Accuracy of computer-guided surgery: A comparison of operator experience.

STATEMENT OF PROBLEM: Even though high-precision technologies have been used in computer-guided implant surgery, studies have shown that linear and angular deviations between the planned and placed implants can be expected. PURPOSE: The purpose of this study was to evaluate the effect of operator experience on the accuracy of implant placement with a computer-guided surgery protocol. MATERIAL AND METHODS: Ten surgically experienced and 10 surgically inexperienced operators participated in this study. Each operator placed 1 dental implant (Replace Select) on the partially edentulous mandibular model that had been planned with software by following a computer-guided surgery (NobelGuide) protocol. Three-dimensional information of the planned and placed implants were then superimposed. The horizontal and vertical linear deviations at both the apex and platform levels and the angular deviation were measured and compared between the experienced and inexperienced groups with the independent t test with Bonferroni adjustment (α=.01). The magnitude and direction of the horizontal deviations were also measured and recorded. RESULTS: No significant differences were found in the angular and linear deviations between the 2 groups (P>.01). Although not statistically significant (P>.01), the amount of vertical deviation in the coronal direction of the implants placed by the inexperienced operators was about twice that placed by the experienced operators. Overall, buccal apical deviations were most frequent and of the highest magnitude. CONCLUSIONS: When a computer-guided protocol was used, the accuracy of the vertical dimension (depth of implant placement) was most influenced by the operator's level of experience.

An Accuracy Study of Computer-Planned Implant Placement in the Augmented Maxilla Using Mucosa-Supported Surgical Templates.

PURPOSE: The purpose of this study was to determine the clinically relevant accuracy of implant placement in the augmented maxilla using computer planning and a mucosa-supported surgical template. MATERIALS AND METHODS: Twenty-five consecutive edentulous patients with an extreme maxillar alveolar ridge resorption were treated with a bone augmentation procedure. In a second stage, six Brånemark MkIII Groovy (Nobel Biocare®, Zürich, Switzerland) implants were installed. Preoperatively, a cone beam computer tomography (CBCT) scan was acquired, followed by virtual implant planning and flapless implant placement using a surgical template. A postoperative CBCT scan was acquired and registered to the preoperative scan. The Implant Position Orthogonal Projection validation method was applied to measure implant deviations in both the buccolingual and mesio-distal plane. The influence of fixation pins and the position on the dental arch were investigated with regard to implant deviations, and rotations and translations of the surgical template. RESULTS: One hundred fifty implants were installed. In mesio-distal direction, a mean implant deviation of 1.50 mm was scored at the implant tip, 1.27 mm at the shoulder, -0.60 mm in depth, as well as a mean deviation of angulation of 2.50°. In buccolingual direction, a mean implant deviation of 0.99 mm was found at the implant tip, 0.76 mm at the implant shoulder, -0.57 mm in depth, and a deviation of angulation of 2.48°. Of all implants, 53% was placed too superficial compared with the planning. The use of fixation pins and implant deviations in both buccal and mesial directions as also for rotations and translation of the surgical template showed statistically significant differences. CONCLUSIONS: Computer-aided implant planning showed to be a clinically relevant tool. However, this study emphasizes that the surgeon should take into account that deviations are larger compared with implant placement without augmentation procedure. Deviations are mainly caused by angulations and translations of the surgical template.

A clinically relevant validation method for implant placement after virtual planning.

PURPOSE: To design a relevant method to compare the virtual planned implant position to the ultimately achieved implant position and to evaluate, in case of discrepancy, the cause for this. MATERIALS AND METHODS: Five consecutive edentulous patients with retention problems of the upper denture received four implants in the maxilla. Preoperatively, first a cone-beam CT (CBCT) scan was acquired, followed by virtual implant planning. Then, a surgical template was designed and endosseous implants were flapless installed using the template as a guide. To inventory any differences in position, the postoperative CBCT scan was matched to the preoperative scan. The accuracy of implant placement was validated three-dimensionally (3D) and the Implant Position Orthogonal Projection (IPOP) validation method was applied to project the results to a bucco-lingual and mesio-distal plane. Subsequently, errors introduced by virtual planning, surgical instruments, and validation process were evaluated. RESULTS: The bucco-lingual deviations were less obvious than mesio-distal deviations. A maximum linear tip deviation of 2.84 mm, shoulder deviation of 2.42 mm, and angular deviation of 3.41° were calculated in mesio-distal direction. Deviations included errors in planning software (maximum 0.15 mm), for surgical procedure (maximum 2.94°), and validation process (maximum 0.10 mm). CONCLUSIONS: This study provides the IPOP validation method as an accurate method to evaluate implant positions and to elucidate inaccuracies in virtual implant planning systems.

