Technological advances in dental implant surgery

Technological
advances in dental
implant surgery
Copyright ©2021 Periowiki.com
1

Contents
-Introduction
- Two Dimensional imaging
- CAD/CAM Technology – related history
- Computer-aided-design/Computer- aided-manufacturing (CAD/CAM)
technology
- Computer guided implant surgery (CGIS)
- Computer navigated implant surgery (CNIS)
- Studies comparing CGIS, CNIS and Laboratory made acrylic guide
- Robotics in dental implantology
- Conclusion
- References 2

INTRODUCTION
Prosthetic replacement of missing teeth with implants has become a predictable
procedure. However, numerous clinicians are encountering difficult cases, with
insufficient amount of bone.
This has created an increasing demand for advanced presurgical imaging procedures,
which enables the clinician to evaluate the osseous and vital anatomic structures
adjacent to the implant site prior to surgical intervention.
Various cross-sectional imaging techniques and innovative software programs have
been developed to help create an accurate presurgical plan.
3

Conventional dental panoramic tomography and plain film
tomography are usually performed with the patient wearing a
radiographic template with integrated metal spheres at the
position of the waxup.
Based on the magnification factor and the known dimensions
of the metal sphere, the depth and dimensions of the implants
are planned.
Two Dimensional imaging
4

Computerized Implant Dentistry
Computed
Tomography (CT)
imaging
CT – based
implant planning
software
CAD/CAM
technology
5

Computerized tomography (CT) was founded by Sir Godfrey Houndsfield and
Allen M. Cormack in 1972.
In 1986, Fellingham et al. first demonstrated the use of interactive graphics
and 3D modeling for surgical planning, prosthesis, and implant design.
In 1986, Dev et al. developed a computer-controlled, indirect milling machine
for reproduction of an anatomical structure.
History
6

Computed Tomography (CT)
Tomos = slice; graphein = to write.
Definition - imaging of an object by analyzing its slices.
7

Generation 1
(1972)
X ray beam - Linear (pencil – like) shape.
Detector – Single.
Movement – translation and then rotation of both x ray beam and detector.
Scan time – 4.5 mins.
8

Generation 2
(1973)
X ray beam - Fan shaped.
Detectors– Multiple (Upto 30) .
Movement – translation and then rotation of both x ray beam and detector.
Scan time – 2.5 mins. 9

Generation 3
(1974)
X ray beam - Fan shaped.
Detectors– Multiple (288).
Movement – Continuous rotation of both X ray beam and detectors.
Scan time – 18 secs.
1989 – Spiral CT based on 3rd generation
10

Generation 4
(1975)
Only X ray tubes rotates, detectors are stationary.
This technology was later abandoned.
2 seconds scan time.
11

Generation 5
(1984)
X-ray tube is not mechanically spun in order to rotate the
source of X-ray photons.
50ms scanning time.
12

Helical CT scanning involves simultaneous patient translation and
X-ray exposure, generating data specific to an angled plane of
section with each rotation of the X-ray tube.
Rapid acquisition of data set eliminates respiratory misregistration
artefacts and prevents discontinuities in the reconstructions due
to the minimization of motion artefacts.
In addition, helical CT scanning allows production of overlapping
images without additional radiation exposure.
Helical Computed Tomography (CT)
13

CT – based dental implant planning software
Computer program that works with a CT scan to determine
exact placement of dental implants and a final design of a
prosthesis (crown, bridge or denture).
14

Computed Tomography (CT) based implant planning software
Advantages
-Digital planning and fabrication of a virtual
wax-up, implant position, abutment design,
surgical guide, provisional restoration, and as
well as final restoration.
-Allows predetermination of the size of the
implant, the abutment and the provisional
restoration.
- Averts any possible complications by
highlighting the inaccuracies in the selection
of implant size or position, during virtual
planning, which, can then be easily rectified
using the software.
15

Computed Tomography (CT) based implant planning software
Advantages
-Assists in anticipation, guiding and planning of procedures like alveolectomy,
alveoplasty, implant positioning in situations with anatomical limitations,
visualization of the amount of available bone in each area and aids in selecting the
ideal donor site for osseous grafts, graft location, shape and volume of graft, sinus
lift technique and placement of implants in one step surgery, treatment of atrophic
maxillae as well as placement of transzygomatic implants etc.
- Allows for the storage of the treatment plan and all other data of the patients on
the computer.
- Demonstration of the virtual treatment plan to the patient is possible.
16

