How much does experience in guided implant surgery play a role in accuracy? A randomized controlled pilot study

Accuracy of an autonomous dental implant robotic system in dental implant surgery

STATEMENT OF PROBLEM

Autonomous dental implant robot systems (ADIRSs) have been marketed for dental implant surgery; however, research on their accuracy is limited.

PURPOSE

The purpose of this clinical study was to examine the accuracy of an ADIRS.

MATERIAL AND METHODS

Seventy-four participants with partial edentulism underwent implant surgery by using the ADIRS. Before surgery, a cone beam computed tomography (CBCT) scan was conducted, and its image data were fed into the ADIRS navigation and positioning system for iterative reconstruction and surgical path planning. After local anesthesia administration, area disinfection, and patient registration, the robot prepared the osteotomy and placed the implant under guidance of the navigation system. A postoperative CBCT scan was made to assess deviations between the planned and actual implant positions. The global coronal, apical, and angular deviations were measured and analyzed. A generalized linear mixed model (GLMM) was used to compare the differences in major outcome variables (α=.05).

RESULTS

All implant procedures were successfully carried out without any complications during surgery. A total of 86 implants were placed in 74 participants. The mean ±standard deviation global coronal deviation, global apical deviation, and angular deviation was 0.61 ±0.20 mm (95% CI: 0.23 to 1.0 mm), 0.79 ±0.32 mm (95% CI: 0.17 to 1.41 mm), and 2.56 ±1.10 degrees (95% CI: 0.42 to 4.70 degrees), respectively. The findings from the GLMM revealed that the implant region (premolar, molar; maxilla, mandible; left, right), implant length, and surgeon did not significantly impact accuracy (P>.05).

CONCLUSIONS

ADIRS showed high accuracy for implant placement because of the control of angular deviation and axial errors. The implant region, implant length, and surgeon had no significant influence on the accuracy of implant placement. Nevertheless, more clinical studies are required to support evidence-based clinical outcomes.

Exploring the Learning Curve of Dental Implant Placement Using a Task-Autonomous Robotic System Among Young Dentists From Different Specialties-A Pilot Module Study

BACKGROUND

The learning curve effect of dynamic computer-assisted implant surgery (D-CAIS) was observed among inexperienced novice surgeons. The learning curves can provide valuable information for novice surgeons and valid comparisons between new and conventional techniques. Recently, robotic computer-assisted implant surgery (R-CAIS) has shown promise as a novel dental implant surgical technique for both partially and edentulous patients. However, its learning curve remains unknown.

PURPOSE

The aim of this study was to explore the learning curve of dental implant placement surgery with a task-autonomous robotic system among young dentists with different specialties.

METHODS AND MATERIALS

Four young dentists (mean age: 25.3 ± 1.5 years at the beginning of their first attempt) with equal representation of males and females and with different specialties participated in this study. None of the participants had prior experience in R-CAIS. Each operator placed eight implants over eight attempts using a semi-active task-autonomous robotic system. Among the eight implants, four were straight lateral incisor implants, and four were 30°-tilted premolar implants. The implants were placed in each dental quadrant of the maxillary and mandibular jaw modules. The operation time was recorded. Coronal, apical, and angular deviations between the planned and actual sites of implant placement were measured by merging preoperative and postoperative cone-beam computed tomography (CBCT) scans. The data were analyzed with repeated-measures ANOVA (α = 0.05).

RESULTS

The mean time for implant placement was associated with the number of attempts (p < 0.01). The time taken for the second attempt was significantly shorter than that of the first attempt (33.26 vs. 30.47 min; p < 0.001) then it plateaued. Three-dimensional (3D) angular (p = 0.31), coronal deviation (p = 0.26), and apical deviation (p = 0.06) did not differ significantly among attempts. The mean values and standard deviations of 3D coronal deviation, 3D apical deviation, and 3D angular deviation were 0.71 ± 0.31 mm, 0.72 ± 0.30 mm, and 0.94 ± 0.58°, respectively. Neither the position of the jaw (p > 0.59) nor the tilt angle of the implant (straight or 30°-tilted, p > 0.85) was related to implant placement accuracy.

CONCLUSIONS

Dentists quickly learned the basic workflow of R-CAIS and thus facilitated the clinicians in the mastery of implant placement on edentulous jaw modules, leading to a comparable operating speed and high precision. Moreover, the accuracy of placement of straight and tilted implants in both the maxilla and mandible with R-CAIS was satisfactory.

Implant placement with an autonomous dental implant robot: A clinical report

Ideal implant placement is the basis for long-term implant survival and satisfactory restoration outcomes. Static and dynamic computer-assisted guidance have been used to improve the accuracy of implant placement, but both have shortcomings that robots can overcome. This clinical report describes the use of an autonomous implant robot to complete the placement of 2 adjacent implants with immediate postoperative restoration.

Influence of Material, Sterilization, and Disinfection on the Accuracy of Three-Dimensional Printed Surgical Templates: An In Vitro Study

OBJECTIVES

To evaluate the influence of the three-dimensional (3D) printing technology, material, sterilization, and disinfection on the accuracy of guided surgical templates.

MATERIAL AND METHODS

Fifty printed resin surgical templates were designed and fabricated using a digital light processing 3D printer with a photopolymerizing resin, and 50 printed metal surgical templates were designed and fabricated using a selective laser melting 3D printer with a titanium alloy. Templates from both groups were randomly divided into five subgroups involving different sterilization and disinfection procedures. The group without any sterilization or disinfection procedure served as the control group, whereas the other groups were used as the study groups (hydrogen peroxide gas plasma sterilization, 5% povidone-iodine disinfection, 75% ethyl alcohol disinfection, and steam autoclave sterilization). Implant simulations were performed on the 3D-printed resin models, and postoperative impressions were acquired with scan bodies attached to the implants. All surgical templates were digitally scanned. The root mean square was used to determine and quantify fabrication accuracy and reproducibility, and the definitive and planned implant positions were compared.

RESULTS

The printed resin templates exhibited lower fabrication accuracy and reproducibility, as well as higher 3D deviations, after steam autoclave sterilization (p < 0.001); however, the printed metal templates were not affected by the different sterilization or disinfection procedures (p > 0.05).

CONCLUSIONS

Printed metal surgical templates are viable alternatives for guided implant surgery. Preoperative steam or gas plasma sterilization is recommended, especially for metal templates, as resin templates show deformation and decreased accuracy after steam sterilization.

TRIAL REGISTRATION

chictr.org.cn number: ChiCTR2400081334.

Safety and accuracy assessment of static computer assisted localized piezoelectric alveolar decortication: an in vitro study

OBJECTIVES

To assess the safety and accuracy of static computer assisted corticotomy surgery (sCACS) in comparison with freehand piezocision.

MATERIALS AND METHODS

A randomized in vitro study was conducted. A total of 260 interradicular corticotomies were performed in 20 identical printed models. sCACS was performed in half of the models, while the rest underwent freehand localized decortication. Accuracy was measured in the three spatial axes by overlapping the digital planning with a previous cone-beam computed tomography (CBCT) scan of the patient and a postoperative CBCT of the models. Safety was determined as the number of damaged root surfaces. Descriptive and bivariate analyses were performed.

RESULTS

Freehand corticotomies increased the likelihood of iatrogenic root damage 2.21-fold (95%CI: 1.30 to 3.77; p = 0.004). Both groups showed some degree of deviation compared to digital planning. Nevertheless, the accuracy of sCACS was significantly greater in sagittal (B = -0.21 mm, 95%CI: -0.29 to -0.12; p < 0.001), axial (B = -0.32 mm, 95%CI: -0.48 to -0.18; p < 0.001) and angular deviation (B = -2.02º; 95%CI: -2.37 to -1.66; p < 0.001) compared to freehand surgery, with the exception of depth.

CONCLUSIONS

The precision and safety of sCACS are greater than the freehand technique.

CLINICAL RELEVANCE

Corticotomies are performed in crowded areas where there is usually space limitation. Clinicians should consider the systematic use of surgical guides, since minimal deviations can cause iatrogenic root damage in areas where malocclusions are present.

