Minimal Invasiveness at Dental Implant Placement A Systematic Review With Meta-Analyses On Flapless Fully Guided Surgery

DOI: 10.1111/prd.
12440
REVIEW ARTICLE
Minimal invasiveness at dental implant placement:

A systematic review with meta-analyses on flapless fully
guided surgery
Mario Romandini1 | Edwin Ruales-Carrera2,3 | Sofya Sadilina1,4 |

Christoph H. F. Hämmerle2 | Mariano Sanz1
1
ETEP (Etiology and Therapy of Periodontal and Peri-implant Diseases) Research Group, University Complutense, Madrid, Spain
2
Clinic of Reconstructive Dentistry, University of Zürich, Zürich, Switzerland
3
Department of Dentistry, Center for Education and Research on Dental Implants (CEPID), Federal University of Santa Catarina, Florianópolis, Brazil
4
Department of Oral and Maxillofacial Surgery, Pavlov University, Saint-Petersburg, Russia
Correspondence
Mario Romandini, Departamento de Especialidades Clínicas Odontológicas, Facultad de Odontología, Universidad Complutense de Madrid, Plaza Ramón y
Cajal, 3, 28040 Madrid, Spain.
Email: mario.romandini@gmail.com
1 | I NTRO D U C TI O N however, is that the topography of the underlying bone cannot be

directly visualized to guide the step-by-step bed preparation and im-
Since the description of the biologic processes leading to implant plant placement, which may lead to implant malposition and, conse-
osseointegration, clinical implant dentistry has evolved significantly. quently, impairment of those outcomes describing implant success.7
In the first stage of development, the focus was to improve the im- However, current breakthroughs in digital imaging technologies can
plant design and surface topography to enhance the predictability overcome this barrier, as flapless surgery can now be combined with
of osseointegration and, thus, to maximize the chances of implant “guided implant placement”.
survival.1–3 The resulting advancements in surgical protocols and Guided (computer-aided) surgery for implant placement was first
implant macro-and micro-components moved the focus to esthetic introduced in the late 1990s and, because of those recent advance-
outcomes and the long-term preservation of peri-implant tissues. ments in digital technologies, it has increasingly been used to attain
Therefore, during this second era of implant dentistry, relevant a biologically and prosthetically ideal implant positioning.8 Guided
additional outcomes were incorporated in the broader concept of implant placement types have commonly been classified according
4
implant success. Within this current notion of implant success, the to the level of guidance (partially vs fully) and to the capability of
concept of minimal invasiveness has attracted great attention from allowing intraoperative changes (static vs dynamic). Although re-
clinicians, manufacturers, and patients as a mean of improving the cent systematic reviews have shown that static fully guided surgery
patient's experience during implant treatment, by decreasing patient has higher accuracy with respect to the planned position than free-
morbidity and enhancing tissue preservation. handed and partially guided implant placement,9 evidence synthesis
While minimal invasiveness in implantology may encompass is needed to verify whether this higher precision is preserved when
several aspects, when related to implant placement it mainly refers employed flapless, and if this combination may contribute to the
to flapless procedures (ie, without elevating a mucoperiosteal flap). concept of minimal invasiveness and at the same time improve the
Indeed, flapless implant placement has been shown to reduce surgi- efficacy of the implant treatment.
cal trauma and to save time, thereby causing less patient discomfort Therefore, the current systematic review of randomized clinical
and postoperative morbidity.5–7 A clear hindrance of flapless surgery, trials (RCTs) aimed to answer the following focused PICO question:
Edwin Ruales-C arrera and Sofya Sadilina contributed equally to this study.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.
Periodontology 2000. 2023;91:89–112. wileyonlinelibrary.com/journal/prd | 89

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90 ROMANDINI et al.
“In adult human subjects undergoing dental implant placement (P), • Biologically correct positioning. Defined dichotomously (yes/no)
is minimally invasive flapless computer-aided fully guided (either when the implant is placed well surrounded by native bone, at
dynamic or static) implant placement (I) superior to flapped conven- ideal distances from adjacent teeth/implants and with its head
tional (FHIP or cPGIP/dPGIP) implant placement surgery (C), in terms more palatal or at the level of the straight imaginary line that con-
of efficacy, patient morbidity, long-term prognosis, and costs (O)?” nects the profile of the adjacent teeth at the level of the gingival
margin. This positioning has been associated with an estimated
lower risk of biologic complications.12–15
2 | M ATE R I A L S A N D M E TH O DS • Prosthetically correct positioning. Defined dichotomously (yes/
no) when the implant is placed according to a prosthetically driven
This systematic review is reported according to the Preferred position (the implant emerges, without applying prosthetic cor-
Reporting Items for Systematic reviews and Meta-Analyses 2020 rections, via the cingulum for anterior teeth or via the occlusal
guidelines.10,11 A detailed protocol was designed before the start of fossa for premolars and molars).
this study and it was registered on PROSPERO (CRD42021283366). • Depth deviation. Metric discrepancy (measured in millimeters)
between the planned and actual implant position in the vertical
plane relative to the long axis of the implant body, measured from
2.1 | Terminology: Level of guidance a fixed reference point (eg, most coronal or apical point of the
implant body).9
Because of the heterogeneity in the terminology reported in the lit- • Angular deviation. Angular discrepancy (measured in degrees) be-
erature, the following definitions were employed to classify implant tween the planned and actual implant position respective to the
placement according to the level of guidance (modified from Tattan center of the implant body. It is primarily ascribed to a variation in
et al9): point of implant entry.9
• Three-
dimensional bodily deviation (both coronal and api-
• Free-handed implant placement (FHIP). Both osteotomy prepara- cal). Metric discrepancy (measured in millimeters) between the
tion and implant placement are performed manually, without the planned and actual three-dimensional implant position, measured
use of any surgical guide that may influence the course of place- both in the most coronal and apical part of the implant body.9
ment into the recipient site.
• Cast-
based partially guided implant placement (cPGIP). While
bone bed preparation and implant placement are performed 2.3 | Eligibility criteria
free-hand, a prosthetically driven nonrestrictive surgical guide is
employed. These guides are manufactured from dental casts and The eligibility criteria of this systematic review were organized by
have no consideration of the underlying bone morphology. the PICOS acronym.
• Drill partially guided implant placement (dPGIP). The bone bed (P) Participants. Adult human subjects (age > 18 years) needing
preparation is guided by means of a restrictive prosthetically one or more dental implants.
driven surgical guide, manufactured considering the underlying (I) Interventions. Flapless and computer-aided fully guided (ei-
bone morphology. Depending on their design, these guides may ther dynamic or static) implant placement.
be used solely for the initial osteotomy (eg, pilot drill guided) or (C) Comparison. Flapped and conventional (FHIP or cPGIP/
for partial or complete osteotomy. Implant placement, however, is dPGIP) implant placement.
still performed by free hand. (O) Outcome measures. At least one of the following outcomes
• Static computer-aided implant placement (sCAIP). A fully guided of interest:
approach involving both restrictive osteotomy preparation and
implant placement through a prosthetically driven surgical guide, • Efficacy: implant survival, implant success, accuracy.
fabricated based on preoperative computerized tomographic and • Morbidity and patient satisfaction: intraoperative morbidity
stereolithographic data. (complications, patient-
reported outcome measures (PROMs)),
• Dynamic computer-aided implant placement (dCAIP). A fully postoperative morbidity (complications, PROMs, early wound
guided approach of both osteotomy preparation and implant healing), surgery duration, patient-perceived esthetics, and pa-
placement via the application of “a surgical navigation system tient perception of the whole treatment.
that reproduces the virtual implant position directly from com- • Long-term prognosis: marginal bone loss/levels, incidence of peri-
puterized tomographic data and allows intra-operative changes”.8 implant diseases.
• Economic costs and entire procedural duration (including plan-
ning and realization).
2.2 | Terminology: Accuracy
(S) Studies. Only RCTs, either with parallel or split-mouth design,
The following five descriptions were considered as measures of im- because no relevant carry-over or period effect could be expected
plant placement accuracy: for this comparison in split-mouth studies. No studies were excluded
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ROMANDINI et al. 91
on the basis of language, date of publication, publication status, were made. The authors from the included RCTs were contacted,
length of follow-up, or number of included patients/arms. asking for additional information or estimates.
For each RCT, the following data were recorded:
2.4 | Information sources • General information. First author; year of publication; country.
• Methods. Study design (ie, parallel or split-
mouth, clustering);
Two review authors (MR and ER) performed in duplicate the sys- setting (university, hospital, private practice); number of centers;
tematic search in four electronic (Medline via PubMed, CENTRAL, experience of surgical operators (undergraduate students, post-
Scopus, Web of Science) and gray literature (OpenGrey; www.openg graduate students or middle experienced, experts); inclusion and
rey.eu) databases, without language restrictions from outset to 4 exclusion criteria; longest follow-up.
October 2021. The complete search strategy for all electronic and • Participants. Total number of randomized participants; total
gray literature databases is reported in Appendix S1. number of randomized implants; age (mean); gender (female,
Six implant-
related key journals were also hand-
searched in male); smoking status (nonsmokers, former smokers, smokers);
duplicate from 1 January 2010 to 20 October 2021 by two review edentulism type (single tooth, multiple teeth, totally edentu-
authors (ER and SS): Journal of Dental Research, Journal of Clinical lous arch); arch distribution (maxilla, mandible); use of antibiotic
Periodontology, Clinical Oral Implants Research, Clinical Implant prophylaxis (yes, no); loading time (immediate/within 1 week,
Dentistry and Related Research, Journal of Periodontology, and early/1 week-2 months, conventional/>2 months22).
International Journal of Periodontics and Restorative Dentistry. Finally, • Interventions and comparisons. Number of study groups; for each
the same two reviewers also performed cross-reference checking in one of the study groups: intervention (FHIP, cPGIP, dPGIP, sCAIP,
the bibliographies of all the included studies and of relevant review dCAIP), number of allocated participants and implants, number
articles on the topic.5,7,9,16–20 of dropouts (participants and implants), flap elevation (flapped,
All studies identified by at least one reviewer were included in flapless); implant brand; only for flapless sCAIP: static guide pro-
the study selection phase. duction (conventional, stereolithography), tissue of support of
the surgical static guide (teeth-, mucosa-, bone-, pin-supported,
mixed), depth control during implant placement (yes, no).
2.5 | Selection process • Outcomes and results of interest. For each outcome considered
in the inclusion criteria: collected (yes, no), definition, time points,
The titles and abstracts (where available) of all the electronically mean results in each group (only for accuracy outcomes), esti-
identified studies were uploaded to the Rayyan website21 (https:// mates (see section 2.8 for measures of intervention effects). In
www.rayyan.ai/), where they were screened independently by two any cases where the same trial reported the depth deviation out-
reviewers (ER and SS). Disagreements were resolved by discussion in come with more than one reference point, it was only considered
joint consensus meetings with a third review author (MR), who made once (ideally the apical one). Whenever possible, intention-to-
the final decision when resolution was not possible. treat data were selected.
The full reports of articles potentially meeting the inclusion cri- • Study funding, and possible conflicts of interest.
teria identified during electronic screening and of publications se- • Risk of bias (see section 2.7).
lected through hand-searching and cross-reference checking were
then evaluated independently by two review authors (MR and SS) In cases of multiple publications from the same trial, the data
to make the final decision. Disagreements were resolved by discus- were extracted once for general characteristics (ie, general informa-
sion in joint consensus meetings with a third review author (ER), who tion, methods, participants, interventions, and comparisons), while
made the final decision when resolution was not possible. The rea- the specific data (ie, outcomes and results of interest, study funding,
sons for excluding studies after full-text evaluation were recorded. risk of bias) were extracted from the most appropriate publications
Inter-reviewer agreement (percentage) during the screening and full- (eg, at loading and longest follow-up for implant survival in case it
text analysis phases was calculated. was reported in more than one report). In cases of multiple-arm
All studies meeting the inclusion criteria were included for data studies also reporting study groups not fulfilling this systematic re-
extraction and risk of bias assessment. view’s inclusion criteria (eg, flapped sCAIP), the results from those
groups were not considered.
2.6 | Data extraction and management

