Impact of digital technologies on implant surgery in fully edentulous patients: A scoping review.

BACKGROUND: For over three decades, digital technologies have been used in Implant Dentistry, beginning with the introduction of planning software for Static Computer-Assisted Implant Surgery (S-CAIS). During this time, this field has witnessed the emergence of diverse methodologies and a proliferation of technological advancements. Today, S-CAIS is a widely adopted procedure for the placement of dental implants in both partially and fully edentulous patients, with Dynamic Computer-Assisted Surgery (D-CAIS) and Robotic-Assisted Implant Surgery (RAIS) rapidly gaining attention among dental professionals. The continuous advancements in this arena are not merely indicative of technological progress; they represent a steadfast dedication to refining precision, enhancing efficiency, and fostering innovation with the goal of optimizing patient outcomes in dental implantology. AIMS: The purpose of the following review is to meticulously examine the spectrum of digital technologies available and to describe their protocols, advantages, and shortcomings as well as to evaluate their accuracy in implant surgery in patients with complete edentulism. MATERIALS AND METHODS: A scoping review was performed following the Joanna Briggs Institute (JBI) protocols, leveraging the population, concept, and context (PCC) framework to construct the research question and determine the inclusion and exclusion criteria. RESULTS: Two hundred and sixty-seven records were identified for screening. After applying all the screening criteria, 41 articles were included for review and qualitative data analysis. DISCUSSION: S-CAIS, D-CAIS, and RAIS were identified as the main technologies for computer assisted implant surgery. Their applications, characteristics, protocols and levels of accuracy were compared and described. CONCLUSION: Taking into consideration the limitations of this study, S-CAIS appears to be the most applied and validated technology in implant surgery for fully edentulous patients followed by D-CAIS and RAIS being these last two promising initiatives in the field. Despite having similar levels of accuracy, the overall comparison showed a slightly higher values in RAIS followed by D-CAIS and S-CAIS.

An in vitro analysis of the accuracy of static and robot-assisted implant surgery.

OBJECTIVES: Robot-assisted implant surgery (RAIS) is purported to improve the accuracy of implant placement. The objective of this study was to compare RAIS with static computer-assisted implant surgery (sCAIS) in a controlled environment. MATERIALS AND METHODS: A total of n = 102 implants were placed in the same modified typodont (n = 17 repeated simulated implant surgeries with each n = 3 implants per group) using robot-assisted or static computer-assisted implant surgery. The final implant positions were digitized utilizing cone-beam tomography and compared with the planned position. The angular deviation was the primary outcome parameter. 3D deviations at the implant platform level and the apex were secondary outcome parameters. Accuracy in terms of trueness and precision were assessed. Means, standard deviation, and 95%-confidence intervals were analyzed statistically. RESULTS: The overall angular deviation was 2.66 ± 1.83° for the robotic system and 0.68 ± 0.38° for guided surgery using static guides (p < .001), the 3D-deviation of the implant platform at crest level was for sCAIS 0.79 ± 0.28 mm and RAIS 1.51 ± 0.53 mm (p < .001) and at the apex for sCAIS 0.82 ± 0.26 mm and for RAIS 1.97 ± 0.79 mm (p < .001), respectively. CONCLUSIONS: Robotically guided implant surgery was less accurate in terms of trueness (planned vs. actual position) and precision (deviations among implants) than traditional static computer-assisted implant surgery in this in vitro study.

A cross-sectional CBCT assessment of the relative position of one-piece titanium-zirconium mini-implants placed for mandibular overdentures using non-guided surgery.

