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Periodontology 2000. 2022;90:197–223.
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197wileyonlinelibrary.com/journal/prd
DOI : 10.1111/prd.12458
REVIEW ARTICLE
Can computer- assisted implant surgery improve clinical
outcomes and reduce the frequency and intensity of
complications in implant dentistry? A critical review
Atiphan Pimkhaokham1 | Sirimanas Jiaranuchart1 |
Boosana Kaboosaya1 | Sirida Arunjaroensuk1 | Keskanya Subbalekha1 |
Nikos Mattheos1,2
1Department of Oral and Maxillofacial Surger y, Faculty of Dentistry, Chulalongkorn Universit y, Bangkok, Thailand
2Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden
Correspondence
Nikos Mattheos, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Wangmai, Pathumwan, Bangkok, Thailand.
Email: nikos@mattheos.net
1 | INTRODUCTION
Computer- assisted implant surgery (CAIS) includes two major tech-
nological pathways, typically distinguished as static and dynamic
Computer- assisted implant surgery (d- CAIS) or real- time navigation.
Static Computer- assisted implant surgery (S- CAIS) technology uti-
lizes a surgical guide for guiding the osteotomy and implant installa-
tion, while the d- CAIS system guides the surgeon during osteotomy
and implant placement through real- time imaging by means of op-
tical tracking devices. Both systems are currently widely used and
have been well documented to help surgeons achieve significantly
higher accuracy of implant placement than conventional freehand
surgery. Several recent systematic reviews and meta- analyses have
shown superior outcomes in terms of accuracy for both static1 as
well as d- CAIS.2,3
Accuracy of implant placement, however, is not the end purpose
in itself. Instead, by offering superior accuracy, the endpoint of CAIS
is to facilitate superior clinical outcomes, by reducing failures, com-
plications, and adverse effects. There are many ways that increased
accuracy is expected to influence clinical outcomes. Some authors
have suggested that CAIS could reduce intraoperative complications
by helping the surgeon avoid damaging sensitive anatomic struc-
tures such as the mandibular nerve and the sinus, as well as avoid
proximity to roots of neighboring teeth.4 Some have suggested CAIS
could reduce the invasiveness, complexity, and duration of surgical
interventions, while others have reported increasing patients’ satis-
faction and acceptance.5 Finally, as this technology aims to empower
the proper prosthetic- driven implant placement, it could potentially
impact the long- term outcomes of implant therapy by allowing im-
plant placement in the optimal position and angulation for pros-
thetic designs that could promote sustainable esthetic outcomes
and health of the peri- implant tissue.6,7 Optimal positioning of the
implants may also reduce the cost of reconstruction, by allowing the
use of stock abutments and minimizing the need for expensive cus-
tomized solutions. Initial research on CAIS and consequent system-
atic reviews have primarily focused on reporting accuracy, although
some authors acknowledge that survival rates, complications,
patient- centered outcomes, and socioeconomic benefits are essen-
tial variables that cannot be ignored.2 As these technologies are in-
creasingly applied, assessing overall effectiveness and efficiency is
critical to identify the potential and limitations of such systems, as
well as help clinicians to make evidence- based decisions.
1.1 | Aims
The primary aims of this critical review were to investigate whether
the use of CAIS can lead to:
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
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198
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PI MKHAOKH AM et Al.
1. Reduction of the frequency and extent of complications (in-
traoperative, postoperative, and medium/long term).
2. Improvement of patient- reported outcomes (PRO) and/or patient-
reported experience (PRE).
The secondary aims were to report the influence of CAIS on:
1. Clinical outcomes related to complications (plaque index, bleed-
ing on probing (BOP), probing depth, keratinized mucosa, mar-
ginal bone loss (MBL), esthetic outcomes, duration of surgery).
2. Clinical outcomes related to the overall efficiency of CAIS (dura-
tion of the surgery, experience, and training of the operator).
2 | MATERIALS AND METHODS
2.1 | Methodology
A comprehensive online search was conducted in PubMed aiming
to identify clinical trials in the last 10 years, where implants were
installed with static or dynamic CAIS or combinations of the two,
either compared with conventional free- hand implant placement
or not. The electronic database PubMed was searched in February
2022 for articles in English with a limit of 10 years using the search
query: {“Computer assisted implant surgery” OR “Computer aided
implant Surgery” OR “guided implant Surgery” OR “implant naviga-
tion” OR “static guided” OR “dynamic guided”} AND Dental. In addi-
tion, a manual search was conducted on the reference lists of four
recent systematic reviews and meta- analyses.1– 3
2.2 | Qualitative data synthesis and quantitative/
statistical analysis
In most cases, the heterogeneity of the data allowed only col-
lective qualitative analysis. In the case of postsurgical PROs of
pain originating from the first week of healing, a meta- analysis
was conducted on three studies.8, 9,4 3 The meta- analysis was con-
ducted using the software RevMan version 5.4 (Review Manager,
the Cochrane Collaboration, 2020). Mean and standard devia-
tion (SD) of patient- reporting pain scores at the designated time
points derived from the selected articles were used as quanti-
tative data, comparing the severity of pain between different
types of surgery (static and d- CAIS data compiled vs freehand
placement (FH), s- CAIS only vs FH). Thus, the standardized mean
difference was applied to identify the magnitude of the effect
and calculated 95% confidence interval. Then the random ef-
fect model was used for analysis. The heterogeneity across the
studies was assessed by Chi- squared and I2 tests. Forest plots
were constructed to represent the results of meta- analysis of the
included studies. A P value of less than .05 was judged to have
statistical difference. Data were extracted and assessed by 77
studies (Table 1 and Figure 1).
2.3 | Frequency/extent of complications and
clinical outcomes with CAIS compared with
conventional placement
2.3.1 | Intraoperative (surgical) complications
Intraoperative complications reported in the literature include the
absence of implant stability,10– 1 3 surgical template fractures,14 in-
stability/misfit of the surgical guide,13,15,16 bone dehiscence after
implant placement,14,17 and anatomic limitation/problematic access
for s- CAIS drills.17,18 Of 10 studies reporting intraoperative compli-
cations (Table 2), only one compared outcomes between s- CAIS and
FH.
Primary stability and related outcomes
Presence/absence of clinical primary stability. Four studies reported
outcomes related to the implant primary stability, none of which
compared outcomes between CAIS and FH. One comparative RCT
by Ko et al12 assessed clinical stability between immediate loading
and delayed loading protocol with s- CAIS and reported that seven
out of 93 implants (7.53%) (five maxilla/two mandible) in four out
of 36 patients had insufficient implant stability in the immediate
loading group. In other prospective and retrospective studies, an
absence of clinical stability after placement with s- CAIS varied from
1.8% to 3.84%10,11,13 (Table 2).
Quantitative measures of primary stability. Eleven studies assessed or
reported primary stability after implant placement utilizing diverse
outcomes measures, including insertion torque value (ITV), reverse
torque (RT), and resonance frequency analysis (RFA) (Table 3). Five of
these studies were comparative, two RCTs comparing static computer-
assisted with freehand implant surgery and two RCTs comparing two
differ ent s- CAIS proto cols. Smitka rn et al,19 in an RC T, found statisti cally
significantly higher implant stability quotient (ISQ) value in implants
inserted freehand (bucco- lingual 72 ± 9, mesio- distal 72 ± 11) than
with s- CAIS (bucco- lingual 63.5 ± 12, mesio- distal 65 ± 12). The same
study found statistically significantly better ITV in implants inserted
by freehand (35 ± 11 Ncm) than with s- CAIS (22.5 ± 20 Ncm). In the
second RC T comparing freehand with s- CAIS , Kaewsiri et al20 reported
that the minimum of 25 Ncm insertion torque was reached in all cases
in both groups. Two more RCTs assessed primary stability between
different s- CAIS techniques. Ko et al12 found a higher ISQ value in
the delayed implant loading group (72.89 ± 7.85) compared with the
immediate implant loading group (70.18 ± 14.45), although all implants
reached the minimum of 25 Ncm insertion torque. Schnutenhaus et
al21 compared mean ISQ values between implants placed with s- CAIS
and alveolar ridge preservation (63 ± 8.75) and nonaugmented sites
(64.12 ± 7.88). Other prospective and retrospective studies with s-
CAIS have only reported that all implants displayed values above the
clinically acceptable thresholds of ITV 25 Ncm, RT 20 Ncm, or ISQ
of 55.1 3,14 ,2 2– 25 With regards to d- CAIS, Pozzi et al,24 in a case series
with 10 fully edentulous patients/60 implants, reported a mean ISQ
of 71 ± 2.8.
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199
PIMKHAO KHAM et Al .
TAB LE 1 Overview of the studies analysed in the present review, including the study design, t ypes of Computer Assisted Implant Surger y utilised and the studied outcomes
Author/year Design Type of surgery
Studied outcomes
Stability Accuracy PROMs Success/survival Complications
Workflow
variations
Peri- implant
tissue Esthetic Duration Other
Almahrous et al/2020 RCT s- CAIS, FH • • • •
Aydemir et al/2020 RCT d- CAIS, FH • •
Bencharit et al/2018 Cross- sectional study s- CAIS • •
Block et al/2016 Prospective study d- CAIS • •
Block et al/2017 Prospective study d- CAIS, FH • •
Cassetta et al/2012 Retrospective s- CAIS • • •
Cassetta et al/2013 Retrospective s- CAIS • •
Cassetta et al/2014 Retrospective s- CAIS • • •
Cassetta et al/2017 RCT s- CAIS • •
Cassetta et al/2020 Prospective cohort s- CAIS • •
Chai et al/2020 Pilot Clinical trial s- CAIS • •
Cristache et al/2021 RCT s- CAIS • • • •
D’Haese et al/2012 Prospective clinical
trial
s- CAIS • • • •
De Souza et al/2022 Retrospective clinical
study
s- CAIS • •
Deeb et al/2018 Retrospective
case- control
s- CAIS •
Derksen et al/2019 Prospective cohort
study
s- CAIS • • •
Di Giacomo
et al/2012
Prospective study s- CAIS • • •
Engkawong
et al/2021
RCT s- CAIS, d- CAIS,
FH
• •
Fand et al/2019 Prospective clinical
trial
s- CAIS •
Fürhauser et al/2015 Retrospective study s- CAIS • •
Geng et al/2015 Prospective clinical
trial
s- CAIS • •
Kaewsiri et al/2019 RCT s- CAIS, d- CAIS • • •
Kiatkroekkrai
et al/2019
RCT s- CAIS • •
(Continues)
200
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PI MKHAOKH AM et Al.
