3D Evaluation the Accuracy of Free-Handed-Countersink Guided and Fully-Guided Implant Surgery in Partially Edentulous Patients: A Clinical Trial With Quasi-experimental Study
Phase: NA
Conditions: Partially Edentulous Jaw, Accuracy of Dental Implant Placement, Implant Deviation and Positioning Errors, Proximity to Anatomical Structures
Sponsor: Islamic University of Caza, Gaza, Palestine

 
 
 
 
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3D Evaluation the Accuracy of Free-Handed- Countersink Guided and Fully-
Guided Implant Surgery in Partially Edentulous Patients: A Protocol for Clinical 
Trial with Quasi-experimental Study 
 
Thiab Alsalibi 1*, Hazem Melad 2, Yasser S. Alajerami 3, Tayseer J. Afifi 4 
Affiliations and Institutions: 
1* Al- Azhar University – Gaza, Faculty of Dentistry, Department of Implantology 
2 Al- Azhar University – Gaza, Faculty of Dentistry, Department of Oral and 
Maxillofacial Department 
3 Al- Azhar University – Gaza, Faculty of Applied Medical Sciences, Department of 
Medical Radiography 
4 Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine 
 
Contact address corresponding author: 
Thiab Alsalibi 
Al- Azhar University – Gaza, Faculty of Dentistry, Department of Implantology 
E-mail: diabm2030@gmail.com 
 
Conflict of interest: 
There are no conflicts of interest. Dental implants, surgical guides were supplied free 
of charge by Dentsply Implants (M4 Implant MIS MF4-10330). 
 
Date: 15 February 2023 
Trial registration: Palestinian Health Research Council ethical approval attains from 
the Helsinki committee trial registration number (PHRC/HC/1242/23) at date of 
registration in it's meeting on 23/02/2023.  
 

 
 
 
 
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ABSTRACT 
Aim: to evaluate the accuracy of tooth-supported fully-guided surgery to free-handed, 
countersink surgery in the posterior maxilla and mandibular of partially edentulous 
patients by using CBCT image after placing implant and superimposed it with pre-
operative CBCT. 
Materials and methods: 
A total of 30 implants of the same brand and type (M4 MIS Dentsply, Germany) were 
placed in15 partially edentulous volunteers in need of implantation in the mandible or 
maxilla or both. All cases were digitally planned using data from cone beam computed 
tomography, and the comparison of the planned and actual implant positions was 
performed using a medical image analysis software (blue sky plan 4). Post-op. CBCT 
was used for nine measurements representing the deviations in angles, implant 
shoulders and apexes. The outcome parameter was angular deviation (AD, degrees), 
crestal global deviation (CGD, mm), vertical linear deviation (VLD, mm), lateral linear 
deviation (LLD, mm), apical global deviation (AGD, mm), apical vertical deviation 
(AVD, mm), apical lateral deviation (ALD, mm), distance from maxillary sinus and 
distance from inferior alveolar nerve. Statistical analysis was performed using Fisher's 
exact test to compare the proportion between groups and Chi square test to test the 
relationship between two categorical variables. 
Keywords: Countersink guided, Quasi experimental study, fully guided, Accuracy, 
partially edentulous. 
Trial registration: Palestinian Health Research Council ethical approval attains from 
the Helsinki committee trial registration number (PHRC/HC/1242/23) at date of 
registration in it's meeting on 23/02/2023.  
 

 
 
 
 
