Journal reading

① Accuracy of a dynamic navigation system for dental

implantation with two different work

② In

報告⽇期：2023/05/19
報告者：RC曾勤予
指導醫師：許⽉閔
fl
fl
 Introduction
• A correct 3D positioning is one of the prerequisite of successful implant
treatment

• Static computer-assisted implant surgery (sCAIS) has been shown to be

superior in terms of accuracy compared to freehand implantation.
(Gargallo- Albiol et al., 2020)

• Drawbacks of sCAIS :
✦ More heat generated during the osteotomy (Frösch et al., 2019)

✦ Insuf
fi
 Introduction

• Dynamic computer-assisted implant surgery (dCAIS) avoid those

disadvantages with similar accuracy (Pellegrino et al., 2021)

• Relatively large extraoral marker systems and bulky camera devices

• A new system for dCAIS (Denacam System, Mininavident AG,

Liestal, Switzerland) was presented with smaller camera and
miniaturized marker
X-Guide®

mininavident

dCAIS system of the presented study

 • The reference element can be included into the treatment planning in two
different work

1. Element placed and

2. Matrix can virtually placed into a pre-existing CBCT, then 3D-printed

and

Marker for navigation

fi
fl
fi
 Introduction

• The aim of this study was to compare the two different work

• Evaluate the in
fl
fl
 The null Hypothesis:
① There is no difference in accuracy of the implant position
between the investigated methods for implant surgery.
② There is no difference in accuracy of the implant position in
the different operative regions.
 Material and methods
• 30 partially edentulous mandibular models made from standardized PU
including teeth 33 34 35 43 44 45 were used to place a total of 270 implants

• Divided in to 3 groups :

• Group TG: sCAIS (n = 90 implants)

• Group DG1: dCAIS with marker in CBCT (n = 90 implants)

• Group DG2: dCAIS with 3D-printed marker tray (n = 90 implants)

 Sextant 4
Sextant 6

Sextant 5
 Materials and methods

• Planning and execution was performed by two different operators,

each with 5＊3 mandibular models

• Take pre-OP CBCT and suface scan for 3D planning the implant
position, which utilizes a planning software (coDiagnostiX Version
10.0.19044; Dental Wings inc.)
 Materials and methods : Group TG
• Templates was designed and printed for every model, then metal
sleeves were inserted

• Implants were placed through a fully guided manner

 Materials and methods : Group DG1

• Marker containing tray is adapted to each model with the aid of

thermo plastic material before the CBCT scan

• Implants were then planned identically to Group TG

• Fully guided osteotomy and non-guided implant insertion

Materials and methods : Group DG1
 Materials and methods : Group DG1

Schnutenhaus S, Knipper A, Wetzel M, Edelmann C, Luthardt R. Accuracy of Computer-Assisted Dynamic Navigation as a Function of Different Intraoral Reference Systems: An In Vitro Study.
Int J Environ Res Public Health. 2021 Mar 21;18(6):3244. doi: 10.3390/ijerph18063244. PMID: 33801039; PMCID: PMC8003934.
 Materials and methods : Group DG2

• implant planning was equal to Group TG and DG1

• After superimposing CBCT scans and surface scans, individual tray

for marker placement was designed virtually in the planning software
for each model in the area of the teeth 43–45

• The trays fabricated utilizing a 3D-printer (Form 3B+; Formlabs

GmbH) and resin material (Surgical Guide Resin; Formlabs GmbH)
Virtually designed marker tray
 Materials and methods

• Accuracy measurement procedure

• Scanbodies were connected after the implantation procedure and

post-OP surface scans were generated of each model

• Software was able to automatically calculate the angular and spatial

deviation between planned and performed implant position
 Frontal view Sagittal view

B-L A-C M-D

Spatial analysis Position Angle analysis Position

Base
B-L deviation Implant angulation Long axis
Tip
Base
M-D deviation
Tip
Base
A-C deviation
Tip
Base
3D deviation
Tip
 Materials and Methods

• Statistical Analysis (SPSS V26.0):

• Mean of absolute values and the 95% con

• Using a Linear Effect Mixed Model to determine the in

fi
fi
Results
Results
 Discussion

• The investigated dCAIS system provides an accuracy that is

comparable to the gold standard method of sCAIS
 Discussion
• Both osteotomy & implant placement guided v.s. only osteotomy guided

• No signi

• The worst-case scenario is accidental damage of roots, sinus, nerves, or vessels

• Special attention the accuracy of depth control

• sCAIS —> drill stop

• dCAIS —> digital indicator on the screen

• Both show comparable result in this study (0.43mm, 0.62mm, 0.46mm)

fi
 Discussion

• The result shows signi

• The

• Depending on the tray's manufacturing, material distortion may occur

and generate a deviation between the actual position and displayed
position of the bur
fi
fi
 Discussion

More inaccuracy!
90°
 Discussion

• Concerning the overall 3D deviation, all three approaches showed

acceptable results

• The highest accuracy was achieved for Group TG followed by Group

DG1 for dCAIS, when regarding the mean of the absolute values at the
implant's tip and base
 Discussion
• The maximum values for 3D deviation and angular deviation are
noticeably larger in Group DG1 compared to Group TG and even
Group DG2
 Discussion
• The results for 3D deviation at the implant's base in Group DG2
revealed a signi

