measured de-
viations. (a) Radial deviation in the x-, y-axis
(dashed lines) corresponds to the lateral er-
ror of the implant base and implant apex.
(b) Depth deviation in the z-axis (dashed line)
corresponds to the depth error. (c) Angular
deviation corresponds to the angle between
the two thick red lines.
Implant base
∆xy
Implant apex
∆z
a b c
Subsequently, the planned implant position was
transferred from CT Image 1:1 onto the template. For
the mechanical positioning, the Hexapod X1med3D
(Georg Schick Dental) was used. The fixation of the drill-
ing template on the edentulous alveolar ridge was cre-
ated through the use of osteosynthesis screws (9 mm
in length and 1.5 mm in diameter) by 3-point fixation
on the facial aspect of the mandible near the depth of
the vestibule in the locations of the left and right first
molar and the right central incisor area. In the control
group, the template was fixed by hand during surgery.
The osteotomy to insert the implants was made ac-
cording to the following drilling protocol:
• First drilling: Pilot Drill Ø 1.6 mm, length 24 mm
• Dilatation drilling: TriSpade Ø 2.5 mm, length 20 mm
• Final drilling for implants S 3.75: TriSpade Ø 3.25 mm,
length 20 mm
• Tappers, ratchet for implants S 3.75

Table 1   Depth, Lateral Error, and Angular Deviation Between Planned and Final Implant
Position
Median
Depth error (mm)
Implant base
  FG (n = 20) 0.44
  HFG (n = 20) 0.52
Lateral error (mm)
Implant base
  FG (n = 20) 0.47
  HFG (n = 20) 0.49
Implant apex
  FG (n = 20) 0.86
  HFG (n = 20) 0.77
Angular deviation (in degrees)
  FG (n = 20) 3.41
  HFG (n = 20) 2.76
Data are given as median and range (minimum–maximum).
FG = screw-fixed template group; HFG = hand-fixed template group.
The implantation was carried out with a Bego drill-
ing set. A torque wrench with a defined torque (30
Ncm) was applied in all 40 implants.
After implantation, the differences between the
planned and postoperative implant positions were
evaluated with the help of the matching library pro-
gram developed by the company, med3D (Fig 1). The
absolute differences were calculated for the implant
base and the implant apex. According to those mea-
suring points, three deviations could be defined as fol-
lows: (1) the depth error at the implant base as depth
deviation in the z-axis; (2) the lateral error at the im-
plant base and at the implant apex as radial deviation
in the x-, y-axis; and (3) the angular deviation (Fig 2).
Statistics
Data were not normally distributed. Data are given as
median (range; minimum–maximum). By using stan-
dardized models, it can be assumed that the model
itself does not affect the accuracy at all. That is why
the placement of 10 implants in each of the four
models was considered as independent samples. The
Mann-Whitney U test was performed for comparison
of the absolute differences of depth and lateral error
as well as the angular deviation between the planned
and final implant positions for the screw-fixed group
(FG) and the hand-fixed group (HFG). The Wilcoxon
matched paired test was performed for comparison of
the relation of radial implant base deviation to radial
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Kauffmann et al
P value
Range (Mann-Whitney U test)
0.03–1.54 .53
0.06–1.69
0.05–1.31 .47
0.10–1.11
0.21–1.68 .85
0.16–1.86
0.48–5.79 .53
0.32–7.54
implant apex deviation in the x-, y-axis within the FG
and the HFG. A P value < .05 was determined for statis-
tical significance. Statistica 8.0 software (Statsoft) and
GraphPad Prism 5 Software (GraphPad Software) were
used.
RESULTS
The main results of depth and lateral error as well as
the angular deviation for implant base and apex posi-
tions are shown in Table 1.
The median implant base depth error difference be-
tween the FG and the HFG was 0.08 mm and without
statistical significance (Fig 3). The median lateral error
differed slightly more, but the difference was not sta-
tistically significant in the implant apex measurements
compared with the implant base measurements (Fig 4).
The angular deviation was lower in the HFG without
statistical significance (Fig 5).
Within the FG and HFG were significant differences
between the relation of radial implant base deviation to
radial implant apex deviation. The significance was stron-
ger for the HFG (P = .033 for FG and P = .001 for HFG).
Over all 40 implants, the median depth error was
0.45 (0.04 to 1.68) mm, the median lateral error for the
implant base was 0.48 (0.06 to 1.31) mm, and 0.82 (0.17
to 1.86) mm for the implant apex. The median angular
deviation was 3.1 (0.32 to 7.54) degrees.
The International Journal of Oral & Maxillofacial Implants 385
Kauffmann et al