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INTRODUCTION 
The successful establishment of a dental implant not only depends on osseointegration 
but also on the function and aesthetics of the final prosthesis (Bell et al., 2018; Motta 
et al., 2016; Smitkarn et al., 2019). Many of the investigations concerning guided 
implant surgery had different approaches to the factors that could affect how precise 
the surgery will be. Dental implants have proven to offer high survival and clinical 
success rates in various indications (De Angelis et al., 2017; Derks et al., 2015). For 
this reason and under this scenario, present implant dentistry has been concentrating on 
improving the treatment plan, so that an aesthetic result is a new variable. 
Precise three-dimensional (3D) positioning of the implant is needed for the best esthetic 
results (Ruppin et al. 2008; Tahmaseb et al. 2014). The implant should be placed 
prosthetically , and taking into consideration the anatomy and bone availability. In 
addition to esthetics, precision in placement can assist in reducing biologic/technical 
complications (Canullo et al.; Cassetta et al.). 
Among the surgical guide protocols, two common design protocols, fully guided and 
free hand, countersink guided, are often mentioned in relation to their effects on 
accuracy. Fully guided surgery entails the surgical guide guiding all actions with guide 
sleeves, from the first drilling through the implant insertion. On the other hand, 
countersink guided surgery is used especially in hard bone, to provide passive seating 
of the implant neck. These special countersink drills are adapted to enlarge the crestal 
zone into thick cortical bone. 
However, until now there is no clinical study specifically addressing the accuracy of 
countersink guided implant placement, which is supported by the implant industry. 
One single randomized clinical trial (Younes et al., 2018) investigated the accuracy of 
FH, PG, and FG implant placement procedures. 
In the past, radiographic stents, which were later translated to surgical guides after 
cone-beam computed tomography (CBCT) scanning, were used to place implants 
(Misch, 2004). However, this approach is fraught with various technical laboratory 
procedures and errors in the placement of implants are a common consequence 
(Nickenig & Eitner, 2007). Digital surgical guides have since solved these problems 
by combining intraoral scans with CBCT images to plan implant positions according 
to the bone, soft tissue, and adjacent teeth (Ganz, 2015). These guides, if perfectly 
designed and fitted from the beginning to the end of the procedure, will allow for more 
accurate implant installation (Kim, Huh, & Yun, 2016). 
Recently, technological progress in the digital era has allowed for the emergence of the 
static computer-assisted implant surgery (s-CAIS) that provides visualization of 3D 
bone, soft tissue and teeth morphology in the preoperative planning (Deeb et al., 2017; 

 
 
 
 
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Ozan et al., 2009; Whitley & Bencharit 2015). Some studies have compared the 
accuracy of implant position between preoperative and postoperative CBCT and 
concluded that s-CAIS has a good precision. Nevertheless, results diverge and cannot 
yet be universally applied due to the heterogeneity of study designs, most of which were 
in vitro experiments (Deeb et al., 2017). 
Whereas, few clinical studies have reported about the accuracy of implant positioning 
in partially edentulous ridges. Besides, most of the accuracy studies have been still 
laboratory-based and have lacked clinical evidence (Ma et al., 2018). The accuracy of 
implants is generally assessed by comparison between primary and secondary surveyor. 
The primary outcome is the angular deviation (AD) and the secondary outcomes are 
the crestal global deviation (CGD), apical global deviation (AGD), vertical linear 
deviation (VLD), lateral linear deviation (LLD), apical vertical deviation (AVD), and 
apical lateral deviation (ALD) (Younes, Yildiz, Bouferguene, Ursi, & Brunharo, 2018). 
 
MATERIAL & METHODS 
Inclusion criteria were as follows: 
 Partially dentate adults with at least 6 remaining teeth 
 The anticipated presence of sufficient bone volume allowing for implant 
placement with no simultaneous bone grafting 
 Extractions within 2 months of welding. 
 Want the missing tooth to be replaced by an implant 
 Adequate related attached mucosa was found 
 Mouth opening ≥ 40 mm 
 Good oral hygiene 
 Good general health 
Exclusion criteria were as follows: 
 Parafunctional habits 
 Heavy smoking 
 Physical or psychiatric disorders preventing the implant treatment. 
 Previous radiotherapy of the head-neck region 
 Younger than 18 years 
 
 

 
 
 
 
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Study design: 
Researcher adopted pre and post Quasi-Experimental study design to fulfill the 
research objectives quantitatively. The Quasi-Experimental design is a popular design 
used in research. Pre/post-test design is a type of quasi-experimental study, in which an 
easily applied intervention can be studied in relationship to the group of subjects in the 
study. Conclusion Because the research design has problems that the validity of pre–
post and type study is not easily satisfied, we cannot expect it, but we can obtain 
associations in outcome measures in this popular research design by choosing 
randomization, controlling inner and external bias, and correctly applying simple 
statistics. 
 
