Robot-assisted surgery for dental implant placement: A narrative review

OBJECTIVE

To determine the current status and accuracy of robotic computer-assisted implant surgery (CAIS) applications by examining the associated clinical and experimental outcomes.

DATA AND SOURCES

PubMed, Medline, and Cochrane Library databases were searched for relevant studies published between January 2000 and November 2023, and focusing on robotic CAIS in dental implant surgery. All search results were then manually reviewed to identify only the pertinent articles. Only in vitro and clinical studies were included in this narrative review, with implant placement accuracy considered the main outcome.

RESULT

Based on our inclusion and exclusion criteria, we included 21 studies (with 1085 implant sites); of them, 8 were clinical studies, 12 were in vitro studies, and 1 included both an in vitro study and a case series. The ranges of the mean implant shoulder, apical, and angular deviations were respectively 0.43-1.04 mm, 0.53-1.06 mm, and 0.77°-3.77° in the clinical studies and 0.23-1.04 mm, 0.24-2.13 mm, and 0.43°-3.78° in the in vitro studies, respectively.

CONCLUSION

The accuracy of robotic CAIS in dental implant procedures appears to be within the clinically acceptable ranges. However, further relevant clinical trials validating the existing evidence are needed.

CLINICAL SIGNIFICANCE

Robotic CAIS can achieve clinically acceptable implant placement accuracy. This innovative technology may improve the precision and success rates of dental implant procedures, with benefit for surgeons and patients.

Accuracy analysis of robotic-assisted immediate implant placement: A retrospective case series

OBJECTIVES

This study aimed to investigate the accuracy of a robotic computer-assisted implant surgery (r-CAIS) for immediate implant placement.

METHODS

Patients requiring immediate implant placement in the maxillary anterior region were enrolled for r-CAIS. Before surgery, the patients underwent a cone beam computed tomography (CBCT) scan with a positioning marker. Virtual implant placement position and drilling sequences were planned. Following spatial registration and calibration, the implants were placed with the robotic system under supervision. A postoperative CBCT was taken to control the actual implant positions. The DICOM data of the virtually planned and the actually placed implant were superimposed and registered through the accuracy verification software of the robotic system. The accuracy was calculated automatically. The deviation at the mesial-distal, labial-palatal, and apico-coronal directions were recorded.

RESULTS

Fifteen patients with 20 implants were included. No adverse surgical events or postoperative complications were reported. The global platform, apex, and angular deviation were 0.75 ± 0.20 mm (95 % CI: 0.65 to 0.84 mm), 0.70 ± 0.27 mm (95 % CI: 0.57 to 0.82 mm), and 1.17 ± 0.73° (95 % CI: 0.83 to 1.51°), respectively. Moreover, the vertical platform and apex deviation were 0.50 ± 0.31 mm, (95 % CI: 0.35 to 0.64 mm) and 0.48 ± 0.32 mm, (95 % CI: 0.33 to 0.63 mm), respectively. All the placed implant positions were further labial and apical than the planned ones, respectively.

CONCLUSIONS

High accuracy of immediate implant placement was achieved with the robotic system.

CLINICAL SIGNIFICANCE

Our study provided evidence to support the potential of the robotic system in implant placement, even in challenging scenarios.

3D virtual patient-Magnetically retained printed stackable system for implant guided placement: Case report

OBJECTIVE

The aim of this report is to present the complete workflow of 3D virtual patient for planning and performing implant surgery with magnetically retained 3D-printed stackable guides.

CLINICAL CONSIDERATIONS

A 3D-printed stackable system was proposed based on bone, dental, and facial references. Initially, a 66-year-old male patient was digitalized through photographs, cone beam computed tomography, and intraoral scans (Virtuo Vivo, Straumann). All files were merged to create a 3D virtual patient in the planning software (coDiagnostiX, Straumann). Sequential stackable guides were designed, printed, and cured. Magnets were inserted into connectors, and the interim protheses received color characterization. Four mounted guides were produced for the specific purposes of pin fixation, bone reduction, implant placement, and immediate provisionalization. After surgery and healing period, patient digital data were updated. Final implant positions were compared to planned values and inconsistencies were clinically acceptable. The mean angular deviation was 5.4° (3.2-7.3) and mean 3D discrepancies were of 0.90 mm (0.46-1.12) at the entry point and 1.68 mm (1.00-2.20) at implant apex. Case follow-up revealed stability, patient's comfort, and no intercurrences.

CONCLUSION

Magnetically retained stackable guides provide treatment accuracy and reduce surgical and prosthetic complications. The projected virtual patient enhances decision-making and communication between the multidisciplinary team and the patient, while decreases time and costs.

CLINICAL SIGNIFICANCE

Bidimensional diagnosis and freehand implant placement have limitations and outcomes often rely on professionals' expertise. Performing facially driven virtual planning improves treatment predictability. This approach promotes function, esthetic harmony, and patient satisfaction. Implant guided surgery and 3D printed prostheses constitute a reproducible digital workflow that can be implemented into clinical practice to optimize dental care.

Mechanical performance of patient-specific prefabricated temporary shell versus laboratory-fabricated CAD/CAM provisional implant-supported single-tooth restorations: A laboratory study

OBJECTIVE

To evaluate the mechanical performance of patient-specific prefabricated temporary shell versus laboratory-fabricated CAD/CAM provisional restorations on titanium temporary abutments, with and without thermo-mechanical ageing.

MATERIALS AND METHODS

Implants with a conical connection were divided into four groups (n = 24) and restored with temporary shell or laboratory-fabricated central or lateral incisor PMMA restorations that were relined or bonded on titanium temporary abutments. The diameter of the central and lateral incisor groups' implants was regular (ϕ 4.3 mm) or narrow (ϕ 3.5 mm), respectively. Half of each group's specimens were subjected to ageing, simultaneous thermocycling (5-55°C) and chewing simulation (120,000 cycles, 50 N, 1.7 Hz) resulting in eight groups in total (n = 12). The aged specimens were evaluated with optical microscopy, and survival and complication rates were determined according to modified USPHS criteria. The non-aged specimens and those that had survived ageing were loaded until failure, whereupon bending moments were calculated.

RESULTS

Survival rates after ageing were 100% for all groups. Apart from wear facets (ϕ 2-3 mm) on the palatal restoration surface, no complications were observed. The mean fracture load and bending moments ranged between 597.6-847.1 N and 433.3-550.6 Ncm, respectively, with no significant differences between the eight groups (p = .25; p = .20).

CONCLUSIONS

As patient-specific temporary shell central and lateral incisor provisional implant-supported restorations are mechanically stable enough to withstand clinical bite forces, even after thermo-mechanical ageing, they may serve as an alternative to laboratory-fabricated provisional restorations.

Accuracy of flapless surgery using an autonomous robotic system in full-arch immediate implant restoration: A case series

OBJECTIVES

This observational study aimed to evaluate the accuracy of robotic computer-assisted implant surgery (r-CAIS) for full-arch immediate restoration and to analyse possible factors contributing to deviations.

METHODS

Three edentulous patients (five arches) underwent r-CAIS. Osteotomies were performed using an autonomous robot under the surgeon's supervision, and implant placement was performed in a freehand or robotic manner. Prefabricated provisional prostheses were delivered immediately after surgery. Postoperative cone beam computed tomography scans were performed to assess the deviations between the planned and placed implants. Statistics were compared with deviations of s-CAIS outlined in a meta-analysis.

RESULTS

A sum of 28 implants were used. The mean global coronal and apical deviations measured 0.91 ± 0.43 mm and 1.01 ± 0.45 mm, respectively, and the mean angular deviation measured 1.21 ± 1.24 º. The r-CAIS showed significantly better precision than the s-CAIS in full-arch cases (P < 0.001). The implants inserted using the robotic arm exhibited fewer deviations than those placed in the freehand manner. Eighty percent of prefabricated provisional prostheses were successfully delivered.

