Guided vs. Non-Guided Implant Surgery: A CBCT In Vitro Comparison

Guided vs. Non-Guided Implant Surgery: A CBCT In Vitro Comparison | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Guided vs. Non-Guided Implant Surgery: A CBCT In Vitro Comparison Gharam BASSAM, Nader Rezallah, Yasser El Ramady, FARAH ALBANNA, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7276802/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objectives The aim of the study is to compare the accuracy of dental implant placement using guided surgery versus freehand (non-guided) techniques in a laboratory (in vitro) setting. Methods Twelve upper jaw models simulating edentulous maxillae were used and divided into two groups. In Group A, implants were placed using 3D-printed surgical guides based on CBCT planning. Group B received implants placed freehand, using only clinical judgment. The same implant system and drilling steps were followed for both groups. After placement, CBCT scans were taken to measure angular deviation, and five clinicians visually assessed how closely the implants matched the planned positions. Results Implants placed with guided surgery showed higher accuracy, with a mean angular deviation of -0.41°, compared to -4.83° in the freehand group. The guided group also had less variation. Visual evaluations by five clinicians showed stronger agreement for the guided group (κ = 0.943) than for the freehand group (κ = 0.868). Conclusions Guided implant surgery proved more accurate and consistent than the freehand method, making it especially useful in complex or sensitive cases. While freehand placement may work in simpler situations, it carries more risk of error. These results support using guided techniques as a standard approach in implant practice. Dental implants Guided surgery Freehand technique Implant accuracy CBCT In vitro study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Introduction In the field of dental implantology, where a few millimeters can mean success or failure, accuracy is not only a clinical goal but the very basis on which patient success is built. Placing a dental implant requires a careful process that combines an understanding of anatomy, surgical skill, and technology. Although dental implants have become the gold standard for tooth replacement, providing unparalleled restoration of function and esthetics, the dental community has emphasized establishing criteria for improved accuracy in placing each implant. The ramifications of implant placement errors reach well beyond technical aspects alone. Unfavorable placement may lead to a considerable range of complications, including nerve injury, sinus perforation, and/or damage to osseointegration, potentially resulting in failure of the implant. The requirements for costly and invasive remedial therapy aside, these complications influence the patient's comfort, function and quality of life. Consequently, the field has experienced a significant paradigm shift toward technology-enhanced placement techniques to reduce both human error and increase predictability. The distinction between guided and non-guided surgical techniques is at the forefront of this evolution. Conventional surgery techniques are classified as non-guided surgical techniques and depend mainly on clinician knowledge and judgement during surgery, utilizing conventional radiographs and manual measurements to establish MRI implant position. In contrast, guided procedures incorporate advanced digital planning software, 3D imaging, and custom-created surgical guides to implement accurate pre-operative planning into the operative field. This notable and recent improvement is asserted to allow improved control of implant angulation, depth, and positioning to critical anatomy [ 1 , 2 ]. The use of Cone Beam Computed Tomography (CBCT) has changed the face of both preoperative assessment and postoperative assessment in implantology. CBCT imaging is different from traditional radiography in that it provides three-dimensional (volumetric data) of the maxillofacial anatomy with minimal distortion, allowing the clinician to view anatomical landmarks with the most clarity and precision ever. The introduction of CBCT imaging and guided surgery technologies has also opened the door to exciting possibilities for treatment planning and treatment outcome assessments; however, questions remain about whether the use of these technologies in any manner is measurable compared to traditional methods, particularly in a controlled environment. Although there is an increasing amount of research comparing guided and non-guided implant placement techniques, the literature shows contradictory findings, methodological differences, and other challenges that impede synthesis or clinical application. Many studies document the measurements of deviation and placement accuracy, but very few studies systematically explored these outcomes in standardized in vitro models, eliminating the confounding variables present in clinical conditions. This knowledge gap highlights the need for a systematic assessment of the comparative effectiveness of these techniques using a controlled situation in which precision metrics can be objectively measured and evaluated [ 3 ]. Researching key differences between guidance and non-guidance is best studied inside an in vitro model. This setting allows patient factors such as mouth opening and tissue compliance to be removed as confounders to isolate the technical aspect of implant placement and generate new knowledge that can inform clinical practice. In addition, standardized models make it much easier to measure essential variables such as entry point deviation, apical deviation, angular deviation, and depth variation metrics, each of which contributes to measuring placement accuracy and identifying potential complications. The purpose of this study is to compare guided vs non-guided implant surgery, with a specific focus of precision outcomes measured specifically by CBCT in controlled in vitro studies, this study will clarify how guided surgery improves placement accuracy, provide an understanding of technical components that impact placement outcomes, and develop quantitative measures to evaluate placement accuracy. The implications of the findings are relevant for developing clinical protocols, surgeon education and training, and the development of optimized technologies for patient care in the surgical environment. Literature Review Non-guided implant surgery, also known as "freehand" implantology, is a conventional technique for placing implants and is seen as the basis of development for dental implantology since its opening. However, this method relies on a broad comprehension of oral anatomy, spatial reasoning ability, and practical manual dexterity that have developed as a result of surgical experience over time. In vitro studies looking at non-guided approaches typically immeasurably in-vitro mimic clinical workflows in which those investigating the approach, use customary means of diagnosable including traditional two-dimensional radiographs, study models, or other habitual means of diagnostic tools as methods for planning to find implant placement. Before the actual surgery, in the prep stage, the dentists examine the bone dimension they have available, assess and establish an anatomy for implant placement, and develop the ultimate success the clinician wants, to be completed all while the clinician decides without the assistance of a surgical template or operating real-time operating and navigational technology. During the surgery, the operator determines drilling trajectory, depth, and angulation all on their own. This is a process that limits dependency of procedural sequencing. In freehand, a clinician has autonomy to reassess how the drilling axis need to be made in real-time through a building aesthetic with each incremental depth, in other words it invokes a fluidity amid basic implant prep for the entire length of the surgery in real-time anticipation of each landmark for mouth surgery or in this case all oral surgical context. In freehand implant surgeries, a surgeon maintains acute control over each surgical step for success: insertion site preparation to pilot drilling to final seating. Each decision the operator is making is solely based on a reading of the contextual anatomy not determined through surgical guides or some pre-selected digital and/or procedural working plan [ 3 ]. For instance, in a rigorous in vitro study by Tan et al., guided implant placement demonstrated significantly superior accuracy compared to freehand techniques when using merged 3D surface and CBCT data. Their findings revealed that guided surgery achieved 56% less angular deviation (3.91° vs 8.82°) and 41% less apical displacement (0.87mm vs 1.48mm) than freehand placement, though shoulder displacement and depth measurements showed no significant differences between approaches [ 4 ]. The existing literature about non-guided surgery in vitro has reported on several unique advantages that sustain its use and relevance amidst advancements in technology. The most notable advantage is the flexibility it affords clinicians, allowing them to respond to unforeseen anatomy in real-time, or challenges that were unknown during the pre-operative planning process, which is commonly documented in comparative controlled laboratory studies. Cost analyses show that non-guided techniques are usually less expensive, having little to no investment in specialized software, fabrication of guides, or imaging with more advanced technology beyond conventional radiographs, and they are an advantage in underfunded/exceedingly funded scenarios. Time efficient studies in vitro show that for uncomplicated cases with sufficient bone volume, experienced clinicians can perform freehand approaches within the same or shorter overall surgical times, and this difference arguably improves even more when the preparation times for guides are taken into consideration. Also, the precision measurement studies employing standardized models show that experiences and skilled operators can achieve clinically acceptable parameters of deviation within acceptable safety ranges, which is typically 1-2mm linear deviation and under 5° of angular deviation; devices that tend to utilize guided spacing (or for posterior implants where tolerant range is greater). These findings suggest that non-guided surgery remains a viable and effective approach when performed by practitioners with sufficient surgical proficiency, particularly in uncomplicated cases where the risk-benefit analysis may not justify the additional resources required for guided techniques [ 1 , 2 ]. In their randomized controlled clinical trial, Smitkarn et al. demonstrated that static computer-assisted implant surgery (CAIS) significantly outperformed freehand techniques in achieving accurate implant positioning in single edentulous spaces. Their findings showed that guided surgery produced considerably less deviation from planned positions, with a median angular deviation of only 2.8° compared to 7.0° in the freehand group. Similarly, implant shoulder deviation (0.9mm vs 1.3mm) and apical deviation (1.2mm vs 2.2mm) were substantially reduced with guided surgery, with statistically significant differences observed in six of nine measured parameters [ 5 ]. This shows the edge guided surgeries have on unguided surgeries. The development of guided surgery for implants was a thoughtful response to the limitations and variability of traditional freehand methods. As dental implantology made the transition from an extraordinary procedure to a routine treatment option, the oral science community was increasingly aware of the need for greater precision and predictability, particularly in more challenging clinical settings. Early in vitro studies in the late 1990s and early 2000s, demonstrated troubling variability in clinical outcomes for implant placements at various experience levels, with acceptable deviation from ideal placement encompassing a significant percentage of clinical experiences, particularly for older or inexperienced operators. While this variability is often manageable with straightforward cases, it is tremendously undesirable in cases where proximity to vital structures is an issue or precision in prosthetic placement is of utmost importance. At the same time, patients were demanding greater predictability in