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. 2022 Mar 22;32(1):62–70. doi: 10.1111/jopr.13503

Influence of Metal Guide Sleeves on the Accuracy and Precision of Dental Implant Placement Using Guided Implant Surgery: An In Vitro Study

Coleman R Adams 1, Rami Ammoun 2, George R Deeb 3, Sompop Bencharit 1,3,4,
PMCID: PMC10078659  PMID: 35257456

Abstract

Purpose

Metal sleeves are commonly used in implant guides for guided surgery. Cost and sleeve specification limit the applications. This in vitro study examined the differences in the implant position deviations produced by a digitally designed surgical guide with no metal sleeve in comparison to a conventional one with a metal sleeve.

Materials and Methods

The experiment was conducted in two steps for each step: n = 20 casts total, 10 casts each group; Step 1 to examine one guide from each group with ten implant placements in a dental cast, and Step 2 to examine one guide to one cast. Implant placement was performed using a guided surgical protocol. Postoperative cone‐beam computed tomography images were made and were superimposed onto the treatment‐planning images. The implant horizontal and angulation deviations from the planned position were measured and analyzed using t‐test and F‐test (p = 0.05).

Results

For Step 1 and 2, respectively, implant deviations for the surgical guide with sleeve were –0.3 ±0.17 mm and 0.15 ±0.23 mm mesially, 0.60 ±1.69 mm, and –1.50 ±0.99 mm buccolingual at the apex, 0.20 ±0.47 mm and –0.60 ±0.27 mm buccolingual at the cervical, and 2.73° ±4.80° and –1.49° ±2.91° in the buccolingual angulation. For Step 1 and 2, respectively, the implant deviations for the surgical guide without sleeve were –0.17 ±0.14 mm and –0.06 ±0.07 mm mesially, 0.35 ±1.04 mm and –1.619 ±1.03 mm buccolingual at the apex, 0.10 ±0.27 mm and –0.62 ±0.27 mm buccolingual at the cervical, and 1.73° ±3.66° and –1.64° ±2.26° in the buccolingual angulation. No statistically significant differences were found in any group except for mesial deviation of the Step 2 group (F‐test, p < 0.001).

Conclusions

A digitally designed surgical guide with no metal sleeve demonstrates similar accuracy but higher precision compared to a surgical guide with a metal sleeve. Metal sleeves may not be required for guided surgery.

Keywords: Dental implant, guided surgery, 3D printing, accuracy, static guide


Advancements of three‐dimensional (3D) printers and computer‐aided design and computer‐aided manufacturing (CAD‐CAM) technology have allowed the widespread use of computer‐aided implant surgery 1 , 2 , 3 which has shown to be an improvement over conventional implant placement. 4 , 5 , 6 Accuracy of implant placement is improved even with planning software alone. Edelman et al 6 compared the planned implant position and the actual implant position with the use of computer‐aided software, and found errors within 0.5‐1 mm at the cervical portion of the implant fixtures and around 1° to 5° in the facio‐lingual plan. However, the study was done using two experienced implant surgeons performing each surgery together which might have contributed to the high accuracy of implant placement. This may not reflect true implant practice in general. 6 Guided implant surgery has the benefits of reduced surgery time, and reduction of postoperative pain from flapless surgery. 7 , 8

While guided implant surgery may be performed using dynamic navigation systems, the cost and complexity of the armamentarium render them impractical for most dental practices. 9 , 10 , 11 The most commonly used guided method is therefore static surgical guide. 12 , 13 , 14 , 15 , 16 The stereolithographic production of surgical guides in office was first outlined by Whitley and Bencharit. 1 , 2 The protocol streamlines and simplifies the design, print, and post‐processing using commercial software. 15 , 17 Talmazov et al 18 demonstrated that a static guided surgery can be done entirely using open‐source software to create implant guides with similar accuracy to previous studies using commercial software. Open‐source software allows modification and customization of an implant guide to supplement features that may not be adequate in the commercially available software.