Author/year Design Type of surgery
Studied outcomes
Stability Accuracy PROMs Success/survival Complications
Workflow
variations
Peri- implant
tissue Esthetic Duration Other
Kivovics et al/2020 RCT s- CAIS • •
Ko et al/2021 RCT s- CAIS • • • •
Kunavisarut
et al/2021
RCT s- CAIS, FH • •
Kuo et al/2021 Case series d- CAIS • • • •
Lee et al/2013 Prospective clinical
trial
s- CAIS •
Lerner et al/2020 Retrospective study s- CAIS • • • • •
Lin et al/2020 Prospective clinical
study
s- CAIS • •
Makarov et al/2021 Prospective pilot
cohort study
s- CAIS • •
Mangano et al/2018 Prospective clinical
study
s- CAIS • • •
Matsumura
et al/2021
Retrospective clinical
study
s- CAIS •
Meloni et al/2013 Prospective case
series
s- CAIS • •
Meloni et al/2013 Prospective clinical
study
s- CAIS • •
Mouhyi et al/2019 Retrospective study s- CAIS • • • •
Naziri et al/2016 Prospective clinical
study
s- CAIS • • •
Ngamprasertkit
et al/2021
Randomized clinical
trial
s- CAIS, FH •
Nocini et al/2013 Retrospective study s- CAIS • • •
Özden Yüce
et al/2020
Prospective cohort
study
s- CAIS, FH • • •
Park et al/2020 RCT s- CAIS •
Peñarrocha
et al/2012
Case control study s- CAIS, FH • • • •
Pettersson et al/2012 Prospective cohort
study
s- CAIS •
TAB LE 1 (Continued)
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201
PIMKHAO KHAM et Al .
Author/year Design Type of surgery
Studied outcomes
Stability Accuracy PROMs Success/survival Complications
Workflow
variations
Peri- implant
tissue Esthetic Duration Other
Polizzi et al/2013 Retrospective study s- CAIS • •
Pozzi et al/2021 Prospective cohort
study
d- CAIS • • •
Sancho- Puchades
et al/2019
RCT s- CAIS, FH • • •
Schelbert et al/2019 Prospective cohort
study
s- CAIS •
Schnutenhaus
et al/2016
Retrospective study s- CAIS • • •
Schnutenhaus
et al/2020
Prospective clinical
study, RC T
s- CAIS • • •
Skjerven et al/2019 Prospective cohort
study
s- CAIS • •
Smitkarn et al/2019 RCT s- CAIS • •
Søndergaard
et al/2021
RCT s- CAIS, FH • • • • •
Stefanelli et al/2019 Retrospective study d- CAIS • •
Sun et al/2020 Prospective cohort
study
s- CAIS, d- CAIS,
FH
•
Van de Wiele
et al/2015
Prospective study s- CAIS • •
Varga et al/2020 RCT s- CAIS, FH • •
Velasco- Ortega
et al/2021
Prospective clinical
study
s- CAIS • •
Velasco- Ortega
et al/2021
Prospective cohort
study
s- CAIS • •
Vercruyssen
et al/2014
RCT s- CAIS, d- CAIS,
FH
•
Vercruyssen
et al/2015
RCT s- CAIS, d- CAIS,
FH
•
Vercruyssen
et al/2016
RCT s- CAIS •
Verhamme et al/2015 Prospective study s- CAIS •
Vieira et al/2013 Prospective study s- CAIS • •
TABLE 1 (Continued)
(Continues)
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PI MKHAOKH AM et Al.
Intraoperative complications of a technical nature
Reported intraoperative complications of a technical nature on s-
CAIS include fracture of the surgical guide, an ill- fitting guide, and
anatomic limitations/deficient access (Table 2). None of the identi-
fied six studies13 – 17, 2 6 included a control group.
Fracture of the surgical guide. Nocini et al,14 in a retrospective study
on s- CAIS full arch placement, reported one surgical guide fracture
(1.54% of patients) in the mandible, which was repaired during the
operation.
Instability/misfit/inadequate stability of the surgical guide. The misfit
or inadequate stability of the surgical guide is a more frequent
complication, as reported in three studies. Mouhyi et al13 investigated
surgical guide fit as a primary outcome by defining and testing specific
parameters (adaptability, open spaces/gaps, interferences/defined
points above the teeth). They found that 34 guides (85%) showed
an excellent fit, four (10%) were acceptable (adaptation was possible
in postprocessing, in the laboratory), and two (5%) were inadequate
for use. The authors also pointed out that the two guides with
inadequate fit and stability were made from resin. They recommended
avoiding delays in the treatment when working with resin guides, as
the dimensions of these guides might change with time. Likewise,
Mangano et al15 assessed the s- CAIS surgical guide fit, with 24 of
them (85.71%) exhibiting an optimal fit and stability, three (10.71%)
showing an optimal fit but only sufficient stability, and one (3.5%)
with an inadequate fit and unsatisfactor y stability. Only in the latter
case, the surgeon elevated a full- thickness flap and proceeded with
convention al implant place ment. The auth ors speculate t hat the reason
for failure was the long time that elapsed between the manufacture of
the template and the surgery in this case (over 1 month) and a possible
consequent deformation of the resin template. Peñarrocha et al,16 in
a case- control study, reported a frequent need to extraorally adjust
ill- fitting surgical guides (11 out of 24 guides); all the surgeries were
nevertheless possible after intraoperative adjustments. Aydemir and
Arisan,26 i n a split- mouth RC T comparing d- CAIS and f reehand implant
surgery, found unsatisfactory stability of the radiopaque stent used in
the registration procedure in two out of 30 patients (6.67%) in the d-
CAIS group. The authors commended that intra- oral adaptation of the
radiopaque stent was challenging and the surgery was postponed for
these two patients until the whole process was repeated.
Anatomic complications, bone dehiscence. Derksen et al17 reported
a bone dehiscence after the placement of two implants (1.37%)
with s- CAIS in one patient. The dehiscence was managed with
simultaneous bone augmentation. Similarly, Nocini et al14 also
reported the position of two out of 342 implants (0.58%) in one
out of 65 patients to have deviated from the plan, causing a minor
buccal bone dehiscence, which did not affect the implant stability,
osseointegration, or final restoration.
Limitation of access/anatomy variation. CAIS, either static or
dynamic, requires specific instruments that might differ from
Author/year Design Type of surgery
Studied outcomes
Stability Accuracy PROMs Success/survival Complications
Workflow
variations
Peri- implant
tissue Esthetic Duration Other
Vinci et al/2020 Retrospective study s- CAIS •
Yimarj et al/2020 RCT s- CAIS, d- CAIS •
Youk et al/2014 Cross- Sectional
Survey
s- CAIS, FH •
Younes et al/2018 RCT s- CAIS, FH •
Younes et al/2019 RCT s- CAIS, FH • • •
Zhao et al/2014 Prospective clinical
study
s- CAIS • • •
Zhu et al/2021 Retrospective study s- CAIS •
Abbreviations: d- CAIS, dynamic computer- assisted implant surger y; FH, freehand placement; PROM, patient- reported outcome measure; RC T, randomized clinical trial; s- CAIS, static computer- assisted
implant surgery.
TAB LE 1 (Continued)
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203
PIMKHAO KHAM et Al .
conventional freehand surgery. Certain anatomic limitations, such
as restricted mouth opening and location of the implant site, can
impact the effectiveness of CAIS. Lin et al,18 in a prospective study
with the BenQ AB s- CAIS system, found it was not possible to place
seven out of 43 implants (16.28%) at the molar area in five out of
21 patients with the fully guided s- CAIS because of limited mouth
opening. Derksen et al17 reported that it was not possible to use
the drill guide in the far distal area (position 37) out of 145 implants
(0.68%) in one out of 66 patients. The CAIS was aborted, and a bone
level implant was placed with the conventional freehand technique,
supplemented by a simultaneous bone augmentation procedure
after a dehiscence was detected.
2.3.2 | Postoperative (healing) complications
Reported postoperative complications included excessive pain,
swelling, inflammation/infection, and loss of implant/osseointegra-
tion failure (Table 2) in six studies.10,11,13,18, 22,27 Three studies10 re-
ported excessive pain and/or swelling between day 2 and 1 month
after s- CAIS, with the percentage of affected patients varying be-
tween 1.6%10 and 5.26%.13 D’Haese et al11 reported the loss of one
out of 78 implants (1.28%) shortly after insertion using s- CAIS and
immediate loading protocol because of abscess formation, possibly
caused by remnants of impression material. Similarly, Zhao et al27
reported the loss of one implant placed and immediately loaded in
a patient with a history of bite reconstruction of a deep overbite.
Lerner et al22 reported that two implants (1.8%) had peri- implant
mucosal inflammation after 3 months in function. Di Giacomo et al10
also found that two patients (3.22%) developed slight gingival in-
flammation during the follow- up period, which was resolved after
professional prophylaxis and plaque control instruction.