2.7 | Assessment of risk of bias
Data from the included studies were extracted independently and in
duplicate by two review authors (ER and SS) with the use of prede- We assessed the risk of bias of the included trials in duplicate as part
fined data extraction forms. All the extracted data and the eventual of the data extraction process, using the recommended Cochrane
disagreements were then jointly discussed, in the presence of a third Risk of Bias 2 tool. 23 The risk of bias was evaluated separately for
reviewer, in consensus meetings, during which the final decisions each one of the four most important outcomes (implant survival,
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92 ROMANDINI et al.
success, accuracy, and postoperative morbidity) in relation to the In one study reporting a RCT with multiple treatment arms ful-
evaluation of the effect of assignment to the interventions at base- filling the inclusion criteria, the most meaningful intervention and
line (ie, intention-to-treat). The overall judgment of the risk of bias comparison group were considered for analyses. 29–33 In this study,
23
was made as follows : flapless sCAIP (facilitate mucosa (Fac Mu)) and flapped FHIP were
selected for the main analyses, while the other groups were selected
• Low risk of bias. Low risk of bias for all domains for the specific for sensitivity analysis.
outcome. Additional planned subgroup (eg, surgical guide production,
• Some concerns. Some concerns in at least one domain regarding experience of surgical operators) or sensitivity (eg, restricting
the specific outcome, but not a high risk of bias evaluations. comparisons to dPGIP, or interventions to dCAIP) analyses for
• High risk of bias. High risk of bias in at least one domain, or some intergroup comparisons were not carried out because of lack of
concerns regarding multiple domains in a way that substantially retrieved data.
reduces confidence in the results for the specific outcome. We used intragroup meta-
analyses using the random effect
model when there were at least two studies assessing positioning
inaccuracies of flapless sCAIP at implant level (using “effective sam-
2.8 | Data analysis ple sizes” for parallel studies with clustering,34 considering an intra-
class correlation coefficient = .05), or evaluating the patient-level
Depending on the nature of the variable, either the implant (eg, accu- rates of intraoperative complications of flapless sCAIP. In the case
racy) or the patient (eg, surgery duration) was considered as the sta- of multiple intervention arms, the flapless sCAIP (Fac Mu) group was
tistical unit. Data for continuous variables were expressed in terms considered. 29–33
of difference in means (MD) and standard error (SE), adjusted for For intragroup meta-analyses, crude numbers were considered
clustering (ie, multiple implants per patient) and/or design (ie, split- for binary variables (complications), while group means and stan-
mouth) whenever appropriate. When possible, MD and SEs were dard deviations were considered for continuous variables (accuracy).
calculated from individual patient data (IPD) either reported in the Intragroup meta-analyses were reported as percentages (95% CI) for
publication24 or provided by the authors after correspondence25–27; binary variables, and as means (95% CI) for continuous ones. In pres-
for one trial, MD and SEs were directly provided by the authors after ence of at least three studies, 95% prediction intervals were also
28 29–33
correspondence. In one RCT with a parallel-group design, MD reported.
and SEs were calculated from crude means and standard deviations We assessed the interstudy heterogeneity in all meta-analyses
for each study group by using the appropriate formula to account for by carefully examining the characteristics of the included studies,
clustering, considering an intraclass correlation coefficient of .05.9,34 by inspecting the forest plots, and by calculating I2 statistics, with
For binary variables, crude numbers were considered because of values of 25%, 50%, and 75% considered as low, moderate, and high,
the presence of 0 events in at least one group of each possible com- respectively.36
parison, which prevented any synthesis by means of effect measures We evaluated publication bias by visually inspecting the funnel
(eg, risk ratios). plots since all meta-analyses included less than 10 studies, thus pre-
In the presence of at least two studies for each comparison, in- venting the use of Egger's and Begg's tests.
tergroup meta-analyses were carried out using the random effects Intergroup meta-analyses were carried out using STATA version
method and the generic inverse variance approach. These meta- 13.1 software (StataCorp LLC), while the intragroup ones carried out
analyses were reported as MD with 95% confidence intervals (CI) with RStudio 1.2.5033 software (RStudio); statistical significance
and, in the presence of at least three studies, also with 95% predic- was set in advance at P values of less than .05.
tion intervals.35
Subgroup analyses for intergroup comparisons were carried out
a priori on the basis of: 2.9 | Evaluation of certainty of evidence
• Study design (parallel, split-mouth). One review author (MR) assessed the certainty of the body of evi-
• Edentulism type (single tooth, multiple teeth, totally edentulous dence using the GRADE approach37 as it related to those studies
arch). that provided data to the meta-analysis for each prespecified out-
• Tissue of support for sCAIP as intervention (tooth-supported, come considered critical or important for the comparison of the
other). two treatment approaches. The certainty of the body of evidence
• Risk of bias (low, some concerns/high). was not evaluated for outcomes for which meta-analyses were not
possible.
Sensitivity analyses for intergroup meta-analyses were also car- Starting from high certainty because only RCTs were included,
ried out, restricting control groups to either flapped FHIP or flapped five factors were used for downgrading (study limitations, consis-
cPGIP and the intervention groups to flapless sCAIP with or without tency of effect, imprecision, indirectness, and publication bias),
depth control. and three were used for upgrading (large effect, dose–response
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ROMANDINI et al. 93
gradient, and plausible confounding effect), if appropriate, the cer- criterion, but reported that implants were all virtually planned em-
tainty of evidence. The certainty of evidence was finally considered bedded into bone. 26,27 All studies only included implant sites suit-
as high, moderate, low, or very low. Methods and recommendations able for type 4 implant placement. 38 None of the included trials
described in sections 8.5 and 8.7, and chapters 11 and 12, of the considered a minimum amount of keratinized tissue as inclusion cri-
Cochrane Handbook for Systematic Reviews of Interventions, were terion; however, one trial only included participants with no need
34
followed. GRADEpro GDT software was then used to prepare a for presurgical soft tissue augmentation in the implant areas. 24 A
“Summary of findings” table including an evaluation of the certainty sufficient mouth opening to allow computer-aided implant place-
of the body of evidence (GRADEpro GDT 2021), where all decisions ment was mentioned as inclusion criterion in only two RCTs, 25,28
to downgrade or upgrade the certainty of studies were justified while untreated periodontitis was regarded as an exclusion criteria
using footnotes. in three trials. 24,26,27,29–33
3 | R E S U LT S 3.2.2 | Interventions and comparisons
3.1 | Study selection Table 2 provides detailed information on the interventions and com-
parisons retrieved from the studies. Three trials had only two study
The initial electronic database search yielded a total of 1836 en- groups (one intervention and one comparison)24,25,28; one trial had
tries, of which 671 were retrieved from Medline (via PubMed), 359 three study groups (one intervention and two comparisons)26,27;
from CENTRAL, 180 from Scopus, 614 from Web of Science, and 12 while the other trial had six study groups (four interventions and two
from OpenGrey. After excluding 114 duplicates, the total number comparisons). 29–33
of entries was 1722. Of these, 1699 were discarded after reviewing The intervention groups included flapless sCAIP in six groups
the titles and abstracts (agreement 98.67%). Four additional articles of five RCTs. 24–33 In one RCT, two additional study groups included
were identified through cross-reference checking (three) and hand flapped sCAIP, 29–33 hence were not considered further. There were
searching (one). In total, 27 publications were selected for full-text no RCTs reporting dCAIP as an intervention group.
analysis, although 17 were excluded during this stage (the reasons The comparison groups included FHIP in three trials26,28–33 and
for exclusion are reported in Table S1) (agreement 96.30%). A flow- cPGIP in three trials, 24,25,29–33 in all cases including the elevation of
chart that depicts the selection process is displayed in Figure S1. a mucoperiosteal flap. dPGIP represented an additional comparison
Finally, 10 publications reporting results from five RCTs and a group in one trial26,27; however, because it was carried out flapless,
total of 124 participants (449 implants) met the inclusion criteria and this group was not considered further.
24–33
were then included in this systematic review. In summary, the current systematic review reports results from
12 treatment arms (six flapless sCAIP as intervention and six flapped
FHIP/cPGIP as comparison groups) in the five included RCTs. sCAIP
3.2 | Characteristics of the included studies always used a surgical guide manufactured by stereolithography. In
four arms from four RCTs24–28 the guide was tooth-supported, while
3.2.1 | Methods and participants in the remaining trial it was mucosa-supported (materialize mucosa
(Mat Mu) and Fac Mu). 29–33
Table 1 depicts the methods and participants of the included studies. Guided implant insertion was carried out using a restrictive
24,25,28
Three of the included trials had a split-mouth design and two depth control system in two RCTs, 25,28 either using (Fac Mu) or not
had a parallel design with clustering (ie, multiple implants in the same using it (Mat Mu) depending on the arm in another, 29–33 without the
26,29–33
randomized participant). Four RCTs were monocentric and depth control system in another, 26,27 and unreported in the remain-
24,25,28–33
carried out in university settings, while the remaining one ing one. 24
was bi-centric taking place at both a university and a private practice.
Sample size varied from 10 participants (20 implants)24,28 to 60 par-
ticipants (314 implants). 29–33 Only two trials declared the inclusion of 3.3 | Efficacy, Part 1: Implant survival and
current smokers (<20% of the included participants). 26,27,29–33 Two implant success
trials only included mandibular single-tooth gaps, 25,28 one trial only
single-tooth gaps but from both arches, 24 one trial only maxillary The studies included in this systematic review did not consider im-
multiple adjacent missing teeth, 26,27 and the other one only maxillary plant success as an outcome, while only one study reported data on
and mandibular similarly distributed edentulous arches. 29–33 implant survival. 29–33 This study resulted in 100% survival because
Table S2 lists the inclusion and exclusion criteria reported in no implant was lost (evaluated up to 36 months) in either flapped
the included RCTs. Four trials considered as inclusion criterion the FHIP, flapped cPGIP, flapless sCAIP (Mat Mu), or flapless sCAIP (Fac
availability of enough bone without the need for bone augmenta- Mu)29–33 (Table 3). In this study the overall risk of bias for this out-
24,25,28–3 3
tion procedures ; the other trial did not have this inclusion come was considered to be low (Figure 1B).
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94 ROMANDINI et al.
TA B L E 1 Characteristics of the included studies -methods, participants, and funding
Methods
Number Experience of surgical