Randomized controlled trial on the efficacy of a custom-made, fully guided implant system for flapless crestal sinus floor elevation: Accuracy and patient-reported outcomes

OBJECTIVE

To compare fully guided flapless implant surgery using a light-cured surgical guide (FG group) with partially guided open flap surgery (PG group) in the posterior maxilla when performing simultaneous sinus floor elevation in terms of the accuracy, time requirements, and patient/clinician-reported outcomes (PROMs and CROMs).

MATERIALS AND METHODS

In this study, 56 tissue-level implants were placed with crestal sinus floor elevation in 56 patients at single-tooth sites, with 28 implants allocated to the PG group and 28 to the FG group. The deviations of the placed implants from the virtually planned positions were measured at the implant platform and apex and for the angular deviation. The presurgical preparation time and the duration of surgery were measured. PROMs and CROMs were made by administering questionnaires at multiple time points.

RESULTS

Horizontal deviations at the platform and apex and the angular deviation were significantly smaller in the FG group than the PG group (p < .05). Presurgical preparation and surgery times were significantly shorter in the FG group (p < .001). Patient satisfaction and willingness to receive repeat treatment were significantly better in the FG group than in the PG group (p < .005 and .025, respectively). Clinicians were more satisfied in the FG group than the PG group (p < .05).

CONCLUSION

When placing an implant with sinus floor elevation, the flapless approach using a fully guided surgical system can be more accurate, faster, and increase the satisfaction of both the clinician and patient compared to the partially guided surgery.

Influence of clinical expertise and practical experience on transfer accuracy in guided dental implant placement - an in vitro study

PURPOSE

To investigate whether inexperienced users applying a static navigation system can perform in-vitro a fully guided implant placement protocol and achieve similar results in terms of accuracy compared to experienced clinicians.

METHODS

Based on 36 identical resin models, a computer-assisted implant planning was performed and a surgical guide was produced accordingly. Three study groups were composed with 12 operators, each: control group with experienced surgeons (DOC), test group 1 with dental technicians (TEC) and test group 2 with non-specialists (OFC). Using a fully guided drilling protocol, two implants were placed into each of the 36 models. Subsequently, the differences between the virtually planned and final implant positions were determined and the transfer accuracy was evaluated.

RESULTS

For the control group DOC, the mean value of axial deviation was 1.90 ± 1.15 degrees, for 3-dimensional deviation at the implant base 0.52 ± 0.33 mm, for 3-dimensional deviation at the implant tip 0.76 ± 0.39 mm and for vertical deviation at the implant tip - 0.11 ± 0.51 mm. For corresponding parameters, the mean values of test group TEC were 1.99 ± 0.87 degrees, 0.42 ± 0.21 mm, 0.68 ± 0.30 mm and - 0.03 ± 0.33 mm and for test group OFC 2.29 ± 1.17 degrees, 0.63 ± 0.35 mm, 0.89 ± 0.43 mm and - 0.24 ± 0.57 mm, respectively. The results did not reveal any statistically significant differences between the control and the 2 test groups (p˃0.05).

CONCLUSION

The results of the present in-vitro study demonstrated that inexperienced users applying a static navigation system can perform a fully guided implant placement protocol and achieve similar results in terms of accuracy compared to experienced clinicians in this specific in vitro setup.

Co-Designing Dynamic Mixed Reality Drill Positioning Widgets: A Collaborative Approach with Dentists in a Realistic Setup

Mixed Reality (MR) is proven in the literature to support precise spatial dental drill positioning by superimposing 3D widgets. Despite this, the related knowledge about widget's visual design and interactive user feedback is still limited. Therefore, this study is contributed to by co-designed MR drill tool positioning widgets with two expert dentists and three MR experts. The results of co-design are two static widgets (SWs): a simple entry point, a target axis, and two dynamic widgets (DWs), variants of dynamic error visualization with and without a target axis (DWTA and DWEP). We evaluated the co-designed widgets in a virtual reality simulation supported by a realistic setup with a tracked phantom patient, a virtual magnifying loupe, and a dentist's foot pedal. The user study involved 35 dentists with various backgrounds and years of experience. The findings demonstrated significant results; DWs outperform SWs in positional and rotational precision, especially with younger generations and subjects with gaming experiences. The user preference remains for DWs (19) instead of SWs (16). However, findings indicated that the precision positively correlates with the time trade-off. The post-experience questionnaire (NASA-TLX) showed that DWs increase mental and physical demand, effort, and frustration more than SWs. Comparisons between DWEP and DWTA show that the DW's complexity level influences time, physical and mental demands. The DWs are extensible to diverse medical and industrial scenarios that demand precision.

Trephination-based autonomous robotic surgery for dental implant placement: A proof of concept

OBJECTIVES

To present a novel drilling protocol of trephine osteotomy technique for autologous bone grafting with simultaneous implant placement using an autonomous robotic system.

METHODS

The novel protocol consists of 1) preoperative procedures: marker fabrication and fixation, data acquisition, and preoperative planning; 2) intraoperative procedures: registration and calibration, and osteotomy and implant placement performed by an autonomous dental implant robot; 3) postoperative procedures: CBCT acquisition and accuracy assessment.

RESULT

The protocol was an effective method for implant osteotomy, with no reported intraoperative complications. The implant surgery was successfully completed, and autogenous bone was obtained. Meanwhile, the accuracy of implant placement was clinically acceptable, with minor deviations.

CONCLUSIONS

Trephination-based robotic surgery can be successfully implemented in implant osteotomy, which might replace freehand implant surgery and conventional drilling protocol. However, further clinical studies are necessary.

CLINICAL SIGNIFICANCE

The main finding of this case is a potential alternative for preserving autogenous bone during implant surgery.

Computer-assisted and robotic implant surgery: Assessing the outcome measures of accuracy and educational implications

OBJECTIVE

This scoping review aimed to (1) critically evaluate the outcomes measures used to assess the accuracy of implant placement with Computer Assisted Implant Surgery (CAIS) and (2) review the evidence supporting the efficient implementation of CAIS in training and education of clinicians.

METHODS

A scoping literature review was conducted aiming to identify (a) clinical trials assessing accuracy of implant placement with CAIS, and (b) clinical trials or simulation/cadaver studies where CAIS was utilised and assessed for the training/education of clinicians. Studies since 1995 were assessed for suitability and data related to the outcomes measures of accuracy and educational efficacy were extracted and synthesised.

RESULTS

Accuracy of CAIS has been mainly assessed through surrogate measures. Individual clinical trials have not shown any difference between static and dynamic CAIS, but recent meta-analyses suggest an advantage of dynamic CAIS in reducing angular deviation. The combination of static and dynamic CAIS might offer higher accuracy than each of the two used alone. Dynamic CAIS is suitable for novice surgeons and might even have added value as an education tool for implant surgery, although mastering the technique requires longer training than static.

CONCLUSION

Meta-analyses of large samples, new and diverse outcomes measures, as well as benchmarking of levels of accuracy with specific clinical outcomes will help to better understand the potential and limitations of CAIS. Dynamic CAIS is suitable for novice operators, but educational interventions distributed over longer periods of time will be required for mastery of the process.

Accuracy of computer-guided implant surgery in partially edentulous patients: a prospective observational study

PURPOSE

This study aims to evaluate the amount of distortion using computer-guided implant surgery with 3D printed surgical guides in limited edentulous spaces.

MATERIALS AND METHODS

25 bone level self-tapping implants (Straumann® BL and BLT) were randomly inserted in either distal or intercalary posterior mandibular edentulism using a fully digital protocol and 3D printed surgical guides. Amount of inaccuracy was evaluated after superimposing the 3 coordinates of virtually planned and final implant images, which were obtained using intra-oral scans and scan bodies. Four evaluation parameters were considered: origo-displacement, error depth, apical displacement and angle between the planned and the placed implant.

RESULTS

The average of distortion was 0.71 mm for the origo-displacement, 0.36 mm for the error depth, 0.52 mm for the horizontal displacement and 3.34º for the error angle.