Study setting: 
The current study conducted in dental implant clinic at Al-Azhar university. Data 
gathered from the patient by using CBCT before and after implant placement to 
compare the result between free hand, countersink guided vs implant placement with 
fully surgical guide. 
 
 
Data Collection procedure: 
Analysis method: 
Free hand (countersink guided) and surgical guide surgeries were carried out by a 
parallel surgical kit (Dentsply®, MIS, M4, Germany), following the manufacturer’s 
recommendations. The surgical guide surgeries were carried out using a dedicated 
(Dentsply®, MIS, M4 Germany) following the above-mentioned surgical plan. Both of 
the implants were performed for the same patient, on the same day and with the same 
devices. One implant per side was placed free hand, countersink guided and the other 
side with a computer-assisted implant guide. 
With Blue Sky Plan 4 (Blue Sky Bio, Grayslake, IL, USA) software, the post-operative 
fixture was extracted as an STL file by segmentation the DICOM file of the CBCT 
taken after surgery used 3D slicer program as show in Figure 1. 

 
 
 
 
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Figure 1: show segmentation the DICOM file of the CBCT taken after surgery used 3D slicer 
program. 
Then, the STL file post-operative fixture imported to Blue Sky Plan 4 program and 
superimposing with planned fixture on the CBCT on the planned implant location 
before surgery as presented in Figure 2. 
 
Figure 2: show import the DICOM file post-operative fixture to Blue Sky Plan 4 program and 
superimposing with the CBCT which have the planned implant location before surgery. 
More than twenty points marked on the two images using a point-based automatic 
image registration algorithm to ensure correspondence as show in Figure 3. 

 
 
 
 
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Figure 3 : aligned using a point-based automatic image registration algorithm. 
 
 
 
 
Measure the deviation for each parameter: 
The definitions concerning accuracy outcome measures are as follows: The primary 
outcome was angular deviation defined as the angle closed by the principal axis of the 
planned implant and the principal axis of the inserted implant in degrees. The secondary 
outcomes were crestal global deviation; the distance between the center of the coronal 
end of the planned and the inserted implants in millimeters, apical global deviation ; 
the distance between the apical endpoints of the planned and the inserted implants in 
millimeters, and vertical linear deviation ; the distance between perpendicular line on 
the hexagon of planned implant and another line draw parallel to it on the hexagon of 
actual implant in millimeters, lateral linear deviation ; the distance between vertical line 
on the long axis of planned implant and another line draw parallel to it on the long axis 
of actual implant in millimeters, apical vertical deviation ; the distance between 
perpendicular line on the apex of planned implant and another line draw parallel to it 
on the apex of actual implant in millimeters, apical lateral deviation ; the distance 
between vertical line on the long axis of planned implant and another line draw parallel 
to it on the long axis of actual implant in millimeters, Two anatomical parameters were 
added to these ones : the distance from the inferior alveolar nerve (IAN) and the 
distance from the maxillary sinus (MS). 
 

 
 
 
 
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Primary outcome is Angular deviation of the final position to the planned implant 
position. Meanwhile, secondary outcomes are described by the following eight 
measurements. 
 
 
Figure 4: Deviation parameters between the planned implant position (blue) and 
placed implant position (yellow): (a) Lateral Linear deviation (mm); (b) Vertical 
Linear deviation (mm); (c) Global Crestal deviation (mm); (d) Apical Lateral 
deviation (mm); (e) Apical Vertical deviation (mm); (f) Apical Global deviation 
(mm); α, Angular deviation (degree). (Ngamprasertkit et al., 2022) 
The real measurements of the primary and secondary outcomes using Blue Sky Plan 4 
Software are presented in Figure 5. 
 