Calibrated segmentation of CBCT and CT images for digitization of dental prostheses.

PURPOSE: State of the art computer aided implant planning procedures typically use a surgical template to transfer the digital 3D planning to the operating room. This surgical template can be generated based on an acrylic copy of the patient's removable prosthesis--the so-called radiographic guide--which is digitized using a CBCT or CT scanner. Since the same accurate fit between the surgical template and the patient as with the radiographic guide and the patient should be ensured, a procedure to accurately digitize this guide is needed. METHODS: A procedure is created to accurately digitize radiographic guides based on a calibrated segmentation. Therefore, two steps have to be executed. First, during a calibration step a calibration object is CBCT or CT scanned and a calibration algorithm which results in an optimal threshold value is executed. Next the guide is CBCT or CT scanned and a 3D model is created using the obtained optimal threshold. To validate our method, we compared a high accuracy laser scanned copy of the guide with the generated 3D model by creating a distance map between both models. RESULTS: The procedure was performed for different CBCT and CT scanners, and the digitization error for each scanner was defined. The 90th percentile error measured on average 0.15 mm, which was always less than the applied voxel size for all CBCT and CT test scans. CONCLUSIONS: The calibration procedure evaluated in this study solves the known problem of digitizing a radiographic guide based on non-standardized gray value CBCT images. The procedure can easily be executed by a clinician and allows an accurate digitization of a radiographic guide using a CBCT or CT scanner. Starting from this digitization, an accurate surgical template can be made which has a good fit on the patient's remaining teeth and surrounding soft tissues.

Three-dimensional treatment planning of orthognathic surgery in the era of virtual imaging.

PURPOSE: The aim of this report was to present an integrated 3-dimensional (3D) virtual approach toward cone-beam computed tomography-based treatment planning of orthognathic surgery in the clinical routine. MATERIALS AND METHODS: We have described the different stages of the workflow process for routine 3D virtual treatment planning of orthognathic surgery: 1) image acquisition for 3D virtual orthognathic surgery; 2) processing of acquired image data toward a 3D virtual augmented model of the patient's head; 3) 3D virtual diagnosis of the patient; 4) 3D virtual treatment planning of orthognathic surgery; 5) 3D virtual treatment planning communication; 6) 3D splint manufacturing; 7) 3D virtual treatment planning transfer to the operating room; and 8) 3D virtual treatment outcome evaluation. CONCLUSIONS: The potential benefits and actual limits of an integrated 3D virtual approach for the treatment of the patient with a maxillofacial deformity are discussed comprehensively from our experience using 3D virtual treatment planning clinically.

A cone-beam computed tomography triple scan procedure to obtain a three-dimensional augmented virtual skull model appropriate for orthognathic surgery planning.

The aim of this study was to present a new approach to acquire a three-dimensional virtual skull model appropriate for orthognathic surgery planning without the use of plaster dental models and without deformation of the facial soft-tissue mask. A "triple" cone-beam computed tomography (CBCT) scan procedure with triple voxel-based rigid registration was evaluated and validated on 10 orthognathic patients. First, the patient was scanned vertically with a wax bite wafer in place (CBCT scan No1). Second, a limited dose scan of the patient with a Triple Tray AlgiNot impression in place was carried out (CBCT scan No2). Finally, a high-resolution scan of the Triple Tray AlgiNot impression was done (CBCT scan No3). Sequential and semiautomatic triple voxel-based rigid registration (RNo1-RNo3) was performed to augment the patient's skull model with accurate occlusal and intercuspidation data (Maxilim, version 2.1.1., Medicim NV, Mechelen, Belgium). All registrations were based on the Maximisation of Mutual Information registration algorithm. Because the accuracy and stability of the voxel-based registration (RNo1) between the Triple Tray AlgiNot impression scan and the limited low-dose patient scan were not known, this particular registration step needed to be validated. The accuracy of registration was measured on a synthetic skull and showed to be highly accurate. A volume overlap of 98.1% was found for registered impression scan No1. The mean distance between registered impression scan No1 and registered impression scan No2 was 0.08 +/- 0.03 mm (range, 0.04-0.11 mm). As far as the stability of registration was concerned, successful registration with a stable optimal position was obtained with a maximum variability of less than 0.1 mm. The results of this study showed that semiautomatic sequential triple voxel-based rigid registration of the triple CBCT scans augmented the 3-D virtual skull model with detailed occlusal and intercuspidation data in a highly accurate and robust way. The method is therefore appropriate and valid for 3-D virtual orthognathic surgery planning in the clinical routine.