CONCLUSION

The major reason of exclusion was CBCT artifacts. Results of this study were aligned with the results of previous studies concerning partially edentulous spaces. CAD/CAM manufacturing process did not result in significant distortion whilst the biggest part of distortions originated from the surgical process. The learning curve in computer-guided implant surgery presented an important source of inaccuracy.

Accuracy of the novel digital non-cross-arch surgical guides with integration of tooth undercut retention and screw-bone support for implant placement in mandibular free-end

BACKGROUND

Large cross-arch free-end surgical guides can obscure the visual field, compromising surgical accuracy due to insufficient stability at the free-end. This in vitro study aims to evaluate the accuracy of novel digital non-cross-arch surgical guides designed for implant placement at the mandibular free-end, incorporating tooth undercut retention and screw-bone support.

MATERIALS AND METHODS

A mandibular dental model lacking left molars was utilized to fabricate unilateral (cross-arch) tooth-supported surgical guides (GT I, n = 20). Subsequently, two additional types of surgical guides were fabricated: GT II (covering two teeth, n = 20) and GT III (covering three teeth, n = 20). These novel surgical guides were designed to utilize the undercut of the supporting teeth for retention and enhance stability with screw-bone support at the guide's free-end. Furthermore, 60 identical guiding blocks were assembled on the three types of surgical guides to facilitate the implants' insertion. On a phantom head, 120 implant replicas were placed at the Federal Dentaire Internationale (FDI) teeth positions #36 and #37 on the dental model, employing a combination of surgical guides and guiding blocks. To assess accuracy, planned and placed implant positions were compared using intraoral optical scanning. Discrepancies in angulation and linear deviations, including the coronal/apical 3D deviations, lateral deviation as well as depth deviation, were measured. Statistical analysis was performed using two-way ANOVA and Bonferroni test (α = 0.05).

RESULTS

GT I exhibited significantly largest discrepancies, including angular and linear deviations at the crest and apex at every implant site. Especially in depth, at implant site #36, the mean deviation value of GT I (0.27 ± 0.13 mm) was twice as large as GT III (0.13 ± 0.07 mm), and almost twice as large as GT II (0.14 ± 0.08 mm). However, at implant site #37, this deviation increased to almost a five-fold relationship between GT I (0.63 ± 0.12 mm) and II (0.14 ± 0.09 mm), as well as between GT I and III (0.13 ± 0.09 mm). No significant discrepancies existed between the novel surgical guides at either implant site #36 or #37.

CONCLUSION

This study provides a practical protocol for enhancing accuracy of implant placement and reducing the size of free-end surgical guides used at mandibular molar sites.

Effect of guided implant placement learning experiences on freehand skills: A pilot study

OBJECTIVES

Guided implant systems can be used as a training approach for placing implants. This in vitro prospective randomized pilot study evaluated the learning progression and skill development in freehand placement of two implants supporting a three-unit fixed prosthesis on a simulation model among novice operators.

MATERIAL AND METHODS

Four senior dental students with no prior implant placement experience participated in the study. As a baseline, each student placed two mandibular and two maxillary implants by freehand technique on a simulation model. Sixteen consecutive guided placements using a static guide, dynamic navigation, and template-based guide followed totaling 32 guided implant placements into maxillary and mandibular models. Freehand implant placements before and after the various guided navigation attempts were compared to assess their impact on freehand skill. Metrics compared included surgical time, horizontal, vertical, and angulation discrepancies between the planned and placed implant positions measured on superimposed CBCT scans and analyzed with repeated measures regression with Tukey's adjusted pairwise comparisons (α = .05).

RESULTS

Before training with guided techniques, the average baseline freehand implant placement took 10.2 min and decreased to 8.2 after training but this difference was not statistically significant (p = .1670) There was marginal evidence of a significant difference in the 3D apex deviation with an average improvement of 0.89 mm (95% CI: -0.38, 2.16, p = .1120); and marginal evidence of a significant improvement in the overall angle with an average improvement of 3.74° (95% CI: -1.00, 8.48, p = .0869) between baseline and final freehand placement attempts.

CONCLUSIONS

Within the limitations of this pilot study, guided implant placement experiences did not significantly benefit or hinder freehand placement skills. Dental students should be exposed to various placement techniques to prepare them for clinical practice and allow them to make informed decisions on the best technique based on their skills and a given clinical scenario.

Accuracy of implant placement with computer-aided static, dynamic, and robot-assisted surgery: a systematic review and meta-analysis of clinical trials

This systematic review explores the accuracy of computerized guided implant placement including computer-aided static, dynamic, and robot-assisted surgery. An electronic search up to February 28, 2023, was conducted using the PubMed, Embase, and Scopus databases using the search terms "surgery", "computer-assisted", "dynamic computer-assisted", "robotic surgical procedures", and "dental implants". The outcome variables were discrepancies including the implant's 3D-coronal, -apical and -angular deviations. Articles were selectively retrieved according to the inclusion and exclusion criteria, and the data were quantitatively meta-analysed to verify the study outcomes. Sixty-seven articles were finally identified and included for analysis. The accuracy comparison revealed an overall mean deviation at the entry point of 1.11 mm (95% CI: 1.02-1.19), and 1.40 mm (95% CI: 1.31-1.49) at the apex, and the angulation was 3.51˚ (95% CI: 3.27-3.75). Amongst computerized guided implant placements, the robotic system tended to show the lowest deviation (0.81 mm in coronal deviation, 0.77 mm in apical deviation, and 1.71˚ in angular deviation). No significant differences were found between the arch type and flap operation in cases of dynamic navigation. The fully-guided protocol demonstrated a significantly higher level of accuracy compared to the pilot-guided protocol, but did not show any significant difference when compared to the partially guided protocol. The use of computerized technology clinically affirms that operators can accurately place implants in three directions. Several studies agree that a fully guided protocol is the gold standard in clinical practice.

Influence of surgeon experience on implant placement in guided surgeries: A systematic review and meta-analysis of randomized clinical trials

STATEMENT OF PROBLEM

Guided surgical techniques in implant dentistry use virtual planning to accurately position implants. Understanding the effect of a surgeon's experience on guided surgery is essential to ensure successful outcomes.

PURPOSE

The purpose of this systematic review and meta-analysis of randomized clinical trials was to evaluate the influence of a surgeon's experience on the accuracy of implant positioning in guided surgery for completely or partially edentulous patients.

MATERIAL AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, searches were conducted in the PubMed, Scopus, Web of Science, EMBASE, Cochrane Library, SciELO, and nonpeer-reviewed literature databases. Studies that met the population, intervention, control, and outcome (PICO) strategy were included: a completely or partially edentulous maxilla or mandible, guided surgery performed by experienced and inexperienced surgeons, and assessing implant positioning accuracy. A random-effects meta-analysis with a 95% confidence interval was conducted using Stata 15.1. The risk of bias was assessed with the Cochrane risk-of-bias tool for randomized trials (RoB2), and evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022302288).

RESULTS

Three articles from 2017 to 2020 encompassing 43 participants (22 men and 21 women) with a mean age of 61.2 years and a total of 150 implants were included. No significant difference was found between experienced and inexperienced surgeons in terms of angular, cervical, or apical deviations of the implants (95% confidence interval, P<.05). The difference between surgeons regarding positioning accuracy was less than 0.01 degrees for angular deviation, 0.35 mm for apical deviation, and 0.16 mm for cervical deviation. Low heterogeneity was observed for angular deviations (Q P=.021, I2=34%, and t2<.001) and cervical deviations (Q P=.18, I2=45%, and t2=.064). High heterogeneity was observed for apical deviations (Q P<.001, I2=87% and t2=.522). The overall bias risk was moderate, with the evidence certainty ranging from low to moderate.

CONCLUSIONS

In guided surgery, the surgeon's experience did not significantly impact the occurrence of deviations in implant positioning.

Evaluation of the accuracy of fully guided implant placement by undergraduate students and postgraduate dentists: a comparative prospective clinical study

PURPOSE

This study aimed to assess the accuracy of implant placement through three-dimensional planning and fully guided insertion, comparing outcomes between undergraduate and postgraduate surgeons.