 

 
 
 
 
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(a) 
(b) 
(c) 
 
(d) 
(e) 
(f) 
 
(g) 
(h) 
 
 
Figure 5: Deviation parameters between the planned implant position (red) and 
placed implant position (yellow): (a) apical lateral deviation (mm); (b) distance 
from inferior alveolar nerve (mm); (c) angular deviation (degree); (d) vertical 
linear deviation (mm); (e) lateral linear deviation (mm); (f) crestal global 
deviation (mm); (g) apical vertical deviation (mm); (h) apical global deviation. 
 
 
 
 
 
 
 
 

 
 
 
 
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Data Analysis 
The researcher employed the Statistical Package for the Social Sciences (SPSS) version 
22 program for both data entry and statistical analysis. The data analysis process 
comprised two stages: first, descriptive analysis to summarize the data, followed by an 
inferential analysis that elucidated the relationships between the variables under 
investigation. Also, the Central tendency measures were performed to describe the 
collected data from patients. Exact Fisher's Test, Chi-square Test and Independent t-
Test were used to examine the possible relationship between variables. The confidence 
interval was considered at 95% and a margin of error 5%. P-value less than 0.05 was 
considered to indicate a statistically significant difference. 
Categorical outcomes were presented as absolute and relative frequencies. A bivariate 
analysis using Independent t-Test, or Fisher's exact test when application conditions 
were not achieved, was used to compare the groups. Differences between groups of 
scale variables were explored using parametric (Student's t test for independent or 
paired samples) or nonparametric tests. Chi square test was used to test the relationship 
between two categorical. In the present study the Independent t-Test, Fisher's exact test 
and Chi square test as well as median were used where the data was classified 
nonparametric. 
 
 
 
 

 
 
 
 
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Abbreviations: 
Symbol
Description
CBCT
Cone Beam Computed Tomography
CAD
Computer Aided Design
CAM
CAI
Computer-aided manufacturing
Computer Assisted Inspection
DICOM
Digital Imaging and Communications in Medicine
GIS
Guided Implant Surgery
STL
Standard Tessellation Language OR Standard Triangulated
AD
Angular deviation
CGD
crestal global deviation
VLD
Vertical Linear Deviation
LLD
Lateral Linear Deviation
AGD
apical global deviation
ALD
Apical Lateral Deviation
MS
Maxillary Sinus
IAN
Inferior Alveolar Nerve
s-CAIS
Static computer‐assisted implant surgery
IOS
Intra oral scan
3D
Three-dimensional
FG
Fully guided
FH
Freehand
CS
Countersink
SD
Standard deviation
  AVD                                      apical vertical deviation
   
 
  FHM                                      free hand method 
     
 
  SGM                                      surgical guide method
 
  FH                                          free hand
 

 
 
 
 
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  SG                                          surgical guide 
 
  PG                                          pilot guide
 
  FG                                           fully guided
 
 
Declaration Funding: 
I declare that this article has been composed solely by myself and that it has not been 
submitted, in whole or in part, in any previous application for a degree. Except where 
states otherwise by reference or acknowledgment, the work presented is entirely my 
own. 
Ethics approval and consent to participate: 
The study was designed as a Quasi-Experimental study including consecutive patients 
referred for implants and seeking treatment in four oral and maxillofacial surgery 
department (Clinics university). The study was approved by the Helsinki Committee 
for 
Ethical 
Approval, 
Palestinian 
Health 
Research 
Council 
(Number: 
PHRC/HC/1242/23) at its meeting on 23/02/2023 and implemented in strict adherence 
with ethical principles, that are on par with the World Medical Association’s 
Declaration of Helsinki. Moreover, study goals were explained to patients. Privacy 
and confidentiality as well as voluntary participation were guaranteed. A consent form 
was signed by each patient enrolled in the present study. 
Consent for publication: 
All participants gave written informed consent for their anonymized data to be used in 
publications. 
Availability of data and materials: 
The materials described in the study are available from the corresponding author upon. 
Competing interests: 
The authors declares that they have no competing interests. 
Finding: 
The authors report no funding. 
Author contributions 
Conception and design: Th.A , H.M and Y.A, Provision of study materials: Th.A and 
Y.A, Literature review: Th.A , Data analysis: Th.A , Manuscript writing: Th.A, Final 
approval of manuscript: Th.A , H.M and Y.A 