Computer-aided-design/Computer- aided-manufacturing
(CAD/CAM) technology
Transferring the virtual treatment plan into actual patient
treatment has been made possible by the revolutionary
CAD/CAM technique.
The use of the CT based implant planning software system
incorporated CAD/CAM technology is used to create
guides and frameworks for the dental prosthesis.
17

Computer-aided-design/Computer- aided-manufacturing
(CAD/CAM) technology
Computer guided
implant Surgery
(static system)
Computer navigated
implant Surgery
(dynamic system)
18

- Introduction of helical CT (spiral or volume acquisition
CT) has dramatically improved the application of CT
imaging in implant dentistry.
-Helical CT, along with advancements in stereolithography,
has allowed for the development of a CAD/CAM
processed surgical guide to be placed directly on the bony
site.
Computer guided implant surgery
(Static system)
19

Stereolithography
Stereolithography is a computer-guided laser dependent, rapid
prototyping polymerization process that can duplicate the exact
shape of the patient’s skeletal anatomical landmarks in a
sequential layer of a special polymer to produce a special three-
dimensional transparent resin model, which fits intimately with
the hard and/or soft tissue surface.
Nikzad S, Azari A. J Oral Maxillofac Surg 2008;66:1446-54.
20

Computer guided implant surgery
(Static system)
The use of a static surgical template that reproduces
the virtual implant position directly from
computerized tomographic data and does not allow
for intraoperative modification of the implant
position.
21

Three or more implants in a row.
Proximity to vital anatomic structures.
Problems related to the proximity of adjacent teeth.
Questionable bone volume.
Implant position that is critical to the planned restoration.
Flapless implant placement.
Multiple unit or full-arch immediate restorations, with or without extractions and
immediate placement.
Significant alteration of the soft tissue or bony anatomy by prior surgery or trauma
Patients with physical, medical, and psychiatric comorbidities.
CT-guided implant surgery - Indications
22

CT-guided implant surgery - Sequence of steps
Step 1 – Preparing Diagnostic wax up
Step 2 - Preparing radiographic guide
Step 3 – CT/CBCT scan made
Step 4 - Images imported to software programs
Step 5 – Manufacturing of surgical guide
Step 6 – Ideal placement of the dental implants
Step 7 - Prosthesis
23

Step 1 : Preparing - Diagnostic wax up
Computer Guided planning and placement of dental implants
Upper and lower arch impressions are made, and a bite registration is obtained.
Poured models are mounted on an articulator.
The prosthodontist or restorative dentist first creates an ideal restorative treatment
plan, determining the planned tooth position by creating a diagnostic wax-up that
indicates the exact anatomy and position of the teeth to be replaced.
This ideal diagnostic wax-up is then incorporated, by a dental laboratory, into an acrylic
prosthesis, referred to as a radiographic guide, scan prosthesis or scan appliance.
24

Step 2: Preparing radiographic guide (i.e. Scan prosthesis or scan appliance)
NobelGuide Radiographic Guide
SimPlant radiographic barium stent EZ Guide radiographic
appliance
25

Step 3 : CT/CBCT scan
According to the individual system protocols, the CT/CBCT scan is
then taken with the patient wearing the scan prosthesis.
26

Step 4: Images are then imported into the various proprietary software
programs.
NobelGuide
SimPlant EZ Guide
27

28

Step 5: The digital treatment plan is then downloaded to the manufacturer for
fabrication of a surgical guide.
NobelBiocare NobelGuide
SimPlant SurgiGuide
EZ Guide
29

Types of guide supporting surfaces
30
Kalaivani, Gunalan et al. “Expectation and reality of guided implant surgery protocol using computer-assisted
static and dynamic navigation system at present scenario: Evidence-based literature review.” Journal of Indian
Society of Periodontology vol. 24,5 (2020): 398-408. doi:10.4103/jisp.jisp_92_20

Design of sleeves in the surgical guide
31
(a) Metallic sleeve; (b) non-metallic sleeve; (c) customized open sleeve

Proper placement of stereolithographic guide using index in static-guided approach
32