METHODS

Thirty-eight patients requiring 42 implants in posterior single-tooth gaps were enrolled from the University Clinic for Prosthodontics at the Martin Luther University Halle Wittenberg and the Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders of Charité University Medicine, Berlin. Twenty-two implants were placed by undergraduate students (n = 18), while 20 implants were placed by trainee postgraduate dentists (n = 5). Pre-operative intraoral scans and cone beam computed tomography images were performed for implant planning and surgical template fabrication. Postoperative intraoral scans were superimposed onto the original scans to analyze implant accuracy in terms of apical, coronal, and angular deviations, as well as vertical discrepancies.

RESULTS

In the student group, two implant insertions were performed by the assistant dentist because of intraoperative complications and, thus, were excluded from further analysis. For the remaining implants, no statistically significant differences were observed between the dentist and student groups in terms of apical (p = 0.245), coronal (p = 0.745), or angular (p = 0.185) implant deviations, as well as vertical discrepancies (p = 0.433).

CONCLUSIONS

This study confirms the viability of fully guided implant placement by undergraduate students, with comparable accuracy to postgraduate dentists. Integration into dental education can prepare students for implant procedures, expanding access and potentially reducing costs in clinical practice. Collaboration is essential for safe implementation, and future research should explore long-term outcomes and patient perspectives, contributing to the advancement of dental education and practice.

TRIAL REGISTRATION

DRKS, DRKS00023024, Registered 8 September 2020-Retrospectively registered, https://drks.de/search/de/trial/DRKS00023024 .

The Use of Dynamic Navigation Systems as a Component of Digital Dentistry

The development of dynamic navigation system (DNS) has facilitated the development of modern digital medicine. In the field of dentistry, the cutting-edge technology is garnering widespread recognition. Based on the principles of 3-dimensional visualization, virtual design, and precise motion tracking, DNS is mainly composed of a computer, a tracking system, specialized tracer instruments, and navigation software. DNS employs a workflow that begins with preoperative data acquisition and imaging data reconstruction, followed by surgical instrument calibration and spatial registration, culminating in real-time guided operations. Currently, the system has been applied in a broad spectrum of dental procedures, encompassing dental implants, oral and maxillofacial surgery (such as tooth extraction, the treatment of maxillofacial fractures, tumors, and foreign bodies, orthognathic surgery, and temporomandibular joint ankylosis surgery), intraosseous anesthesia, and endodontic treatment (including root canal therapy and endodontic surgery). These applications benefit from its enhancements in direct visualization, treatment precision, efficiency, safety, and procedural adaptability. However, the adoption of DNS is not without substantial upfront costs, required comprehensive training, additional preparatory time, and increased radiation exposure. Despite challenges, the ongoing advancements in DNS are poised to broaden its utility and substantially strengthen digital dentistry.

Case report and literature review: autonomous robotic system assisted palatal implantation at an anterior teeth site compromised by periapical cyst

Background

Immediate implant placement (IIP), which preserves gingival height and papilla shape while simultaneously accelerating the implant treatment period, has become a popular method due to its commendable clinical outcomes. Nonetheless, deploying immediate implants demands specific preconditions concerning the remaining alveolar bone. This poses a challenge to the accuracy of implant surgery.

Case presentation

In this report, we present the case of a 60-year-old woman with a left upper anterior tooth crown dislodged for over a month. Cone beam computed tomography (CBCT) revealed the absence of a labial bone wall on tooth 22, a remaining 1 mm bone wall on the labial side of the root apex, and a 17.2 mm*8.9 mm*4.7 mm shadow in the periapical region of the root apices of teeth 21 and 22, with the narrowest width on the sagittal plane being approximately 5 mm. After the surgeon removed the cyst, they completed the subsequent implantation surgery using an autonomous robot in a challenging aesthetic area. This method circumvented the potential exposure of the screw thread on the labial implant surface, assured initial implant stability.

Conclusion

Five months after the operation, the dental crown was restored. The implant remained stable, with yielding notable clinical results. To the best of our knowledge, this clinical case is the first to report the feasibility and precision of immediate implantation in anterior teeth site with periapical cyst removal, performed by an autonomous robotic surgical system. Autonomous robots exhibit exceptional accuracy by accurately controlling axial and angular errors. It can improve the accuracy of implant surgery, which may become a key technology for changing implant surgery. However, further clinical trials are still needed to provide a basis for the rapid development of robotic surgery field.

Advancing accuracy in guided implant placement: A comprehensive meta-analysis: Meta-Analysis evaluation of the accuracy of available implant placement Methods

OBJECTIVES

This meta-analysis aimed to determine the accuracy of currently available computer-assisted implant surgery (CAIS) modalities under in vitro conditions and investigate whether these novel techniques can achieve clinically acceptable accuracy.

DATA

In vitro studies comparing the postoperative implant position with the preoperative plan were included. Risk of bias was assessed using the Quality Assessment Tool For In Vitro Studies (QUIN Tool) and a sensitivity analysis was conducted using funnel plots.

SOURCES

A systematic search was performed on April 18, 2023, using the following three databases: MEDLINE (via PubMed), EMBASE, and Cochrane Central Register of Controlled Trials. No filters or restrictions were applied during the search.

RESULTS

A total of 5,894 studies were included following study selection. Robotic- and static CAIS (sCAIS) had the most accurate and clinically acceptable outcomes. sCAIS was further divided according to the guidance level. Among the sCAIS groups, fully guided implant placement had the greatest accuracy. Augmented reality-based CAIS (AR-based CAIS) had clinically acceptable results for all the outcomes except for apical global deviation. Dynamic CAIS (dCAIS) demonstrated clinically safe results, except for horizontal apical deviation. Freehand implant placement was associated with the greatest number of errors.

CONCLUSIONS

Fully guided sCAIS demonstrated the most predictable outcomes, whereas freehand sCAIS demonstrated the lowest accuracy. AR-based and robotic CAIS may be promising alternatives.

CLINICAL SIGNIFICANCE

To our knowledge, this is the first meta-analysis to evaluate the accuracy of robotic CAIS and investigate the accuracy of various CAIS modalities.

Is dynamic computer-assisted surgery more accurate than the static method for dental implant placement? A systematic review and meta-analysis

STATEMENT OF PROBLEM

Dynamic computer-assisted surgery for dental implant placement has become popular, but systematic comparisons of the accuracy of computer-assisted surgery with static surgery are lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to determine evidence on the difference in the accuracy of dynamic computer-assisted surgery compared with the static method for dental implant placement.

MATERIAL AND METHODS

A systematic search was conducted in 3 electronic databases: PubMed, Ovid, and Cochrane. Studies conducted on dental implants that compared the accuracy of positioning implants with a dynamic system with that of a static system were included. Randomized clinical trials, prospective and retrospective cohort studies, and in vitro studies were included in the review. Review articles, case reports, letters, opinion articles, commentaries, and nonpeer-reviewed literature were excluded.

RESULTS

Of the 26 full-text articles, 14 fulfilled the inclusion criteria. Of these, 2 were randomized clinical trials, 2 were prospective studies, and 1 was a retrospective cohort study. The remaining 9 were in vitro studies. A total of 1633 implants were placed with the static and 902 with the dynamic method. A significant mean difference (-0.51 degrees [95% CI: -0.90, -0.13]) between dynamic and static systems was only observed in the angular deviation of in vitro studies (P=.009). Meta-analysis was performed using Review Manager statistical software and forest plots were generated.

CONCLUSIONS

A difference was found in the angular deviation of implants placed with the dynamic approach compared with the static system. The dynamic system was better, but this difference was not demonstrable in clinical studies. No significant difference was found in the apical and coronal deviations of the dynamic and static systems.

Prosthetically guided oral implant surgery. A retrospective cohort study evaluating the 5-year surgical outcome

Purpose

This study primarily evaluated the 5-year implant survival and success rate of prosthetically guided inserted implants. The secondary aim was to evaluate the impact of clinical variables on the development of mucositis, peri-implant bone resorption, peri-implantitis, as well as early and late implant failure.