 
 
 
 
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All authors have critically reviewed and approved the final draft and are responsible for 
the content and similarity index of the manuscript. 
Acknowledgement 
First and foremost, I would like to praise Allah the almighty for the help and assistance 
He granted me during my research journey. 
I would like to express my greatest gratitude to my supervisors, Assistant Prof. Hazem 
Melad and Associated Prof. Yasser Alajerami 
invaluable guidance, advice, and endless encouragement throughout this research. 
Special thanks are directed to my lovely parents, sons (Yazen, Leen, Tim and Selena), 
brothers and sisters whose wisdom and love shaped me as I grew up. 
 
 
 
 
 
 

 
 
 
 
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References 
Apostolakis, D., & Kourakis, G. (2018). CAD/CAM implant surgical guides: 
maximum errors in implant positioning attributable to the properties of 
the metal sleeve/osteotomy drill combination. International journal of 
implant dentistry, 4, 1-9. 
Behneke, A., Burwinkel, M., Knierim, K., & Behneke, N. (2012). Accuracy 
assessment of cone beam computed tomography‐derived laboratory‐
based surgical templates on partially edentulous patients. Clinical oral 
implants research, 23(2), 137-143. 
Bell, C. K., Sahl, E. F., Kim, Y. J., & Rice, D. D. (2018). Accuracy of Implants 
Placed with Surgical Guides: Thermoplastic Versus 3D Printed. 
International Journal of Periodontics & Restorative Dentistry, 38(1). 
Block, M. S., & Emery, R. W. (2016). Static or dynamic navigation for implant 
placement—choosing the method of guidance. Journal of oral and 
maxillofacial surgery, 74(2), 269-277. 
Canullo, L., Tallarico, M., Radovanovic, S., Delibasic, B., Covani, U., & Rakic, 
M. (2016). Distinguishing predictive profiles for patient‐based risk 
assessment and diagnostics of plaque induced, surgically and 
prosthetically triggered peri‐implantitis. Clinical oral implants research, 
27(10), 1243-1250. 
Cassetta, M., Giansanti, M., Di Mambro, A., & Vito Stefanelli, L. (2014). 
Accuracy of positioning of implants inserted using a mucosa-supported 
stereolithographic surgical guide in the edentulous maxilla and 
mandible. International Journal of Oral & Maxillofacial Implants, 29(5). 
D'haese, J., Van De Velde, T., Elaut, L., & De Bruyn, H. (2012). A prospective 
study on the accuracy of mucosally supported stereolithographic 
surgical guides in fully edentulous maxillae. Clinical Implant Dentistry 
and Related Research, 14(2), 293-303. 
Davidowitz, G., & Kotick, P. G. (2011). The use of CAD/CAM in dentistry. 
Dental Clinics, 55(3), 559-570. 
DE ANGELIS, F., Papi, P., Mencio, F., Rosella, D., DI CARLO, S., & Pompa, 
G. (2017). Implant survival and success rates in patients with risk 
factors: results from a long-term retrospective study with a 10 to 18 
years follow-up. European review for medical and pharmacological 
sciences, 21(3), 433-437. 
Deeb, G. R., Allen, R. K., Hall, V. P., Whitley III, D., Laskin, D. M., & Bencharit, 
S. (2017). How accurate are implant surgical guides produced with 
desktop stereolithographic 3-dimentional printers? Journal of oral and 
maxillofacial surgery, 75(12), 2559. e2551-2559. e2558. 
Derks, J., Håkansson, J., Wennström, J., Tomasi, C., Larsson, M., & 
Berglundh, T. (2015). Effectiveness of implant therapy analyzed in a 
Swedish population: early and late implant loss. Journal of dental 
research, 94(3_suppl), 44S-51S. 
Ewers, R., Schicho, K., Undt, G., Wanschitz, F., Truppe, M., Seemann, R., & 
Wagner, A. (2005). Basic research and 12 years of clinical experience 

