Accuracy of Implant Placement with

Computer-Guided Surgery:
A Systematic Review and Meta-Analysis
Comparing Cadaver, Clinical, and In Vitro Studies
Fernando Bover-Ramos, DDS1/José Viña-Almunia, DDS, PhD2/Juan Cervera-Ballester, DDS3/
Miguel Peñarrocha-Diago, DDS, PhD, MD4/Berta García-Mira, DDS, PhD5

Purpose: The aim of this systematic review was to analyze the accuracy of implant placement using computer-
guided surgery and to compare virtual treatment planning and outcome in relation to study type (in vitro,
clinical, or cadaver). A further objective was to compare the accuracy of half-guided implant surgery with that
of full-guided implant surgery. Materials and Methods: A PubMed search was performed to identify studies
published between January 2005 and February 2015, searching the keywords “reliability AND dental implant
planning” and “accuracy dental implant planning.” Inclusion criteria were established a priori. Horizontal coronal
deviation, horizontal apical deviation, angular deviation, and vertical deviation were analyzed. Results: A total of
186 articles were reviewed, and 34 fulfilled the inclusion criteria. Information about 3,033 implants was analyzed
in 8 in vitro studies (543 implants), 4 cadaver studies (246 implants), and 22 clinical studies (2,244 implants).
Significantly less horizontal apical deviation and angular deviation were observed in in vitro studies compared
to clinical and cadaver studies, but there were no statistically significant differences in apical coronal deviation
or vertical deviation between the groups. Compared to half-guided surgery, full-guided implant surgery showed
significantly less horizontal coronal deviation for cadaver studies, significantly less horizontal apical deviation
for clinical studies, and significantly less angular deviation for both clinical and cadaver studies. Conclusion:
Implant placement accuracy was lower in clinical and cadaver studies compared with in vitro studies, especially
in terms of horizontal apical deviation and angular deviation. Full-guided implant surgery achieved greater
accuracy than half-guided surgery. Int J Oral Maxillofac Implants 2018;33:101–115. doi: 10.11607/jomi.5556

Keywords: computer-guided accuracy, computer-guided precision, computer-guided surgery, planning in

implant dentistry

T he accuracy of a computer-guided procedure is

defined as the deviation in location or angle between
1Resident of the Master in Oral Surgery and Implant Dentistry,
Stomatology Department, Faculty of Medicine and Dentistry,
University of Valencia, Spain.
2Professor of the Master in Oral Surgery and Implant Dentistry,
Stomatology Department, Faculty of Medicine and Dentistry,
University of Valencia, Spain.
3 Professor of the Master in Oral Surgery and Implant Dentistry,
Stomatology Department, Faculty of Medicine and Dentistry,
University of Valencia, Spain.
4 Chairman of Oral Surgery, Stomatology Department, Faculty of
Medicine and Dentistry, University of Valencia, Spain.
5Associate Professor of Oral Surgery, Stomatology Department,
Faculty of Medicine and Dentistry, University of Valencia, Spain.
Correspondence to: Dr Berta García-Mira, Clínicas
Odontológicas, Gascó Oliag 1, 46021 Valencia, Spain.
Fax: +34-96-3864139. Email: berta.garcia@uv.es
©2018 by Quintessence Publishing Co Inc.
the treatment plan and placement, and errors can occur
from image acquisition to surgical implant positioning.1
Match between planned and placed implant position is
determined by a second cone beam computed tomogra-
phy (CBCT) or multislice computed tomography (MSCT)
scan, allowing fusion between the preoperative planning
and postoperative implant positions.2 There is always
a certain deviation between virtual planning and the
actual in vivo location of the implants.3 Inaccuracy can be
compounded by errors accumulated during computed
tomographic image acquisition and data processing,
stereolithographic surgical template production, and
tolerance of the guiding sleeve.4 Since implants are
inserted in close proximity to vital structures such as
vessels and nerves, it is essential for the technique to
be accurate. Serious and even fatal complications have
been attributed to inaccurate implant placement.5
At present, some clinicians favor guided implant
insertion while others still have doubts about the useful-
ness and especially the accuracy of the technique.2 An

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Bover-Ramos et al
Coronal deviation
Virtual
implant Real implant position
position
Angular deviation
Apical deviation
Vertical deviation
Fig 1   Measurement of deviations between planned and placed
implants.
analysis of the literature on the accuracy of computer-
guided surgery yielded heterogenous results.5 Jung et
al6 performed a systematic review and found studies
reporting maximum apical deviation values of 7.1 mm
while others recorded maximum values of only 0.30
mm. In addition, there is no consensus on various other
aspects: Some authors claim more accuracy with tooth-
supported templates7–10 while others obtain better
results with mucosa-supported templates,5,11 in some
articles accuracy is related to operator experience9,12,13
while in others it is not,5,14,15 and for some authors the
accuracy of implants placed without the splint after
osteotomy (half-guided implant surgery) is comparable
to that obtained with full-guided implant surgery16 while
other authors report better accuracy with the latter.10,17
Another factor that can influence accuracy is the type
of study (ie, cadaver, clinical, or in vitro). In vitro studies
should have better accuracy than human studies due
to better access, better visual axis of the osteotomy, no
movement of the patient, and no saliva or blood in the
in vitro models.6
The purpose of the present systematic review and
meta-analysis was to analyze and compare implant
accuracy in implant patients, cadavers, and in vitro
models. A further objective was to compare the accuracy
of half-guided implant surgery with that of full-guided
implant surgery.
MATERIALS AND METHODS
The PubMed (Medline) database of the United States
National Library of Medicine was used to electronically
search the literature published between 1 January 2005
and 4 February 2015. The following search terms were
used: “reliability AND dental implant planning” and
“accuracy dental implant planning.”
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Study Selection Criteria
Full-text articles were required to meet the following
criteria, established a priori: in vitro, clinical, and cadaver
studies specifying the deviation (horizontal coronal
deviation, horizontal apical deviation, and angular
deviation) in implant position from prior virtual planning;
prospective and retrospective studies with or without
a control group; and a minimum of 10 implants placed
with guided surgery.
The following articles were excluded: articles in which
implants had been placed using intraoperative navigation
systems (dynamic systems); studies involving orthodontic
microscrews; zygomatic or pterygoid implants; literature
reviews; and case reports. Articles with duplicated data
from the same authors were excluded.
Authors were contacted for missing information
when necessary. In cases of more than one study using
data from the same patients, information on the last
publication was used for the meta-analysis.
Data Collection
Deviations from the exact positions were documented
as follows (Fig 1): horizontal coronal deviation, horizontal
apical deviation, and vertical deviation in mm, and angu-
lar deviation in degrees. Data on the type of guidance
(full-guided or half-guided) were also recorded.
Statistical Analysis
The meta-analysis involved estimation of the mean
deviation within each type of study using random-effects
models based on the inverse variances approach of
DerSimonian and Laird. Forest plots show the mean devia-
tion obtained by each author and the global deviation,
solution of the meta-analysis with the corresponding
95% confidence interval (95% CI), and the null test.
A mixed-effects model or meta-regression analysis was
used to evaluate the differences in deviation according
to the type of study. A similar model in turn was used
to evaluate the influence of half-guided or full-guided
surgery.
Some studies divided the information on mean devia-
tion according to independent implant groups.11,16,18–20
In these cases a mean deviation weighted according
to the size of each subgroup was obtained. The same
strategy was used to obtain a weighted standard devia-
tion (SD). In other studies,21–23 the linear deviations are
presented in terms of mean deviation horizontal and
vertical to the reference point, and so their Euclidean
distance was therefore used as an estimation of mean
linear deviation. In the study published by Pettersson
et al,24 the deviations were calculated from the 95% CI
initially provided by the authors.
The reference level of significance was 5% (α = 0.05).
The analyses were made using the R version 3.0.2 software
(R Foundation for Statistical Computing).
 Bover-Ramos et al

Fig 2  PRISMA flow diagram of the

search process and results. Articles in PubMed database
from January 2005 to
February 2015 (n = 193)

Selected articles after Excluded abstracts

duplicates removed
(n = 186)
Selected articles after screening
all titles and abstracts
(n = 66)
•Off topic (n = 93)
•Literature review (n = 19)
•Zygomatic implants (n = 2)
•Mini screws (n = 2)
•No access (n = 4)
(n = 120)

Articles meeting inclusion
criteria for meta-analysis
(n = 34)
Excluded articles
•Intraoperative navigation systems (n = 12)
•Articles from same author and same
results (n = 2)
•Without standard deviation (n = 3)
•Does not analyze all deviations (n = 5)
•Deviation measurement with other
parameters (n = 3)
•Does not analyze implant position (n = 5)
•Less than 10 implants (n = 2)
(n = 32)

Interstudy Heterogeneity and Publication Bias
The Q heterogeneity statistic and corresponding P value
for the chi-squared test were recorded. A P value of the
Q statistic of < .10 was considered statistically signifi-
cant.25 I2 values of 25%, 50%, and 75% corresponded
to cut-off points for low, moderate, and high degrees
of heterogeneity, respectively.
was analyzed in 8 in vitro studies (543 implants), 4
cadaver studies (246 implants), and 22 clinical studies
(2,244 implants). Regarding vertical deviation, data
were provided by only 14 of the 34 studies analyzed
(Table 1). With these figures, the mixed-effects meta-
analysis reached a statistical power of 0.998 in detecting
a significant effect size of 0.10 (small) between groups,
with a confidence level of 95%.