2.3.3 | Short- term clinical outcomes, biological and
technical complications
Nonosseointegration
Five studies reported implants without osseointegration after com-
pletion of the healing period, all of which concerned s- CAIS place-
ment13,15,18, 23,28 (Table 4). Failure of osseointegration in cases of
conventional loading18,23, 28 was reported in 0.69%- 3.23% of the
implants placed, affecting 1.52%- 9.09% of patients. In the case of
immediate loading,13,15 failure of osseointegration was reported in
3.23%- 4.28% of the implants, occurring in 9.09%- 9.72% of patients.
2.3.4 | Survival, medium- /long- term clinical
outcomes, and biological and technical complications
Survival
Four comparative studies reported the implant survival rate be-
tween CAIS and FH (Table 4). Three of them demonstrated 100%
implant survival for both protocols,9,28,29 however, two of them9, 29
FIGURE 1 Flowchart of the articles
included in the review. CBCT, cone beam
computed tomography
307 studies identified through
database searching
30 studies identified through
manual search
244 papers removed
-duplicates
- excluded at title level or
abstract level
Identification
93 full-text articles assessed
for eligibility
16 full-text articles excluded,
with reasons
-4 implant placement in extra oral
bone graft
-2 patient numbers < 10
-4 full text not possible to
retrieve
-2 in vitro study
-2 reporting unconventional
procedures (socket shield and
trephination-based osteotomy)
-1abstract for conference
presentation only
-1 did not use CBCT in planning
77 full-text articles included
in the systematic review
Screening
Eligibility
Included
204
|
PI MKHAOKH AM et Al.
TAB LE 2 Studies reporting surgical complications (intraoperative and postoperative)
Author/year Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No. of
implants/
patient
Observation
period
Surgical complications
Intra- op. postop.
Aydemir et al/2020 Split- mouth RCT PS SI d- CAIS, FH 60/86 1.43 n /a Deficient stability of the radiopaque
stent during surger y in 2 patients
(3.33%)
n/a
Derksen et al/2019 Prospective
cohort study
PS PE s- CAIS 66/145 2.19 24 mo 1. Impossible to use the long guide drill
in 37 area for 1 implant (0.68%)
2. Buccal dehiscence, 2 implants (1.37%)
n/a
D’Haese et al/2012 Prospective
clinical trial
AZ, PS PE s- CAIS 13/78 6.00 12 mo Insufficient primary stability, 3 implants
(3.84%)
Abscess formation
caused implant loss,
1 implant (1.28%)
Di Giacomo
et al/2012
Prospective
study
AZ, PS PE, FE s- CAIS 12/62 5.16 30 mo 1. Lingual soft tissue was pulled by drill,
4 implants (6.45%)
2. Wider implant than planned were
used to improve primar y stability, 4
implants (6.45%)
3. Implant instability, 2 implants (3.22%)
1. Prolonged severe
pain, in 1 patient
(1.61%)
2. Gingival
inflammation in 2
patients (3.22%)
Ko et al/2021 RCT AZ, PS SI, PE s- CAIS 72/187 2.59 12 mo Deficient primary stability, 7 out of 93
implants in immediate loading group
(7.53%)
n/a
Lerner et al/2020 Retrospective
study
AZ, PS PE, FE s- CAIS 12/110 9.16 12 mo n/a Peri- implant mucosal
inflammation with
bleeding on probing
after 3 mo in 2
implants (1.8%)
Lin et al/2020 Prospective
clinical study
AZ, PS SI, PE s- CAIS 21/43 2.04 n/a Implant were inserted free- handed due
to the limited mouth opening, 7
implants (16.28%)
Implants were removed
due to pain, 2
implants (4.65%) in
1 patient
Mangano
et al/2018
Prospective
clinical study
AZ, PS SI, PE s- CAIS 19/36 1.89 12 mo Inadequate fit and unsatisfactory
stability, 1 of 28 stents (3.57%)
n/a
Mouhyi et al/2019 Retrospective
study
AZ, PS SI, PE s- CAIS 38/110 2.89 12 mo 1. Deficient primary stability in 2
implants (1.8%)
2. Inadequate fit and stability of stent, 2
stent (5%)
1. Pain and swelling, 2
patients (5.26%)
2. Peri- implant
mucositis, 2
implants (1.8%)
|
205
PIMKHAO KHAM et Al .
had a very short observation period, and only one study had 2 years
of follow- up.28 Peñarrocha et al16 reported a similar survival rate for
s- CAIS (94.8%) and FH (95.4%) in a case- control study, without any
statistically significant difference.
Apart from the few comparative studies, 17 studies reported
survival rates of implants placed with different static or d- CAIS pro-
tocols. Fourteen of these studies had a follow- up of at least 1 year,
one was 3 months,30 while in the other two,28,31 the observation pe-
riod was not reported. Among these, eight studies reported 100%
survival of the implants without complications.15,25,30– 35 Seven stud-
ies repor ted overall implant sur vival of 93.5%- 99.3%.10,11,13,14,17,22 ,27
One study12 reported a low survival rate when s- CAIS was used for
immediate loading (83.4%) as opposed to delayed loading (100%).
With regard to implants placed with d- CAIS, one study24 reported
100% survival after an average 1.5- year follow- up.
Peri- implant tissue conditions and related outcomes: mucositis/
peri- implantitis
The diagnosis of peri- implant mucositis/peri- implantitis is reported in
four studies, none of which, however, provided detailed case defini-
tions (Table 5). At 1- year follow- up, the prevalence of peri- implantitis
for CAIS- placed implants varied from 0%36 to 1.8%.13 In the only
comparative RCT, Almahrous et al36 found no statistically significant
difference at 1 year between implants placed with the conventional
freehand technique, as opposed to short implants placed with s- CAIS
in posterior maxilla. Velasco- Ortega et al,37 in a prospective cohort
study, followed up 22 fully edentulous patients with 198 flapless
mandibular implants with s- CAIS and immediate loading for an aver-
age of 84.2 ± 4.9 months. They found 18 (9.3%) of the 193 remaining
implants in 10 patients (45.4%) were associated with peri- implantitis.
Peri- implantitis was statistically significantly more frequent in pa-
tients who smoked (66.6%). Finally, in another study of 14 fully eden-
tulous patients/28 flapless implants with s- CAIS (average follow- up
44.7 ± 31.4 months), Velasco- Ortega et al34 found four implants
(14.3%) in two patients (14.3%) associated with peri- implantitis.
2.3.5 | Secondary clinical outcomes that can be
related to complications and pathology
Plaque index, bleeding on probing, probing depth
Assessment of plaque, bleeding, and/or probing depths around
implants placed conventionally or with CAIS are reported in four
studies, one of which is comparative (Table 5). In the only com-
parative RCT, Almahrous et al36 found no statistically significant
difference at 1- year follow- up in plaque, bleeding, and probing
depths between implants placed with the conventional freehand
technique and s- CAIS. Meloni et al,30 in a prospective case series
with 12 fully edentulous patients and 72 implants, found the aver-
age probing depth (PD) at 24 months to be 2.75 ± 0.40 mm, and the
average BOP value to be 3.8% ± 1.8%. Polizzi and Cantoni,38 in a
5- year retrospective study with 27 partially and fully edentulous
patients/160 flapless implants, reported a cumulative plaque score
Author/year Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No. of
implants/
patient
Observation
period
Surgical complications
Intra- op. postop.
Nocini et al/2013 Retrospective
study
AZ, PS FE s- CAIS 65/342 5.26 12- 60 mo
(mean
32.87 mo)
1. Fracture of stent, 1 stent (1.54%)
2. Implants deviated from the planned
position with vestibular bone
dehiscence, 2 implants (0.58%)
3. Implant loss due to fracture of maxilla,
5 implants (1.46%)
n/a
Peñarrocha
et al/2012
Case control
study
n/a SI, PE s- CAIS FH 12/19
12/22
1.58
1.83
3 mo Inadequate fit of surgical guide (11/24,
45.83%)
n/a
Zhao et al/2014 Prospective
clinical study
AZ, PS PE s- CAIS 11/31 2.81 n/a n/a Implant loss, 1 implant
(3.22%) in a deep
bite patient with
immediate loading
Abbreviations: AZ, esthetic zone; d- CAIS, dynamic computer- assisted implant surger y; FE, fully edentulous; FH, freehand placement; n/a, the data were not provided in the articles; PE, partially edentulous;
PS, posterior; SI, single implant; s- CAIS, static computer- assisted implant surgery; RCT, randomized clinical trial.
TAB LE 2 (Continued)
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TAB LE 3 Studies included in the analysis for primary stability
Author/year Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No.
implants/
patient
Observation
period Primary stability
Kaewsiri et al 2019 RCT AZ, PS SI s- CAIS
d- CAIS
30/30 30/30 1
1
12 mo ITV > 25 Ncm in all implants
Ko et al 2021 RCT AZ, PS SI, PE s- CAIS 72/187 2.59 12 mo Mean ± SD of ISQ:
DL: 72.89 ± 7. 8 5
IL: 70.18 ± 14.45
Kuo et al 2022 Case Series AZ SI, PE d- CAIS 10/10 1.00 12 mo ITV >25 Ncm in all implants
Lerner et al 2020 Retrospective study AZ, PS PE, FE s- CAIS 12/110 9.16 12 mo 1. ITV <35 = 22.7% of implants, > 35 = 77.3% of
implants
2. ISQ <55 = 25.5% of implants
55- 85 = 74.5% of implants
Makarov et al 2021 Prospective pilot
cohort study
AZ, PS FE s- CAIS 10/55 5.50 12 mo ITV > 35 Ncm in all implants
Mouhyi et al 2019 Retrospective study A Z, PS SI, PE s- CAIS 38/110 2.89 12 mo RT 20 Ncm (applying immediately after implant
placement)
Nocini et al 2013 Retrospective study A Z, PS FE s- CAIS 65/342 5.26 12- 60 mo (mean
32.87 mo)
1. median of ITV 40 Ncm, IQR 35- 50
2. ITV > 3 0 Ncm in all implants placed in smokers and in
the mandible
Pozzi et al 2021 Prospective cohort
study
AZ, PS PE, FE d- CAIS 10/60 614- 18 mo
(mean ± SD
16.2 ± 1.7 mo)
Mean ± SD ISQ: 71 ± 2.8, range 65- 78
Schnutenhaus
et al 2020
Prospective clinical
study, RC T
AZ, PZ SI s- CAIS 48/48 1n/a No significant differences in ISQ value between ARP
and control groups.