CONCLUSIONS

Within the limitations of the present study, our data suggest that autonomous r-CAIS is a feasible approach for simultaneous immediate restoration in edentulous patients, showing better accuracy than s-CAIS. Further large-scale studies are necessary to verify the advantages and disadvantages of this novel technique and to explore possible factors that influence its accuracy.

CLINICAL SIGNIFICANCE

Autonomous r-CAIS can provide clinically acceptable implant placement accuracy in edentulous patients, significantly surpassing s-CAIS. This level of accuracy may represent a viable therapeutic approach for simultaneous immediate full-arch restoration.

Recent Advances in Digital Technology in Implant Dentistry

Digital technology has emerged as a transformative tool in dental implantation, profoundly enhancing accuracy and effectiveness across multiple facets, such as diagnosis, preoperative treatment planning, surgical procedures, and restoration delivery. The multiple integration of radiographic data and intraoral data, sometimes with facial scan data or electronic facebow through virtual planning software, enables comprehensive 3-dimensional visualization of the hard and soft tissue and the position of future restoration, resulting in heightened diagnostic precision. In virtual surgery design, the incorporation of both prosthetic arrangement and individual anatomical details enables the virtual execution of critical procedures (e.g., implant placement, extended applications, etc.) through analysis of cross-sectional images and the reconstruction of 3-dimensional surface models. After verification, the utilization of digital technology including templates, navigation, combined techniques, and implant robots achieved seamless transfer of the virtual treatment plan to the actual surgical sites, ultimately leading to enhanced surgical outcomes with highly improved accuracy. In restoration delivery, digital techniques for impression, shade matching, and prosthesis fabrication have advanced, enabling seamless digital data conversion and efficient communication among clinicians and technicians. Compared with clinical medicine, artificial intelligence (AI) technology in dental implantology primarily focuses on diagnosis and prediction. AI-supported preoperative planning and surgery remain in developmental phases, impeded by the complexity of clinical cases and ethical considerations, thereby constraining widespread adoption.

Cone-wedge anchored surgical templates for stackable metal guide: a novel technique

OBJECTIVE

To address the instability in implant surgical guides, this technique proposes an alternative anchoring mechanism in the stackable metal surgical guides utilizing cone-wedge anchors for improved stability.

METHODS

Postoperative implant position superimposed onto the preoperatively planned design using Mimics Medical 21.0 and Materialise Magics 24.0 to assess 3D coronal implant deviation, 3D apical implant deviation, and implant angular deviation.

RESULTS

Postoperative cone-beam computed tomography (CBCT) revealed a high level of precision in the implant placement, with an average 0.97 mm deviation at implant coronal region, 1.56 mm at implant apexes, and 2.95° angular deviation.

CONCLUSION

This technique introduces a novel cone-wedge anchoring mechanism to enhance the stability of stackable metal surgical guide templates, addressing inherent instability issues. The utilization of this approach significantly improves the accuracy of implant placement procedures.

Current knowledge about stackable guides: a scoping review

PURPOSE

The rise of stereolithographic surgical guides and digital workflow, combined with a better knowledge of materials and loading principle, has enabled the placement of the temporary prosthesis at the time of implant placement. This scoping review aimed to assess the current knowledge available on stackable guides.

METHODS

The review focused on fully edentulous or requiring total edentulism patients. The procedure studied was the use of stackable guides for edentulous patients in order to place immediate temporary prostheses. The clinical endpoint was immediate placement of the provisional prosthesis after surgery combined with a prior bone reduction using a stackable guide.

RESULTS

12 case reports or case series articles met inclusion criteria, which did not allow an analysis by a systematic review. The included studies were case reports or case series. Most of the articles showed a base stabilized by 3 or 4 bone-pins, anchored in buccal or lingual part. Regarding the accuracy of bone reduction (ranged from 0.0248 mm to 1.98 mm) and implant placement when compared to planned, only 4 articles reported quantitative data. 11 articles showed an immediate loading with the transitional prosthesis after implant placement.

CONCLUSIONS

There are as yet no prospective or comparative studies on the efficiency of this technique. In a reliable way, stackable guides seem to be able to guide the practitioner from the flap elevation to the placement of the temporary screw-retained implant supported prosthesis. Given the lack of studies in this specific field of guided surgery, further studies are needed to confirm the clinical relevance of this technique.

Superimposing digital arch scans onto cone beam computed tomography scans with metallic artifacts by applying a radiopaque occlusal registration material: A chairside dental technique

Precise alignment between digital arch scans and cone beam computed tomography (CBCT) scans is a crucial step in computer-aided implant planning and placement. However, clinicians frequently encounter challenges during this process when imaging patients with existing metal restorations or orthodontic devices, as these can introduce metallic artifacts on CBCT scans that lead to alignment deviations. The presented technique describes a straightforward approach using a radiopaque occlusal registration material as a radiographic marker to facilitate the alignment between digital arch scans and CBCT scans with metallic artifacts. This technique simplifies the clinical workflow by eliminating the need for additional radiographic templates or specialized devices, offering a cost-effective option for clinicians.

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.

An overview of artificial intelligence based applications for assisting digital data acquisition and implant planning procedures

OBJECTIVES

To provide an overview of the current artificial intelligence (AI) based applications for assisting digital data acquisition and implant planning procedures.

OVERVIEW

A review of the main AI-based applications integrated into digital data acquisitions technologies (facial scanners (FS), intraoral scanners (IOSs), cone beam computed tomography (CBCT) devices, and jaw trackers) and computer-aided static implant planning programs are provided.

CONCLUSIONS

The main AI-based application integrated in some FS's programs involves the automatic alignment of facial and intraoral scans for virtual patient integration. The AI-based applications integrated into IOSs programs include scan cleaning, assist scanning, and automatic alignment between the implant scan body with its corresponding CAD object while scanning. The more frequently AI-based applications integrated into the programs of CBCT units involve positioning assistant, noise and artifacts reduction, structures identification and segmentation, airway analysis, and alignment of facial, intraoral, and CBCT scans. Some computer-aided static implant planning programs include patient's digital files, identification, labeling, and segmentation of anatomical structures, mandibular nerve tracing, automatic implant placement, and surgical implant guide design.

Accuracy of dynamic navigation compared to static surgical guides and the freehand approach in implant placement: a prospective clinical study

BACKGROUND

Computer-guided implant surgery has improved the quality of implant treatment by facilitating the placement of implants in a more accurate manner. This study aimed to assess the accuracy of implant placement in a clinical setting using three techniques: dynamic navigation, static surgical guides, and freehand placement. We also investigated potential factors influencing accuracy to provide a comprehensive evaluation of each technique's advantages and disadvantages.

MATERIALS AND METHODS

Ninety-four implants in 65 patients were included in this prospective study. Patients were randomly assigned to one of three groups: dynamic navigation, static surgical guides, or freehand placement. Implants were placed using a prosthetically oriented digital implant planning approach, and postoperative CBCT scans were superimposed on preoperative plans to measure accuracy. Seven deviation values were calculated, including angular, platform, and apical deviations. Demographic and consistency analyses were performed, along with one-way ANOVA and post-hoc tests for deviation values.

RESULTS

The mean global platform, global apical, and angular deviations were 0.99 mm (SD 0.52), 1.14 mm (SD 0.56), and 3.66° (SD 1.64°) for the dynamic navigation group; 0.92 mm (SD 0.36), 1.06 mm (SD 0.47), and 2.52° (SD 1.18°) for the surgical guide group; and 1.36 mm (SD 0.62), 1.73 mm (SD 0.66), and 5.82° (SD 2.79°) for the freehand group. Both the dynamic navigation and surgical guide groups exhibited statistically significant differences in all values except depth deviations compared to the freehand group (p < 0.05), whereas only the angular deviation showed a significant difference between the dynamic navigation and surgical guide groups (p = 0.002).

CONCLUSION

Our findings highlight the superior accuracy and consistency of dynamic navigation and static surgical guides compared to freehand placement in implant surgery. Dynamic navigation offers precision and flexibility. However, it comes with cost and convenience considerations. Future research should focus on improving its practicality.