Step 6: CT/CBCT-guided surgery allows for the ideal placement of multiple
dental implants according to the planned restoration(s), the relationships
of implants to surrounding anatomy, and principles of ideal prosthodontic
implant positioning and spacing.
33

Step 7: CT/CBCT-guided surgery allows for the ideal placement of multiple
dental implants according to the planned restoration(s), the relationships
of implants to surrounding anatomy, and principles of ideal prosthodontic
implant positioning and spacing.
34

• It precisely guides the osteotomy drills.
• Directs the surgeon in the exact location and angulation to place the implant
based on virtual treatment plan.
• It allows flapless surgery, which entails less bleeding, less swelling,
decreased healing time and postoperative pain.
• Aids in the preservation of hard and soft tissue and maintains blood
circulation to the surgical site.
• Considerably increased accuracy of implant placement.
• Avoidance of vital structures.
• Shorter period required for surgery.
The computer guided implant surgery employing surgical template has
the following advantages:
35

the following drawbacks and limitations:
-Error in data acquisition or incorrect processing of the image.
-Deviations from planned implant positions especially in the coronal
and apical portions of the implants as well as with implant angulation.
- Inaccurate fixation of the guide resulting in displacement
during perforation
- Mechanical errors caused by angulation of the drills during
Perforation.
- Changed positioning of surgical instruments due to reduced
mouth opening. 36

the following drawbacks and limitations:
-Fracture of the surgical guide.
-Complexity of the whole system.
- The total cost of tools needed including the software program and
surgical templates.
-The potential for thermal injury secondary to reduced access for
external irrigation during osteotomy preparation during flapless
implant placement with surgical guides.
- Does not allow intraoperative modification of implant position. 37

Planning of implant positions using cone-beam CT data and
surgical guide templates
38
Nickenig HJ, Eitner S in 2007 assessed the reliability of implant placement after virtual
planning of implant positions using cone-beam CT data and surgical guide templates.
They performed the study on 102 patients (250 implants, 55.4% mandibular; mean patient
age, 40.4 years) who had undergone implant treatment therapy in an armed forces dental
clinic (Cologne, Germany) . They were treated with a system that allows transfer of virtual
planning to surgical guide templates.
The study conclusion was as follows: Implant placement after virtual planning of implant
positions using cone beam CT data and surgical templates can be reliable for preoperative
assessment of implant size, position, and anatomical complications. It is also indicative of
cases amenable to flapless surgery.
Nickenig HJ, Eitner S. Reliability of implant placement after virtual planning of implant positions using cone beam CT
data and surgical (guide) templates. J Craniomaxillofac Surg. 2007 Jun-Jul;35(4-5):207-11. doi:
10.1016/j.jcms.2007.02.004. Epub 2007 Jun 18. PMID: 17576068.

Computer navigated implant Surgery (CNIS)
(dynamic system)
The use of a surgical navigation system that
reproduces the virtual implant position directly
from computerized tomographic data and allows
for intraoperative changes in implant position.
39

Computer navigated implant surgery (CNIS) has many
advantages over CGIS
• It allows intraoperative changes in implant position that is, the virtual
surgical plan can be altered or modified during surgery and the clinician can
use the navigation system to concurrently visualize the patient’s anatomy,
permitting the surgeon to steer around obstacles, defects etc., that were
not apparent on the presurgical scan.
• Bur tracking allows the drill to be continuously visualized on a computer
screen in all three-dimensions (x, y and z).
• It overcomes other limitations of CGIS like secondary thermal injury,
displacement or fracture of guide etc.
40

Computer navigated implant surgery (CNIS)
Procedure
Step 1 - The anatomy of the patient’s jaw, with a dental splint
incorporating special fiducial markers, is first captured on CT.
This CT anatomy forms the virtual patient. The fiducial markers
superimpose the virtual patient on the real patient during surgery.
41

Procedure
Step 2 - During surgery, the IGITM System tracks the position of the
patient’s jaw and the drill through signals from the infrared light
emitters fitted to the patient and surgical instruments.
The spatial position of the drill in relation to the patient is
calculated by the system’s processing unit and is visually displayed
in real-time on the navigation screen.
42

