Computer Methods and Programs in Biomedicine 249 (2024) 108156

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Computer Methods and Programs in Biomedicine

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and-programs-in-biomedicine

A hybrid robotic system for zygomatic implant placement based on mixed

reality navigation
Xingqi Fan a, 1, Yuan Feng b, 1, Baoxin Tao c, 1, Yihan Shen c, Yiqun Wu c, Xiaojun Chen a, d, *
a
Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering,
Shanghai Jiao Tong University, Shanghai, China
b
Institute of Mechatronics and Logistics Equipment, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
c
Department of Second Dental Center, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
d
Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China

A R T I C L E I N F O A B S T R A C T

Keywords: Backgrounds: Zygomatic implant (ZI) placement surgery is a viable surgical option for patients with severe
Zygomatic implant surgery maxillary atrophy and insufficient residual maxillary bone. Still, it is difficult and risky due to the long path of ZI
Mixed reality navigation placement and the narrow field of vision. Dynamic navigation is a superior solution, but it presents challenges
Hybrid robotic system
such as requiring operators to have advanced skills and experience. Moreover, the precision and stability of
manual implantation remain inadequate. These issues are anticipated to be addressed by implementing robot-
assisted surgery and achieved by introducing a mixed reality (MR) navigation-guided hybrid robotic system
for ZI placement surgery.
Methods: This study utilized a hybrid robotic system to perform the ZI placement surgery. Our first step was to
reconstruct a virtual 3D model from preoperative cone-beam CT (CBCT) images. We proposed a series of algo­
rithms based on coordinate transformation, which includes image-phantom registration, HoloLens-tracker
registration, drill-phantom calibration, and robot-implant calibration, to unify all objects within the same co­
ordinate system. These algorithms enable real-time tracking of the surgical drill’s position and orientation
relative to the patient phantom. Subsequently, the surgical drill is directed to the entry position, and the planned
implantation paths are superimposed on the patient phantom using HoloLens 2 for visualization. Finally, the
hybrid robot system performs the processed of drilling, expansion, and placement of ZIs under the guidance of
the MR navigation system.
Results: Phantom experiments of ZI placement were conducted using 10 patient phantoms, with a total of 40 ZIs
inserted. Out of these, 20 were manually implanted, and the remaining 20 were robotically implanted. Com­
parisons between the actual implanted ZI paths and the preoperatively planned ZI paths showed that our MR
navigation-guided hybrid robotic system achieved a coronal deviation of 0.887 ± 0.213 mm, an apical deviation
of 1.201 ± 0.318 mm, and an angular deviation of 3.468 ± 0.339◦ This demonstrates significantly better ac­
curacy and stability than manual implantation.
Conclusion: Our proposed hybrid robotic system enables automated ZI placement surgery guided by MR navi­
gation, achieving greater accuracy and stability compared to manual operations in phantom experiments.
Furthermore, this system is expected to apply to animal and cadaveric experiments, to get a good ready for
clinical studies.

1. Introduction insufficient residual maxillary bone, the zygomatic implant (ZI) has
emerged as the optimal solution for implant surgery. This involves
For edentulous patients with severe maxillary atrophy and implanting the ZI from the alveolar ridge through the maxillary sinus

* Corresponding author at:Room A925, School of Mechanical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Minhang District, Shanghai,
China, Post Code: 200240.
E-mail address: xiaojunchen@sjtu.edu.cn (X. Chen).
1
Xingqi Fan, Yuan Feng and Baoxin Tao have contributed equally to this work.