treatment outcomes and complications when making choices in surgical interventions (though, beyond the oral science procedural standards). Clearly, the literature demonstrates an appropriate sequence of development, where researchers systematically recognized precision deficiencies in minimally guided procedures, then progressed to viewing and exploring technological applications for improvement/development - procedures and technologies intended to facilitate efficiencies as well. The significant evolution of Cone Beam Computed Tomography technology changed the game by providing three-dimensional images of anatomy with amazing detail and little distortion. This imaging modality and the deployment of sophisticated implant planning software platforms provided the infrastructure for guided surgery protocols. Followed by advancements in guide fabrication with stereolithographic and the relatively newer availability of 3D printing technology to fabricate guides, this facilitated the ability to take digital plans and create a reality to bring into the clinic closing the gap between planning in cyberspace and clinical space [ 6 , 7 ]. Tan et al. (2018) conducted an in vitro study comparing guided versus freehand implant placement accuracy using a novel combined workflow incorporating TRIOS surface scanning, Implant Studio software, CBCT imaging, and stereolithographic planning. Their findings demonstrated significantly superior precision with guided surgery, particularly in terms of angular deviation (3.91° vs 8.82°) and apical displacement (0.87mm vs 1.48mm), though shoulder and depth measurements showed no significant differences between techniques. This high-quality research, published in the Q1-ranked International Journal of Computerized Dentistry, provides compelling evidence supporting the integration of digital workflows for enhanced implant placement precision [ 4 ]. In vitro studies studying the methodology of guided surgery have proven to consistently standardize results among various experience levels of practitioners, an important finding for educational programs and quality assurance processes. Laboratory experiments using standardized models demonstrated that guided surgery can reduce mean angular deviations by 50–700% when compared to unrestricted freehand approaches, with the most pronounced effects shown among less experienced operators. The digital aspect of the planning process allows for collaborative decision making in regards to implant position and an objective, retrospective assessment of the implant position in relation to the anatomical realities as well as the anticipated prosthetic realities, prior to any surgical intervention. This represents a paradigm shift from traditional surgical planning where optimal positioning was defined during the intervention, and through the surgeon's interpretation of anatomical landmark features. It is also documented in the published literature that the methodology of guided surgery has evolved from simply predetermined transfer of an implant position, to larger digital workflows that incorporate prosthetic design, bone density, and biomechanical information. Incorporating these elements has yielded a more organized way to derive implant planning treatment regimens that ensure the least reliance on subjective clinical decision making. Laboratory studies comparing early generation guides to modern systems demonstrate a significant milestone in technological advancement, where accuracy has been achieved in custom guides, and when appropriately executed, can be within a submillimeter condition. This is now recognized as a standard in the growth of dental implantology, demonstrating the profession's ongoing improvement and validation over traditional techniques where a guide was not used at all. Overall, it reflects that guided systems can improve the level of care that governs everyday practice in different clinical scenarios when appropriately and accurately executed [ 8 – 10 ]. Research from the comparative literature on case preferences for guided vs non-guided will provide some more complicated decision matrix with many variables including case complexity, anatomy, and experience of the provider. In vitro literature always suggests the success of non-guided solutions in more basic clinical situations with good bone volume and anatomy and sufficient distance away from critical structures (vital anatomy). In these circumstances, experienced clinician can place an implant within accepted clinical parameters without the additional time and cost of a guided solution. Non-guided solutions remain important specifically in posterior regions where there is good bone volume and little aesthetic component when appeared with a single tooth restoration, where minor errors in implant position would not threaten functional or biological parameters. On the other hand, there is ample evidence demonstrating a case preference for guided surgery in cases that are anatomically complicated, limited bone availability and close proximity to important structures (e.g., inferior alveolar nerve or maxillary sinus). Within these higher risk settings, in vitro articles have shown significantly lower deviation measures and complication rates utilizing a guided method versus freehand, regardless of the operator's experience. The benefits of precision with guided surgery can be markedly greater when it comes to inter-implant positioning, including but not limited to full-arch rehabilitations, or when the implants need to be positioned in specific angulations so angled abutments can be utilized or to avoid anatomical structures. Controlled laboratory studies, when studying implant placement in the aesthetic zone, which also employs prosthetic driven backward planning, show advantages with the emergence profile, and greater predictability with prosthetic development when a guided method is employed. The findings essentially led to evidence to assist in establishing decision-making and criteria to aid in developing selection criteria to aid in determining the approach which would get optimal benefit-to-cost ratio for a given case type. The implications of the studies are helpful in moving away from the binary conversation of guided vs non-guided, and with the development of evidence based decision making, to a decision based on evidence which is case specific, experience, operator preference, and etc. [ 3 , 4 , 11 ]. Cone Beam Computed Tomography (CBCT) is the technological foundation for modern guided implant surgery workflows, changing the accuracy paradigm through its densified application across the procedural framework. Firstly, in the pre-operative planning phase, CBCT produces volumetric datasets which allow clinicians to visualize anatomical structures in three dimensions with submillimeter precision. Whereas bone quality, quantity, and proximity to important anatomical landmarks are traditionally assessed in two dimensions, volumetric datasets create the opportunity for thorough 3D assessment pre-operatively. The volumetric data is then imported into surgical planning software, where a virtual implant can be placed taking into consideration adequate prosthetic space as well as anatomical distance, setting the digital planning phase for surgical guidance fabrication [ 12 ]. In the surgical fabrication phase, models created from CBCT will ensure patient-specific anatomical contours for surgical guides all whilst maintaining specific accuracy to the planned position of the implant. Most importantly, unique to CBCT, is the utilized an in vitro studies for the postoperative evaluation of guided implant surgery where a pre- and post- placement scan can be superimposed to measure deviation to planned implant position on multiple parameters, including entry point deviation, apical deviation, angular deviation, and depth deviation. This capacity for precise measurement has established CBCT as the gold standard assessment tool in comparative research, enabling objective evaluation of different guided surgery protocols and iterative refinement based on quantifiable outcomes [ 13 , 14 ]. Henceforth, the inclusion of CBCT in educational systems has transformed the training process for implants via interactive simulation formats, allowing early-stage practitioners to refine their skills in complex cases without putting the patient in danger. Studies in a controlled lab setting show that CBCT training significantly differs in time to competency, as novices could obtain deviation measurements quite like testers who are already adept at implant placement when they practiced with a fully-guided implant-training protocol. In addition to anatomical visualization, advanced applications are emerging, including biomechanical analysis in the planning phase based on bone density values from CBCT to guide decision-making related to implant design, drilling protocols, and achieved primary stability in cases of compromised bone quality or quantity. In addition, the use of CBCT standardized in measurement protocols enhances the reproducibility of research studies across institutions, and advances the comparison of guided surgery methodologies over time for meta-analysis. These advances illustrate the means by which CBCT surpasses its initial innovative purpose as a diagnostic tool to become an integral component of the digital ecosystem of implantology serving typically as the component elements needed for planning, a standard for fabrication and construction, and as a barometer for outcome measurement. Methodology This in vitro experimental study aims to evaluate the accuracy of angulation of dental implant placement using guided and non-guided surgical techniques. The precision of implant positioning was assessed using cone beam computed tomography (CBCT) imaging. A 6 models rigid foam shell with inner cancellous material. The surface is similar to cortical bone; the interior is similar to cancellous bone these models representing edentulous upper jaws were used. Each model prepared to receive a 6 dental implant. The models were divided in to two equal groups: Group A (Guided Surgery) : Implants were placed using custom-made surgical guides fabricated from digital planning based on preoperative CBCT scans. Group B (Non-Guided Surgery) : Implants were placed freehand, relying solely on anatomical landmarks and clinical experience, without the use of any guiding templates. All implants were placed in the designated site using the same implant system, following the manufacturer’s protocol for drilling and insertion. Materials and Equipment Models : Rigid Foam Shell with Inner Cancellous Material Cone Beam CT Scanner : New tom Go 3D made in Italy CBCT settings: FOV: 10x10 Mode: Regular Kv: 90 S: 9.60 Gutta Percha Points : Meta Biomed Gutta Percha Hand piece : W&H 20:1 Surgical Hand piece Implant System : DS Prime Taper – DENTSPLY SIRONA KIT Surgical Guide : Mucosa Soft Tissue Supported Flapless Surgery (made in which lab) Sample preparation The standardized model simulating of an edentulous maxilla was prepared to receive the six implants. Marks was drown using pencil,1cm between each point then a round bur low speed hand piece used to make drill with depth 4 mm, then the Gutta Percha was heated with torch and condensed in each preparation site using condenser. Following site preparation, cone-beam computed tomography (CBCT) scans were obtained for the treatment planning process for implant placement. The samples were then divided into two groups. Group A models were sent to a dental laboratory (YMed Laboratory) for the fabrication of custom surgical guides. Group A implant placement technique The maxillary models for this group were prepared using prime taper Drills EV-GS Medium (4.2). First drill (1.9), second drill (2.95), third drill (3.55) were used consequently to prepare the implant site through the surgical guide ensuring parallelism. The implant driver EV-GS was placed in handle with torque wrench EV to carry the implant which was placed 1mm under alveolar crest in all models in the same group. Group B where implants were placed freehand, without the use of surgical guides, utilizing the Dentsply Sirona implant kit. Placement in this group was based solely on anatomical landmarks and the operator’s clinical judgment and experience. Group B implant placement technique: The maxillary models for this group were prepared the same method as group A using prime taper