 
 
 
 
15 
 
 
in computer-assisted navigation technology: a review. International 
journal of oral and maxillofacial surgery, 34(1), 1-8. 
Farley, N. E., Kennedy, K., McGlumphy, E. A., & Clelland, N. L. (2013). Split-
mouth comparison of the accuracy of computer-generated and 
conventional surgical guides. International Journal of Oral & 
Maxillofacial Implants, 28(2). 
Ganz, S. D. (2015). Three-dimensional imaging and guided surgery for dental 
implants. Dental Clinics, 59(2), 265-290. 
Gargallo-Albiol, J., Barootchi, S., Marqués-Guasch, J., & Wang, H.-L. (2020). 
Fully Guided Versus Half-Guided and Freehand Implant Placement: 
Systematic Review and Meta-analysis. International Journal of Oral & 
Maxillofacial Implants, 35(6). 
Giacomo, G. A. D., Cury, P. R., de Araujo, N. S., Sendyk, W. R., & Sendyk, C. 
L. (2005). Clinical application of stereolithographic surgical guides for 
implant placement: preliminary results. Journal of periodontology, 
76(4), 503-507. 
Jorba-García, A., Figueiredo, R., González-Barnadas, A., Camps-Font, O., & 
Valmaseda-Castellón, E. (2019). Accuracy and the role of experience 
in dynamic computer guided dental implant surgery: An in-vitro study. 
Medicina oral, patologia oral y cirugia bucal, 24(1), e76. 
Kim, J.-E., Kim, N.-H., Park, J.-H., & Shim, J.-S. (2016). A procedure for the 
computer-guided implant planning: A narrative review. The Journal of 
the Korean dental association, 54(2), 108-122. 
Koop, R., Vercruyssen, M., Vermeulen, K., & Quirynen, M. (2013). Tolerance 
within the sleeve inserts of different surgical guides for guided implant 
surgery. Clinical oral implants research, 24(6), 630-634. 
Lee, J. H., Lee, J. B., Park, J. I., Choi, S. H., & Kim, Y. T. (2015). Mechanical 
complication rates and optimal horizontal distance of the most distally 
positioned implant‐supported single crowns in the posterior region: A 
study with a mean follow‐up of 3 years. Journal of Prosthodontics, 
24(7), 517-524. 
Li, J., Chen, Z., Chan, H. L., Sinjab, K., Yu, H., & Wang, H. L. (2019). Does 
flap opening or not influence the accuracy of semi‐guided implant 
placement in partially edentulous sites? Clinical Implant Dentistry and 
Related Research, 21(6), 1253-1261. 
López, D. A. S., García, I., Salomao, G. D. S., & Laganá, D. C. (2019). 
Potential deviation factors affecting stereolithographic surgical guides: 
a systematic review. Implant Dentistry, 28(1), 68-73. 
Ma, B., Park, T., Chun, I., & Yun, K. (2018). The accuracy of a 3D printing 
surgical guide determined by CBCT and model analysis. The journal of 
advanced prosthodontics, 10(4), 279-285. 
Machtei, E. E., Oettinger-Barak, O., & Horwitz, J. (2014). Axial relationship 
between dental implants and teeth/implants: a radiographic study. 
Journal of Oral Implantology, 40(4), 425-431. 
Misch, C. E. (2004). Dental implant prosthetics-E-book. Elsevier Health 
Sciences. 
Mistry, A., Ucer, C., Thompson, J. D., Khan, R. S., Karahmet, E., & Sher, F. 
(2021). 3D guided dental implant placement: impact on surgical 

 
 
 
 