Materials and methods

An observational retrospective single-centre study was conducted on patients who were treated with dental implants in the department of oral and plastic maxillofacial surgery of the military hospital of Ulm University between 2008 and 2010. In all patients, computer-assisted 3D planning after wax-up of the prosthetic restoration and template-guided surgery with titanium implants were performed. Bone augmentation procedures were performed primarily if needed. Intraoperative and postoperative complications as well as technical and mechanical complications after prosthesis loading were evaluated. In a 5-year clinical and radiological follow-up, implant success and implant survival were assessed using descriptive statistics. A multivariable regression analysis evaluated the potential impact of augmentation procedures, wound healing complications, smoking, history of periodontitis, and preoperative API (approximal plaque index) and SBI (sulcus bleeding index) values on peri-implant mucositis, peri-implant bone resorption, peri-implantitis, as well as early and late implant failure.

Results

In this study, 466 implants in 283 patients were considered for inclusion, and sufficient data were obtained for analysis from 368 (78.9%) implants in 229 (80.9%) patients. An overall implant survival rate of 98.1% (n=361/368) at the 5-year follow-up was revealed. According to the success criteria of the study, the 5-year success rate was 97.04% (n=263/271). An early implant failure of 1.07% (n=5/466) was recorded. 48.2% of the implants were affected by peri-implant mucositis (n=122/253), while peri-implant bone resorption was detected in 21.7% of the radiologically examined implants (n=59/271). Fifteen cases of peri-implantitis (5.5%) were detected. Peri-implant bone resorption increased significantly after bone augmentation procedures (p=0.028). Wound healing complications after implantation significantly increased the prevalence of late implant failure in the maxilla (p<0.001). Peri-implant bone resorption and peri-implantitis were significantly more prevalent in smokers (p=0.022/p=0.043). Implants in patients with API>20% presented significantly higher rates of peri-implant mucositis (p=0.042). Wound healing complications after augmentation, history of periodontitis, and SBI>20% had no significant impact on the study parameters.

Conclusions

The study confirms the reliability of prosthetically guided implant surgery, showing a high implant survival and success rate in a 5-year follow-up. Intraoperative complications and technical or mechanical complications after prosthesis loading remain within acceptable clinical limits. The rate of peri-implant mucositis, peri-implant bone resorption, and peri-implantitis was within the current literature range. Optimizing periodontal health and reducing smoking would improve the outcome. Further studies need to clarify the clinical indications and investigate the long-term surgical outcome of this treatment concept.

Performances of novel custom 3D-printed cutting guide in canine caudal maxillectomy: a cadaveric study

Introduction

Caudal maxillectomies are challenging procedures for most veterinary surgeons. Custom guides may allow the procedure to become more accessible.

Methods

A cadaveric study was performed to evaluate the accuracy and efficiency of stereolithography guided (3D-printed) caudal maxillectomy. Mean absolute linear deviation from planned to performed cuts and mean procedure duration were compared pairwise between three study groups, with 10 canine cadaver head sides per group: 3D-printed guided caudal maxillectomy performed by an experienced surgeon (ESG) and a novice surgery resident (NSG), and freehand procedure performed by an experienced surgeon (ESF).

Results

Accuracy was systematically higher for ESG versus ESF, and statistically significant for 4 of 5 osteotomies (p < 0.05). There was no statistical difference in accuracy between ESG and NSG. The highest absolute mean linear deviation for ESG was <2 mm and >5 mm for ESF. Procedure duration was statistically significantly longer for ESG than ESF (p < 0.001), and for NSG than ESG (p < 0.001).

Discussion

Surgical accuracy of canine caudal maxillectomy was improved with the use of our novel custom cutting guide, despite a longer duration procedure. Improved accuracy obtained with the use of the custom cutting guide could prove beneficial in achieving complete oncologic margins. The time increase might be acceptable if hemorrhage can be adequately controlled in vivo. Further development in custom guides may improve the overall efficacy of the procedure.

Three-dimensionally printed implant surgical guide-related experience, knowledge, attitude, and professional behaviors among 2028 dentists in China: A cross-sectional study

STATEMENT OF PROBLEM

Research on the current place of 3-dimensionally printed implant surgical guides (3D-ISGs) among practicing dentists worldwide is lacking, with little research focused on dentists' experience, knowledge, attitude, or professional behavior related to 3D-ISG or on the main obstacle to adoption.

PURPOSE

The purpose of this cross-sectional study was to identify the adoption of 3D-ISG in dental practice in China and to determine factors that influence its further application and dentists' attitudes and willingness.

MATERIAL AND METHODS

Semistructured questionnaires were sent to a sample of Chinese dentists composed of users and nonusers of 3D-ISG. The questionnaires were displayed and distributed through a professional online survey system (http://www.wjx.cn) and a social media platform (WeChat). The responses were analyzed with multivariable generalized equations, and the effect of various demographic variables was determined, including dentist experience, academic degree, and type of practice (public or private).

RESULTS

A total of 2028 valid questionnaires were collected. In dental practice, 39.3% of the respondents used 3D-ISG. Respondents with a PhD (62.4%) used the 3D-ISG more than twice as frequently as respondents with a junior college degree or below (31.8%). The majority of the members of implantology departments (81.7%) applied 3D-ISG, but doctors in other departments used it at a rate of less than half. The 3D-ISG was most frequently used in the maxillary anterior area (78.4%), followed by the edentulous maxilla and mandible (61.0% and 60.5%, respectively). The main barriers were high initial cost, complex and time-consuming digital design, and lack of expertise in the proper use of 3D-ISG.

CONCLUSIONS

Most dentists did not use 3D-ISG in dental practice. The 3D-ISG application rate was significantly associated with sex, academic degree, years of dental practice, department, monthly income, and type of healthcare facility. To improve the popularity of 3D-ISG, particularly among dentists without advanced degrees, it would be important to optimize the digital design software program and provide sufficient training.

The effect of implant surgery experience on the learning curve of a dynamic navigation system: an in vitro study

BACKGROUND

Dynamic navigation systems have a broad application prospect in digital implanting field. This study aimed to explore and compare the dynamic navigation system learning curve of dentists with different implant surgery experience through dental models.

METHODS

The nine participants from the same hospital were divided equally into three groups. Group 1 (G1) and Group 2 (G2) were dentists who had more than 5 years of implant surgery experience. G1 also had more than 3 years of experience with dynamic navigation, while G2 had no experience with dynamic navigation. Group 3 (G3) consisted of dentists with no implant surgery experience and no experience with dynamic navigation. Each participant sequentially placed two implants (31 and 36) on dental models according to four practice courses (1-3, 4-6, 7-9, 10-12 exercises). Each dentist completed 1-3, 4-6 exercises in one day, and then 7-9 and 10-12 exercises 7 ± 1 days later. The preparation time, surgery time and related implant accuracy were analyzed.

RESULTS

Three groups placed 216 implants in four practice courses. The regressions for preparation time (F = 10.294, R² = 0.284), coronal deviation (F = 4.117, R² = 0.071), apical deviation (F = 13.016, R² = 0.194) and axial deviation (F = 30.736, R² = 0.363) were statistically significant in G2. The regressions for preparation time (F = 9.544, R² = 0.269), surgery time (F = 45.032, R² = 0.455), apical deviation (F = 4.295, R² = 0.074) and axial deviation (F = 21.656, R² = 0.286) were statistically significant in G3. Regarding preparation and surgery time, differences were found between G1 and G3, G2 and G3. Regarding implant accuracy, differences were found in the first two practice courses between G1 and G3.

CONCLUSIONS

The operation process of dynamic navigation system is relatively simple and easy to use. The linear regression analysis showed there is a dynamic navigation learning curve for dentists with or without implant experience and the learning curve of surgery time for dentists with implant experience fluctuates. However, dentists with implant experience learn more efficiently and have a shorter learning curve.

Learning Curve and Comparison of Dynamic Implant Placement Accuracy Using a Navigation System in Young Professionals

The aim of the current study was to evaluate the learning curve and accuracy of implant placement by young professionals using a dynamic computer-assisted surgical system for dental implant placement. Ten students tried to place eight implants with a dynamic surgical system in predefined positions on two consecutive weekends, resulting in 160 implant placements in total. Postoperatively, the positions of the implants were scanned with an intraoral scanner and compared for deviations at the entry point, the apex, as well as angular deviations to the master model. The mean values of all measurements improved; statistical significance was found for the changes in the angle as well as for the position of the implants to the apex (p < 0.001). Furthermore, the young professionals indicated subjective improvement in handling the dynamic surgery system. Navigated surgical dental implant placement can be learned quickly and can support young professionals in everyday clinical practice, especially in difficult anatomic situations.