TRIAL REGISTRATION

This study was retrospectively registered at the Thai Clinical Trials Register-Medical Research Foundation of Thailand (MRF) with the TCTR identification number TCTR20230804001 on 04/08/2023. It was also conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee at the Xian Jiaotong University Hospital of Stomatology, Xian, China (xjkqII[2021] No: 043). Written informed consent was obtained from all participants.

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.

The three-dimensional stability and accuracy of 3D printing surgical templates: An In Vitro study

OBJECTIVE

To evaluate the three-dimensional (3D) stability and accuracy of additively manufactured surgical templates fabricated using two different 3D printers and materials.

MATERIALS AND METHODS

Forty surgical templates were designed and printed using two different 3D printers: the resin group (n = 20) used a digital light processing (DLP) 3D printer with photopolymer resin, and the metal group (n = 20) employed a selective laser melting (SLM) 3D printer with titanium alloy. All surgical templates were scanned immediately after production and re-digitalized after one month of storage. Similarly, the implant simulations were performed twice. Three-dimensional congruency between the original design and the manufactured surgical templates was quantified using the root mean square (RMS), and the definitive and planned implant positions were determined and compared.

RESULTS

At the postproduction stage, the metal templates exhibited higher accuracy than the resin templates (p < 0.001), and these differences persisted after one month of storage (p < 0.001). The resin templates demonstrated a significant decrease in three-dimensional stability after one month of storage (p < 0.001), whereas the metal templates were not affected (p > 0.05). No significant differences in implant accuracy were found between the two groups. However, the resin templates showed a significant increase in apical and angular deviations after one month of storage (p < 0.001), whereas the metal templates were not affected (p > 0.05).

CONCLUSION

Printed metal templates showed higher fabrication accuracy than printed resin templates. The three-dimensional stability and implant accuracy of printed metal templates remained unaffected by one month of storage.

CLINICAL SIGNIFICANCE

With superior three-dimensional stability and acceptable implant accuracy, printed metal templates can be considered a viable alternative technique for guided surgery.

Impact of digital technologies on implant surgery in fully edentulous patients: A scoping review

BACKGROUND

For over three decades, digital technologies have been used in Implant Dentistry, beginning with the introduction of planning software for Static Computer-Assisted Implant Surgery (S-CAIS). During this time, this field has witnessed the emergence of diverse methodologies and a proliferation of technological advancements. Today, S-CAIS is a widely adopted procedure for the placement of dental implants in both partially and fully edentulous patients, with Dynamic Computer-Assisted Surgery (D-CAIS) and Robotic-Assisted Implant Surgery (RAIS) rapidly gaining attention among dental professionals. The continuous advancements in this arena are not merely indicative of technological progress; they represent a steadfast dedication to refining precision, enhancing efficiency, and fostering innovation with the goal of optimizing patient outcomes in dental implantology.

AIMS

The purpose of the following review is to meticulously examine the spectrum of digital technologies available and to describe their protocols, advantages, and shortcomings as well as to evaluate their accuracy in implant surgery in patients with complete edentulism.

MATERIALS AND METHODS

A scoping review was performed following the Joanna Briggs Institute (JBI) protocols, leveraging the population, concept, and context (PCC) framework to construct the research question and determine the inclusion and exclusion criteria.

RESULTS

Two hundred and sixty-seven records were identified for screening. After applying all the screening criteria, 41 articles were included for review and qualitative data analysis.

DISCUSSION

S-CAIS, D-CAIS, and RAIS were identified as the main technologies for computer assisted implant surgery. Their applications, characteristics, protocols and levels of accuracy were compared and described.

CONCLUSION

Taking into consideration the limitations of this study, S-CAIS appears to be the most applied and validated technology in implant surgery for fully edentulous patients followed by D-CAIS and RAIS being these last two promising initiatives in the field. Despite having similar levels of accuracy, the overall comparison showed a slightly higher values in RAIS followed by D-CAIS and S-CAIS.

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.

Jumping gap in immediate implant placement in the esthetic zone: A virtual implant planning using cone-beam computed tomography

PURPOSE

A jumping gap (JG) refers to the implant's future buccal wall; this study aims to estimate the jumping gap dimension in relation to virtual implant placement and subsequently link the implant diameter and implant position with the anatomical site.

METHODS

This observational study was conducted to analyze the maxillary teeth in the esthetic zone from cone-beam computed tomography (CBCT) scans using OnDemand software. The horizontal jumping gap dimension of each tooth was assessed by subtracting the calculated virtual implant diameter from the socket dimensions.

RESULTS

A total of 253 anterior and premolar maxillary teeth were analyzed from 52 CBCT scans. The estimated JG dimensions were 1.23 ± 0.59 mm, 1.80 ± 0.64 mm, 3.02 ± 0.69 mm, for central incisors, lateral incisors and canines respectively, 3.70 ± 0.68 mm for the first premolars showing the highest horizontal gap and 3.19 ± 0.88 mm for second premolars. The incisors showed the smallest horizontal gap compared to the canines and premolars.

CONCLUSIONS

In terms of JG, immediate implant placement is more favorable at the canine and premolar sites. By contrast, the incisors sites should be handled with extreme caution, where the use of narrower implants is advisable when necessary.

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.

Navigating the future of guided dental implantology: A scoping review

BACKGROUND

The aim of this scoping review was to understand the development of robotics and its accuracy in placing dental implants when compared to other forms of guided surgery.

METHODS

An electronic search was conducted on the electronic databases of PubMed, Cochrane, and Science direct with the following queries: ((robotics) AND (dental implant)) AND (accuracy). The search timeline was between 2017 and 2022.

RESULTS

A total of 54 articles were screened for title and abstract, of which 16 were deemed eligible for inclusion. Thirty-one articles were excluded mainly because they were out of topic (not relevant) or not in English. In total, 16 articles were included for analysis.

CONCLUSIONS

This review thoroughly analyses 5 years of literature concerning the evolution of robotics in dental implant surgery, underscoring the necessity for additional research on nascent technologies reported and a comparative study with static and dynamic systems for clinical efficacy evaluation.

Volumetric analysis of artifacts from fiducial markers under cone beam computed tomography

Abstract Background/purpose

Computer aided implant surgery has been widely adopted in modern implant dentistry. However, absence of reliable anatomic landmarks for superimposing digital data sets for patients with terminal dentition or complete edentulism remained challenging. Utilization of additional fiducial markers intraorally as the reference points for the improvement of accuracy became crucial in implant digital workflow. Nevertheless, the choice of the material for fiducial markers should present the least radiographic artifacts under cone beam computed tomography (CBCT) for better accuracy. The aim of this in vitro study was to investigate the volume of radiographic artifacts generated through different materials under the image of CBCT.

Materials and methods

Fifteen dental materials were selected and configured into cubic shape. All the materials were scanned initially with the laboratory scanner as the control groups. The samples were scanned by CBCT machine as test groups and the volume of artifact generated under CBCT images were compared and analyzed using 3D modeling software.

Results

Eleven out of fifteen materials could be recognized under CBCT images. Volumetric analysis reported that statistically significant differences among the materials could be noted, and the flowable composite resin presented the least volumetric difference. Lithium disilicate glass-ceramic, flowable composite resin, and gutta-percha presented the least deformation and maintained their cubic shapes.

Conclusion

The results of the present study may imply that flowable composite resin compared to all ceramic materials, amalgam and gutta-percha may be a preferable choice when utilized as fiducial markers under CBCT images.

Flapless dental implant surgery enabled by haptic robotic guidance: A case report

This case report presents the use of haptic robotic technology in one patient with six implants placed in the maxilla and five implants in the lower mandible with the goal of individual single implant supported crowns to be placed over each implant after 6 months. All implants were placed using a flapless technique, with one immediate implant placement after extraction. All implants were placed with a high degree of accuracy relative to the pre-operative plan as determined by post-op CBCT analysis with an average angular deviation of 2.58° and positional deviations at the coronal and apical aspects of the implant around 1 mm (0.93 and 1.06 mm, respectively). Total surgical time of less than 2 h. Haptic robotics physically guides the location, orientation, and depth of the tools during both drilling and implantation and thus allows for accurate placement as well as the intra-operative flexibility to change the plan as necessary while providing excellent visualization and irrigation. This robotic technology provides a treatment that focuses on accuracy and safety providing the best chance at excellent surgical outcomes for the patient.