Procedure
The system guides the surgeon to prepare the receptacle site in
accordance with the planned position of the implant.
The virtual position, angulation and depth of the drill tip are displayed
in real time in relation to the pre-acquired CT image of the anatomical
structures.
Any deviation from the planned path of drilling will trigger an
audio and visual alert. This guides the surgeon to maintain the
planned course and avoid encroaching on critical structures
during surgery.
43

Procedure
44

Dynamic navigation system
45
(a) Components: Patient jaw attachment, handpiece attachment and a system consisting of a camera,
overhead blue emitting lights, computer and sensor; (b) ) Surgical procedure: I- Thermoplastic stent attaches
with the remaining teeth in the arch using the radiographic marker; II-Digital planning; III and IV-
Preoperative planning; V- Osteotomy drilling by viewing on the screen; VI- Postoperative image after implant
placement. Kalaivani, Gunalan et al. “Expectation and reality of guided implant surgery protocol using computer-assisted static and dynamic
navigation system at present scenario: Evidence-based literature review.” Journal of Indian Society of Periodontology vol. 24,5 (2020): 398-408.
doi:10.4103/jisp.jisp_92_20

46

Computer navigated implant surgery (CNIS) - Limitations
• They are sensitive to reflections and interference with the line of sight
between the sensors and the cameras that is, a line-of-sight between
the tracking device and the instrument to be tracked has to be
maintained, which is not always convenient especially with the typical
seating arrangement of dental surgeon and assistant and hence may
preclude tracking of instruments.
• More expensive and requires an expensive hardware.
• Requires rigorous intraoperative referencing.
• Significant learning curve.
47

Computer Guided Implant Surgery (CGIS) – related studies
Schneider D, Marquardt P, Zwahlen M, Jung RE. Clin Oral Implants
Res 2009;20 Suppl. 4:73-86.
Implant survival rates of 91-100% after an observation time of 12-
60 months are reported in six clinical studies with 537 implants
mainly restored immediately after flapless implantation
procedures.
Early surgical complications occurred in 9.1%, early prosthetic
complications in 18.8% and late prosthetic complications in 12% of
the cases.
48

Vasak et al., (2014) also verified the viability of the CGIS concept and
revealed a cumulative survival rate and success rate of 98.8% and 96.3% of
immediate and delayed loaded implants respectively, placed using CGIS
technique.
Meloni et al. (2013) conducted a clinical trial where in 23 edentulous jaws
were treated with three-dimensional software planning, guided surgery,
and immediate loading and restored with CAD-CAM full arch frameworks
and concluded that computer-guided surgery and immediate loading seem
to represent a viable option for the immediate rehabilitations of
completely edentulous jaws with fixed implant supported restorations.
49

50
As per the results and conclusions drawn by Azari A, Nikzad S (2008) in their
study:
computer-assisted/-guided/-aided implantology was found to overcome
the errors encountered during implant osteotomies and to position the
implants more precisely.
The protocols followed by this sophisticated technique are based upon the
advocated concept of prosthetic-driven implantology and CT-scan analysis
recently approved.
Azari A, Nikzad S. Computer-assisted implantology: historical background and potential
outcomes-a review. Int J Med Robot. 2008 Jun;4(2):95-104. doi: 10.1002/rcs.188. PMID:
18348182.

M Siessegger et al. Journal of cranio maxillofacial surgery 2001; 29(5):276-81.
Five patients were treated with the aid of CAS, a total of 18 dental implants being
placed. Only difficult operation sites, e.g. following bone augmentation or
anatomically malformed jaws were included in this study.
An infra-red light based navigation system (Vector Vision 2, BrainLAB, Munich,
Germany) including a three-dimensional planning approach for maxillofacial
surgery was used.
The use of an image-guided navigation system provides a valuable tool in implant
dentistry and proved superior to conventional implant surgery especially in
difficult anatomical regions.
51

Rolf Ewers, MD, Kurt Schicho, Michael Truppe, Rudolf Seemann, Astrid Reichwein,
Michael Figl, and Arne Wagner. J Oral Maxillofac Surg 62:329-334, 2004.
In 7 years (1995 to 2002), 55 patients with 327 dental implants were
successfully positioned with computer-aided navigation technology.
The mean number of implants per patient was 6 (minimum, 1;
maximum, 11). No complications were observed; the preoperative
planning could be exactly realized. The average expenditure of time
for the preparation of a surgical intervention with navigation
decreased from 2 to 3 days in the initial phase to one-half day in
clinical routine use with software that is optimized for dental
implantology.
Computer Navigated Implant Surgery (CNIS) – related studies
52