Drills EV-GS Medium (4.2). First drill (1.9), second drill (2.95), third drill (3.55) were used consequently to prepare the implant site, the operator referred to the planned CBCT and depended on his freehand skills to ensure parallelism. The implant driver EV-GS was placed in handle with torque wrench EV to carry the implant which was placed 1mm under alveolar crest in all models in the same group. Accuracy Evaluation After implant placement, postoperative CBCT scans were obtained for all models. These were compared with the preoperative planned positions. Analysis of the scans were performed to assess Angular deviation (in degrees), All measurements were performed in three dimensions to determine the spatial accuracy of implant placement. A copy of the scans was sent to 5 different evaluators to compare the visual resemblance of implant planning on CBCT. 3 resemblance levels were defined to the raters as following: High: Implant position is nearly identical to the planned CBCT image in angulation, depth, and mesio-distal location. Moderate: Minor deviation from the planned position, but still within acceptable functional and aesthetic limits. Low: Clear mismatch between planned and placed implant position, which could affect clinical or esthetic outcomes. Results Result 1: CBCT-Based Angular Deviation Analysis This analysis evaluates how accurately implants were placed relative to the pre-planned CBCT angulation using the NNT software. Two techniques were compared: - Guided Surgery Group (n = 9): Implants inserted using a 3D-printed surgical guide. - Freehand Surgery Group (n = 9): Implants placed manually based on operator skill. Metric Guided Surgery Freehand Surgery Mean Deviation (°) -0.41 -4.83 Standard Deviation 1.19 3.24 Minimum Deviation (°) -3.30 -11.10 Maximum Deviation (°) 1.80 0.00 Interpretation: On average, guided surgery was more accurate and less variable, with mean angular deviations close to zero. Freehand placement exhibited a greater range and more pronounced negative deviation, reflecting larger differences from the planned trajectory. The chart below clearly shows that the guided group maintained a tighter cluster around the target angulation, while the freehand group had a greater spread and more outliers. Discussion of Result 1 The data strongly supports the claim that guided implant placement ensures better accuracy compared to freehand surgery. The guided group's mean deviation of -0.41° falls well within clinically acceptable limits (usually ±3°), whereas the freehand group shows a much larger mean deviation of -4.83° with high variability. This suggests that surgical guides provide structural control and reduce human variability, particularly beneficial in aesthetic zones or proximity to vital structures. Conversely, freehand techniques may still be viable but carry a higher risk of placement errors, particularly among less experienced clinicians or in anatomically complex cases. Result 2: Inter-Rater Reliability in Visual Assessment of Implant Placement To assess the subjective agreement among professionals evaluating the implant positioning accuracy, five experienced examiners visually compared CBCT post-op scans to the original implant plan. Each implant was scored based on visual resemblance to the plan using a 3-point scale: - 1 = Poor resemblance - 2 = Moderate resemblance - 3 = Excellent resemblance Ratings were collected for both: - Guided Surgery Implants - Freehand Surgery Implants Group Fleiss’ Kappa (κ) Interpretation Guided Surgery 0.943 Almost Perfect Agreement Freehand Surgery 0.868 Strong Agreement Discussion of Result 2 This high inter-rater agreement, especially for guided surgery (κ = 0.943), reflects not only the objective accuracy of guided placement but also the perceptual clarity it affords to clinicians evaluating outcomes. Freehand implant placement, while still showing substantial agreement (κ = 0.868), had slightly more subjective interpretation differences, likely due to greater placement variation and difficulty in aligning outcomes with original plans. These findings suggest that guided surgery standardizes implant results in a way that enhances clinical agreement, which is crucial in education, quality assurance, and post-surgical evaluations. Discussion The outcomes of this in vitro study strongly reinforce the growing body of evidence advocating for guided implant surgery as a superior alternative to the traditional freehand technique, particularly in terms of accuracy and standardization of implant placement. The two primary assessments conducted angular deviation analysis via CBCT and visual inter-rater evaluations consistently favored the guided method across multiple domains. The angular deviation findings revealed a stark contrast: guided surgery showed a mean deviation of -0.41° (SD = 1.19°) while freehand placement averaged − 4.83° (SD = 3.24°). These results are well aligned with prior studies such as Tan et al. [ 4 ] and Smitkarn et al. [ 5 ], who demonstrated that guided systems reduce angular and apical deviation significantly. Tan et al. reported angular deviations of 3.91° for guided vs 8.82° for freehand techniques, closely mirroring our comparative values and confirming the utility of guided systems in reducing variability and surgical risk. Moreover, the high inter-rater reliability achieved through guided procedures (κ = 0.943) further validates the claim that guided techniques not only produce more precise outcomes but also enhance consensus among expert evaluators. This high level of agreement is consistent with studies by Jorba-García et al. [ 8 ] and Herstell et al. [ 10 ], which have shown that surgical guidance results in reproducible outcomes, even across different levels of surgical experience. By contrast, while freehand implants also achieved commendable inter-rater agreement (κ = 0.868), the variation in placement made visual assessment inherently more subjective and prone to interpretive discrepancies. From a methodological standpoint, the application of NNT software for pre- and post-operative CBCT comparison offers robust, objective metrics. The findings are particularly significant when juxtaposed with earlier technological reviews such as those by Yeung et al. [ 12 ] and Shah et al. [ 14 ], who emphasized the role of digital workflows and volumetric analysis in enhancing diagnostic and procedural precision. The three-dimensional insight provided by CBCT imaging, especially when combined with planning software, is what transforms a static pre-operative plan into an actionable surgical reality. The broader literature, including systematic reviews by Saini et al. [ 7 ] and dynamic navigation research by Struwe et al. [ 9 ], agrees that digital and guided technologies significantly outperform manual placement in complex scenarios or when high prosthetic accuracy is required. Notably, our study reflects the same benefits even in a controlled in vitro setting, removing anatomical variability and human tissue compliance from the equation. This underscores the core value of guided techniques not just in complex clinical cases but also in educational and research settings where reproducibility is paramount. Interestingly, the findings also validate the enduring relevance of freehand surgery in less complex scenarios. Research by Vermeulen [ 3 ] and Hama & Mahmood [ 11 ] supports that when performed by experienced clinicians in anatomically favorable sites, freehand techniques can still fall within clinically acceptable deviation thresholds (1–2 mm, ≤ 5°). Our results confirm that while the average deviation in the freehand group was higher, some placements still matched or closely approximated the planned angle, particularly in straightforward cases. Furthermore, the economic and procedural implications cannot be overlooked. Alexe et al and Drobyshev et al. [ 1 , 2 ] highlight the cost-effectiveness of non-guided surgeries and their continued applicability in resource-constrained settings. Our results, when contextualized with this literature, suggest a nuanced approach: while guided surgery should be the gold standard for precision-demanding scenarios, freehand placement retains value in simpler cases or where resource optimization is needed. The educational implications of this research are equally critical. As discussed by Chai et al. [ 13 ] and Yeager et al. [ 6 ], incorporating guided technologies and CBCT-based workflows into dental training programs could significantly reduce learning curves, allowing novice clinicians to achieve expert-level accuracy earlier in their careers. Our inter-rater reliability data support this, as uniform outcomes make feedback and evaluation more objective and meaningful for trainees. In summary, the Research Project affirms that guided surgery, when evaluated both quantitatively and through professional consensus, consistently outperforms freehand techniques in implant placement precision. The harmonization of our findings with international literature underscores the robustness of this methodology. As technological capabilities continue to evolve, future research must explore hybrid workflows, patient-centered outcome measures, and long-term clinical implications, with the ultimate aim of establishing precision-driven implantology as a global standard. Conclusion This study, conducted under controlled in vitro conditions, provides strong evidence favoring the precision and reliability of guided implant placement over conventional freehand techniques. Using Cone Beam Computed Tomography (CBCT) and standardized visual assessments, both quantitative and qualitative analyses demonstrated the superior accuracy, consistency, and evaluability of guided surgical approaches. The angular deviation in guided implant placement was minimal and consistently within clinically acceptable limits, while freehand placement exhibited broader variability and more significant divergence from planned implant trajectories. This was mirrored in the inter-rater reliability outcomes, where guided surgeries showed near-perfect agreement among experienced evaluators, signifying reproducibility and ease of outcome interpretation. These findings align closely with and substantiate a wide body of international research that emphasizes the clinical, educational, and technological advantages of digital guidance in implantology. While the freehand approach remains viable in straightforward cases, particularly for seasoned clinicians, the data underscores that guided surgery offers a higher standard of predictability and precision, especially when proximity to anatomical structures or aesthetic outcomes is critical. Recommendations: 1. Incorporate guided surgery protocols into standard clinical practice for complex or anatomically sensitive implant cases. 2. Integrate CBCT imaging and digital planning tools into dental education and training programs to improve early clinician competency. 3. Promote interdisciplinary collaboration in surgical planning using digital workflows to enhance clinical accuracy and outcomes. 4. Consider freehand surgery only in cases with favorable bone architecture, good accessibility, and when conducted by highly experienced clinicians. 