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.

Magnetic resonance imaging in dental implant surgery: a systematic review

PURPOSE

To comprehensively assess the existing literature regarding the rapidly evolving in vivo application of magnetic resonance imaging (MRI) for potential applications, benefits, and challenges in dental implant surgery.

METHODS

Electronic and manual searches were conducted in PubMed MEDLINE, EMBASE, Biosis, and Cochrane databases by two reviewers following the PICOS search strategy. This involved using medical subject headings (MeSH) terms, keywords, and their combinations.

RESULTS

Sixteen studies were included in this systematic review. Of the 16, nine studies focused on preoperative planning and follow-up phases, four evaluated image-guided implant surgery, while three examined artifact reduction techniques. The current literature highlights several MRI protocols that have recently investigated and evaluated the in vivo feasibility and accuracy, focusing on its potential to provide surgically relevant quantitative and qualitative parameters in the assessment of osseointegration, peri-implant soft tissues, surrounding anatomical structures, reduction of artifacts caused by dental implants, and geometric accuracy relevant to implant placement. Black Bone and MSVAT-SPACE MRI, acquired within a short time, demonstrate improved hard and soft tissue resolution and offer high sensitivity in detecting pathological changes, making them a valuable alternative in targeted cases where CBCT is insufficient. Given the data heterogeneity, a meta-analysis was not possible.

CONCLUSIONS

The results of this systematic review highlight the potential of dental MRI, within its indications and limitations, to provide perioperative surgically relevant parameters for accurate placement of dental implants.

Accuracy of dental implants positioning in computer-assisted surgeries: In vitro study

OBJECTIVES

The aim of this study is to presents an experimental method for surgical guide confection using an intraoral scanner to obtain a 3D model of the patient's complete denture and compare its accuracy with the conventional methodology using computed tomography.

STUDY DESIGN

This prospective in-vitro study used 30 polyurethane pre-manufactured mandibles which were divided into two groups, conventional technique (group I) and a new method using intraoral scanner (group II), establishing the virtually planned position of the dental implants as a control group, considered as the gold standard for postoperative comparison.

RESULTS

The difference between these methods is close to zero and not statistically significant (p > 0.05), being heigh deviation (Xh) with p:0.130 and angulation difference of dental implants between the groups (Ang) with p:0.396.

CONCLUSION

The acquisition of stereolithography image of the prosthesis using an intraoral scanner has a clinically acceptable accuracy, being in agreement with the conventional method.

Augmented reality in implantology: Virtual surgical checklist and augmented implant placement

OBJECTIVES

Aim of the present study was to create a pedagogical checklist for implant surgical protocol with an augmented reality (AR) guided freehand surgery to inexperienced surgeons using a head mounted display (HMD) with tracking.

METHODS

The anatomical model of a patient with two missing mandibular teeth requiring conventional single-tooth implants was selected. The computed tomography (CT) scans were extracted and imported into segmentation and implant planning software. A Patient-specific dental splint through an intermediate strut, supported 3D-printed QR code. A checklist was generated to guide surgical procedure. After tracking, the AR-HMD projects the virtual pre-surgical plan (inferior alveolar nerve (IAN), implant axis, implant location) onto the real 3D-printed anatomical models. The entire drilling sequence was based on the manufacturer's recommendations, on 3D-printed anatomical models. After the implant surgical procedure, CT of the 3D-printed models was performed to compare the actual and simulated implant placements. All procedures in the study were performed in accordance with the Declaration of Helsinki.

RESULTS

In total, two implants were placed in a 3D-printed anatomical model of a female patient who required implant rehabilitation for dental agenesis at the second mandibular premolar positions (#35 and #45). Superimposition of the actual and simulated implants showed high concordance between them.

CONCLUSION

AR in education offers crucial surgical information for novice surgeons in real time. However, the benefits provided by AR in clinical and educational implantology must be demonstrated in other studies involving a larger number of patients, surgeons and apprentices.

A randomized clinical trial on the accuracy of guided implant surgery between two implant-planning programs used by inexperienced operators

STATEMENT OF PROBLEM

Various static implant planning software packages have been developed for the purpose of static computer-assisted implant surgery. However, how different software programs affect the accuracy of implant placement is unclear.

PURPOSE

The purpose of this clinical study was to evaluate and examine the difference in posterior implant positioning between the planned and placed positions when inexperienced operators, following a fully guided implant surgery protocol, used 2 static implant planning software packages.

MATERIAL AND METHODS

Twenty-four participants who needed single posterior implant placement were randomly divided into 2 groups based on the used implant planning software program (coDiagnostiX, n=12; Implant Studio, n=12). The dataset of the placed implant position, generated by digitizing the implant impression, was superimposed on the planned implant position. The number of horizontal, angular, and vertical deviations of the placed implants were measured for each software package and statistically analyzed with the independent t test (α=.05).

RESULTS

The coDiagnostiX group presented with a mean horizontal deviation at the entry point (DE) of 1.07 ±0.36 mm, mean angular deviation (DA) of 3.52 ±1.64 degrees, and mean depth deviation (DD) of -0.71 ±0.29 mm, while the mean DE, mean DA, and mean DD in the Implant Studio group were 0.97 ±0.33 mm, 3.77 ±2.16 degrees, and -0.84 ±0.30 mm, respectively. Statistically, no significant differences were found between coDiagnostiX and Implant Studio programs for all these results (P>.05).

CONCLUSIONS

Acceptable accuracy of implant positioning can be expected by inexperienced operators if they follow the guidelines of either of the 2 software packages. Both the coDiagnostiX and Implant Studio programs showed similar results, with a shallower than planned implant depth of 0.71 and 0.84 mm, respectively.

Reconstruction of dental roots for implant planning purposes: a retrospective computational and radiographic assessment of single-implant cases

PURPOSE

The aim of the study was to assess the deviation between clinical implant axes (CIA) determined by a surgeon during preoperative planning and reconstructed tooth axes (RTA) of missing teeth which were automatically computed by a previously introduced anatomical SSM.

METHODS

For this purpose all available planning datasets of single-implant cases of our clinic, which were planned with coDiagnostix Version 9.9 between 2018 and 2021, were collected for retrospective investigation. Informed consent was obtained. First, the intraoral scans of implant patients were annotated and subsequently analyzed using the SSM. The RTA, computed by the SSM, was then projected into the preoperative planning dataset. The amount and direction of spatial deviation between RTA and CIA were then measured.

RESULTS

Thirty-five patients were implemented. The mean distance between the occlusal entry point of anterior and posterior implants and the RTA was 0.99 mm ± 0.78 mm and 1.19 mm ± 0.55, respectively. The mean angular deviation between the CIA of anterior and posterior implants and the RTA was 12.4° ± 3.85° and 5.27° ± 2.97° respectively. The deviations in anterior implant cases were systematic and could be corrected by computing a modified RTA (mRTA) with decreased deviations (0.99 mm ± 0.84 and 4.62° ± 1.95°). The safety distances of implants set along the (m)RTA to neighboring teeth were maintained in 30 of 35 cases.

CONCLUSION

The RTA estimated by the SSM revealed to be a viable implant axis for most of the posterior implant cases. As there are natural differences between the anatomical tooth axis and a desirable implant axis, modifications were necessary to correct the deviations which occurred in anterior implant cases. However, the presented approach is not applicable for clinical use and always requires manual optimization by the planning surgeon.

Management of an Implant-Supported Fixed Partial Denture in the Esthetic Zone in a Patient With a Very Limited Mouth Opening: A Case Report

In the maxillary anterior area, the esthetic integration of prosthetic restorations is a challenge, particularly for screw-retained implant prostheses. This case report presents the management and clinical outcome of an old partial edentulous maxillary jaw in an esthetic zone in a young patient with a very limited mouth opening. This patient was rehabilitated with an implant screw-retained fixed partial denture (FPD) using both digital and conventional techniques.