One of the reasons for clinicians to not use static implant guided surgery is a need for specific metal sleeves that will fit with implant drills and drill adaptors. Most implant companies and implant planning software require clinicians to use these metal sleeves as part of the implant guided surgery protocol. The metal sleeve, however, increases cost and is specific to each implant system and surgical implant tool kit. Suriyan et al 19 used static guides with and without surgical sleeves in combination with trephine drills. This trephination‐based guided protocol not only provides a universal tool for guided implant surgery for multiple implant systems, but also demonstrates that an implant surgical sleeve may not be needed for a static implant guide. However, the trephine drills only have one cutting side at the end of the drill and do not cut the bone in the same fashion as normal osteotomy drills. Therefore, there was a need to demonstrate if implant placement can be done through a conventional guided surgery drilling protocol using a 3D printed guide without a metal sleeve.

This study proposed to examine if the metal sleeve is necessary for implant guided surgery and if there is any statistical difference between the accuracy of implant guides with and without a metal sleeve. The study was divided into two steps. The first step (Step 1) was to analyze the postoperative angulation and positional differences created by the modification of a single 3D printed surgical guide sleeve in comparison to those of a single surgical guide with a metal sleeve. It was hypothesized that the overall range of implant deviations generated by the modified surgical guide sleeve would be consistent with those of the metal sleeve. The second step (Step 2) was to analyze angulation and positional differences produced when the sample size of the surgical guides was increased for the two different groups to produce a guide to cast ratio of 1:1. It was hypothesized that the increase in the number of surgical guides for the two different groups would yield similar accuracy.

Materials and methods

A cone‐beam computed tomography (CBCT) data set and intraoral scans were obtained from the unidentified patient who was missing a maxillary right central incisor based on the protocol approved by the University Human Research Protection Program/Institutional Review Board (IRB no. HM20009486). The CBCT scans were obtained previously using the following protocol: i‐CAT FLX V10 (Kavo Dental, Brea, CA) with standard implant scan parameters. The intraoral scans were made using an intraoral scanner (TriOS 3; a3Shape A/S, Copenhagen, Denmark). The treatment planning was carried out using the Implant Studio 2021 (3Shape A/S) for a Tapered Screw Vent (TSV) Zimmer Biomet (3.7 mm × 13 mm) implant.

The protocol for fabricating the dental cast and surgical guide is similar to previous studies. 3 , 4 The intraoral scan was imported into a software program (Implant Studio V; 3Shape A/S), in which the dental cast and surgical guide were designed. The cast was exported in standard tessellation language (STL) format and was used to print 40 total dental casts (Form 3; Formlabs, Somerville, MA). Twenty Dental Model resin (Formlabs) for the first‐round experiment and 20 Dental Clear LT resin V2 (Formlabs) casts for the second‐round experiment were all printed at a resolution of 0.05 mm.

The surgical guide STL file was imported into Blender 3D software. The internal faces/vertices of the guide tube were selected. The wall thickness of the 4.2 mm Zimmer guide tube was measured to be 0.4 mm. The selected areas were then extruded using the “Extrude Faces Along Normal” to a thickness of 0.38 mm to allow for minimum drill tolerance. The top of the surgical guide was also selected and extruded to the proper height of the surrounding walls. The surgical guide was then exported to be 3D printed (Fig 1).

Figure 1.

Figure 1

Blender 3D workflow for creation of metal‐free surgical guide.

The implant surgical guides were exported into a 3D CAD software (Preform; Formlabs) in STL format. A total of 22 guides were printed in resin (Surgical Guide Resin; Formlabs) at a resolution of 0.05 mm (Form 3B, Formlabs). The print supports were removed and post‐processed per manufacturer's recommendation using an automated post‐processing method (Form Wash and Form Cure, Formlabs). The guide was rinsed twice in isopropanol and air‐dried, and the surgical guide tube was placed. Finally, the surgical guide was subjected to UV light‐polymerization (405 nm) at 60°C for 1 hour and sterilized in an autoclave (Fig 2).

Figure 2.

Figure 2

Clinical workflow exhibiting implant planning, guide design, 3D printing, and implant placement.