RESULTS Degree of Accuracy

Study Selection and Description
The combinations of search terms resulted in a list of 193
titles. After removal of 7 duplicates, 186 references were
reviewed, and 120 were excluded on the basis of the
evaluation of the title and abstract, leaving 66 articles to
be assessed for eligibility. Of these 66 articles, 34 were seen
to meet the inclusion criteria. The reasons for exclusion
of the 152 articles were as follows: 93 did not coincide
with the study topic, 19 were literature reviews, 2 articles
involved zygomatic implants, 2 involved orthodontic
microscrews, full-text retrieval was not possible in 4, 12
used intraoperative navigation systems, 2 were by the
same authors and involved data on the same patients,
3 did not specify SD, 5 did not analyze all deviations, 3
measured deviation with different parameters, 5 did not
analyze implant positions, and 2 involved fewer than 10
implants (Fig 2).
The studies meeting the inclusion criteria are sum-
marized in Table 1. Information about 3,033 implants
Horizontal Coronal Deviation. Table 2 shows the hori-
zontal coronal deviation of each study, mean deviation
within each group (cadaver, clinical, and in vitro), and
total horizontal coronal deviation of all studies. For ca-
daver studies, mean horizontal coronal deviation (± SD)
was 1.18 ± 0.12 mm, for clinical studies 1.10 ± 0.09 mm,
and for in vitro models 0.77 ± 0.15 mm.
Horizontal coronal deviation did not vary significantly
(P = .128) among the three types of studies. The differences
were not statistically significant between cadaver and
in vitro studies or cadaver and clinical studies (P = .108
and P = .668, respectively). However, the in vitro group
showed less deviation than the clinical group, approach-
ing statistical significance (P = .063) (Table 2).
A lack of homogeneity between studies of the same
group was observed (Fig 3). This finding was confirmed
by the statistical Q. In cadaver studies, heterogeneity
between studies reached values of I² = 0.834, while in
clinical and in vitro studies heterogeneity increased to
values of I² = 0.989 and I² = 0.994, respectively.

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Table 1   Studies Included in the Meta-Analysis

No. implants Full- or half- Coronal deviation Apical deviation
Author (year) Study type (No. patients) guided surgery (mm, mean ± SD) (mm, mean ± SD)
Di Giacomo et al26 (2005) Clinical 21 (4) Half 1.45 ± 1.42 2.99 ± 1.77

Van Assche et al27 (2007) Cadaver 12 Full 1.1 ± 0.7 2 ± 0.7

Ersoy et al28 (2008) Clinical 94 (21) Full 1.22 ± 0.85 1.51 ± 1
Ozan et al8 (2009) Clinical 110 (30) Full 1.11 ± 0.7 1.41 ± 0.9
Valente et al5 (2009) Clinical 89 (25) Half 1.4 ± 1.3 1.6 ± 1.2
Dreiseidler et al29 (2009) In vitro 54 Full 0.22 ± 0.09 0.34 ± 0.14
Horwitz et al30 (2009) In vitro 54 Full 0.38 ± 0.24 0.63 ± 0.38
Arisan et al11 (2010) Clinical 279 (53) Half/Full Mixed 1.70 ± 0.52 1.99 ± 0.64
1.31 ± 0.59 1.62 ± 0.54
1.24 ± 0.51 1.4 ± 0.47
1.56 ± 0.25 1.86 ± 0.4
0.81 ± 0.33 1.01 ± 0.40
0.7 ± 0.13 0.76 ± 0.15
Behneke et al17 (2012) Clinical 132 (89) Full 0.32 ± 0.23 0.49 ± 0.29
Van Assche et al31 (2010) Clinical 19 (8) Full 0.6 ± 0.3 0.9 ± 0.4
Dreiseidler et al21 (2012) In vitro 48 Full 0.41 ± 0.3 0.46 ± 0.36
0.34 ± 0.22 0.45 ± 0.47
Pettersson et al32 (2010) Cadaver 145 (17) Full 1.06 ± 0.58 1.25 ± 0.68
Vasak et al22 (2011) Clinical 86 (18) Full 0.46 ± 0.35 0.7 ± 0.49
0.43 ± 0.32 0.59 ± 0.44
Arisan et al18 (2013) Clinical 102 (CT: 50 Full 0.75 ± 0.32 0.80 ± 0.35
CBCT: 52) (11) 0.81 ± 0.32 0.87 ± 0.32
Kühl et al16 (2013) Cadaver 38 19 Full 19 Half 1.52 ± 0.98 1.55 ± 0.95
1.56 ± 0.75 1.84 ± 0.61
1.58 ± 0.87 1.71 ± 0.80
Cassetta et al15 (2012) Clinical 95 (11) Full 1.65 ± 0.56 2.15 ± 0.81
Dreiseidler et al33 (2012) In vitro 108 Full 0.89 ± 0.44 1.09 ± 0.69
Turbush and Turkyilmaz7 (2012) In vitro 150 Full 1.18 ± 0.42 1.44 ± 0.67
Soares et al34 (2012) In vitro 18 Full 1.38 ± 0.42 1.39 ± 0.40
Cassetta et al35 (2012) Clinical 116 (10) Full 1.47 ± 0.68 1.83 ± 1.03
Vercruyssen et al19 (2014) Clinical 209 (-) 55 Half 53 Half 1.23 ± 0.60 1.57 ± 0.71
52 Full 49 Full 1.60 ± 0.92 1.65 ± 0.82
1.38 ± 0.64 1.60 ± 0.70
1.33 ± 0.82 1.50 ± 0.72
1.38 ± 0.75 1.58 ± 0.74
Di Giacomo et al36 (2012) Clinical 60 (12) Half 1.35 ± 0.65 1.79 ± 1.01
Cassetta et al37 (2013) Clinical 111 (10) Full 1.52 ± 0.62 1.97 ± 0.86
Beretta et al38 (2014) Clinical 14 (2) Full 0.56 ± 0.23 0.64 ± 0.29
Verhamme et al39 (2015) Clinical 150 (25) Full 1.96 ± 0.23 2.29 ± 0.27
Cushen and Turkyilmaz13 (2013) In vitro 100 Full 0.69 ± 0.31 0.38 ± 0.17
Van de Wiele et al14 (2015) Clinical 75 (16) Full 0.88 ± 0.50 1.10 ± 0.53
Cassetta et al20 (2013) Clinical Total: 227 Group A: Full 1.47 ± 0.68 1.83 ± 1.03
Group A: 116 Group B1: Half 1.49 ± 0.63 1.90 ± 0.83
Group B1: 57 Group B2: Half 1.55 ± 0.59 2.05 ± 0.89
Group B2: 54 (20)
D’Haese et al3 (2012) Clinical 77 (13) Full 0.91 ± 0.44 1.13 ± 0.52
Bilhan et al40 (2012) In vitro 11 – 1.12 ± 0.22 1.21 ± 0.53
Nickenig et al23 (2010) Clinical 23 (10) Full 0.9 ± 1.06 0.6 ± 0.57
0.9 ± 1.22 0.9 ± 0.94
Widmann et al41 (2010) Cadaver 51 Full 1.06 ± 0.60 1.24 ± 0.70
Chen et al42 (2010) Clinical 16 (4) – 0.79 ± 0.39 1.01 ± 0.39
Pettersson et al24 (2012) Clinical 139 (25) Full 0.80 ± 0.53 1.09 ± 0.53