OBJECTIVE: To assess the relative position of mini-implants to retain a mandibular overdenture, according to the surgical protocol, technical and anatomical factors. METHODS: Mandibular cone-beam computed tomography (CBCT) scans were analyzed for 73 patients who received four one-piece titanium-zirconium mini-implants. Drilling was performed using a 1.6 mm needle drill and a 2.2 mm Pilot Drill, according to the bone density with a surgical stent. Post-insertion CBCT images in DICOM format were analyzed using the E-Vol-DX software with BAR filters. Divergence angle between implants and between implants and the overdenture path of insertion was measured using CliniView 10.2.6 software. RESULTS: Divergence between implants ranged from 0° to 22.3° (mean = 4.2; SD = 3.7) in the lateral and from 0° to 26.2° (mean = 5.3; SD = 4.1) in the frontal projections (p < .001). Only 1 (0.2%) and 3 (0.7%) of the measurements were higher than 20° in the lateral and frontal views, respectively. The mean angulations between the implant and the path of insertion for the overdenture were 9.3° (SD = 7.5) and 4.0° (SD = 2.9) for the lateral and frontal views, respectively (p < .001). Regression analyses showed a significant association between the divergence of implants and the frontal view projection (p < .001), greater distance between the paired implants (p = .017), the flapped surgical protocol (p = .002), higher final insertion torque (p = .011), and deeper preparation with the needle drill (p < .001). CONCLUSIONS: The mini-implants were placed with low divergence angles and satisfactory parallelism. Factors including shorter distances between the implants, higher density bone, and a flapless surgical approach all contributed positively to improved parallelism of the mini-implants.

Are Sleeves Necessary in Static Computer-Assisted Implant Surgery? A Comparative In Vitro Analysis.

OBJECTIVES: This study aims to examine differences in trueness and precision between surgical guides with (S) and without sleeves (SL). A secondary aim was to assess the impact of the sleeve-to-bone distance. MATERIALS AND METHODS: Mandible replicas (n = 120) were printed from an STL file obtained from a clinical CBCT. The mandibles were divided into sleeved (S, n = 60) and sleeveless (SL, n = 60) groups, each further divided into three categories (n = 20 each) with different heights from the guide to the implant platform: 2 mm (H2), 4 mm (H4), or 6 mm (H6). Digital planning and surgical guide design were done for a 4.1 × 10 mm implant for site #30. Post-op positions were captured using a scan body and lab scanner. Angular deviation was the primary outcome, with 3D and 2D deviations as secondary parameters. Statistical analysis included two-sample t-tests, and one-way and two-way ANOVA. RESULTS: Group S (2.41 ± 1.41°) had significantly greater angular deviation than Group SL (1.65 ± 0.93°; p = 0.0001). Angular deviation increased with sleeve-to-bone distance. H2 deviations were 1.48 ± 0.80° (S) vs. 1.02 ± 0.45° (SL; p < 0.05), H4: 2.36 ± 1.04° (S) vs. 1.48 ± 0.79° (SL; p < 0.05), H6: 3.37 ± 0.67° (S) vs. 2.46 ± 0.89° (SL; p < 0.05). 3D deviation at the implant platform was 0.36 ± 0.17 mm (S) vs. 0.30 ± 0.15 mm (SL; p < 0.05) and at the apex 0.74 ± 0.34 mm (S) vs. 0.53 ± 0.31 mm (SL; p < 0.01). Group SL at H2 had the smallest inter-implant distance (0.53 ± 0.37°), while Group S at H4 had the largest (1.20 ± 0.84°; p < 0.05). CONCLUSIONS: Sleeveless guides are more accurate than sleeved guides, and angular deviation is influenced by the distance from the guide to the implant platform.

Effect of implant shape and length on the accuracy of robot-assisted immediate implant surgery: An in vitro study.

OBJECTIVES: To compare the accuracy of immediate implant placement of cylindrical implants (CI) and tapered implants (TI) of different lengths using a robotic dental implant system. MATERIALS AND METHODS: CI and TI of three lengths (8, 10, and 12 mm) each were digitally planned and placed in a three-dimensional printed extraction socket model under robotic guidance. There were six groups with three samples in each group, resulting in a total of 18 samples. Implant angular deviation, platform point deviation (total, lateral, depth), and implant apical point deviation (total, lateral, depth) were recorded and compared between the different groups. RESULTS: The angular deviations for CI 8 mm, CI 10 mm, CI 12 mm, TI 8 mm, TI 10 mm, and TI 12 mm were 1.32° ± 0.19°, 1.03° ± 0.56°, 1.31° ± 0.38°, 1.27° ± 0.64°, 1.10° ± 0.43° and 1.05° ± 0.45°, respectively. The total deviations of platform and apical points for CI 8 mm, CI 10 mm, CI 12 mm, TI 8 mm, TI 10 mm, and TI 12 mm were 0.79 ± 0.18 mm, 0.77 ± 0.33 mm; 0.64 ± 0.21 mm, 0.55 ± 0.17 mm; 0.64 ± 0.37 mm, 0.65 ± 0.34 mm; 0.68 ± 0.26 mm, 0.71 ± 0.20 mm; 0.70 ± 0.12 mm, 0.66 ± 0.23 mm; and 0.71 ± 0.15 mm, 0.77 ± 0.29 mm, respectively, and had no significant differences. CONCLUSIONS: Within the limitation of this study, acceptable accuracy can be achieved for both TI and CI using robotic systems. Our study demonstrated that the implant shape and length did not affect the accuracy of immediate implant placement under robotic guidance in vitro. However, further trials are required to confirm their efficacy in clinical practice.