The placement of the implants within the resin casts was performed in two steps, Step 1 and Step 2. In Step 1, two guides with and without a metal sleeve were used to examine the deviation of the implant placement when one guide in each group was used (one guide per ten casts for each group). In Step 2, ten guides for each group were fabricated to mimic the variations that can occur during normal 3D printing fabrication of the guide. Therefore, in Step 2 there was one‐to‐one guide and cast pairing. For Step 1, only two surgical guides were used, one with and without metal sleeve to place 20 implants in 20 dental casts (n = 20) to evaluate the implant placement deviations. For the second step of implant placement, 1 cast and 1 guide were used for each implant placed, creating 10 sample sets for each group (n = 20) to evaluate the implant deviations resulting from pairs of guide/cast (Fig 3). The same surgical guide and implant surgical kit were used for each system to control the variations of guide fitting and drills. The implants were placed based on the manufacturer's recommendation. All osteotomy sites were prepared through surgical guides. The osteotomes were evaluated for depth and width before implant placement. Then, the implants were placed after the removal of the surgical guide per manufacturer's recommendation. Postoperative CBCT scans were made using a postoperative scanning protocol similar to that of a previous study. 3

Figure 3.

Figure 3

Samples for Step 1 and Step 2 of the study.

The dimensions and angulations of the implant position were determined similar to previous studies using the measuring tools in the planning software. 3 , 4 , 5 , 19 The distances between the most cervical part of the planned implant and the closest adjacent natural tooth root surfaces mesially and distally were recorded as mesial (M). The distances between the most cervical part of the planned implant and the outer surface dental cast labially and palatially were recorded as CL. The distances between the most apex part of the implant and the soft tissue were recorded as AL. The buccolingual implant angulation in relation to the plane of the cast was recorded as BLA.

Similar to the preoperative measurement, the postoperative positions of the placed implants were measured using a previously published protocol. 3 The postoperative implant placed CBCT scans were superimposed onto the planned implant position within the planning software. The implant positions were measured and compared with the planned positions. For each measurement, two observers (C.R.A. and S.B.) measured each site at the same time and came to an agreement. The postoperative CBCT scans were superimposed onto the planned implant position. The implant positions and the implant angulations were measured and compared with the planned positions (Fig 4). The differences between the planned and placed implant positions in each dimension and at each angulation were recorded and compared using t‐test (α = 0.05).

Figure 4.

Figure 4

Measurements for planned and placed implants. (A) Digital implant placement planning; (B) Schematic for measurements using implant long axis (green), reference plan (red) from cast landmarks (arrows) in the facio‐palatal plane (left) and mesiodistal plan (right), and measurements (magenta); (C) Measurement for the surgical guide with sleeve; and (D) Measurements for the metal‐free surgical guide. This figure visualizes the process of the superimposition of the placed implants in the resin casts atop the original planned placement from 3Shape.

Tube dimension deviations for each group were analyzed. All guide samples were scanned using cone beam computed tomography (iCAT FLX V10) with standard postoperative implant scan parameters (16 cm deep, 10 high cm volume, 0.3‐mm voxel size, 4.8‐second scan time, 2.0‐second exposure time, 120 kVP, 5 mA, and 283, 582, or 291 mGy/cm2) similar to previous studies. 3 , 15 , 17 The set of DICOM files of each scanned guide were converted into an STL file using slicer 3D (version 4.5.0, https://www.slicer.org/). Each STL file was superimposed onto the original STL guide designed file using the overall best fitting algorithm in the 3D compare software (Geomagic Design X, 3D Systems, Andover, MA). 15 , 17 In Blender 3D, two reference cylinders were extracted from the top and bottom portions of the cylinder region of the reference STL files. The centers of these cylinders formed a reference vector (V1). The tested surgical guide STL file was then imported into Blender 3D. In the guide tube region, two cylinders were extracted in the same region of the reference cylinders. The centers of these cylinders formed the vector of angulation of the guide tube (V2). This was done for both sleeveless and sleeve surgical guides. The angular measurements were done between the tested surgical guide's formed vector (V2) and the reference guide vector (V1). The angle between V1 and V2 is shown in the provided table (Tables 1 and 2, Figs 5 and 6). Figure 7 illustrates the superimposition and measurement processes.

Table 1.

