Analysis of the accuracy of a dynamic navigation system when performing dental implant surgery with transcrestal sinus floor elevation: A pilot study

Digital Workflow and Guided Surgery in Implant Therapy-Literature Review and Practical Tips to Optimize Precision

The application of digital technology in implant dentistry refines prosthetically-driven treatment planning by integrating virtual facial and intraoral models with cone-beam computed tomography (CBCT) images. This integration enables the development of more personalized treatment plans, ensures precise implant positioning, and strengthens communication between clinicians and patients, thereby reducing potential errors and risks. Computer-aided implant surgery consists of two primary approaches: static-guided surgery, which uses a physical surgical stent to guide the osteotomy based on the preoperatively planned virtual implant position, and dynamic-guided surgery, which employs an optical tracking system with a real-time monitor display for the visualization of implant osteotomy inside the alveolar bone. Each approach offers distinct advantages and poses unique clinical challenges. This paper provides an overview of the current applications and literature on digital treatment planning and computer-aided implant surgery, discussing the advantages and limitations of each approach. Clinical cases are presented to illustrate the digital workflow and highlight key considerations for implementing these methods. Currently, the use of digital workflow in implant dentistry is rising, and it is essential to strike a balance between precision and practicality. The future is promising, with generalized adoption anticipated.

Application of a semi-active robotic system for implant placement in atrophic posterior maxilla: A retrospective case series

OBJECTIVE

The study aimed to evaluate the accuracy and safety of a semi-active robotic system for implant placement in atrophic posterior maxilla.

METHODS

Patients underwent robot-assisted implant placement in atrophic posterior maxilla were identified and included. Cone-beam computed tomography (CBCT) was performed before surgery. The virtual implant position and drilling sequences were planned in the robotic planning system. Patients with positioning marker took an intraoral scan. The preoperative CBCT and the intraoral scan were superimposed in the robotic software. After registration, the implant bed was prepared utilizing the robotic arm with 1 mm safety margin below the maxillary sinus floor. The transcrestal sinus floor elevation (TSFE) was performed by the dentist, followed by the implant placement with the robotic arm. A postoperative CBCT was taken and superimposed with the preoperative one to calculate the accuracy of implant placement. Complications and adverse events were recorded. Deviations between the implant platform and apex levels were analyzed using the paired t-test. P < 0.05 was considered statistically significant.

RESULTS

Twenty-seven implants of 20 patients were included. No intraoperative and postoperative complications were reported. The global, lateral and vertical platform deviations were 0.73 ± 0.27 mm, 0.35 ± 0.23 mm and 0.35 ± 0.57 mm, respectively. The global, lateral and vertical apex deviations were 0.77 ± 0.23 mm, 0.41 ± 0.20 mm and 0.34 ± 0.57 mm, respectively. There were significant differences between the global, lateral and vertical deviations between the implant platform and apex levels (P < 0.05, respectively). The angular deviation was 1.58 ± 0.76°.

CONCLUSIONS

High accuracy and safety for implant placement in atrophic posterior maxilla could be achieved using a semi-active robotic system, with the TSFE procedure performed by the dentist.

CLINICAL SIGNIFICANCE

This study provides significant evidence to support the application of semi-active robotic systems for implant placement in atrophic posterior maxilla.

Digitally Guided Aspiration Technique for Maxillary Sinus Floor Elevation in the Presence of Cysts: A Case Series

OBJECTIVES

Sinus floor elevation (SFE) is a widely established surgical procedure for dental implant placement in the atrophic posterior maxilla. However, the presence of maxillary sinus cysts (MSCs) can significantly complicate this intervention. This study presents and evaluates the efficacy and safety of the Digitally Guided Aspiration Technique (DGAT), a novel approach for managing MSCs during SFE procedures.