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Angular deviation Vertical deviation

(degrees, mean ± SD) (mm, mean ± SD) Type of surgical guide Planning software
7.25 ± 2.67 – Bone-supported, tooth-supported, and both bone- and Simplant
tooth-supported
2 ± 0.7 – – Procera
4.9 ± 2.36 – Bone-supported, tooth-supported, and mucosa-supported StentCad
4.10 ± 2.3 – Bone-supported, tooth-supported, and mucosa-supported StentCad
7.9 ± 4.7 1.1 ± 1 Bone-supported, tooth-supported, and mucosa-supported Simplant
1.09 ± 0.51 0.25 ± 0.20 – SICAT + Procera
2.17 ± 1.06 0.49 ± 0.36 – Med 3D System
5 ± 1.66 – Bone-supported, tooth-supported, and mucosa-supported Simplant + StentCad
3.5 ± 1.38 –
4.23 ± 0.72 –
4.73 ± 1.28 –
3.39 ± 0.84 –
2.9 ± 0.39 –
2.1 ± 1.31 0 ± 0.41 Tooth-supported Implant 3D
2.2 ± 1.1 0.9 ± 0.5 Tooth-supported Procera
1.90 ± 1.54 0.27 ± 0.22 – Sky-PlanX

2.64 ± 1.42 0.28 ± 0.59 – Procera

3.53 ± 1.77 0.52 ± 0.42 Mucosa-supported or tooth- and mucosa-supported Procera

3.30 ± 1.09 – Mucosa-supported Simplant

3.47 ± 1.14 –
3.60 ± 2.68 – – coDiagnostX
4.3 ± 3.13 –
4.12 ± 2.90 –
4.62 ± 2.74 – Mucosa-supported Simplant
2.01 ± 1.94 0.51 ± 0.43 – Sky-PlanX
2.2 ± 1.2 – Bone-supported, tooth-supported, and mucosa-supported Mimic Materialise
2.16 ± 0.91 0.80 ± 0.58 – DentalSlice
5.09 ± 3.70 0.97 ± 0.65 Bone-supported, tooth-supported, and mucosa-supported Simplant
2.86 ± 1.60 – Bone-supported and mucosa-supported Simplant
3.79 ± 2.36 –
2.71 ± 1.36 –
3.20 ± 2.70 –
3.14 ± 2.06 –
6.53 ± 4.31 – – Implant Viewer
4.68 ± 2.98 – Bone-supported, tooth-supported and mucosa-supported Simplant
2.42 ± 1.02 – – 3Diagnosys
3.93 ± 0.41 0.58 ± 0.16 Mucosa-supported Procera
3.28 ± 1.60 0.60 ± 0.13 Bone-supported Mimic Materialise
2.79 ± 1.48 0.48 ± 0.50 Mucosa-supported Simplant
5.09 ± 3.70 0.98 ± 0.52 Bone-supported, tooth-supported, and mucosa-supported Simplant
3.93 ± 2.34 0.85 ± 0.63
5.46 ± 3.38 0.63 ± 0.43

2.60 ± 1.61 – Mucosa-supported Facilitate

4.71 ± 1.63 1.42 ± 0.31 Bone-supported StentCad
4.2 ± 3.04 – – coDiagnostX

2.81 ± 2.17 – – Treon

2.07 ± 0.78 – Bone-tooth–combined supported CAPPOIS
2.26 ± 1.59 – – Procera

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Bover-Ramos et al

Table 2   Individual and Combined Measures for the Three Types of Studies and Total Combined
Measure for Horizontal Coronal Deviation
Study Mean Lower limit Upper limit
Author (year) type n (mm) SD SE 95% CI 95% CI P value
Van Assche et al27 (2007) Cad 12 1.10 0.7 0.202 0.704 1.496 < .001
Pettersson et al32 (2010) Cad 145 1.06 0.58 0.048 0.966 1.154 < .001
Widmann et al41 (2010) Cad 51 1.06 0.6 0.084 0.895 1.225 < .001
Kühl et al16 (2013) Cad 38 1.58 0.87 0.141 1.303 1.857 < .001
Cadaver total 1.18 0.123 0.945 1.428 < .001
Di Giacomo et al26 (2005) Cli 21 1.45 1.42 0.310 0.843 2.057 < .001
Ersoy et al28 (2008) Cli 94 1.22 0.85 0.088 1.048 1.392 < .001
Ozan et al8 (2009) Cli 110 1.11 0.7 0.067 0.979 1.241 < .001
Valente et al5 (2009) Cli 89 1.40 1.3 0.138 1.130 1.670 < .001
Arisan et al11 (2010) Cli 279 1.22 0.39 0.023 1.174 1.266 < .001
Behneke et al17 (2012) Cli 132 0.32 0.23 0.020 0.281 0.359 < .001
Van Assche et al31 (2010) Cli 19 0.60 0.3 0.069 0.465 0.735 < .001
Vasak et al22 (2011) Cli 86 0.45 0.34 0.037 0.378 0.522 < .001
Arisan et al18 (2013) Cli 102 0.78 0.32 0.032 0.718 0.842 < .001
Chen et al42 (2010) Cli 16 0.79 0.39 0.098 0.599 0.981 < .001
Nickenig et al23 (2010) Cli 23 0.90 1.14 0.238 0.434 1.366 < .001
Pettersson et al24 (2012) Cli 139 0.80 0.53 0.045 0.712 0.888 < .001
Cassetta et al15 (2012) Cli 95 1.65 0.56 0.057 1.537 1.763 < .001
Cassetta et al35 (2012) Cli 116 1.47 0.68 0.063 1.346 1.594 < .001
Vercruyssen et al19 (2014) Cli 209 1.38 0.75 0.052 1.278 1.482 < .001
Di Giacomo et al36 (2012) Cli 60 1.35 0.65 0.084 1.186 1.514 < .001
Cassetta et al37 (2013) Cli 111 1.52 0.62 0.059 1.405 1.635 < .001
Cassetta et al20 (2013) Cli 227 1.49 0.65 0.043 1.405 1.575 < .001
D’Haese et al3 (2012) Cli 77 0.91 0.44 0.050 0.812 1.008 < .001
Beretta et al38 (2014) Cli 14 0.56 0.23 0.061 0.440 0.680 < .001
Verhamme et al39 (2014) Cli 150 1.96 0.23 0.019 1.923 1.997 < .001
Van de Wiele et al14 (2014) Cli 75 0.88 0.5 0.058 0.767 0.993 < .001
Clinical total 1.10 0.094 0.912 1.280 < .001
Dreiseidler et al29 (2009) Inv 54 0.22 0.09 0.012 0.196 0.244 < .001
Horwitz et al30 (2009) Inv 54 0.38 0.24 0.033 0.316 0.444 < .001
Dreiseidler et al21 (2012) Inv 48 0.38 0.26 0.038 0.306 0.454 < .001
Dreiseidler et al33 (2012) Inv 108 0.89 0.44 0.042 0.807 0.973 < .001
Turbush and Turkyilmaz7 Inv 150 1.18 0.42 0.034 1.113 1.247 < .001
(2012)
Soares et al34 (2012) Inv 18 1.38 0.42 0.099 1.186 1.574 < .001
Bilhan et al40 (2012) Inv 11 1.12 0.22 0.066 0.990 1.250 < .001
Cushen and Turkyilmaz13 Inv 100 0.69 0.31 0.031 0.629 0.751 < .001
(2013)
In vitro total 0.77 0.151 0.480 1.071 < .001
Total 1.03 0.075 0.882 1.178 Q2 = 4.10
(P = .128)

Meta-regression was performed to evaluate the effect
of the guiding technique (full-guided or half-guided) on
horizontal coronal deviation (Table 3). In the full-guided
group, the mean coronal deviation was 1.00 ± 0.08 mm,
and in the half-guided group 1.44 ± 0.18 mm. The differ-
ences were statistically significant (Q1 = 4.93, P = .026).
Greater horizontal coronal deviation was observed
when implants were not placed full-guided. On studying
this effect by groups, only the cadaver studies showed
statistically significant differences (P = .006) (Table 3).
Horizontal Apical Deviation. Mean horizontal api-
cal deviation was 1.52 ± 0.18 mm in cadaver studies,
1.40 ± 0.12 mm in clinical studies, and 0.17 ± 0.85 mm
in in vitro studies. No statistically significant differenc-
es between clinical and cadaver studies were found
(P = .637); however, deviation in in vitro studies was