https://doi.org/10.1016/j.cmpb.2024.108156
Received 22 January 2024; Received in revised form 25 March 2024; Accepted 26 March 2024
Available online 27 March 2024
0169-2607/© 2024 Elsevier B.V. All rights reserved.
X. Fan et al.
into the zygomatic bone, utilizing the zygomatic bone for additional
support [1,2]. However, the implantation of ZIs has problems such as a
long surgical path and a narrow surgical field of view, which hinders
visualization and increases the risk of surgery. Even a slight deviation in
the entrance position may cause a significant deviation at the zygomatic
bone, potentially leading to the implant mistakenly entering the orbit or
infratemporal fossa [3,4]. Therefore, improving the accuracy of the
placement of the ZIs is the key to the success of ZI placement surgery.
To enhance the precision of ZI placement surgery, digital technolo­
gies such as static surgical templates, dynamic navigation systems, ro­
bots, and augmented or mixed reality (AR/MR) technologies have been
integrated into ZI placement surgery. Static surgical templates were
initially used to guide surgeons on the position and orientation of dril­
ling holes [5–7]. However, due to the long and inclined path of zygo­
matic implantation, static surgical templates are prone to accumulating
deviations. Insufficient maxillary bone also makes it challenging to
provide stable support for the template [8]. The introduction of dynamic
navigation systems in ZI placement surgery is an excellent solution to
address the aforementioned problems. Many researchers and surgeons
have studied dynamic navigation for ZI placement surgery [9,10]. Chen
et al. developed a zygomatic implant navigation system and achieved
relatively high accuracy [11,12]. Hung et al. evaluated the accuracy of a
real-time surgical navigation system used for quad zygomatic implant
placement [13]. Qin et al. proposed a navigation system for the auto­
matic recognition of fiducial points in ZI placement surgery [14]. Wu
et al. validated the feasibility of navigation-guided zygomatic implan­
tation surgery and proposed a workflow [15]. However, the preparation
process for the dynamic navigation system, such as registration and
calibration, is complex due to the high operational difficulty and steep
learning curve [8,16]. The accuracy and safety of the ZI placement
surgery largely depend on the skills and experience of surgeons. Hence,
the clinical implementation of dynamic navigation in ZI placement
surgery still encounters significant challenges.
Currently, several surgical robots for dental implant placement can
be utilized in clinical surgery, enhancing the precision and stability of
the procedures [17,18]. At the same time, some studies have also
incorporated surgical robots into the navigation of zygomatic implant
surgery. They utilize navigation systems to locate the position of the
implant path and employ the robotic system to conduct the surgery. Cao
et al. developed a six-degree-of-freedom (6DoF) robot based on a UR
robotic arm and conducted model experiments on zygomatic bone im­
plantation using a surgical navigation system. They further optimized
the calibration algorithm of the serial robot, improved the accuracy of
the optical navigation surgical robot system, and conducted animal ex­
periments [19,20]. Li et al. divided the zygomatic implant surgery into
two stages: the alveolar ridge segment and the zygomatic bone segment.
They also developed a semi-automatic zygomatic implantation robotic
system to overcome the limitation of patient mouth opening [21–24]. In
the field of ZI placement surgery, commercial robots are utilized for
various tasks. Reebye et al. employed the Yomi robot to execute the
preparation of zygomatic cavities. This involved the initial use of a
standard drill to create a cavity, followed by the insertion of the zygo­
matic drill into the prepared cavity. Subsequently, the handpiece on the
robotic arm was connected, the direction of implantation was secured,
and the robot was activated to carry out the ZI implantation process.
[25]. Olivetto et al. proposed a zygomatic implant placement scheme
guided by ROSA robots [26]. The aforementioned studies have
demonstrated good accuracy in implant placement. However, the clin­
ical utilization of robotic systems in ZI placement surgery remains
limited thus far.
In our previous study, we developed a hybrid robot designed for
traditional dental implantation, which demonstrated superior implan­
tation accuracy compared to manual implantation techniques [27–29].
We have also developed a mixed reality (MR)-based dental implant
placement navigation system and conducted phantom experiments [30,
31]. By introducing MR technology, it is possible to avoid the repetitive
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Computer Methods and Programs in Biomedicine 249 (2024) 108156
switching of the surgeon’s vision between the surgical site and the
screen and to project the preoperatively planned path directly onto the
surgical site. This study introduces hybrid surgical robots and MR
technology into the ZI placement navigation system, achieving the
integration of dynamic navigation, hybrid robots, and MR in zygomatic
implant surgery. The accuracy of the system is verified through phantom
experiments.
2. Materials and methods
Based on the hybrid robotic system, the NDI optical navigation de­
vice, and the HoloLens 2 MR device, we proposed a set of algorithms,
including image-phantom registration, HoloLens-tracker registration,
drill-phantom calibration, and robot-implant calibration. After
completing the registration and calibration algorithms, the MR-based
navigation system can integrate the preoperatively planned ZI paths to
the location where the implants will be positioned on the patient
phantom through the spatial transformation of the translation-rotation
matrix. The hybrid robotic system can automatically align the position
and axis of the ZIs’ path and prepare the cavities for the placement of ZIs
under the guidance of the navigation system.
2.1. Workflow of the MR navigation-based hybrid robotic system
The overall architecture of our mixed reality navigation-based
hybrid robotic system is shown in Fig. 1.
The system is based on an optical tracking device for real-time
navigation, an optical see-through head-mounted display (OST-HMD)
like HoloLens 2 for implementing MR, and a hybrid robotic system for
conducting the ZI placement surgery. The development of the MR-based
implant navigation software and the robot-controlling software is based
on several open-source platforms, including VTK, ITK, IGSTK, Qt, Unity,
and MRTK. The workflow of the system can be divided into four stan­
dard steps. Firstly, the utilization of a preoperative planning software
called "DentalHelper" is employed to delineate the paths for the place­
ment of ZI based on the 3D model reconstructed from preoperative CBCT
images. Secondly, a series of algorithms based on coordinate trans­
formation, including image-phantom registration, HoloLens-tracker
registration, drill-phantom calibration, and robot-implant calibration,
are used to unify all objects under the same coordinate system. These
algorithms will be discussed in detail in Sections 2.3-2.6. After the
registration and calibration procedures, the position and axial direction
of the drill relative to the patient phantom can be tracked in real-time
and displayed on the computer screen. The planned implantation
paths are aligned with the patient phantom using HoloLens 2 technol­
ogy. Finally, the hybrid robot system drives the surgical drills for drilling
holes, expanding them, and placing ZIs under the guidance of the MR
navigation system.
2.2. Hardware components
All hardware devices necessary for our proposed MR navigation-
based hybrid robotic system for ZI placement surgery are depicted in
Fig. 2.
As shown in the devices above, a hybrid robotic system was utilized
to grasp the handpiece and control the position and orientation of the
surgical drill along the preoperatively planned ZI path. The planned ZI
paths are visualized using the MR device (Microsoft HoloLens 2), while
the real-time position and orientation of the drill are determined by an
optical navigation device (NDI Polaris Spectra) tracking the positions of
reflective balls placed on registration and calibration tools. These
registration and calibration tools, including the probe, the patient
reference frame, and the handpiece reference frame fixed on the hybrid
robot (Zhejiang Zhihang Tianshu Medical Technology Co., Ltd., China),
were used to establish the positional relationship between objects. The
patient phantom and the registration cube are made using 3D printing
X. Fan et al.
Fig. 1. The workflow of MR navigation-based hybrid robotic system.
technology (WEILAI 8000 resin, Shenzhen Wenext Technology Co., Ltd,
China) with a machining error of 200 μm. Several mini-screws (φ1.7 mm
× 10 mm) (Jianwei Co., Ltd, Shenzhen, China) were implanted into the
alveolar bone of each patient phantom as fiducial markers for image-
phantom registration.
2.3. Image-Phantom registration
In dynamic navigation for ZI placement surgery, it is essential to
select a series of marker points as fiducial points to display the real-time
3D model reconstructed from the CBCT images on the computer screen.
Corresponding the fiducial points at the same position in the image and
patient phantom one by one is necessary to obtain the transformation
matrix between them. Generally, anatomical landmarks such as tooth
cusps, the tip of the nose, and the inner canthus, which maintain a fixed
anatomical position during surgery, are chosen as registration markers.
In ZI placement surgery, it is challenging to locate the placement due to
patients typically being edentulous, accompanied by severe alveolar
bone atrophy or maxillary bone defects, making it difficult to rely on
anatomical landmarks. Therefore, 8 titanium screws were implanted
into the maxilla of the patient model, and CBCT images were taken. By
matching the vertex of the titanium screws in the CBCT image with those
in the patient phantom, the transformation matrix between the image
and the patient phantom can be obtained, facilitating the registration
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Computer Methods and Programs in Biomedicine 249 (2024) 108156
process.
After selecting fiducial markers, a Singular Value Decomposition
(SVD) registration algorithm is used to align the CBCT images with the
patient phantom. Define the transformation matrix as the conversion
from coordinate system A to coordinate system B, where TAB is a 4 × 4
matrix capable of both translation and rotation. This can be represented
by the following equation:
( )
RBA tAB
B
TA = (1)
0 1
where RBA is a 3 × 3 rotation matrix and tAB is a 3 × 1 translation matrix. In
this way, for any point P in space, the transformation between coordi­
nate systems A and B can be represented by TAB as Eq. (2) and Eq. (3):
PB = TAB PA (2)
pB = RBA pA + tAB (3)
where PA = (xA,yA,zA,1)T and pA = (xA,yA,zA)T are the coordinates of
point P in coordinate system A, while PB = (xB,yB,zB,1)T and pB = (xB,yB,
zB)T are the coordinates of point P in coordinate system B.
The way to solve matrix TAB using the SVD algorithm is to obtain the
coordinates of the same series of fiducial points in both the A and B
coordinate systems. Define the set of fiducial points as S =
X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

