Margareta Hultin Clinical advantages of computer-

Krister G. Svensson
Mats Trulsson
guided implant placement: a system-
atic review

Authors’ affiliations: Key words: complications, computer guided, dental implants, implant dentistry, implant treat-
Margareta Hultin, Division of Periodontology, ment
Department of Dental Medicine, Karolinska
Institutet, P.O. Box 4064, SE-141 04, Huddinge,
Sweden Abstract
Krister G. Svensson, Mats Trulsson, Division of
Prosthetic Dentistry, Department of Dental
Objectives: To systematically scrutinize the current scientific literature regarding the clinical
Medicine, Karolinska Institutet, P.O. Box 4064, advantages of computer guidance of implant placement.
SE-141 04, Huddinge, Sweden Materials and methods: Four electronic databases were searched using specified indexing terms.
Corresponding author: The reference lists of publications were also searched manually. For inclusion, publications had to
Dr Margareta Hultin meet pre-established criteria.
Department of Dental Medicine Results: The searches yielded 1028 titles and abstracts. After data extraction and interpretation, 28
Karolinska Institutet
P.O. Box 4064 publications and 2 systematic reviews remained for inclusion. Fifteen studies were prospective
SE-141 04 Huddinge observational and four were retrospective observational. Nine studies included a control group
Sweden (controlled clinical trials) of which seven were prospective and two retrospective. Only three of the
Tel.: +46 8 52488248
Fax: +46 8 7118343 prospective studies were randomized (RCT’s). A total of 852 patients were treated with 4032
e-mail: Margareta.Hultin@ki.se implants using computer-guided implant surgery. The number of patients included in each study
ranged from 6 to 206. The age ranged from 16 to 92 years and the follow-up period varied
Conflicts of interest:
The authors have not declared any potential between 1 and 49 months.
conflicts. Conclusions: The limited scientific evidence available suggests that guided placement has at least
as good implant survival as conventional protocols. However, several unexpected procedure-linked
adverse events during guided implant placement indicate that the clinical demands on the surgeon
were no less than those during conventional placement. A clinical advantage with flapless guided
surgery is that the technique is likely to decrease pain and discomfort in the immediate
postoperative period.

Today, insertion of dental implants is a ideal implant placement according to the

Date:
Accepted 09 June 2012
To cite this article:
Hultin M, Svensson KG, Trulsson M. Clinical advantages of
computer-guided implant placement: A systematic review.
Clin. Oral Implants Res. 23 (Suppl. 6), 2012, 124–135
doi: 10.1111/j.1600-0501.2012.02545.x
routine method for the rehabilitation of par-
tially and completely edentulous jaws. Long
term follow-up has shown successful results
in a substantial number of long term studies
(Albrektsson et al. 1988; Lekholm et al.
1999; Ekelund et al. 2003; Pjetursson et al.
2004; Jemt & Johansson 2006).
In rehabilitation of tooth loss with dental
implants, a thorough preoperative planning is
an important requirement for a successful
restorative result. Using traditional surgical
protocols the pre-surgical planning includes
radiographic assessment of accessible bone
volume/anatomic structures which in most
cases is determined by periapical and
panoramic radiographs. Implant positioning
is evaluated by a combined judgement of
bone volume on radiographs, by visual
inspection of the alveolar crest in the oral
cavity and on study casts. In some cases the
implant position at surgery can be indicated
by using acrylic templates demonstrating the
outline of the permanent prosthesis.
However, the final seating of implants
depends in general on the skills and experi-
ence of the dental surgeon.
During the last decade, the technique for
implant insertion has developed mostly due
to achievements in radiographic three-dimen-
sional (3D) imaging technique and computer
technology (Jung et al. 2009; Schneider et al.
2009; D’haese et al. 2010). The techniques
providing 3D digital information with respect
to anatomical and prosthetic parameters
using computed tomography (cone beam-CT/
CBCT) and 3D implant planning software
have developed rapidly during the past
decade. Together with the advances in CAD/
CAM (Computer-Aided Design/Computer-
Assisted Manufacturing) technique, digital
data from the surgical plan can be transferred
to the actual clinical settings using computer-
milled templates or stereolitographic surgical
guides. Computer navigation systems, where