16 
 
 
accuracy and collateral damage to the inferior alveolar nerve. Dentistry 
Journal, 9(9), 99. 
Motta, M., Monsano, R., Velloso, G. R., de Oliveira Silva, J. C., Luvizuto, E. 
R., Margonar, R., & Queiroz, T. P. (2016). Guided surgery in esthetic 
region. Journal of Craniofacial Surgery, 27(3), e262-e265. 
Ngamprasertkit, C., Aunmeungthong, W., & Khongkhunthian, P. (2022). The 
implant position accuracy between using only surgical drill guide and 
surgical drill guide with implant guide in fully digital workflow: a 
randomized clinical trial. Oral and Maxillofacial Surgery, 26(2), 229-
237. 
Nickenig, H.-J., & Eitner, S. (2007). Reliability of implant placement after 
virtual planning of implant positions using cone beam CT data and 
surgical (guide) templates. Journal of Cranio-Maxillofacial Surgery, 
35(4-5), 207-211. 
Ozan, O., Turkyilmaz, I., Ersoy, A. E., McGlumphy, E. A., & Rosenstiel, S. F. 
(2009). Clinical accuracy of 3 different types of computed tomography-
derived stereolithographic surgical guides in implant placement. 
Journal of oral and maxillofacial surgery, 67(2), 394-401. 
Ruppin, J., Popovic, A., Strauss, M., Spüntrup, E., Steiner, A., & Stoll, C. 
(2008). Evaluation of the accuracy of three different computer‐aided 
surgery systems in dental implantology: optical tracking vs. 
stereolithographic splint systems. Clinical oral implants research, 19(7), 
709-716. 
Sarhan, M. M., Khamis, M. M., & El-Sharkawy, A. M. (2021). Evaluation of the 
accuracy of implant placement by using fully guided versus partially 
guided tissue-supported surgical guides with cylindrical versus C-
shaped guiding holes: A split-mouth clinical study. The Journal of 
Prosthetic Dentistry, 125(4), 620-627. 
Scherer, U., Stoetzer, M., Ruecker, M., Gellrich, N.-C., & von See, C. (2015). 
Template-guided vs. non-guided drilling in site preparation of dental 
implants. Clinical oral investigations, 19, 1339-1346. 
Smitkarn, P., Subbalekha, K., Mattheos, N., & Pimkhaokham, A. (2019). The 
accuracy of single‐tooth implants placed using fully digital‐guided 
surgery and freehand implant surgery. Journal of Clinical 
Periodontology, 46(9), 949-957. 
Tahmaseb, A., Wismeijer, D., Coucke, W., & Derksen, W. (2014). Computer 
technology applications in surgical implant dentistry: a systematic 
review. International Journal of Oral & Maxillofacial Implants, 29. 
Van Assche, N., Van Steenberghe, D., Quirynen, M., & Jacobs, R. (2010). 
Accuracy assessment of computer‐assisted flapless implant placement 
in partial edentulism. Journal of Clinical Periodontology, 37(4), 398-
403. 
Van Assche, N., Vercruyssen, M., Coucke, W., Teughels, W., Jacobs, R., & 
Quirynen, M. (2012). Accuracy of computer‐aided implant placement. 
Clinical oral implants research, 23, 112-123. 
Varga Jr, E., Antal, M., Major, L., Kiscsatári, R., Braunitzer, G., & Piffkó, J. 
(2020). Guidance means accuracy: A randomized clinical trial on 
freehand versus guided dental implantation. Clinical oral implants 
research, 31(5), 417-430. 

 
 
 
 
17 
 
 
Vercruyssen, M., Coucke, W., Naert, I., Jacobs, R., Teughels, W., & Quirynen, 
M. (2015). Depth and lateral deviations in guided implant surgery: An 
RCT comparing guided surgery with mental navigation or the use of a 
pilot‐drill template. Clinical oral implants research, 26(11), 1315-1320. 
Whitley, D., & Bencharit, S. (2015). Digital implantology with desktop 3D 
printing. Formlabs white paper, 1-15. 
Younes, F., Cosyn, J., De Bruyckere, T., Cleymaet, R., Bouckaert, E., & 
Eghbali, A. (2018). A randomized controlled study on the accuracy of 
free‐handed, pilot‐drill guided and fully guided implant surgery in 
partially edentulous patients. Journal of Clinical Periodontology, 45(6), 
721-732.