5. Encourage ongoing research to refine hybrid digital workflows and explore patient-reported outcome measures in guided implantology. Limitations While this in vitro study provided robust data supporting the accuracy of guided implant surgery, several limitations warrant acknowledgment: Sample Size and Generalizability: The limited number of models utilized (n=12) restricts the broader generalization of findings to clinical practice. A larger sample size might provide more conclusive evidence regarding the accuracy differences observed between guided and non-guided approaches. In Vitro Conditions: The controlled laboratory environment may not fully replicate clinical complexities such as patient movement, saliva, soft tissue variability, and anatomical constraints like limited mouth opening or patient cooperation. Consequently, the findings may differ under real clinical conditions. Operator Skill and Experience: The performance of the freehand technique depends significantly on clinician experience and skill level. In this study, operator expertise was standardized, which may not represent variability in clinical settings where less experienced clinicians could exhibit larger deviations. CBCT Imaging Limitations: Although CBCT is considered a highly accurate imaging modality, inherent minor errors in imaging and 3D reconstruction could introduce slight deviations in measurements. Future studies may benefit from comparative validation using alternative imaging technologies. Fabrication Accuracy of Surgical Guides: Potential inaccuracies or variability in the fabrication process of 3D-printed surgical guides were not specifically assessed. These could influence the final placement accuracy and should be considered in future studies. Measurement Protocol: The assessment primarily focused on angular deviation. Other critical implant placement factors, such as apical and crestal deviations, depth variations, and overall prosthetic considerations, were not comprehensively evaluated. Despite these limitations, this study contributes valuable insights into the comparative accuracy of guided versus freehand implant placement methods. Future research incorporating clinical trials and larger, diverse samples is recommended to further validate these findings. Abbreviations CBCT: Cone Beam Computed Tomography FOV: Field of View MRI: Magnetic Resonance Imaging SD: Standard Deviation Declarations Ethics Approval and Consent to Participate This study was conducted as an in vitro experiment using laboratory models. It did not involve human participants or animal subjects; therefore, ethical approval and a trial registration number are not applicable. Clinical trial number: not applicable Consent for Publication Not applicable. The manuscript does not contain any individual's personal data or images requiring consent. Consent to Participate Declaration Not applicable. No human subjects were involved in this study. Availability of Data and Materials The datasets used and analyzed during the current study are included within the manuscript. Additional data and supplementary materials can be made available by contacting the corresponding authors at [email protected] or [email protected] . Competing Interests The authors declare that they have no competing interests relevant to the content of this manuscript. Funding No specific funding was received for this study from any funding agency in the public, commercial, or not-for-profit sectors. Authors' Contributions Dr. Gharam Bassam: Conceptualization, methodology design, data collection, manuscript drafting, and final review. Dr. Nader Nabil: Project supervision, conceptualization, methodology refinement, critical manuscript revision, and approval of the final manuscript. Dr. Yasser Elramady: Data interpretation, statistical analysis, manuscript editing, and final approval. Dr. Farah Albanna: Sample preparation, data acquisition, manuscript drafting support, and final manuscript approval. Dr. Ahmed Tarek: Statistical analysis, result interpretation, and manuscript revision. Dr. Alexander Luke: Literature review, methodological support, manuscript editing, and final approval. All authors have read and approved the final manuscript submitted for publication. Acknowledgements I would like to express my sincere gratitude to Dr. Nader Nabil, for his continuous support, guidance, and encouragement throughout this research. I am also deeply thankful to Dr. Yasser Elramady, Dr. Farah Albanna, and Dr. Ahmed Tarek, for their valuable insights and helpful feedback, which greatly contributed to the completion of this study. A special thanks goes to my family and my husband, whose unwavering love, patience, and support have been my greatest source of strength. This work would not have been possible without all of you. References Alexe D et al. Placement of dental implants using 3D surgical guide, Romanian Journal of Stomatology , 2024-12-31 2024. 10.37897/rjs.2024.4.7 Drobyshev A, Vaulina D, Redko N, Pankov EV. Accuracy of different types of surgical guides for dental implant placement, Russian Journal of Dentistry , 2023-08-15 2023, 10.17816/dent322870 Vermeulen J. The Accuracy of Implant Placement by Experienced Surgeons: Guided vs Freehand Approach in a Simulated Plastic Model, The International journal of oral & maxillofacial implants , vol. 32 3, p. 617, 2017-03-01 2017. 10.11607/jomi.5065 Tan P, Layton D, Wise S. In vitro comparison of guided versus freehand implant placement: use of a new combined TRIOS surface scanning, Implant Studio, CBCT, and stereolithographic virtually planned and guided technique, International journal of computerized dentistry , vol. 21 2, pp. 87–95, 2018. [Online]. Available: https://consensus.app/papers/in-vitro-comparison-of-guided-versus-freehand-implant-tan-layton/ea1ba912a41754788a845a435a949295 /. Smitkarn P, Subbalekha K, Mattheos N, Pimkhaokham A. The accuracy of single-tooth implants placed using fully digital-guided surgery and freehand implant surgery, Journal of clinical periodontology , 2019-09-01 2019. 10.1111/jcpe.13160 Yeager B, Çakmak G, Zheng F, Johnston W, Yılmaz B. Error analysis of stages involved in CBCT-guided implant placement with surgical guides when different printing technologies are used, The Journal of prosthetic dentistry , 2023-01-01 2023. 10.1016/j.prosdent.2022.11.018 Saini R et al. Impact of 3D imaging techniques and virtual patients on the accuracy of planning and surgical placement of dental implants: A systematic review, Digital Health , vol. 10, 2023-11-24 2023. 10.1177/20552076241253550 Jorba-García A, Figueiredo R, González-Barnadas A, Camps-Font O, Valmaseda-Castellón E. Accuracy and the role of experience in dynamic computer guided dental implant surgery: An in-vitro study. Med Oral, Patología Oral y Cirugía Bucal, 24, 2018-06-01 2018, 10.4317/medoral.22785 Struwe M et al. Accuracy of a Dynamic Navigation System for Dental Implantation with Two Different Workflows and Intraoral Markers Compared to Static Guided Implant Surgery: An In-Vitro Study, Clinical oral implants research , 2023-01-10 2023, 10.1111/clr.14030 Herstell H, Berndt S, Kühne C, Reich S. Accuracy of guided implant surgery obtained using 3D-printed surgical guides - An in vitro comparison of four evaluation methods, International journal of computerized dentistry , vol. 25 2, pp. 161–172, 2022-07-19 2022. [Online]. Available: https://consensus.app/papers/accuracy-of-guided-implant-surgery-obtained-using-herstell-berndt/f4cd55d5afb157098e3b2d38edcb10a3 /. Hama DR, Mahmood BJ. Comparison of accuracy between free-hand and surgical guide implant placement among experienced and non-experienced dental implant practitioners: an in vitro study. J Periodontal Implant Sci, 53, pp. 388–401, 2023-04-24 2023, 10.5051/jpis.2204700235 Yeung M, Abdulmajeed A, Carrico C, Deeb G, Bencharit S. Accuracy and precision of 3D-printed implant surgical guides with different implant systems: An in vitro study, The Journal of prosthetic dentistry , 2020-06-01 2020. 10.1016/j.prosdent.2019.05.027 Chai J et al. [Evaluation of the fabrication deviation of a kind of milling digital implant surgical guides], Beijing da xue xue bao. Yi xue ban = Journal of Peking University. Health sciences , vol. 50 5, pp. 892–898, 2018-10-18 2018. [Online]. Available: https://consensus.app/papers/evaluation-of-the-fabrication-deviation-of-a-kind-of-chai-liu/452bbf49b7fb56549487c8b2cebb5916 /. Shah N, Khanna A, Pai A, Sheth V, Raut S. An evaluation of virtually planned and 3D-printed stereolithographic surgical guides from CBCT and digital scans: An in vitro study, The Journal of prosthetic dentistry , 2021-02-11 2021. 10.1016/j.prosdent.2020.12.035 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 25 Aug, 2025 Reviewers agreed at journal 22 Aug, 2025 Reviewers invited by journal 21 Aug, 2025 Editor invited by journal 14 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Submission checks completed at journal 13 Aug, 2025 First submitted to journal 02 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7276802","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":505532671,"identity":"8e057d88-1f3d-41f4-8efd-5beb2b94b064","order_by":0,"name":"Gharam BASSAM","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACfmbGxgcfDCR4+InWItne3Gw4o8JGRrKBWC0GZ463SfOcSbMxOEC0NTcS2yRnth3mMT5+xoDhRw2DPEEXMs5IbLb4CNRidibHgLHnGIPhTEIuZJZIbLwJssXsBo8BA28DA+MGQi5kk0hskOYFOWwGjwHj3wYG+/2EtPDwHGwCeZ8HGM4GzEBbEjcQ8osEeyM4kHkkzqQVHJY5JpE8g5At9ofZH4Ki0p6//fDGh29qbGz7GwhZgwyA5kuQon4UjIJRMApGAS4AAAtpQIRmBnEcAAAAAElFTkSuQmCC","orcid":"","institution":"City University Ajman","correspondingAuthor":true,"prefix":"","firstName":"Gharam","middleName":"","lastName":"BASSAM","suffix":""},{"id":505532672,"identity":"39d52f81-b551-48fa-93b3-fcb3e90456de","order_by":1,"name":"Nader Rezallah","email":"","orcid":"","institution":"City University Ajman","correspondingAuthor":false,"prefix":"","firstName":"Nader","middleName":"","lastName":"Rezallah","suffix":""},{"id":505532673,"identity":"b8190a41-6133-4dc0-8ea2-f210e85ee2d2","order_by":2,"name":"Yasser El 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University","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Luke","suffix":""}],"badges":[],"createdAt":"2025-08-02 08:38:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7276802/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7276802/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90313559,"identity":"0d68f919-04a1-49c1-8c41-f0ec31032e86","added_by":"auto","created_at":"2025-09-01 10:08:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":199870,"visible":true,"origin":"","legend":"\u003cp\u003eModels with inner cancellous material\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/5fa8bc353c9b50e83179e8e5.png"},{"id":90313556,"identity":"c3aea1f4-b206-4a82-887e-f25d507b77b9","added_by":"auto","created_at":"2025-09-01 10:08:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":177668,"visible":true,"origin":"","legend":"\u003cp\u003eModels with surface is similar to cortical bone\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/73fa446eb6d852a2c4c76c6a.png"},{"id":90315781,"identity":"a0dab9da-00df-4fed-bf7d-1b35b98993b0","added_by":"auto","created_at":"2025-09-01 10:16:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":715078,"visible":true,"origin":"","legend":"\u003cp\u003eSample pictures of Standardized Gutta percha landmarks\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/bc46e67bd86d63380bc57bf1.png"},{"id":90313562,"identity":"ef8a654f-2dd2-4876-9db5-e3ea2064c84a","added_by":"auto","created_at":"2025-09-01 10:08:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":124577,"visible":true,"origin":"","legend":"\u003cp\u003e4CBCT Planning Preimplantation Insertion of group A\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/aa6fac2f9d63771c4c45f550.png"},{"id":90315782,"identity":"f5b441e6-5a9e-4427-a9fc-649949ba94dd","added_by":"auto","created_at":"2025-09-01 10:16:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":440031,"visible":true,"origin":"","legend":"\u003cp\u003esample of treatment Planning,manufacturer,Type,Size of implant for group A\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/3cd06986c1714c7017919dee.png"},{"id":90313563,"identity":"fff2c7a6-d085-40bf-9652-17092d6c6471","added_by":"auto","created_at":"2025-09-01 10:08:01","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":195889,"visible":true,"origin":"","legend":"\u003cp\u003esurgical kit DS Prime Taper from Dentsply Sirona\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/1c53b2af5f5f05a528c6d3c0.png"},{"id":90313567,"identity":"c5147156-6179-4938-b04e-9b7a641a2bb2","added_by":"auto","created_at":"2025-09-01 10:08:01","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":305327,"visible":true,"origin":"","legend":"\u003cp\u003esurgical kit DS Prime Taper from Dentsply Sirona\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/65fc84d477c55021f0a838dc.png"},{"id":90313571,"identity":"340e2a86-b33a-4163-9a23-e630d7ab8dd0","added_by":"auto","created_at":"2025-09-01 10:08:01","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":531752,"visible":true,"origin":"","legend":"\u003cp\u003eBefore and After implant placement using surgical guides\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/6d318124fbfbdf4447091a02.png"},{"id":90313566,"identity":"7a64d9cb-3aa5-4358-afab-5a6a51b4e22d","added_by":"auto","created_at":"2025-09-01 10:08:01","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":485658,"visible":true,"origin":"","legend":"\u003cp\u003eBefore, During and After implant placement using Free-Handed