124 © 2012 John Wiley & Sons A/S


implants are guided to their preplanned posi-
tion with optical assistance and real-time
tracking, is an alternative method also allow-
ing computer-controlled implant placement.
Since the implants during surgery using these
two digital methods can be “computer
guided” to their planned position, mucosal
flap elevation for inspection of bony anatomy
is not needed. A flapless surgical procedure
may therefore be used applying these meth-
ods (Brodala 2009; Hämmerle et al. 2009). In
addition, using the linkage of transferring the
exact positioning of implants from the presur-
gical plan to the dental laboratory a prefabri-
cated fixed prosthesis can be manufactured
for immediate function of the inserted
implants.
This technique was primarily aimed at
improving diagnostic, surgical and prosthetic
precision. However, since the trend in
implant dentistry today has focused mainly
toward a rapid and simplified use, several
commercially systems are at present avail-
able for clinical use where computer-guided
implant placement can be implemented in a
complete sequence from the flapless surgical
technique to immediate load with a prefabri-
cated fixed prosthesis. The new concept is
launched as being safe, predictable, causing
minimal discomfort during periods of healing
in combination with a reduced “chair time”
for treatment.
Theoretically, the concept of computer-
guided implant placement may offer several
clinical advantages in individual patient
cases (Hämmerle et al. 2009; Sanz & Naert
2009). For example, bone augmentation
procedures may be avoided or reduced by
optimizing implant positioning in accessible
bone (Fortin et al. 2009). By providing the
clinician with realistic information of the
bony anatomy as well as information of the
prosthesis outline, an ideal implant place-
ment can be virtually executed also in a
prosthetically driven manner. As such, an
optimal positioning may positively affect
the final prosthesis function, speech and
aesthetics.
The flapless surgical technique is consid-
ered to cause less damage to the host and
could as such be of advantage for clinically
vulnerable patients, for example irradiated
patients (Horowitz et al. 2009) or when
extensive bone grafting has been applied (Bar-
ter et al. 2010). The minimally invasive sur-
gical technique may therefore be of
advantage in selected patient cases. Patients
with fear and dental anxiety may also benefit
from the flapless procedure since the surgical
procedure is shortened and may give less
© 2012 John Wiley & Sons A/S
Hultin et al
Computer-guided implant placement, clinical advantage
postoperative discomfort, swelling, and pain
(Nkenke et al. 2007).
By using the link of transferring the exact
positioning of implants from the presurgical
planning to the dental laboratory the CAD/
CAM technique has made it possible to man-
ufacture a prefabricated fixed prosthesis
which can be directly connected to the newly
inserted fixtures. The advantage of such pro-
tocol is obvious in that the time of edentu-
lism for the patient has been reduced giving
immediate function and aesthetics (van
Steenberghe et al. 2005; Sanna et al. 2007).
However, introducing new treatment
methods for clinical use is in most cases a
challenging process. When implant therapy
was introduced more than 50 years ago, this
was performed under well-controlled clinical
conditions where each change in the treat-
ment concept first was evaluated in long-
term observational clinical trials before any
change in the protocol was introduced. This
was likely a major contributing factor for
success. Therefore, research introducing new
techniques should always be executed on the
highest level of evidence, i.e., in randomized
controlled clinical trials or controlled clini-
cal trials which allow comparison to conven-
tional treatment procedures. In the rapid
development of computer technology, which
already has influenced the traditional treat-
ment concept of planning and implementing
the different treatment steps of implant
reconstruction, the clinical benefit of com-
puter-guided implant placement has to be
consistently evaluated. Otherwise the com-
mercially driven marketing may lead to
unrealistic clinical expectations for the clini-
cal efficacy and ease of use of these develop-
ing techniques. In addition, to give a
realistic understanding of a new technique,
assessments must include cost effectiveness
as well as patient-centered outcomes. The
aim of the present review was therefore to
systematically scrutinize the current scien-
tific literature regarding the clinical advanta-
ges of computer guidance of implant
placement.
Materials and methods
Review of the literature – description of
methods
To ensure a systematic approach, the review
of the literature comprised the following
steps: definition of research questions to be
addressed, formulation of a strategy for the
electronic database search, literature search/
retrieval of publications, data extraction, and
evaluation of relevant information.
125 |
Definition of questions to be addressed
The following questions were to be
addressed, with reference to methods for
rehabilitation of tooth loss in adult patients
with dental implants:
Is there scientific evidence to support that
there is a clinical advantage using computer-
guided implant placement compared to con-
ventional treatment protocols regarding the
following questions:
• Technical and biological complications?
• Implant and prosthesis survival rates?
• Immediate function?
• Postoperative sequel?
• Patient-centered outcomes?
• Duration of treatment?
• Cost-effectiveness?
• Avoidance of bone augmentation, by opti-
mal implant positioning?
• Surgical trauma (e.g. in specified groups
of patients/clinical conditions)?
Search strategy and selection criteria for
electronic database search
References for this review were identified by
searches of: Cochrane, Embase.com (1974 to
the present), Medline/PubMed (1950 to the
present) and Web of Science (1945 to the
present). The searches were made in October
2011 with the MeSH terms “Surgery,
Computer-Assisted”, “Therapy, Computer-
Assisted”, “Dental Implantation, Endos-
seous”, “Dental Implants” and the Emtree
terms “Tooth implantation”, “Computer
assisted surgery”. Several free text terms like
“Implant treatment” and “Computer guided”
were added to all of the searches. The
MEDLINE-searches were limited to Human,
most terms were truncated and different
proximity operators were used. No language
restriction was made. Search date was set to
2011-10-01. Both original research and sys-
tematic reviews were included.
Literature search, inclusion and exclusion
criteria
The search which was held wide, covered
four electronic databases, yielded 1028 titles
and abstracts. Prior to reading the retrieved
abstracts, consensus was reached on criteria
to be applied for further full text evaluation
of a publication (Appendix 1).
For evaluation of clinical performance in
observational studies, randomized controlled
or comparative studies, a study population of
at least five patients in each group had to be
included.
For evaluation of implant and prosthesis
survival, patients had to be clinically assessed
after at least 12 months of follow-up.
Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
Hultin et al
Computer-guided implant placement, clinical advantage

However, for evaluation of surgical or pros-
thetic complications during implant insertion
or assessment of patient-centered outcomes
of the surgical intervention and immediate
postoperative period, a specific time period of
follow-up was not defined.
To be selected, at least one of the following
parameters had to be assessed: clinical, radio-
graphic, patient centered/health economy.
Excluded from this review were studies not
reporting on the above listed outcome vari-
ables and case reports including less than five
patients. Studies reporting on zygoma/ptery-
goid implants, mini implants for orthodontic
anchorage, and radiographic evaluation on
accuracy of implant positioning were also
excluded for this review.
Data extraction, interpretation, and evaluation
of evidence from retrieved literature
Three assessors independently read the arti-
cles and recommended inclusion or exclu-
sion according to the predetermined criteria.
When at least one author considered that a
publication met the initial inclusion criteria,
the paper was ordered and read in full text
version. A second step of the search con-
sisted of a manual search of the reference
lists of included publications. When the
screening process was completed, the studies
remaining as eligible for inclusion were
tabulated.
Results
Literature search
Figure 1 depicts a flow chart of the selection
process for publications relevant to our
review. The first step of the search, using a
series of combined search terms, yielded
1028 abstracts, of which 62 met the initial
inclusion criteria and were thus read in the
full text version: 29 were potentially original
studies and 33 were case reports/and or
methodological studies including less than 5
patients, or studies reporting on implant posi-
tioning/accuracy. Two systematic reviews
were retrieved, which met the inclusion cri-
teria by evaluated endpoint variables and
were thus included. Manual search of refer-
ence lists and systematic reviews gave one
additional publication for inclusion.
Of 63 publications evaluated in full text,
28 original studies and 2 systematic reviews
were finally included. The major reason for
exclusion of studies was that they focused on
accuracy of implant positioning (12 of 33).
Two other grounds for exclusion of studies
were: case series including <5 patients/
follow-up <12 months (9 of 33) and methodo-
logical discussions/consensus statements (6
of 33) (see Appendix 2).
Demographics of studies included
Twenty-eight original studies published
between 2005 and 2011 and one manuscript
not yet published (D’haese 2011) provided
information about clinical, radiographic or
patient-based outcomes using computer-
guided implant placement (see Table 1). More
than half of the studies (15 of 28) were pro-
spective observational studies and four were
retrospective observational studies. Nine
studies included a control group, and were
regarded as controlled clinical trials; seven
prospective and two retrospective. Only three
of the prospective studies were randomized
(RCT’s).
A total number of 1086 patients with 4900
implants were included in the studies for
review. Of these, 852 patients were treated
with 4032 implants using computer-guided
implant surgery. The age ranged from 16 to
92 years and the follow-up period ranged
from 1 to 49 months. The number of patients
included in each study ranged from 6 to 206
(Table 1).
Two studies used dynamic-guided sys-
tems (Wittwer et al. 2007a,b) while 25 used