Depth error
DISCUSSION
2.0

In this model study, the depth, lateral, and angular

1.5
deviations between the planned and final implant po-
Deviation (mm)

sition showed no significant difference between a tem-

1.0 plate fixation with screws in comparison with a fixation
by hand. The template fixation by hand was related to
0.5 a significantly stronger radial deviation tendency from
the implant base to the implant apex compared with
0 the temporary template fixation with screws.
FG HFG
Implant base
All results should be interpreted with caution be-
cause of the limited sample size of 20 implants for each
Fig 3   Depth error (depth deviation in the z-axis) between the group, whereby Tahmaseb et al showed in a systematic
planned and final implant base position of the screw-fixed group review comparable or even much lower sample sizes in
(FG) and hand-fixed group (HFG). Data are given as median and
range. Deviation between planned and final implant base posi- model studies of computer technology applications in
tion is given in mm. surgical implant dentistry.18
The precision of the image-guided procedure is de-
fined as the deviation in localization and the angular
2.0 Lateral error deviation of the planning, compared with the imple-
mented result, and includes all possible individual er-
1.5 rors, from the image data extraction to implantation
Deviation (mm)

itself. The errors are cumulative and interactive.9

1.0 The overall accuracy of the present study is the sum
obtained from the following: the determined inher-
0.5 ent errors of CT of 0.63 mm, the image resolution of
0.26 mm, and the template production of 0.1 mm. The
0
software can be disregarded. The determined value of
FG HFG FG HFG 0.99 mm is consistent with previous studies.19,20
Implant base Implant apex The estimated deviations of the present work corre-
spond to the common literature and confirm the preci-
Fig 4   Lateral error (radial deviation in the x-, y-axis) between
the planned and final implant base position (left two boxplots) sion of drilling templates described by other working
and implant base apex position (right two boxplots) of the screw- groups.20 Tahmaseb et al reported in a systematic re-
fixed group (FG) and hand-fixed group (HFG). Data are given as view an overall accuracy between the planned and ac-
median and range. Deviation between planned and final implant
base and apex position is given in mm, respectively. tual positions of 1.12 mm in the horizontal deviation at
the entry point in 1,530 implants.18 For the mean apex
deviation of 1,465 implants, 1.39 mm was calculated,
and 3.89 degrees was calculated for the angular devia-
8 Angular deviation
tion of 1,854 implants.18 Furthermore, in the Tahmaseb
review, the data for model studies were reported sepa-
Deviation (degrees)

6 rately. In 74 implants, the lowest and the highest mean

base deviations were 0.025 and 1.38 mm, the lowest
4 and highest mean deviations at the implant apex were
0.34 and 1.39 mm, and the lowest and highest reported
2 mean angular deviations were 0.7 and 2.16 degrees, re-
spectively.18 Apart from the angular deviations of the
0 present study, which were higher only compared with
FG HFG the reported model studies, not for all reported studies
in the quoted review paper, the resulting average accu-
Fig 5   Angular deviation between the planned and final implant racy of this study was in accordance with the transmis-
position of the screw-fixed group (FG) and hand-fixed group
(HFG). Data are given as median and range. Deviation between
sion accuracy of previous studies.18,20
planned and final implant position is given in degrees. Several groups already have investigated the
accuracy of the computerized production of tem-
plates.5,20–25 The precision accuracy in the range of 0.5
to 1 mm emphasizes the reliability of template systems
for the clinical application of implants.20,25,26 Widmann

