Abstract
Background/purpose
Augmented reality has been gradually applied in dental implant surgery. However, whether the dynamic navigation system integrated with augmented reality technology will further improve the accuracy is still unknown. The purpose of this study is to investigate the accuracy of dental implant placement using dynamic navigation and augmented reality-based dynamic navigation systems.
Materials and methods
Thirty-two cone-beam CT (CBCT) scans from clinical patients were collected and used to generate 64 phantoms that were allocated to the augmented reality-based dynamic navigation (ARDN) group or the conventional dynamic navigation (DN) group. The primary outcomes were global coronal, apical and angular deviations, and they were measured after image fusion. A linear mixed model with a random intercept was used. A P value < 0.05 was considered to indicate statistical significance.
Results
A total of 242 dental implants were placed in two groups. The global coronal, apical and angular deviations of the ARDN and DN groups were 1.31 ± 0.67 mm vs. 1.18 ± 0.59 mm, 1.36 ± 0.67 mm vs. 1.39 ± 0.55 mm, and 3.72 ± 2.13° vs. 3.1 ± 1.56°, respectively. No significant differences were found with regard to coronal and apical deviations (P = 0.16 and 0.6, respectively), but the DN group had a significantly lower angular deviation than the ARDN group (P = 0.02).
Conclusion
The augmented reality-based dynamic navigation system yielded a similar accuracy to the conventional dynamic navigation system for dental implant placement in coronal and apical points, but the augmented reality-based dynamic navigation system yielded a higher angular deviation.
Keywords: Surgery, Computer-assisted, Augmented reality, Dental implants
Introduction
Because proper three-dimensional (3D) positioning of dental implants ensures promising prosthetic and aesthetic outcomes, the accurate reproduction of the planned virtual implant in a real surgical environment is essential.1 To guarantee the accuracy of reproduction, computer-assisted implant surgery (CAIS) has been introduced,2 which can provide more accurate dental implant placement than free-hand surgery.3, 4, 5 CAIS can be classified into static and dynamic systems according to guiding principles. Static CAIS (sCAIS) has been widely applied in clinical practice and uses a prefabricated surgical guide to restrict the position and direction of drills according to preoperative plans. According to a recent systematic review, sCAIS yielded a high accuracy with entry, exit and angle deviations of 1.03 mm, 1.33 mm and 2.68°, respectively.6 However, the accuracy of sCAIS may decrease when patients have limited mouth opening or poorly supported tissues.7,8 The static guide cannot offer constant visualization and obtain real-time feedback on the relationship between drills and planned paths.9 Therefore, dynamic navigation is introduced in dental implant surgery to overcome these limitations.
A dynamic navigation system can track the movements of the patient and surgical instruments.10 Therefore, surgeons can perform edentulous site preparation and implant placement according to the real-time displayed relative position of patients and surgical instruments. According to a systematic review and meta-analysis, the entry, exit and angle deviations of dynamic CAIS (dCAIS) were 0.91 mm, 1.04 mm and 3.7°, respectively.11 However, because computer screens and real surgical fields are usually separated, surgeons have to shift the view between them, which may lead to surgeons missing important cues in either the surgical field or dynamic navigation system, thereby increasing the risk of postoperative adverse effects. Moreover, frequent view shifts may interrupt the continuity of the surgery and cause surgeon fatigue, thus prolonging the surgical time and compromising the accuracy of dental implants.12
Augmented reality (AR) is a technology that can immerse virtual digital images in the real world through a head-mounted device (HMD) or an integral videography (IV) overlay device.13,14 With the help of AR technology, dental implant planning paths, 3D reconstructed models, computer screens and calibrated surgical instruments can be merged with the real environment.15 Therefore, the integration of AR enables surgeons to pay attention to real-time information obtained from dynamic navigation and from actual surgical sites simultaneously, improving the continuity and flexibility of dCAIS. Pellegrino et al. and Yotpibulwong et al. applied an HMD to directly project the computer interface of a dynamic navigation system in a real environment around the patient.16,17 Ochandiano et al. developed a smartphone-based AR navigation system that displays bone structures and planned dental implants.18 Ma et al. and Jiang et al. used an IV overlay device to superimpose the inferior alveolar nerve and planned dental implant paths in mandible phantoms.14,19 Lin et al. combined a surgical template and AR to guide osteotomy with a virtual auxiliary line and drill stop.20 The core concept is to overlay a virtual presurgical plan over the actual surgical site and enable real-time guidance, with or without integrating auxiliary guiding information such as a drill direction line, indication crosshairs, an alarm system based on color change, and real-time lateral and angle deviations between the handpiece and planned paths.12,13,19, 20, 21 Liu et al. reported a mixed reality (MR)-based navigation method in dental implant surgery.12 However, the core technology in the study can still be ascribed to non-in situ AR according to previous reviews.22,23 The accuracy of AR-based navigation in dental implant surgery has been verified, with global entry, exit and angle deviations of 0.89 mm, 1.47 mm and 3.96°, respectively.9 The comparison accuracy of AR-based dynamic navigation, static guide and free-hand was conducted by Kivovics et al., and AR-based dynamic navigation yielded a comparable accuracy with static guides.13 However, to the best of our knowledge, few studies have focused on comparing the accuracy between AR-based dynamic navigation and dynamic navigation systems.