The impacts of registration-and-fixation device positioning on the performance of implant placement assisted by dynamic computer-aided surgery: A randomized controlled trial.

OBJECTIVES: To assess the efficacy of dynamic computer-aided surgery (dCAS) in replacing a single missing posterior tooth, we compare outcomes when using registration-and-fixation devices positioned anterior or posterior to the surgical site. Registration is performed on either the anterior or opposite posterior teeth. METHODS: Forty individuals needing posterior single-tooth implant placement were randomly assigned to anterior or posterior registration. Nine parameters were analyzed to detect the deviations between planned and actual implant placement, using Mann-Whitney and t-tests for nonnormally and normally distributed data, respectively. RESULTS: The overall average angular deviation for this study was 2.08 ± 1.12°, with the respective average 3D platform and apex deviations of 0.77 ± 0.32 mm and 0.88 ± 0.32 mm. Angular deviation values for individuals in the anterior and posterior registration groups were 1.58°(IQR: 0.98°-2.38°) and 2.25°(IQR: 1.46°-3.43°), respectively (p = .165), with 3D platform deviations of 0.81 ± 0.29 mm and 0.74 ± 0.36 mm (p = .464), as well as 3D apex deviations of 0.89 ± 0.32 mm and 0.88 ± 0.33 mm (p = .986). No significant variations in absolute buccolingual (platform, p = .659; apex, p = .063), apicocoronal (platform, p = .671; apex, p = .649), or mesiodistal (platform, p = .134; apex, p = .355) deviations were observed at either analyzed levels. CONCLUSIONS: Both anterior and posterior registration approaches facilitate accurate dCAS-mediated implant placement for single missing posterior teeth. The device's placement (posterior-to or anterior-to the surgical site) did not affect the clinician's ability to achieve the planned implant location.

Clinical evaluation of autonomous robotic-assisted full-arch implant surgery: A 1-year prospective clinical study.

OBJECTIVES: This prospective clinical study aimed to evaluate the accuracy and 1-year clinical follow-up performance of dental implant placement with an autonomous dental implant robot (ADIR) system in full-arch implant surgery. MATERIALS AND METHODS: Twelve patients with edentulous arches or final dentition received 102 implants using the ADIR system. Global platform deviation, global apex deviation, and global angular deviation between the planned and actual implants were calculated after surgery. Data were statistically analyzed for factors including jaws, implant positions, patient sequences, implant systems, and implant length. Surgery duration was recorded. Patients were followed for 3 months and 1 year after surgery. Periodontal parameters, buccal bone thickness (BBT), and facial vertical bone wall peak (IP-FC) were recorded. RESULTS: Among the 102 implants, the mean (SD) global platform deviation, global apex deviation, and global angular deviation were 0.53 (0.19) mm, 0.58 (0.17) mm, and 1.83 (0.82)°, respectively. The deviation differences between the mandible and maxilla did not show statistical significance (p > .05). No statistically significant differences were found for the jaws, implant positions, patient sequences, implant systems, and implant length to the deviations (p > .05). The periodontal parameters, the BBT, and IP-FC remained stable during 1-year follow-up. CONCLUSION: The ADIR system showed excellent positional accuracy. The 1-year follow-up after full-arch implant surgery indicated that the ADIR system could achieve promising clinical performance. Additional clinical evidence is requisite to furnish guidelines for the implementation of the ADIR system in full-arch implant surgery.

A comparison of accuracy among different approaches of static-guided implant placement in patients treated with mandibular reconstruction: A retrospective study.