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and Bale postulate that human error may affect the
image data acquisition, planning, and transfer phases.
The positioning of the registration markers, the mo-
tion-free CT data acquisition, the precise planning, the
verification of the registration accuracy, and the con-
tinuous control of the stable and secure fit of the tem-
plate or the reference frame are essential.9
Ruppin et al stated that the evaluation of the im-
plants, predrilled osteotomies, and evaluation of the
method itself should be considered for the interpreta-
tion of results.27 In the present study, no difference in the
fixation methods could be detected. However, it can be
assumed that an even more realistic simulation model
can provide the advantages of a fixed template variant,
based on implantation accuracy. Although the anatomi-
cal bone structures and the resilient mucosa are repro-
duced exactly,17 it remains a phantom study where it is
not possible to consider individual anatomical criteria
such as salivation, the soft tissue situation, or the mobile
tongue. The perfect template fixation within a patient’s
mouth will be more difficult than in the present study.
Widmann et al showed that a three-point fixation
in an edentulous human cadaver might provide simi-
lar accuracy as reported for tooth-supported surgical
templates.28 Even though fixation on existing teeth
is sufficient, the question of fixing the surgical tem-
plate with miniscrews on an edentulous arch is still
largely unanswered.29 Because of precision errors in
the edentulous arch, earlier studies recommended
the fixation of the template with bone screws.9,30 Sys-
tematic studies on template mobility, the temporary
insertion of miniscrews and success rates, depend-
ing on the implantation of the fixation mode, are still
missing. Widmann and Bale recommend attaching
the template with miniscrews to the dental arch to
avoid the risk of unnoticed loosening of the modified
template. For the adequate use of the drilling tem-
plate for edentulous patients or in the distal free-end,
it is necessary to fix the template with bone screws.9
Widmann and Bale compare the static and dynamic
methods and report differences up to 0.5 mm in drill
navigation and up to 0.4 mm in the template tech-
nique, in a comparison between the patient case and
the model situation. These values are also reflected in
recent studies.20 If the drilling side of the template is
fixed by hand, it can affect the opposite side of the
template, like unnoticed lifting. In cases where im-
plants are planned in the molar region, the template
is usually held in the front, which can lead to the lift-
ing of the distal portion. This is difficult to observe and
verify and may lead to an incorrect positioning of the
implant. In the present study, the relation of radial im-
plant base error to radial implant apex error was more
significantly different in the hand-fixed group than in
the fixed group. That indicates a better control of the
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Kauffmann et al
drill in the depth in the group with the screw-fixed
template. Consequently, in cases demanding a high
depth precision in order to avoid, for instance, nerve
damage in the mandible, the fixation of the drilling
template could lead to better implant results. Another
aspect where a template fixation for the aforemen-
tioned reason could be useful is in situations where
different and even low bone qualities can lead to dif-
ficulties in controlling depth drilling.
The secure anchoring of the template to existing
dentition or the bone has to be considered as an ad-
vantage. Currently, osteosynthesis or interim implants
are available. Without the use of these, the overall sys-
tem inaccuracies in clinical use, in an edentulous arch,
are classified as significantly larger.4,9,25,31 Tardieu et al
showed a clinical case for the supply of the mandible
using a stereolithographic surgical template. After
preparation of the mucosa, the template was fixed with
bone screws directly on the exposed bone to avoid
slipping during drilling.30 In the case of inadequate
bone anatomy, the CT scan should be used to plan
ahead for the most ideal location for template fixation
with bone screws. Unnecessary weakening of the bone
near the implant site or the impediment of the implan-
tation procedure by unfavorable positioning of the
auxiliary implant can be avoided. It is well-known that
the temporary auxiliary bone screws frequently block
implant positions for the definitive implant placement.
In particular, in highly atrophied and edentulous arch-
es, there is only limited alveolar residual ridge volume,
which must be used in its entirety for the implant po-
sitioning. Additional provisional implants often have
no space. A palatal or vestibular fixation should be pre-
ferred because it allows the implant capable jaw ridge
to be untouched. A classification of the anchor points
in indications with essential template fixation needs
to be postulated. Further in vivo studies are needed to
make a decision in anatomically difficult situations.
CONCLUSIONS
The comparison between the screw-fixed and hand-
fixed approaches in the Goettingen study model of
the lightly atrophic edentulous mandible showed no
significant differences in this study. The results of this
study indicate that in cases demanding a high depth
precision in order to avoid, for instance, nerve damage
in the mandible, the screw fixation of the drilling tem-
plate can be helpful for better implant results.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
The International Journal of Oral & Maxillofacial Implants 387
Kauffmann et al
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