MATERIALS AND METHODS

Implant survival and success rates were evaluated according to established criteria, and all complications were systematically documented. Three-dimensional measurements, including MSC volume, residual bone height (BH) surrounding the implants, and apical bone coverage, were obtained using cone beam computed tomography (CBCT). Marginal bone loss (MBL) was assessed through standardized periapical radiographs following prosthetic loading. The accuracy of implant positioning was evaluated by measuring the three-dimensional deviations between virtually planned and actually placed implants. Comprehensive cytological and histological analyses were conducted on aspirated cystic fluid and harvested bone specimens, respectively. Patient-reported outcomes were assessed using questionnaires at the 6-month post-restoration follow-up.

RESULTS

The study comprised seven patients with seven cysts receiving a total of 10 implants. At the 6-month follow-up, the implant survival rate was 100% with no biological or technical complications observed. Volumetric analysis revealed a significant mean reduction in MSC volume of 45.34% ± 33.08% (p = 0.012). Postoperative measurements demonstrated a statistically significant increase in BH compared to baseline values (p < 0.001). This gain remained largely stable throughout the 6-month observation period, with minimal resorption noted in the buccal aspect (p = 0.03) and mean value (p = 0.05). Prior to second-stage surgery, radiographic evaluation confirmed complete bone coverage of all implants, with 60% exhibiting > 2 mm of apical bone coverage. MBL remained within physiological limits. Analysis of implant positioning accuracy showed that coronal global and vertical deviations fell within acceptable clinical parameters, while apical global deviation and angular deviation marginally exceeded recommended thresholds. Cytological analysis of the aspirated cystic fluid revealed no evidence of infection, while histological examination of the regenerated tissue demonstrated mature bone formation with abundant vascularization. Patient-reported outcomes indicated high satisfaction levels.

CONCLUSIONS

DGAT can reduce the volume of MSCs, achieve favorable bone grafting and dental implant outcomes with a low incidence of complications. The safety and effectiveness of this procedure need to be compared to the traditional aspiration technique in future randomized controlled trials.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2400083235. This clinical trial was not registered prior to participant recruitment and randomization.

The learning curve of a dynamic navigation system used in endodontic apical surgery

Background/purpose

Quantitative in vitro research was conducted on the learning process of a dynamic navigation system. This study provides guidance for the promotion and application of dynamic navigation technology in the endodontic apical surgery field.

Materials and methods

Standardized models were designed and 3D printed to form the approach operation of endodontic apical surgery. 6 clinicians with no experience in dynamic navigation performed the operation. The distance deviation tolerance was set as 0.6 mm, and the angle deviation tolerance was set as 5°. Fifteen mm deep approach operation was completed using dynamic navigation. Each operator performed 10 consecutive exercises on the models. The positioning deviation and operation time of each operator for each practice were recorded. Based on this, the learning curve of the dynamic navigation of every operator was mapped. The learning difficulty of dynamic navigation was evaluated.

Results

The learning curves of all operators reached a stable level after the 7th practice, which can ensure that the distance and angle deviations are maintained within the deviation tolerances (0.6 mm, 5°).

Conclusion

Operators with no experience in dynamic navigation technology need practice to master dynamic navigation operations. For this navigation system, operators with no operational experience can master dynamic navigation operations after 7 exercises.

Accuracy of different registration areas using active and passive dynamic navigation systems in dental implant surgery: An in vitro study

OBJECTIVES

To gauge the relative accuracy of the use of passive and active dynamic navigation systems when placing dental implants, and to determine how registration areas affect the performance of these systems.

MATERIALS AND METHODS

Eighty implants were assigned to be placed into 40 total resin mandible models missing either the left or right first molars using either passive or active dynamic navigation system approaches. U-shaped tube registration devices were fixed in the edentulous site for 20 models each on the left or right side. Planned and actual implant positions were superimposed to assess procedural accuracy, and parameters including 3D entry deviation, angular deviation, and 3D apex deviation were evaluated with Mann-Whitney U tests and Wilcoxon signed-rank tests.