Reference Country Study design Setting of centers operators Longest follow-up
24
Farley et al (2013) USA Split-mouth University 1 NR Same day of implant placement
Frizzera et al (2021)28 Brazil Split-mouth University 1 Undergraduate 1 wk

students
Magrin et al (2020)25 Brazil Split-mouth University 1 Expert 1 wk
Vercruyssen Belgium Parallel with University 1 Expert 3y

et al (2014a,b,c, clustering
2015); Bernard
et al (2019)29–33
Younes et al (2018, Belgium Parallel with University 2 Middle experienced 12 wk

2019)26,27 clustering and
private
practice
Abbreviations: N, number; NR, not reported.

a
Actually 16 subjects (32 implants) were included, but two subjects (four implants) were excluded before randomization and two subjects (four
implants) were excluded in the available “per-protocol” analyses; data about those subjects were not available.
b
Arch distribution reported at jaw-level and not at patient-level.
c
One additional subject was randomized, but did not receive the surgery; descriptive data about this participant were not available.
3.4 | Efficacy, Part 2: Accuracy considered at overall low risk of bias for these outcomes,26,27,29–33
while one was considered to have some concerns24 and one to have a
24–27,29–33
Accuracy outcomes were reported in four RCTs. high risk of bias, because of the exclusion of two randomized partici-
Prosthetically correct positioning was analyzed in one RCT, 26,27 while pants from the trial as a consequence of intrasurgical complications in
biologically correct positioning was never considered. Depth devia- the flapless sCAIP group (intervention-related exclusion).25
tion was reported in three RCTs,24,29–33 while angular deviation, and Table S3 reports the mean depth, angular, and three-dimensional
three-dimensional bodily deviations of the coronal and of the apical bodily deviation values in each study group, while Table 3 reports
portion of the implant, were reported in four RCTs.24–27,29–33 Figure 1C the estimates for comparisons between groups. With regard to im-
reports the risk of bias assessment for these studies. Two RCTs were plant placement in a prosthetically correct position, Younes et al26,27
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ROMANDINI et al. 95
Participants (patient-level)
Randomized—
participants Age Gender—N Smoking Edentulism type—N Arch distribution—N Funding and possible
(implants) (y)—mean (%) status—N (%) (%) (%) conflicts of interest
10 (20) 42.1 Males: Nonsmokers: Single tooth gap: Maxilla: Biomet 3i