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Author Mean [95% CI]

Van Assche et al27 2007 (Cad) 1.10 [0.70, 1.50]
Pettersson et al32 2010 (Cad) 1.06 [0.97, 1.15]
Widmann et al41 2010 (Cad) 1.06 [0.90, 1.22]
Kühl et al16 2013 (Cad) 1.58 [1.30, 1.86]
Di Giacomo et al26 2005 (Cli) 1.45 [0.84, 2.06]
Ersoy et al28 2008 (Cli) 1.22 [1.05, 1.39]
Ozan et al8 2009 (Cli) 1.11 [0.98, 1.24]
Valente et al5 2009 (Cli) 1.40 [1.13, 1.67]
Arisan et al11 2010 (Cli) 1.22 [1.17, 1.27]
Behneke et al17 2012 (Cli) 0.32 [0.28, 0.36]
Van Assche et al31 2010 (Cli) 0.60 [0.47, 0.73]
Vasak et al22 2011 (Cli) 0.45 [0.38, 0.52]
Arisan et al18 2013 (Cli) 0.78 [0.72, 0.84]
Chen et al8 2010 (Cli) 0.79 [0.60, 0.98]
Nickenig et al23 2010 (Cli) 0.90 [0.43, 1.37]
Pettersson et al24 2012 (Cli) 0.80 [0.71, 0.89]
Cassetta et al15 2012 (Cli) 1.65 [1.54, 1.76]
Cassetta et al35 2012 (Cli) 1.47 [1.35, 1.59]
Vercruyssen et al19 2014 (Cli) 1.38 [1.28, 1.48]
Di Giacomo et al26 2012 (Cli) 1.35 [1.19, 1.51]
Cassetta et al37 2013 (Cli) 1.52 [1.40, 1.64]
Cassetta et al20 2013 (Cli) 1.49 [1.41, 1.57]
D’Haese et al3 2012 (Cli) 0.91 [0.81, 1.01]
Beretta et al38 2014 (Cli) 0.56 [0.44, 0.68]
Verhamme et al39 2014 (Cli) 1.96 [1.92, 2.00]
Van de Wiele et al14 2014 (Cli) 0.88 [0.77, 0.99]
Dreiseidler et al29 2009 (Inv) 0.22 [0.20, 0.24]
Horwitz et al30 2009 (Inv) 0.38 [0.32, 0.44]
Dreiseidler et al33 2012 (Inv) 0.38 [0.31, 0.45]
Dreiseidler et al21 2012 (Inv) 0.89 [0.81, 0.97]
Turbush and Turkyilmaz7 2012 (Inv) 1.18 [1.11, 1.25]
Soares et al34 2012 (Inv) 1.38 [1.19, 1.57]
Bilhan et al40 2012 (Inv) 1.12 [0.99, 1.25]
Cushen and Turkyilmaz13 2013 (Inv) 0.69 [0.63, 0.75]
RE MODEL 1.03 [0.88, 1.18]
0.00 0.50 1.00 1.50 2.00 2.50
Observed outcome

Fig 3   Forest plot showing the confidence intervals of horizontal coronal deviation across the studies.

significantly smaller than in cadaver (P = .038) and clin-
ical studies (P = .013) (Table 4).
A lack of homogeneity between studies was observed
for horizontal apical deviation (Fig 4), confirmed by I²
values of 0.879, 0.989, and 0.994 for cadaver, clinical,
and in vitro studies, respectively.
Implants placed with full-guided surgery yielded lower
deviation values than those placed with half-guided
surgery (1.23 ± 0.10 mm and 1.91 ± 0.23 mm, respectively)
(Q1 = 7.16; P = .007). These differences were statistically
significant for the clinical studies (P = .042), but not for
the cadaver studies (P = .331) (Table 3).
Angular Deviation. Mean angular deviation in ca-
daver studies was 2.82 ± 0.40 degrees, in clinical studies
3.98 ± 0.33 degrees, and in in vitro studies 2.39 ± 0.35
degrees (Table 5). No statistically significant differenc-

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Table 3   Meta-Regression Analysis to Evaluate Vertical deviation was the measurement exhibiting
the Effect of Guidance Type on the least homogeneity between studies (I2 = 99.0%;
Horizontal Coronal, Horizontal Apical, P < .001) (Fig 6).
Angular, and Vertical Deviation Vertical deviation in relation to the surgical technique
(full- or half-guided) could only be analyzed in clinical
Deviation/ Full-guided Half-guided studies, and no statistically significant differences were
study type surgery surgery P value
found (P = .419) (Table 3).
Horizontal coronal
 Total 1.00 ± 0.08 1.44 ± 0.18 .026
 Cadaver 1.07 ± 0.04 1.56 ± 0.17 .006 DISCUSSION
 Clinical 1.08 ± 0.10 1.42 ± 0.20 .126
  In vitro – – – In the present meta-analysis, deviations between planned
Horizontal apical and clinical positions of the implants were found in
 Total 1.23 ± 0.10 1.91 ± 0.23 .007 all the included studies, though great heterogeneity
between publications was observed. Guided surgery
 Cadaver 1.47 ± 0.17 1.84 ± 0.34 .331
studies presented many variables, making interstudy
 Clinical 1.35 ± 0.12 1.92 ± 0.25 .042
comparison difficult. A larger number of studies in which
  In vitro – – – all the variables are homogenous would be required in
Angular this regard.
 Total 3.13 ± 0.23 4.30 ± 0.73 .041 Jung et al,6 in a review published in 2009, posited
 Cadaver 2.69 ± 0.29 4.30 ± 0.73 .041 that an increase in deviation could be caused by limited
 Clinical 3.62 ± 0.29 5.82 ± 0.59 < .001 access, poorer visual control, possible movement of
  In vitro – – – the patient, and the presence of blood and saliva. It is
therefore assumed that in vitro studies would yield the
Vertical
lowest deviation values. The present results confirm
 Total 0.62 ± 0.08 0.83 ± 0.23 .387
this hypothesis, with better accuracy being recorded in
 Cadaver 0.28 ± 0.04 – – the in vitro studies. These differences were statistically
 Clinical 0.63 ± 0.11 0.83 ± 0.21 .419 significant between in vitro and clinical studies in relation
  In vitro – – – to horizontal apical deviation and among in vitro, clini-
cal, and cadaver studies in relation to angular deviation.
Mention also must be made of the strong trend observed
in in vitro studies toward greater accuracy in relation
to horizontal coronal deviation (P = .06). Although no
es were found between clinical and cadaver (P = .153) statistically significant differences in vertical deviation
or between cadaver and in vitro studies (P = .601); were found, only 14 of the 34 studies included this
however, the differences were statistically significant parameter, and only one cadaver study analyzed this
between in vitro and clinical studies (P = .007). deviation. This could explain why vertical deviation
There was a lack of homogeneity between studies was the only parameter exhibiting greater accuracy in
(Fig 5), with I² values > 0.90 in all three groups. cadaver studies than in in vitro studies. It is striking that
When the guiding technique (Table 3) was compared, so few authors measured vertical deviation, since it is
implants placed with full-guided surgery again reached one of the most important deviations to be determined
lower deviation values than implants placed with half- to avoid damaging anatomical structures such as the
guided surgery, with values of 3.13 ± 0.23 degrees and maxillary sinus or the inferior alveolar nerve.
4.30 ± 0.73 degrees, respectively (Q1 = 4.19; P = .041). In recent years, different meta-analyses2,6,43 have com-
These differences were statistically significant in both pared accuracy in different types of studies, obtaining
clinical (P < .001) and cadaver studies (P = .041). more accurate values in in vitro studies. In 2009, Jung
Vertical Deviation. Vertical deviation was not con- et al6 conducted a meta-analysis in which horizontal
sidered an inclusion criterion, but was nevertheless coronal and horizontal apical deviation were evaluated,
documented from those studies in which it was mea- but the great majority of Jung et al’s included articles
sured. Only 14 of the 34 studies of the meta-analysis made use of dynamic systems while in the present
measured vertical deviation, with a mean value of 0.28 meta-analysis only publications using static systems
± 0.049 mm for cadaver studies, 0.74 ± 0.103 mm for were included; therefore, comparison of the results
clinical studies, and 0.61 ± 0.149 mm for in vitro studies are not possible. That same year, Schneider et al43 also
(Table 6). No statistically significant differences were published a meta-analysis, though in contrast to Jung et
found among the three types of studies (P > .05). al6 they included only articles involving static systems.