Electronic search

1028 titles and abstracts Exclusion of 966 titles and abstracts

Three reviewers independently

selected 62 full text articles Exclusion of 33 full text articles
for further review not full filling stated criteria

A total number of 29 full text articles

which full filled predetermined
inclusion criteria

Hand search of reference lists and

systematic reviews gave in addition:
1 full text article

Total number of publications included:

28 original articles,
2 systematic reviews

Fig. 1. Flow chart of search process and retrieval of publications corresponding to selected inclusion and exclusion criteria.

126 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135 © 2012 John Wiley & Sons A/S
 Hultin et al
Computer-guided implant placement, clinical advantage

Table 1. Study demographics

After dropouts
No. of patients Follow up
Study Total no. with guided Gender Patient Total no. No. of impl with Mean age period,
Study design of patients surgery F/M dropouts of implants guided surgery (range), years months
Abad-Gallegos RO 19 19 5/14 NA 122 122 61.9 (45–79) NR
et al. (2011)
Arisan et al. PC* 52 31 27/25 0 341 200 48.4 (28–63) 2–4
(2010)
Barter et al. PO 6 6 4/2 0 43 43 63 (54–71) mean 49
(2010)
Berdougo RC* 169 99 111/58 NA 552 271 53.1 (20–84) 12–48
et al. (2010)
Cassetta et al. RO 10 10 3/7 NA 111 111 54 (NR) NA
(2011)
Danza et al. RC* 93 8 58/35 NA 300 66 median 48 (16–89) 1–41 (mean
(2009) 14)
D´haese (2011) PO 26 26 10/16 0 114 114 51.8 (20–81) 12
Di Giacomo PO 12 12 8/4 0 62 62 16 (41–71) 30
et al. (2012)
Fortin et al. RCT* 60 30 38/22 0 152 80 NR (19–82) NA
(2006)
Fortin et al. PO 11 11 7/4 0 42 42 NR (44–75) 48
(2009)
Gillot et al. PO 33 33 21/12 0 211 211 61.2 (46–80) 12–51
(2010)
Johansson PO 52 52 ratio 2/3 4 312 312 72 (37–85) 12
et al. (2012)
Katsoulis et al. PC* 40 17 16/24 0 195 85 61 (47–78) 3
(2011)
Komiyama PO 29 29 9/20 0 176 176 71.5 (42–90) 6–44
et al. (2008) (mean  15)
Komiyama PO 34 34 NR 5 cases 165 165 71.9 (44–92) >12 (mean
et al. (2012) 19)
Lindeboom & RCT 16 16 13/3 0 96 96 56.7(NR) 1
van Wijk
(2010)
Malo et al. PO 23 23 NR 0 92 92 NR (NR) 6–21 (mean
(2007) 13)
Meloni et al. RO 15 15 10/5 0 90 90 NR (40–70) 18
(2010)
Merli et al. PO 13 13 9/4 1 89* 89* 62 (44–80) 8
(2008)
Mischkowski PC 206 206 NR NR 746 746 NR (NR) 6
et al. (2006)
Nikzad & Azari PO 16 16 7/9 0 57 57 51.9 (42–66) 12
(2010)
Nkenke et al. PC* 10 5 2/8 0 60 30 65 (55–75) 12
(2007)
Pomares (2010) RO 30 30 24/6 0 195 195 53 (36–84) 12
Sanna et al. PO 30 30 12/10 4 183 183 56 (38–74) 6 - 60 (mean
(2007) 26)
van PO 27 27 NR 3 164 164 63 (34–89) 12
Steenberghe
et al. (2005)
Wittwer et al. RCT 16 16 NR 0 64 64 63.4 (56–77) NA
(2007a)
Wittwer et al. PO 25 25 9/16 3 88 88 62.1 (55–77) 24
(2007b)
Yong & Moy PO 13 13 7/6 0 78 78 67.5 (NR) mean 27
(2008)
Total: 1086 852 4900 4032

PC = Prospective comparative; PO = Prospective observational; RC = Retrospective comparative; RO = Retrospective observational; RCT = Randomized control
trial; NA = Not applicable ; NR = Not reported
*
=Control group included conventional

static-guided systems for computer-assisted
placement of implants. The Nobel Guide sys-
tem was the most commonly used (15 of 28)
although several different systems have been
applied (see Table 2). One study used both
static and dynamic systems (Mischkowski
et al. 2006).
The surgical procedure to install the
implants included a flapless technique in all
studies. However, three studies (Arisan et al.
2010; Lindeboom & Wijk 2010; Cassetta
et al. 2011) also used an open flap guided sur-
gery approach in some cases.
In 15 of the 28 studies immediate loading
of the guided placed implants with a fixed

© 2012 John Wiley & Sons A/S 127 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
Hultin et al
Computer-guided implant placement, clinical advantage

Table 2. Case types and complications and failures in patients with guided placed implants

