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Complete Denture Prosthodontics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
Oral Implantology and Regenerative Dental Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
art ic l e i nf o
a b s t r a c t
Article history:
Received 30 March 2013
Accepted 28 July 2013
This study aimed to evaluate the accuracy of implant placement with mucosa-supported surgical guides
in edentulous mandibles and to determine the factors affecting accuracy. Implant placement was
simulated on the preoperative CT image and mucosa-supported surgical guides were fabricated for six
edentulous mandible models and 15 patients with edentulous mandibles, using CAD/CAM technology.
Deviations of the actual implant position from the planned position were calculated by comparing the
planned image and the postoperative image. Based on the results, it was concluded that mucosasupported surgical guides have high accuracy and that bone density and mucosal thickness could affect
accuracy.
& 2013 Elsevier Ltd. All rights reserved.
Keywords:
Dental implant
Edentulous mandible
Accuracy
Mucosa-supported surgical guide
Stereolithographic
Computed tomography
1. Introduction
Stereolithographic surgical guides can simplify the techniquesensitive and operator-dependent surgical procedures in implantsupported restorations, beneting both patient and dentist [1].
When stereolithographic surgical guides were used, variations in
accuracy of implant placement within surgeons and between
surgeons were reduced, compared to surgery using conventional
guides [2]. Shorter surgery duration and less discomfort after
surgery were recorded when mucosa-supported surgical guides
were used [3]. Therefore, the use of mucosa-supported stereolithographic surgical guides in edentulous patients will increase
along with the demand for implant-supported restorations in
edentulous patients.
Although many researchers have evaluated the accuracy of
implant placement with mucosa-supported surgical guides [417],
few studies have assessed factors affecting the accuracy of
mucosa-supported surgical guides. Errors during implant placement have often been explained by instability of the surgical guide
[4]. Considering a report that alveolar ridge resorption was
associated with denture stability in edentulous mandibles [18],
alveolar ridge shape seems to inuence surgical guide accuracy,
n
Correspondence to: Complete Denture Prosthodontics, Graduate School
of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45,
Yushima, Bunkyo-ku, Tokyo 113-8549, Japan. Tel.: 81 3 5803 5563;
fax: 81 3 5803 5586.
E-mail address: m.kanazawa.ore@tmd.ac.jp (M. Kanazawa).
0010-4825/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.compbiomed.2013.07.029
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Fig. 1. Radiographic guides for the (a) model study and (b) clinical study. (a) Radiographic guide (1) was fabricated on stone cast (2) with articial mucosa (3). (b) The
patient's complete denture made of acrylic resin was used as a radiographic guide, in which gutta-percha markers were placed as reference points (arrow).
Fig. 2. Planning on the Procera software in the (a) model study and (b) clinical study. Placement of two implants (1) and three anchor pins (2) was planned presurgically,
according to anatomy and prosthetic design.
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Fig. 3. Stereolithographic surgical guides for the (a) model study and (b) clinical study.
Fig. 4. Surgical procedure. During the operation, the surgical guide was stabilized on (a) the model or (b) the mucosa, using anchor pins.
Fig. 5. Matching procedure. (a) Positions of the planned and placed implants were compared by matching the planned (blue) and postoperative (red) images. (b) The x-axis was
dened as the line connecting the neck of the right (blue) and left (light blue) implant of the planned image, while the z-axis was dened as the central axis of the right implant. Each
deviation was calculated at the implant neck and apex. (For interpretation of the references to color in this gure legend, the reader is referred to the web version of this article.)
compose the 3D objects in n.stl les were used as the closest points and
an algorithm that minimized the distance between corresponding
apices was repeated. For exclusion of outliers and accurate matching, a
distance threshold was set and decreased from 3 mm to 0.01 mm
during the repeated algorithm. Global deviation between the planned
and actually inserted implant positions was measured. Mesio-distal,
bucco-lingual, and depth deviation were also taken as measurement
parameters by setting the 3D space coordinates (Fig. 5b). Each
deviation was calculated at the implant neck and apex. When the
coordinates of the measurement sites were (x1, y1, z1) in the planned
image and (x2, y2, z2) in the postoperative image, each deviation was
calculated by the following formulas:
Global deviation mm fx2 x1 2 y2 y1 2 z2 z1 2 g1=2
Mesio distal deviation mm x2 x1
Bucco lingual deviation mm y2 y1
Depth deviation mm z2 z1
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Fig. 6. Measurement of bone density. On a cross-section in the planning software, ve equally spaced points (red points in the right image) were located along the major axis
of the planned implant site. The mean gray value at the points was calculated and regarded as bone density at the implant site. (For interpretation of the references to color
in this gure legend, the reader is referred to the web version of this article.)
3. Results
Twelve implants were placed on six models, and 30 implants
were placed in 15 patients (seven males and eight females, mean
age 67.1 years) with edentulous mandibles. A total of 42 implants
were analyzed by comparing the preoperatively planned and actually
placed positions.