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Table 4   Individual and Combined Measures for the Three Types of Studies and Total Combined
Measure Referred to Horizontal Apical Deviation
Study Mean Lower limit Upper limit
Author (year) type n (mm) SD SE 95% CI 95% CI P value
Van Assche et al27 (2007) Cad 12 2.00 0.7 0.202 1.604 2.396 < .001
Pettersson et al32 (2010) Cad 145 1.25 0.68 0.056 1.139 1.361 < .001
Widmann et al41 (2010) Cad 51 1.24 0.7 0.098 1.048 1.432 < .001
Kühl et al16 (2013) Cad 38 1.71 0.8 0.130 1.456 1.964 < .001
Cadaver total 1.52 0.176 1.171 1.865 < .001
Di Giacomo et al26 (2005) Cli 21 2.99 1.77 0.386 2.233 3.747 < .001
Ersoy et al28 (2008) Cli 94 1.51 1 0.103 1.308 1.712 < .001
Ozan et al8 (2009) Cli 110 1.41 0.9 0.086 1.242 1.578 < .001
Valente et al5 (2009) Cli 89 1.6 1.2 0.127 1.351 1.849 < .001
Arisan et al11 (2010) Cli 279 1.44 0.43 0.026 1.390 1.490 < .001
Behneke et al17 (2012) Cli 132 0.49 0.29 0.025 0.441 0.539 < .001
Van Assche et al31 (2010) Cli 19 0.9 0.4 0.092 0.720 1.080 < .001
Vasak et al22 (2011) Cli 86 0.91 0.65 0.070 0.773 1.047 < .001
Arisan et al18 (2013) Cli 102 0.83 0.34 0.034 0.764 0.896 < .001
Chen et al42 (2010) Cli 16 1.01 0.39 0.098 0.819 1.201 < .001
Nickenig et al23 (2010) Cli 23 0.75 0.76 0.158 0.439 1.061 < .001
Pettersson et al24 (2012) Cli 139 1.09 0.53 0.045 1.002 1.178 < .001
Cassetta et al15 (2012) Cli 95 2.15 0.81 0.083 1.987 2.313 < .001
Cassetta et al35 (2012) Cli 116 1.83 1.03 0.096 1.643 2.017 < .001
Vercruyssen et al19 (2014) Cli 209 1.58 0.74 0.051 1.480 1.680 < .001
Di Giacomo et al36 (2012) Cli 60 1.79 1.01 0.130 1.534 2.046 < .001
Cassetta et al20 (2013) Cli 111 1.97 0.86 0.082 1.810 2.130 < .001
Cassetta et al37 (2013) Cli 227 1.90 0.95 0.063 1.776 2.024 < .001
D’Haese et al3 (2012) Cli 77 1.13 0.52 0.059 1.014 1.246 < .001
Beretta et al38 (2014) Cli 14 0.64 0.29 0.078 0.488 0.792 < .001
Verhamme et al39 (2014) Cli 150 2.29 0.27 0.022 2.247 2.333 < .001
Van de Wiele et al14 (2014) Cli 75 1.10 0.53 0.061 0.980 1.220 < .001
Clinical total 1.40 0.122 1.163 1.639 < .001
Dreiseidler et al29 (2009) Inv 54 0.34 0.15 0.020 0.300 0.380 < .001
Horwitz et al30 (2009) Inv 54 0.63 0.38 0.052 0.529 0.731 < .001
Dreiseidler et al21 (2012) Inv 48 0.45 0.42 0.061 0.331 0.569 < .001
Dreiseidler et al33 (2012) Inv 108 1.09 0.69 0.066 0.960 1.220 < .001
Turbush and Turkyilmaz7 (2012) Inv 150 1.44 0.67 0.055 1.333 1.547 < .001
Soares et al34 (2012) Inv 18 1.39 0.4 0.094 1.205 1.575 < .001
Bilhan et al40 (2012) Inv 11 1.21 0.53 0.160 0.897 1.523 < .001
Cushen and Turkyilmaz13 (2013) Inv 100 0.38 0.17 0.017 0.347 0.413 < .001
In vitro total 0.85 0.165 0.535 1.183 < .001
Total 1.29 0.098 1.109 1.479 Q2 = 7.13
(P = .028)

Horizontal coronal, horizontal apical, and angular devia- to reach statistical significance. A possible explanation
tion were evaluated. Although lesser deviation values for this is the fact that their meta-analysis was limited
in in vitro vs clinical and cadaver studies were recorded, to only 10 articles.
the differences among the three types of studies failed

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Author Mean [95% CI]

Van Assche et al27 2007 (Cad) 2.00 [1.60, 2.40]
Pettersson et al32 2010 (Cad) 1.25 [1.14, 1.36]
Widmann et al41 2010 (Cad) 1.24 [1.05, 1.43]
Kühl et al16 2013 (Cad) 1.71 [1.46, 1.96]
Di Giacomo et al26 2005 (Cli) 2.99 [2.23, 3.75]
Ersoy et al28 2008 (Cli) 1.51 [1.31, 1.71]
Ozan et al8 2009 (Cli) 1.41 [1.24, 1.58]
Valente et al5 2009 (Cli) 1.60 [1.35, 1.85]
Arisan et al11 2010 (Cli) 1.44 [1.39, 1.49]
Behneke et al17 2012 (Cli) 0.49 [0.44, 0.54]
Van Assche et al31 2010 (Cli) 0.90 [0.72, 1.08]
Vasak et al22 2011 (Cli) 0.91 [0.77, 1.05]
Arisan et al18 2013 (Cli) 0.83 [0.76, 0.90]
Chen et al8 2010 (Cli) 1.01 [0.82, 1.20]
Nickenig et al23 2010 (Cli) 0.75 [0.44, 1.06]
Pettersson et al24 2012 (Cli) 1.09 [1.00, 1.18]
Cassetta et al15 2012 (Cli) 2.15 [1.99, 2.31]
Cassetta et al35 2012 (Cli) 1.83 [1.64, 2.02]
Vercruyssen et al19 2014 (Cli) 1.58 [1.48, 1.68]
Di Giacomo et al26 2012 (Cli) 1.79 [1.53, 2.05]
Cassetta et al37 2013 (Cli) 1.97 [1.81, 2.13]
Cassetta et al20 2013 (Cli) 1.90 [1.78, 2.02]
D’Haese et al3 2012 (Cli) 1.13 [1.01, 1.25]
Beretta et al38 2014 (Cli) 0.64 [0.49, 0.79]
Verhamme et al39 2014 (Cli) 2.29 [2.25, 2.33]
Van de Wiele et al14 2014 (Cli) 1.10 [0.98, 1.22]
Dreiseidler et al29 2009 (Inv) 0.34 [0.30, 0.38]
Horwitz et al30 2009 (Inv) 0.63 [0.53, 0.73]
Dreiseidler et al33 2012 (Inv) 0.45 [0.33, 0.57]
Dreiseidler et al21 2012 (Inv) 1.09 [0.96, 1.22]
Turbush and Turkyilmaz7 2012 (Inv) 1.44 [1.33, 1.55]
Soares et al34 2012 (Inv) 1.39 [1.21, 1.57]
Bilhan et al40 2012 (Inv) 1.21 [0.90, 1.52]
Cushen and Turkyilmaz13 2013 (Inv) 0.38 [0.35, 0.41]

0.00 1.00 2.00 3.00 4.00

Observed outcome

Fig 4   Forest plot showing the confidence intervals of horizontal apical deviation across the studies.

A few years later, in 2012, Van Assche et al2 published a
meta-analysis in which the four deviations were considered,
in coincidence with the present study (horizontal coronal,
horizontal apical, angular, and vertical). The results obtained
by these authors were similar to the present, with statisti-
cally significantly less deviation in the in vitro studies of
horizontal apical and horizontal coronal deviations. It
must be emphasized that Van Assche et al included only
two in vitro studies. In their meta-analysis, only 6 of the 19
included articles assessed vertical deviation, and of these
publications, only one was conducted in vitro and one in
cadavers. Although more articles were included, the same
limitation also affected the present study (only 14 out of
34 articles evaluated vertical deviation). Consequently,
it would be advisable for future precision studies to also
analyze vertical deviation.