Mean ± SD
ARP Not grafted
B63.00 ± 8.75 64.12 ± 7. 8 8
M63.48 ± 9.6 0 65.1 5 ± 8.30
Smitkarn et al 2019 RCT AZ, PZ SI s- CAIS, FH 52 /60 1.15 0.5 mo Significant differences for both ISQ and ITV
median (IQR)
s- CAIS FH
ISQ at B 63.5 (12) 72 (9)
ISQ at M 65.0 (12) 72 (11)
ITV 22.5 (20) 35 (11)
Abbreviations: ARP, alveolar ridge preservation; AZ, esthetic zone; B, vestibulo- oral direction; d- CAIS, dynamic computer- assisted implant surgery; DL, delayed loading; FE, fully edentulous; FH, freehand
placement; IL, immediate loading; IQR, interquartile range; ISQ, implant stabilit y quotient; ITV, inser tion torque value; M, mesio- distal direction; n/a, the data were not provided in the articles; PE, partially
edentulous; PS, posterior; RCT, randomized clinical trial; RT, reverse torque value; s- CAIS, static computer- assisted implant surgery; SD, standard deviation; SI, single implants.
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TAB LE 4 Studies included in the analysis for nonosseointegration and survivor rate
Author/year Design Location Edentulism
Type of
surgery
No. of patients/
implants
No.
implants/
patient
Observation
period Non- osseointrgation
Survival
(implant level)
Cristache et al 2021 RCT PS SI, PE s- CAIS FH 49/111 66/145 2.26
2.19
24 mo no 100%
Derksen et al 2019 Prospective
cohort
study
PS PE s- CAIS 66/145 2.19 24 mo 1 implant (0.65%) 99. 30%
D’Haese et al 2012 Prospective
clinical
trial
AZ, PS PE s- CAIS 13/78 6.00 12 mo n/a 98.71%
Di Giacomo et al 2012 Prospective
study
AZ, PS PE, FE s- CAIS 12/62 5.16 30 mo n/a 98.33%
Ko et al 2021 RC T AZ, PS SI, PE s- CAIS 72/187 2.59 12 mo 8 implants (4.27%) in 7 patients 100% (delayed
loading)
83.4%
(immediate
loading)
Kunavisarut
et al 2021
RCT PS SI s- CAIS FH 20/20
20/20
1
1
7 d no 100%
Kuo et al 2021 Case series AZ SI, PE s- CAIS 10/10 112 mo no 100 %
Lerner et al 2020 Retrospective
study
AZ, PS PE, FE s- CAIS 12 /110 9.16 12 mo 2 implants (1.81%) in 1 patient 98.20%
Meloni et al 2013 Prospective
case series
AZ, PS FE s- CAIS 12/72 6 24 mo no 100%
Meloni et al 2013 Prospective
clinical
study
AZ, PS, FE s- CAIS 10/60 612 mo no 100%
Naziri et al 2016 Prospective
clinical
study
AZ, PS SI, PE s- CAIS n/a n/a 3 mo no 100%
Nocini et al 2013 Retrospective
study
AZ, PS FE s- CAIS 65/3 42 5.26 12- 60 mo (mean
32.87)
7 implants (2.05%) in 6 patients 96.50%
Mangano et al 2018 Prospective
study
AZ, PS, SI, PE s- CAIS 19/36 1.89 12 mo no 100%
Mouhyi et al 2019 Retrospective
study
AZ, PS SI, PE s- CAIS 38/110 2.89 12 mo n/a 98.18%
Peñarrocha et al 2012 Case control
study
n/a SI, PE s- CAIS
FH
12/19
12/22
1.58
1.83
3 mo n/a 94.8%,
95.4%
(Continues)
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Author/year Design Location Edentulism
Type of
surgery
No. of patients/
implants
No.
implants/
patient
Observation
period Non- osseointrgation
Survival
(implant level)
Pozzi et al 2021 Prospective
cohort
study
AZ, PS PE, FE d- CAIS 10/60 614- 18 mo
(mean ± SD
16.2 ± 1.7)
no 100%
Skjerven et al 2019 Prospective
cohort
study
n/a SI s- CAIS 20/27 1.35 n/a no 10 0%
Søndergaard
et al 2021
RCT n/a SI s- CAIS FH 13/14
12/12
1.07
1
2 mo no 100%
Velasco- Ortega
et al 2021
Prospective
clinical
study
AZ FE s- CAIS 14/28 212- 84 mo
(mean ± SD
44.7 ± 31.4)
no 100%
Vinci et al 2020 Retrospective
study
AZ, PS FE s- CAIS 14/100 7.14 12 mo no 10 0%
Zhao et al 2014 Prospective
clinical
study
AZ, PS PE s- CAIS 11/31 2.81 n/a 1 implant (3.22%) 93.50%
Abbrevitions: AZ, esthetic zone; d- CAIS, dynamic computer- assisted implant surger y; FE, fully edentulous; FH, freehand placement; n/a, the data were not provided in the articles; PE, partially edentulous;
PS, posterior; RC T, randomized clinical trial; s- CAIS, static computer- assisted implant surgery; SD, standard deviation; SI, single implants.
TAB LE 4 (Continued)
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TABLE 5 Studies included in the analysis of outcomes related to the condition of the peri- implant tissue
Author/year Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No.
implants/
patient
Observation
Period
Peri- implantitis
(%implants/%
patients)
Soft tissue
outcomes
Marginal
bone loss,
mean ± SD
(mm)
Keratinized
mucosa Studied outcomes
Almahrous
et al 2020
RCT PS PE s- CA IS
FH
27/ 75
29/69
2.57 12 mo` s- C AIS: 0/0
FH: n/a/4
BOP
s- C AIS: 11 .1%
FH: 0%
Plaque
s- C AIS: 14.8%
FH: 12%
n/a Patients
s- CA IS: 100 %
FH: 92%
No difference in prevalence of peri-
implantitis, clinical detection of
the keratinized mucosa around
implants, PI and BOP between
s- CAIS and FH.
Kuo et al 2021 Case Series AZ SI, PE d- CAIS 10/10 11 2 mo n/a n/a −0 .76 ± 0.15 n/a The d- CAIS for single implant
placement in the es thetic zone
demonstrated acceptable
marginal bone level changes
Meloni et al 2013 Prospective
study
AZ, PS FE s- CAIS 12/72 624 m o n/a BOP 3.8%
PD 2.75 mm
−1. 35 ± 0. 25 n/a Immediate s- CAIS into fresh
extraction sockets of fully
edentulous ridges resulted in
acceptable outcomes of marginal
bone loss and peri- implant
mucosal condition.
Peñarrocha
et al 2012
Case control
study
n/a SI, PE s- CAIS
FH
12/19
12/22
1.7 3 mo n/a n/a n/a s- CAIS:
2.9 mm
FH: 3.2 m m
The att ached vestibular mucos a width
was greater in FH group than that
in s- CAIS group, no statistical
analysis was provided.
Polizzi et al 2013 Retrospective
study
AZ, PS PE, FE s- CAIS 27/160 5.92 61.3 mo n/a Plaque:
Implants 15%
Patients 11%
−1. 39 ± 1. 88 n/a Mucosal conditions were reported as:
- 90 % normal mucosa
- 7% mild inflammation;
- 1.75% mo derate inflammation and
BOP
Pozzi, et al 2021 Prospective
study
AZ, PS PE, FE d- CAIS 10/60 616 mo n /a BOP
Implants 14.5%
Plaque
Implants 7.15%
−0.53 ± 0.28 n/a The d- CAIS in fully ede ntulous
patients demonstrated good
treatm ent outcomes in marginal
bone changes and peri- implant
soft tissue conditions.
Velasco- Ortega
et al 2021
Prospective
clinical
study
AZ, PS FE s- CAIS 22/198 984 mo 9.3 %/4 5. 4% n/a −1 . 44 ± 0.45 n /a 1. Peri- implantitis and
2. Marginal bone loss
was higher in edentulous patients
with history of smoking
Velasco- Ortega
et al 2021
Prospective
cohort
study
AZ FE s- CAIS 14/28 2 44.7 mo 14.3%/14.3% n /a 1.25 ± 0 .94 n/a 1. Peri- implantitis was more frequent
in
- patients with a history of smoking
and periodontitis.
2. Marginal bone loss was high er in
patients
- older than 70- y- old
- followed more than 5 y
Abbreviations: AZ, esthetic zone; BOP, bleeding on probing; d- CAIS, dynamic computer- assisted implant surgery; FE, fully edentulous; FH, freehand placement; n/a, the data were not provided in the
articles; PD, pocket depth; PE, partially edentulous; PS, posterior; RCT, randomized clinical trial; s- CAIS, static computer- assisted implant surger y; SD, standard deviation; SI, single implants.