OBJECTIVE: This study aimed to evaluate the differences in the accuracy of immediate intraoral, immediate extraoral, and delayed dental implant placement with surgical guides (static computer-aided implant surgery) in patients treated with mandibular reconstruction. METHODS: This was a retrospective study. The patients were divided into three groups: immediate intraoral placement (IIO), immediate extraoral placement (IEO), and delayed placement (DEL). Four variables were used to compare the planned and actual implant positions: angular deviation, three-dimensional (3D) deviation at the entry point of the implant, 3D deviation at the apical point of the implant, and depth deviation. RESULTS: The angular deviation was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .05) groups. The 3D deviation at the entry point was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .01) groups. The 3D deviation at the apical point was significantly higher in the IIO group than in the IEO (p < .01) and DEL (p < .01) groups. The depth deviation was significantly higher in the IIO group than in the IEO (p < .05) and DEL (p < .05) groups. There was no statistical difference between the IEO and DEL group in angular and 3D deviation. CONCLUSION: With surgical guides, among the different approaches for implant placement, delayed implant placement remains the most accurate approach for patients treated with mandibular reconstruction.

Accuracy and patient-centered results of marker-based and marker-free registrations for dynamic computer-assisted implant surgery: A randomized controlled trial.

OBJECTIVES: To compare implant placement accuracy and patient-centered results between the dynamic computer-assisted implant surgeries (d-CAISs) using marker-based and marker-free registration methods. MATERIALS AND METHODS: A double-armed, single-blinded randomized controlled trial was conducted, in which 34 patients requiring single implant placement at the esthetic zone were randomly assigned to the marker-based (n = 17) or marker-free (n = 17) groups. The marker-based registration was performed using a splint containing radiopaque markers, while the marker-free registration used natural teeth. The primary outcome assessed implant positioning accuracy via angular and linear deviations between preoperative and postoperative implant positions in CBCT. Patients were also surveyed about the intraoperative experience and oral health impact profile (OHIP). RESULTS: The global linear deviations at the implant platform (0.82 ± 0.28 and 0.85 ± 0.41 mm) and apex (1.28 ± 0.34 and 0.85 (IQR: 0.64-1.50) mm) for the marker-based and marker-free groups respectively showed no significant difference. However, the angular deviation of the marker-free group (2.77 ± 0.92 ° ) was significantly lower than the marker-based group (4.28 ± 1.58 ° ). There was no significant difference in the mean postoperative OHIP scores between the two groups (p = .758), with scores of 2.74 ± 1.21 for marker-based and 2.93 ± 2.18 for marker-free groups, indicating mild oral health-related impairment in both. Notably, patients in the marker-free group showed significantly higher satisfaction (p = .031) with the treatment procedures. CONCLUSIONS: D-CAIS with a marker-free registration method for single implantation in the anterior maxilla has advantages in improving implant placement accuracy and patients' satisfaction, without generating a significant increase in clinical time and expenses.

Accuracy of manual and artificial intelligence-based superimposition of cone-beam computed tomography with digital scan data, utilizing an implant planning software: A randomized clinical study.

OBJECTIVES: To investigate the accuracy of conventional and automatic artificial intelligence (AI)-based registration of cone-beam computed tomography (CBCT) with intraoral scans and to evaluate the impact of user's experience, restoration artifact, number of missing teeth, and free-ended edentulous area. MATERIALS AND METHODS: Three initial registrations were performed for each of the 150 randomly selected patients, in an implant planning software: one from an experienced user, one from an inexperienced operator, and one from a randomly selected post-graduate student of implant dentistry. Six more registrations were performed for each dataset by the experienced clinician: implementing a manual or an automatic refinement, selecting 3 small or 3 large in-diameter surface areas and using multiple small or multiple large in-diameter surface areas. Finally, an automatic AI-driven registration was performed, using the AI tools that were integrated into the utilized implant planning software. The accuracy between each type of registration was measured using linear measurements between anatomical landmarks in metrology software. RESULTS: Fully automatic-based AI registration was not significantly different from the conventional methods tested for patients without restorations. In the presence of multiple restoration artifacts, user's experience was important for an accurate registration. Registrations' accuracy was affected by the number of free-ended edentulous areas, but not by the absolute number of missing teeth (p < .0083). CONCLUSIONS: In the absence of imaging artifacts, automated AI-based registration of CBCT data and model scan data can be as accurate as conventional superimposition methods. The number and size of selected superimposition areas should be individually chosen depending on each clinical situation.

Digital planning and bone regenerative technologies: A narrative review.