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Table 5   Individual and Combined Measures for the Three Types of Studies and Total Combined
Measure of Angular Deviation
Study Mean Lower limit Upper limit
Author (year) type n (grades) SD SE 95% CI 95% CI P value
Van Assche et al27 (2007) Cad 12 2 0.8 0.231 1.547 2.453 < .001
Pettersson et al32 (2010) Cad 145 2.64 1.42 0.118 2.409 2.871 < .001
Widmann et al41 (2010) Cad 51 2.81 2.17 0.304 2.214 3.406 < .001
Kühl et al16 (2013) Cad 38 4.12 2.9 0.470 3.198 5.042 < .001
Cadaver total 2.82 0.404 2.028 3.612 < .001
Di Giacomo et al26 (2005) Cli 21 7.25 2.67 0.583 6.108 8.392 < .001
Ersoy et al28 (2008) Cli 94 4.9 2.36 0.243 4.423 5.377 < .001
Ozan et al8 (2009) Cli 110 4.1 2.3 0.219 3.670 4.530 < .001
Valente et al5 (2009) Cli 89 7.9 4.7 0.498 6.924 8.876 < .001
Arisan et al11 (2010) Cli 279 3.96 1.04 0.062 3.838 4.082 < .001
Behneke et al17 (2012) Cli 132 2.1 1.31 0.114 1.877 2.323 < .001
Van Assche et al31 (2010) Cli 19 2.2 1.1 0.252 1.705 2.695 < .001
Vasak et al22 (2011) Cli 86 3.53 1.77 0.191 3.156 3.904 < .001
Arisan et al18 (2013) Cli 102 3.38 1.11 0.110 3.165 3.595 < .001
Chen et al42 (2010) Cli 16 2.07 0.78 0.195 1.688 2.452 < .001
Nickenig et al23 (2010) Cli 23 4.20 3.04 0.634 2.958 5.442 < .001
Pettersson et al24 2012 Cli 139 2.26 1.59 0.135 1.996 2.524 < .001
Cassetta et al15 (201) Cli 95 4.62 2.74 0.281 4.069 5.171 < .001
Cassetta et al35 (2012) Cli 116 5.09 3.7 0.344 4.417 5.763 < .001
Vercruyssen et al19 2014 Cli 209 3.14 2.06 0.142 2.861 3.419 < .001
Di Giacomo et al36 (2012) Cli 60 6.53 4.31 0.556 5.439 7.621 < .001
Cassetta et al37 (2013) Cli 111 4.68 2.98 0.283 4.126 5.234 < .001
Cassetta et al20 (2013) Cli 227 4.89 3.33 0.221 4.457 5.323 < .001
D’Haese et al3 (2012) Cli 77 2.60 1.61 0.183 2.240 2.960 < .001
Beretta et al38 (2014) Cli 14 2.42 1.02 0.273 1.886 2.954 < .001
Verhamme et al39 (2015) Cli 150 3.93 0.41 0.033 3.864 3.996 < .001
Van de Wiele et al14 (2014) Cli 75 2.79 1.48 0.171 2.455 3.125 < .001
Clinical total 3.98 0.339 3.313 4.642 < .001
Dreiseidler et al29 (2009) Inv 54 1.09 0.51 0.069 0.954 1.226 < .001
Horwitz et al30 (2009) Inv 54 2.17 1.06 0.144 1.887 2.453 < .001
Dreiseidler et al21 (2012) Inv 48 1.9 1.54 0.222 1.464 2.336 < .001
Dreiseidler et al33 (2012) Inv 108 2.01 1.94 0.187 1.644 2.376 < .001
Turbush and Turkyilmaz7 (2012) Inv 150 2.24 1.2 0.098 2.048 2.432 < .001
Soares et al34 (2012) Inv 18 2.16 0.91 0.214 1.740 2.580 < .001
Bilhan et al40 (2012) Inv 11 4.71 1.63 0.491 3.747 5.673 < .001
Cushen and Turkyilmaz13 (2013) Inv 100 3.28 1.6 0.160 2.966 3.594 < .001
In vitro total 2.39 0.353 1.698 3.083 < .001
Total 3.48 0.264 2.959 3.992 Q2 = 7.97
(P = .019)

In the literature, studies using the same planning
software obtained different results. Dreiseidler et al,29 in an
in vitro study, obtained mean values of 0.2 mm, 0.3 mm,
and 1.1 degrees for horizontal apical deviation, horizontal
coronal deviation, and angular deviation, respectively.
On the other hand, clinical studies of Van Assche et al31
(0.6 mm, 0.9 mm, and 2.2 degrees, respectively), Vasak et
al22 (0.4 mm, 0.7 mm, and 3.5 degrees, respectively), and
Pettersson et al24 (0.8 mm, 1.09 mm, and 2.26 degrees,
respectively), using the same software (Procera), obtained
higher deviation values. This strengthens the theory that
in vitro studies reach lower values of deviation.

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Author Mean [95% CI]

Van Assche et al27 2007 (Cad) 2.00 [1.55, 2.45]
Pettersson et al32 2010 (Cad) 2.64 [2.41, 2.87]
Widmann et al41 2010 (Cad) 2.81 [2.21, 3.41]
Kühl et al16 2013 (Cad) 4.12 [3.20, 5.04]
Di Giacomo et al26 2005 (Cli) 7.25 [6.11, 8.39]
Ersoy et al28 2008 (Cli) 4.90 [4.42, 5.38]
Ozan et al8 2009 (Cli) 4.10 [3.67, 4.53]
Valente et al5 2009 (Cli) 790 [6.92, 8.88]
Arisan et al11 2010 (Cli) 3.96 [3.84, 4.08]
Behneke et al17 2012 (Cli) 2.10 [1.88, 2.32]
Van Assche et al31 2010 (Cli) 2.20 [1.71, 2.69]
Vasak et al22 2011 (Cli) 3.53 [3.16, 3.90]
Arisan et al18 2013 (Cli) 3.38 [3.16, 3.60]
Chen et al8 2010 (Cli) 2.07 [1.69, 2.45]
Nickenig et al23 2010 (Cli) 4.20 [2.96, 5.44]
Pettersson et al24 2012 (Cli) 2.26 [2.00, 2.52]
Cassetta et al15 2012 (Cli) 4.62 [4.07, 5.17]
Cassetta et al35 2012 (Cli) 5.09 [4.42, 5.76]
Vercruyssen et al19 2014 (Cli) 3.14 [2.86, 3.42]
Di Giacomo et al26 2012 (Cli) 6.53 [5.44, 7.62]
Cassetta et al37 2013 (Cli) 4.68 [4.13, 5.23]
Cassetta et al20 2013 (Cli) 4.89 [4.46, 5.32]
D’Haese et al3 2012 (Cli) 2.60 [2.24, 2.96]
Beretta et al38 2014 (Cli) 2.42 [1.89, 2.95]
Verhamme et al39 2014 (Cli) 3.93 [3.86, 4.00]
Van de Wiele et al14 2014 (Cli) 2.79 [2.46, 3.12]
Dreiseidler et al29 2009 (Inv) 1.09 [0.95, 1.23]
Horwitz et al30 2009 (Inv) 2.17 [1.89, 2.45]
Dreiseidler et al33 2012 (Inv) 1.90 [1.46, 2.34]
Dreiseidler et al21 2012 (Inv) 2.01 [1.64, 2.38]
Turbush and Turkyilmaz7 2012 (Inv) 2.24 [2.05, 2.43]
Soares et al34 2012 (Inv) 2.16 [1.74, 2.58]
Bilhan et al40 2012 (Inv) 4.71 [3.75, 5.67]
Cushen and Turkyilmaz13 2013 (Inv) 3.28 [2.97, 3.59]
RE MODEL 3.48 [2.96, 3.99]
0.00 2.00 4.00 6.00 8.00 10.00
Observed outcome

Fig 5   Forest plot showing the confidence intervals of angular deviation across the studies.