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TAB LE 6 Studies included in the analysis for esthetic outcomes
Author/year Design Location Edentulism
Type of
surgery
No. of patients/
implants
No.
implants/
patient
Observation
period Instruments Studied outcomes
Fürhauser et al/2015 Retrospective
study
AZ SI s- CAIS 27/27 127.6 m o 1. PES
2. Accuracy of
placement
1. Higher deviation between planned and
placed implant position correlated with
lower PES.
Kuo et al/2021 Case Series AZ SI, PE d- CAIS 10/10 112 mo 1. PES/WES Patients were satisfied with implant
therapy’s function and esthetic outcome
in the esthetic zone.
Lerner et al/2020 Retrospective
study
AZ, PS PE, FE s- CAIS 12/110 9.17 12 mo 1. Patient satisfaction
questionnaire
(a) Overall, how satisfied
are you with the
treatment received?
(b) Are you satisfied
with the function
of your implant
supported
restorations?
(c) Are you satisfied
with the esthetics
of your implant-
supported
restorations?
(d) Are you satisfied
with the clean
ability of your
implant- supported
restorations?
1. Soft- tissue was stable in all patients and
showed satisfactory esthetic results.
2. Complete- arch fixed reconstruction by
means of guided surgery and immediate
loading of implants placed in fresh
extraction sockets resulted in stable
tissue outcomes and esthetics
Abbreviations: AZ, esthetic zone; d- CAIS, dynamic computer- assisted implant surger y; FE, fully edentulous; PE, partially edentulous; PES, pink esthetic score; PS, posterior; s- CAIS, static computer- assisted
implant surgery; SI, single implants; WES, white esthetic score.
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PIMKHAO KHAM et Al .
of 15% at implant level (24 implants) and 11% at patient level. With
regard to the gingival condition at site level, they reported 90% of
sites as “normal gingiva”, 7% with “mild inflammation”, and 1.75%
with moderate inflammation and BOP. Pozzi et al,24 in a prospective
case series with 10 fully edentulous patients/60 implants placed
with d- CAIS and followed up for at least 1 year, found average
plaque and bleeding scores to be 14.5% ± 8.18% and 7.15% ± 4.4%,
respectively, at site level (Table 6).
Keratinized mucosa
The presence of keratinized mucosa at implants placed with s- CAIS
and conventional FH has been assessed in two comparative stud-
ies (Table 5). Peñarrocha et al16 found the mean attached vestibular
peri- implant mucosa width to be 2.9 (range 1- 4) mm in the s- CAIS
group (n = 12/19 implants) vs 3.2 (2- 5) mm in the conventional free-
hand group (n = 12/22 implants) 3 months after implant placement.
No statistical analysis was attempted. On the contrary, Almahrous
et al36 found that the number of patients who had keratinized mu-
cosa was higher in CAIS (27 patients, 100.0% for s- CAIS vs 23 pa-
tients, 92.0% for FH); however, this difference was not statistically
significant. There seems to be selection bias with regard to report-
ing outcomes related to keratinized mucosa, as some authors have
reported the absence of keratinized mucosa as a contraindic ation for
flapless placement with CAIS,39 thus excluding such patients from
respective groups.
Marginal bone loss
Changes in marginal bone level around implants placed conven-
tionally or with CAIS have been reported in six studies (Table 5),
none of which was comparative. Velasco- Ortega et al34 reported
mean MBL of 1.44 (±0.45) mm after a period of 84.2 ± 4.9 months.
They found the bone loss statistically significantly higher in smok-
ers (1.75 ± 0.33 vs 1.34 ± 0.39). Polizzi and Cantoni,38 based on
27 edentulous patients followed up for 4- 5 years, found MBL of
1.39 (±1.88) mm. Meloni et al30 found average MBL from baseline
to 24 months to be 1.35 ± 0.25 mm. In a shorter study (average
follow- up: 44.7 ± 31.4 months) of 14 fully edentulous patients/28
flapless implants with s- CAIS and restored with overdentures,
Velasco- Ortega et al34 found mean MBL of 1.25 ± 0.94 mm after
44.7 ± 31.4 months. The authors found statistically significant pre-
dictors of MBL to be an age older than 70 years (1.50 ± 0.80 vs
0.91 ± 0.88; P = .0077) and an observation period of more than
5 years (1.66 ± 0.58 vs 0.93 ± 0.81; P = .0001). Pozzi et al,24 in a pro-
spective case series with 10 fully edentulous patients/60 implants
placed with d- CAIS, found an average MBL of −0.53 ± 0.28 mm
after 16.2 ± 1.7 months. In a case series, Kuo et al25 assessed 10
immediate esthetic flapless implants placed through d- CAIS. The
cumulative mean MBL between implant placement and the 1- year
follow- up was −0.76 ± 0.15 mm.
Esthetic outcomes
Esthetic outcomes were assessed in three studies, none of which
was Table 6 comparative. Fürhauser et al,6 in a retrospective study,
assessed clinical outcomes of single- tooth implants for delayed re-
placement of upper incisors in 27 patients using s- CAIS after a mean
follow- up of 2.3 years. The authors found that mean deviation be-
tween planned and actual implant position at the implant shoulder
(0.84, SD 0.44 mm) and at the apex (1.16, SD 0.69 mm) statistically
significantly correlated with the average pink esthetic score (PES),
as implants with PESs of at least 10 showed statistically significantly
less positional deviation (0.71 ± 0.46 mm) than implants with com-
promised esthetics (1.05 ± 0.32 mm). Direction of inaccuracy was
not associated with any PES variables. The amount of deviation, by
contrast, had a statistically significant impact (median PES: 9.5, inter-
quartile range: 8- 11) compared with more accurate implant positions
(mean PES: 13, interquartile range: 12- 13).
Lerner et al22 studied the soft tissue stability 1- year postimmedi-
ate restoration of fully edentulous patients (n = 12 patients/110 im-
mediate flapless implants) through clinical photographs, focusing on
the stability of the papillae and the soft tissue contours, using an index
modified from Fürhauser et al.6 The authors found no difference in
the soft tissue contours, as well as some evidence of “tissue maturing”
and growth of interimplant “papillae”. Finally, Kuo et al25 assessed PES
and pink esthetic/white esthetic scores (WESs) in a case series with
10 immediate esthetic flapless implants placed through d- CAIS. The
median values of total PES/WES, PES, and WES at 1- year recall were
17 (range: 15- 19), 8 (7- 9), and 8 (7- 10), respectively, with a score of 12
set as the threshold for clinical acceptability of total PES/WES.
2.3.6 | Main conclusions concerning the impact of
CAIS on the frequency/extent of complications and
clinical outcomes
The available evidence failed to show differences in terms of intra-
operative complications, clinical primary stability, immediate post-
surgical healing, survival, and osseointegration of implants placed
with CAIS or freehand protocols.
Moreover, the use of static or d- CAIS does not appear to lead to
any different outcomes with regard to the morphology or inflammatory
status of the peri- implant tissue, at least in the short to medium term.
2.4 | PROs and PRE of CAIS compared with
conventional placement
Ten studies assessed PROs or PRE as primary or secondary out-
comes (Table 7). The studies utilized a wide diversity of instruments,
from validated questionnaires such as the Modified Dental Anxiety
Scale, OHiP 14,9 McGill pain and health- related quality of life
(HRQoL) questionnaires,40 established practices such as 1- 10 visual
analog scale (VAS) scores of PRE (pain, swelling),8,1 5,41 to nonstand-
ardized custom- made questionnaires.22, 28 Noncomparative studies
often reported high levels of “satisfaction” using descriptive ques-
tionnaires19,2 2, 42; such conclusions cannot, however, be extrapolated
beyond the limits of each individual study.
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TAB LE 7 Studies included in the analysis for patient- reported outcomes/patient- reported experience
Author/year Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No.
implants/
patient
Observation
period Instruments Main results
Almahrous
et al/2020
RCT PS PE s- CA IS
FH
27/ 75
29/69
2.48 12 mo 1. Pain (verbal rating sc ale)
2. Difficulty of treatment (4- step Liker t
scale)
3. Overall satisfaction (4- step Likert
scale)
No difference in PROs between s- CAIS and FH of
short implants in posterior maxilla at place ment
and after 1 y
Cristache et al/2021 RCT PS SI , PE s- CAIS 49/111 2.26 12 mo Patient satisfaction (custom
questionnaire - 3 item/0- 10 VAS)
Patients who underwent fully digital workflow of
s- CAIS reported significantly better experience
with the dental implant insertion a minimum
value of 6 was noticed for PDW and 9 for FDW.
Engkawong
et al/2021
RCT AZ, PS, SI, PE d- CAIS
s- CAIS
FH
28/6 4
30/61
30/54
2.03 14 d 1. Patient’s perceptions (5- step Likert
scale Yao et al)
2. Patient’s expe ctations (VAS 10 cm)
3. Heali ng Outcomes (VAS 10 cm)
No difference in PROs between s- CAIS, d- CAIS and
FH. Preoperative expectations a ppeared similar
among all 3 groups, as well as postsurgery PRE
Kunavisarut
et al/2021
RCT PS SI s- CA IS
FH
20/20
20/20
1 7 d 1. MDAS
2. Healing outcomes (VAS 10 cm)
3. Oral health- related quality of life
No difference in PROs between s- CAIS and FH for
single- tooth implant surgery in the poste rior
area.
Lerner et al/2020 Retrospective
study
AZ,PS PE, FE s- CAIS 12/110 9. 17 12 mo Patient’s satisfaction (custom
questionnaire/5- step Likert scale)
The great majorit y of patients reported high level of
satisfaction.