• May be associated with the process of 3D-printing (offset spacing )

• Material deformation at the connecting part of tray

fi
 Discussion

• As a conclusion of the present study, work

fl
 Conclusion
① This in-vitro experimental trial revealed that dCAIS enables accurate
implant positioning

② Interaction between the operation site and the chosen type of

navigation method seems to play an important role in accuracy

③ Further investigation and especially prospective clinical trials are

necessary to con
fl
 Introduction

• The most commonly used guided method is static surgical guide

• One of the reasons not to use static implant guided surgery is the
need for speci

• The metal sleeve increases cost and is speci

fi
fi
 Introduction
• Suriyan et al. 2019 JPD:
✓ Clinical study tested trephine bur for osteotomy site preparation, using static guide with
and without metal sleeve
✓ No statistically signi

• The trephine drills only have one cutting side at the end of the drill, without cutting the bone
tin lateral direction

• Further test should be done to verify if template-guided implant placement can be done
without a metal sleeve.
fi
 Introduction

• This study is proposed to examine if the metal sleeve is necessary for

implant guided surgery and if there is any statistical difference
between the accuracy of implant guides with and without a metal
sleeve
 Introduction
• The study was divided into two steps :

Step 2:
Step 1:
Analyze andgulation and
To analyze the post-OP
positional differences
angulation and positional
produced when the sample
differences created by not
size of the surgical guides
using metal guide sleeves
increased
 Materials and methods
• CBCT data and intraoral scans obtained from a patient who was missing
tooth #11

• Treatment planning using Implant Studio 2021 (3Shape A/S) for a Tapered
Screw Vent (TSV) Zimmer Biomet (3.7 mm × 13 mm) implant

• 40 dental cast was designed and printed:

• 20 with Dental Model resin(Formlabs) for

• 20 with Dental Clear LT resin V2 (Formlabs) for second round experiment

fi
 Materials and methods

• Surgical guides were exported and total 22 guides were printed in

resin at a resolution of 0.05mm
 Materials and methods

• There is two steps in this experiment

• Step 1: Two guides with and without metal sleeve used for each
group ( one guide per ten casts)

• Step 2: Ten guides for each group ( one to one guide and cast
pairing)
Materials and methods
 Materials and methods

• The same surgical guide and implant surgical kits were used.

• The implants were placed based on the manufacturer’s

recommendation, after removing the surgical guide.

• Post-OP CBCT scans were made after the implant procedure.

 Materials and methods
AL
Distance between the most apical
part of the implant and the soft
tissue

M
Distance between the most
cervical part of the implant to
the root surface of the most
adjacent tooth medially or
distally
CL
Distance between the most
cervical part of the implant and
the outer surface dental cast
labially and palatally
BLA
Buccal lingual angulation of
the implant to the plane of
the cast
Materials and methods
 Material and methods
t-test Compare between
Accuracy means of different
surgical groups

F-test
Compare between
Precision ranges/variation of
different surgical groups
Results
Results
Results
 Discussion- Step 1
• The deviation of “sleeveless” surgical guide are in consistent with
those with metal sleeves

• The means and range of sleeveless surgical guide are lower than those
with metal sleeves
 Discussion- Step 2
• Two groups has similar accuracy

• The group without metal sleeve has a higher precision at the mesial
dimension
 Discussion
• Different model material:

• Step 1 - Dental Model resin (

• Step 2 - Dental Clear LT V2 resin (

Flexural modulus of female trabecular bone

ranges from ~300 to ~3000 MPa
fl
fl
 Discussion

• Cost-Effectiveness : lower cost while maintaining accuracy

 Discussion - limitations

• Minor movements of natural structures while

• Drilling homogenous resin v.s. non-homogenous alveolar bone

• Limited to only Zimmer Biomet TSV guided implant system

• Only examined single anterior edentulous area with both adjacent

tooth to support the guide

fi
 Conclusions

① A sleeve free surgical guide demonstrates similar accuracy and

precision as the surgical guide with the metal sleeve

② Metal sleeves may not be required for accurate implant placement

Thanks for your attention
 References
• Struwe, Maximilian et al. “Accuracy of a dynamic navigation system for dental implantation with two different work

• Adams, Coleman R et al. “In

• Schnutenhaus S, Knipper A, Wetzel M, Edelmann C, Luthardt R. Accuracy of Computer-Assisted Dynamic Navigation as a Function of
Different Intraoral Reference Systems: An In Vitro Study. Int J Environ Res Public Health. 2021 Mar 21;18(6):3244. doi: 10.3390/
ijerph18063244.

• Talmazov, Georgi et al. “Accuracy of Implant Placement Position Using Nondental Open-Source Software: An In Vitro Study.” Journal of
prosthodontics : of

• Dalal N, Ammoun R, Abdulmajeed AA, et al: Intaglio surface dimension and guide tube deviations of implant surgical guides in

• Gargallo-Albiol J, Barootchi S, Salomó-Coll O, Wang HL. Advantages and disadvantages of implant navigation surgery. A systematic review.
Ann Anat. 2019 Sep;225:1-10. doi: 10.1016/j.aanat.2019.04.005.
fi
fi


fl