Implant placement deviations and statistical analyses for Step 1

Deviation Presence of sleeve Mean SD Range Min Q1 Q3 Max t‐test F‐test
M Sleeve −0.30 0.17 0.48 −0.60 −0.39 −0.17 −0.12 0.07 0.24
No sleeve −0.17 0.14 0.42 −0.31 −0.27 −0.12 0.11
AL Sleeve 0.60 1.69 5.43 −2.08 −0.16 1.42 3.35 0.69 0.08
No sleeve 0.35 1.04 3.53 −1.10 −0.05 0.56 2.43
CL Sleeve 0.20 0.47 1.62 −0.59 0.04 0.38 1.03 0.59 0.06
No sleeve 0.10 0.27 0.95 −0.32 −0.04 0.24 0.63
BLA Sleeve 2.73 4.80 13.91 −5.16 −0.63 5.95 8.75 0.61 0.22
No sleeve 1.73 3.66 11.56 −3.35 0.47 1.40 8.21

This table highlights the implant placement deviations occurring within the first step. The four parameters utilized were mesial (M), apex buccolingual (AL), cervical buccolingual (CL), and buccolingual angulation (BLA). The means, standard deviations, and ranges are noted. A t‐test was utilized to compare accuracy between the different surgical guide group's means. An F‐test was utilized to compare the precision between the two different group's ranges. No statistically significant differences were found between either group with t‐test nor F‐test.

Table 2.

Implant placement deviations and statistical analyses for the second round of implants

Deviation Presence of sleeve Mean SD Range Min Q1 Q3 Max t‐test F‐test
M Sleeve −0.15 0.23 0.66 −0.54 −0.21 0.03 0.12 0.28 >0.001
No sleeve −0.06 0.07 0.19 −0.16 −0.10 0.00 0.03
AL Sleeve −1.50 0.99 2.66 −3.04 −2.23 −0.65 −0.38 0.79 0.44
No sleeve −1.62 1.03 3.13 −2.67 −2.35 −1.38 0.46
CL Sleeve −0.60 0.27 0.90 −1.26 −0.70 −0.41 −0.36 0.86 0.47
No sleeve −0.62 0.28 0.87 −0.89 −0.76 −0.66 −0.02
BLA Sleeve −1.49 2.91 7.90 −5.54 −4.10 0.98 2.36 0.90 0.23
No sleeve −1.64 2.26 6.39 −4.07 −3.27 −0.49 2.32

This table highlights the implant placement deviations occurring within the second step. The four parameters utilized were mesial (M), apex buccolingual (AL), cervical buccolingual (CL), and buccolingual angulation (BLA). The means, standard deviations, and ranges are noted. A t‐test was utilized to compare accuracy between the different surgical guide group's means. An F‐test was utilized to compare the precision between the two different group's ranges. A statistically significant difference was found with the F‐test in the mesial dimension. Neither the t‐test nor the remainder of the other parameter's F‐tests highlighted any statistically significant differences.

Figure 5.

Figure 5

Box plots for Step 1 positional and angulation implant deviations showing first and third quartile box plots and maximal and minimal values. (A) Mesial (M). (B) Apex buccolingual (AL). (C) Cervical buccolingual (CL). (D) Angulation buccolingual (BLA). All four parameters are exemplified here with (A).

Figure 6.

Figure 6

Box plots for Step 2 positional and angulation implant deviations showing first and third quartile box plots and maximal and minimal values. (A) Mesial (M). (B) Apex buccolingual (AL). (C) Cervical buccolingual (CL). (D) Angulation buccolingual (BLA). All four parameters are exemplified here with (A).

Figure 7.

Figure 7

Superimposition of the STL file of the printed guide with the original STL file.

