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Journal of Cranio-Maxillofacial Surgery (2007) 35, 207211 r 2007 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2007.02.004, available online at http://www.sciencedirect.com

Reliability of implant placement after virtual planning of implant positions using cone beam CT data and surgical (guide) templates
Hans-Joachim NICKENIG, Stephan EITNER Department of Prosthodontics (Head: Prof. Dr. Manfred Wichmann), Friedrich-Alexander-University Erlangen-Nuremberg, Glu ckstr. 11, G-91054 Erlangen, Germany
Available online 18 June 2007

SUMMARY. Objective: We assessed the reliability of implant placement after virtual planning of implant positions using cone-beam CT data and surgical guide templates. Material and methods: A total of 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) between July 1, 2005 and December 1, 2005. They were treated with a system that allows transfer of virtual planning to surgical guide templates. Results: Only in eight cases the surgical guides were not used because a delayed implant placement was necessary. In four posterior mandibular cases, handling was limited because of reduced interocclusal distance, requiring 50% shortening of the drill guides. The predictability of implant size was high: only one implant was changed to a smaller diameter (because of insufcient bone). In all cases, critical anatomical structures were protected and no complications were detected in postoperative panoramic radiographs. In 58.1% (147) of the 250 implants, a apless surgery plan was realized. Conclusions: 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 apless surgery. r 2007 European Association for CranioMaxillofacial Surgery

Keywords: dental implantation, image processing, computer-assisted, three-dimensional, patient care planning

INTRODUCTION Computer-assisted navigation has proved to be a valuable tool in several surgical disciplines (Siessegger et al., 2001; Schneider et al., 2005). During oral implant placement, a CT-based template should allow precise implant placement and reduce the risk of damage to adjacent structures. Accurate application of the presurgical plan to the patient also facilitates restoration permits implementation of restorative goals. Recently published in vitro studies indicate that creating these surgical guides with computer assistance results in an average precision within 1 mm of implant position and within 51 of deviation for implant inclination (Besimo et al., 2000; Sarment et al., 2003; Widman et al., 2005). Similar results have been found for in vitro studies of navigation systems with optical tracking technology (Gaggl et al., 2001; Wagner et al., 2003; Casap et al., 2005; Hoffmann et al., 2005). In comparison to image-guided template-production techniques, navigation technology requires a greater nancial investment and effort (e.g., intraoperative referencing for bur tracking). The potential for eliminating possible manual placement errors and systematizing reproducible treatment success is the same for both techniques. Long-term clinical studies are necessary to conrm the value of these methods (Widmann and Bale, 2006).
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The purpose of this study was to assess the clinical reliability of the planning software that allows transfer of virtual planning data to a surgical template that is stabilized on the residual teeth, or anchor pins in edentulous cases. MATERIAL AND METHODS All patients who had undergone implant placement in an armed forces dental clinic (Cologne-Wahn, German Air Force ) from July 1, 2005 until December 1, 2005, were treated with the image-guided system (coDiagnostiXs, IVS-Solutions, Chemnitz, Germany). For each patient, a study prosthesis was fabricated and duplicated in radiopaque acrylic resin to serve as a scanning template. Axial images were obtained by cone-beam CT with a DVT 9000 machine (New Tom Company, Verona, Italy) and transferred to planning software that provides real three-dimensional (3-D) information for planning implant positions (Fig. 1). Once the nal position of the implant was dened, preoperative data such as implant size or the distance from anatomical structures were recorded. The position of the scanning template could be detected by an automatic search of three integrated titanium markers (Fig. 2), allowing calculation for the virtual planning of the implant position. The technician

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Fig. 1 Planning software that provides real 3-D information for planning implant position, showing a screen shot of the clinical case in Figs. 6 and 7.

Fig. 3 The scanning template remounted into a special laboratory appliance into which the coordinates of each virtual implant position were input. After input, the scanning template was drilled for each implant position, dened by the different coordinates provided during virtual planning.

Fig. 2 Scanning template with three integrated titanium markers, which allowed calculation of the 3-D position of the template and data for the virtual implant position.

remounted this template into a special laboratory appliance, inputting the coordinates of each virtual implant position. The scanning template was then drilled step-by-step for each implant position, as dened by the different coordinates (Fig. 3). The drilled template was then prepared with small tubein-tubes with varied channel diameters (2 mm, 2.5 mm, or 3 mm) because of different drill sizes for the oral surgery. During surgery, this template was used as a drill guide. The following intraoperative ndings were assessed during implant placement: the t of the surgical template and handling problems, the reliability of the 3-D planned surgical protocol (apless surgery/ augmentation procedure), and actual implant placement with the template as a real drill guide.