A comparison of accuracy among different approaches of static-guided implant placement in patients treated with mandibular reconstruction: A retrospective study

OBJECTIVE

This study aimed to evaluate the differences in the accuracy of immediate intraoral, immediate extraoral, and delayed dental implant placement with surgical guides (static computer-aided implant surgery) in patients treated with mandibular reconstruction.

METHODS

This was a retrospective study. The patients were divided into three groups: immediate intraoral placement (IIO), immediate extraoral placement (IEO), and delayed placement (DEL). Four variables were used to compare the planned and actual implant positions: angular deviation, three-dimensional (3D) deviation at the entry point of the implant, 3D deviation at the apical point of the implant, and depth deviation.

RESULTS

The angular deviation was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .05) groups. The 3D deviation at the entry point was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .01) groups. The 3D deviation at the apical point was significantly higher in the IIO group than in the IEO (p < .01) and DEL (p < .01) groups. The depth deviation was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .05) groups. There was no statistical difference between the IEO and DEL group in angular and 3D deviation.

CONCLUSION

With surgical guides, among the different approaches for implant placement, delayed implant placement remains the most accurate approach for patients treated with mandibular reconstruction.

Placement accuracy and primary stability of implants in the esthetic zone using dynamic and static computer-assisted navigation: A retrospective case-control study

STATEMENT OF PROBLEM

Both the placement accuracy and primary stability of implants are important to implant therapy in the esthetic zone. The effect of dynamic and static computer-assisted navigation on the primary stability of implants in the esthetic zone remains uncertain.

PURPOSE

The purpose of this case-control study was to investigate the effect of dynamic and static computer-assisted navigation on the placement accuracy and primary stability of implants in the esthetic zone.

MATERIAL AND METHODS

Partially edentulous participants who received at least 1 implant in the anterior maxilla using either fully guided static or dynamic computer-assisted implant surgery (s-CAIS, d-CAIS) from January 2020 to February 2022 were screened. Participant demographic information, timing of implant placement, primary stability represented by the insertion torque value (ITV) in Ncm, and implant survival were collected from the treatment record. Bone quality at the implant sites was determined according to the Lekholm and Zarb classification. The accuracy of implant placement represented by the linear (platform: Dpl, mm; apex: Dap, mm) and angular deviations (axis: Dan, degree) between the planned and placed implants was evaluated based on the preoperative surgical plan and postoperative cone beam computed tomography (CBCT) data. A statistical analysis of the data was completed by using the chi-squared, Fisher exact, Student t, and Mann-Whitney U tests (α=.05).

RESULTS

A total of 32 study participants (38 implants) were included. The groups of s-CAIS (16 participants, 18 implants) and d-CAIS (16 participants, 20 implants) were statistically comparable in sex (P=.072), age (P=.548), bone quality (P=.671), and timing of implant placement (P=.719). All implants survived during an average follow-up period of 13 months. The d-CAIS group showed close linear deviations (Dpl 1.07 ±0.57 mm, Dap 1.26 ±0.53 mm) but lower angular deviation (Dan 2.14 ±1.20 degrees) and primary stability (ITV 25.25 ±7.52 Ncm) than the s-CAIS group (Dpl 0.92 ±0.46 mm, Dap 1.31 ±0.43 mm, Dan 3.31 ±1.61 degrees, ITV 30.56 ±11.23 Ncm, PDpl=.613, PDap=.743, PDan=.016, PITV=.028).

CONCLUSIONS

Comparable linear positioning accuracy and higher angular deviation were found for implants placed in the esthetic zone by using s-CAIS than when using d-CAIS. Higher primary stability of implants may be achieved by using s-CAIS, as s-CAIS seemed to have higher osteotomy accuracy than d-CAIS.

Accuracy of Dental Implant Placement with Dynamic Navigation-Investigation of the Influence of Two Different Optical Reference Systems: A Randomized Clinical Trial

This randomized prospective clinical study aims to analyze the differences between the computer-assisted planned implant position and the clinically realized implant position using dynamic navigation. In the randomized prospective clinical study, 30 patients were recruited, of whom 27 could receive an implant (BLT, Straumann Institut AG, Basel, Switzerland) using a dynamic computer-assisted approach. Patients with at least six teeth in their jaws to be implanted were included in the study. Digital planning was performed using cone beam tomography imaging, and the visualization of the actual situation was carried out using an intraoral scan. Two different workflows with differently prepared reference markers were performed with 15 patients per group. The actual clinically achieved implant position was recorded with scan bodies fixed to the implants and an intraoral scan. The deviations between the planned and realized implant positions were recorded using evaluation software. The clinical examinations revealed no significant differences between procedures A and B in the mesiodistal, buccolingual and apicocoronal directions. For the mean angular deviation, group B showed a significantly more accurate value of 2.7° (95% CI 1.6-3.9°) than group A, with a value of 6.3° (95% CI 4.0-8.7°). The mean 3D deviation at the implant shoulder was 2.35 mm for workflow A (95% CI 1.92-2.78 mm) and 1.62 mm for workflow B (95% CI 1.2-2.05 mm). Workflow B also showed significantly higher accuracy in this respect. Similar values were determined at the implant apex. The clinical examination shows that sufficiently accurate implant placement is possible with the dynamic navigation system used here. The use of different workflows sometimes resulted in significantly different accuracy results. The data of the present study are comparable with the published findings of other static and dynamic navigation procedures.

Influence of bone density on the accuracy of artificial intelligence-guided implant surgery: An in vitro study

STATEMENT OF PROBLEM

Artificial intelligence (AI) has been found to be applicable in medical tests and diagnostics. However, studies on the application of AI technology in oral implantology are lacking. In addition, whether bone density affects the accuracy of guided implant surgery has not been determined.

PURPOSE

The purpose of this in vitro study was to determine the clinical reliability of an AI-assisted implant planning software program with an in vitro model. An additional goal was to determine the effect of bone density on the accuracy of static computer-assisted implant surgery (CAIS).

MATERIAL AND METHODS

Ten participants with missing mandibular left first molars were selected for analysis, and surgical fully guided templates were designed by using an AI implant planning software program. Jaw models were produced in 3 filling rate groups (group L: 25%; group M: 40%; group H: 55%, higher filling rate with representatives of the denser simulated bone density) by 3-dimensional (3D) printing. The preoperative and postoperative positions of the implants were compared by measuring the value of deviation through oral scanning. The mean 3D shoulder and apical and angular deviations were calculated for each group. The data were analyzed using 1-way ANOVA (α=.05 corrected for multiple testing by using Bonferroni-Holm adjustment).

RESULTS

The mean ±standard deviation 3D shoulder and apical and angular deviations were 0.80 ±0.32 mm, 1.43 ±0.47 mm, and 3.68 ±1.30 degrees. These values were lower than the clinical safety distance of the fully guided implant template. A significantly lower mean 3D apical deviation (1.12 ±0.33 mm, P=.023) and angular deviation (2.81 ±1.11 degrees, P=.018) were observed in group L than in group H (1.68 ±0.37 mm, 4.32 ±0.99 degrees). However, no significant differences were found among the 3 groups in 3D deviation at the shoulder (P>.05).

CONCLUSIONS

AI implant planning software program could design the ideal implant position through self-learning. The accuracy of the AI-assisted designed implant template in this study indicated its clinical reliability. Higher bone density led to increased implant deviations.

Effects of a modified surgical protocol on the positional accuracy of dental implants placed using fully guided implant surgery in the partially edentulous posterior ridge with distal extension: a dentiform model study

PURPOSE

The present experiment aimed to evaluate the placement accuracy of fully guided implant surgery using a mucosa-supported surgical guide when the protocol of osteotomy and installation was modified (MP) compared to when the protocol was sequentially and conventionally carried out (CP).