technique\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/839af9a7840dfa5f4e64dbd2.png"},{"id":90313577,"identity":"848479ea-368d-4b84-972c-ee3024d84f9c","added_by":"auto","created_at":"2025-09-01 10:08:01","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":29074,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Angular deviation\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/8277dac6867c80982fca0965.png"},{"id":90318268,"identity":"b84ed8b7-ae13-48ba-b6b0-14372832a079","added_by":"auto","created_at":"2025-09-01 10:32:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4348223,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7276802/v1/e1fd5ce5-5b0a-4aa7-916b-75d07d5486e6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Guided vs. Non-Guided Implant Surgery: A CBCT In Vitro Comparison","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the field of dental implantology, where a few millimeters can mean success or failure, accuracy is not only a clinical goal but the very basis on which patient success is built. Placing a dental implant requires a careful process that combines an understanding of anatomy, surgical skill, and technology. Although dental implants have become the gold standard for tooth replacement, providing unparalleled restoration of function and esthetics, the dental community has emphasized establishing criteria for improved accuracy in placing each implant. The ramifications of implant placement errors reach well beyond technical aspects alone. Unfavorable placement may lead to a considerable range of complications, including nerve injury, sinus perforation, and/or damage to osseointegration, potentially resulting in failure of the implant. The requirements for costly and invasive remedial therapy aside, these complications influence the patient's comfort, function and quality of life. Consequently, the field has experienced a significant paradigm shift toward technology-enhanced placement techniques to reduce both human error and increase predictability.\u003c/p\u003e\u003cp\u003eThe distinction between guided and non-guided surgical techniques is at the forefront of this evolution. Conventional surgery techniques are classified as non-guided surgical techniques and depend mainly on clinician knowledge and judgement during surgery, utilizing conventional radiographs and manual measurements to establish MRI implant position. In contrast, guided procedures incorporate advanced digital planning software, 3D imaging, and custom-created surgical guides to implement accurate pre-operative planning into the operative field. This notable and recent improvement is asserted to allow improved control of implant angulation, depth, and positioning to critical anatomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe use of Cone Beam Computed Tomography (CBCT) has changed the face of both preoperative assessment and postoperative assessment in implantology. CBCT imaging is different from traditional radiography in that it provides three-dimensional (volumetric data) of the maxillofacial anatomy with minimal distortion, allowing the clinician to view anatomical landmarks with the most clarity and precision ever. The introduction of CBCT imaging and guided surgery technologies has also opened the door to exciting possibilities for treatment planning and treatment outcome assessments; however, questions remain about whether the use of these technologies in any manner is measurable compared to traditional methods, particularly in a controlled environment. Although there is an increasing amount of research comparing guided and non-guided implant placement techniques, the literature shows contradictory findings, methodological differences, and other challenges that impede synthesis or clinical application. Many studies document the measurements of deviation and placement accuracy, but very few studies systematically explored these outcomes in standardized in vitro models, eliminating the confounding variables present in clinical conditions. This knowledge gap highlights the need for a systematic assessment of the comparative effectiveness of these techniques using a controlled situation in which precision metrics can be objectively measured and evaluated [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResearching key differences between guidance and non-guidance is best studied inside an in vitro model. This setting allows patient factors such as mouth opening and tissue compliance to be removed as confounders to isolate the technical aspect of implant placement and generate new knowledge that can inform clinical practice. In addition, standardized models make it much easier to measure essential variables such as entry point deviation, apical deviation, angular deviation, and depth variation metrics, each of which contributes to measuring placement accuracy and identifying potential complications.\u003c/p\u003e\u003cp\u003eThe purpose of this study is to compare guided vs non-guided implant surgery, with a specific focus of precision outcomes measured specifically by CBCT in controlled in vitro studies, this study will clarify how guided surgery improves placement accuracy, provide an understanding of technical components that impact placement outcomes, and develop quantitative measures to evaluate placement accuracy. The implications of the findings are relevant for developing clinical protocols, surgeon education and training, and the development of optimized technologies for patient care in the surgical environment.\u003c/p\u003e"},{"header":"Literature Review","content":"\u003cp\u003eNon-guided implant surgery, also known as \"freehand\" implantology, is a conventional technique for placing implants and is seen as the basis of development for dental implantology since its opening. However, this method relies on a broad comprehension of oral anatomy, spatial reasoning ability, and practical manual dexterity that have developed as a result of surgical experience over time. In vitro studies looking at non-guided approaches typically immeasurably in-vitro mimic clinical workflows in which those investigating the approach, use customary means of diagnosable including traditional two-dimensional radiographs, study models, or other habitual means of diagnostic tools as methods for planning to find implant placement. Before the actual surgery, in the prep stage, the dentists examine the bone dimension they have available, assess and establish an anatomy for implant placement, and develop the ultimate success the clinician wants, to be completed all while the clinician decides without the assistance of a surgical template or operating real-time operating and navigational technology. During the surgery, the operator determines drilling trajectory, depth, and angulation all on their own. This is a process that limits dependency of procedural sequencing. In freehand, a clinician has autonomy to reassess how the drilling axis need to be made in real-time through a building aesthetic with each incremental depth, in other words it invokes a fluidity amid basic implant prep for the entire length of the surgery in real-time anticipation of each landmark for mouth surgery or in this case all oral surgical context. In freehand implant surgeries, a surgeon maintains acute control over each surgical step for success: insertion site preparation to pilot drilling to final seating. Each decision the operator is making is solely based on a reading of the contextual anatomy not determined through surgical guides or some pre-selected digital and/or procedural working plan [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For instance, in a rigorous in vitro study by Tan et al., guided implant placement demonstrated significantly superior accuracy compared to freehand techniques when using merged 3D surface and CBCT data. Their findings revealed that guided surgery achieved 56% less angular deviation (3.91\u0026deg; vs 8.82\u0026deg;) and 41% less apical displacement (0.87mm vs 1.48mm) than freehand placement, though shoulder displacement and depth measurements showed no significant differences between approaches [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe existing literature about non-guided surgery in vitro has reported on several unique advantages that sustain its use and relevance amidst advancements in technology. The most notable advantage is the flexibility it affords clinicians, allowing them to respond to unforeseen anatomy in real-time, or challenges that were unknown during the pre-operative planning process, which is commonly documented in comparative controlled laboratory studies. Cost analyses show that non-guided techniques are usually less expensive, having little to no investment in specialized software, fabrication of guides, or imaging with more advanced technology beyond conventional radiographs, and they are an advantage in underfunded/exceedingly funded scenarios. Time efficient studies in vitro show that for uncomplicated cases with sufficient bone volume, experienced clinicians can perform freehand approaches within the same or shorter overall surgical times, and this difference arguably improves even more when the preparation times for guides are taken into consideration. Also, the precision measurement studies employing standardized models show that experiences and skilled operators can achieve clinically acceptable parameters of deviation within acceptable safety ranges, which is typically 1-2mm linear deviation and under 5\u0026deg; of angular deviation; devices that tend to utilize guided spacing (or for posterior implants where tolerant range is greater). These findings suggest that non-guided surgery remains a viable and effective approach when performed by practitioners with sufficient surgical proficiency, particularly in uncomplicated cases where the risk-benefit analysis may not justify the additional resources required for guided techniques [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In their randomized controlled clinical trial, Smitkarn et al. demonstrated that static computer-assisted implant surgery (CAIS) significantly outperformed freehand techniques in achieving accurate implant positioning in single edentulous spaces. Their findings showed that guided surgery produced considerably less deviation from planned positions, with a median angular deviation of only 2.8\u0026deg; compared to 7.0\u0026deg; in the freehand group. Similarly, implant shoulder deviation (0.9mm vs 1.3mm) and apical deviation (1.2mm vs 2.2mm) were substantially reduced with guided surgery, with statistically significant differences observed in six of nine measured parameters [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This shows the edge guided surgeries have on unguided surgeries.