Fig. 2. Hardware components of MR navigation-based hybrid robotic system.

( P1 P2 … Pn ). Then, the coordinates under the coordinate system Tracker Tracker

OA can be expressed as SA = ( PA1 PA2 … PAn ), and the coordinates TPatientRef PRefi = TProbe
( Probe )− (6)
under the coordinate system OB can also be expressed as SB = PatientRef 1
PRefi = TTracker TTracker
( PB1 PB2 … PBn ). Define the objective function F of the SVD
registration, which reflects the error of the transformation between the After obtaining the coordinates of the fiducial points in both the
PatientRef
two coordinate systems A and B, as follows: OImage and the OPatientRef, the transformation matrix TImage can be
calculated by substituting the coordinates of SIm and SPRef into Eq. (5).
∑
n
F= ‖PBi − TAB PAi ‖2 (4) This process achieves the image-phantom registration as follows:
i=1 ( )
∑
n

Therefore, the goal of the SVD algorithm is to obtain the TAB that
PatientRef
TImage = argmin PatientRef
‖PRefi − TImage PImi ‖2
(7)
minimizes the value of F, which satisfies the following equation:
i=1

( )
∑n
B
TA = argmin B
‖PBi − TA PAi ‖2
(5) 2.4. HoloLens-Tracker registration
i=1

For the registration of the CBCT image with the patient phantom, the To visually represent the preoperatively planned ZI paths in the
PatientRef patient phantom more intuitively, a virtual 3D model reconstructed
transformation matrix TImage
needs to be calculated between the
from CBCT images is projected onto the patient phantom using the
image coordinate system OImage and the patient reference coordinate
HoloLens 2 MR device, and the coordinate of the virtual model under the
system OPatientRef. The coordinates of the fiducial point set SIm =
HoloLens 2 device is defined as OVModel. Because the coordinate trans­
( PIm1 PIm2 … PImn ) under the OImage have been pre-selected in the formation from the right-hand coordinate system OImage of the CBCT
CBCT image. A probe is then used to determine the coordinates of the image to the left-hand coordinate system OVModel under the HoloLens
( )
fiducial point set SPRef = PPRef1 PPRef2 … PPRefn under the OPatien­ camera requires a mirror transformation on the x-axis, the coordinate
tRef by placing the tip of the probe on the fiducial points (the vertices of transformation from OImage to OVModel can be represented by a diagonal
the titanium screws). In the coordinate system of the probe, the position matrix:
of the tip is fixed and can be directly obtained by the NDI tracking device
through the transformation matrix TTrackerProbe
. The position and posture
VModel
TImage Image
= TVModel = diag( − 1, 1, 1, 1) (8)
PatientRef
matrix TTracker
of the patient reference frame can also be obtained in To achieve the fusion of virtual and physical models through the
real-time by the tracking device. Therefore, when the probe tip coincides HoloLens 2 device, it is essential to acquire the transformation matrix
with one of the fiducial points, the transformation that converts to the TVModel
Holo
that relates the virtual model to the HoloLens device. Through the
coordinate system of the tracking device holds at both ends of the Eq. (6) continuous transformation of coordinate systems, TVModelHolo
can be calcu­
to obtain the coordinates of the selected fiducial point.
lated using the following equation.
( PatientRef )− 1 PatientRef Image
Holo
TVModel Holo
= TTracker TTracker TImage TVModel (9)