Integration of digital dental casts in 3-dimensional facial photographs.

INTRODUCTION: Since 1915, various researchers have tried to make a 3-dimensional (3D) model of the complete face, with the dentition in the anatomically correct position. This was a difficult and time-consuming process. With the introduction of 3D digital imaging of the face and dental casts, researchers have regained interest in this topic. The purpose of this technical report is to present a feasibility study of the integration of a digital dental cast into a 3D facial picture. METHODS: For the integration, 3 digital data sets were constructed: a digital dental cast, a digital 3D photograph of the patient with the teeth visible, and a digital 3D photograph of the patient with the teeth in occlusion. By using a special iterated closest point algorithm, these 3 data sets were matched to place them in the correct anatomical position. RESULTS: After matching the 3 data sets, we obtained a 3D digital model with the dental cast visible through the transparent picture of the patient's face. When the distance between the matched data sets was calculated, an average distance of 0.35 mm (SD, 0.32 mm) was shown. This means that matching the data sets is acceptable. CONCLUSIONS: It seems technically possible to make a data set of a patient's face with the dentition positioned into this 3D picture. Future research needs to establish the value of this 3D fused data set of the face and the dentition in orthodontic diagnosis and treatment planning.

The use of a wax bite wafer and a double computed tomography scan procedure to obtain a three-dimensional augmented virtual skull model.

A detailed visualization of the interocclusal relationship is essential in a three-dimensional virtual planning setup for orthognathic and facial orthomorphic surgery. The purpose of this study was to introduce and evaluate the use of a wax bite wafer in combination with a double computed tomography (CT) scan procedure to augment the three-dimensional virtual model of the skull with a detailed dental surface. A total of 10 orthognathic patients were scanned after a standardized multislice CT scanning protocol with dose reduction with their wax bite wafer in place. Afterward, the impressions of the upper and lower arches and the wax bite wafer were scanned for each patient separately using a high-resolution standardized multislice CT scanning protocol. Accurate fitting of the virtual impressions on the wax bite wafer was done with surface matching using iterative closest points. Consecutively, automatic rigid point-based registration of the wax bite wafer on the patient scan was performed to implement the digital virtual dental arches into the patient's skull model (Maxilim, version 2.0; Medicim NV, St-Niklaas, Belgium). Probability error histograms showed errors of < or =0.16 mm (25% percentile), < or =0.31 mm (50% percentile), and < or =0.92 (90% percentile) for iterative closest point surface matching. The mean registration error for automatic point-based registration was 0.17 +/- 0.07 mm (range, 0.12-0.22 mm). The combination of the wax bite wafer with the double CT scan procedure allowed for the setup of an accurate three-dimensional virtual augmented model of the skull with detailed dental surface. However, from a clinical workload, data handling, and computational point of view, this method is too time-consuming to be introduced in the clinical routine.

Three-dimensional cephalometry: spiral multi-slice vs cone-beam computed tomography.

Three-dimensional (3D) craniofacial imaging techniques are becoming increasingly popular and have opened new possibilities for orthodontic assessment, treatment, and follow-up. Recently, a new 3D cephalometric method based on spiral multi-slice (MS) computed tomography (CT) was developed and validated by our research group. This innovative 3D virtual approach is a bridge between conventional cephalometry and modern craniofacial imaging techniques and provides high-quality, accurate, and reliable quantitative 3D data. The aim of this article was to describe the advantages and the disadvantages of spiral MS-CT 3D cephalometry and to discuss the potential of cone-beam CT 3D cephalometry.