Results

In Step 1, overall implant deviations were −0.23 ±0.16 mm mesially (M), 0.48 ±1.37 mm of the apex region buccolingually (AL), 0.15 ±0.38 mm of the cervical region buccolingually (CL), and 2.23 ±4.18° in the buccolingual angulation (BLA). Detailed measurements and analysis of the in vitro study are presented in Table 1. Differences between the planned and placed implant positioning are also presented with 95% confidence intervals (CIs) for means of within‐subject paired differences. Table 1 demonstrates the mean, standard deviation, range, minimum (Min), Q1 (first quartile), Q3 (third quartile), and maximum (Max) values for both the sleeve and sleeveless surgical guides, as well as the p values. Figure 5 demonstrates the box plots of dimension and angulation deviation overall and for both types of guides. The implant deviations for the surgical guide with sleeve were −0.30 ±0.17 mm (M), 0.60 ±1.69 mm (AL), 0.20 ±0.47 mm (CL), and 2.73° ±4.80° (BLA). The implant deviations for the surgical guide without sleeve were −0.17 ± 0.14 mm (M), 0.35 ± 1.04 mm (AL), 0.10 ±0.27 mm (CL), and 1.73° ±3.66° (BLA). In relation to implant accuracy, none of the deviations in the M (p = 0.071), AL (p = 0.691), CL (p = 0.586), nor BLA (p = 0.608) showed significant differences. The range for the deviations from those with the sleeve to those without were 0.48 and 0.42 mm (M), 5.43 and 3.53 mm (AL), 1.62 and 0.95 mm (CL), and 13.91° and 11.56° (BLA). The ranges for the guide without sleeve appeared to exhibit a narrower range in the AL and BLA. In terms of precision, referring to the consistency of displacement or the least variation in deviations, the F‐tests for differences in variance (α = 0.05) suggested no statistically significant differences in M (p = 0.246), AL (p = 0.081), CL (p = 0.056), or BLA (p = 0.216).

In Step 2, overall implant deviations were −0.10 ±0.17 mm (M), −1.48 ±1.02 mm (AL), −0.61 ±0.26 mm (BL), and −1.57° ±2.54° (BLA). Detailed measurements and analysis of the in vitro study are presented in Table 2. Differences between the planned and placed implant positioning are also presented with 95% confidence intervals (CIs) for means of within‐subject paired differences. Table 2 demonstrates the mean, standard deviation, range, minimum (Min), Q1 (first quartile), Q3 (third quartile), and maximum (Max) values for both the sleeve and sleeveless surgical guides, as well as the p values. Figure 6 demonstrates the box plots of dimension and angulation deviation overall and for both types of guides. The implant deviations for the surgical guide with sleeve were −0.15 ±0.23 mm (M), −1.50 ±0.99 mm (AL), −0.60 ±0.27 mm (CL), and −1.49° ±2.91° (BLA). The implant deviations for the surgical guide without sleeve were −0.06 ±0.07 mm (M), −1.619 ±1.03 mm (AL), −0.62 ±0.27 mm (CL), and −1.64° ±2.26° (BLA). In relation to implant accuracy, none of the deviations in the M (p = 0.28), AL (p = 0.79), CL (p = 0.86), or BLA (p = 0.90) showed significant differences. The range for the deviations from those with the sleeve to those without were 0.66 and 0.19 mm (M), 2.66 and 3.13 mm (AL), 0.9 and 0.87 mm (CL), and 7.90° and 2.32° (BLA). The ranges for the guides without sleeves appeared to exhibit a narrower range in the M and BLA dimensions.

In terms of precision, referring to the consistency of displacement or the least variation in deviations, the Levene tests for differences in variance (α = 0.05) suggested statistically significant differences in only the M dimension (p > 0.001), but the other dimensions did not show significance with AL (p = 0.45), CL (p = 0.49), or BLA (p = 0.23).

The superimpositions of the guides onto the original STL file demonstrated slightly lower angulation deviations for the group with a sleeve compared to the one without a sleeve. The tube angulation deviations and statistical analysis are shown in Table 3. However, there was no statistically significant difference between the groups.

Table 3.

Analysis of surgical sleeve deviations

No sleeve With sleeve
Average 3.99° 2.79°
Standard deviation 1.38° 1.31°
t‐test p = 0.06
F‐test p = 0.44

The table shows the average and standard deviations values of surgical guides with no sleeve and with sleeve. The t‐test with assuming equal variances was used to determine the accuracy of sleeve placement. The F‐test was used to determine the precision of sleeve placement.