OBJECTIVES: The aim of this narrative review was to explore the application of digital technologies (DT) for the simplification and improvement of bone augmentation procedures in advanced implant dentistry. MATERIAL AND METHODS: A search on electronic databases was performed to identify systematic reviews, meta-analyses, randomized and non-randomized controlled trials, prospective/retrospective case series, and case reports related to the application of DT in advanced implant dentistry. RESULTS: Seventy-nine articles were included. Potential fields of application of DT are the following: 1) the use of intra-oral scanners for the definition of soft tissue profile and the residual dentition; 2) the use of dental lab CAD (computer-aided design) software to create a digital wax-up replicating the ideal ridge and tooth morphology; 3) the matching of STL (Standard Triangulation Language) files with DICOM (DIgital COmmunication in Medicine) files from CBCTs with a dedicated software; 4) the production of stereolithographic 3D models reproducing the jaws and the bone defects; 5) the creation of surgical templates to guide implant placement and augmentation procedures; 6) the production of customized meshes for bone regeneration; and 7) the use of static or dynamic computer-aided implant placement. CONCLUSIONS: Results from this narrative review seem to demonstrate that the use of a partially or fully digital workflow can be successfully used also in advanced implant dentistry. However, the number of studies (in particular RCTs) focused on the use of a fully digital workflow in advanced implant dentistry is still limited and more studies are needed to properly evaluate the potentials of DT.

Entirely robotic cochlear implant surgery.

INTRODUCTION: Robot-assisted cochlear implant surgery (RACIS) as defined by the HEARO®-procedure performs minimal invasive cochlear implant (CI) surgery by directly drilling a keyhole trajectory towards the inner ear. Hitherto, an entirely robotic automation including electrode insertion has not been described yet. The feasability of using a newly developed, dedicated motorised device for automated electrode insertion in the first clinical case of entirely robotic cochlear implant surgery was investigated. AIM: The aim is to report the first experience of entirely robotic cochlear implantation surgery. INTERVENTION: RACIS with a straight flexible lateral wall electrode. PRIMARY OUTCOME MEASUREMENTS: Electrode cochlear insertion depth. SECONDARY OUTCOME MEASUREMENTS: The audiological outcome in terms of mean hearing thresholds. CONCLUSION: Here, we report on a cochlear implant robot that performs the most complex surgical steps to place a cochlear implant array successfully in the inner ear and render similar audiological results as in conventional surgery. Robots can execute tasks beyond human dexterity and will probably pave the way to standardize residual hearing preservation and broadening the indication for electric-acoustic stimulation in the same ear with hybrid implants.

Evaluation of insertion quality of a slim perimodiolar electrode array.

OBJECTIVES: The influence of cochlear morphology and electrode array design on scalar position and dislocation rates is of great interest in CI surgery. The aim of this study is to evaluate scalar position and specific points of dislocation in relation to cochlear morphology in patients implanted with a new slim perimodiolar electrode array. MATERIALS AND METHODS: Patients were implanted using the slim modiolar electrode array (= SMA) (= 532/632 electrode array of Cochlear™). Postoperative imaging was performed via cone beam computed tomography (CBCT) and the scans were analyzed regarding cochlear morphology (distances A and B and cochlear height), scalar location of the electrode array, basal insertion depth and apical insertion angle. Furthermore, electrode array design and surgical protocols were evaluated. RESULTS: 81 ears implanted with the SMA were retrospectively included. We evaluated 3 electrode array tip fold over intraoperatively via X-ray imaging and performed revision during the same surgery. The CBCT scans showed 76 initial scala tympani (ST) insertions without dislocation. Two ears showed a dislocated array, one at 77° and the other at 163°. Three arrays were inserted into scala vestibuli (SV) via cochleostomy. These patients showed no signs of obliteration. Cochlear morphology showed no influence on angular insertion depth and scalar position. CONCLUSIONS: The SMA showed a very low rate of scalar dislocations due to its slim electrode array design (2.7%). We could find a learning curve regarding the handling and the risk of dislocation and tip fold over with this electrode array. The rate of intraoperative tip fold over detection via X-ray imaging was 3.7%. Therefore, we highly recommend X-ray imaging and transimpedance matrix measurements within the surgery protocol. Scala vestibuli insertions happened in patients with cochleostomy only. We could identify two specific points of dislocation depending on electrode array design.