5 (50.0) 10 (100.0) 10 (100.0) 3 (30.0)
Females: Smokers: Multiple adjacent Mandible:
5 (50.0) 0 (0.0) missing teeth: 7 (70.0)
0 (0.0)
Edentulous arch:
0 (0.0)
10 (20) NR NR Nonsmokers: Single tooth gap: Maxilla: FAESA (Faculdades
10 (100.0) 10 (100.0) 0 (0.0) Integradas Espírito-
Smokers: Multiple adjacent Mandible: Santenses) and FAPES
0 (0.0) missing teeth: 10 (100.0) (Fundação de Amparo à
0 (0.0) Pesquisa e Inovação no
Edentulous arch: Espírito Santo). Dérig-
0 (0.0) Implantes do Brasil
provided the implants
12 (24)a 42 Males: NR Single tooth gap: Maxilla: Coordination for
1 (8.3) 12 (100.0) 0 (0.0) Improvement of Higher
Females: Multiple adjacent Mandible: Education Personnel
11 (91.7) missing teeth: 12 (100.0) (CAPES)
0 (0.0)
Edentulous arch:
0 (0.0)
60 (314) 58 Males: Nonsmokers: Single tooth gap: Maxilla: Dentsply Sirona provided
29 (48.3) 53 (88.3) 0 (0.0) 39 (54.2)b implants, prosthetic
Females: Smokers: Multiple adjacent Mandible: materials, and
31 (51.7) 7 (11.7) missing teeth: 33 (45.8)b stereolithographic
0 (0.0) guides. One of the
Edentulous arch: authors was employed
60 (100.0) at Dentsply Sirona at the
time of the publication of
Bernard et al (2019)
32 (71)c 57.6 Males: Nonsmokers: Single tooth gap: Maxilla: Dentsply Sirona
11 (34.4) 26 (81.2) 0 (0.0) 32 (100.0)
Females: Smokers: Multiple adjacent Mandible:
21 (65.6) 6 (18.8) missing teeth: 0 (0.0)
32 (100.0)
Edentulous arch:
0 (0.0)
reported that 80.8% and 100.0% of the implants could be restored cPGIP groups. In three RCTs there was less angular deviation in
with a screw-retained prosthesis in the flapped free-handed and flapless sCAIP compared with flapped FHIP/cPGIP, 25–27,29–33 while
flapless sCAIP groups, respectively. in one trial24 there was a nonsignificant tendency in the same
The mean depth deviation varied from 0.43 to 1.24 mm in flapless direction.
sCAIP and from 0.50 to 2.20 mm in flapped FHIP/cPGIP groups. While Mean coronal three-dimensional bodily deviation varied from
statistically significantly less depth deviation was reported in flapless 0.73 to 2.34 mm in flapless sCAIP and from 1.45 to 2.97 mm in
sCAIP compared with flapped FHIP/cPGIP in one RCT,29–33 two other flapped FHIP/cPGIP groups. Mean apical three-dimensional bodily
RCTs reported no statistically significant differences.24,26,27 deviation varied from 0.97 to 2.53 mm in flapless sCAIP vs 2.11 to
The mean angular deviation varied from 2.20 to 3.68 degrees 3.40 mm in flapped FHIP/cPGIP groups. Two trials reported less
in flapless sCAIP and from 3.50 to 9.92 degrees in flapped FHIP/ three-dimensional bodily deviation, both in the coronal and in the
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96 ROMANDINI et al.
TA B L E 2 Characteristics of the included studies -interventions and comparisons
Number of dropouts
Number Number allocated in each in each group—N
of study Interventions and group—N participants (N participants (N
Reference groups comparisons implants) implants) Flap elevation
24
Farley et al (2013) 2 Comparison: cPGIP: cPGIP: cPGIP:
cPGIP 10 (10) 0 (0) Flapped
Intervention: sCAIP: sCAIP: sCAIP:
sCAIP 10 (10) 0 (0) Flapless
Frizzera et al (2021)28 2 Comparison: cPGIP: cPGIP: cPGIP:
FHIP 10 (10) 0 (0) Flapped
Magrin et al (2020)25 2 Comparison: cPGIP: cPGIP: cPGIP:
Vercruyssen et al (2014a,b,c, 6 Comparison 1: FHIP: FHIP: FHIP:
2015), Bernard FHIP 12 (51) 0 (0) Flapped
et al (2019)29–33 Comparison 2: cPGIP: cPGIP: cPGIP:
Intervention 1: sCAIP (Mat Mu): sCAIP (Mat Mu): sCAIP (Mat Mu):
sCAIP (Mat Mu) 12 (55) 0 (0)b Flapless
Intervention 2: sCAIP (Fac Mu): sCAIP (Fac Mu): sCAIP (Fac Mu):
sCAIP (Fac Mu) 12 (52) 0 (0)b Flapless
Intervention 3: sCAIP (Mat Bo): sCAIP (Mat Bo): sCAIP (Mat Bo):
sCAIP (Mat Bo) 12 (53) 0 (0)a Flappedc
Intervention 4: sCAIP (Fac Bo): sCAIP (Fac Bo): sCAIP (Fac Bo):
sCAIP (Fac Bo) 12 (52) 0 (0)b Flappedc
Younes et al (2018, 2019)26,27 3 Comparison 1: FHIP: FHIP: FHIP:
FHIP 11 (26) 0 (0) Flapped
Comparison 2: dPGIP: dPGIP: dPGIP:
dPGIP 11 (24) 0 (0) Flaplessc
Abbreviations: cPGIP, cast-based partially guided implant placement; dPGIP, drill partially guided implant placement; Fac, facilitate; FHIP,
free-handed implant placement; Mat, materialize; Mu, mucosa-supported; N, number; NR, not reported; sCAIP, static computer-aided implant
placement.
a
Vercruyssen et al31 had one patient (four implants) as dropout in the sCAIP (Mat Bo) group.
b
Bernard et al33 had one patient (four implants) as dropout in each one of the following three groups: sCAIP (Mat Mu), sCAIP (FacMu), sCAIP (Fac
Bo).
c
The results from those groups were not considered, as they did not fulfill the systematic review inclusion criteria.
apical portion of the implants with flapless sCAIP compared with bodily deviation of 1.43 mm and an apical three-dimensional
flapped FHIP/cPGIP, 26,27,29–33 while the other two trials reported no bodily deviation of 1.68, when compared with the planned po-
statistically significant differences. 24,25 sition. While intragroup meta-
a nalyses on angular deviations
Accuracy outcomes did not show statistically significant differ- showed a low level of heterogeneity, the other accuracy errors
ences in the only trial that also compared flapless sCAIP with and showed high heterogeneity.
without depth control. 29–33 In the same trial, more depth deviation Intergroup meta-
analyses comparing accuracy outcomes in
was observed in flapped cPGIP compared with flapped FHIP (with- flapless sCAIP with flapped FHIP/cPGIP are reported in Figure 3.
out differences in the other accuracy outcomes). 29–33 There was statistically significantly less angular deviation
Intragroup meta-
analyses describing the accuracy errors for (MD = −3.88 degrees) and apical three-dimensional bodily deviation
flapless sCAIP are reported in Figure 2. (MD = −0.75 mm) in flapless sCAIP compared with flapped FHIP/
Flapless sCAIP resulted in a mean depth deviation of 0.76 mm, cPGIP. Less depth deviation (MD = −0.28 mm) and coronal three-
an angular deviation of 2.57 mm, a coronal three-dimensional dimensional bodily deviation (MD = −0.60 mm) were also found in
|
ROMANDINI et al. 97
Only sCAIP
Antibiotic Depth control during

prophylaxis Loading time Implant brand Guide production Tissue of support implant placement
NR NR Biomet 3i Stereolithography Tooth-supported NR
Yes NR Singular Dérig- Stereolithography Tooth-supported Yes

Implantes do
Brasil
No NR Neodent Stereolithography Tooth-supported Yes
Yes Conventional Astra Tech TX Stereolithography Mat Mu & Fac Mu: Mat Mu & Mat Bo:
(>2 mo), with (Astra Tech) Mucosa-supported No
the exception of Mat Bo & Fac Bo: Fac Mu & Fac Bo:
one participant Pin-supported Yes
(immediate)
Yes Conventional (>2 mo) OsseoSpeed EV Stereolithography Tooth-supported No

(Astra Tech)
flapless sCAIP vs flapped FHIP/cPGIP, although without reaching Subgroup meta-analyses (Appendix S1) revealed better accuracy
the level of statistical significance. All intergroup meta-analyses for in flapless sCAIP compared with flapped FHIP/cPGIP in edentulous
accuracy outcomes demonstrated a moderate to high level of het- arches or multiple adjacent teeth gaps, as well as in trials with a par-
erogeneity. Visual inspection of funnel plots showed no obvious ev- allel design or with a low risk of bias. However, these subgroups al-
idence of publication bias. ways corresponded to the same two trials. 26,27,29–33
Sensitivity analyses (Appendix S1) demonstrated the same ten-
dencies when restricting the intervention groups to flapless sCAIP
with or without depth and the control group to flapped FHIP or 3.5 | Postoperative morbidity
flapped cPGIP. However, the magnitude of the estimates was almost
double in terms of angular deviation and three-dimensional bodily Three of the included RCTs reported data on postoperative mor-
deviation (both coronal and apical) when restricting the intervention bidity outcomes. 24–27,29–33 The rate of postoperative complications
arms to flapless sCAIP without depth control and the control groups was reported in two RCTs. 25,28 Postoperative pain was reported in
to flapped FHIP. three RCTs, 25,28–33 while postoperative swelling was reported in
|
98 ROMANDINI et al.
TA B L E 3 Characteristics of the included studies -outcomes and results of interest: efficacy
Implant
success Time-point Accuracy 1—Biologically
(total for accuracy correct positioning (total
Reference Implant survival (total number) number) outcomes number)
24
Farley et al (2013) NC NC Just after surgery NC
Frizzera et al (2021)28 NC NC NC NC
25
Magrin et al (2020) NC NC 1 wk NC
Vercruyssen Implant survival at loading (4 mo) NC 10 d NC

et al (2014a,b,c, 2015), FHIP: 51 out of 51 implants (12 out of 12
Bernard et al (2019)29–33 participants).
cPGIP: 51 out of 51 implants (12 out of 12
participants).
sCAIP (Mat Mu): 55 out of 55 implants (12 out of 12
participants).
sCAIP (Fac Mu): 52 out of 52 implants (12 out of 12
participants).
Implant survival at 36 mo
FHIP: 51 out of 51 implants (12 out of 12
participants).
cPGIP: 51 out of 51 implants (12 out of 12
participants).
sCAIP (Mat Mu): 51 out of 51 implants (11 out of 11
participants).
sCAIP (Fac Mu): 48 out of 48 implants (11 out of 11
participants)
Younes et al (2018, NC NC At implant NC
2019)26,27 loading (12
wk)
Note: Time points consider implant placement as reference. Results on binary outcomes are reported as crude numbers, while results on continuous
outcomes are reported as MD (SE).
Abbreviations: Bo, bone-supported; cPGIP, cast-based partially guided implant placement; dPGIP, drill partially guided implant
placement; Fac, Facilitate; FHIP, free-handed implant placement; Mat, Materialise; MD, difference in means; mm, millimeters; Mu,
mucosa-supported; NC, not collected; NR, not reported; sCAIP, static computer-aided implant placement; SE, standard error.
a
Apical.
b
Coronal.
c
Defined as implants that could be restored with screw-retained restoration.
*P < .05.
two25,29–33; in one study, these outcomes were also assessed indi- complications in both the flapless sCAIP and flapped cPGIP
rectly by counting the number of analgesics and anti-inflammatory groups. 25,28 In one study, statistically significantly less postoper-
28 25 25
drugs. Bleeding, ecchymosis, and oral health-related quality ative pain was reported for flapless sCAIP compared with flapped
of life (OHRQol) were also reported in one study each. 29–33 Wound FHIP/cPGIP, 29–33 while in the remaining two RCTs25,28 there was
healing as an outcome was not reported in any study. only a nonsignificant tendency for less pain in flapless sCAIP
Figure 1D reports the risk of bias assessment in relation to these compared with flapped cPGIP. Similarly, in one study there was
outcomes. Two studies were considered to have some concerns, in a nonsignificant tendency for using fewer analgesics and anti-
relation to either missing outcome data25 or selection or measure- inflammatory drugs in the first 7 postoperative days, 28 and in an-
ment bias, 28 while one trial was considered to have an overall low other less postoperative bleeding, swelling, and ecchymosis25 in
29–33
risk of bias. flapless sCAIP compared with flapped cPGIP. The trial conducted
Table 4 reports the between-
group estimates for postop- by Vercruyssen et al and Bernard et al29–33 reported less postoper-
erative morbidity. In two studies there were no postoperative ative swelling only in the flapless sCAIP group (Fac Mu) vs flapped
|
ROMANDINI et al. 99
Accuracy
2—Prosthetically
correct positioning Accuracy 3—Depth Accuracy 4—Angular Accuracy 5—3D bodily Accuracy 6—3D bodily
(total number) deviation (mm) deviation (degrees) deviations (coronal) (mm) deviations (apical) (mm)
NC sCAIP vs cPGIPa: sCAIP vs cPGIP: sCAIP vs cPGIP: sCAIP vs cPGIP.