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

PatientRef PatientRef HandRef

In the above equation, TTracker can be obtained in real-time using the frame TTracker and the handpiece reference frame TTracker . Therefore,
PatientRef Image DrillTip
NDI tracking device, while TImage and TVModel can be derived from Eq. by calibrating and calculating the transformation matrix THandRef be­
(7) and Eq. (8), respectively. Therefore, the key to achieving real-time tween the handpiece reference frame and the tip of the surgical drill, Eq.
navigation based on MR lies in calculating the transformation matrix (11) can be utilized for real-time tracking of the surgical drill.
between the HoloLens 2 device and the NDI tracking device TTracker Holo
, ( PatientRef )−
(11)
1
which can also be accomplished through the SVD registration algorithm.
DrillTip DrillTip HandRef
TPatientRef = THandRef TTracker TTracker
Using a cube with a reflective ball that can be recognized by an NDI DrillTip
tracking device and a black-white block that can be recognized by the The calibration operation for calculating the THandRef involves using a
camera of HoloLens 2 on its surface as the registration tool, with the fixed groove on the patient reference frame as a pivotal reference point
cube vertices as fiducial points, then calculate the coordinates of the PCaliPt, which is a constant value relative to the patient reference frame.
fiducial point set under the NDI navigation device STracker and the During the calibration process, two drills of different lengths are suc­
fiducial point set under HoloLens 2 camera SHolo. Therefore, TTracker Holo
can cessively inserted into the groove. The offsets of the short and long drills
ShortTip LongTip
be obtained by substituting the SHolo and STracker into Eq. (5), facilitating relative to the handpiece reference frame, denoted as tHandRef and tHandRef ,
the HoloLens-Tracker registration as follows: are calculated using the following equation.
( ) ⎛ ⎞
∑
n ShortTip
( HandRef )− 1 tHandRef ( PatientRef )− 1
Holo
TTracker = argmin Holo
‖PHoloi − TTracker PTrackeri ‖2
(10) TTracker ⎝ ⎠ = TTracker PCaliPt
i=1 1
⎛ ⎞ (12)
The complete matrix transformation operation of the registration is LongTip
( HandRef )− 1 tHandRef ( PatientRef )− 1
illustrated in Fig. 3. It accomplishes the virtual-actual transformation TTracker ⎝ ⎠ = TTracker PCaliPt
1
between the virtual image and the actual phantom by creating closed
loops with the transformation matrix. During calibration, the relationship can be described as Eq. (12). the
coordinates of the tip of the surgical drill and the bottom of the fixed
groove coincide under the navigation device.
2.5. Drill-phantom calibration ShortTip LongTip
After calculating tHandRef and tHandRef , the direction vector of the
In order to achieve real-time intraoperative navigation and ensure orientation of the surgical drill relative to the handpiece reference frame
̅̅→
that the surgical drill advances along the preoperatively planned ZI path, drill = (x, y, z) can then be calculated as follows:
it is also necessary to display the position and orientation of the drill
LongTip ShortTip
relative to the patient phantom in real-time on the computer screen. ̅̅→ tHandRef
drill = LongTip
− tHandRef
(13)
DrillTip ShortTip
Therefore, it is necessary to calculate the transformation matrix TPatientRef ‖ tHandRef − tHandRef ‖
of the tip of the surgical drill relative to the patient phantom in real-time. Define the direction in which the surgical drill is drilling as the
DrillTip
To calculate the matrix TPatientRef , it is necessary to have a handpiece positive direction of the x-axis in the coordinate system of the drill tip;
reference frame that is fixed relative to the surgical drill throughout the then, the transformed direction vector is (1, 0, 0). The rotation matrix
entire process of surgery. This frame is fixed on the handpiece in manual from the handpiece reference frame to the drill tip satisfies:
ZI placement surgery and on the end of the moving parts in robotic ZI ̅̅→T
placement surgery. This is essential because the NDI navigation device RDrillTip T
HandRef (1, 0, 0) = drill = (x, y, z)
T
(14)
can provide the real-time position and posture of the patient reference

Fig. 3. The procedure of registration.