MATERIALS AND METHODS

For 24 mandibular dentiform models, 12 dentists (6 experts and 6 beginners) performed fully guided implant placements two times at the right first and second molar sites using a mucosa-supported surgical guide, once by the CP (CP group) and at the other time by the MP (MP group). The presurgical and postsurgical stereolithographic images were superimposed, and the deviations between the virtually planned and actually placed implant positions and the procedure time were compared statistically (P < .05).

RESULTS

The accuracies were similar in the CP and MP groups. In the CP group, the mean platform and apex deviations at the second molar site for the beginners were +0.75 mm and +1.14 mm, respectively, which were significantly larger than those for the experts (P < .05). In the MP group, only the mean vertical deviation at the second molar site for the beginners (+0.53 mm) was significantly larger than that for the experts (P < .05). The procedure time was significantly longer for the MP group (+94.0 sec) than for the CP group (P < .05).

CONCLUSION

In fully guided implant surgery using a mucosa-supported guide, the MP may improve the placement accuracy when compared to the CP, especially at sites farther from the most-posterior natural tooth.

The success rate of mini-screws for incisors intrusion and patient age, gender, and insertion angle in the maxilla using CBCT and implant-guided surgery. A split-mouth, randomized control trail

BACKGROUND AND OBJECTIVES

The intrusion of anterior teeth is a routine procedure in orthodontics, which has been performed efficiently with the help of mini-screws in the anterior region, especially the upper maxilla. This study aimed to investigate the effect of insertion angle and sociodemographic features on the success rate of mini-screws at the anterior maxillary region.

MATERIALS AND METHODS

Twenty-nine patients (18 Females and 11 Males) aged 18-40 years old were involved in the current study. A split-mouth design was carried out in which recruited patients needed bilateral anterior screws at the labial bone in the region of the incisor for the intrusion of upper anterior incisor teeth as part of their orthodontic treatment with a fixed appliance (upper right side received 90-degree insertion angle mini-screw and 45° for left side) using a surgical guide fabricated from patients CBCT and intraoral scans. The mini-screws were inserted at the attached gingiva bilaterally to achieve intrusion of upper anterior teeth with a power chain ligated from the main archwire to the anterior min-implants. The patient was recalled monthly for orthodontic appliance activation and screw assessment for 6 months. The intrusion force was 15 g on each side.

RESULTS

The results of the study showed that screw stability was higher in the male group than the female group at the 6th monthly follow-up visit with a statistically significant difference between both genders (P = .044). Concerning insertion angle, results showed a statistically significant difference between 45° and 90° as an insertion angle with a P-value <.01 in most of the follow-up months.

CONCLUSION

This study found that male patients with mini-screws inserted at 90° showed greater screw stability over time.

Digital versus conventional surgical guide fabrication: A randomized crossover study on operator preference, difficulty, effectiveness, and operating time

AIM

If surgical guide fabrication is introduced in a dental education program, a digital and conventional workflow can be used. This study evaluated operator preference, perceived difficulty and effectiveness and operating time of both fabrication methods.

MATERIALS AND METHODS

Forty participants in a university setting (students, n = 20; dentists, n = 20) with varying levels of dental experience, but no experience in surgical guide fabrication, were randomly assigned to consecutively fabricate surgical guides on a standardized training model, with either the digital or conventional workflow first. The operating time was measured, and operator preference and the perception of difficulty and effectiveness were assessed with a questionnaire. T tests were used for statistical analysis (α = .05).

RESULT

Of the students, 95% preferred the digital workflow and of the dentists 70%. The perceived difficulty of the digital workflow was significantly lower than the conventional workflow in the student group. Both groups perceived the digital workflow to be more effective. The mean operating time (mm:ss) amounted 12:34 ± 2:24 (students) and 18:07 ± 6:03 (dentists) for the digital, and 22:20 ± 3:59 (students) and 20:16 ± 4:03 (dentists) for the conventional workflow.

CONCLUSION

Both students and dentists prefer the digital workflow for surgical guide fabrication. Students perceive the digital workflow as less difficult and more effective than the conventional workflow. The operating time for surgical guide fabrication is shorter with a digital workflow. This study indicates that digital fabrication techniques for surgical guides are preferred to be incorporated into the dental curriculum to teach students about treatment planning in implant dentistry.

Surgical guides for flapless dental implant placement and immediate definitive prosthesis installation by using selective laser melting and sintering for 3D metal and polymer printing: A clinical report

Integration between the phases of computer-based guided dental implant surgery can be used to optimize oral rehabilitation. Two new surgical guides prepared by using the 3D metal and polymer printing technology are presented for immediate implant loading and definitive fixed prosthesis construction in flapless dental implant surgery. Nine implants and 2 fixed prostheses were installed in 2 completely edentulous adult patients by using a metallopolymer surgical guide with a metal central bar attached to a polymer seal or a metal guide. Virtual planning was used to design the 3D printed surgical guides, which were then constructed by using selective laser sintering (SLM) and selective laser melting (SLS). The 3D printed surgical guides oriented the surgical placement of the implants and were welded to the abutments and attached to the denture framework. The technique allowed implants and prostheses to be installed on the same day.

Accuracy of implant placement via dynamic navigation and autonomous robotic computer-assisted implant surgery methods: A retrospective study

OBJECTIVE

Optimal implant planning and placement allows the prosthesis to be well designed to achieve a satisfactory aesthetic and functional outcome. We aimed to compare deviations between implant planning and placement with the assistance of dynamic computer-assisted implant surgery (d-CAIS) or autonomous robotic computer-assisted implant surgery (r-CAIS) methods in a clinical setting.

METHODS

The retrospective analysis of medical records between 2021 July and 2022 December was conducted to compare the implantation accuracy of the d-CAIS and r-CAIS system in partially edentulous patients through cone-beam computed tomography. Patient-reported outcomes (PROs) were recorded using a visual analogue scale (VAS). The Kolmogorov-Smirnov test was used to check the data distribution. Student's t-test or Mann-Whitney U-test was used as appropriate, with a defined significant difference (p < .05).

RESULTS

Seventy-seven patients were analysed (124 implants), with 38 patients (62 implants) in the d-CAIS group and 39 patients (62 implants) in the r-CAIS group. The differences between d-CAIS and r-CAIS were 4.09 ± 1.79° versus 1.37 ± 0.92° (p < .001) in angular deviation; 1.25 ± 0.54 versus 0.68 ± 0.36 mm (p < .001) in coronal global deviation; 1.39 ± 0.52 versus 0.69 ± 0.36 mm (p < .001) in apical global deviation; the results of the PROMs showed no statistical difference between the two groups.

CONCLUSIONS

r-CAIS allows more accurate implant placement than the d-CAIS technology. And both groups achieved overall satisfactory outcomes via VAS (Chinese Clinical Trial Registry ChiCTR2300072004).

Influence of the macrodesign of an implant and the sleeve system on the accuracy of template-guided implant placement: A prospective clinical study

STATEMENT OF PROBLEM

Three-dimensional (3D) implant planning facilitates determining the optimal position and number of implants, in terms of function and esthetics, by taking into account adjacent structures. Template-guided implant placement is an established procedure for implementing this planning, although the accuracy between the planned and the actual implant position is subject to many influences. The influences of the macrodesign of the implants and the sleeve materials used have rarely been investigated clinically.

PURPOSE

The purpose of this prospective clinical study was to investigate the accuracy of template-guided implant placement according to the macrodesign of different implants and the design of the drill sleeve.

MATERIAL AND METHODS

Implants were placed in 60 participants within 3 groups (n=20): tapered implant with a metal sleeve (T-MS), tapered implant with a polymeric sleeve (T-PS), and progressive tapered implant with a polymeric sleeve (XT-PS). After overlaying the 3D implant planning image with the postoperative intraoral scan, deviations were 2-dimensionally related to the implant shoulder (S) and the apex (A) in terms of height (2DHS/2DHA), mesiodistal (2DSmd/2DAmd) and buccolingual (2DSbo/2DAbo), as well as 3-dimensionally on the implant shoulder (3DS), on the apex (3DA), and on the axis deviation (Axis). The groups were compared by using the analysis of variance. The Tukey post hoc test was performed for normally distributed data to identify significant differences among groups (α=.05).