The global, mesio-distal, bucco-lingual, and depth deviations at the
implant neck and apex in the model study and the clinical study are
summarized in Table 1. Global deviations in the Absorbed group, Nonabsorbed group and the clinical study were 0.4170.11 mm, 0.337
4. Discussion
In the model study, the present results suggest that the alveolar
ridge shape of the model does not inuence the accuracy, as no
signicant difference was observed in global deviations between the
Absorbed group and Non-absorbed group. When the alveolar ridge is
absorbed in an edentulous mandible, the surgical guide will be lifted
up by the mouth oor or moved horizontally by the tongue and buccal
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mucosa. In the model, the surgical guide is far more stable compared
to the actual surgical environment, as the model has no mouth oor,
tongue, or buccal mucosa that may cause instability of the guide.
Therefore, deviations that result from instability of the surgical guide
caused by ridge resorption may seldom occur on the model. Movement of the surgical guide related to the resilience of articial mucosa
[10,11] was minimized by using anchor pins and the same rubber
band that xed the radiographic guide during CT scan. Therefore, the
deviations in the model study were presumably system-related
deviations caused by errors during CT image acquisition, data processing, and manufacturing of the surgical guides using rapid prototyping
[21,22], and mechanical errors caused by the bur-sleeve gap [12]. The
error during image acquisition and data processing could be almost
0.5 mm [23]. Although the accuracy of rapid prototyping is reported to
range from 0.1 to 0.2 mm [13], incorrect setting in the software prior
to rapid prototyping can result in gross deformation of surgical guides
[22]. Horwitz et al. [24] suggested that deviations related to examiner
errors or errors during CT image acquisition ranged from 0.32 to
0.49 mm, which accounted for a major portion of whole deviations. In
the present study, errors during the matching procedure could occur
from incorrect threshold setting during n.stl conversion. Another factor
for examiner error would be the difference between the 3D images
of radiographic guides and surgical guides, which were used as
reference objects during matching. The mean global deviations in
the present model study were 0.3770.11 mm at the implant neck and
0.4970.12 mm at the apex, which were within the range of systemrelated deviations so far reported. Combining the ndings of Horwitz
et al. [24], if there were examiner errors during measurement of
deviations in the present study, the actual deviation would possibly be
around 00.97 mm at the neck and 01.1 mm at the apex. When the
system-related deviations compensate each other, the total deviation
will be minimized. However, as the deviations are theoretically
generated from the cumulative sum of all errors, it is important to
be aware of the largest deviation possible.
Signicantly higher deviations were observed in the clinical
study compared with the model study. Various procedure-related
factors, such as patients' movement during CT scan, instability of
the surgical guides while drilling, limited mouth opening, and
bone density, seem to have inuenced the accuracy and further
added to the system-related deviations.
Cassetta et al. suggested that higher bone density resulted in a
more supercial implant position when single-type guides with
depth control were used [14], and higher global deviations at the
implant neck and apex when multiple-type guides without depth
control were used [15]. In the present clinical study, single-type
guides with depth control were used and signicant negative
correlations between bone density and depth deviations at the
implant neck and apex were observed. Of the 30 implants placed,
21 were placed more supercially and nine were placed more
Table 1
Global, mesio-distal, bucco-lingual, and depth deviations in the model study and the clinical study (n42).
Deviations
Absorbed group (n 6)
Neck (mm)
Apex (mm)
Global
Mesio-distal
Bucco-lingual
Depth
Global
Mesio-distal
Bucco-lingual
Depth
Non-absorbed group (n 6)
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
0.59
0.22
0.08
0.21
0.67
0.26
0.00
0.20
0.29
0.09
0.28
0.59
0.39
0.46
0.42
0.59
0.41a
0.02
0.08
0.35
0.53c
0.20
0.21
0.35
0.11
0.10
0.12
0.13
0.11
0.22
0.13
0.14
0.44
0.20
0.14
0.20
0.63
0.56
0.36
0.20
0.21
0.09
0.08
0.42
0.32
0.22
0.31
0.42
0.33a
0.04
0.02
0.30
0.45c
0.03
0.04
0.30
0.09
0.09
0.08
0.08
0.12
0.27
0.20
0.08
2.66
0.74
0.70
1.22
2.21
1.47
0.91
1.17
0.21
0.40
2.50
1.16
0.20
1.96
1.92
1.19
0.89b
0.14
0.29
0.28
1.08d
0.11
0.29
0.30
0.44
0.34
0.55
0.61
0.47
0.70
0.59
0.61
Global deviations of each row with a different superscript letters were signicantly different (p o 0.05).
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Table 2
Spearman's rank correlation coefcients between bone density and each deviation (n 30).
Deviation at the neck
Bone density
r
95% CI
p
Global
Mesio-distal
Bucco-lingual
Depth
Global
Mesio-distal
Bucco-lingual
Depth
0.10
0.27, 0.44
0.62
0.37
0.01, 0.64
0.05
0.03
0.33, 0.39
0.88
0.57
0.77, 0.26
o0.01
0.07
0.30, 0.42
0.72
0.37
0.01, 0.64
0.06
0.18
0.19, 0.51
0.37
0.56
0.77, 0.25
o 0.01
rSpearman's rank correlation coefcients; 95% CI95% condence interval; and pp-value.