128 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135 © 2012 John Wiley & Sons A/S

prosthesis was carried out. In five studies a
delayed loading protocol was used. Two stud-
ies included cases of both immediate and
delayed loading (Abad-Gallegos et al. 2011; D
′haese. 2011). Six studies did not report on
the type of implant loading (Table 2).
The majority of the studies (20 of 28)
included treatment of completely edentulous
jaws whereas only five studies comprised par-
tially edentulous cases. Six studies did not
report on the type of cases treated. Both max-
illas and mandibles were treated. For detailed
distribution of types of cases treated see
Table 2.
Technical and biological complications
The total number of reported complications
or unexpected events at guided implant and
prosthesis placement was 115. A majority of
these (69%, n = 79) could be referred to
the surgical procedure and 31% (n = 36) to
the immediate connection of the prosthesis.
The most common surgical complication
was fracture of the surgical guide (reported in
six studies) and the most common prosthetic
complication was misfit of the prosthesis
(reported in eight studies). However, nine
studies did not report on early complications
(see Table 2). Of the six studies with control
groups using conventional surgical protocols
(see Table 1), only two (Nkenke et al. 2007;
Arisan et al. 2010) reported on complica-
tions/unexpected events during implant
placement; Arisan et al. (2010) showed no
complications among the controls but 2
unexpected events (surgical guide fracture)
during guided implant placement. Nkenke
et al. (2007) had no complications or unex-
pected events for any of the patients
included.
Reported complications after guided
implant placement were in total 168. Sixty-
four percent (n = 107) of these were implant
failures and the total implant failure rate was
thus 3%. Thirty-six percent (n = 61) of the
failures referred to the prosthesis. The most
common prosthetic complication was pros-
thesis fracture (reported in 11 studies). Six
studies did not report on complications after
guided placement (see Table 2). The two
studies comparing guided placement and con-
ventional surgical protocol found no differ-
ences between groups regarding implant
failure (Nkenke et al. 2007; Arisan et al.
2010) or prosthesis complications (Nkenke
et al. 2007).
Implant and prosthesis survival rates
Only studies with a mean follow-up of
patients of at least 12 months were included
© 2012 John Wiley & Sons A/S
Hultin et al
Computer-guided implant placement, clinical advantage
for evaluation of the outcome variables
implant and prosthesis survival (Table 3).
This resulted in a total number of 18 studies
of which 17 used a static/template-based sur-
gical approach for guided implant placement.
Only one study presented outcomes after use
of dynamic/navigation system in edentulous
mandibles (Wittwer et al. 2007b).
Most of the studies were observational
cohort studies with a prospective design (15
of 18) (see Table 1). Three studies were iden-
tified comparing treatment outcomes
between guided implant placement and
implant placement without computer guid-
ance (Nkenke et al. 2007; Danza et al. 2009;
Berdougo et al. 2010). Just one of the compar-
ative studies was of prospective design
(Nkenke et al. 2007). This study included 10
patients with edentulous maxillas with 5
patients in each group.
A total number of 465 patients treated
with 2263 implants placed computer guided
were evaluated after a mean of at least
12 months (see Table 1). A protocol of imme-
diate loading of implants inserted was used
in a majority of studies (14 of 18). Although
definition of implant or prosthesis survival
was not consistently described, it was in
most studies equivalent to implants and ori-
ginal prosthesis in place after 1 year. Implant
survival rate was reported in all studies with
a follow-up  12 months although prosthesis
survival rate was only reported in 10 of 17
studies (Table 3).
Implant survival after 1 year ranged
between 89 and 100% (study mean 97%) and
the corresponding prosthesis survival between
62 and 100% (study mean 95%). In the three
studies including control groups using
conventional surgical protocols (Nkenke
et al. 2007; Danza et al. 2009; Berdougo et al.
2010) no differences in implant survival rates
could be seen. The only comparative study
reporting on prosthesis survival showed no
difference in survival between guided and
non-guided protocols (Nkenke et al. 2007)
(Table 3). In addition, no obvious difference
in implant survival rate was observed
between studies using an immediate or
delayed loading protocol. Prosthesis survival
was not reported in studies using delayed
loading protocols (Table 3).
Five studies with follow-up of 1 year have
used a protocol of static-guided implant
placement in combination with the connec-
tion of a prefabricated permanent fixed pros-
thesis for immediate loading (van
Steenberghe et al. 2005; Sanna et al. 2007;
Komiyama et al. 2008; Yong & Moy 2008;
Johansson et al. 2009). A summary of the
129 |
outcome in these studies is presented in
Table 4. The limited amount of data avail-
able for this treatment protocol indicates no
difference in implant survival rate compared
to other prosthetic protocols. However, the
reported occurrence of complications or
unexpected events at prosthesis placement
(27 events in 114 patients/cases) was more
than twice as common as when prefabricated
temporary or chair-side adjustable permanent
fixed prosthesis were used for immediate
loading (11 events in 128 patients/cases, see
Tables 2 and 4). Only three of the five stud-
ies reported prosthesis survival rate (range 84
–100%).
Patient reported outcome measures
Seven original studies were identified that
reported on patient-centered outcome mea-
sures (see Table 5). Three of these were
observational studies (two prospective and
one retrospective), two were prospective com-
parative studies and two were RCT’s.
The three observational studies used VAS-
scales or a verbal scale to evaluate different
aspects on patient-centered outcomes after
flapless guided surgery. Generally, good
scores were reported on patient comfort and
pain after surgery and patient satisfaction
with oral functions after 3–12 months
(Steenberghe et al. 2005; Nikzad & Azari
2010; Abad-Gallegos et al. 2011).
Two of the controlled studies (one compar-
ative and one RCT) evaluated a patient group
after flapless guided surgery and compared
the results with a control group treated with
conventional implant surgery (Fortin et al.
2006; Nkenke et al. 2007). The other compar-
ative study evaluated three patient groups;
two with guided surgery (flapless and open
flap) and one with conventional implant sur-
gery (Arisan et al. 2010). In the second RCT,
two types of guided surgical techniques (with
and without elevation of a flap) were used
(Lindeboom & Wijk 2010).
Except for the study by Lindeboom & Wijk
(2010), all of the controlled studies used VAS-
scales to evaluate the patient reported out-
come measures. These three studies consis-
tently reported that flapless guided surgery
generated less pain for shorter period of time
compared to the open flap techniques (Fortin
et al. 2006; Nkenke et al. 2007; Arisan et al.
2010). This was evaluated both in terms of
self-assessed pain at the day of surgery and
during the following week, as well as number
of analgesics consumed. Furthermore, the
patients treated with the flapless guided sur-
gery also reported less edema, hematoma,
hemorrhage, and trismus (Fortin et al. 2006;
Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
Hultin et al
Computer-guided implant placement, clinical advantage