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

An orthogonalized solution to this equation is: during surgery. Compared to serial mechanisms, parallel mechanisms,
⎛ ⎞ as closed-loop mechanisms, can offer greater stiffness and unique in­
x y z
verse kinematics solutions, but they have a limited workspace. There­
⎜ ⎟
fore, a hybrid robotic system that combines serial and parallel
2
⎜ y yz ⎟
⎜y − 1 ⎟
DrillTip
RHandRef = ⎜ 1 + x 1 + x ⎟ (15) mechanisms is constructed. The arm of this hybrid robot has 11 degrees
⎜ ⎟
⎝ yz z2 ⎠ of freedom (DoF) and consists of a 5-DoF serial manipulator and a 6-DoF
z − 1
1+x 1+x Stewart platform. The 5-DoF serial manipulator consists of three moving
joints T1, T2, T3, and two rotating joints R1, R2. Joint T1 provides linear
Using the long drill as the surgical tool for ZI placement surgery,
DrillTip LongTip
motion perpendicular to the baseplate, while joints T2 and T3 provide
where tHandRef = tHandRef , then the final calibration matrix is obtained as: linear motion parallel to the baseplate. R1 provides rotational motion
( ) around the axis perpendicular to the baseplate by means of gearing,
RDrillTip DrillTip
tHandRef while R2 provides rotational motion perpendicular to the axis of R1. The
DrillTip
THandRef = HandRef
(16)
0 1 6-DoF Stewart platform comprises a fixed platform, a moving platform,
and six legs, each featuring two gimbals at both ends. During surgical
The complete matrix transformation operation for calibration is
operations, the serial mechanism aids in expanding the workspace and
illustrated in Fig. 4. This process enables real-time tracking of the sur­
making coarse adjustments, while the parallel mechanism is crucial for
gical tools’ position and posture relative to the patient phantom by
fine-tuning the position, axial alignment, and the drilling procedure.
creating closed loops with the transformation matrix.
The coordinate systems of the hybrid robotic system were established
During ZI placement surgery, when it is necessary to change the drill,
and illustrated in Fig. 5. The center of the baseplate serves as the origin
the orientation of the drill remains constant, and only the position of the
of the coordinate system O0, and its x, y, and z axes take the direction of
drill tip is adjusted. As a result, the rotational part RDrillTip
HandRef remains movement of T3, T2, and T1, respectively. The coordinate system O1 is
DrillTip
unchanged, and only the translational part tHandRef requires adjustment the center of the moving plane, which has the same axis direction as O0
with the corresponding amount of change. Assuming that the difference and can be obtained by translating O0. The coordinate systems O2 and O3
between the length of the replaced drill and the length of the original are defined on two rotational joints R1 and R2, with their axis of rotation
DrillTip being the z-axis. The end of the serial manipulator and the fixed platform
drill is Δl, then tHandRef becomes:
of the Stewart mechanism were described in the coordinate system O4,
NewDrillTip
tHandRef OldDrillTip
= tHandRef + Δl(x, y, z)T (17) with the z-axis perpendicular to the fixed platform, while the moving
platform was described in the coordinate system O5, with the z-axis
perpendicular to the moving platform.
2.6. Robot-Implant calibration The forward kinematic solution of the serial mechanism can be
calculated using the Denavit-Hartenberg (D-H) method. The trans­
Currently, most robots used in implantation applications are serial formation from O0 to O1 involves translation in three directions, and the
mechanisms with large workspaces but low stiffness and non-unique D-H parameters from O1 to O4 are determined as outlined in Table 1,
inverse kinematics solutions. This may result in attitude instability

Fig. 4. The procedure of drill calibration.

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

Fig. 5. Coordinate systems of the hybrid robot.

DrillTip
reference frame THandRef is fixed after the drill-phantom calibration, the
Table 1
D-H parameters of the serial mechanism in hybrid robot. position of the handpiece reference frame coordinate system OHandRef
can be uniquely determined. Moreover, the handpiece reference frame is
Coordinate αi-1 ai-1 di θi
fixed to the moving platform, so the transformation matrix with O5,
O1-O2 0 0 d1 HandRef
TO5 is also constant. Consequently, the position of O5 can also be
θ1
O2-O3 − 90◦ 0 0 θ2
O3-O4 − 90◦ d2 d3 0 uniquely determined to obtain TO4 O5
. Subsequently, the inverse kinematic
of the Stewart mechanism is solved, which enables the hybrid robot to
move to the position where the surgical drill aligns with the planned
following the definition provided above. implantation path.
Since the inverse kinematics solution for the Stewart parallel Once the alignment of the drill fixed on the hybrid robot with the
mechanism is unique, a singular solution for the robot’s motion state can planned ZI path is completed, the robot-assisted drilling operation can
be derived when coordinate systems O4 and O5 are provided. The motion be performed under the guidance of the navigation system (Fig. 6A). The
O5
state can also be represented as TO4 using a transformation matrix. location of the drill and its deviation from the preoperatively planned
During the robot-implant calibration process, it is essential to align path can be observed in real-time through the three sectional views and
the tip of the drill with the beginning of the planned ZI path and ensure the 3D view on the screen (Fig. 6B). Moreover, the operator can wear the
that the axial direction of the drill matches the planned ZI path. HoloLens 2 device to observe the alignment between the virtual model
Assuming that the coordinate of the entry point of the planned implant and the physical patient phantom through the HoloLens 2 view
path is represented by (xe,ye,ze) and the normal vector by (vx, vy, vz), (Fig. 6C). They can also verify if the actual path drilled by the robot
then according to the Eq. (15) and Eq. (16), it can be inferred that: aligns with the planned ZI path overlaid on the model (Fig. 6D), enabling
⎛ ⎞ a more intuitive understanding and monitoring of the surgical
vx vy vz xe
⎜ ⎟ procedure.
⎜ vy2 vyvz ⎟
⎜ vy − 1 ye ⎟
⎜ ⎟
PatientRef
TDrillTip PatientRef ⎜
= TImage
1 + vx 1 + vx ⎟ (18) 3. Results of phantom experiments
⎜ ⎟
⎜ vyvz vz2 ⎟
⎜ vz − 1 ze ⎟
⎝ 1 + vx 1 + vx ⎠ A series of phantom experiments were conducted to evaluate the
0 0 0 1 performance of the MR navigation-based hybrid robotic system in
positioning the ZI. The phantoms utilized in this study were derived
Once the transformation matrix of the drill tip under the patient from five patients with atrophied maxilla necessitating the placement of
PatientRef
reference frame TDrillTip is obtained, the coordinates of the drill tip implants in the zygomatic bone. The CBCT images were acquired using
DrillTip
under the NDI tracking device TTracker can also be obtained in real-time. the Planmeca CBCT imaging system (Planmeca Oy, Helsinki, Finland).
Since the transformation matrix between the drill tip and the handpiece Subsequently, an experiment will be carried out to compare robotic

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

Fig. 6. MR navigation-guided hybrid robot-assisted drilling (A: Robot-assisted drilling. B: Real-time navigation. C &D: MR-based navigation under HoloLens 2).