Peñarrocha,
et al/2012
Case control
study
n/a PE, SI s- CAIS
FH
12/19
12/22
1.71 3 mo Healing outcomes ( VAS 10 cm) No significant difference in postoperative PROs
between s- CAIS and FH was reported.
SanchoPuchades
et al/2019
RCT AZ, PS, PE s- CAIS
FH
47/(n/a)
26/(n/a)
n/a 7 d 1. He aling outcomes (VAS 10 cm)
2. Oral h ealth- related quality of life
(custom q uestio nnaire/100 m m
VAS)
No difference in intraoperative or postoperative
PROs bet ween s- CAIS and FH
Søndergaard,
et al/2021
RCT N/A SI s- C AIS
FH
13/14
12/12
1.04 n/a 1. Intraope rative Discomfor t (3 items,
0- 1 0 VA S)
2. Operator (student) satisfaction (0- 10
VAS)
No signif icant difference was found in intraoperative
discomfort bet ween s- CAIS and FH implant
placement by senior dental students.
Vercruyssen
et al/2016
RCT AZ, PS FE s- C AIS 15/90 610 d 1. McGill Pain Questionnaire
(a) NWC- T
(b ) PR I- T
(c) Healin g outcome s (100 mm VAS)
(d) level of s welling (100 m m VAS)
No difference in all PROs afte r s- C AIS and immediate
or delayed loading.
Youk et al/2014 Questionnaire
Survey
AZ, PS , n/a s- CAIS
FH
37/(n/a)
90/(n/a)
n/a n/a 1. Healing outcomes (custom
questionnaire/VAS)
2. Patient satisfaction (custom
questionnaire/VAS)
Patients who underwent computer- guided surgery
reported statistically significant lower degree
of pain and higher satisfaction than those und er
conventional surgery (postop questionnaire
survey)
Abbreviations: AZ, esthetic zone; d- CAIS, dynamic computer- assisted implant surger y; FDW, Fully Digital Workflow; FE, fully edentulous; FH, freehand placement; MDAS, Modified Dental Anxiety Scale;
n/a, the data were not provided in the ar ticles; NWC- T, number of words chosen; PDW, Partially Digital Workflow; PE, partially edentulous; PRI- T, pain rating index; PRE, patient- reported experience; PRO,
patient- reported outcome; PS, posterior; RCT, randomized clinical trial; s- CAIS, static computer- assisted implant surgery; SI, single implants; VAS, visual analog scale.
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Fi ve RCTs8 ,9, 29, 36, 43 with a total of 282 patients (conventional
freehand, n = 117; CAIS, n = 166), one small case- control study,16
and one cross- sectional survey,42 have assessed different aspects of
PROs and PRE between patients with s- CAIS/d- CAIS and conven-
tional placement controls. Furthermore, one RCT compared PROs
between partially and fully guided CAIS,28 and another between
CAIS with immediate and delayed loading.40
2.4.1 | Preoperative assessment of perceptions and
expectations
Sancho- Puchades et al43 suggested some influence of a “novelty
effect” of CAIS on patients' presurgical expectations, as they found
that the majority of patients favored the CAIS approach even with-
out having prior experience of implant surgery (CAIS preferred by
FIGURE 2 Meta analysis of three studies9,1 0, 43 for daily postsurgical pain reported by patients after static and dynamic computer- assisted
implant surgery (CAIS) implant placement compared with those of freehand (FH) implant placement. SD, standard deviation
Pain score day 1
Pain score day 2
Pain score day 3
Pain score day 5
Pain score day 7
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83% vs conventional by 6% of patients). However, when a more
detailed assessment of presurgical expectations was conducted
by Engkawong et al8 (ie, anticipated symptoms duration and inten-
sity) and Kunavisarut et al9 (ie, Modified Dental Anxiety Score), no
statistically significant differences were found between the ex-
pectations of patients scheduled for CAIS or conventional implant
placement.
2.4.2 | Intraoperative patient- reported experience
Two RCTs assessed pain during the inter vention day. Almahrous
et al36 used a verbal rating scale range of 1- 4, while Sancho-
Puchades et al43 assessed intraoperative pain and discomfort on
VASs completed by patients immediately after the surgery. Neither
study found any statistically significant difference in the intraop-
erative pain reported by the patients in the two groups. In addition,
Sancho- Puchades et al43 also assessed patients' perceived duration
of the surgery, without, however, finding any statistically signifi-
cant difference. Interestingly, patients in all groups had a rather ac-
curate perception of the duration of the surgery, not statistically
significantly different to the actual time recorded by the operators.
Likewise, in Engkawong et al,8 the majority of patients (72%) found
the duration of surgery acceptable, with no statistically significant
differences noted between static and d- CAIS and conventional
placement. The same was true for Søndergaard et al,29 who as-
sessed patients' intraoperative discomfort during fully and partial
s- CAIS by means of a questionnaire, without recording any statisti-
cally significant difference. Rather than the technology used, it was
the length of the surgery that correlated well with higher intraop-
erative discomfort.43
2.4.3 | Postoperative healing patient- reported
outcomes/patient- reported experience
Events associated with the immediate postsurgical healing are
probably the most studied and reported patient- reported outcome
measures (PROMs), typically including symptoms observed in the
first 7 days (pain, swelling, bruising, functional disturbances), as
well as overall expressions of satisfaction. Five RCTs and one small
case- control study reported short- term postoperative PROs/PRE
adequately for collective analysis. Three RCTs8,9, 43 utilized a VAS
of 1- 10 to record pain and swelling among other outcomes but did
not find any statistically significant difference in any major post-
operative PROs. A small case- control study (n = 24/41 implants)
assessing the same outcomes did not attempt statistical analysis.16
The four above- mentioned studies qualify for a meta- analysis
with regard to the outcomes of pain and swelling, thus the origi-
nal raw data were requested from the respective authors. Data
from three RCTs8,9, 43 were made available and were included in
the meta- analysis conducted for pain and swelling during the first
week after surgery (Figures 2 and 3). The meta- analysis confirmed
the trend favoring CAIS, which did not, however, reach statistical
significant difference (Figures 2 and 3). All studies that followed
daily outcomes using a VAS showed a similar pattern of reduction
in the intensity of the symptoms (Figures 4 and 5). Pain reached a
peak at 6 hours8,16 or on the first day,9,43 painkiller consumption on
the first day,8,9 and swelling on the second day after surgery.8,9,16,43
It should be noted that all five previously mentioned studies uti-
lized flap surgery together with CAIS. Vercruyssen et al40 utilized
flapless CAIS comparing immediate with delayed full arch loading;
however, the instrument used to record pain (MPQ- DLV) was not
directly comparable with the VAS 1- 10 scores. Nevertheless, the
authors found no statistically significant differences regarding pain
response treatment perception, or concerning the consumption or
the type of painkiller.
2.4.4 | Postoperative oral health- related quality of
life and functional disturbance PROMs/patient-
reported experience
Kunavisarut et al9 assessed oral HRQoL by means of a 14- item ques-
tionnaire covering oral function, daily activity, and postoperative
symptoms for during the first 7 days after the surgery. Engkawong
et al8 assessed six items related to postsurger y function disturbance,
including the ability to perform oral hygiene, chewing, and speaking.
Both of the above RCTs found no significant differences between
s- CAIS, d- CAIS, and conventional surgery patients.
Vercruyssen et al40 found no statistically significant differences
on HRQoL scores (a questionnaire consisting of 15 items assessing
aspects of quality of life) when flapless CAIS was used for immediate
or delayed full arch loading.
2.4.5 | Main conclusions concerning the impact of
CAIS on patient- reported outcomes and patient-
reported experience
Intraoperative and healing (pain, swelling, bruising, bleeding) events
as well as postsurger y functional disturbances reported by patients
did not differ statistically significantly between CAIS used with flap
elevation and conventional implant placement.
2.5 | Clinical outcomes related
to the overall efficiency of CAIS compared with
conventional placement
2.5.1 | Duration of the surgery with CAIS vs
conventional implant placement
A widespread range of duration for surgical interventions has been
reported by different authors, possibly reflecting the extent of sur-
gery (eg, partial vs fully edentulous), the diversity of protocols and
surgical setup, as well as defining different time points and measur-
ing protocols (eg, continuous vs 5- minute intervals). Comparisons of
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PIMKHAO KHAM et Al .
surgical duration are therefore only meaningful within studies with
a comparative design, and eight studies were finally analyzed with
regard to this outcome (Table 8). One RCT8 compared the surgi-
cal duration of static and d- CAIS and conventional freehand, while
three RCTs36,43,44 compared the duration of s- CAIS and conven-
tional freehand. Furthermore, one RCT compared the duration of
d- CAIS and conventional freehand surgery.20 Finally, one RCT,28 one
prospective,15 and one retrospective study13 compared surgical du-
ration between different protocols of s- CAIS.