Assessment of bone segmentation quality of cone-beam CT versus multislice spiral CT: a pilot study.

OBJECTIVES: The objective of this study was to quantitatively assess the quality of jawbone models generated from cone beam computed tomography (CBCT) by comparison with similar models obtained from multislice spiral computed tomography (MSCT). MATERIAL AND METHODS: Three case studies were performed involving images of anthropomorphic head phantoms and real patients acquired with 3 CBCT (NewTom 9000 DVT, Accuitomo 3D, and i-CAT) and 2 MSCT scanners (Somatom VolumeZoom and Lightspeed). Bone was segmented from the CBCT and MSCT images using global thresholding. CBCT vs MSCT segmentation differences were assessed by comparing bone thickness measurements at anatomically corresponding sites, identified automatically by CBCT to MSCT image registration. RESULTS: There was a statistically significant difference between the MSCT and CBCT segmented bone thicknesses, varying from 0.05 +/- 0.47 mm (i-CAT) up to 1.2 +/- 1.00 mm (3D Accuitomo, posterior maxilla). CONCLUSIONS: An automated, reproducible, and observer-independent method has been developed to assess the quality of CBCT bone models using MSCT as a clinically established method of reference. Our validation method is generally applicable in cases where no geometric ground-truth is available.

A new method of 3-D cephalometry Part I: the anatomic Cartesian 3-D reference system.

The purpose of this study was to present a new innovative three-dimensional (3-D) cephalometric method. Part I deals with the set-up and validation of a voxel-based semi-automatic 3-D cephalometric reference system. The CT data (DICOM 3.0 files) of 20 control patients with normal skeletal relationships were used for this study. To investigate accuracy and reliability of the 3-D cephalometric reference system (Maxilimtrade mark, version 1.3.0) a total of 42 (14 horizontal, 14 vertical and 14 transversal) orthogonal measurements were performed on each patient twice by each of two investigators. The intra-observer measurement error was less then 0.88 mm, 0.76 mm and 0.84 mm for horizontal, vertical and transversal orthogonal measurements, respectively. The inter-observer measurement error was less as 0.78 mm, 0.86 mm and 1.26 mm for horizontal, vertical and transversal orthogonal measurements, respectively. Squared correlation coefficients showed a high intra-observer and inter-observer reliability. The presented 3-D cephalometric reference system proved to be accurate and reliable and can therefore be used for 3-D cephalometric hard and soft tissue analysis.

State-of-the-art on cone beam CT imaging for preoperative planning of implant placement.

Orofacial diagnostic imaging has grown dramatically in recent years. As the use of endosseous implants has revolutionized oral rehabilitation, a specialized technique has become available for the preoperative planning of oral implant placement: cone beam computed tomography (CT). This imaging technology provides 3D and cross-sectional views of the jaws. It is obvious that this hardware is not in the same class as CT machines in cost, size, weight, complexity, and radiation dose. It is thus considered to be the examination of choice when making a risk-benefit assessment. The present review deals with imaging modalities available for preoperative planning purposes with a specific focus on the use of the cone beam CT and software for planning of oral implant surgery. It is apparent that cone beam CT is the medium of the future, thus, many changes will be performed to improve these. Any adaptation of the future systems should go hand in hand with a further dose optimalization.

A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study.