Using postoperative panoramic radiographs, we assessed the safe distance to adjacent anatomic structures and the position and angle of the implant. Differences, if any, between the virtual position of the implant in the panoramic view derived from the planning data and the actual position of the implant in the panoramic radiograph were recorded. All cases were followed until the end of prosthetic treatment with the insertion of the superstructure. All data were entered into a database system and evaluated using SPSSs (Chicago, USA, 2001) for Windows. In addition to frequency counts, w2 statistics to test for independence were also performed. Characterization of patients and distribution of implants A total of 102 patients were treated using a surgical guide. At the time of oral surgery, the average patient age was 40.4 years (range, 22.558.0). Most (55.4%) of the 250 implants were planned in the posterior mandible, and most (81.8%) were planned in the posterior tooth bearing area (Fig. 4). As Fig. 5 shows, most of the implant operations were planned in the free-end gap (33.2%, n 83). The frequencies of single tooth replacement (23.2%, n 58), dental gap completion (requiring more than

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Fig. 4 Distribution of implants (n 250) and frequencies.

Fig. 5 Indication of implants (n 250) and frequencies.

one implant; 18.4%, n 46), and reduced residual dentition (only one to three teeth left; 18%, n 45) were similar. There were only 18 edentulous jaws (7.2%), and in all these cases, the surgical template was stabilized by anchor pins.

Surgical protocol Using the real 3-D information from the cone-beam CT image, the implant operations were categorized into three surgical protocols: (1) in 147 (58.8%) of the

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overall 250 cases, implants were used for a apless surgery; (2) in 103 (41.2%) placements, an alveolar augmentation was required; and (3) in 32 cases, implant operations with bone splitting/-spreading (without bone grafting) were planned. For the remaining 71 cases, different methods of bone augmentation were necessary: most were external sinus oor elevations (n 39); others involved bone splitting with bone graft (n 13) and lateral bone augmentation (n 19).

RESULTS Agreement between preoperative plan and intraoperative ndings. Fit of surgical template and handling problems: In 98.4% of cases, there were no problems with the t and intraoperative handling of the guide templates. In four posterior mandiblular cases, handling was limited because of a reduced interocclusal distance. In these cases, the tube-in-tubes needed to be shortened by 50% ( 4 mm). Reliability of the 3-D planned surgical protocol (apless surgery/augmentation procedure): all cases in which apless surgery was planned were completed successfully (n 147 implant placements; examples in Figs. 6 and 7). In eight cases, the planned augmentation surgical protocol had to be changed, resulting in delayed implant placement in these cases. Implant placement using the template as a (real) drill guide: In all cases, the surgical templates were used with the exception of the eight cases requiring a change in the augmentation surgical protocol (six planned implants in a free-end situation and two in the edentulous jaws). The predictability of implant size was very high; only one implant had to be changed to a smaller diameter, (because of insufcient bone).

Fig. 7 The same patient as in Fig. 6 after implant placement.

Agreement between preoperative plan and postoperative radiographs The postoperative panoramic radiograph control showed that such anatomical structures as the maxillary sinus, mental foramen, mandibular canal and adjacent teeth could all be protected. When compared with the virtual position of the implant in the panoramic view derived from the planning data, the true angle of the implant differed in only nine cases. In these cases, the implants were not exactly parallel to the adjacent teeth, but in no case were there clinical consequences. In the other 233 cases, there were no ascertainable differences. DISCUSSION Surgical templates based on virtual planning data promise an additional advantage of precise guidance for implant placement. The position and angle of implants are as expected with only a small transfer error of less than 1 mm (in vitro studies). The purpose of this study was to assess the reliability of a planning software system that allows transfer of virtual planning data to a surgical template that is then used

Fig. 6 Surgical template based on virtual planning data, used as a drill guide.

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as a drill guide during surgery. Comparison of these results with those of other studies is limited because of the rarity of in vivo studies involving this (targeting) technique. Within the scope of a clinical study with 30 consecutive partially or completely edentulous patients, Fortin et al. (2003) concluded that the image- guided implant placement system, based on a mechanical device coupled with a template, is reliable for the preoperative assessment of implant size and anatomical complications. The results of the current study suggest that using a 3-D planned template as a drill guide during surgery is a reliable technique for implant placement. In only eight cases, in which the surgical augmentation protocol had to be changed, were the surgical guides not used and delayed implant placement was necessary. The main reason for the change in protocol was a misinterpretation of the 3-D view of the anatomical situation. In all other cases, the surgical templates served as a guidance for implant placement. The predictability of implant size was very high: Only one implant had to be changed to a smaller diameter. In all cases, critical anatomical structures were protected, and no further complications were detected in the postoperative panoramic radiographs. Because of the high agreement between the preoperative plan and intraoperative ndings, image-guided navigation or 3-D planned templates may also be reliable for apless surgery (Naitoh et al., 2000; Fortin et al., 2003; Van Steenberghe et al., 2005). In the current study, 58% of the 242 implants could be inserted without aps (n 147 implants). CONCLUSION The results suggest that implant placement after computer-assisted, virtual planning of implant positions using cone-beam CT data and surgical templates is reliable. The process facilitates preoperative assessment of implant size, position, and anatomical complications and is also indicative of cases suitable for apless surgery. References
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Hans-Joachim Nickenig, DMD, Dr. med. dent. Department of Prosthodontics Friedrich-Alexander-University Erlangen-Nuremberg Gluckstr. 11 G-91054 Erlangen Germany Fax: +49 2203 908 2052 E-mail: dr.a.nickenig@t-online.de Paper received 3 August 2006 Accepted 18 January 2007