Table 3. Outcome in studies using static guided systems with mean follow-up  12 months
Survival rate
Immediate/Delayed
loading Implants Prosthesis

With Without With Without With Without Follow-up

guided guided guided guided guided guided period,
Study placement placement placement placement placement placement months Other outcome
Barter et al. NR NR 98% NA 100% NA Mean 49
(2010)
Berdougo et al. NR NR 96% 99% NR NR 12–48
(2010) *
Danza et al. I/D I/D 100% 96% NR NR 1–41
(2009) * (mean 14)
D´haese (2011) I/D NA 89% NA 62% NA 12 99% impl. surv. rate in nonsmokers and
74% in smokers. Smoking and immediate
loading in combination in edent. maxillas
increased impl. loss
Di Giacomo I NA 96% NA 92% NA 30
et al. (2012)
Fortin et al. D NA 98% NA NR NA 48
(2009)
Gillot et al. I NA 98% NA 100% NA 12–51 Removal and replacement of adjustable
(2010) abutments used in the temporary
prosthesis were unpleasant for the
patients
Johansson et al. I NA 99% NA 96% NA 12 Mean marginal bone loss of 1.3 mm. 19%
(2009) of the subjects had >2 mm bone loss.
Mucosal inflammation in 23% of probed
sites
Komiyama et al. I NA 89% NA 84% NA 6–44 Bleeding on probing: 82% (16–100). Bone
(2008) (mean  15) loss more common when pressure-like
mucosal ulcers was detected under the
prosthesis
Malo et al. I NA 98% NA NR NA 6–21 (mean 21% of all measured sites at 6 months and
(2007) 13) 28% at 12 months had >2 mm
radiographic bone loss
Meloni et al. I NA 98% NA 87%‡ NA 18 Mean marginal bone loss of 1.6 mm after
(2010) 18 months
Nikzad & Azari D NA 96% NA NR NA 12 Mean pain score on VAS-scale at the
(2010) follow-up was within the range for little or
no pain
Nkenke et al. I I 100% 100% 100% 100% 12 Guided surgery generated less
(2007) * postoperative pain and swelling compared
to open flap surgery
Pomares (2010) I NA 98% NA 100% NA 12
Sanna et al. I NA 95% NA NR NA 6–60 Mean marginal bone loss of 2.6 mm in
(2007) (mean 26) smokers and 1.2 mm in non-smokers
van Steenberghe NA 100% NA 100% NA 12 Mean marginal bone loss of 1.2 mm mesial
et al. (2005) and 1.1 mm distal
Yong & Moy I NA 91% NA NR NA Mean 27
(2008)

I = Immediate loading; D = Delayed loading; NR = Not reported; NA = Not applicable.

*
=Control group included conventional surgery open flap;
†
=Survival rate reported on temporary prosthesis for the immediate loaded cases;
‡
=Survival rate reported on temporary prosthesis.

Table 4. Summary of outcome in studies using static guided systems and immediate loading by a prefabricated permanent fixed prosthesis and with
a mean follow-up  12 months
No. of complications/
unexpected
No. of patients No. of No. of implant Implant survival events at prosthesis Prosthesis
Study after dropout implants failure rate placement survival rate
Johansson et al. (2009) 48 312 2 99% 15 96%
Komiyama et al. (2008) 29 176 19 89% 8 84%
Sanna et al. (2007) 26 183 9 95% NR NR
van Steenberghe et al. (2005) 24 164 0 100% 2 100%
Yong & Moy (2008) 13 78 8 90% 2 NR
Total: 140 913 38 96% 27 94%*

NR = Not reported;
*
=weighted calculation according to sample size in the studies

130 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135 © 2012 John Wiley & Sons A/S
 Hultin et al
Computer-guided implant placement, clinical advantage

Table 5. Studies reporting on patient reported outcome measures (PROMS)

Study
Study design Patient groups Evaluated variables Methods Outcome
Abad- RO GS FL (19 pat) Patient comfort after surgery and Verbal Patient comfort: 95% good, very good or excellent.
Gallegos satisfaction with the immediate and scale Patient satisfaction with immediate prosthesis: 84%
et al. (2011) definitive prostheses good, very good or excellent. Patient satisfaction with
definitive prosthesis:100% good, very good or
excellent
Arisan et al. PC GS FL (15 pat), Pain, number of analgesics, hemorrhaging VAS Flapless guided surgery generated less pain, less
(2010) GS OF (16 pat), and trismus (day 1 – 6 after surgery) hemorrhage and less trissmus
CS OF (21 pat)
Fortin et al. RCT GS FL (30 pat), Pain, number of analgesics, edema and VAS Flapless guided surgery generated less pain for shorter
(2006) CS OF (30 pat) hematoma (day of surgery, day 1 t– 7 after periods of time as well as less edema and hematoma
surgery)
Lindeboom RCT GS FL (8 pat), Emotional impact, dental anxiety, Quality of IES-R, No difference was observed between groups regarding
& van Wijk GS OF (8 pat) life and pain (before surgery, day of surgery, s-DAI, emotional impact and dental anxiety. The convential
(2010) day 1 – 7 and 1 month after surgery) OHIP-14, group reported less impact on quality of life and
NRS included more patients who reported feeling no pain
at all during placement
Nikzad & PO GS FL (16 pat) Pain (2 days and 1 week after surgery) and VAS All patients reported pain scores within the range for
Azari (2010) oral function (3, 6 and 12 months after little or no pain, and the functional scores ranged from
surgery) fair to excellent except in one case
Nkenke PC GS FL (5 pat), Pain and discomfort (day of surgery and day VAS Flapless guided surgery generated less pain
et al. (2007) CS OF (5 pat) 1 and 7 after surgery) postoperatively
van PO GS FL (27 pat) Speech, oral function, aesthetics and tactile VAS Most patients reported good scores (better than 5 on
Steenberghe sensation (3 months after surgery) the VAS-scale) for speech (89%), oral function (100%),
et al. (2005) aesthetics (89%) and tactile sensation (81%)