Noise exposure of the inner ear during robotic drilling.

INTRODUCTION: Preserving the cochlear structures and thus hearing preservation, has become a prominent topic of discussion in cochlear implant (CI) surgery. Various approaches and soft surgical techniques have been described when approaching the inner ear. Robot-assisted cochlear implant surgery (RACIS) reaches the round window in a minimally invasive manner by following a trajectory of minimal trauma. This involves the drilling of a keyhole trajectory to the round window, through the facial recess, with no need for a complete mastoidectomy. It involves less drilling, less drilling time and less structural damage. A lot of attention has been paid to the structural traumatic causes of hearing loss but acoustic trauma during the exposure of the inner ear appears to be neglected topic. AIM: The aim was to measure the noise exposure of the inner ear during the robotic drilling of the mastoid and bony overhang of the round window. The results were compared with the milling in conventional cochlear implantation surgery. INTERVENTION: RACIS on fresh frozen human cadavers. OUTCOME MEASUREMENTS: The equivalent frequency-weighted and time-averaged sound pressure level LAF in dB and the noise dose in % derived from a noise damage model, both obtained during RACIS. MATERIALS AND METHODS: The robotic drilling of 6 trajectories towards the inner ear were performed, including 4 trajectories through round window access and 2 trajectories through cochleostomy. The results were compared with the data of 7 cases of conventional CI surgery that have been described in literature. The induced equivalent sound pressure level LAF was determined via an accelleration sensor at the zygomatic arch and a calibration according to bone conduction audiometry. A noise dose for the whole procedure was calculated from the equivalent sound pressure level LAF and the exposure time using a noise damage model. A noise dose of 100% is considered a critical exposure limit and values above are considered potentially harmful, with the risk of hearing impairment. RESULTS: The maximum LAF was 82 dB during fiducial screw placement; 87 dB during middle ear access; 95 dB for the accesses through the round window and 88 dB for the accesses through cochleostomy. The noise dose due to the HEARO®-procedure was always far below the critical value of 100%. There was no acoustic trauma of the inner ear in all cases with the noise dose being smaller than 0.1% in five out of the six cases. The maximum LAF in the seven cases of conventional CI surgery was 118 dB with a maximum cumulative noise dose of 172.6%. The critical exposure limit of 100% was exceeded in three cases of conventional CI surgery. CONCLUSION: RACIS provokes significantly less acoustic trauma than conventional mastoid surgery in our findings. There were no observable differences in noise exposure levels between a cochleostomy or a round window approach where the bony overhang needed to be drilled.

Influence of dental implant clinical experience on the accuracy of robot-assisted immediate implant placement: an in vitro study.

OBJECTIVES: To assess the accuracy and effectiveness among operators with different levels of experience in a robot-assisted immediate implant surgery. MATERIALS AND METHODS: The study included four participants who had received dental training at the same institution but have varying levels of clinical experience in implant dentistry, denoted as undergraduate student (UG), dental resident (DR), specialist with no robot experience (IS) and specialist with robot experience (RS). Following comprehensive theoretical training in robot-assisted implant operation, each operator participated in five robotic-assisted implant procedures at 21 sites, resulting in the implant surgery of a total of 20 implants. Subsequently, the accuracy of the implants was assessed by analyzing the preoperative planning and the postoperative CBCT scans, and the time required for each procedure was also recorded. RESULTS: Angular deviation in UG, DR, IS and RS group was 0.82 ± 0.27°, 0.55 ± 0.27°, 0.83 ± 0.27°, and 0.56 ± 0.36°, respectively. The total deviation of the implant platform point was 0.28 ± 0.10 mm, 0.26 ± 0.16 mm, 0.34 ± 0.08 mm and 0.31 ± 0.06 mm, respectively. The total deviation of the apical point was 0.30 ± 0.08 mm, 0.25 ± 0.18 mm, 0.31 ± 0.09 mm, and 0.31 ± 0.05 mm, respectively. The time spent was 10.37 ± 0.57 min, 10.56 ± 1.77 min, 9.93 ± 0.78 min, and 11.76 ± 0.78 min for each operator. As the number of operations increased, the operation time decreased, but there was no significant difference in implant accuracy between the different groups. CONCLUSIONS: Within the scope of this study, robot-assisted implant surgery demonstrated high accuracy, with no significant differences in performance between operators with varying levels of clinical experience or implant robot-user experience. Furthermore, the learning curve for robotic implant surgery is steep and consistent. CLINICAL RELEVANCE: Robot-assisted implant surgery demonstrates consistent high accuracy across operators of varying clinical and robotic experience levels, highlighting its potential to standardize procedures and enhance predictability in clinical outcomes.