RESULTS

Respective angular, entry, and apex deviation values of 1.563 ± 0.977°, 0.725 ± 0.268 mm, and 0.808 ± 0.284 mm were calculated for all included implants, with corresponding values of 1.388 ± 1.090°, 0.789 ± 0.285 mm, and 0.846 ± 0.301 mm in the active group and 1.739 ± 0.826°, 0.661 ± 0.236 mm, and 0.769 ± 0.264 mm in the passive group. Only angular deviation differed significantly among groups, and the registration area was not associated with any significant differences among groups.

CONCLUSIONS

Passive and active dynamic navigation approaches can achieve comparable in vitro accuracy. Registration on one side of the missing single posterior tooth area in the mandible can complete single-tooth implantation on both sides of the posterior teeth, highlighting the promise of further clinical research focused on this topic.

Digital planning and bone regenerative technologies: A narrative review

OBJECTIVES

The aim of this narrative review was to explore the application of digital technologies (DT) for the simplification and improvement of bone augmentation procedures in advanced implant dentistry.

MATERIAL AND METHODS

A search on electronic databases was performed to identify systematic reviews, meta-analyses, randomized and non-randomized controlled trials, prospective/retrospective case series, and case reports related to the application of DT in advanced implant dentistry.

RESULTS

Seventy-nine articles were included. Potential fields of application of DT are the following: 1) the use of intra-oral scanners for the definition of soft tissue profile and the residual dentition; 2) the use of dental lab CAD (computer-aided design) software to create a digital wax-up replicating the ideal ridge and tooth morphology; 3) the matching of STL (Standard Triangulation Language) files with DICOM (DIgital COmmunication in Medicine) files from CBCTs with a dedicated software; 4) the production of stereolithographic 3D models reproducing the jaws and the bone defects; 5) the creation of surgical templates to guide implant placement and augmentation procedures; 6) the production of customized meshes for bone regeneration; and 7) the use of static or dynamic computer-aided implant placement.

CONCLUSIONS

Results from this narrative review seem to demonstrate that the use of a partially or fully digital workflow can be successfully used also in advanced implant dentistry. However, the number of studies (in particular RCTs) focused on the use of a fully digital workflow in advanced implant dentistry is still limited and more studies are needed to properly evaluate the potentials of DT.

The safety of maxillary sinus floor elevation and the accuracy of implant placement using dynamic navigation

OBJECTIVE

To date, it remains a challenge to conduct maxillary sinus floor elevation (MSFE) owing to heterogeneity of anatomical structures and limited operative visibility of the maxillary sinus. The aim of this study is to investigate the safety of MSFE and the accuracy of implant placement using dynamic navigation.

METHODS

Forty-two implants were placed in thirty-five patients requiring implantation in posterior maxilla with dynamic navigation. They were assigned to either lateral window sinus floor elevation (LWSFE) group (n = 22) or transcrestal sinus floor elevation (TSFE) group (n = 20) according to the residual alveolar bone height (RBH). Platform deviation, apex deviation and angular deviation between actual and planned implant placement were measured in precision evaluation software. Three deviations of two groups were compared via SPSS 22.0 software.

RESULTS

Neither accidental bleeding nor perforation of Schneiderian membrane occurred in any patients. The actual window position of LWSFE was consistent with the preoperative design. There were no significant differences in platform, apex and angular deviations between the two groups (P > 0.05).

CONCLUSION

In this study the dynamic navigation harvested clinically acceptable safety of MSFE and accuracy for implant placement in posterior maxillary region. The dynamic navigation would provide the clinician with assistance in achieving precise preoperative planning and reducing complications in surgical procedures. The granular bone grafts used in the LWSFE did not significantly affection on the accuracy of the simultaneous implant placement under the guidance of dynamic navigation.