Exploring training dental implant placement using static or dynamic devices among dental students

BACKGROUND

Static computer-assisted surgery (s-CAIS) and dynamic computer-assisted implant surgery (d-CAIS) are the main digital approaches in guiding dental implant placement.

PURPOSE

The aim of this study was to explore and compare the learning curves for s-CAIS and d-CAIS by beginners.

MATERIALS AND METHODS

Three dental students used each dental model for drilling five positions with missing teeth. Operators performed the drilling test for five sets of dental models with an interval of 7 ± 1 days assisted by the d-CAIS system. After a six-month break, the same students performed the drilling test again in the same way but with the s-CAIS system. A total of thirty models were used, and 150 implants were inserted. The operation time and relative deviations were recorded and calculated. Correlations between various deviation parameters and attempts were tested with independent-samples Kruskal-Wallis tests.

RESULTS

A significant difference between the two groups was found in the operation time (p < .001). For accuracy, the difference was found in the first attempt of coronal and apical deviations but disappeared as the training went on. As the practice progressed, improvement was evident in the d-CAIS group but not in the s-CAIS group. When reaching the plateau stage of the learning curve of the d-CAIS group (after five attempts), the influence of different methods of guidance was limited between the two groups.

CONCLUSIONS

A learning curve effect was found in d-CAIS but not in s-CAIS in vitro tests by beginners. The operating procedure of dynamic navigated and static template-guided implant placement was easy to master.

Accuracy of Computer-Assisted Flapless Implant Placement by Means of Mucosa-Supported Templates in Complete-Arch Restorations: A Systematic Review

The aim of this study was to systematically review the current scientific literature regarding the accuracy of fully guided flapless implant positioning for complete-arch rehabilitations in edentulous patients and to assess if there was any statistically significant correlation between linear deviation at shoulder point, at apex point and angular deviation. The electronic and manual literature search of clinical studies was carried out using specified indexing terms. A total of 13 studies were eligible for qualitative analysis and 277 edentulous patients were rehabilitated with 1556 implants patients by means of fully guided mucosa-supported template-assisted flapless surgery. Angular deviation was 3.42° (95% CI 2.82–4.03), linear deviation at shoulder point 1.23 mm (95% CI 0.97–1.49) and linear deviation at apex point 1.46 mm (95% CI 1.17–1.74). No statistically significant correlations were found between the linear and angular deviations. A statistically significant correlation was found between the two linear deviations (correlation coefficient 0.91) that can be summarized by the regression equation y = 0.03080 + 0.8254x. Computer-assisted flapless implant placement by means of mucosa-supported templates in complete arch restorations can be considered a reliable and predictable treatment choice despite the potential effects that flapless approach could bring to the overall treatment.

A Novel Guided Zygomatic and Pterygoid Implant Surgery System: A Human Cadaver Study on Accuracy

The aim of this human cadaver study was to assess the accuracy of zygomatic/pterygoid implant placement using custom-made bone-supported laser sintered titanium templates. For this purpose, pre-surgical planning was done on computed tomography scans of each cadaver. Surgical guides were printed using direct metal laser sintering technology. Four zygomatic and two pterygoid implants were inserted in each case using the guided protocol and related tools. Post-operative computed tomography (CT) scans were obtained to evaluate deviations between the planned and inserted implants. Accuracy was measured by overlaying the real position in the post-operative CT on the virtual presurgical placement of the implant in a CT image. Descriptive and bivariate analyses of the data were performed. As a result, a total of 40 zygomatic and 20 pterygoid implants were inserted in 10 cadavers. The mean deviations between the planned and the placed zygomatic and pterygoid implants were respectively (mean ± SD): 1.69° ± 1.12° and 4.15° ± 3.53° for angular deviation. Linear distance deviations: 0.93 mm ± 1.23 mm and 1.35 mm ± 1.45 mm at platform depth, 1.35 mm ± 0.78 mm and 1.81 mm ± 1.47 mm at apical plane, 1.07 mm ± 1.47 mm and 1.22 mm ± 1.44 mm for apical depth. In conclusion, the surgical guide system showed accuracy for all the variables studied and allowed acceptable and accurate implant placement regardless of the case complexity.

Accuracy of half-way mucosa-supported implant guides for edentulous jaws: a retrospective study with a median follow-up of 2 years

OBJECTIVE

To assess the accuracy of half-way digital mucosa-supported implant guides (HDMIGs) for edentulous jaws.

METHODS

Ninety-five consecutive patients (859 implants) with edentulous jaws who underwent implant placement using an HDMIG from July 2012 to June 2018 were retrospectively identified. The primary endpoint was implant-related complications (nerve injury and unexpected perforation), and the secondary endpoints were the faciolingual distance, mesiodistal distance, buccolingual angle, and mesiodistal angle. Follow-ups occurred at 1 month, 2 months, and then every 2 months following implant placement.

RESULTS

Twenty-seven (28.4%) patients met the exclusion criteria, leaving 68 eligible patients (636 implants) for the final analysis. The median follow-up was 24 months (range, 18-27 months). No patients developed nerve injury, revision, or unexpected perforation. At the final follow-up, the mean faciolingual distance was 0.65 ± 0.16 mm, the mean mesiodistal distance was 1.16 ± 0.61 mm, the mean buccolingual angle was 4.04° ± 2.26°, and the mean mesiodistal angle was 3.75° ± 2.56°. In the comparison of the first month after surgery and the last follow-up, no significant differences were detected in any of the four measured variables.

CONCLUSION

Use of an HDMIG may be a convenient and safe method to ensure correct implantation.

Multivariate analysis of causal factors influencing accuracy of guided implant surgery for partial edentulism: a retrospective clinical study

Abstract

Background

In dental implant treatment, the placement position of the implant body is important. The hypothesis is that there are factors that have a greater impact than the factors that have been studied so far.

Material and Methods

The deviation between planned and actually placed implants was measured three-dimensionally by modified treatment evaluation method in 110 patients who underwent implant placement with guided surgery for partial edentulism. Ten factors that seemed to affect errors in placement were selected: the type of tooth, type of edentulism, distance from the remaining teeth, the type of implant, implant length, number of implants, method of guidance, the number of teeth supporting the surgical guide, number of anchor pins, and presence or absence of a reinforcement structure. The effect of each factor that corrected each confounding was calculated using multivariate analysis.

Results

In this study, 188 implant bodies were set to target, and the errors measurement data of the implant position were as follows: average Angle, 2.5 ± 1.6° (95% CI 2.25–2.69); Base, 0.67 ± 0.37 mm (95% CI 0.62–0.72); and Apex, 0.92 ± 0.47 mm (95% CI 0.86–0.98). As the result of multivariate analysis, larger errors were present in the partially guided group than the fully guided group. The number of teeth supporting the surgical guide significantly influenced the error in placement position. The error caused by the number of anchor pins was significantly different for the Angle. Similarly, the presence of the reinforcement structure influenced the error significantly for the Angle.

Conclusions

It was suggested that the smaller errors could be present by performing guided surgery with full guidance and devising the design of the guide such as the number of teeth supporting the surgical guide, the setting of the anchor pin, and the reinforcement structure.

Accuracy assessment of dynamic computer-aided implant placement: a systematic review and meta-analysis

OBJECTIVES

To assess the accuracy of dynamic computer-aided implant surgery (dCAIS) systems when used to place dental implants and to compare its accuracy with static computer-aided implant surgery (sCAIS) systems and freehand implant placement.

MATERIALS AND METHODS

An electronic search was made to identify all relevant studies reporting on the accuracy of dCAIS systems for dental implant placement. The following PICO question was developed: "In patients or artificial models, is dental implant placement accuracy higher when dCAIS systems are used in comparison with sCAIS systems or with freehand placement? The main outcome variable was angular deviation between the central axes of the planned and final position of the implant. The data were extracted in descriptive tables, and a meta-analysis of single means was performed in order to estimate the deviations for each variable using a random-effects model.