Recommendations for successful virtual patient-assisted esthetic implant rehabilitation: A guide for optimal function and clinical efficiency.

OBJECTIVE: Complete arch implant rehabilitation necessitates meticulous treatment planning and high-level collaboration between surgical and prosthetic dental teams. Emerging virtual technologies hold considerable promise in streamlining this process. The aim of this article is to extend recommendations to clinicians venturing into the virtual patient-assisted esthetic implant rehabilitation workflow. OVERVIEW: This article summarizes recommendations for virtual patient-assisted esthetic implant rehabilitation in the following five aspects: three-dimensional data handling and superimposition, occlusion and virtual articulator integration in creating virtual patients, streamlined face- and prosthetic-driven surgical planning, reuse of presurgical data ("Copy & Paste"), and final impression for passive fitting of final restoration. To illustrate these principles, a case with complete-mouth implant rehabilitation completed within six visits using this virtual patient workflow is presented. CONCLUSION: The virtual patient workflow serves as an invaluable tool to perform treatment planning, enhance efficiency, and ensure predictable outcomes in esthetic complete arch implant rehabilitation. CLINICAL SIGNIFICANCE: Virtual workflows are increasingly prevalent in esthetic implant rehabilitation. Nevertheless, these workflows necessitate a distinct set of knowledge and tools divergent from conventional dentistry practices. This article offers guidelines and recommendations for dental clinicians who are new to this field.

Considerations for predictable outcomes in static computer- aided implant surgery in the esthetic zone.

OBJECTIVE: To provide technical and clinical recommendations for implementing a digital workflow in Static Computer-Aided Implant Surgery in the anterior maxilla. CLINICAL CONSIDERATIONS: An optimal 3D implant position is crucial for achieving satisfying results in implant rehabilitation in the esthetic area. Due to its complexity, implant placement in the esthetic zone should be executed with precision and predictability. Static Computer-Aided Implant Surgery requires thorough planning and detailed attention to every step of the digital workflow protocol. CONCLUSIONS: Implant positioning in the esthetic zone using Static Computer-Aided Implant Surgery is a technique-sensitive procedure that requires precise execution of each step. This approach ensures accurate prosthetically driven 3D implant placement and prevents potential errors that could lead to inaccurate positioning. CLINICAL SIGNIFICANCE: The proper implementation of Static Computer-Aided Implant Surgery may increase the level of agreement between the planned and definitive implant 3D positions in the esthetic zone, thus enhancing the esthetic outcomes of implant rehabilitation.

Comparing the accuracies of freehand, static computer-assisted and robot-assisted dental implant placements: an in vitro study.

OBJECTIVE: To compare the accuracies among three oral implant surgical techniques: freehand (FH), static computer-assisted implant surgery (sCAIS), and robotic computer-assisted implant surgery (rCAIS). METHODS: The polyurethane and bovine femur implant models were fabricated, and 126 and 96 implant sites were designed on them. The implant sites were divided into three groups: FH, sCAIS, and rCAIS, according to the implantation method. The deviation between the actual implant position and the planned position was analyzed and compared by cone beam computed tomography. RESULTS: In the polyurethane model test, the entry deviation, entry-level deviation, apical deviation, apical level deviation, and angle deviation in sCAIS and rCAIS groups were significantly reduced compared with those in the FH group (P<0.05). No significant differences were observed in all kinds of deviations between the sCAIS and rCAIS groups (P>0.05). In the bovine femur model test, the entry deviation, entry-level deviation, apical deviation, apical level deviation, and angle deviation in both sCAIS and rCAIS groups were significantly reduced compared with those in the FH group (P<0.05). No significant differences were observed in all kinds of deviations between the sCAIS and rCAIS groups (P>0.05). CONCLUSION: This in vitro study shows that the rCAIS technique is superior to the freehand, but has the same accuracy as the sCAIS.