\u003c/p\u003e\u003cp\u003eThe development of guided surgery for implants was a thoughtful response to the limitations and variability of traditional freehand methods. As dental implantology made the transition from an extraordinary procedure to a routine treatment option, the oral science community was increasingly aware of the need for greater precision and predictability, particularly in more challenging clinical settings. Early in vitro studies in the late 1990s and early 2000s, demonstrated troubling variability in clinical outcomes for implant placements at various experience levels, with acceptable deviation from ideal placement encompassing a significant percentage of clinical experiences, particularly for older or inexperienced operators. While this variability is often manageable with straightforward cases, it is tremendously undesirable in cases where proximity to vital structures is an issue or precision in prosthetic placement is of utmost importance. At the same time, patients were demanding greater predictability in treatment outcomes and complications when making choices in surgical interventions (though, beyond the oral science procedural standards). Clearly, the literature demonstrates an appropriate sequence of development, where researchers systematically recognized precision deficiencies in minimally guided procedures, then progressed to viewing and exploring technological applications for improvement/development - procedures and technologies intended to facilitate efficiencies as well. The significant evolution of Cone Beam Computed Tomography technology changed the game by providing three-dimensional images of anatomy with amazing detail and little distortion. This imaging modality and the deployment of sophisticated implant planning software platforms provided the infrastructure for guided surgery protocols. Followed by advancements in guide fabrication with stereolithographic and the relatively newer availability of 3D printing technology to fabricate guides, this facilitated the ability to take digital plans and create a reality to bring into the clinic closing the gap between planning in cyberspace and clinical space [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Tan et al. (2018) conducted an in vitro study comparing guided versus freehand implant placement accuracy using a novel combined workflow incorporating TRIOS surface scanning, Implant Studio software, CBCT imaging, and stereolithographic planning. Their findings demonstrated significantly superior precision with guided surgery, particularly in terms of angular deviation (3.91\u0026deg; vs 8.82\u0026deg;) and apical displacement (0.87mm vs 1.48mm), though shoulder and depth measurements showed no significant differences between techniques. This high-quality research, published in the Q1-ranked International Journal of Computerized Dentistry, provides compelling evidence supporting the integration of digital workflows for enhanced implant placement precision [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn vitro studies studying the methodology of guided surgery have proven to consistently standardize results among various experience levels of practitioners, an important finding for educational programs and quality assurance processes. Laboratory experiments using standardized models demonstrated that guided surgery can reduce mean angular deviations by 50\u0026ndash;700% when compared to unrestricted freehand approaches, with the most pronounced effects shown among less experienced operators. The digital aspect of the planning process allows for collaborative decision making in regards to implant position and an objective, retrospective assessment of the implant position in relation to the anatomical realities as well as the anticipated prosthetic realities, prior to any surgical intervention. This represents a paradigm shift from traditional surgical planning where optimal positioning was defined during the intervention, and through the surgeon's interpretation of anatomical landmark features. It is also documented in the published literature that the methodology of guided surgery has evolved from simply predetermined transfer of an implant position, to larger digital workflows that incorporate prosthetic design, bone density, and biomechanical information. Incorporating these elements has yielded a more organized way to derive implant planning treatment regimens that ensure the least reliance on subjective clinical decision making. Laboratory studies comparing early generation guides to modern systems demonstrate a significant milestone in technological advancement, where accuracy has been achieved in custom guides, and when appropriately executed, can be within a submillimeter condition. This is now recognized as a standard in the growth of dental implantology, demonstrating the profession's ongoing improvement and validation over traditional techniques where a guide was not used at all. Overall, it reflects that guided systems can improve the level of care that governs everyday practice in different clinical scenarios when appropriately and accurately executed [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResearch from the comparative literature on case preferences for guided vs non-guided will provide some more complicated decision matrix with many variables including case complexity, anatomy, and experience of the provider. In vitro literature always suggests the success of non-guided solutions in more basic clinical situations with good bone volume and anatomy and sufficient distance away from critical structures (vital anatomy). In these circumstances, experienced clinician can place an implant within accepted clinical parameters without the additional time and cost of a guided solution. Non-guided solutions remain important specifically in posterior regions where there is good bone volume and little aesthetic component when appeared with a single tooth restoration, where minor errors in implant position would not threaten functional or biological parameters. On the other hand, there is ample evidence demonstrating a case preference for guided surgery in cases that are anatomically complicated, limited bone availability and close proximity to important structures (e.g., inferior alveolar nerve or maxillary sinus). Within these higher risk settings, in vitro articles have shown significantly lower deviation measures and complication rates utilizing a guided method versus freehand, regardless of the operator's experience. The benefits of precision with guided surgery can be markedly greater when it comes to inter-implant positioning, including but not limited to full-arch rehabilitations, or when the implants need to be positioned in specific angulations so angled abutments can be utilized or to avoid anatomical structures. Controlled laboratory studies, when studying implant placement in the aesthetic zone, which also employs prosthetic driven backward planning, show advantages with the emergence profile, and greater predictability with prosthetic development when a guided method is employed. The findings essentially led to evidence to assist in establishing decision-making and criteria to aid in developing selection criteria to aid in determining the approach which would get optimal benefit-to-cost ratio for a given case type. The implications of the studies are helpful in moving away from the binary conversation of guided vs non-guided, and with the development of evidence based decision making, to a decision based on evidence which is case specific, experience, operator preference, and etc. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Cone Beam Computed Tomography (CBCT) is the technological foundation for modern guided implant surgery workflows, changing the accuracy paradigm through its densified application across the procedural framework. Firstly, in the pre-operative planning phase, CBCT produces volumetric datasets which allow clinicians to visualize anatomical structures in three dimensions with submillimeter precision. Whereas bone quality, quantity, and proximity to important anatomical landmarks are traditionally assessed in two dimensions, volumetric datasets create the opportunity for thorough 3D assessment pre-operatively. The volumetric data is then imported into surgical planning software, where a virtual implant can be placed taking into consideration adequate prosthetic space as well as anatomical distance, setting the digital planning phase for surgical guidance fabrication [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the surgical fabrication phase, models created from CBCT will ensure patient-specific anatomical contours for surgical guides all whilst maintaining specific accuracy to the planned position of the implant. Most importantly, unique to CBCT, is the utilized an in vitro studies for the postoperative evaluation of guided implant surgery where a pre- and post- placement scan can be superimposed to measure deviation to planned implant position on multiple parameters, including entry point deviation, apical deviation, angular deviation, and depth deviation. This capacity for precise measurement has established CBCT as the gold standard assessment tool in comparative research, enabling objective evaluation of different guided surgery protocols and iterative refinement based on quantifiable outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHenceforth, the inclusion of CBCT in educational systems has transformed the training process for implants via interactive simulation formats, allowing early-stage practitioners to refine their skills in complex cases without putting the patient in danger. Studies in a controlled lab setting show that CBCT training significantly differs in time to competency, as novices could obtain deviation measurements quite like testers who are already adept at implant placement when they practiced with a fully-guided implant-training protocol. In addition to anatomical visualization, advanced applications are emerging, including biomechanical analysis in the planning phase based on bone density values from CBCT to guide decision-making related to implant design, drilling protocols, and achieved primary stability in cases of compromised bone quality or quantity. In addition, the use of CBCT standardized in measurement protocols enhances the reproducibility of research studies across institutions, and advances the comparison of guided surgery methodologies over time for meta-analysis. These advances illustrate the means by which CBCT surpasses its initial innovative purpose as a diagnostic tool to become an integral component of the digital ecosystem of implantology serving typically as the component elements needed for planning, a standard for fabrication and construction, and as a barometer for outcome measurement.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis in vitro experimental study aims to evaluate the accuracy of angulation of dental implant placement using guided and non-guided surgical techniques. The precision of implant positioning was assessed using cone beam computed tomography (CBCT) imaging.\u003c/p\u003e\u003cp\u003eA 6 models rigid foam shell with inner cancellous material. The surface is similar to cortical bone; the interior is similar to cancellous bone these models representing edentulous upper jaws were used. Each model prepared to receive a 6 dental implant.\u003c/p\u003e\u003cp\u003eThe models were divided in to two equal groups:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGroup A (Guided Surgery)\u003c/b\u003e: Implants were placed using custom-made surgical guides fabricated from digital planning based on preoperative CBCT scans.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGroup B (Non-Guided Surgery)\u003c/b\u003e: Implants were placed freehand, relying solely on anatomical landmarks and clinical experience, without the use of any guiding templates.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAll implants were placed in the designated site using the same implant system, following the manufacturer\u0026rsquo;s protocol for drilling and insertion.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eMaterials and Equipment\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eModels\u003c/b\u003e: Rigid Foam Shell with Inner Cancellous Material\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCone Beam CT Scanner\u003c/b\u003e: New tom Go 3D made in Italy\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCBCT settings:\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFOV: 10x10\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMode: Regular\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eKv: 90\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eS: 9.60\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGutta Percha Points\u003c/b\u003e: Meta Biomed Gutta Percha\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHand piece\u003c/b\u003e: W\u0026amp;H 20:1 Surgical Hand piece\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eImplant System\u003c/b\u003e: DS Prime Taper \u0026ndash; DENTSPLY SIRONA KIT\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSurgical Guide\u003c/b\u003e: Mucosa Soft Tissue Supported Flapless Surgery (made in which lab)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eSample preparation\u003c/p\u003e\u003cp\u003eThe standardized model simulating of an edentulous maxilla was prepared to receive the six implants. Marks was drown using pencil,1cm between each point then a round bur low speed hand piece used to make drill with depth 4 mm, then the Gutta Percha was heated with torch and condensed in each preparation site using condenser.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFollowing site preparation, cone-beam computed tomography (CBCT) scans were obtained for the treatment planning process for implant placement. The samples were then divided into two groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eGroup A models\u003c/b\u003e were sent to a dental laboratory (YMed Laboratory) for the fabrication of custom surgical guides.