RESULTS

Out of 904 potential articles, the 24 selected assessed 9 different dynamic navigation systems. The mean angular and entry 3D global deviations for clinical studies were 3.68° (95% CI: 3.61 to 3.74; I² = 99.4%) and 1.03 mm (95% CI: 1.01 to 1.04; I² = 82.4%), respectively. Lower deviation values were reported in in vitro studies (mean angular deviation of 2.01° (95% CI: 1.95 to 2.07; I² = 99.1%) and mean entry 3D global deviation of 0.46 mm (95% CI: 0.44 to 0.48 ; I² = 98.5%). No significant differences were found between the different dCAIS systems. These systems were significantly more accurate than sCAIS systems (mean difference (MD): -0.86°; 95% CI: -1.35 to -0.36) and freehand implant placement (MD: -4.33°; 95% CI: -5.40 to -3.25).

CONCLUSION

dCAIS systems allow highly accurate implant placement with a mean angular of less than 4°. However, a 2-mm safety margin should be applied, since deviations of more than 1 mm were observed. dCAIS systems increase the implant placement accuracy when compared with freehand implant placement and also seem to slightly decrease the angular deviation in comparison with sCAIS systems.

CLINICAL RELEVANCE

The use of dCAIS could reduce the rate of complications since it allows a highly accurate implant placement.

The Influence of Surgical Experience and Bone Density on the Accuracy of Static Computer-Assisted Implant Surgery in Edentulous Jaws Using a Mucosa-Supported Surgical Template with a Half-Guided Implant Placement Protocol-A Randomized Clinical Study

The aim of our randomized clinical study was to analyze the influence of surgical experience and bone density on the accuracy of static computer-assisted implant surgery (CAIS) in edentulous jaws using a mucosa-supported surgical template with a half-guided implant placement protocol. Altogether, 40 dental implants were placed in the edentulous jaws of 13 patients (novice surgeons: 18 implants, 6 patients (4 male), age 71 ± 10.1 years; experienced surgeons: 22 implants, 7 patients (4 male), age 69.2 ± 4.55 years). Angular deviation, coronal and apical global deviation and grey level measurements were calculated for all implants by a blinded investigator using coDiagnostiX software. 3DSlicer software was applied to calculate the bone volume fraction (BV/TV) for each site of implant placement. There were no statistically significant differences between the two study groups in either of the primary outcome variables. There was a statistically significant negative correlation between angular deviation and both grey level measurements (R-value: −0.331, p < 0.05) and BV/TV (R-value: −0.377, p < 0.05). The results of the study suggest that surgical experience did not influence the accuracy of implant placement. The higher the bone density at the sites of implant placement, the higher the accuracy of static CAIS.

Comparison between computer-guided and freehand dental implant placement surgery: A systematic review and meta-analysis

The purpose of this systematic review was to compare computer-guided (fully guided) and freehand implant placement surgery in terms of marginal bone loss, complications, and implant survival. This review followed the PRISMA guidelines and was registered in the PROSPERO database (CRD42019135893). Two independent investigators performed the search of the PubMed/MEDLINE, Scopus, and Cochrane Library databases for studies published up to April 2020 and identified 1508 references. After a detailed review, only four studies were considered eligible. These studies involved a total of 154 patients with 597 dental implants and a mean follow-up period of 2.25 years. There was no difference between computer-guided surgery and freehand surgery in terms of the marginal bone loss (mean difference -0.11mm, 95% confidence interval (CI) -0.27 to 0.04mm; P=0.16), mechanical complications (risk ratio (RR) 0.85, 95% CI 0.36-2.04; P=0.72), biological complications (RR 1.56, 95% CI 0.42-5.74; P=0.51), and implant survival rate (RR 0.53, 95% CI 0.11-2.43; P=0.41). This meta-analysis demonstrated that both computer-guided and freehand surgeries yielded similar results for marginal bone loss, mechanical and biological complications, and implant survival rate.

Alveolar ridge preservation and primary stability as influencing factors on the transfer accuracy of static guided implant placement: a prospective clinical trial

Background

The aim of this prospective clinical study was to investigate differences between virtually planned and clinically achieved implant positions in completely template-guided implant placements as a function of the tooth area, the use of alveolar ridge preservation, the implant length and diameter, and the primary implant stability.

Methods

The accuracy of 48 implants was analyzed. The implants were placed in a completely template-guided manner. The data of the planned implant positions were superimposed on the actual clinical implant positions, followed by measurements of the 3D deviations in terms of the coronal (dc) and apical distance (da), height (h), angulation (ang), and statistical analysis.

Results

The mean dc was 0.7 mm (SD: 0.3), the mean da was 1.4 mm (SD: 0.6), the mean h was 0.3 mm (SD: 0.3), and the mean ang was 4.1° (SD: 2.1). The tooth area and the use of alveolar ridge preservation had no significant effect on the results in terms of the implant positions. The implant length had a significant influence on da (p = 0.02). The implant diameter had a significant influence on ang (p = 0.04), and the primary stability had a significant influence on h (p = 0.02).

Conclusion

Template-guided implant placement offers a high degree of accuracy independent of the tooth area, the use of measures for alveolar ridge preservation or the implant configuration.

A clinical benefit is therefore present, especially from a prosthetic point of view.

Trial registration

German Clinical Trial Register and the International Clinical Trials Registry Platform of the WHO: DRKS00005978; date of registration: 11/09/2015.

Dynamic Navigation in Dental Implantology: The Influence of Surgical Experience on Implant Placement Accuracy and Operating Time. An in Vitro Study

AIM

the aim of this in vitro study was to test whether the implant placement accuracy and the operating time can be influenced by the operator's experience.

MATERIALS AND METHODS

sixteen models underwent a (Cone Beam Computer Tomography) CBCT and implant positioning was digitally planned on this. The models were randomly assigned to four operators with different levels of surgical experience. One hundred and twelve implant sites were drilled using a dynamic navigation system and operating times were measured. Based on postoperative CBCTs, dental implants were virtually inserted and superimposed over the planned ones. Two-dimensional and 3D deviations between planned and virtually inserted implants were measured at the entry point and at the apical point. Angular and vertical errors were also calculated.

RESULTS

considering coronal and apical 3D deviations, no statistically significant differences were found between the four operators (p = 0.27; p = 0.06). Some vectorial components of the deviation at the apical point and the angular errors of some operators differed from each other.

CONCLUSIONS

within the limitations of this study, dynamic navigation can be considered a reliable technique both for experienced and novice clinicians.

Is there a learning curve in static computer-assisted implant surgery? A prospective clinical study

Static computer-assisted surgery (s-CAS) has been introduced to improve the results of implantology. A prospective cohort study was conducted following the STROBE guidelines to determine the presence of a learning curve in s-CAS. Six partially and six totally edentulous patients were treated by two surgeons experienced in implantology but completely inexperienced in s-CAS. Preoperative and postoperative computed tomography scans were matched to assess coronal, apical, and angular deviation and the positioning error. The accuracy data were used to evaluate the learning curve. Fifty-six implants were inserted. In partially and totally edentulous patients, the mean (range; standard deviation) coronal deviation was 0.87 (0.34-1.27; 0.35) and 1.24 (0.72-2.67; 0.79); the mean apical deviation was 1.13 (0.48-1.63; 0.39) and 1.52 (0.88-3.84; 1.15); the mean angular deviation was 2.63 (1.89-4.50; 0.98) and 3.59 (1.69-6.30; 1.65); and the mean positioning error was 0.80 (0.32-1.25; 0.35) and 1.14 (0.35-2.56; 0.77), respectively. A typical 'learning curve' effect was not identified for s-CAS.

Dynamic Navigation for Dental Implant Surgery

Dynamic navigation (DN) has been used by many fields previously and recently applied to dental implant surgery. DN allows the implant surgeon to evaluate a patient, scan the patient, plan the implant position, and perform the implant surgery in the same day without the delay or cost of fabrication of a static surgical guide stent. The current DN workflow requires (1) cone-beam computed tomography with fiducials, (2) virtual implant planning, (3) calibration, and (4) implant placement in accordance to the 3-D image on the navigation screen. This technology allows for improved precision and accuracy in the placement of dental implants.