Elian N, Jalbout ZN, Classi AJ, Wexler A, Sarment D, Tarnow DP. (2008)
The accuracy in implant placement by the CNIS system
demonstrated a mean linear accuracy of less than 1 mm at both the
implant neck and apical tip and the reported mean angular
deviation of less than 4° for the implants placed via CNIS system
that is, an accurate match between the planned implant and final
implant was revealed.
Computer guided implant surgery (CGIS) Versus Computer navigated implant surgery (CNIS)
Related Studies
53

Related Studies
Ozan O, Turkyilmaz I, Ersoy AE, Mc Glumphy EA, Rosenstiel SF. J Oral Maxillofac Surg
2009;67:394-401.
Di Giacomo GA, Cury PR, de Araujo NS, Sendyk WR, Sendyk CL. J Periodontol
2005;76:503-7.
A mean linear accuracy ranging between 1.1 mm and 1.45 mm at the implant neck
and between 1.41 mm and 2.99 mm at the implant apical tip along with a mean
angular deviation ranging between 2° and 7.25° in the implants placed with
stereolithographic guides has been reported
Based on the preceding studies, it can be assumed that CNIS system provides higher
accuracy than the CGIS system.
54

Ruppin J, Popovic A, Strauss M, Spüntrup E, Steiner A, Stoll C Clin Oral Implants
Res 2008;19:709-16.
Evaluated the accuracy of optical tracking versus stereolithographic
system for implant placement, no statistically significant
differences were found between the two systems.
Related Studies
55

CGIS Versus CNIS Versus Laboratory made acrylic guide
Related Studies
Somogyi-Ganss E, Holmes HI, Jokstad A Clin Oral Implants Res 2014
Accuracy of a dynamic CNIS system was compared with three
commercial CGIS static systems and the use of an acrylic stent
for implant osteotomy preparation. It was revealed that the
dynamic and static systems provided superior accuracy versus
a laboratory-made acrylic guide and that both dynamic and
static systems showed an average error of <2 mm and 5°.
56

Colombo M, Mangano C, Mijiritsky E, Krebs M, Hauschild U, Fortin T. Clinical applications and
effectiveness of guided implant surgery: a critical review based on randomized controlled
trials. BMC Oral Health. 2017;17(1):150.
57
Conclusions :
Based on the results of the screened literature it is evident that the overall
scientific evidence in the field of image guided implant placement is low.
Only two RCTs with at least 6 months of follow-up could be identified.
The only evidence that is retrieved is there are no statistically significant
differences between conventional and computer-guided implant placement
procedures, both for patient outcomes and implant survival rate. Reduction
of post-operative pain and surgical time are discussed.
Consequently, certain clinical recommendations cannot be given. However,
indications for guided-implant surgery could be the need for minimally
traumatic or flapless surgery, optimal implant positioning and immediate
loading.

Marlière DAA, Demètrio MS, Picinini LS, Oliveira RG, Netto HDMC. Accuracy of computer-
guided surgery for dental implant placement in fully edentulous patients: A systematic
review. Eur J Dent. 2018;12(1):153-160. doi:10.4103/ejd.ejd_249_17
58
Conclusions :
Seven articles were included in this review.
They describe the use of bone and muco-supported guides, demonstrating
angular deviations cervically and apically ranging from (minimum and
maximum means), respectively, 1.85–8.4 (°), 0.17–2.17 (mm), and 0.77–2.86
(mm).
Angular deviations obtained most inaccuracy in maxilla.
For cervical and apical deviations, accuracy was preponderantly lower in
maxilla.
Despite the similar deviations measurement approaches described, clinical
relevance of this study may be useful to warn the surgeon about the safety
margins in clinical situations. Copyright ©2021 Periowiki.com

Daniele De Santis, Luciano Malchiodi, Alessandro Cucchi, Adam Cybulski, Giuseppe Verlato,
Federico Gelpi, Pier Francesco Nocini, "The Accuracy of Computer-Assisted Implant Surgery
Performed Using Fully Guided Templates versus Pilot-Drill Guided Templates", BioMed
Research International, vol. 2019, 10pages.
59
Computer-assisted stereolithographically guided surgery allows an ideal implant
placement for prosthetic restoration.
Two types of stereolithographic templates are currently available: a fully guided
template and a pilot-drill guided template.
A total of 50 implants were inserted in 15 patients using CAD-CAM templates.
The authors observed:
Fully guided implant surgery was more accurate than pilot-drill guided surgery for
different parameters.
For both types of surgery, a safety margin of at least 2mm should be preserved
during implant planning to prevent damage to nearby anatomical structures.