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGroup A implant placement technique The maxillary models for this group were prepared using prime taper Drills EV-GS Medium (4.2). First drill (1.9), second drill (2.95), third drill (3.55) were used consequently to prepare the implant site through the surgical guide ensuring parallelism. The implant driver EV-GS was placed in handle with torque wrench EV to carry the implant which was placed 1mm under alveolar crest in all models in the same group.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGroup B\u003c/b\u003e where implants were placed freehand, without the use of surgical guides, utilizing the Dentsply Sirona implant kit. Placement in this group was based solely on anatomical landmarks and the operator\u0026rsquo;s clinical judgment and experience.\u003c/p\u003e\u003cp\u003eGroup B implant placement technique: The maxillary models for this group were prepared the same method as group A using prime taper Drills EV-GS Medium (4.2). First drill (1.9), second drill (2.95), third drill (3.55) were used consequently to prepare the implant site, the operator referred to the planned CBCT and depended on his freehand skills to ensure parallelism. The implant driver EV-GS was placed in handle with torque wrench EV to carry the implant which was placed 1mm under alveolar crest in all models in the same group.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAccuracy Evaluation\u003c/p\u003e\u003cp\u003eAfter implant placement, postoperative CBCT scans were obtained for all models. These were compared with the preoperative planned positions. Analysis of the scans were performed to assess Angular deviation (in degrees), All measurements were performed in three dimensions to determine the spatial accuracy of implant placement.\u003c/p\u003e\u003cp\u003eA copy of the scans was sent to 5 different evaluators to compare the visual resemblance of implant planning on CBCT.\u003c/p\u003e\u003cp\u003e3 resemblance levels were defined to the raters as following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eHigh: Implant position is nearly identical to the planned CBCT image in angulation, depth, and mesio-distal location.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eModerate: Minor deviation from the planned position, but still within acceptable functional and aesthetic limits.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLow: Clear mismatch between planned and placed implant position, which could affect clinical or esthetic outcomes.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eResult 1: CBCT-Based Angular Deviation Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis analysis evaluates how accurately implants were placed relative to the pre-planned CBCT angulation using the NNT software.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTwo techniques were compared:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e- Guided Surgery Group (n = 9): Implants inserted using a 3D-printed surgical guide.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Freehand Surgery Group (n = 9): Implants placed manually based on operator skill.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cstrong\u003eMetric\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cstrong\u003eGuided Surgery\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cstrong\u003eFreehand Surgery\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eMean Deviation (\u0026deg;)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e-0.41\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e-4.83\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eStandard Deviation\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e1.19\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e3.24\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eMinimum Deviation (\u0026deg;)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e-3.30\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e-11.10\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eMaximum Deviation (\u0026deg;)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e1.80\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e0.00\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eInterpretation:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn average, guided surgery was more accurate and less variable, with mean angular deviations close to zero. Freehand placement exhibited a greater range and more pronounced negative deviation, reflecting larger differences from the planned trajectory.\u003c/p\u003e\n\u003cp\u003eThe chart below clearly shows that the guided group maintained a tighter cluster around the target angulation, while the freehand group had a greater spread and more outliers.\u003c/p\u003e\n\u003cp id=\"_Toc204810426\"\u003e\u003cstrong\u003eDiscussion of Result 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data strongly supports the claim that guided implant placement ensures better accuracy compared to freehand surgery. The guided group\u0026apos;s mean deviation of -0.41\u0026deg; falls well within clinically acceptable limits (usually \u0026plusmn;3\u0026deg;), whereas the freehand group shows a much larger mean deviation of -4.83\u0026deg; with high variability.\u003cbr\u003e\u0026nbsp;\u003cbr\u003eThis suggests that surgical guides provide structural control and reduce human variability, particularly beneficial in aesthetic zones or proximity to vital structures. Conversely, freehand techniques may still be viable but carry a higher risk of placement errors, particularly among less experienced clinicians or in anatomically complex cases.\u003c/p\u003e\n\u003cp id=\"_Toc204810427\"\u003eResult 2: Inter-Rater Reliability in Visual Assessment of Implant Placement\u003c/p\u003e\n\u003cp\u003eTo assess the subjective agreement among professionals evaluating the implant positioning accuracy, five experienced examiners visually compared CBCT post-op scans to the original implant plan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEach implant was scored based on visual resemblance to the plan using a 3-point scale:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e- 1 = Poor resemblance\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- 2 = Moderate resemblance\u003c/p\u003e\n\u003cp\u003e- 3 = Excellent resemblance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRatings were collected for both:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Guided Surgery Implants\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Freehand Surgery Implants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\u003cstrong\u003eFleiss\u0026rsquo; Kappa (\u0026kappa;)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003eGuided Surgery\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e0.943\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003eAlmost Perfect Agreement\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003eFreehand Surgery\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e0.868\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003eStrong Agreement\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp id=\"_Toc204810428\"\u003e\u003cstrong\u003eDiscussion of Result 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis high inter-rater agreement, especially for guided surgery (\u0026kappa; = 0.943), reflects not only the objective accuracy of guided placement but also the perceptual clarity it affords to clinicians evaluating outcomes. Freehand implant placement, while still showing substantial agreement (\u0026kappa; = 0.868), had slightly more subjective interpretation differences, likely due to greater placement variation and difficulty in aligning outcomes with original plans.\u003cbr\u003e\u0026nbsp;\u003cbr\u003eThese findings suggest that guided surgery standardizes implant results in a way that enhances clinical agreement, which is crucial in education, quality assurance, and post-surgical evaluations.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe outcomes of this in vitro study strongly reinforce the growing body of evidence advocating for guided implant surgery as a superior alternative to the traditional freehand technique, particularly in terms of accuracy and standardization of implant placement. The two primary assessments conducted angular deviation analysis via CBCT and visual inter-rater evaluations consistently favored the guided method across multiple domains. The angular deviation findings revealed a stark contrast: guided surgery showed a mean deviation of -0.41\u0026deg; (SD\u0026thinsp;=\u0026thinsp;1.19\u0026deg;) while freehand placement averaged \u0026minus;\u0026thinsp;4.83\u0026deg; (SD\u0026thinsp;=\u0026thinsp;3.24\u0026deg;). These results are well aligned with prior studies such as Tan et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and Smitkarn et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], who demonstrated that guided systems reduce angular and apical deviation significantly. Tan et al. reported angular deviations of 3.91\u0026deg; for guided vs 8.82\u0026deg; for freehand techniques, closely mirroring our comparative values and confirming the utility of guided systems in reducing variability and surgical risk. Moreover, the high inter-rater reliability achieved through guided procedures (κ\u0026thinsp;=\u0026thinsp;0.943) further validates the claim that guided techniques not only produce more precise outcomes but also enhance consensus among expert evaluators. This high level of agreement is consistent with studies by Jorba-Garc\u0026iacute;a et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Herstell et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which have shown that surgical guidance results in reproducible outcomes, even across different levels of surgical experience. By contrast, while freehand implants also achieved commendable inter-rater agreement (κ\u0026thinsp;=\u0026thinsp;0.868), the variation in placement made visual assessment inherently more subjective and prone to interpretive discrepancies. From a methodological standpoint, the application of NNT software for pre- and post-operative CBCT comparison offers robust, objective metrics. The findings are particularly significant when juxtaposed with earlier technological reviews such as those by Yeung et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and Shah et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], who emphasized the role of digital workflows and volumetric analysis in enhancing diagnostic and procedural precision. The three-dimensional insight provided by CBCT imaging, especially when combined with planning software, is what transforms a static pre-operative plan into an actionable surgical reality. The broader literature, including systematic reviews by Saini et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and dynamic navigation research by Struwe et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], agrees that digital and guided technologies significantly outperform manual placement in complex scenarios or when high prosthetic accuracy is required. Notably, our study reflects the same benefits even in a controlled in vitro setting, removing anatomical variability and human tissue compliance from the equation. This underscores the core value of guided techniques not just in complex clinical cases but also in educational and research settings where reproducibility is paramount. Interestingly, the findings also validate the enduring relevance of freehand surgery in less complex scenarios. Research by Vermeulen [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Hama \u0026amp; Mahmood [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] supports that when performed by experienced clinicians in anatomically favorable sites, freehand techniques can still fall within clinically acceptable deviation thresholds (1\u0026ndash;2 mm, \u0026le;\u0026thinsp;5\u0026deg;). Our results confirm that while the average deviation in the freehand group was higher, some placements still matched or closely approximated the planned angle, particularly in straightforward cases. Furthermore, the economic and procedural implications cannot be overlooked. Alexe et al and Drobyshev et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] highlight the cost-effectiveness of non-guided surgeries and their continued applicability in resource-constrained settings. Our results, when contextualized with this literature, suggest a nuanced approach: while guided surgery should be the gold standard for precision-demanding scenarios, freehand placement retains value in simpler cases or where resource optimization is needed. The educational implications of this research are equally critical. As discussed by Chai et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Yeager et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], incorporating guided technologies and CBCT-based workflows into dental training programs could significantly reduce learning curves, allowing novice clinicians to achieve expert-level accuracy earlier in their careers. Our inter-rater reliability data support this, as uniform outcomes make feedback and evaluation more objective and meaningful for trainees. In summary, the Research Project affirms that guided surgery, when evaluated both quantitatively and through professional consensus, consistently outperforms freehand techniques in implant placement precision. The harmonization of our findings with international literature underscores the robustness of this methodology. As technological capabilities continue to evolve, future research must explore hybrid workflows, patient-centered outcome measures, and long-term clinical implications, with the ultimate aim of establishing precision-driven implantology as a global standard.