Radiographic Study of Transcrestal Sinus Floor Elevation Using Osseodensification Technique with Graft Material: A Pilot Study

This pilot study aimed to evaluate the level of implant success after transcrestal sinus floor elevation (tSFE) using the osseodensification technique (OD) combined with beta-tricalcium phosphate (β-TCP) by analyzing clinical and radiographic results. Moreover, the increase in bone height was analyzed immediately after surgery, 3 months after, and before loading by taking standardized radiographic measurements. Thirteen patients, four males and nine females, with a mean age of 54.69 ± 5.86 years, requiring the placement of one implant in the upper posterior maxilla, with a residual bone height of <8 mm and a minimum bone width of 5 mm, participated in the study. The bone gain data was obtained using cone-beam computed tomography (CBCT) immediately after surgery and twelve months after the placement. The correlation between initial and final bone height with implant stability was also assessed. The results were analyzed using SPSS 23 software (p < 0.05). The results of the study indicated a 100% implant success rate after a follow-up period of twelve months. Preoperative main bone height was 5.70 ± 0.95 mm. The osseodensification technique allowed a significant increase of 6.65 ± 1.06 mm immediately after surgery. After a twelve-month follow-up, a graft material contraction of 0.90 ± 0.49 mm was observed. No correlation was observed between the bone height at the different times of the study and the primary stability of the implant. Considering the limitations of the size sample of this study, the osseodensification technique used for transcrestal sinus lift with the additional bone graft material (β-TCP) may provide a predictable elevation of the maxillary sinus floor, allowing simultaneous implant insertion with adequate stability irrespective of bone height limitations.

The impacts of registration-and-fixation device positioning on the performance of implant placement assisted by dynamic computer-aided surgery: A randomized controlled trial

OBJECTIVES

To assess the efficacy of dynamic computer-aided surgery (dCAS) in replacing a single missing posterior tooth, we compare outcomes when using registration-and-fixation devices positioned anterior or posterior to the surgical site. Registration is performed on either the anterior or opposite posterior teeth.

METHODS

Forty individuals needing posterior single-tooth implant placement were randomly assigned to anterior or posterior registration. Nine parameters were analyzed to detect the deviations between planned and actual implant placement, using Mann-Whitney and t-tests for nonnormally and normally distributed data, respectively.

RESULTS

The overall average angular deviation for this study was 2.08 ± 1.12°, with the respective average 3D platform and apex deviations of 0.77 ± 0.32 mm and 0.88 ± 0.32 mm. Angular deviation values for individuals in the anterior and posterior registration groups were 1.58°(IQR: 0.98°-2.38°) and 2.25°(IQR: 1.46°-3.43°), respectively (p = .165), with 3D platform deviations of 0.81 ± 0.29 mm and 0.74 ± 0.36 mm (p = .464), as well as 3D apex deviations of 0.89 ± 0.32 mm and 0.88 ± 0.33 mm (p = .986). No significant variations in absolute buccolingual (platform, p = .659; apex, p = .063), apicocoronal (platform, p = .671; apex, p = .649), or mesiodistal (platform, p = .134; apex, p = .355) deviations were observed at either analyzed levels.

CONCLUSIONS

Both anterior and posterior registration approaches facilitate accurate dCAS-mediated implant placement for single missing posterior teeth. The device's placement (posterior-to or anterior-to the surgical site) did not affect the clinician's ability to achieve the planned implant location.

Dynamic Navigation Protocol for Direct Sinus Lift and Simultaneous Implant Placement: A Case Report

AIM

This study aims to evaluate the accuracy associated with the use of a dynamic navigation system for the lateral window opening for a direct sinus floor elevation (SFE) procedure with simultaneous implant placement.

MATERIALS AND METHODS

A female patient, aged 27 years, reported to the Department of Implantology seeking treatment for her lost tooth. On radiographic examination, the residual alveolar ridge height was 6 mm in the 26 (left upper first molar) region. For the implant placement, the case was planned to be carried out under dynamic navigation (Navident, Claronav, Canada). To make the lateral window accessible to the sinus floor, an implant trajectory resembling the required window dimensions and prosthetic implant position was planned. Post-surgery cone beam computed tomography (CBCT) was taken to assess the accuracy of the lateral window and implant trajectories using Evalunav (Navident, Claronav, Canada) analysis with dynamic navigation software.