Table 3
Spearman's rank correlation coefcients between mucosal thickness and each deviation (n 15).
Deviation at the neck
Mucosal thickness
r
95% CI
p
Global
Mesio-distal
Bucco-lingual
Depth
Global
Mesio-distal
Bucco-lingual
Depth
0.01
0.51, 0.52
0.96
0.05
0.55, 0.47
0.85
0.08
0.45, 0.57
0.79
0.21
0.34, 0.65
0.44
0.73
0.35, 0.90
o0.01
0.08
0.45, 0.57
0.77
0.16
0.38, 0.62
0.56
0.21
0.34, 0.65
0.44
rSpearman's rank correlation coefcients; 95% CI95% condence interval; and pp-value.
Table 4
Spearman's rank correlation coefcients between area of the supporting mucosa and each deviation (n 15).
Deviation at the neck
r
95% CI
p
Area
Global
Mesio-distal
Bucco-lingual
Depth
Global
Mesio-distal
Bucco-lingual
Depth
0.20
0.35, 0.65
0.47
0.06
0.47, 0.56
0.82
0.14
0.40, 0.61
0.63
0.42
0.12, 0.77
0.12
0.01
0.51, 0.52
0.97
0.06
0.47, 0.56
0.83
0.15
0.62, 0.39
0.59
0.42
0.12, 0.77
0.12
rSpearman's rank correlation coefcients; 95% CI95% condence interval; and pp-value.
1.5
1
0.5
0
-0.5
-1
-1.5
200
400
600
800
1000
1200
Bone density
1.5
1
0.5
0
-0.5
-1
-1.5
200
400
600
800
1000
1200
Bone density
Fig. 9. Correlation between bone density and depth deviation at the implant neck
(n30). The line is an approximate line.
Fig. 10. Correlation between bone density and depth deviation at the implant apex
(n 30). The line is an approximate line.
2.50
2.00
1.50
1.00
0.50
0.00
1.00
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1.50
2.00
2.50
3.00
5. Conclusions
Within the limitations of this study, the following conclusions
can be drawn:
1. System-related deviations are slight even if errors occur during
measurement of deviations.
2. Implants are more likely to be placed deeply at bone sites with
lower bone density. In the surgery using surgical guides, the
implants tend to be placed more supercially compared to the
planned position.
3. The global deviations at the implant apex are more likely to
increase when the mucosa is thicker.
From these ndings, it can be concluded that mucosa-supported
surgical guides have high accuracy and that factors such as bone
density and mucosal thickness could affect accuracy.
6. Summary
Stereolithographic surgical guides manufactured by CAD/CAM
technology enable transfer of the software plan to the surgical eld
more accurately. Though the accuracy of implant placement with
mucosa-supported surgical guides has been reported previously, few
studies have assessed factors affecting accuracy. This study aimed to
evaluate the accuracy of implant placement with mucosa-supported
surgical guides in edentulous mandibles and determine the factors
affecting accuracy.
Six edentulous mandible models with articial mucosa were
fabricated for the model study and divided into two groups
according to the alveolar ridge shape (Absorbed group and Nonabsorbed group). Fifteen patients with edentulous mandibles were
enrolled in the clinical study. A preoperative CT scan was taken
and mucosa-supported surgical guides were prepared by virtual
treatment planning in which two implants were located in the
intraforaminal area. After the implants were inserted using the
surgical guides, a postoperative CT scan was taken and the planned
image and postoperative image were superimposed with a matching method using an iterative closest point algorithm. The global,
mesio-distal, bucco-lingual, and depth deviations at implant neck
and apex were determined and compared between the groups
with the SteelDwass multiple comparisons. In the clinical study,
correlations between each deviation and bone density, mucosal
thickness, and area of supporting mucosa were tested with the
Spearman's rank correlation coefcient.
Global deviations in the Absorbed group, Non-absorbed group and
the clinical study were 0.4170.11 mm, 0.3370.09 mm and 0.897
0.44 at the implant neck and 0.5370.11 mm, 0.4570.12 mm and
1.0870.47 mm at the implant apex respectively. No signicant
difference was observed in any deviation when comparing the
Absorbed and Non-absorbed groups of the model study. Global
deviations at the implant neck and apex were signicantly higher in
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Daisuke Sato is an Adjunct Lecturer in Department of Oral Implantology and Regenerative Dental Medicine, Tokyo Medical and Dental University in Japan. He has received
his Ph.D. degree in 2004. His research interests focus on immediate loading of dental
implants.
Shunsuke Minakuchi is a Professor in Department of Complete Denture Prosthodontics, Tokyo Medical and Dental University in Japan. He has received his Ph.D.
degree in 1987. His research interests focus on CAD/CAM, masticatory performance
and denture base material.