Static vs freehand: single implants and partially edentulous
Engkawong et al8 found a trend marginally above statistical signifi-
cance (P = .07) for surgery duration to be shorter with conventional
placement (70.3 ± 47.08 minutes) than with s- CAIS (89.70 ± 45.75
FIGURE 3 Meta analysis of three studies9,1 0, 43 for daily postsurgical pain reported by patients after static computer- assisted implant
surgery (s- CAIS) only, compared with those of freehand (FH) implant placement. SD, standard deviation
Pain score day 1
Pain score day 2
Pain score day 3
Pain score day 5
Pain score day 7
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PI MKHAOKH AM et Al.
minutes). A similar pattern was reported in the RCT conducted by
Sancho- Puchades et al43 on 73 partially edentulous patients, where
the average duration for FH was 92.88 (± 39.8) minutes, while it
was 113.77 (±43.77) and 142.77 (±47.25) minutes for two work-
flows of s- CAIS, respectively, although no statistical analysis was
attempted. Interestingly, the authors noted that an average of 6.91
FIGURE 4 Average pain scores as recorded daily on visual analog sc ale 1- 10 by patients in four comparative studies9,10,17,43
FIGURE 5 Average swelling scores as recorded daily on visual analog scale 1- 10 by patients in two comparative studies9,17
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PIMKHAO KHAM et Al .
and 5.56 minutes was invested for modifications of deficient fitting
surgical guides in the two CAIS groups, respectively. The duration of
implant placement reported by Almahrous et al36 was not statisti-
cally significantly dif ferent between FH (74.56 ± 31.66 minutes) and
s- CAIS of short implants (72.79 ± 31.65 minutes); however, it was
noted that three implants were placed on average in the freehand
group as opposed to two in the s- CAIS group. Likewise, Søndergaard
et al29 found no statistically significant difference in the duration
of surgeries of posterior implants placed by senior dental students
under flap with s- CAIS or freehand. The mean time spent included
discussion/instructions with supervisor and was 70.65 (41.25-
100) minutes for the CAIS group and 70.13 (55.5- 90) minutes for
the freehand group. On the contrary, Younes et al44 found the mean
duration of fully guided (40.10 minutes) and partially guided CAIS
(41.36 minutes) to be statistically significantly shorter than that of
freehand (58.64 minutes). However, the authors added that con-
siderably more preoperative planning time was needed for guided
surgery, resulting in the total time investment being similar for the
CAIS and freehand groups. Mangano et al,16 in a study of flapless
s- CAIS, concluded that the average time required was slightly higher
in the case of a nonoptimal template fit with 13.6 ± 1.5 minutes per
implant as opposed to 11.4 ± 2.9 minutes when the surgical template
did have an optimal fit.
Dynamic computer- assisted implant surgery vs freehand and static
computer- assisted implant surgery: single implants and partially
edentulous
Engkawong et al8 found d- CAIS (70.95 ± 42.48 minutes) to be of
similar duration to that of conventional placement (70.3 ± 47.08
minutes). The authors also noted a trend marginally above statisti-
cal significance (P = .07) for surgery duration to be shorter with dy-
namic than with s- CAIS (89.70 ± 45.75 minutes). Likewise, Kaewsiri
et al20 found no statistically significant difference in the duration of
surgery between static and d- CAIS, adding, however, an average of
3 (2- 5) minutes in d- CAIS group due to the registration procedure.
The average surgical time of static and d- CAIS under flap in cases
without bone augmentation was 15 (12- 20) and 18 (13- 25) minutes;
in cases with Guided Bone Regeneration (GBR) it was 40 (30 - 45) and
48 (30- 90) minutes. With a flapless approach, the average surgical
time was 13 (12- 14) and 17 (12- 22) minutes for static and d- CAIS,
respectively.
2.5.2 | Influence of the experience and
training of the operator
Outcomes related to the influence of the operator's experience
and training have not been systematically assessed in comparative
clinical trials. Relevant information can only be indirectly extracted
from a small number of studies. Van de Wiele et al45 studied the
outcomes of flapless s- CAIS conducted by postgraduate students
with those of experienced specialists from another study,46 where
similar planning and clinical settings were utilized. The authors did
not find any difference in the accuracy of placement between post-
graduate students and specialists, but no PROs or other clinical out-
comes were compared. Søndergaard et al29 conducted a clinical trial
with implant placement by senior dental students utilizing s- CAIS.
Although the study suggested favorable outcomes with both fully
and partial guided s- CAIS, more interventions were required by
the instructors to correct the angle of osteotomy in partial guided
s- CAIS, while some students working with fully guided s- CAIS felt
that the learning outcome was diminished, as they did not have to
“think for themselves”. With regards to d- CAIS, Block et al47 con-
cluded that the highest accuracy was achieved after completing 20
patient cases, after studying the outcomes of consecutive surgeries
by three implant surgeons. Some studies reported that right- handed
surgeons had lower accuracy when treating the left side of the pa-
tient compared with the right side.45,46
2.5.3 | Main conclusions on length of surgery using
computer- assisted implant surgery
The evidence does not suggest any difference with regard to the
length of surgeries with s- CAIS on single implants or in partially
edentulous patients.
However, differences between the evaluated CAIS systems and
protocols, as well as in the way surgical time was calculated, can ob-
struct comparisons.
3 | DISCUSSION
Although the application of CAIS has attracted a significant volume
of research in the last 10 years, there is lit tle evidence indicating
superior clinical outcomes, both in terms of reducing complica-
tions and in improving patient experience. It is important to note,
however, that the focus of research so far has been on assessing
the accuracy of implant placement with CAIS, with most studies
reporting little other than deviation from the planned implant po-
sition. Very few studies have systematically assessed clinical and
PROs, with only a handful actually having primary outcomes other
than accuracy. As the study of accuracy appears increasingly satu-
rated, it is anticipated that the focus of research will gradually shift
towards clinical and PROs, in particular with longer observation
periods.
Another important characteristic of the currently available lit-
erature is that it is skewed towards the straightforward side of the
clinical spectrum, with single gaps and partially edentulous patients
being studied more, especially in the comparative segment of the lit-
erature. This might reduce the potential to document differences in
clinical and PROs, which are indicated to be superior in the complex
cases of fully edentulous patients and immediacy protocols. Again,
the wider introduction of CAIS in clinical practice might expand the
frontiers of research towards more complex protocols and patient
scenaria.
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TAB LE 8 Studies reporting duration of the surgery with computer- assisted implant surgery vs conventional implant placement
Author/y Design Location Edentulism
Type of
surgery
No. of
patients/
implants
No.
implants/
patient
Observation
period Software Studied outcomes
Almahrous
et al/2020
RCT PS PE s- CAIS
FH
27/ 75
29/69
3
2
12 mo n/a FH: 74.56 ± 31.66 min
s- CAIS (short implants): 72.79 ± 31.65
No significant difference was found
Engkawong
et al/2021
RCT AZ, PS SI, PE d- CAIS
s- CAIS
FH
28/6 4
30/61
30/54
2.28
2.03
1.8
14 d 1. IRIS- 100 (EPED Inc.,
Taiwan)
2. coDiagnostiX version
9 (Dental Wings,
Canada)
1. FH: 70.3 min ± 47.08 was significantly shorter
duration than s- CAIS: 89.70 min ± 45.75.
2. d- C AIS: 70.95 ± 42.48 took significantly
shorter duration than s- CAIS:
89.70 min ± 45.75.
3. No significant difference between d- CAIS
and FH.
Kaewsiri
et al/2019
RCT AZ,PS SI d- CAIS
s- CAIS
30/30
30/30
1
1
12 mo 1. IRIS- 100 (EPED Inc.,
Taiwan)
2. coDiagnostiX version
9.7 (Dental Wings,
Canada)
d- CAIS: 15 min (12- 20 min)
s- CAIS: 18 min (13- 25 min)
d- CAIS + GBR: 40 min (30- 45 min)
s- CAIS + GBR: 48 min (30- 90 min).
No significant difference between s- CAIS and
d- CAIS was found.
Mangano
et al/2018
Prospective
clinical
study
AZ, PS SI, PE s- CAIS 19/36 1.89 12 mo 1. EXOCAD (Darmstad,
Germany)
2. SMOP (Swissmeda,
Switzerland)
Surgical guides with nonoptimal fit required
13.6 ± 1. 5 min per implant as opposed to
11.4 ± 2.9 min per implant with optimal fit
guides.
Mouhyi
et al/2019
Retrospective
study
AZ, PS SI, PE s- CAIS 38/110 2.89 12 mo SMOP (Swissmeda,
Switzerland)
1. The mean duration was 23.7 ± 6.7 min per
template. (median 22, 95% CI: 21.7- 25.7)
2. The mean duration was 6.5 min per implant.
Sancho-
Puchades
et al/2019
RCT AZ, PS PE s- CAIS
FH
47/n /a
26/n/a
n/a
n/a
7 d 1. Simplant (Dentsply
Sirona, USA)
2. SMOP (Swissmeda,
Switzerland)
FH 92.88 min (± 39.8)
s- CAIS (a) 113.77 (±43.77)
s- CAIS (b) 142.77 (±47.2 5 )
No statistical analysis was conducted
Søndergaard
et al 2021
RCT PS SI s- CAIS
FH
13/14
12/12
1.07
1
n/a MySimplant service
(Dentsply Sirona,
USA)
s- CAIS: 70.65 min
FH: 70.13 min
No significant difference was found
Younes
et al/2019
RCT PS PE s- CAIS
FH
10/21
11/26
2.1
2.36
3 mo Simplant 17.0 (Dentsply
Sirona, USA)
s- CAIS (fully): 40.10 min
s- CAIS (partial): 41.36
FH: 58.6 4 min
s- CAIS was significant faster than FH.
Abbreviations: AZ, esthetic zone; CI, confidence interval; d- CAIS, dynamic computer- assisted implant surgery; FH, freehand placement; GBR, Guided Bone Regeneration; n/a, the data were not provided in
the articles; PE, partially edentulous; PS, posterior; RCT, randomized clinical trial; s- CAIS, static computer- assisted implant surger y; SI, single implants.
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PIMKHAO KHAM et Al .
Although no evidence of an impact of CAIS on the frequency
and extent of complications was found, comparative studies are
relatively few and the prevalence of intraoperative or early healing
complications is in general already low at conventional placement.