surgery with manual surgery, which will involve the division of partic­ phantom after the registration. According to Eq. (7), the FRE and TRE
ipants into two groups: one for robotic surgery and the other for manual can be defined as:
surgery. In each group, five phantom experiments will be conducted. √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
Phantoms, which are 3D-printed based on the CBCT images of the 1∑n (19)
FRE = ‖PRefi − T PatientRef
Image PImi ‖2
aforementioned five patients, will undergo bilateral zygomatic implant n i=1
placement. Specifically, two zygomatic implants (ZIs) will be placed in m √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
1 ∑
each zygomatic bone, resulting in a total of 4 ZIs per phantom, 20 ZIs per TRE = ‖ PRefj − T PatientRef
Image PImj ‖2 (20)
m j=1
group, and 40 ZIs to be implanted in total.
During the phantom experiment, the handpiece and motor system In the context of HoloLens-Tracker registration, the HRE can be
utilized were from Bien-Air (Bien-Air Medical Technologies, defined as the mean distance between a given landmark point set S =
Switzerland), while the drills from Nobel (Nobel Biocare, Sweden) ( P1 P2 … Pm ) on the virtual model displayed by the HoloLens 2
including the Round Bur (φ2.5 mm × 70 mm), Pilot Drill (φ2.9 mm × device and its corresponding position on the patient phantom following
75/95 mm), and Twist Drill (φ3.5 mm × 67.5 mm/100 mm) were the HoloLens-tracker registration process and can be defined as:
employed for the preparation of holes for the placement of dental im­
m √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
plants. Typically, ZIs with a diameter of 4 mm are chosen for insertion 1 ∑ ( PatientRef )− 1
HRE = ‖ PHoloj − T Holo Tracker T Tracker PRefj ‖2 (21)
into the drilled holes. Various lengths of ZIs are used for different tooth m j=1
positions. A length of 40 mm was selected for the distal position,
whereas 50 mm was selected for the mesial position. For the indicators in drill-phantom registration, the DCE reflects the
average distance of a given landmark point set S = ( P1 P2 … Pm )
within the coordinate systems of the surgical drill tip and the patient
3.1. The systematic error of the MR navigation-based hybrid robotic phantom following the calibration of the surgical instrument and can be
system defined as:
m √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
The MR navigation-based hybrid robotic system is susceptible to 1 ∑
DCE = ‖ PRefj − T PatientRef PDrillj ‖2 (22)
errors during various stages, including image-phantom registration, m j=1 Drill

HoloLens-tracker registration, drill-phantom calibration, and robot-

implant calibration. The cumulative effect of these errors could poten­
tially affect the precision of the implantation process. To assess the ac­
curacy and stability of the system, five error indicators were defined for
evaluation. These indicators include fiducial registration error (FRE),
target registration error (TRE), HoloLens registration error (HRE), drill
calibration error (DCE), and robot alignment error (RAE).
In the context of image-model registration, the FRE signifies the
mean distance between fiducial points in the 3D reconstructed CBCT
image and the patient phantom after the matrix transformation of
registration, and the TRE reflects the average distance of a given point
set S = ( P1 P2 … Pm ) between the CBCT image and the patient
Finally, for the indicators in robot-implant calibration, it is necessary
to control the robot so that the drill tip aligns with the starting point of
the planned ZI path. The RAE is a measure of the average distance be­
tween the tip of the drill PDrillj and the starting point of the ZI path in the
CBCT image S = ( PIm1 PIm2 ⋯ PImm ) after the alignment of the
robot-controlled drill and the ZI path and can be defined as:
m √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
1 ∑
‖ T PatientRef (23)
PatientRef
RAE = DrillTip PDrillj − T Image PImj ‖2
m j=1
To validate these indicators, the measurement and calculation of

