## 4 Discussion  
The aim of this study was to assess the clinical and radiographical performance and accuracy of the surgical workflow during maxillary immediate implant placement assisted by DTX studio Implant software planning and X-Guide Navigation. The navigation systems have been used primarily in implant dentistry [12; 13] but recently have been used in endodontics for guided access cavity preparation in calcified root canals or for removing fiber posts from root canal-treated teeth with greater accuracy than free-hand methods [14; 15]. \begin{table}
\begin{tabular}{c c} \hline Number of Patients & 12 \\ Mean age (SD) & 45.5 (6.15) \\ Age range & 38–55 \\ Total number of inserted implants & 22 \\ Average number of implants in each patient & 1.83 (0.83) \\ Mean diameter of inserted implants (SD) & 3.7 (0.36) mm \\ Mean length of inserted implants (SD) & 12 (1.17) mm \\ \hline SD: standard deviation. \\ \end{tabular}
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Table 1: Patient and intervention characteristics. Figure 4: Post-operative radiographic images: (**A**) opt; (**B**) sagittal section of CBCT; (**C**) axial section of CBCT. \begin{table}
\begin{tabular}{c c c c c} \hline  & **Max (mm)** & **Min (mm)** & **Mean (mm)** & **SD** \\ \hline Insertion & 1.2 & 0.4 & 0.77 & 0.25 \\ deviation & 2.2 & 0.5 & 1.2 & 0.61 \\ Avial deviation & 3.1 & 2 & 2.5 & 0.41 \\ Depth error & 0.9 & 0.3 & 0.5 & 0.21 \\ \hline \end{tabular} Max: maximum value; Min: minimum value; SD: standard deviation.  
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Table 2: Summary of results. The accuracy can be defined as the degree to which the result of a measurement, calculation, or specification conforms to the correct value or standard. In the present study, the accuracy was measured mainly as angle deviation. This was justified in the prosthetic importance of these parameters. Our results show that the axis deviation was 2.5 \(\pm\) 0.41 degrees. This value is less than the values of averaged 4.1 degrees for clinical studies and 3.7 degrees for in vitro studies reported in a recent systematic review, showing in addition that the accuracy of dynamic navigation is comparable to that of static navigation [16]. [PERSON] and collaborators found that guided implant surgery using desktop 3D printed mucosa-supported guides has a clinically acceptable level of accuracy [17]. The dynamic navigation system allows the surgeon to place the dental implant based on the ideal position to achieve the best outcome, ideally as prosthetic-driven. This is even more true when the placement of the implants relates to the esthetic region of the maxilla [18; 19; 20]. The rehabilitation of the esthetic region represents a challenge for the clinicians because of patients' exacting esthetic demands and difficult pre-existing anatomy. The main esthetic objectives of implant therapy from a surgical point of view are the achievement of a harmonious gingival margin without abrupt changes in tissue height, maintaining intact papillae, and obtaining or preserving a convex contour of the alveolar crest. Incorrect inclination of the implants in this region can have serious consequences on the esthetic outcomes and on the success in a long term. An inadequate vestibular thickness around the dental implants may be associated with peri-implant bone loss and mucosal recession [21]. With regard to this matter, dynamic navigation was also shown to be effective to guide bone and soft tissue sculpturing [22]. Moreover, the accuracy may depend on the experience of the surgeon. [PERSON] and collaborators compared the accuracy with guided implant surgery from five different surgeons. A statistically significant difference between the virtually planned and placed implant positions was observed for three of the four outcome variables (the apex, hexagon, and depth). A statistically significant difference was also noted among all surgeons regarding the positions of the apex, depth, and angle [23].