In the literature, the type of surgical guide has been
seen to be a factor that can influence accuracy in guided
surgery. In the present meta-analysis, the type of guide
used was not studied, although some authors included
in this meta-analysis compared them. Ersoy et al,28
Ozan et al,8 and Cassetta et al37 affirmed that the best
accuracy was obtained with tooth-supported splints;
nevertheless, Valente et al,5 Arisan et al,11 and Cassetta
et al35 obtained better results with mucosa-supported
guides. In the last EAO consensus, bone-supported
templates gave less accurate results than tooth- and
mucosa-supported templates.
When full-guided surgery was compared with half-
guided surgery, lesser deviation values were obtained
with full-guided implant surgery; however, the very small
size of the half-guided group compared to the full-guided

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 Bover-Ramos et al

Table 6   Individual and Combined Measures for the Three Types of Studies and Total Combined
Measure of Vertical Deviation
Study Mean Lower limit Upper limit
Author (year) type n (mm) SD SE 95% CI 95% CI P value
Pettersson et al32 (2010) Cad 145 0.28 0.59 0.049 0.184 0.376 < .001
Cadaver total 0.28 0.049 0.184 0.376 < .001
Valente et al5 (2009) Cli 89 1.1 1 0.106 0.892 1.308 < .001
Vasak et al22 (2011) Cli 86 0.52 0.42 0.045 0.431 0.609 < .001
Cassetta et al35 (2012) Cli 116 0.97 0.65 0.060 0.852 1.088 < .001
Cassetta et al20 (2013) Cli 227 0.86 0.53 0.035 0.791 0.929 < .001
Verhamme et al39 (2014) Cli 150 0.58 0.16 0.013 0.554 0.606
Van de Wiele et al14 (2014) Cli 75 0.48 0.5 0.058 0.367 0.593
Clinical total 0.74 0.103 0.541 0.945 < .001
Dreiseidler et al29 (2009) Inv 54 0.25 0.2 0.027 0.197 0.303 < .001
Horwitz et al30 (2009) Inv 54 0.49 0.36 0.049 0.394 0.586 < .001
Dreiseidler et al21 (2012) Inv 48 0.27 0.22 0.032 0.208 0.332 < .001
Dreiseidler et al33 (2012) Inv 108 0.51 0.43 0.041 0.429 0.591 < .001
Soares et al34 (2012) Inv 18 0.80 0.58 0.137 0.532 1.068 < .001
Bilhan et al40 (2012) Inv 11 1.42 0.31 0.093 1.237 1.603 < .001
Cushen and Turkyilmaz13 (2013) Inv 100 0.60 0.13 0.013 0.575 0.625 < .001
In vitro total 0.61 0.149 0.319 0.904 < .001
Total 0.64 0.089 0.469 0.819 Q2 = 1.82
(P = .401)

Author Mean [95% CI]

Pettersson et al32 2010 (Cad) 0.28 [0.18, 0.38]
Valente et al5 2009 (Cli) 1.10 [0.89, 1.31]
Vasak et al22 2011 (Cli) 0.52 [0.43, 0.61]
Cassetta et al15 2012ii (Cli) 0.97 [0.85, 1.09]
Cassetta et al35 2013ii (Cli) 0.86 [0.79, 0.93]
Verhamme et al39 2014 (Cli) 0.58 [0.55, 0.61]
Van de Wiele et al14 2015 (Cli) 0.48 [0.37, 0.59]
Dreiseidler et al29 2009 (Inv) 0.25 [0.20, 0.30]
Horwitz et al30 2009 (Inv) 0.49 [0.39, 0.59]
Dreiseidler et al33 2012i (Inv) 0.27 [0.21, 0.33]
Dreiseidler et al21 2012ii (Inv) 0.51 [0.43, 0.59]
Soares et al34 2012 (Inv) 0.80 [0.53, 1.07]
Bilhan et al40 2012 (Inv) 1.42 [1.24, 1.60]
Cushen and Turkyilmaz13 2013 (Inv) 0.60 [0.57, 0.63]
RE MODEL 0.64 [0.47, 0.82]

0.00 0.50 1.00 1.50 2.00

Observed outcome

Fig 6   Forest plot showing the confidence intervals of vertical deviation across the studies.

group must be taken into account as a limitation. This
finding is consistent with the meta-analysis of Van Assche
et al2 and the conclusions of the last EAO consensus,10
recommending implant placement guided through the
splint. However, it must be pointed out that on placing
implants in posterior areas and in situations of limited
mouth opening, the clinician might be forced to remove
the splint, so mouth opening is a very important factor
in planning guided surgery.

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Bover-Ramos et al
The average deviation values must be considered when
evaluating safety distances, especially with templates
for flapless surgery,15 but it is also important to take
into account the maximum deviation, which is crucial
for preventing damage of anatomical structures.6 Thus,
based on the results of the present meta-analysis, it would
be advisable to leave as a minimum safe distance the
highest value of the confidence interval (CI) of the clini-
cal studies; however, it must be taken into account that
some authors have obtained higher values. Accordingly,
in relation to horizontal coronal deviation, it would be
prudent to leave a safe distance of at least 1.3 mm to
avoid any complications. This value is very close to the
safety distance of 1.2 mm recommended by the EAO
consensus of 2012.12 In relation to horizontal apical
deviation, it would be advisable to leave a safety distance
of at least 1.7 mm. In the case of angular deviation, it
would be reasonable to leave at least 4.7 degrees. Lastly,
in relation to vertical deviation, it would be advisable
to leave at least 1 mm of margin. Soares et al34 also
recommend leaving 1 mm of vertical distance as a
safety measure; however, the EAO consensus of 201212
recommends only 0.5 mm.
CONCLUSIONS
For apical horizontal deviation, in vitro studies (mean
0.85 mm, 95% CI 0.5–1.2) obtained more accuracy than
clinical studies (mean 1.40 mm, 95% CI 1.2–1.6) and
cadaver studies (mean 1.52 mm, 95% CI 1.2–1.9). For
angular deviation, in vitro studies also obtained more
accuracy (mean 2.39 degrees, 95% CI 1.7–3.1) than
clinical studies (mean 3.98 degrees, 95% CI 3.3–4.6) and
cadaver studies (mean 2.82 degrees, 95% CI 2.0–3.6). For
horizontal coronal deviation and vertical deviation, the
differences were not statistically significant. The clinical
relevance of these (expected) differences may be useful
to warn the surgeon that safety margins to consider
should refer to clinical studies.
Implants placed with full-guided surgery achieved
greater accuracy than implants placed with half-guided
surgery in horizontal coronal deviation (1.00 mm and
1.44 mm, respectively), in apical horizontal deviation
(1.91 mm and 1.23 mm, respectively), and in angular
deviation (3.13 degrees and 4.30 degrees, respectively).
Therefore, whenever possible, the surgical guide should
be removed once implants have been placed.
ACKNOWLEDGMENTS
The authors report no conflicts of interest.
114 Volume 33, Number 1, 2018
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REFERENCES
1. Widmann G, Bale RJ. Accuracy in computer-aided implant surgery–
A review. Int J Oral Maxillofac Implants 2006;21:305–313.
2. Van Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R,
Quirynen M. Accuracy of computer-aided implant placement. Clin
Oral Implants Res 2012;23(suppl):s112–s123.
3. D’Haese J, Van De Velde T, Elaut L, De Bruyn H. A prospective study
on the accuracy of mucosally supported stereolithographic surgical
guides in fully edentulous maxillae. Clin Implant Dent Relat Res
2012;14:293–303.
4. Rungcharassaeng K, Caruso JM, Kan JY, Schutyser F, Boumans T.
Accuracy of computer-guided surgery: A comparison of operator
experience. J Prosthet Dent 2015;114:407–413.
5. Valente F, Schiroli G, Sbrenna A. Accuracy of computer-aided oral
implant surgery: A clinical and radiographic study. Int J Oral Maxil-
lofac Implants 2009;24:234–242.
6. Jung RE, Schneider D, Ganeles J, et al. Computer technology appli-
cations in surgical implant dentistry: A systematic review. Int J Oral
Maxillofac Implants 2009;24(suppl):s92–s109.
7. Turbush SK, Turkyilmaz I. Accuracy of three different types of
stereolithographic surgical guide in implant placement: An in vitro
study. J Prosthet Dent 2012;108:181–188.
8. Ozan O, Turkyilmaz I, Ersoy AE, McGlumphy EA, Rosenstiel SF. Clini-
cal accuracy of 3 different types of computed tomography-derived
stereolithographic surgical guides in implant placement. J Oral
Maxillofac Surg 2009;67:394–401.
9. Cassetta M, Stefanelli LV, Giansanti M, Di Mambro A, Calasso S.
Depth deviation and occurrence of early surgical complications or
unexpected events using a single stereolithographic surgi-guide.
Int J Oral Maxillofac Surg 2011;40:1377–1387.
10. Hämmerle CH, Cordaro L, van Assche N, et al. Digital technologies
to support planning, treatment, and fabrication processes and
outcome assessments in implant dentistry. Summary and consen-
sus statements. The 4th EAO consensus conference 2015. Clin Oral
Implants Res 2015;26(suppl):s97–s101.
11. Arisan V, Karabuda ZC, Ozdemir T. Accuracy of two stereolitho-
graphic guide systems for computer-aided implant placement:
A computed tomography-based clinical comparative study.
J Periodontol 2010;81:43–51.
12. Sicilia A, Botticelli D, Working Group 3. Computer-guided implant
therapy and soft- and hard-tissue aspects. The Third EAO Consensus
Conference 2012. Clin Oral Implants Res 2012;23(suppl):s157–s161.
13. Cushen SE, Turkyilmaz I. Impact of operator experience on the
accuracy of implant placement with stereolithographic surgical
templates: An in vitro study. J Prosthet Dent 2013;109:248–254.
14. Van de Wiele G, Teughels W, Vercruyssen M, Coucke W, Tem-
merman A, Quirynen M. The accuracy of guided surgery via
mucosa-supported stereolithographic surgical templates in the
hands of surgeons with little experience. Clin Oral Implants Res
2015;26:1489–1494.
15. Cassetta M, Pompa G, Di Carlo S, Piccoli L, Pacifici A, Pacifici L. The influ-
ence of smoking and surgical technique on the accuracy of mucosa-
supported stereolithographic surgical guide in complete edentulous
upper jaws. Eur Rev Med Pharmacol Sci 2012;16:1546–1553.
16. Kühl S, Zürcher S, Mahid T, Müller-Gerbl M, Filippi A, Cattin P.
Accuracy of full guided vs. half-guided implant surgery. Clin Oral
Implants Res 2013;24:763–769.
17. Behneke A, Burwinkel M, Knierim K, Behneke N. Accuracy assess-
ment of cone beam computed tomography-derived laboratory-
based surgical templates on partially edentulous patients. Clin Oral
Implants Res 2012;23:137–143.
18. Arisan V, Karabuda ZC, Pişkin B, Özdemir T. Conventional multi-
slice computed tomography (CT) and cone-beam CT (CBCT) for
computer-aided implant placement. Part II: Reliability of mucosa-
supported stereolithographic guides. Clin Implant Dent Relat Res
2013;15:907–917.
19. Vercruyssen M, Cox C, Coucke W, Naert I, Jacobs R, Quirynen M. A
randomized clinical trial comparing guided implant surgery (bone-
or mucosa-supported) with mental navigation or the use of a pilot-
drill template. J Clin Periodontol 2014;41:717–723.