MD = −0.35 (SE = 0.32) MD = −2.45 (SE = 1.38) MD = −0.53 (SE = 0.34) MD = −0.72 (SE = 0.40)
NC NC NC NC NC
NC NC sCAIP vs cPGIP: sCAIP vs cPGIP: sCAIP vs cPGIP:
MD = −1.30 (SE = 0.54)* MD = 0.41 (SE = 0.36) MD = 0.34 (SE = 0.39)
NC cPGIP vs FHIPb: cPGIP vs FHIP: cPGIP vs FHIP: cPGIP vs FHIP:
MD = 0.95 (SE = 0.27)* MD = −1.49 (SE = 1.22) MD = 0.20 (SE = 0.32) MD = 0.49 (SE = 0.35)
sCAIP (Mat Mu) vs FHIPb: sCAIP (Mat Mu) vs FHIP: sCAIP (Mat Mu) vs FHIP: sCAIP (Mat Mu) vs FHIP:
MD = −0.51 (SE = 0.17)* MD = −7.06 (SE = 0.93)* MD = −1.54 (SE = 0.25)* MD = −1.34 (SE = 0.25)*
sCAIP (Fac Mu) vs FHIPb: sCAIP (Fac Mu) vs FHIP: sCAIP (Fac Mu) vs FHIP: sCAIP (Fac Mu) vs FHIP:
MD = −0.51 (SE = 0.18)* MD = −7.21 (SE = 0.94)* MD = −1.39 (SE = 0.26)* MD = −1.31 (SE = 0.26)*
sCAIP (Mat Mu) vs cPGIPb: sCAIP (Mat Mu) vs cPGIP: sCAIP (Mat Mu) vs cPGIP: sCAIP (Mat Mu) vs
MD = −1.46 (SE = 0.23)* MD = −5.57 (SE = 0.80)* MD = −1.74 (SE = 0.23)* cPGIP:
sCAIP (Fac Mu) vs cPGIPb: sCAIP (Fac Mu) vs cPGIP: sCAIP (Fac Mu) vs cPGIP: MD = −1.83 (SE = 0.27)*
MD = −1.46 (SE = 0.24)* MD = −5.72 (SE = 0.81)* MD = −1.59 (SE = 0.24)* sCAIP (Fac Mu) vs cPGIP:
sCAIP (Fac Mu) vs sCAIP sCAIP (Fac Mu) vs sCAIP (Mat sCAIP (Fac Mu) vs sCAIP (Mat MD = −1.80 (SE = 0.28)*
(Mat Mu)b: Mu): Mu): sCAIP (Fac Mu) vs sCAIP
MD = 0.00 (SE = 0.13) MD = −0.15 (SE = 0.32) MD = 0.15 (SE = 0.13) (Mat Mu):
MD = 0.03 (SE = 0.15)
FHIP: 21 out of sCAIP vs FHIPa: sCAIP vs FHIP: sCAIP vs FHIP: sCAIP vs FHIP:
26 implants MD = −0.08 (SE = 0.12) MD = −4.68 (SE = 1.36)* MD = −0.72 (SE = 0.15)* MD = −1.13 (SE = 0.29)*
(NR out of 11
participants)c
sCAIP: 21 out of
21 implants
(10 out of 10
participants)c
FHIP group. In the same trial, higher values for of OHRQol (ie, less Intergroup meta-
analyses (flapless sCAIP vs flapped FHIP/
postoperative discomfort and inconvenience in daily life39) were cPGIP) on postoperative morbidity outcomes from at least two in-
reported for flapless sCAIP (Mat Mu), but not for flapless sCAIP cluded trials are reported in Figure 4. They indicate statistically sig-
(Fac Mu), compared with flapped FHIP/cPGIP. 29–33 nificantly less postoperative pain (MD = −17.09 mm on the VAS) and
The only trial comparing cPGIP with FHIP reported greater a nonstatistically significant tendency for less postoperative swell-
postoperative pain and higher values of OHRQol in flapped FHIP ing (MD = −6.59 mm on the VAS) in flapless sCAIP compared with
compared with flapped cPGIP, but no differences in postopera- flapped FHIP/cPGIP, in both cases with a high level of heterogene-
tive swelling. 29–33 The same trial also reported no statistically sig- ity. Visual inspection of funnel plots showed no obvious evidence of
nificant differences in postoperative morbidity when comparing publication bias.
flapless sCAIP with and without depth control (ie, Fac Mu vs Mat Sensitivity analyses (Appendix S1) showed the same tendency
Mu). 29–33 when restricting control groups to either flapped FHIP or flapped
|
100 ROMANDINI et al.
F I G U R E 1 Risk of bias summary of the included studies: review of authors' judgments in relation to the four outcomes considered critical
or important for the comparison of the two treatment approaches: A, Implant survival; B, Implant success; C, Accuracy; and D, Postoperative
morbidity
cPGIP, as well as when restricting intervention groups to flapless complications was 0% for flapped cPGIP, 25,28 while it ranged from
sCAIP with depth control. 0%28 to 30%26,27 for flapless sCAIP. These included nonfitting
Subgroup meta-analyses (Appendix S1) were only possible for guides, 26,27 surgical guide not delivered in time, 26,27 fracture of
postoperative pain, revealing results that were consistent with the the insertion driver inside the implant, 25 and perforation of buccal
main analyses when only considering the two split-mouth trials em- bone. 25
25,28
ploying tooth-supported guides and including single-tooth gaps. Less intraoperative pain was reported in one trial for flap-
less sCAIP (Mat Mu) than flapped FHIP/cPGIP, 29–33 while another
study reported only a nonsignificant tendency. 25 The research by
3.6 | Additional PROMs and Vercruyssen et al and Bernard et al29–33 also reported how these
intraoperative outcomes results were not applied for flapless sCAIP (Fac Mu), which was as-
sociated with more intraoperative pain than sCAIP (Mat Mu)29–33; no
Surgery duration was measured in three trials, 26,28–33 while the rate differences in intraoperative pain were reported for flapped cPGIP
of intraoperative complications was reported in three trials25–28 and flapped FHIP in the same trial.
and two trials each analyzed intraoperative pain25,29–33 and discom- A nonstatistically significant tendency for less intraoperative
fort. 25,28 Patients’ perception of the overall treatment was reported discomfort in flapless sCAIP vs flapped cPGIP was reported in the
in only one trial, 28 while no trial reported on patient self-perceived two trials reporting this outcome. 25,28
esthetics. One RCT reported a shorter surgery duration for flapless
Table 5 reports the estimates for comparisons between groups sCAIP (both Mat Mu and Fac Mu) compared with flapped FHIP,
with respect to these outcomes. The reporting of intraoperative for flapless sCAIP (Mat Mu) vs flapped cPGIP, for flapped cPGIP
|
ROMANDINI et al. 101
F I G U R E 2 Intragroup meta-analyses. Flapless static computer-aided implant placement: accuracy outcomes. A, Depth deviation; B,
Angular deviation; C, Three-dimensional bodily deviation—coronal; D, Three-dimensional bodily deviation—apical. “Effective sample sizes”
were calculated for the Vercruyssen et al29–33 (45 instead of 52) and Younes et al26,27 (20 instead of 21) trials to account for clustering.
MRAW, raw mean
|
F I G U R E 3 Intergroup meta-analyses. Flapped free-handed implant placement (FHIP)/cast-based partially guided implant placement
(cPGIP) vs flapless static computer-aided implant placement (sCAIP): accuracy outcomes. A, Depth deviation; B, Angular deviation; C, Three-
dimensional bodily deviation—coronal; D, Three-dimensional bodily deviation—apical. DL, DerSimonian-L aird
TA B L E 4 Characteristics of the included studies -outcomes and results of interest: postoperative morbidity
ROMANDINI et al.
Postoperative
PROMs 2—number
Time point for painkillers and Postoperative
postoperative Postoperative anti-inflammatory Postoperative PROMs Early
morbidity complications (total Postoperative PROMs 1— drugs (total PROMs Postoperative PROMs 5—ecchymosisa Postoperative PROMs wound
Reference assessment number) paina (mm) number) 3—bleedinga (mm) 4—swellinga (mm) (mm) 6—OHRQoL healing
Farley et al (2013)24 NC NC NC NC NC NC NC NC NC
Frizzera et al (2021)28 Day 7b cPGIP: 0 out of 10 sCAIP vs cPGIP: sCAIP vs cPGIPc: NC NC NC NC NC

sCAIP: 0 out of 10 MD = −34.40 (SE = 6.20) MD = −2.40
(SE = 0.91)
Magrin et al (2020)25 Day 7b cPGIP: 0 out of 12 sCAIP vs cPGIP: NC sCAIP vs cPGIP: sCAIP vs cPGIP: sCAIP vs cPGIP: NC NC
sCAIP: 0 out of 12 MD = −10.70 (SE = 6.92) MD = −9.22 MD = −14.50 (SE = 6.09)* MD = −7.20
(SE = 6.85) (SE = 5.36)
Vercruyssen Day 7d NC cPGIP vs FHIP: NC NC cPGIP vs FHIP: NC cPGIP vs FHIPe: NC