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

them were carried out sequentially on the 10 phantoms to be used for

± 0.601◦ In contrast, robot-assisted ZI placement had an average coronal
the experiment (manual group: M1-M5, robotic group: R1-R5, and RAE
deviation of 0.887 ± 0.213 mm, an average apical deviation of 1.201 ±
was not calculated in the manual group). The results obtained are shown
0.318 mm, and an average angular deviation of 1.543 ± 0.511◦ The data
in Table 2.
presented above has been graphed, and the resulting plots are depicted
To guarantee the precise placement of the ZI, it is recommended that
in Fig. 8.
the FRE, TRE, DCE, and HRE do not surpass 1 mm. To guarantee superior
As illustrated in the 3D scatter plot depicted in Fig. 8A, the data
accuracy and stability in robotic drilling compared to manual operation,
points representing deviation results are clustered closely together for
it is recommended that the RAE does not surpass 0.5 mm. Consequently,
robotic implantation, whereas they are more widely spread out for
the accuracy of the MR-DINS has been assessed to fulfill the criteria
manual implantation. This observation implies that robotic implanta­
necessary for conducting dental implant surgery.
tion exhibits higher stability compared to manual implantation. The box
plot depicted in Fig. 8B illustrates that the coronal, apical, and angular
3.2. The comparison of the accuracy manual and robotic ZI placement deviations of the robotic implantation are all reduced compared to those
of the manual implantation. This indicates that the robotic implantation
Following the confirmation of the system accuracy meeting the method exhibits higher accuracy levels than the manual approach.
surgical requirements, 40 ZIs were inserted into 10 phantoms along the Moreover, the study aims to assess the accuracy of manual proced­
preoperatively planned paths. ZIs were drilled and implanted by ures in contrast to those assisted by robots. A hypothesis test was con­
manually gripping the handpiece in the manual group, whereas by ducted comparing the two groups under examination. Assuming no
robotically gripping the handpiece in the robotic group. To assess the significant difference in accuracy between the manual group and the
accuracy of the placement of these ZIs, postoperative CBCT images of the robotic group, the p-value of these two groups is calculated at a 95 %
implanted phantoms were captured following the completion of the ZI confidence level. If p < 0.05, the null hypothesis is rejected, indicating a
placement surgery, allowing for the visualization and delineation of the significant difference in accuracy between the two tested groups.
implant positions. In the postoperative CBCT images, the preoperative The results of the hypothesis testing presented in Table 3 indicated
planning software "DentalHelper" can be utilized to create a path that that the p-values for the three deviations between the manual and ro­
completely overlaps with the actual implanted ZI. By registering the botic groups were 0.003, 0.028, and 0.017, respectively. Consequently,
postoperative CBCT image to the preoperative CBCT image using fidu­ a notable distinction was observed between the two groups. It can be
cial markers (the apexes of the titanium screws present in both pre and inferred that utilizing a hybrid robotic system for ZI placement, despite
postoperative images) within the 3D Slicer platform (https://www. encountering similar systematic errors in the navigation system, resulted
slicer.org), it is possible to match the actual path of the implanted ZI in a notable enhancement in coronal, apical, and angular accuracy
outlined in the postoperative stage with the planned path from the compared to manual procedures.
preoperative stage (Fig. 7A). Subsequently, the deviations between these
paths can be analyzed (Fig. 7B). 4. Discussion
Three indicators, namely coronal deviation, apical deviation, and
angular deviation, are commonly used to evaluate the deviation be­ Due to the considerable distance involved and the numerous key
tween the preoperatively planned implant path and the actual implant tissues traversed during zygomatic implantation, the surgery for ZI
path, as illustrated in Fig.7B. Define the coronal point and apical point of placement requires a high level of precision and stability. The accuracy
the preoperatively planned implant path as points A and B, respectively, of zygomatic implant placement is guaranteed through the imple­
and the coronal point and apical point of the actual implant path as mentation of real-time dynamic navigation. Nevertheless, the process of
points C and D. The coronal deviation, apical deviation, and angular zygomatic implantation presents challenges in terms of surgical opera­
deviation can be calculated based on the coordinates of points A to D. tion, demanding a high level of skill from the surgeon, thereby
( ̅→ ̅→ ) restricting its clinical applicability. The integration of a hybrid robotic
̅→ ̅→
Coronal = ‖ AC ‖, Apical = ‖ BD ‖, Angular = arccos
AB ⋅CD system with the navigation system for MR navigation-guided hybrid
̅→ ̅→
‖ AB ‖‖CD ‖ robot-assisted ZI placement surgery presents a viable approach to miti­
(24) gate the complexity of the procedure and improve the stability and
dependability of ZI placement.
The overall deviation between the planned and actual paths of the
Our team has developed a hybrid robotic system for ZI placement
total 40 ZIs is tabulated in Table 3, as calculated by Eq. (24).
surgery. This system is founded on the MR-based navigation system for
The statistical analysis of the data revealed the mean, standard de­
precise dental implant placement. The hybrid robot integrates both the
viation (SD), and the 95 % confidence intervals (95 % CI). The results
serial structure and the Stewart parallel structure for enhanced perfor­
indicate that, at a 95 % confidence level, manual ZI placement had an
mance and accuracy during the surgical procedure. By conducting rigid
average coronal deviation of 1.450 ± 0.301 mm, an average apical de­
coordinate transformations among the system components, such as
viation of 1.835 ± 0.483 mm, and an average angular deviation of 2.487
image-phantom registration, HoloLens-tracker registration, drill-
phantom calibration, and robot-implant calibration, it is possible to
Table 2 attain real-time accurate positioning of the ZI placement site. Subse­
Systematic errors of MR navigation-based hybrid robotic system (unit: mm).
quently, the robot can grasp the handpiece for cavities drilling and
Type Number FRE TRE HRE DCE RAE implant insertion, thereby ensuring precision and stability in zygomatic
Manual M1 0.718 0.705 0.812 0.760 / implant surgery.
M2 0.627 0.514 0.468 0.466 / The primary determinants influencing the accuracy of ZI placement
M3 0.895 0.806 0.916 0.778 / surgery predominantly encompass the systematic errors that accrue
M4 0.671 0.728 0.545 0.649 /
during registration, calibration, and the robot’s motion. These errors
M5 0.421 0.601 0.852 0.756 /
Robotic R1 0.432 0.774 0.624 0.619 0.223 necessitate minimization to enhance accuracy. Four indicators, namely
R2 0.530 0.549 0.770 0.702 0.138 FRE, TRE, HRE, and DCE, were employed to evaluate the accumulative
R3 0.699 0.731 0.720 0.896 0.315 error of the navigation system. The accuracy of the navigation system
R4 0.835 0.688 0.868 0.644 0.125
was deemed to comply with the standards of clinical surgery when none
R5 0.783 0.659 0.794 0.422 0.151
Total Mean 0.661 0.676 0.737 0.669 0.190
of these indicators exceeded 1 mm. Additionally, the Robot Alignment
SD 0.153 0.090 0.140 0.136 0.071 Error (RAE) was employed to evaluate the accuracy and performance of

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

Fig. 7. The deviation between the actual and planned ZI path (A: Comparison between the planned and actual ZI paths. B: Calculation of deviations between the
planned and actual ZI paths.).