GS = Guided surgery; CS = Conventional surgery; FL = Flapless; OF = Open flap; VAS = Visual analog scale; IES-R = Impact of Event Scale-Revised;
s-DAI = Short version of the Dental Anxiety Inventory; OHIP-14 = Oral health-related quality of life; NRS = Numerical rating scale

Arisan et al. 2010). Nkenke et al. (2007),
using optical three-dimensional images to
measured swelling of the upper lip and
cheeks, showed that flapless guided surgery
generated less swelling postoperatively com-
pared to an open approach.
The study by Lindeboom & Wijk (2010)
evaluated emotional impact (IES-R), dental
anxiety (s-DAI), oral health-related quality of
life (OHIP-14), and pain. In contrast to the
studies described above their results were not
in favor of the flapless technique; no differ-
ence was observed between groups regarding
emotional impact and dental anxiety. The
negative effect on quality of life was more
pronounced in the flapless group up to
1 week after surgery. A lower number of
patients in this group reported no pain during
implant placement compared to the open flap
group.
Duration of treatment and cost-effectiveness
Only one of the included studies reported on
treatment duration using guided surgery.
Arisan and coworkers (2010) found the flap-
less guided surgery technique to be signifi-
cantly faster (24 min) compared to both open
flap guided surgery (61 min) and conventional
surgery (69 min). No study has reported on
cost-effectiveness measurements.
Alternative to bone augmentation
One study was identified reporting on guided
implant placement as an alternative to bone
augmentation (Fortin et al. 2009). This study
reported 98% implant survival rate after
4 year in partially edentulous cases with
severely resorbed maxillas.
Surgical trauma
The study by Barter (2010) was based on
patients previously treated with extensive
onlay bone grafting of severely resorbed max-
illas. They reported 98% implant survival
rate and 100% prosthesis survival rate after
more than 4 years.
Discussion
Conventional implant treatment with both
delayed and immediate loading has shown
successful long-term results with implant sur-
vival rates exceeding 95% after more than
5 years (Albrektsson et al. 1988; Lekholm
et al. 1999; Ekelund et al. 2003; Pjetursson
et al. 2004; Jemt & Johansson 2006; Jung et al.
2008; Romanos et al. 2010). Only a few of the
studies in this systematic review have com-
pared the guided implant placement tech-
nique with conventional implant protocols.
Therefore, comparisons between the tech-
niques have to be made with available pro-
spective observational studies.
In the present review, several studies pre-
senting prospective observational data on
clinical performance of guided implant place-
ment were identified. However, most of these
studies have an observational period of less
than 2 years (see Table 1) and only one study
(Sanna et al. 2007) had a follow-up period of
up to 5 years. Even though, a direct compari-
son of long-term implant survival rates
between conventional and guided implant
treatments is not easily made, the reported
survival rates are comparable. Thus, the sci-
entific evidence suggests that guided place-
ment shows at least as good implant survival
as conventional protocols.
Prosthesis survival rate showed a wide
range between 62% and 100% possibly due
to several factors (e.g. definition of prosthesis
survival, immediate or delayed loading, eval-
uation of temporary or permanent prosthesis)
and direct comparison with conventional
technique can therefore not be made.
The computer-guided implant concept in
combination with immediate loading is mar-
keted as easy, safe, and predictable. However,
several complications or unexpected events
at guided implant and prosthesis placement
were reported. The most common surgical
complication was fracture of the surgical
guide and the most common prosthetic com-
plication was misfit of the prosthesis. When
using conventional implant surgical tech-
niques these kinds of events are not applica-
ble/not referred to as complications. Thus,
direct comparisons between techniques are
not possible. However, it seems obvious that
the guided surgery technique, especially in