Daniele De Santis, Luciano Malchiodi, Alessandro Cucchi, Adam Cybulski, Giuseppe Verlato,
Federico Gelpi, Pier Francesco Nocini, "The Accuracy of Computer-Assisted Implant Surgery
Performed Using Fully Guided Templates versus Pilot-Drill Guided Templates", BioMed
Research International, vol. 2019, 10pages.
60
Authors could suggest the pilot-drill guided surgery when :
(1) coronal osteoplasty is required;
(2) flap-raising is essential to improve the view near important anatomical
structures;
(3) soft tissue plastic surgery is needed;
(4) implantation under crestal bone is planned;
(5) keratinised tissue is sparse;
(6) a bone-regeneration procedure is required;
(7) an implant is to be placed near remaining teeth; and
(8) the interocclusal distance is insufficient.

Kalaivani G, Balaji VR, Manikandan D, Rohini G. Expectation and reality of guided implant
surgery protocol using computer-assisted static and dynamic navigation system at present
scenario: Evidence-based literature review. J Indian Soc Periodontol. 2020;24(5):398-408.
doi:10.4103/jisp.jisp_92_20
61
Includes reference of publications from 2000 to 2019, which is related to
promising outcomes using computer-assisted static or dynamic navigation system
for the placement of implant. Out of these, 809 were related to the computer-
guided implant placement.
Authors noted:
Guided implant surgery provides precise, effective, and efficient implant
placement compared to freehand implant surgery without damaging the critical
anatomic dental structures.
The major advantage of the dynamic design is the ability to intraoperatively
adjust the planned implant positioning.

List of complications/failures may encounter using computer-assisted
implant placement:
62
Early surgical complication/failures
Limited access
Fracture of template
Unpredicted bony dehiscence
Infection
Difficulties when bone augmentation needed
Insertion of wider, narrower or shorter implant than planned
Lack of implant stability
Soft tissue deficiency
Fistula
Pain
Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the
clinical outcome of computer-guided template-based implant dentistry. Clin Oral Implants
Res. 2009;20(Suppl 4):73–86. [PubMed: 19663953]

List of complications/failures may encounter using computer-assisted
implant placement:
63
Early prosthetic complication/failures
Misfit or loosening of prosthesis
Occlusal problem
Difficulties in speech
Cheek biting
Late prosthetic complication/failures
Loosening of screw
Fracture or misfit of prosthesis
Occlusal wear
Esthetic unhappiness
Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the
clinical outcome of computer-guided template-based implant dentistry. Clin Oral Implants
Res. 2009;20(Suppl 4):73–86. [PubMed: 19663953]

Robotic implant surgery
Pre operative surgical planning
Haptic based environment- DICOM dataset patient model is
converted into wavefront.obj
64

Robotic implant surgery
The position in the virtual environment are related with the
position of the robotic manipulator through image guided
navigation system to maintain the alignment between prototype
surgical manipulator end effector and the drill to perform the safe
experimental surgery.
65

Robotics in Dental Implantology
Although dental implants date back to thousands of years, it wasn’t a
major breakthrough until the 1980s.
Many medical research teams in the 1990s used interactive computer
applications including hardware and software as an aid for implant
planning (Azari A, Nikzad S. 2008).
For instance, SIM/PLANT a computer guided implant treatment was the
first commercially released software in 1993 which provided the clinicians
with the ability to view and interact with the CT scan data to pre-surgically
place the implant body and visualize the prosthodontic implications
virtually at the same time (Verstreken K, Van Cleynenbreugel J, Marchal G,
et al. 1996).
66