utilizing navigation systems to enhance the accuracy of zygomatic im­

Table 3
plantation. Furthermore, our research conducted a comparative analysis
Comparisons of deviations of the ZI positioning between robot and surgeons.
of the precision in placing implants in the zygomatic bone using manual
Type Statistic Coronal (mm) Apical (mm) Angular (◦ ) and robotic techniques under navigation. The average coronal, apical,
Manual Mean 1.450 1.835 2.487 and angular deviations between robotic and manual implantation pro­
SD 0.626 1.006 1.251 cedures were 0.887 ± 0.213 mm compared to 1.450 ± 0.301 mm, 1.201
95 % CI 1.450 ± 0.301 1.835 ± 0.483 2.487 ± 0.601 ± 0.318 mm compared to 1.835 ± 0.483 mm, and 1.543 ± 0.511◦
Robotic Mean 0.887 1.201 1.543
SD 0.443 0.663 1.065
compared to 2.487 ± 0.601◦ , respectively. Through a hypothesis test, it
95 % CI 0.887 ± 0.213 1.201 ± 0.318 1.543 ± 0.511 was determined that the p-values for all three indicators were below
t-test p-value 0.003* 0.028* 0.017* 0.05. This suggests that the accuracy of robotic implantation signifi­
cantly surpassed that of manual implantation, highlighting the accuracy
and reliability of the MR navigation-based hybrid robotic system in ZI
the robot’s movement. A deviation of less than 0.5 mm in this error
placement surgery.
indicated that the robot’s gripping and movement were deemed to be
The MR navigation-based hybrid robotic system proposed also pre­
stable and dependable. In this experiment, the mean values of FRE, TRE,
sents opportunities for further improvement and enhancement. Firstly,
HRE, DCE, and RAE were 0.661 mm, 0.676 mm, 0.737 mm, 0.669 mm,
the hybrid robot demonstrates rapid positional adjustment for placing
and 0.190 mm, respectively. These values all satisfied the clinical
the ZIs on the same side of the zygomatic bone. However, when the ZIs
criteria and guaranteed the accuracy of ZI placement.
require placement on the contralateral side of the zygomatic bone, sig­
The assessment conducted postoperatively to evaluate the accuracy
nificant repositioning of the robot is necessary, leading to prolonged
of the ZI placement surgery revealed that the mean discrepancies be­
duration and decreased surgical efficiency. Secondly, during the pro­
tween the preoperatively planned ZI paths and the ZI paths actually
cedure, there is a risk of the surgical drill slipping and causing deviation
implanted were as follows: a coronal deviation of 0.887 ± 0.213 mm, an
when it is about to penetrate the bone at the entry point of the ZI path.
apical deviation of 1.201 ± 0.318 mm, and an angular deviation of
To address this issue, the operator must guide the drill into the bone with
1.543 ± 0.511◦ . Previous research has made significant contributions to
manual support, highlighting a challenge that requires resolution in
robot-assisted ZI placement surgery. A comparison with other ZI
future developments. To date, only phantom experiments have been
placement robotic systems is presented in Table 4 below. The compar­
conducted. The accuracy, feasibility, and reliability of this system
ative analysis indicates that the zygomatic implantation accuracy of our
necessitate evaluation through animal experiments, cadaveric experi­
system is comparable to that of the leading international zygomatic
ments, and further clinical studies.
implantation robots.
Moreover, we conducted a comparison of various techniques for ZI
5. Conclusion
implantation surgery. A study regarding the accuracy of freehand ZI
placement revealed that the average coronal, apical, and angular de­
In this study, a hybrid robotic system based on MR navigation was
viations for freehand ZI placement were 2.04 mm ± 0.56 mm, 3.23 mm
introduced to assist surgeons in zygomatic implantation surgery. The
± 1.43 mm, and 4.92◦ ± 1.71◦ , respectively [32]. In contrast, the ac­
integration of the preoperatively planned ZI paths, the patient phantom,
curacy of implantation of ZI under navigation in our study is 1.450 ±
the handpiece and surgical drill, and the hybrid robot was successfully
0.301 mm, 1.835 ± 0.483 mm, and 2.487 ± 0.601◦ , respectively. The
accomplished in our system through a series of registration and
comparative result highlights the effectiveness and importance of

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X. Fan et al. Computer Methods and Programs in Biomedicine 249 (2024) 108156

Fig. 8. Comparison of deviations between manual and robotic implantation.

Declaration of competing interest

Table 4
Comparisons with other ZI placement robotic systems.
The authors declare that they have no known competing financial
Research Coronal (mm) Apical (mm) Angular (◦ ) interests or personal relationships that could have appeared to influence
Fan et al. [20]. 2.34±0.79 2.57±1.73 2.76±1.39 the work reported in this paper.
Cao et al. [19]. 0.79±0.19 1.52±0.58 1.49±0.48
Li et al. [23]. 0.78±0.34 0.80±0.25 1.33±0.41 Acknowledgments
Deng et al. [22]. 0.57±0.19 1.07±0.48 0.91±0.51
Deng et al. [24]. 0.97±0.42 1.27±0.56 1.48±0.51
Ours 0.89±0.21 1.20±0.32 1.54±0.51 This work was supported by grants from the National Natural Science
Foundation of China (82330063; M-0019), Shanghai Jiao Tong Uni­
versity Foundation on Medical and Technological Joint Science
calibration algorithms. These algorithms encompassed image-phantom Research (YG2021ZD21; YG2021QN72; YG2022QN056; YG2023ZD19;
registration, HoloLens-tracker registration, drill-phantom calibration, YG2023ZD15), the Funding of Xiamen Science and Technology Bureau
and robot-implant calibration. The real-time tracking of the surgical (3502Z20221012), SJTU Global Strategic Partnership Fund (2023 SJTU-
drill’s relative position and posture can be achieved using the navigation CORNELL)
device, allowing direct observation of the planned ZI paths through the
HoloLens. Experimental findings indicate that our hybrid robotic MR References
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