Depth distortion and angular deviation of a fully guided tooth-supported static surgical guide in a partially edentulous patient: A systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to evaluate the depth distortion and angular deviation of fully-guided tooth-supported static surgical guides (FTSG) in partially edentulous arches compared to partially guided surgical guides or freehand. MATERIAL AND METHODS: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in the Open Science Framework (OSF). The formulated population, intervention, comparison, and outcome (PICO) question was: "In partially edentulous arches, what are the depth distortion and angular deviation of FTSG compared to partially guided surgical guides or freehand?" The search strategy involved four main electronic databases, and an additional manual search was completed in November 2023 by following an established search strategy. Initial inclusion was based on titles and abstracts, followed by a detailed review of selected studies, and clinical studies that evaluated the angular deviations or depth distortion in FTSG in partial arches, compared to partially guided surgical guides or freehand, were included. In FTSG, two surgical approaches were compared: open flap and flapless techniques, and two digital methods were assessed for surgical guide design with fiducial markers or dental surfaces. A qualitative analysis for clinical studies was used to assess the risk of bias. The certainty of the evidence was assessed according to the grading of recommendations, assessment, development, and evaluations (GRADE) system. In addition, a single-arm meta-analysis of proportion was performed to evaluate the angular deviation of freehand and FTSG. RESULTS: Ten studies, published between 2018 and 2023, met the eligibility criteria. Among them, 10 studies reported angular deviations ranging from -0.32° to 4.96° for FTSG. Regarding FTSG surgical approaches, seven studies examined the open flap technique for FTSG, reporting mean angular deviations ranging from 2.03° to 4.23°, and four studies evaluated flapless FTSG, reporting angular deviations ranging from -0.32° to 3.38°. Six studies assessed the freehand surgical approach, reporting angular deviations ranging from 1.40° to 7.36°. The mean depth distortion ranged between 0.19 mm to 2.05 mm for open flap FTSG, and between 0.15 mm to 0.45 mm for flapless FTSG. For partially guided surgical guides, two studies reported angular deviations ranging from 0.59° to 3.44°. Seven studies were eligible for meta-analysis, focusing on the FTSG in open flap technique, with high heterogeneity (I2 (95%CI) = 92.3% (88.7%-96.4%)). In contrast, heterogeneity was low in studies comparing freehand versus FTSG in open flap techniques (I2 (95%CI) = 21.3% (0.0%-67.8%)), favoring the FTSG surgical approach. CONCLUSION: In partially edentulous arches, FTSG systems exhibited less angular deviation than freehand and partially guided surgical guides. Flapless surgical approaches were associated with reduced angular deviation and depth distortion, suggesting a potential preference for the FTSG method in these procedures.

Evaluation of Post-Operative Morbidity and Palatal Wound Healing after Implant Uncovering Surgical Procedure Performed with Apically Positioned Flap (APF) and Leukocyte and Platelet-Rich-Fibrin (L-PRF): An Original Technique.

Background and Objectives: Dental implants are recognized as an effective treatment in the management of edentulous patients; controversies surround the connection between the sufficiency of keratinized gingiva (KG) and peri-implant health. Maintaining an ample amount of peri-implant KG is crucial for minimizing gingival inflammation, highlighting the need for regular consideration of soft-tissue augmentation. Among the diverse periodontal plastic surgical procedures, the apically positioned flap (APF) is notable for its ability to enhance the width of keratinized tissue while minimizing patient morbidity. The aim of this study was to evaluate the effects of L-PRF on palatal wound healing and patient discomfort after surgery. Materials and Methods: Twenty patients with two adjacent submerged fixtures in the maxilla and buccal keratinized gingiva widths < 2 mm were treated with APF and L-PRF. Clinical evaluations were performed at 1, 2, 3, and 4 weeks post-surgery, focusing on parameters such as complete wound epithelialization (CWE), postoperative discomfort (D), changes in feeding habits (CFH), alteration of sensitivity (AS) around the wound area, and the consumption of analgesics. Results: Our data revealed CWE in 5 patients by the end of the second week, with the remaining 15 achieving CWE by the end of the third week. For D and CHF, a statistically significant improvement was recorded for all cases between the first and second weeks, as well as AS, although less substantial, by the third week. No significant changes were noted for AS over the initial two weeks. Conclusions: These findings suggest that L-PRF may enhance wound healing and decrease patient discomfort following APF for fixture uncovering.