et al (2014a,b,c, MD = −3.80 (SE = 2.00)* MD = −0.20 (SE = 0.81) MD = −3.90 (SE = 1.09)*
2015), Bernard sCAIP (Mat Mu) vs FHIP: sCAIP (Mat Mu) vs FHIP: sCAIP (Mat Mu) vs FHIPe:
et al (2019)29–33 MD = −6.60 (SE = 1.99)* MD = −0.60 (SE = 1.08) MD = −5.10 (SE = 1.27)*
sCAIP (Fac Mu) vs FHIP: sCAIP (Fac Mu) vs FHIP: sCAIP (Fac Mu) vs FHIPe:
MD = −7.70 (SE = 1.88)* MD = −1.50 (SE = 0.68)* MD = −2.90 (SE = 1.76)
sCAIP (Mat Mu) vs cPGIP: sCAIP (Mat Mu) vs cPGIP: sCAIP (Mat Mu) vs cPGIPe:
MD = −2.80 (SE = 1.31)* MD = −0.40 (SE = 1.29) MD = −2.10 (SE = 0.85)*
sCAIP (Fac Mu) vs cPGIP: sCAIP (Fac Mu) vs cPGIP: sCAIP (Fac Mu) vs cPGIPe:
MD = −3.90 (SE = 1.10)* MD = −1.30 (SE = 0.99) MD = 1.00 (SE = 1.47)
sCAIP (Fac Mu) vs sCAIP sCAIP (Fac Mu) vs sCAIP sCAIP (Fac Mu) vs sCAIP
(Mat Mu): (Mat Mu): (Mat Mu) e:
MD = −1.10 (SE = 1.16) MD = −0.90 (SE = 1.20) MD = 3.10 (SE = 1.59)
Younes et al (2018, NC NC NC NC NC NC NC NC NC
2019)26,27
Note: Time points consider implant placement as reference. Results on binary outcomes are reported as crude numbers, while results on continuous outcomes are reported as MD (SE).
Abbreviations: Bo, bone-supported; cPGIP, cast-based partially guided implant placement; dPGIP, drill partially guided implant placement; Fac, Facilitate; FHIP, free-handed implant placement; Mat,
Materialise; MD, difference in means; mm, millimeters; Mu, mucosa-supported; NC, not collected; OHRQol, oral health-related quality of life; PROMs, patient-reported outcome measures; sCAIP, static
computer-aided implant placement; SE, standard error; VAS, visual analogue scale.
a
Self-reported VAS, measured in mm.
b
Refers to the entire postoperative period up to day 7.
c
Self-reported number of painkillers and anti-inflammatory drugs, recalled by the patients at the 7-d follow-up.
d
Refers to the moment of filling the questionnaire at day 7.
e
Self-reported answers to 15 questions about OHRQol (ranging from 0 to 75; Shugars et al39), with higher scores indicative of more postoperative discomfort and inconvenience in daily life.
*P < .05.
| 103
|
(cPGIP) vs flapless static computer-aided implant placement (sCAIP): postoperative morbidity outcomes. A, Postoperative pain; B,
Postoperative swelling
compared with flapped FHIP, and for flapless sCAIP (Mat Mu) vs both trials employed tooth-supported guides, included single-tooth
29–3 3
flapless sCAIP (Fac Mu). In the other two trials, a nonsignif- gaps, and had a split-mouth design). Subgroup meta-analyses for sur-
icant difference in surgery duration (around 20 minutes less in gery duration (Appendix S1) revealed a tendency for similar results
flapless sCAIP compared with either flapped FHIP 26,27 or flapped to the main analyses when considering only studies that included
cPGIP 28), was reported. single-tooth gaps or had a parallel design.
28
Finally, Frizzera et al reported no statistically significant differ-
ences in patients’ general satisfaction regarding the entire treatment
when comparing flapless sCAIP with flapped cPGIP. 3.7 | Long-term prognosis
Intragroup meta-analyses on the rate of complications in flapless
sCAIP are reported in Figure 5, resulting in a 12% overall intraopera- Despite the relevance of long-term prognosis outcomes when com-
tive complications rate (moderate heterogeneity) and, consequently, paring flapless sCAIP with flapped FHIP/cPGIP, only one trial29–33
an inability to place the implant with this protocol in 7% of cases (no reported a follow-up amenable for comparing changes in marginal
heterogeneity). bone levels and the incidence of peri-implant diseases between
Intergroup meta-
analyses (flapless sCAIP vs flapped FHIP/ groups (Table 6). 29–33
cPGIP) of intraoperative PROMs and surgery duration are re- Marginal bone level was higher (ie, bone more apical with respect
ported in Figure 6, indicating with no/low level of heterogene- to a fixed reference point40) in flapped cPGIP compared with both
ity less intraoperative discomfort (MD = −9.36 mm of VAS) and flapped FHIP and flapless sCAIP (Mat Mu) at implant loading, 12-, and
shorter surgery duration (MD = −24.28 minutes) for flapless sCAIP 36-month follow-ups. Flapless sCAIP (Fac Mu) showed a higher bone
compared with flapped FHIP/cPGIP. Conversely, intraoperative level than flapless sCAIP (Mat Mu) at the 36-month follow-up.29–33
pain did not show statistically significant differences between Because of the paucity of data found, intergroup meta-analyses
groups. Visual inspection of funnel plots showed no obvious ev- were not possible for these outcomes.
idence of publication bias.
Sensitivity analyses (Appendix S1) showed that results were
consistent with the main analyses when restricting the intervention 3.8 | Economic costs and entire
groups to flapless sCAIP either with or without depth control, and procedural duration
the control groups to either flapped FHIP or flapped cPGIP.
Subgroup meta-analyses were not possible for intraoperative Only the trial from Younes et al26,27 analyzed the economic costs
pain (the two trials belonged to different subgroups), while they cor- (up to restoration delivery), which were higher in flapless sCAIP
responded with the main analyses for intraoperative discomfort (as compared with flapped FHIP, while the entire procedural duration
TA B L E 5 Characteristics of the included studies -outcomes and results of interest: intraoperative outcomes and additional PROMs
Intraoperative outcomes Additional PROMs
Intraoperative Time point for Time point for Patient self- Patient perception of
complications (total intraoperative Intraoperative PROMs Intraoperative PROMs additional PROMs perceived the whole treatment
ROMANDINI et al.
Reference number) PROMs assessment 1—paina (mm) 2—discomfort a (mm) Surgery duration (min) assessment esthetics (mm)
24
Farley et al (2013) NC NC NC NC NC NC NC NC
Frizzera et al (2021)28 cPGIP: 0 out of 10 Just after surgery NC sCAIP vs cPGIP: sCAIP vs cPGIP: NR NC sCAIP vs cPGIPb:
sCAIP: 0 out of 10 MD = −11.00 (SE = 5.30) MD = −26.77 (SE = 2.83) MD = 0.50 (SE = 0.20)
Magrin et al (2020)25 cPGIP: 0 out of 14 Day 7, answering in sCAIP vs cPGIP: sCAIP vs cPGIP: NC NC NC NC
sCAIP: 2 out of 14 c relation to the MD = −13.40 MD = −7.30 (SE = 5.93)
day of surgery (SE = 10.05)
Vercruyssen NC Just after surgery cPGIP vs FHIP: NC cPGIP vs FHIP: NC NC NC
et al (2014a,b,c, MD = 1.30 (SE = 5.22) MD = −23.60 (SE = 3.52)*
2015), Bernard sCAIP (Mat Mu) vs FHIP: sCAIP (Mat Mu) vs FHIP.
et al (2019)29–33 MD = −10.50 MD = −28.50 (SE = 3.35)*
(SE = 4.25)* sCAIP (Fac Mu) vs FHIP.
sCAIP (Fac Mu) vs FHIP: MD = −22.00 (SE = 3.78)*
MD = 0.80 (SE = 5.42) sCAIP (Mat Mu) vs cPGIP:
sCAIP (Mat Mu) vs MD = −4.90 (SE = 2.42)*
cPGIP: sCAIP (Fac Mu) vs cPGIP:
MD = −11.80 MD = 1.60 (SE = 2.94)
(SE = 3.96)* sCAIP (Fac Mu) vs sCAIP
sCAIP (Fac Mu) vs cPGIP: (Mat Mu):
MD = −0.50 (SE = 5.19) MD = 6.50 (SE = 2.79)*
sCAIP (Fac Mu) vs sCAIP
(Mat Mu):
MD = 11.30 (SE = 4.24)*
Younes et al (2018, FHIP: NR NC NC NC sCAIP vs FHIP: NC NC NC
2019)26,27 sCAIP: NR out of 21 MD = −17.54 (SE = 6.99)
implants (3 out of 10
participants) d
Note: Time points consider implant placement as reference. Results on binary outcomes are reported as crude numbers, while results on continuous outcomes are reported as MD (SE).
Abbreviations: Bo, bone-supported; cPGIP, cast-based partially guided implant placement; dPGIP, drill partially guided implant placement; Fac, Facilitate; FHIP, free-handed implant placement; Mat,
Materialise; MD, difference in means; mm, millimeters; Mu, mucosa-supported; NC, not collected; NR, not reported; PROMs, patient-reported outcome measures; sCAIP, static computer-aided implant
placement; SE, standard error; VAS, visual analogue scale.
a
Self-reported VAS, measured in mm.
b
Self-reported “general satisfaction” on a VAS, measured in mm.
c
Complications reported: “(a) fracture of the buccal bone wall during implant insertion, which hampered the implant placement at the planned site (one implant); (b) fracture of the insertion driver inside the
implant during its installation, preventing the implant from reaching the position indicated in the planning (one implant).”
d
Refers to nonfitting surgical guide which was solved before surgery (two participants, four implants), or surgical guide not delivered in time (with consequent FHIP, but retained in sCAIP group for
intention-to treat analysis).
*P < .05.
| 105
|
F I G U R E 5 Intragroup meta-analyses. Flapless static computer-aided implant placement (sCAIP): intraoperative complications. A, Overall
intraoperative complication rate; B, Complication rate making flapless sCAIP infeasible. DL, DerSimonian-L aird.
(planning + surgery) did not differ between the groups (Table 6). Data 4 | DISCUSSION
on long-term costs were not reported.
Because of the paucity of data found, intergroup meta-analyses Results from the current systematic review indicate that flapless
were not possible for these outcomes. sCAIP is more accurate than flapped FHIP/cPGIP with respect to
the planned position, especially in terms of angular deviation (4 de-
grees less deviation) and apical three-dimensional bodily deviations
3.9 | Certainty of evidence (0.75 mm less deviation). This difference in accuracy was even higher
when comparing only with flapped FHIP. However, evidence regard-
The “summary of findings” is reported in Table 7. Certainty of ing more clinically relevant outcomes of efficacy (implant survival
evidence was not evaluated for some of the outcomes considered and success, prosthetically and biologically correct positioning), is
as critical or important (ie, implant survival and success, biologi- currently lacking. Furthermore, flapless sCAIP, when compared with
cally and prosthetically correct positioning), as evidence for those flapped FHIP/cPGIP surgeries, have a shorter duration (~24 minutes
outcomes was absent or based on single RCTs. The certainty of less) and appear to result in less intraoperative and postoperative
the body of evidence was considered high for reduction in angu- morbidity. However, at patient level, a 12% group-specific intraop-
lar deviation, moderate for reductions in depth and apical three- erative complication rate was reported for flapless sCAIP, which fi-
dimensional bodily deviations, low for reductions in coronal nally made it infeasible in 7% of cases. Evidence from single RCTs
three-dimensional bodily deviation and postoperative pain, and indicates higher economic costs in flaples sCAIP and similar entire
very low for reduction in postoperative swelling, in flapless sCAIP procedural duration (ie, including planning) between groups, while
vs flapped FHIP/cPGIP. inconclusive to no evidence was found with regard to long-term
|
(cPGIP) vs flapless static computer-aided implant placement (sCAIP): intraoperative PROMs and surgery duration. A, Intraoperative pain; B,
Intraoperative discomfort; C, Surgery duration. DL, DerSimonian-L aird.
prognosis outcomes (ie, changes in marginal bone levels and inci- that computer guidance (sCAIP) may provide an additional reduction
dence of peri-implant diseases). In summary, the findings from the in surgery duration to the one provided by flapless surgery alone.
current systematic review corroborate the reduced invasiveness of The higher accuracy of sCAIP compared with FHIP/cPGIP with
flapless implant placement combined with the accuracy of guided respect to the planned position, regardless of the elevation (or not)
surgery (flapless sCAIP). However, there were no RCTs evaluating of a mucoperiosteal flap, was already indicated in a recent systematic
dCAIP, which limits the applicability of the present findings to flap- review, which reported lower meta-analytical estimates for angular,
less sCAIP. coronal, and apical deviation in fully guided surgery of a similar mag-
The reduced invasiveness of flapless surgery was already indi- nitude to that found in the current study.9 Raico Gallardo et al18 re-
6
cated in RCTs from the beginning of the 21st century. Fortin et al ported that the tissue of support of the guide may have an influence
showed less postoperative pain measured on VAS and less con- on accuracy outcomes, but this concept could not be verified in the
sumption of analgesic medications in a RCT comparing flapless with current systematic review, as four out of the five included trials em-
flapped surgery. Similarly, the results from the split-mouth RCT con- ployed tooth-supported guides. Finally, despite being more accurate
ducted by Cannizzaro et al41 showed shorter surgery (a difference of than flapped FHIP/cPGIP with respect to the planned position, re-
17 minutes) duration and less postoperative swelling in fully edentu- sults from the current systematic review suggest that flapless sCAIP
lous cases treated with flapless compared with flapped surgery. The is not free from positioning errors. Inaccuracies of a similar magni-
difference in the magnitude of duration compared with the results tude were already reported in the systematic review by Tahamaseb
from this systematic review (~24 minutes) may indirectly suggest et al19 studying the accuracy of sCAIP irrespective of flap elevation
|
TA B L E 6 Characteristics of the included studies -outcomes and results of interest: long-term prognosis, economic costs, and entire
procedural duration
Long-term prognosis
Peri-implant diseases Economic costs Whole procedural