© 2012 John Wiley & Sons A/S 131 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
Hultin et al
Computer-guided implant placement, clinical advantage
combination with immediate loading, cannot
be regarded as easier than conventional tech-
niques.
Complications after guided implant place-
ment were implant failures or referred to the
prosthesis. The reported implant failure rate
of 3% is comparable to conventional surgery
(Pjetursson et al. 2004). It seems that most
complications in cases using a prefabricated
prosthesis occurred during the guided place-
ment (misfit of the prosthesis) whereas, when
using temporary prosthesis, complications
occurred after placement (prosthesis fracture).
Three controlled studies, comparing guided
flapless surgery with conventional open flap
surgery and reporting on patient-centered out-
comes were identified in this systematic
review (Fortin et al. 2006; Nkenke et al. 2007;
Arisan et al. 2010). These studies demon-
strated a statistically significant reduction in
immediate postoperative pain, use of analge-
sics, swelling, edema, hematoma, hemor-
rhage, and trismus when flapless guided
surgery was performed. Furthermore, one of
these studies (Arisan et al. 2010) also com-
pared guided flapless surgery with guided open
flap surgery and demonstrated consistently
better outcome measures for the flapless
guided technique. These results are supported
by the good scores for patient comfort and sat-
isfaction reported by the observational studies
on patient groups treated with guided flapless
surgery (van Steenberghe et al. 2005; Nikzad
& Azari 2010; Abad-Gallegos et al. 2011).
Thus, even if the information is limited, the
existing scientific literature demonstrate that
flapless guided surgery may have benefits in
decreasing patient pain and discomfort in the
immediate postoperative period.
It should be noted that one study (Linde-
boom & Wijk 2010) comparing two types of
guided surgical techniques (with and without
elevation of a flap) reported patient-based
data that was not in favor of the flapless
technique. However, since this study did not
compare the outcome with a conventional
open flap technique, the results are not easily
comparable with the rest of the literature.
A prolonged oral surgical intervention may
increase postoperative pain and discomfort
for the patient (Sato et al. 2009). One of the
controlled studies identified in this review
found that the duration of the treatment with
flapless guided surgery was less than half
(24 min) compared to open flap guided sur-
gery and conventional surgery (Arisan et al.
2010). This observation is supported by
Komiyama et al. (2008) who reported that the
duration of the flapless guided surgical inter-
vention including immediate reconstruction
132 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
(Teeth-in-an-Hour concept, Nobel Biocare ies. Methodical data collection, consistent
AB, Gothenburg, Sweden) took 30–45 min. evaluation of outcomes in prospectively con-
Thus, the time factor may indeed be a part of trolled trials is therefore urgently needed to
the explanation why less pain and discomfort facilitate comparisons and meta-analysis. It
was reported by patients after flapless guided is also important for future research to
surgery. Interestingly, Lindeboom & Wijk include the cost effectiveness of these techni-
(2010), who reported no difference regarding cally advanced methods. There is currently a
procedure duration between the guided sur- lack of knowledge in this area.
gery with and without an open flap, found Although patient-centered evaluations have
only small differences in the patient reported been performed in some studies, this has lar-
outcome measures between groups. gely focused on the immediate postoperative
Even if the duration of the surgical inter- period i.e. post operative pain and discomfort.
vention may be shorter with flapless guided For a more thorough understanding of
surgery compared to conventional tech- patient-centered outcomes, future studies
niques, it seems that much more time has to should be based on a combination of quanti-
be invested in the preoperative planning. tative as well as qualitative methods (i.e.
This, together with the uncertainty regarding questionnaires and interviews). The follow-
the total cost of the treatment, makes it diffi- up times should be appropriate for this kind
cult to estimate the cost-effectiveness of dif- of rehabilitative treatment.
ferent guided surgery protocols. No In addition, future research considering the
information regarding cost-effectiveness mea- use of guided implant placement for minimal
surements are available in the scientific liter- invasive surgery as well as optimal position-
ature selected for review. ing of implants in severely resorbed jaws is
Since the computer-guided implant place- suggested.
ment techniques take advantage of the local-
izing capabilities of imaging, they may be
Conclusion
advantageous compared to conventional sur-
gical protocols when it comes to patients
Several different systems that allow for com-
with limited amount of bone. An interesting
puter-guided implant placement with and
clinical question is if these techniques can be
without an open flap and with and without
used as an alternative to bone augmentation.
immediate loading are described in the litera-
Unfortunately, only one of the reviewed arti-
ture.
cles addresses this question. In the study by
This systematic review reveals no obvious
Fortin et al. (2009) on guided implant place-
differences between conventional and guided
ment in partially edentulous cases with
implant treatments regarding implant sur-
severely resorbed maxillas, good results were
vival rate. However, limited scientific evi-
reported (98% implant survival rate) after
dence is available. Several unexpected
4 years.
procedure linked adverse events were
The flapless guided implant placement
reported in most studies, indicating that the
techniques allow the surgeon to install the
clinical demands on the surgeon were no less
implants with minimal surgical trauma to
during guided implant placement than during
the bone and associated soft tissues. As such,
conventional placement. Flapless guided sur-
these techniques may be particularly attrac-
gery may lead to less pain and less discom-
tive to use in frail patient groups. However,
fort than conventional implant surgery in the
very limited information is available about
immediate postoperative period.
the use of guided surgery in these types of
cases. Horowitz (2009) described the use of
flapless guided implant placement in an irra-
diated cancer patient and showed good
results after 2 years. In the study by Barter
(2010), six patients were treated with flapless
guided surgery to avoid a secondary exposure
of earlier grafted sites. The implant survival
rate was 98% and all prostheses were in use
after 4 years.
A common dilemma identified in the stud-
ies included for this review has been the
inconsistency of reporting clinical data and
outcome variables. Another shortcoming is
the low number of comparative clinical stud-
© 2012 John Wiley & Sons A/S
 Hultin et al
Computer-guided implant placement, clinical advantage

1 Appendix My interpretation of the aim is:
sion criteria):
Computer guided implant placement
Protocol for inclusion or exclusion System used name: Surgical procedure
of titles and abstracts Flapless □ Not flapless □ Not reported □
Intraoperative events during surgery
1st author: unexpected events
Journal: Year: Volume: Pages: Reported □ Not reported □
Publication type □ Primary □ Review Immediate restoration
□ Other Yes □ No □
Construction for the edentulous
If “Other”, specify type: □ FDP Max □ FDP Mand
Relevance for this review □ Yes □ No Constructions for partially edentulous
AIM/PURPOSE well defined? □ Yes □ No □ Implant supported FDP □ Single
□ Can not tell implants
Reason for exclusion (according to exclu-
□ < 5 patients included □ <12 months fol-
low-up for evaluation of implant and pros-
thesis survival
□ Not reporting on clinical, radiographic
or patient-centered outcomes
□ Zygoma implants, petrygiod implants,
orthodontic implants or simultaneous
bone augmentation procedures □ Other,
specify:
Reviewed by: Date:

2 Appendix

List of excluded studies evaluated in full text and reason for exclusion
Author, Year, Title, Journal Reason for exclusion
Arisan et al. (2010). “Accuracy of two stereolithographic guide systems for computer-aided implant placement: a Evaluation of accuracy
computed tomography-based clinical comparative study.” J Periodontol 81(1): 43–51.
Balshi et al. (2008). “Guided implant placement and immediate prosthesis delivery using traditional Branemark <1 year follow-up
System abutments: a pilot study of 23 patients.” Implant Dent 17(2): 128–135.
Balshi et al. (2008). “Ct-generated surgical guides and flapless surgery.” Int J Oral Maxillofac Implants 23(2): Methodological discussion
190–197.
Block and Chandler (2009). “Computed tomography-guided surgery: complications associated with scanning, Methodological discussion No patient
processing, surgery, and prosthetics.” J Oral Maxillofac Surg 67(11 Suppl): 13–22. sample
de Almeida et al. (2010). “Computer-guided surgery in implantology: review of basic concepts.” J Craniofac Surg 21 Review not systematic
(6): 1917–1921.
Danza & Carinci (2010). “Flapless surgery and immediately loaded implants: a retrospective comparison between Report on already included cohort
implantation with and without computer-assisted planned surgical stent.” Stomatologija 12: 35–41. Danza et al. 2009;
D’haese et al. (2012). “Accuracy and Complications Using Computer-Designed Stereolithographic Surgical Guides Review not systematic
for Oral Rehabilitation by Means of Dental Implants: A Review of the Literature.” Clin Implant Dent Relat Res.
[14(3):321–35.]
Ersoy et al. (2008). “Reliability of implant placement with stereolithographic surgical guides generated from Evaluation of accuracy
computed tomography: clinical data from 94 implants.” J Periodontol 79(8): 1339–1345.
Ewers et al. (2004). “Computer-aided navigation in dental implantology: 7 years of clinical experience.” Journal of Methodological experience/Discussion
Oral and Maxillofacial Surgery 62(3): 329–334.
Fortin et al. (2003). “Reliability of preoperative planning of an image-guided system for oral implant placement Evaluation of accuracy
based on 3-dimensional images: an in vivo study.” Int J Oral Maxillofac Implants 18(6): 886–893.
Fortin et al. (2004). “An image-guided system-drilled surgical template and trephine guide pin to make treatment Case series
of completely edentulous patients easier: a clinical report on immediate loading.” Clin Implant Dent Relat Res 6(2):
111–119.
Hämmerle et al. (2009). “Consensus statements and recommended clinical procedures regarding computer-assisted Consensus statement/No patient
implant dentistry.” Int J Oral Maxillofac Implants 24 Suppl: 126–131. sample
Hämmerle et al. (2010). “Consensus Statements and clinical Recommendations for computer-assisted dental Consensus statement/No patient
Implantology.” Implantologie 18(3): S8-S12. sample
Holst et al. (2007). “Precision for computer-guided implant placement: using 3D planning software and fixed Case presentation
intraoral reference points.” J Oral Maxillofac Surg 65(3): 393–399.
Horowitz et al. (2009). “Computerized implantology for the irradiated patient.” International Journal of Oral & Case presentation
Maxillofacial Surgery 67: 619–623.
Kupeyan et al. (2006). “Definitive CAD/CAM-guided prosthesis for immediate loading of bone-grafted maxilla: a Case presentation
case report.” Clin Implant Dent Relat Res 8(3): 161–167.
Marchack & Moy (2003). “The use of a custom template for immediate loading with the definitive prosthesis: a Case presentation
clinical report.” J Calif Dent Assoc 31(12): 925–929.
Nickenig & Eitner (2007). “Reliability of implant placement after virtual planning of implant positions using cone Evaluation of accuracy
beam-CT data and surgical (guide) templates.” J Craniomaxillofac Surg 35(4–5): 207–211.
Nickenig & Eitner (2010). “An alternative method to match planned and achieved positions of implants, after Evaluation of accuracy
virtual planning using cone beam-CT data and surgical guide templates - A method reducing patient radiation
exposure (part I).” Journal of Cranio-Maxillofacial Surgery 38(6): 436–440.
Nickenig et al. (2010). “Evaluation of the difference in accuracy between implant placement by virtual planning In vitro model study/No patient
data and surgical guide templates versus the conventional free-hand method - a combined in vivo - in vitro sample
technique using cone beam-CT (Part II)." Journal of Craniomaxillofacial Surgery 38(7): 488–493.
Nikzad & Azari (2008). “Computer-assisted implant surgery; a flapless surgical/immediate loaded approach with Case presentation
1 year follow-up.” Int J Med Robot 4(4): 348–354.
Ozan et al. (2009). “Clinical accuracy of 3 different types of computed tomography-derived stereolithographic Evaluation of accuracy
surgical guides in implant placement.” J Oral Maxillofac Surg 67(2): 394–401.

© 2012 John Wiley & Sons A/S 133 | Clin. Oral Implants Res. 23 (Suppl. 6), 2012 / 124–135
Hultin et al
Computer-guided implant placement, clinical advantage

List of excluded studies (continued)

Author, Year, Title, Journal Reason for exclusion
Ozan et al. (2007). “A preliminary report of patients treated with early loaded implants using computerized <1 year follow-up
tomography-guided surgical stents: flapless versus conventional flapped surgery.” J Oral Rehabil 34(11): 835–840.
Parel & Triplett (2004). “Interactive imaging for implant planning, placement, and prosthesis construction.” J Oral Case presentation/Methodology
Maxillofac Surg 62(9 Suppl 2): 41–47.
Rocci et al. (2003). “Immediate loading in the maxilla using flapless surgery, implants placed in predetermined Model based placement
positions, and prefabricated provisional restorations: a retrospective 3-year clinical study.” Clin Implant Dent Relat
Res 5 Suppl 1: 29–36. 12
Sanz and Naert (2009). “Biomechanics/risk management (Working Group 2).” Clin Oral Implants Res 20 Suppl 4: Consensus statement No patient
107–111. sample
Siessegger et al. (2001). “Use of an image-guided navigation system in dental implant surgery in anatomically Complex cases/bone augmentation
complex operation sites.” J Craniomaxillofac Surg 29(5): 276–281.
Valente et al. (2009). “Accuracy of computer-aided oral implant surgery: a clinical and radiographic study.” Int J Evaluation of accuracy
Oral Maxillofac Implants 24(2): 234–242.
Van Assche et al. (2010). “Accuracy assessment of computer-assisted flapless implant placement in partial Evaluation of accuracy
edentulism.” J Clin Periodontol 37(4): 398–403.
van Steenberghe (2002). “A custom template and definitive prosthesis allowing immediate implant loading in the Cadaver and human case series
maxilla: a clinical report.” Int J Oral Maxillofac Implants 17(5): 663–670.
Vasak et al. (2011). “Computed tomography-based evaluation of template (NobelGuideTM)-guided implant Evaluation of accuracy
positions: a prospective radiological study.” Clinical Oral Implants Research 22(10): 1157–1163.
Wittwer et al. (2007). “Navigated flapless transmucosal implant placement in the mandible: a pilot study in 20 Evaluation of accuracy
patients.” Int J Oral Maxillofac Implants 22(5): 801–807.
Wittwer et al. (2006). “Computer-guided flapless transmucosal implant placement in the mandible: a new Evaluation of accuracy
combination of two innovative techniques.” Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101(6): 718–723.

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