The United States, the first robotic dental surgery system was cleared
by the Food and Drug Administration for dental implant procedures in
2017.
At the end of 2017, the world's first autonomous dental implant
placement system was developed by Zhao and colleagues in China.
This so-called intelligent robot has a high degree of autonomy, can
automatically adjust during intraoperative procedures, and can execute
surgical tasks directly on patients without any apparent control by a
surgeon.
Wu Y, Wang F, Fan S, Chow JK (2019)
67

• A Robot-guided Implantology
increases accuracy and aesthetics in
dental implant procedures through
visual and physical guidance and a
simple digital workflow.
Robot-assisted
Implantology
• A fully autonomous implant robot on
the other hand is independent under
the supervision of a Dentist (Bhat T
2017).
Fully
autonomous
Implant Robots.
68

Robot guided implantology
o Spearheaded by Neocis, a company based in the United States of America
(Miami, Florida, USA).
o Founded in 2009, this organization has been approved by Food and Drug
Administration (FDA) to use its flagship product “Yomi” with real-world
patients in a clinical setting.
o Yomi three basic components :-
1) Sensors,
2) Effectors
3) Control systems
Consortium on Cognitive Science Instruction, Parts of Robots.
http://www.mind.ilstu.edu/curriculum/medical_ro botics/parts_of_robots.php. Accessed January 6,
2018.
69

Sensors
• Help robots gather information about the environment to guide its
actions.
• Some of the commonly used sensors are microphones, buttons, cameras
etc.
Effector
• An effector of the robot is the one that actually does the work.
• An example of effectors is robotic arms helping a surgeon pick a surgical
knife.
Control
system
• Also known as the brains of the robot determines the behaviour of the
robot.
70

primary input to the robot-guided Yomi comes
from a CT scan.
CT information is then fed into dynamic planning
software that allows the surgeon plan the
surgery accounting for key anatomical features
like the nerves, sinus and adjacent teeth.
This step sets the parameters of the implant
surgery and establishes limits for visual and
physical guidance.
71

Visual guidance
• Is a real time three
dimensional graphics
that provide navigation
during surgery and
confirms progress.
Physical guidance
• by robotic arm
• guides the surgeon to
position and drill till
appropriate depth.
• robotic arm physically
constraints the surgeon’s
drill movement to match
the plan through Haptic
guidance technology.
• This collaborative
robotic arm enables
minimally invasive
surgery which leads to
faster surgery, faster
recovery and less pain
for the patients.
Patient tracking
• Patient tracking
throughout the surgery
is done through intra-
operative tracking that
maintains accuracy
throughout the surgery
and follows the patient if
they move.
Yomi prevents any deviation from the plan with full view of the surgical site. The
surgeon precisely drills into the osteotomy and is stopped when reaching the
planned depth. 72

73

Advantages
1) Extremely high accuracy and precision,
2)Stable and untiring repeated
performance and
3)Ability to accurately process
quantitative information fed into the
system.
Limitations
1) Include the fact that the judgment of
the situation is limited to the data fed
into the software and/or tracked by
patient tracking system,
2) Supervision by an experienced Dentist
is still required and the cost of the system
is prohibitive.
74

Fully-Autonomous Robotic Implantology
75
Robot dentist is first to fit implants without a human touch. South China Morning Post.
http://www.scmp.com/news/china/article/2112197 /chinese-robot-dentist-first-fit-implants-patients-mouth-
without-any-human. Published September 22, 2017. Accessed January 7, 2018.

76
The one hour procedure resulted in implant fitted within a margin of error of 0.2-
0.3mm.
The artificial teeth the robot implanted were created by 3D printing which is another
breakthrough technology gaining popularity among Dentists since early 2000s
(Ventola L. 2014).
Fully autonomous Robot took four years to develop jointly by the Stomatological
Hospital, based in Xian, and the robot institute at Beihang University in Beijing.
The technology is still in its infancy in a demonstration stage when compared to
Robot-guided technology which Neocis (maker of Yomi) claims that the units are being
sold to Dentists in the USA.
Nevertheless the achievement is significant and has set a high bar for Implant
technologies being developed.