RESULTS

The errors for 2DSmd and 2DSbo were 0.26 to 0.40 mm across all groups. The 3DS group varied between 0.67 and 0.87 mm. No significant differences were found in terms of the material of the sleeves or the macrodesign of the implants (P>.05). Significant differences were found for 2DHS (P=.029) and 2DHA (P=.016) between the groups with the different sleeves. Group T-PS showed the least height deviation.

CONCLUSIONS

In terms of height deviation, significant differences were found among the groups, with deviations depending on the implant type and the sleeve type. Overall, the method showed a high level of accuracy, providing good predictability of the prosthetic rehabilitation.

Influence of parallel pins on the angle deviation for placement of dental implants: an in vitro study

The aim of the present study was to analyze and compare the angle deviation of two, four and six adjacent dental implants placed with and without straight parallel pins.

MATERIALS AND METHODS

Two hundred and forty (240) dental implants were selected and randomly allocated into the following study groups: Two dental implants placed with straight parallel pins (Ref.: 144-100, BioHorizons, Birmingham, AL, USA) (n = 10) (2PP); Two dental implants placed without parallel pins (n = 10) (2withoutPP); Four dental implants placed with straight parallel pins hT(n = 10) (4PP); Four dental implants placed without parallel pins (n = 10) (4withoutPP); Six dental implants placed with straight parallel pins (n = 10) (6PP) and Six dental implants placed without parallel pins (n = 10) (6withoutPP). The dental implants randomly assigned to groups 2PP and 2withoutPP were placed into standardized polyurethane models of partially edentulous upper jaws in tooth positions 2.4 and 2.6, the dental implants randomly assigned to groups 4PP and 4withoutPP were placed into standardized polyurethane models of fully edentulous upper jaws in tooth positions 1.6, 1.4, 2.4 and 2.6, and the dental implants randomly assigned to groups 6PP and 6withoutPP were placed into standardized polyurethane models of fully edentulous upper jaws in tooth positions 1.6, 1.4, 1.2, 2.2, 2.4 and 2.6. Afterwards, postoperative CBCT scans and digital impressions were aligned in a 3D implant-planning software to compare the angle deviation (°) of two, four and six adjacent dental implants placed with and without straight parallel pins using the General Linear Model statistical analysis.

RESULTS

Statistically significant differences were found between the angle deviation of 2 dental implants placed with straight parallel pins (p < 0.0001) and between the angle deviation of 4 dental implants placed with straight parallel pins (p = 0.0024); however, no statistically significant differences were found in the angle deviation of 6 dental implants placed with straight parallel pins (p = 0.9967).

CONCLUSION

The use of a straight parallelization pin results in lower angle deviation between two and four adjacent dental implants; however, it is not effective for a larger number of dental implants.

Effect of pilot-guided implant placement concept on the accuracy of osteotomy preparation and implant placement

PURPOSE

To evaluate the accuracy of osteotomy preparation and implant placement for 3 pilot-guided (PG) concepts, namely, a surgical template with a metal sleeve (MS), a surgical template with an in-built nonmetal sleeve (NMS), and a surgical template with an in-built nonmetal sleeve for round bur indentation (RB).

METHODS

Surgical models with missing maxillary molars were studied. The MS templates were designed to accept metal sleeves, while the NMS and RB templates were designed with in-built nonmetal sleeves. Ten templates were tested per group (n = 10). After each step (pilot drilling, 2nd drilling, 3rd drilling, profiling, and implant placement), the surgical model was scanned and compared against the planning model to determine maximum horizontal deviation (MHD) and maximum angle deviation (MAD).

RESULTS

The MS and NMS templates exhibited a similar increase in MHD with successive drilling steps. The MAD for the pilot drilling step was significantly lower for MS than for the other groups. However, the differences among groups for MHD and MAD diminished in later steps. All templates had an MHD of 1.0 mm or less and an MAD less than 8°.

CONCLUSION

The investigated PG implant placement concepts resulted in similar deviations in the placed implants.

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.

Considerations for predictable outcomes in static computer- aided implant surgery in the esthetic zone

OBJECTIVE

To provide technical and clinical recommendations for implementing a digital workflow in Static Computer-Aided Implant Surgery in the anterior maxilla.

CLINICAL CONSIDERATIONS

An optimal 3D implant position is crucial for achieving satisfying results in implant rehabilitation in the esthetic area. Due to its complexity, implant placement in the esthetic zone should be executed with precision and predictability. Static Computer-Aided Implant Surgery requires thorough planning and detailed attention to every step of the digital workflow protocol.

CONCLUSIONS

Implant positioning in the esthetic zone using Static Computer-Aided Implant Surgery is a technique-sensitive procedure that requires precise execution of each step. This approach ensures accurate prosthetically driven 3D implant placement and prevents potential errors that could lead to inaccurate positioning.

CLINICAL SIGNIFICANCE

The proper implementation of Static Computer-Aided Implant Surgery may increase the level of agreement between the planned and definitive implant 3D positions in the esthetic zone, thus enhancing the esthetic outcomes of implant rehabilitation.

Automation in Dentistry with Mechanical Drills and Lasers for Implant Osteotomy: A Narrative-Scoping Review

The popularity of implants is increasing with the aging population requiring oral-dental rehabilitation. There are several critical steps in the implant workflow, including case selection, implant design, surgical procedure, biological tissue responses, and functional restoration. Among these steps, surgical osteotomy procedures are a crucial determinant of clinical success. This brief review was aimed at outlining the current state of the field in automation-assisted implant surgical osteotomy technologies. A broad search of the literature was performed to identify current literature. The results are outlined in three broad categories: semi-automated static (image-guided) or dynamic (navigation-assisted) systems, and fully-automated robotic systems. As well as the current mechanical rotary approaches, the literature supporting the use of lasers in further refinement of these approaches is reviewed. The advantages and limitations of adopting autonomous technologies in practical clinical dental practices are discussed. In summary, advances in clinical technologies enable improved precision and efficacious clinical outcomes with implant dentistry. Hard-tissue lasers offer further advancements in precision, improved biological responses, and favorable clinical outcomes that require further investigation.

Influence of Kennedy class and number of implants on the accuracy of dynamic implant navigation: An in vitro study using an X-ray free evaluation methodology

OBJECTIVES

The aim of this in vitro study was to evaluate the accuracy of fully guided dynamic implant navigation surgery in Kennedy I, II, and III class dental arch defects with two different implant designs, using an X-ray free evaluation method.

METHODS

Polyurethane resin maxillary models simulated posterior edentulous defects. Four cone beam computed tomography (CBCT) scans and four intraoral (IOS) scans were obtained for each model and a digital wax-up with the correct implant positions was made. The accuracy of implant positions was evaluated using an IOS-based X-ray-free method (3Shape). Four deviation characteristics were evaluated: insertion point, depth deviation, horizontal and angle deviation.

RESULTS

The insertion point deviation measures ranged from 0.19 mm to 1.71 mm. Depth (s) and (u) deviations ranged from -1.47 mm to 0.74 mm and from 0.02 mm to 1.47 mm, respectively. Horizontal deviation ranged from 0.09 mm to 1.37 mm.

CONCLUSIONS

There is a tendency of a decreasing insertion point deviation for an increasing number and distribution area of the teeth (increasing Kennedy class number). Kennedy class II and distal implant position had the most influence for the higher deviations.

CLINICAL SIGNIFICANCE

Dynamic implant guidance provides accurate spacing, angulation, depth and position of the implants. It is important to understand how the number of missing teeth and implant design could influence the accuracy of dynamic implant navigation. Thus, it is important to evaluate factors influencing the accuracy of dynamic systems by using a X-ray-free post-operative method and to overcome the limitations of providing multiple CBCT scans.

Evaluation of the accuracy of implant placement by using implant positional guide versus freehand: a prospective clinical study

PURPOSE

The aim of this study is to examine and compare the accuracy of implant placement using implant positional guide and freehand.