Reference Marginal bone loss/level (mm) incidence (total number) (Euros) durationa (min)
Farley et al (2013)24 NC NC NC NC
28
Frizzera et al (2021) NC NC NC NC
Magrin et al (2020)25 NC NC NC NC
b
Vercruyssen At implant loading (4 mo) NR. NC NC
et al (2014a,b,c, cPGIP vs FHIP: MD = 0.56 (SE = 0.16)* The authors reported that
2015), Bernard sCAIP (Mat Mu) vs FHIP: MD = 0.23 three patients were
et al (2019)29–33 (SE = 0.12) diagnosed as affected
sCAIP (Fac Mu) vs FHIP: MD = 0.19 by peri-implantitis at
(SE = 0.15) the 12-mo follow-up
sCAIP (Mat Mu) vs cPGIP: MD = −0.44 according to the Sanz
(SE = 0.16)* and Chapple (2012) case
sCAIP (Fac Mu) vs cPGIP: MD = −0.37 definition,42 without
(SE = 0.19) indicating their study
sCAIP (Fac Mu) vs sCAIP (Mat Mu): groups
MD = 0.07 (SE = 0.16)
12-mob
cPGIP vs FHIP: MD = 0.55 (SE = 0.18)*
sCAIP (Mat Mu) vs FHIP: MD = 0.14
(SE = 0.11)
sCAIP (Fac Mu) vs FHIP: MD = 0.25
(SE = 0.17)
sCAIP (Mat Mu) vs cPGIP: MD = −0.41
(SE = 0.19)*
sCAIP (Fac Mu) vs cPGIP: MD = −0.30
(SE = 0.23)
sCAIP (Fac Mu) vs sCAIP (Mat Mu):
MD = 0.11 (SE = 0.18)
36 mob
cPGIP vs FHIP: MD = 0.30 (SE = 0.13)*
sCAIP (Mat Mu) vs FHIP: MD = −0.10
(SE = 0.10)
sCAIP (Fac Mu) vs FHIP: MD = 0.40
(SE = 0.22)
sCAIP (Mat Mu) vs cPGIP: MD = −0.40
(SE = 0.12)*
sCAIP (Fac Mu) vs cPGIP: MD = 0.10
(SE = 0.23)
sCAIP (Fac Mu) vs sCAIP (Mat Mu):
MD = 0.50 (SE = 0.21)*
Younes et al (2018, NC NC sCAIP vs sCAIP vs FHIP:
2019)26,27 FHIPc: MD = 2.86
MD = 222.52 (SE = 7.26)
(SE = 7.40)*
Note: Time points consider implant placement as reference. Results on continuous outcomes are reported as MD (SE).
Abbreviations: Bo, bone-supported; cPGIP, cast-based partially guided implant placement; dPGIP, drill partially guided implant placement; Fac,
Facilitate; FHIP, free-handed implant placement; Mat, Materialise; MD, difference in means; mm, millimeters; Mu, mucosa-supported; NC, not
collected; NR, not reported; sCAIP, static computer-aided implant placement; SE, standard error.
a
The time necessary for the whole implant placement procedure (planning and surgery).
b
Refers to bone levels.40
c
The estimated imposed costs to the patient were calculated simulating that treatments were performed in normal clinical practice. A distinction was
made between standard costs (including radiographic examinations and prosthetic fees), which were identical for the study groups, and additional
costs, which were group-specific for sCAIP groups; evaluated at 12 wk (restoration delivery).
*P < .05.
TA B L E 7 Summary of findings
ROMANDINI et al.
Authors: Mario Romandini, Edwin Ruales, Sofya Sadilina, Christoph Hämmerle, Mariano Sanz
Question: Flapless sCAIP compared with flapped FHIP/cPGIP for implant placement
Setting: When the objective is to guarantee minimally invasiveness
Certainty assessment No. of implants Effect
Relative
Other flapped FHIP/ (95%
No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision considerations flapless sCAIP cPGIP CI) Absolute (95% CI) Certainty Importance
Depth deviation (assessed with: Metric discrepancy [measured in mm] on CBCT)
3 Randomized Not serious Not serious Not serious Seriousa None 83 87 — MD 0.28 mm lower (0.59 lower to ⨁⨁⨁◯ Important
trials 0.03 higher) Moderate
Angular deviation (assessed with: Angular discrepancy [measured in degrees] on CBCT)
4 Randomized Not serious Not serious Not serious Not serious None 95 99 — MD 3.88 degrees lower (7 lower ⨁⨁⨁⨁ Important
trials to 0.77 lower) High
Coronal 3D bodily deviation (assessed with: Metric discrepancy [measured in mm] on CBCT)
4 Randomized Not serious Seriousb Not serious Serious a None 95 99 — MD 0.6 mm lower (1.21 lower to ⨁⨁◯◯ Important
trials 0.01 higher) Low
Apical 3D bodily deviation (assessed with: Metric discrepancy [measured in mm] on CBCT)
4 Randomized Not serious Seriousb Not serious Not serious None 95 99 — MD 0.75 mm lower (1.43 lower to ⨁⨁⨁◯ Important
trials 0.07 lower) Moderate
Postoperative pain (follow-up: median 7 d; assessed with: VAS (mm); Scale from: 0 to 100)
3 Randomized Seriousc Seriousb Not serious Not serious None 74 73 — MD 17.09 mm lower (33.38 lower ⨁⨁◯◯ Important
trials to 0.8 lower) Low
Postoperative swelling (follow-up: median 7 d; assessed with: VAS (mm); Scale from: 0 to 100)
2 Randomized Seriousc Seriousb Not serious Seriousd None 64 63 — MD 6.59 mm lower (19.03 lower to ⨁◯◯◯ Important
trials 5.85 higher) Very low
Abbreviations: CBCT, cone beam computed tomography; CI, confidence interval; MD, difference in means; OIS, optimal information size; OR, odds ratio; VAS, visual analogue scale.
a
The OIS criterion was met, but the 95% CI slightly overlapped no effect and at the same time it failed to exclude an important benefit (0.5 mm).
b
High level of unexplained heterogeneity in the effect size.
c
Most information is from studies at low/unclear risk of bias, but potential limitations are likely to lower confidence in the estimate of effect.
d
The OIS was met, but the 95% CI clearly overlapped no effect and at the same time it failed to exclude an important benefit (10 mm).
| 109
|
and suggesting a safety margin of at least 2 mm. These errors may be procedures to cases characterized by the presence of a sufficient
even more relevant when sCAIP is applied flapless. amount of keratinized tissue and no need for bone augmentation.
This systematic review was carried out following an “a priori” Moreover, despite being associated with better accuracy than
protocol registered on PROSPERO and in accordance with Cochrane flapped FHIP/cPGIP, clinicians should consider that flapless sCAIP is
Collaboration recommendations. Further data submission by the still associated with some inaccuracies with respect to the planned
authors in three out of five studies allowed the realization of IPD implant position. Accordingly, and considering the meta-
analytic
analysis, which made meta-analyses feasible despite the small num- measures of dispersions, a prudent safety margin of around 2 mm in
ber of included trials, and enabled merging studies with different depth, 3 mm in coronal and apical three-dimensional bodily position,
designs using proper estimates (ie, adjusted for split-mouth and/or and 4 degrees in angulation, may be recommended when applying
clustering). Moreover, data on nonpublished outcome results were sCAIP flapless. Finally, clinicians should consider that realizing flap-
provided by authors, thus minimizing the risk of selective reporting less sCAIP procedures requires a learning curve for managing all the
bias. Finally, publication bias risk was reduced by searching unpub- preoperative and intraoperative procedures associated with this ap-
lished trials in the gray literature. proach (eg, three-dimensional planning). All these factors should be
Several limitations should, however, be considered when inter- weighed up on a case-by-case basis.
preting the results of the current systematic review. Despite the ex- The findings of this systematic review also highlight the need for
tensive literature search, only five RCTs fulfilling the inclusion criteria future research in this field. Priority should be given to design RCTs
were found. The overall risk of bias evaluation was frequently not comparing flapless dCAIP with flapped FHIP/cPGIP. Moreover, long-
considered as low, and only one trial reported data with a follow-up term data on flapless sCAIP vs flapped FHIP/cPGIP are needed, spe-
longer than 12 weeks. Moreover, clinically meaningful outcomes (eg, cifically on implant survival, success, the incidence of peri-implant
biologically/prosthetically correct positioning, long-term implant sur- diseases, and long-term costs.
vival and success), were lacking. This may be relevant, because de-
spite the benefits in accuracy demonstrated in this systematic review AC K N OW L E D G M E N T S
when comparing flapless sCAIP with flapped FHIP/cPGIP surgeries, The authors are extremely grateful to Gabriel Magrin, Nichlas
these differences may potentially have no impact on the long-term Nicchio, and Faris Younes for providing more information about
prognosis of placed implants. Additional limitations worth mention- their trials, as well as the requested additional data analyses and/
ing are the moderate/high level of heterogeneity present in most or IPD. Moreover, the authors would like to kindly thank Volkan
meta-analyses that was not always explained by subgroup analyses Arisan, Lauren Bernard, Gábor Braunitzer, Nancy Clelland, Sigmar
(even if calculations of heterogeneity values may be questionable Schnutenhaus, and Tommie Van de Velde for the information they
because of the small number of trials included), the wide prediction provided about their published or ongoing trials, regardless of the
intervals (which indicate that flapless sCAIP may not be beneficial in final decision whether to include them in the current systematic
some settings), and the limited external validity attributable to the review. Finally, the authors wish to thank Mustafa Tattan and
inclusion criteria and methods employed in the included trials (eg, Leandro Chambrone for the kind information provided about their
no need for bone augmentation, most evidence coming from tooth- systematic review on a similar topic, as well as Crystal Marruganti
supported guides, and no evidence about flapless dCAIP). and Georgios Antonoglou for their precious help during data
synthesis.
5 | CO N C LU S I O N S C O N FL I C T O F I N T E R E S T
There were no conflicts of interest in relation to this systematic
In conclusion, when considering the surgical invasiveness and the review.
accuracy of implant placement with respect to the planned posi-
tion, this systematic review has shown improved outcomes when DATA AVA I L A B I L I T Y S TAT E M E N T
using flapless sCAIP. Indeed, on one hand, flapless sCAIP seems to The data that support the findings of this study are available from
be associated with the reduced invasiveness distinctive of flapless the corresponding author upon reasonable request.
approaches, specifically to a shorter surgical time, and to less in-
traoperative and postoperative morbidity (very low/low certainty). ORCID
On the other hand, it preserves and even maximizes the short-term Mario Romandini https://orcid.org/0000-0001-5646-083X
efficacy outcomes characterizing fully guided surgeries, especially Edwin Ruales-Carrera https://orcid.org/0000-0001-7385-5673
in terms of accuracy with respect to the planned implant position
(moderate/high certainty). However, whether these advantages
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41. Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless

versus open flap implant surgery in partially edentulous patients How to cite this article: Romandini M, Ruales-C arrera E,
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DOI: 10.1111/prd.

Minimal invasiveness at dental implant placement:

Mario Romandini1 | Edwin Ruales-­Carrera2,3 | Sofya Sadilina1,4 |

1 | I NTRO D U C TI O N however, is that the topography of the underlying bone cannot be

Periodontology 2000. 2023;91:89–112. ﻿ wileyonlinelibrary.com/journal/prd | 89

2.6 | Data extraction and management

3 | R E S U LT S 3.2.2 | Interventions and comparisons

TA B L E 1 Characteristics of the included studies -­methods, participants, and funding

Number Experience of surgical

Frizzera et al (2021)28 Brazil Split-­mouth University 1 Undergraduate 1 wk

Magrin et al (2020)25 Brazil Split-­mouth University 1 Expert 1 wk

Vercruyssen Belgium Parallel with University 1 Expert 3y

Younes et al (2018, Belgium Parallel with University 2 Middle experienced 12 wk

Abbreviations: N, number; NR, not reported.

10 (20) 42.1 Males: Nonsmokers: Single tooth gap: Maxilla: Biomet 3i

TA B L E 2 Characteristics of the included studies -­interventions and comparisons

Antibiotic Depth control during

NR NR Biomet 3i Stereolithography Tooth-­supported NR

Yes NR Singular Dérig-­ Stereolithography Tooth-­supported Yes

No NR Neodent Stereolithography Tooth-­supported Yes

Yes Conventional (>2 mo) OsseoSpeed EV Stereolithography Tooth-­supported No

TA B L E 3 Characteristics of the included studies -­outcomes and results of interest: efficacy

Vercruyssen Implant survival at loading (4 mo) NC 10 d NC

NC sCAIP vs cPGIPa: sCAIP vs cPGIP: sCAIP vs cPGIP: sCAIP vs cPGIP.

Frizzera et al (2021)28 Day 7b cPGIP: 0 out of 10 sCAIP vs cPGIP: sCAIP vs cPGIPc: NC NC NC NC NC

Vercruyssen Day 7d NC cPGIP vs FHIP: NC NC cPGIP vs FHIP: NC cPGIP vs FHIPe: NC

Intraoperative outcomes Additional PROMs

Peri-­implant diseases Economic costs Whole procedural

Setting: When the objective is to guarantee minimally invasiveness

Certainty assessment No. of implants Effect

Depth deviation (assessed with: Metric discrepancy [measured in mm] on CBCT)

Angular deviation (assessed with: Angular discrepancy [measured in degrees] on CBCT)

41. Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless

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Mario Romandini1 | Edwin Ruales-Carrera2,3 | Sofya Sadilina1,4 |

Periodontology 2000. 2023;91:89–112. wileyonlinelibrary.com/journal/prd | 89

TA B L E 1 Characteristics of the included studies -methods, participants, and funding

Frizzera et al (2021)28 Brazil Split-mouth University 1 Undergraduate 1 wk

Magrin et al (2020)25 Brazil Split-mouth University 1 Expert 1 wk

TA B L E 2 Characteristics of the included studies -interventions and comparisons

NR NR Biomet 3i Stereolithography Tooth-supported NR

Yes NR Singular Dérig- Stereolithography Tooth-supported Yes

No NR Neodent Stereolithography Tooth-supported Yes

Yes Conventional (>2 mo) OsseoSpeed EV Stereolithography Tooth-supported No

TA B L E 3 Characteristics of the included studies -outcomes and results of interest: efficacy

Peri-implant diseases Economic costs Whole procedural