77
Fully-autonomous surgery by a Robot being the first of its kind, it involved a lot of
planning and multiple Dentists supervision.
The dental staff fitted position orientation equipment to the patient and the robot
was programmed to move into the correct position to carry out the surgery in a pre-
determined movements, angle and depth needed to fit the new teeth.
The robot adjusted its positions in-line with patient’s own movement. The
functioning, process and set up is very similar to Robot-guided Implantology discussed
above with the exception that in an ideal implementation a fully-autonomous robot
will require minimal to zero Dentist involvement.
Dr. Manju Natarajan. A review of robotics in dental implantology. e-MIDAS Chennai
2018;5(1):1-16.

78
A phantom experiment of image-guided robotics for dental implantation
concluded that the system accuracy is comparable to other similar systems
for dental implantation with a Fiducial Registration Error (FRE) and Target
Registration Error (TRE) values recorded as less than 0.30 mm and 1.42+/-
0.7mm (Sun X, Mckenzie FD, Bawab S, Li J, Yoon Y, Huang J-K. 2011).
FRE is a common measure which is the root-mean square error in fiducial
alignment between image space and physical space (Fitzpatrick JM. Fiducial
registration error and target registration error are uncorrelated. Medical Imaging 2009:
Visualization, Image-Guided Procedures, and Modeling. 2009. doi:10.1117/12.813601.).
The estimate of FRE error is an indication of the accuracy of the system’s
ability to provide guidance to surgical targets for a given case. TRE is the
measure of displacement of actual probe from the target in a guidance
system (Fitzpatrick JM. The role of registration in accurate surgical guidance. Proceedings of the
Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine. 2009;224(5):607-
622. doi:10.1243/ 09544119jeim589). .

79

Conclusion
With significant achievements accomplished in the field of computerized
implant-dentistry implant placement has become highly predictable, even in
patients where implant surgery was contra-indicated formerly.
As a result, attempts are now been made toward complete automation of
implant-dentistry.
Yet, keeping the limitation of high radiation dose, computerized
implant-dentistry must be limited to anatomically complicated cases.
Future tasks include advanced intraoperative imaging techniques for
navigated surgeries along with sophisticated mechanized surgical tools and
new robotic developments, which will revolutionize the field of implantology.
80

References
Carranza’s Clinical Periodontology. 10th edition. Recent advances in implant surgical
technology.
Kathleen M D’souza, Meena A Aras Applications of computer-aided design/computer
assisted manufacturing technology in dental implant planning. Journal of Dental
Implants | Jan - Jun 2012 | Vol 2 | Issue 1.
Christoph H. F. Hämmerle, Paul Stone, Ronald E. Jung, Theodoros Kapos, Nadine
Brodala. Consensus Statements and Recommended Clinical Procedures Regarding
Computer-Assisted Implant Dentistry. The International Journal of Oral & Maxillofacial
Implants Volume 24, Supplement, 2009.
 Computer-Guided Planning and Placement of Dental Implants. Gary Orentlicher,
Douglas Goldsmith, Marcus Abboud. Atlas Oral Maxillofacial Surg Clin N Am 20 (2012)
53–79.
Rolf Ewers, Kurt Schicho, Michael Truppe,Rudolf Seemann, Astrid Reichwein, Michael
Figl and Arne Wagner. Computer-Aided Navigation in Dental Implantology: 7 Years of
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Minkle Gulati, Vishal Anand, Sanjeev Kumar Salaria, Nikil Jain, Shilpi Gupta.
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81

Lucia H. C. Cevidanes, A Scott Tucker, B Martin Styner, C Hyungmin Kim,D Jonas
Chapuis, E Mauricio Reyes, F William Proffit, G Timothy Turvey, H and Michael
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Amjad Ali Syed, Amir Mahmood Soomro, Arbab Nighat Khizar, Xing-guang Duan,
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Bhat T. How Technology is Shaping the Future of Dental Implants. Zentist.
https://blog.zentist.io/how-technology-is-shaping-the-future-of-dental-implants-
5e92348fbcab?gi=811f28db1812. Published October 31, 2017. Accessed January 6,
2018
Yomi, The First Robotic Dental Surgery System Now Cleared by FDA |. Medgadget.
https://www.medgadget.com/2017/03/yomi-first-robotic-dental-surgery-system-now-
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 Consortium on Cognitive Science Instruction, Parts of Robots.
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Ventola L. Medical Applications for 3D Printing: Current and Projected Uses. Pharmacy
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