Discussion

This paper examined the accuracies of sleeveless 3D printed surgical guides in comparison to the conventional surgical guide that uses metal sleeves. Step 1 was meant to determine the range of implant deviations occurring between a surgical guide with a metal guide sleeve and without. Also, to analyze any significant differences between the two. The results support the idea that the sleeveless surgical guide's deviations are consistent with those of the surgical guide with metal sleeve and are consistent with those of previous studies that placed implants using a 3D printed surgical guide. 3 , 4 , 5 , 21 It is interesting to note that the means and ranges for the surgical guide without metal sleeve appear slightly lower than those of the metal sleeve for all four parameters. This could possibly be due to the fact that only one surgical guide was used per group thus decreasing the amount of error introduced from the printing process. However, these small differences in overall deviations were in range of the average deviations exhibited by studies that examined implant deviations with surgical guides. 3 , 4 , 5 , 19 , 20 , 21

Step 2 of this study aimed to determine the overall differences generated in implant deviations between the two groups of surgical guides from the first step but decreased the guide to cast ratio to 1:1. It was hypothesized that the increase in the number of surgical guides for the two different groups would yield similar accuracy and precision. From this decrease in guide to cast ratio, it was found that that accuracy between the guides with and without metal exemplified similar accuracy. However, in terms of precision there was a statistically significant difference between the two groups, especially within the mesial dimension. This was interesting as it can allow speculation that the guide without metal sleeve is more precise, but the remainder of the parameters saw no statistically significant differences. Also, the pattern that surgical guides without the metal sleeve saw decreased means as shown in the first step did not continue in the second step. This could be due to the fact that more surgical guides were produced and thus there was an increased possibility of errors introduced during the printing process.

During the initial round of implant placement, some models made of Dental Model resin appeared to crack. The switch to the Dental Clear LT V2 resin decreased the visible cracks within the model during implant site preparation and implant placement. The use of the Dental Clear LT V2 resin during the second round of this study could introduce a new and improved method for future implant studies.

Another factor for examining this subject is the overall cost‐effectiveness of using a surgical guide that does not contain a metal guide sleeve. By showing that the differences in implant deviation between utilizing a metal guide sleeve and not are minimal, it can be concluded that the clinician will be reducing the cost of the operation while maintaining accuracy. Many clinicians can be pushed away from using surgical guides due to cost and overall misunderstanding of their fabrication in‐house. This study simplifies all those parameters to decrease any complications that could arise during planning and creation of the surgical guides without metal guide sleeves. Similar studies examined the effectiveness of implant surgical guides and found results consistent with this study. 15 , 18 However, utilization of Blender 3D was uniquely presented here. This may be more applicable to most practitioners because it uses a simple series of steps that are readily reproducible to manipulate the guide tube with ease.

There are a few limitations that must be highlighted. First, the fitting of the guide atop the resin casts may differ from that of the natural teeth and soft tissue. The minor movements of the natural structures may allow for increased deviations. However, previous papers have shown that the implant deviations within resin models is similar to those in human studies. 4 , 5 , 19 Second, the deviations of the implant drills when preparing the sites in homogenous resin may differ from those in non‐homogenous alveolar bone. The flexural modulus of the trabecular bone for a female subject range from ∼300 to ∼3000 MPa. 22 The flexural modulus of the dental model and dental clear resins used in this study have flexural modulus values of 95.8 and 2300 MPa. The different values of flexural modulus may allow implication for a normal range of human trabecular bone. Third, this study is limited to only the Zimmer Biomet TSV guided implant system. A review of more implant systems may create a wider array of results to interpret due to the variability of each implant system's protocols. It is interesting to note that the surgical guide with and without a sleeve had no difference in sleeve axis positioning. This suggests that while the metal sleeve provides a better axis to the implant drill direction, it does not give the implant guide any advantage in improving the implant placement positioning. Lastly, this study only examined one single anterior edentulous area with two adjacent natural teeth to support the implant guide. Thus, the results may have some limitations when applied to larger edentulous areas.

Future studies should consider for the implant manufacturers to implement a “no metal sleeve” option into their treatment planning software to further streamline the process. Static guided implant surgery relies on the fitting of a portion of the osteotomy drill to the guide sleeve or sleeve adaptor. Clinicians should pay attention so that the drill does not cut the guide sleeve or sleeve adaptor which may contaminate the implant osteotomy site with metal or polymer particles. 23

Conclusions

A sleeve free implant surgical guide demonstrates similar accuracy and precision as the surgical guide with the metal sleeve. Metal sleeves may not be required for accurate implant placement. Furthermore, open‐source software can be applied to enhance conventional implant planning software to modify implant surgical guides.

Funding

ZimVie provided material support of this study. However, the sponsor had no role in the study design, experiment, or publication of this work.

Conflict of interest statement

The authors do not have any conflicts of interest in regards to the current study.

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