20. Cassetta M, Giansanti M, Di Mambro A, Calasso S, Barbato E. Accu-
racy of two stereolithographic surgical templates: A retrospective
study. Clin Implant Dent Relat Res 2013;15:448–459.
21. Dreiseidler T, Tandon D, Ritter L, et al. Accuracy of a newly devel-
oped open-source system for dental implant planning. Int J Oral
Maxillofac Implants 2012;27:128–137.
22. Vasak C, Watzak G, Gahleitner A, Strbac G, Schemper M, Zech-
ner W. Computed tomography-based evaluation of template
(NobelGuide™)-guided implant positions: A prospective radiologi-
cal study. Clin Oral Implants Res 2011;22:1157–1163.
23. Nickenig HJ, Wichmann M, Hamel J, Schlegel KA, Eitner S. Evalu-
ation of the difference in accuracy between implant placement
by virtual planning data and surgical guide templates versus the
conventional free-hand method–A combined in vivo - in vitro
technique using cone-beam CT (Part II). J Craniomaxillofac Surg
2010;38:488–493.
24. Pettersson A, Komiyama A, Hultin M, Näsström K, Klinge B. Accu-
racy of virtually planned and template guided implant surgery on
edentate patients. Clin Implant Dent Relat Res 2012;14:527–537.
25. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-
analysis. Stat Med 2002;21:1539–1558.
26. Di Giacomo GA, Cury PR, de Araujo NS, Sendyk WR, Sendyk CL. Clin-
ical application of stereolithographic surgical guides for implant
placement: Preliminary results. J Periodontol 2005;76:503–507.
27. Van Assche N, van Steenberghe D, Guerrero ME, et al. Accuracy
of implant placement based on pre-surgical planning of three-
dimensional cone-beam images: A pilot study. J Clin Periodontol
2007;34:816–821.
28. Ersoy AE, Turkyilmaz I, Ozan O, McGlumphy EA. Reliability of im-
plant placement with stereolithographic surgical guides generated
from computed tomography: Clinical data from 94 implants.
J Periodontol 2008;79:1339–1345.
29. Dreiseidler T, Neugebauer J, Ritter L, et al. Accuracy of a newly
developed integrated system for dental implant planning. Clin Oral
Implants Res 2009;20:1191–1199.
30. Horwitz J, Zuabi O, Machtei EE. Accuracy of a computerized
tomography-guided template-assisted implant placement system:
An in vitro study. Clin Oral Implants Res 2009;20:1156–1162.
31. Van Assche N, van Steenberghe D, Quirynen M, Jacobs R. Accuracy
assessment of computer-assisted flapless implant placement in
partial edentulism. J Clin Periodontol 2010;37:398–403.
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Bover-Ramos et al
32. Pettersson A, Kero T, Gillot L, et al. Accuracy of CAD/CAM-guided
surgical template implant surgery on human cadavers: Part I.
J Prosthet Dent 2010;103:334–342.
33. Dreiseidler T, Tandon D, Kreppel M, et al. CBCT device dependency
on the transfer accuracy from computer-aided implantology proce-
dures. Clin Oral Implants Res 2012;23:1089–1097.
34. Soares MM, Harari ND, Cardoso ES, Manso MC, Conz MB, Vidigal
GM Jr. An in vitro model to evaluate the accuracy of guided surgery
systems. Int J Oral Maxillofac Implants 2012;27:824–831.
35. Cassetta M, Stefanelli LV, Giansanti M, Calasso S. Accuracy of im-
plant placement with a stereolithographic surgical template.
Int J Oral Maxillofac Implants 2012;27:655–663.
36. Di Giacomo GA, da Silva JV, da Silva AM, Paschoal GH, Cury PR, Szarf G.
Accuracy and complications of computer-designed selective laser sinter-
ing surgical guides for flapless dental implant placement and immediate
definitive prosthesis installation. J Periodontol 2012;83:410–419.
37. Cassetta M, Stefanelli LV, Giansanti M, Di Mambro A, Calasso S.
Accuracy of a computer-aided implant surgical technique. Int J
Periodontics Restorative Dent 2013;33:317–325.
38. Beretta M, Poli PP, Maiorana C. Accuracy of computer-aided
template-guided oral implant placement: A prospective clinical
study. J Periodontal Implant Sci 2014;44:184–193.
39. Verhamme LM, Meijer GJ, Bergé SJ, et al. An accuracy study of
computer-planned implant placement in the augmented maxilla
using mucosa-supported surgical templates. Clin Implant Dent
Relat Res 2015;17:1154–1163.
40. Bilhan H, Arat S, Mumcu E, Geckili O, Sakar O. Precision of implant
placement with stereolithographic templates: A pilot in vitro study.
J Oral Implantol 2012;38:569–574.
41. Widmann G, Zangerl A, Keiler M, Stoffner R, Bale R, Puelacher W.
Flapless implant surgery in the edentulous jaw based on three fixed
intraoral reference points and image-guided surgical templates: Ac-
curacy in human cadavers. Clin Oral Implants Res 2010;21:835–841.
42. Chen X, Yuan J, Wang C, Huang Y, Kang L. Modular preoperative
planning software for computer-aided oral implantology and the
application of a novel stereolithographic template: A pilot study.
Clin Implant Dent Relat Res 2010;12:181–193.
43. Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on
the accuracy and the clinical outcome of computer-guided template-
based implant dentistry. Clin Oral Implants Res 2009;20(suppl):s73–s86.
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