Also, the current consensus with the use of CAIS, which requires a
“safety zone of 2 mm” from any sensitive anatomic structures,1 might
hamper the ability to see a difference. The evidence suggests that
the type of placement (eg, immediate vs delayed) might be a more
important determinant for primary stability than the use of CAIS
or not. With regard to the extent of mechanical stability, as this is
measured by ITV, RFA, or RT, the evidence suggests that both static
and d- CAIS can reach the acceptable thresholds with high predict-
ability. Whether FH or CAIS can reach higher values of ITV, RFA, or
RT remains to be further investigated, as the available evidence is
ambivalent.
Looking at medium- to long- term outcomes, the use of CAIS
does not appear to affect the morphology and condition of the peri-
implant tissue, as well as tissue inflammatory status. However, none
of the comparative studies was longer than a year, a rather short pe-
riod to assess certain outcomes, such as for example the occurrence
of peri- implantitis. Longer noncomparative studies on implants
placed with CAIS have reported outcomes within the anticipated
range of those with conventionally placed implants and demon-
strating similar risk predictors (eg, smoking and years in function
for MBL). Longer duration comparative studies utilizing accepted
case definitions could clarify whether CAIS can lead to different
long- term tissue health outcomes. Assessment of clinical outcomes
specific to esthetics has been scarce and not the subject of any com-
parative studies. Nevertheless, evidence from a retrospective study
suggests a direct relationship between implant placement accuracy
and esthetics measured by means of PES in the esthetic zone, while
other smaller case series suggest PES/WES outcomes were above
the acceptable threshold when CAIS was utilized.
The study of PROs and PRE has steadily increased in the last
10 years. Although patients appear to favor CAIS when asked prior
to surgery, their actual expectations when it comes to specific as-
pects of the surger y, as well as presurgical stress levels, do not ap-
pear to differ statistically significantly. This might well be attributed
to the well known “novelty effect”, which typically occurs with tech-
nologies the patients perceive as being innovative.48 Such a novelty
effect might have a stronger influence when patients are asked to
recollect experiences retrospectively at time points after treatment
completion49 by means of treatment satisfaction questionnaires, as
in Youk et al.42 At the same time, when more detailed outcomes mea-
sures were collected systematically during the respective phases of
treatment, healing events, as well as postsurgery functional distur-
bances reported by patients, did not differ statistically significantly
between CAIS used with flap elevation and conventional implant
placement. Evidence points to the use of a flapless technique being a
more potent determinant of postsurgical healing events. CAIS com-
bined with flapless technique reduced the postsurgical pain statis-
tically significantly and improved reported healing outcomes when
compared with a similar CAIS protocol under flap.39 It is therefore
reasonable to assume that the use of CAIS could indirectly contrib-
ute towards improving patient- reported healing outcomes, to the
extent that it can facilitate and empower wider use of flapless sur-
gery (Figure 6).
Duration of the surgical intervention is an important parame-
ter of success and efficacy, as well as patient experience, as an in-
creased length of surgery is correlated with increased frequency and
intensity of postsurgical pain and healing complications.43 Several
authors have empirically reported CAIS to provide a “sensible re-
duction of surgery time”14, 38 in studies involving full arch rehabilita-
tion; however, the data in the literature remain scarce and collective
analysis is difficult. S- CAIS is the best- studied protocol with regard
to the length of surgeries, and most studies on partially edentulous
patients point towards no difference or even a possible trend for
FH being faster. Even within the group of s- CAIS, however, there is
a wide diversity of protocols, software and hardware designs being
utilized, each with the potential to impact clinical outcomes in dif-
ferent ways (Figure 7). In the case of the fully edentulous patients,
past evidence39 showed no difference in surgery duration between
conventional (68.71 ± 11.4 minutes) and s- CAIS placement with a
flap (60.94 ± 13.07 minutes), but found flapless s- CAIS placement
to be statistically significantly faster (23.53 ± 5.48 minutes). It is
reasonable to expect that time reduction using CAIS will be more
pronounced in multiple implant placement and may thus result in an
overall shortening of treatment time in cases of higher complexity
such as immediate loading of fully edentulous patients. It is also evi-
dent that factors such as raising a flap or not can impact the duration
of surgery much more than the use of CAIS or not. The data are even
more scarce in the case of the d- CAIS, where only two RCTs were
available. Although none showed statistically significant differences,
they pointed to opposing trends, which can be attributed to the fact
that one of the studies included the presurgery registration time in
the overall calculated length of the surgery. This is indicative of the
difficulty of synthesizing data from diverse protocols. In addition,
different d- CAIS systems have been shown to result in statistically
significant differences in terms of surgery duration,50 possibly due
to different technologies and specifications, while deficient fit of s-
CAIS guides is also known to increase the duration of the surgery.
Conclusively, although there are limited data to suggest that s- CAIS
can substantially reduce the duration of implant placement surger-
ies for fully edentulous patients, the same remains questionable in
the case of single implants and partially edentulous patients, where
freehand surgery might at times be faster. To the extent that CAIS
can increase the utilization of flapless surgery, its use could indi-
rectly lead to a substantial reduction in time.
At the same time, CAIS introduces a set of, mostly minor, technical
problems and complications specific to each technology used. S- CAIS
is more frequently reported with technic al problems, with the fracture
of the surgical guide being the most severe, but very rare. Deficient fit
and instability of the guide on the other hand are frequently reported,
but only rarely led to abolishment of the CAIS protocol. Instead, in-
traoperative corrections have frequently taken place, which, how-
ever, can lead to a significant increase in the duration of the surger y.15
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PI MKHAOKH AM et Al.
FIGURE 7 Overview of the principle charac teristics of the static computer- assisted implant surgery (CAIS) systems utilized in studies
analyzed in this review. Implants were placed with diverse combinations of planning software, surgical guide design, and manufacturing
techniques, as well as guided surgery drills and sequences. To this diversity one can add the potential influence of different hardware and
algorithms of cone beam computed tomography, intra- oral scanners, and hybrid digital- analog protocols
FIGURE 6 A, Partially edentulous
mandible, with adequate bone volume and
keratinized mucosa for full arch, implant-
supported, fixed dental prosthesis. B,
Digital surgical plan for the placement of
six implants with static computer- assisted
implant surgery (s- CAIS) (the placement
of six implants with 33, 43 immediate
placement; 35, 37, 45, 47 with flapless
placement). C, Extraction of teeth Nr.
33, 43. D, Fabrication of acrylic surgical
guide (mucosa- supported, acrylic with
titanium sleeves, anchored with three
fixation pins) for the s- CAIS placement
of two immediate and four flapless
implants. E, Placement of s- CAIS guide
in the mandible. F, Final placement of six
implants and healing abutments
A
C
EF
D
B
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PIMKHAO KHAM et Al .
D- CAIS has rarely been reported to have complications of a technical
nature, but technical issues such as “loss of connection” between the
sensors and the camera have been reported to be a nuisance, while
system specifications, such as frame renewal rate, are indicated to
significantly influence the duration of surgeries (Figure 8). Although
not as wide as with s- CAIS, high diversity exists within d- CAIS soft-
ware and hardware, which can potentially influence performance and
clinical outcomes. At the same time, d- CAIS is reported to be “oper-
ator sensitive” with a clinical study suggesting optimal results to be
achieved only after treating at least 20 cases.50
The findings of this review should be seen under the limitations
of the available literature, as well as those of the current review,
which was limited to the last 10 years, as the evolution of proto-
cols might hamper comparisons with outcomes from older studies.
Nevertheless, some important older studies might still be relevant,
and were therefore used in the discussion of the results where it was
deemed appropriate.
4 | SUMMARY AND CONCLUSIONS
1. The current evidence does not suggest any difference in terms
of
a. intraoperative complications, immediate postsurgical healing
and osseointegration, medium/long- term survival and peri-
implantitis prevalence of implants placed with CAIS or free-
hand protocols;
b. intraoperative and early healing events as reported by pa-
tients (PROs and PRE) between CAIS with flap elevation and
conventional implant placement;
c. length of surgeries in cases of single implants and partially
edentulous patients, although there appears to be an advan-
tage of CAIS for fully edentulous patients.
2. There is limited evidence that increased accuracy of placement
with CAIS is correlated with superior esthetic outcomes.
3. Although CAIS as a sole parameter does not seem to consistently
impact healing events, clinical and PROs, to the extent that it can
increase the utilization of flapless surgery, predictability of imme-
diacy protocols, and restorative- driven implant placement, its use
may indirectly lead to substantial improvements in all of the above
parameters.
ORCID
Atiphan Pimkhaokham https://orcid.org/0000-0002-0170-243X
Sirimanas Jiaranuchart https://orcid.org/0000-0002-8403-275X
Boosana Kaboosaya https://orcid.org/0000-0002-0511-4678
Sirida Arunjaroensuk https://orcid.org/0000-0003-0897-6764
Keskanya Subbalekha https://orcid.org/0000-0002-1570-2289
Nikos Mattheos https://orcid.org/0000-0001-7358-7496
FIGURE 8 Dynamic computer- assisted implant surgery systems employed in the studies analyzed in this review were first and second
generation systems, typically based on: A, A set of optical tracking devices placed in the front or on top of the surgeon, B, Fiducial markers
attached to a splint to be worn by the patient during the surgery, in order to register the jaw position in real time; C, Fiducial markers
attached to the handpiece in order to register the position of the drill in real time; D, Calibration device to be utilized for alignment of the
handpiece and the tracking device prior to the surgery. Third- generation systems available today have further simplified some of these
devices and procedures involved
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How to cite this article: Pimkhaokham A, Jiaranuchart S,
Kaboosaya B, Arunjaroensuk S, Subbalekha K, Mattheos N.
Can computer-assisted implant surgery improve clinical
outcomes and reduce the frequency and intensity of
complications in implant dentistry? A critical review.
Periodontol 2000. 2022;90:197-223. doi: 10.1111/prd.12458
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