RESULTS

There was improved accuracy of the lateral window opening, and the visualization of the lateral window was maintained in real-time throughout the procedure, which was advantageous to eliminate the tearing of the thin sinus membrane. The deviations found in the trajectory of the lateral window in comparison between the planning and post-procedure were: (a) entry was deviated by 2.83 mm; (b) the apex was deviated by 2.52 mm; (c) vertically, the apex was deviated by 0.29 mm; and (d) there was an 8.93° deviation in the angulation of the trajectory. The implant that was placed simultaneously with the SFE's accuracy was in comparison with the position that was planned: (a) entry was deviated by 0.03 mm, (b) the apex was deviated by 0.82 mm, (c) vertically, the apex was deviated by 0.82 mm, and (d) there was a 0° deviation in the angulation of the trajectory.

CONCLUSION

Dynamic navigation technology can help overcome complications associated with direct sinus lift procedures by providing highly accurate and precise planning and execution of the surgical procedure. This can lead to improved implant stability and a reduced risk of complications.

Accuracy of computer-assisted dynamic navigation when performing coronectomy of the mandibular third molar: A pilot study

OBJECTIVES

The study represents a preliminary evaluation of the accuracy of the dynamic navigation system (DNS) in coronectomy of the mandibular third molar (M3M).

METHODS

The study included participants with an impacted M3M near the inferior alveolar canal. The coronectomy planes were designed before the surgery using cone-beam computed tomography (CBCT) imaging data and then loaded into the DNS program. Intraoperatively, the navigation system was used to guide the complete removal of the target crown. Postoperative CBCT imaging was used to assess any three-dimensional deviations of the actual postoperative from the planned preoperative section planes for each patient.

RESULTS

A total of 12 patients (13 teeth) were included. The root mean square (RMS) deviation of the preoperatively designed plane from the actual postoperative surface was 0.69 ± 0.21 mm, with a maximum of 1.45 ± 0.83/-1.87 ± 0.63 mm deviation. The areas with distance deviations < 1 mm, 1-2 mm, and 2-3 mm were 71.97 ± 5.72 %, 22.96 ± 6.57 %, and 4.52 ± 2.28 %, respectively. Most patients showed extremely high convexity of the surface area located in the mesial region adjacent to the base of the extraction socket. There was no observable evidence of scratching of the buccolingual bone plate at the base of the extraction socket by the handpiece drill.

CONCLUSIONS

These results provide preliminary support for the use of DNS-based techniques when extracting M3M using a buccal approach. This would improve the accuracy of coronectomy and reduce the potiential damage to the surrounding tissue.

CLINICAL SIGNIFICANCE

DNS is effective for guiding coronectomy.

CBCT for Diagnostics, Treatment Planning and Monitoring of Sinus Floor Elevation Procedures

Sinus floor elevation (SFE) is a standard surgical technique used to compensate for alveolar bone resorption in the posterior maxilla. Such a surgical procedure requires radiographic imaging pre- and postoperatively for diagnosis, treatment planning, and outcome assessment. Cone beam computed tomography (CBCT) has become a well-established imaging modality in the dentomaxillofacial region. The following narrative review is aimed to provide clinicians with an overview of the role of three-dimensional (3D) CBCT imaging for diagnostics, treatment planning, and postoperative monitoring of SFE procedures. CBCT imaging prior to SFE provides surgeons with a more detailed view of the surgical site, allows for the detection of potential pathologies three-dimensionally, and helps to virtually plan the procedure more precisely while reducing patient morbidity. In addition, it serves as a useful follow-up tool for assessing sinus and bone graft changes. Meanwhile, using CBCT imaging has to be standardized and justified based on the recognized diagnostic imaging guidelines, taking into account both the technical and clinical considerations. Future studies are recommended to incorporate artificial intelligence-based solutions for automating and standardizing the diagnostic and decision-making process in the context of SFE procedures to further improve the standards of patient care.