BACKGROUND: Based on three-dimensional implant planning software for computed tomographic (CT) scan data, customized surgical templates and final dental prostheses could be designed to ensure high precision transfer of the implant treatment planning to the operative field and an immediate rigid splinting of the installed implants, respectively. PURPOSE: The aim of the present study was to (1) evaluate a concept including a treatment planning procedure based on CT scan images and a prefabricated fixed prosthetic reconstruction for immediate function in upper jaws using a flapless surgical technique and (2) validate the universality of this concept in a prospective multicenter clinical study. MATERIALS AND METHODS: Twenty-seven consecutive patients with edentulous maxillae were included. Treatments were performed according to the Teeth-in-an-Hour concept (Nobel Biocare AB, Göteborg, Sweden), which includes a CT scan-derived customized surgical template for flapless surgery and a prefabricated prosthetic suprastructure. RESULTS: All patients received their final prosthetic restoration immediately after implant placement, that is, both the surgery and the prosthesis insertion were completed within approximately 1 hour. In the 24 patients followed for 1 year, all prostheses and individual implants were recorded as stable. CONCLUSION: The present prospective multicenter study indicates that the prefabrication, on the basis of models derived from three-dimensional oral implant planning software, of both surgical templates for flapless surgery and dental prostheses for immediate loading is a very reliable treatment option. It is evident that the same approach could be used for staged surgery and in partial edentulism.

Robust visualization of the dental occlusion by a double scan procedure.

A detailed visualization of the dental occlusion in 3D image-based planning environments for oral and maxillofacial planning is important. With CT imaging however, this occlusion is often deteriorated by streak artifacts caused by amalgam fillings. Moreover, more detailed surface information at the level of the dental cuspids is often desired. In this paper, a double scan technique is introduced to image the dental occlusion by means of a newly designed 3D splint. The patient wears this splint between the upper and lower teeth during CT-scan. In a second step, the splint is positioned between the plaster casts of the upper and lower jaw, and this setup is scanned. Based on markers in the 3D splint, both data sets are fused and a combined visualization is possible. The accuracy, robustness and applicability in clinical routine is shown. This technology enables meticulous 3D cephalometric analysis, detailed maxillofacial planning and opens possibilities towards intraoperative support.

Accuracy of drilling guides for transfer from three-dimensional CT-based planning to placement of zygoma implants in human cadavers.

The accuracy of surgical drilling guides was assessed for placement of zygoma implants. Six zygoma fixtures of length 45 mm (Nobel Biocare, Göteborg, Sweden) were placed in three formalin-fixed human cadavers using surgical drilling guides. The fabrication of these custom-made drilling guides was based on three-dimensional computerized tomography (3D-CT) data for the maxillary-zygomatic complex. The installation of the implants was simulated preoperatively using an adopted 3D-CT planning system. In addition, anatomical measurements of the zygomatic bone were performed on the 3D images. The preoperative CT images were then matched with postoperative ones in order to assess the deviation between the planned and installed implants. The angle between the planned and actually placed implants was < 3 degrees in four out of six cases. The largest deviation found at the exit point of one of the six implants was 2.7 mm. The present study showed that the use of surgical drilling guides should be encouraged for zygoma implant placement because of the lengths of the implants involved and the anatomical intricacies of the region.

Image-based planning and validation of C1-C2 transarticular screw fixation using personalized drill guides.

OBJECTIVE: Posterior transarticular spine fusion is a surgical procedure used to stabilize the cervical bodies C1 and C2. Currently, spine screws are used most frequently, according to the procedure of Magerl. As the anatomy is rather complex and the view is limited, this procedure has a high risk factor. We present and validate a planning system for cervical screw insertion based on preoperative CT imaging. MATERIALS AND METHODS: The planning system discussed allowed a neurosurgeon to interactively determine the desired position of the cervical screws, based on appropriate and real-time reslices through the preoperative CT image volume. From the planning, a personalized mechanical drill guide was derived as a means of transferring the plan intraoperatively. Eight cadaver experiments were performed to validate this approach. Postoperative CT was applied, and screw locations were extracted from the postoperative images after registering them to preoperative images. In this way, the deviations of the axes of the planned and inserted screws were determined. RESULTS: From an initial cadaver series, it was observed that the drill guides were not stable enough to cope with the drilling forces, and tended to become displaced. Still, most of the inserted screws were reported to be placed adequately. No vascular compromise or invasion of the spinal canal was observed. For a second cadaver series, the design of the drill guide was altered. In this series, the displacement was no longer present, and all screws were optimally placed. CONCLUSIONS: The preoperative planning system allowed the neurosurgeon to rehearse screw insertion in a way that is closer to surgical reality. The image-based validation technique allowed verification and enhancement of the template design on a cadaver study, giving accuracies comparable to those obtained with transfer by navigation.