METHODS

48 implants were placed in patients with single tooth loss with implant positional guide and freehand, respectively. The accuracy of implant placement was assessed by comparing the actual and planned position, including four parameters: coronal deviation, apical deviation, angular deviation, and vertical deviation.

RESULTS

Comparing all the variables, it has been found that the implant positional guide is more accurate than the freehand. All parameters describing in the deviation were significantly lower in the implant positional guide group than the freehand.

CONCLUSIONS

The implant positional guide can act as a practicable tool for dental implant surgery. It is a promising technology that guarantees low cost and high precision in implant surgery. However, based on the restricted evidence from clinical studies, longer follow-up periods, larger population studies, and standardized experimental studies are required. Trial registration CHICTR, ChiCTR2300071024. Registered 28 April 2023-CHICTR, ChiCTR2300071024. Registered 28 April 2023-Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=195424 .

Robot assisted implant surgery: Hype or hope?

The 21st century is characterized by accelerated technological innovation, resulting in digitization of most areas of medicine and dentistry. Dental implant surgical planning has evolved from using analog static guides to computer generated guides and dynamic surgical guidance. Dynamic surgical placement has started gaining ground with the use of navigated surgery and robot assisted implant placement. Have static surgical guides become obsolete? Although innovative and cutting edge, the use of dynamic guidance requires a learning curve and added expenses for the dental team. Also, could dynamic guidance, and specifically robot assisted implant surgery lead to more accurate fixture placement? In this article we will share our experience using robotic implant surgery from the perspective of an academic institution that has used the YOMI robot for several years now.

Inter- and intraindividual variability in virtual single-tooth implant positioning

OBJECTIVES

The purpose of this prospective study was to determine the inter- and intraindividual variability in virtual single-tooth implant positioning based on the level of expertise, specialty, total time spent, and the use of a prosthetic tooth setup.

MATERIALS AND METHODS

Virtual implant planning was performed on matched pre- and post-extraction intraoral scans (IOS), and cone-beam computed tomography scans of 15 patients. Twelve individual examiners, involving six novices and experts from oral surgery and prosthodontics positioned the implants, first based on anatomical landmarks utilizing only the post-extraction, and second with the use of the pre-extraction IOS as a setup. The time for implant positioning was recorded. After 1 month, all virtual plannings were performed again. The individual implant positions were superimposed to obtain 3D deviations using a software algorithm.

RESULTS

An interindividual variability with mean angular, crestal, and apical positional deviations of 3.8 ± 1.94°, 1.11 ± 0.55, and 1.54 ± 0.66 mm, respectively, was found. When assessing intraindividual variability, deviations of 3.28 ± 1.99°, 0.78 ± 0.46, and 1.12 ± 0.61 mm, respectively, were observed. Implants planned by experts exhibited statistically lower deviations compared to those planned by novices. Longer planning times resulted in lower deviations in the experts' group but not in the novices. Oral surgeons demonstrated lower crestal, but not angular and apical deviations than prosthodontists. The use of a setup only led to minor adjustments.

CONCLUSIONS

Substantial inter- and intraindividual variability exists during implant positioning utilizing specialized software planning. The level of expertise and the time invested influenced the deviations of the implant position during the planning sequence.

Positional accuracy during the sequence of static computer-assisted implant surgery in three alveolar ridge morphologies: An in vitro study

PURPOSE

This in vitro study aimed to assess the positional accuracy during the sequence of static computer-assisted implant surgery (sCAIS) according to the anatomical characteristics of the alveolar ridge.

MATERIAL AND METHODS

Maxillary bone models with six single tooth gaps including clinical scenarios of healed alveolar ridge (HR), single-rooted (SRS), and three-rooted socket (TRS) morphologies were used in this study. Positional deviations during implant placement procedures were evaluated after the pilot osteotomy (PD), final osteotomy (FD), and implant placement with respect to the pre-planned implant position by using a software package. ANOVA and post hoc analyses were performed.

RESULTS

A total of 90 implants were included in this study. Higher mean angular, crestal, and apical deviations were found after the PD and FD (3.5 ± 2.4°, 0.7 ± 0.3 mm, and 1.4 ± 0.8 mm versus 3.6 ±2.2°, 0.6 ± 0.3 mm, and 1.2 ± 0.6 mm) compared to IP (2.8 ± 1.6°, 0.7 ± 0.3 mm, and 1.2 ± 0.5 mm, p ≤ 0.004). Implants placed in TRS demonstrated higher mean angular, crestal, and apical deviations (4.0 ± 1.7°, 0.8 ± 0.3 mm, and 1.6 ± 0.5 mm) compared to implants placed in SRS (2.5 ± 1.2°, 0.7 ± 0.3 mm, and 1.1 ± 0.4 mm) or HR (2.0 ± 0.9°, 0.5 ± 0.3 mm, and 0.8 ± 0.4 mm, p < 0.001).

CONCLUSIONS

Positional deviations during sCAIS procedures are initiated with the first implant osteotomy and persist throughout the drilling sequence. However, deviations slightly decreased after implant placement. The alveolar ridge morphology is strongly associated with positional deviations. Higher deviations were observed in three-rooted and single-rooted sockets simulating an immediate approach compared to healed sites simulating a delayed protocol.

Accuracy of a novel modified single computed tomography scanning method for assisting dental implant placement: a retrospective observational study

PURPOSE

The aim of this study is to compare dental implant placement accuracy of three surgical guide fabrication methods: single (SCT) and double computed tomography (DCT), and a newly developed modified SCT (MSCT) scan method.

METHODS

A total of 183 cases (183 surgical guides, and 485 implants) of static-guide-assisted implant placement surgery using the SCT, DCT, or MSCT methods in a dental clinic were included in the study. Three-dimensional (3D) deviations (mm) at the entry and tip of the implant body between preoperative simulation and actual placement were measured as surrogate endpoints of implant placement accuracy. The following survey details were collected from medical records and CT data: sex, age at implant placement surgery, surgical guide fabrication method, number of remaining teeth, implant length, implant location, alveolar bone quality, and bone surface inclination at implant placement site in preoperative simulation, etc. Risk factors for reducing implant placement accuracy were investigated using generalized estimating equations.

RESULTS

The SCT and DCT methods (odds ratios [ORs] vs. MSCT method: 1.438, 1.178, respectively), posterior location (OR: 1.114), bone surface buccolingual inclination (OR: 0.997), and age at implant placement surgery (OR: 0.995) were significant risk factors for larger 3D deviation at the entry; the SCT (OR: 1.361) and DCT methods (OR: 1.418), posterior location (OR: 1.190), implant length (OR: 1.051), and age at implant placement surgery (OR: 0.995) were significant risk factors for larger 3D deviation at the tip of the implant body.

CONCLUSIONS

Implant placement accuracy was better using the MSCT method compared to the SCT and DCT methods.

The accuracy of dynamic computer assisted implant surgery in fully edentulous jaws: A retrospective case series

OBJECTIVES

To evaluate the accuracy of implant placement using a dynamic navigation system in fully edentulous jaws and to analyze the influence of implant distribution on implant position accuracy.

MATERIALS AND METHODS

Edentulous patients who received implant placement using a dynamic navigation system were included. Four to six mini screws were placed in the edentulous jaw under local anesthesia as fiducial markers. Then patients received CBCT scans. Virtual implant positions were designed in the planning software based on CBCT data. Under local anesthesia, implants were inserted under the guidance of the dynamic navigation system. CBCTs were taken following implant placement. The deviation between the actual and planned implant positions was measured by comparing the pre- and postsurgery CBCT.

RESULTS

A total of 13 edentulous patients with 13 edentulous maxillae and 7 edentulous mandibles were included, and 108 implants were placed. The average linear deviations at the implant entry point and apex were 1.08 ± 0.52 mm and 1.15 ± 0.60 mm, respectively. The average angular deviation was 2.85 ± 1.20°. No significant difference was detected in linear and angular deviations between the maxillary and mandibular implants, neither between the anterior and posterior implants.

CONCLUSIONS

The dynamic navigation system provides high accuracy for implant placement in fully edentulous jaws, while the distribution of the implants showed little impact on implant position accuracy.