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study, conducted under controlled in vitro conditions, provides strong evidence favoring the precision and reliability of guided implant placement over conventional freehand techniques. Using Cone Beam Computed Tomography (CBCT) and standardized visual assessments, both quantitative and qualitative analyses demonstrated the superior accuracy, consistency, and evaluability of guided surgical approaches.\u003c/p\u003e\n\u003cp\u003eThe angular deviation in guided implant placement was minimal and consistently within clinically acceptable limits, while freehand placement exhibited broader variability and more significant divergence from planned implant trajectories. This was mirrored in the inter-rater reliability outcomes, where guided surgeries showed near-perfect agreement among experienced evaluators, signifying reproducibility and ease of outcome interpretation. These findings align closely with and substantiate a wide body of international research that emphasizes the clinical, educational, and technological advantages of digital guidance in implantology.\u003c/p\u003e\n\u003cp\u003eWhile the freehand approach remains viable in straightforward cases, particularly for seasoned clinicians, the data underscores that guided surgery offers a higher standard of predictability and precision, especially when proximity to anatomical structures or aesthetic outcomes is critical.\u003c/p\u003e\n\u003cp id=\"_Toc204810431\"\u003eRecommendations:\u003c/p\u003e\n\u003cp\u003e1. Incorporate guided surgery protocols into standard clinical practice for complex or anatomically sensitive implant cases.\u003c/p\u003e\n\u003cp\u003e2. Integrate CBCT imaging and digital planning tools into dental education and training programs to improve early clinician competency.\u003c/p\u003e\n\u003cp\u003e3. Promote interdisciplinary collaboration in surgical planning using digital workflows to enhance clinical accuracy and outcomes.\u003c/p\u003e\n\u003cp\u003e4. Consider freehand surgery only in cases with favorable bone architecture, good accessibility, and when conducted by highly experienced clinicians.\u003c/p\u003e\n\u003cp\u003e5. Encourage ongoing research to refine hybrid digital workflows and explore patient-reported outcome measures in guided implantology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this in vitro study provided robust data supporting the accuracy of guided implant surgery, several limitations warrant acknowledgment:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSample Size and Generalizability: The limited number of models utilized (n=12) restricts the broader generalization of findings to clinical practice. A larger sample size might provide more conclusive evidence regarding the accuracy differences observed between guided and non-guided approaches.\u003c/li\u003e\n \u003cli\u003eIn Vitro Conditions: The controlled laboratory environment may not fully replicate clinical complexities such as patient movement, saliva, soft tissue variability, and anatomical constraints like limited mouth opening or patient cooperation. Consequently, the findings may differ under real clinical conditions.\u003c/li\u003e\n \u003cli\u003eOperator Skill and Experience: The performance of the freehand technique depends significantly on clinician experience and skill level. In this study, operator expertise was standardized, which may not represent variability in clinical settings where less experienced clinicians could exhibit larger deviations.\u003c/li\u003e\n \u003cli\u003eCBCT Imaging Limitations: Although CBCT is considered a highly accurate imaging modality, inherent minor errors in imaging and 3D reconstruction could introduce slight deviations in measurements. Future studies may benefit from comparative validation using alternative imaging technologies.\u003c/li\u003e\n \u003cli\u003eFabrication Accuracy of Surgical Guides: Potential inaccuracies or variability in the fabrication process of 3D-printed surgical guides were not specifically assessed. These could influence the final placement accuracy and should be considered in future studies.\u003c/li\u003e\n \u003cli\u003eMeasurement Protocol: The assessment primarily focused on angular deviation. Other critical implant placement factors, such as apical and crestal deviations, depth variations, and overall prosthetic considerations, were not comprehensively evaluated.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDespite these limitations, this study contributes valuable insights into the comparative accuracy of guided versus freehand implant placement methods. Future research incorporating clinical trials and larger, diverse samples is recommended to further validate these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBCT: Cone Beam Computed Tomography\u003c/p\u003e\n\u003cp\u003eFOV: Field of View\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted as an in vitro experiment using laboratory models. It did not involve human participants or animal subjects; therefore, ethical approval and a trial registration number are not applicable.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003eConsent for Publication\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual\u0026apos;s personal data or images requiring consent.\u003c/p\u003e\n\u003cp\u003eConsent to Participate Declaration\u003c/p\u003e\n\u003cp\u003eNot applicable. No human subjects were involved in this study.\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are included within the manuscript. Additional data and supplementary materials can be made available by contacting the corresponding authors at [email protected] or [email protected].\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests relevant to the content of this manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo specific funding was received for this study from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Contributions\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDr. Gharam Bassam: Conceptualization, methodology design, data collection, manuscript drafting, and final review.\u003c/li\u003e\n \u003cli\u003eDr. Nader Nabil: Project supervision, conceptualization, methodology refinement, critical manuscript revision, and approval of the final manuscript.\u003c/li\u003e\n \u003cli\u003eDr. Yasser Elramady: Data interpretation, statistical analysis, manuscript editing, and final approval.\u003c/li\u003e\n \u003cli\u003eDr. Farah Albanna: Sample preparation, data acquisition, manuscript drafting support, and final manuscript approval.\u003c/li\u003e\n \u003cli\u003eDr. Ahmed Tarek: Statistical analysis, result interpretation, and manuscript revision.\u003c/li\u003e\n \u003cli\u003eDr. Alexander Luke: Literature review, methodological support, manuscript editing, and final approval.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript submitted for publication.\u003c/p\u003e\n\u003cp id=\"_Toc204810414\"\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eI would like to express my sincere gratitude to Dr. Nader Nabil, for his continuous support, guidance, and encouragement throughout this research.\u003c/p\u003e\n\u003cp\u003eI am also deeply thankful to Dr. Yasser Elramady, Dr. Farah Albanna, and Dr. Ahmed Tarek, for their valuable insights and helpful feedback, which greatly contributed to the completion of this study.\u003c/p\u003e\n\u003cp\u003eA special thanks goes to my family and my husband, whose unwavering love, patience, and support have been my greatest source of strength.\u003c/p\u003e\n\u003cp\u003eThis work would not have been possible without all of you.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlexe D et al. 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An evaluation of virtually planned and 3D-printed stereolithographic surgical guides from CBCT and digital scans: An in vitro study, \u003cem\u003eThe Journal of prosthetic dentistry\u003c/em\u003e, 2021-02-11 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.prosdent.2020.12.035\u003c/span\u003e\u003cspan address=\"10.1016/j.prosdent.2020.12.035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dental implants, Guided surgery, Freehand technique, Implant accuracy, CBCT, In vitro study","lastPublishedDoi":"10.21203/rs.3.rs-7276802/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7276802/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThe aim of the study is to compare the accuracy of dental implant placement using guided surgery versus freehand (non-guided) techniques in a laboratory (in vitro) setting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eTwelve upper jaw models simulating edentulous maxillae were used and divided into two groups. In Group A, implants were placed using 3D-printed surgical guides based on CBCT planning. Group B received implants placed freehand, using only clinical judgment. The same implant system and drilling steps were followed for both groups. After placement, CBCT scans were taken to measure angular deviation, and five clinicians visually assessed how closely the implants matched the planned positions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eImplants placed with guided surgery showed higher accuracy, with a mean angular deviation of -0.41\u0026deg;, compared to -4.83\u0026deg; in the freehand group. The guided group also had less variation. Visual evaluations by five clinicians showed stronger agreement for the guided group (κ\u0026thinsp;=\u0026thinsp;0.943) than for the freehand group (κ\u0026thinsp;=\u0026thinsp;0.868).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eGuided implant surgery proved more accurate and consistent than the freehand method, making it especially useful in complex or sensitive cases. While freehand placement may work in simpler situations, it carries more risk of error. These results support using guided techniques as a standard approach in implant practice.\u003c/p\u003e","manuscriptTitle":"Guided vs. Non-Guided Implant Surgery: A CBCT In Vitro Comparison","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 10:07:55","doi":"10.21203/rs.3.rs-7276802/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-26T02:31:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63617909550971832009367376522628941352","date":"2025-08-22T11:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-21T13:23:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T05:45:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T05:13:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-13T05:12:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-08-02T08:32:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"563583ac-26b6-43c1-a465-75ebc88f99ca","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T10:07:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 10:07:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7276802","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7276802","identity":"rs-7276802","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}