Guided implant surgery risks and their prevention

Ideal implant placement may reduce surgical complications, such as nerve injury and lingual cortical plate perforation, and minimize the likelihood of functional and prosthetic compromises. Guided implant surgery (GIS) has been used as the means to achieve ideal implant placement. GIS refers to the process of digital planning, custom-guide fabrication, and implant placement using the custom guide and an implant system-specific guided surgery kit. GIS includes numerous additional steps beyond the initial prosthetic diagnosis, treatment planning, and fabrication of surgical guide. Substantial errors can occur at each of these individual steps and can accumulate, significantly impacting the final accuracy of the process with potentially disastrous deviations from proper implant placement. Pertinent overall strategies to reduce or eliminate these risks can be summarized as follows: complete understanding of the possible risks is fundamental; knowledge of the systems and tools used is essential; consistent verification of both diagnostic and surgical procedures after each step is crucial; proper training and surgical experience are critical. This review article summarizes information on the accuracy and efficacy of GIS, provides insight on the potential risks and problems associated with each procedural step, and offers clinically relevant recommendations to minimize or eliminate these risks.

Accuracy of guided implant surgery: an experimental set-up

BACKGROUND

The aim of the study was to evaluate the opportunities of guided implant surgery compared to conventional implant surgery.

METHODS

For this purpose 7 mandibles were prepared, which were sectioned in order to have an edentulous area. Seven half-mandibles were assigned to guided implant surgery group (test) and an equal number to conventional surgery group (control).

RESULTS

The results of the test group were as follows: mean vertical implant level discrepancy 0.44±0.29 mm, buccolingual implant position discrepancy 1.31±0.65 mm, mesio-distal implant position discrepancy 0.68±0.42 mm, implant apex discrepancy 1.92±0.92 mm, mean distance between the two fixtures 0.26±0.19 mm. The results of the control group are as follows: mean vertical implant level discrepancy 1.1±0.4 mm, mean bucco-lingual implant position discrepancy 2.14±0.89 mm, mean mesio-distal implant position discrepancy 1.7±0.79 mm, mean implant apex discrepancy 2.91±0.50 mm, mean distance between the two fixtures 0.78±0.63 mm.

CONCLUSIONS

Within the limitations of an experimental set up, the results may demonstrate how the use of guided implant surgery may be a valid help for the clinician for a more accurate and safe implant placement.

Exploring training dental implant placement using computer-guided implant navigation system for predoctoral students: A pilot study

INTRODUCTION

Recent computer-guided dynamic navigation systems promise a novel training approach for implant surgery. This study aimed to examine learning progress in placement of dental implants among dental students using dynamic navigation on a simulation model.

MATERIALS AND METHODS

Senior students with no implant placement experience were randomly assigned five implant placement attempts involving either three maxillary or four mandibular implants distributed in the anterior/posterior, and left/right segments. Implant placement was planned using a Navident Dynamic Guidance system. Surgical time was recorded. Horizontal, vertical and angulation discrepancies between the planned and placed implant positions were measured using superimposed CBCT scans. Data were analysed with repeated measures regression with Tukey's adjusted pairwise comparisons (α = 0.05).

RESULTS

Fourteen students participated, with a mean age of 26.1 years and equal males and females. Mean time for implant placement was associated with attempt number (P < 0.001), implant site (P = 0.010) and marginally related to gender (P = 0.061). Students had a significant reduction in time from their first attempt to their second (10.6 vs 7.6 minutes; adjusted P < 0.001) then plateaued. Overall 3D angulation (P < 0.001) and 2D vertical apex deviation (P = 0.014) improved with each attempt, but changes in lateral 2D (P = 0.513) and overall 3D apex deviations (P = 0.784) were not statistically significant. Implant sites were associated with lateral 2D, 2D vertical and overall 3D apex deviation (P < 0.001).

DISCUSSION

Males were marginally faster than females, had slightly lower overall 3D angulation, and reported higher proficiency with video games. Novice operators improved significantly in speed and angulation deviation within the first three attempts of placing implants using dynamic navigation.

CONCLUSION

Computer-aided dynamic implant navigation systems can improve implant surgical training in novice population.

The accuracy of static vs. dynamic computer-assisted implant surgery in single tooth space: A randomized controlled trial

OBJECTIVES

The aim of this RCT was to compare the accuracy of implant placement between static and dynamic computer-assisted implant surgery (CAIS) systems in single tooth space.

MATERIALS AND METHODS

A total of 60 patients in need of a single implant were randomly assigned to two CAIS groups (Static n = 30, Dynamic n = 30) and implants were placed by one surgeon. Preoperative CBCT was transferred to implant planning software to plan the optimal implant position. Implants were placed using either stereolithographic guide template (Static CAIS) or implant navigation system (Dynamic CAIS). Postoperative CBCT was imported to implant planning software, and deviation analysis with the planned position was performed. Primary outcomes were the deviation measurements at implant platform, apex, and angle of placement. Secondary outcome was the distribution of the implant deviation into each 3D direction.

RESULTS

The mean deviation at implant platform and implant apex in the static CAIS group was 0.97 ± 0.44 mm and 1.28 ± 0.46 mm, while that in the dynamic CAIS group was 1.05 ± 0.44 mm and 1.29 ± 0.50 mm, respectively. The angular deviation in static and dynamic CAIS group was 2.84 ± 1.71 degrees and 3.06 ± 1.37 degrees. None of the above differences between the two groups reached statistical significance. The deviation of implants toward the mesial direction in dynamic CAIS group was significantly higher than that of the static CAIS (p = 0.032).

CONCLUSIONS

Implant placement accuracy in single tooth space using dynamic CAIS appear to be the same to that of static CAIS. (Thai Clinical Trials Registry TCTR20180826001).

Is Digital Guided Implant Surgery Accurate and Reliable?

The digital workflow for computer-aided implant surgery includes a range of steps leading to generation of a prosthetically driven, 3-dimensional virtual plan, which is transitioned into the patient's mouth by the surgical guide and protocol. Guided implant surgery is believed to be accurate and reliable compared with free-handed implant surgery. However, deviation between implant virtual plan and implant real position may occur as a result of accumulated errors throughout the digital workflow. This article reviews the digital workflow of static computer-aided implant surgery. Factors that may affect the accuracy and clinical outcome of the guided surgery are also reviewed.

Accuracy of Guided Surgery via Stereolithographic Mucosa-Supported Surgical Guide in Implant Surgery for Edentulous Patient: a Systematic Review

Objectives

The purpose of the present study is to systematically review the accuracy of implant placement with mucosa-supported stereolithographic surgical guide and to find out what factors can influence the accuracy.

Material and Methods

An electronic literature search was performed through the MEDLINE (PubMed) and EMBASE databases. The articles are including human studies published in English from October 2008 to October, 2017. From the examination of selected articles, deviations between virtual planning and actual implant placement were analysed regarding the global apical, global coronal, and angulation position.

Results

A total of 119 articles were reviewed, and 6 of the most relevant articles that are suitable to the criteria were selected. The present data included 572 implants and 93 patients. The result in the present systematic review shows that mean apical global deviation ranges from 0.67 (SD 0.34) mm to 2.19 (SD 0.83) mm, mean coronal global deviation ranges from 0.6 (SD 0.25) mm to 1.68 (SD 0.25) mm and mean angular deviation - from 2.6° (SD 1.61°) to 4.67° (SD 2.68°).

Conclusions

It's clearly shown from most of the examined studies that the mucosa-supported stereolithographic surgical guide, showed not exceeding in apically 2.19 mm, in coronally 1.68 mm and in angular deviation 4.67°. Surgeons should be aware of the possible linear and angular deviations of the system. Accuracy can be influenced by bone density, mucosal thickness, surgical techniques, type of jaw, smoking habits and implant length. Further studies should be performed in order to find out which jaw can have better accuracy and how the experience can influence the accuracy.