The aim of the in vitro study was to compare the accuracy of dental implant placement using AR-based dynamic navigation and conventional dynamic navigation systems. The null hypothesis was that there is no significant difference with regard to the accuracy of dental implant placement using the two navigation systems.
Materials and methods
Study design
This in vitro study was approved by the ethics committee (SH9H-2023-T82-1). The sample size was calculated based on two previous studies using G∗power 3.1 software, where α was 0.05 and the power was set at 95%.13,24 The minimal sample size was 28 dental implants in each group. Four types of jaws were chosen: edentulous maxilla, edentulous mandible, partially edentulous maxilla and partially edentulous mandible. To mimic real clinical conditions, the phantoms were reconstructed and printed from cone-beam computed tomography (CBCT) images of real patients. For each type, eight patients were included. Patients who required mass guided bone regeneration (GBR) surgery or zygomatic implant surgery were excluded. Each collected CBCT was used to generate two identical phantoms, and the phantoms were allocated to the AR-based dynamic navigation group (ARDN) and conventional dynamic navigation group (DN).
Phantom preparation and planning
The phantoms were reconstructed and manufactured by stereolithography using Somos® EvoLVe 128 resin (Covestro AG, Leverkusen, Germany). To ensure registration accuracy, eight mini-screws (φ1.7 mm × 10 mm) (Jianwei, Shenzhen, China) were inserted into both partially edentulous and edentulous phantoms as fiducial markers according to a previous study.25,26 For 3D dental implant planning, a preoperative CBCT scan (Planmeca Oy, Helsinki, Finland) for each phantom was taken with the following parameters: 96 kV; 7.1 mA; voxel size of 0.4 mm. Dental implants were planned in an in-house Dental-Helper software (Shanghai, China) according to the residual alveolar bone.7 For the edentulous maxilla, implants were planned at the incisor, canine, first premolar and first molar on both sides, while in the edentulous mandible, six dental implants were assigned at the lateral incisor, second premolar and first molar on the left and right sides. For phantoms with insufficient residual alveolar volume in the posterior region, two axial implants were planned at the lateral incisor combined with two tilted implants at the premolar region on both sides. Dental implants were placed in edentulous sites in partially edentulous jaws. To simulate normal mouth opening, the phantoms were then mounted on a platform that was fixed on a table by a bench vice (Fig. 1a and b).
Figure 1.
Overview of the hardware components and experimental setup. (a) and (c) The dynamic navigation system group. (b) and (d) The AR-based dynamic navigation system group.
AR-based dynamic navigation protocol
A reference frame with three reflective spheres was fixed on the residual alveolar bone. The CBCT scans and corresponding surgical plans were imported into MR-SNS software (Shanghai, China), and the reconstructed virtual phantom and planning paths were imported into HoloLens 2 (Microsoft Corp., Redmond, WA, USA). The infrared camera was set properly to track the phantom, handpiece and HoloLens 2 (Microsoft Corp.) simultaneously. The registration of the phantom and calibration of the drill were performed according to a previous study.7 The registration of HoloLens 2 (Microsoft Corp.) was conducted using a registration cube that loads 4 reflective spheres.27 The surgeon should wear HoloLens 2 and hold the registration cube to match four vertices of the cube to the corresponding vertices of the virtual cube displayed in HoloLens 2 (Fig. 2). To reduce random error and improve registration accuracy, four groups of vertices in four different positions, a total of 16 vertices, were used for registration. Then, the virtual phantom and planning paths were superimposed on the real phantom. Due to the simultaneous localization and mapping (SLAM) technology integrated into HoloLens 2 (Microsoft Corp.), the virtual phantom and planning paths can remain in place when the head of the surgeon moves or turns.28 Therefore, surgeons can check the accuracy of superimposition from multiple perspectives. The virtual phantom was used to check the accuracy of superimposition; if satisfactory, the surgeon could conceal the virtual phantom by touching the “Model” button in the air, and the planning paths were then left. Then, the surgeon conducted the osteotomy procedure by adjusting the position between the drill and virtual dental implant path (Fig. 1d). The sequencing drilling procedure was adopted according to the manufacturer's protocols, and a dental implant (φ4.1 mm × 10 mm) (Institut Straumann AG, Basel, Switzerland) was finally placed under the guidance of an AR-based navigation system.
Figure 2.
The registration procedure of HoloLens 2. (a) The diagram of registration. (b) Overview and HoloLens 2 perspective of the registration procedure.
Dynamic navigation protocol
After CBCT data and planning paths were imported into BeiDou-SNS software (Shanghai, China), registration and drill calibration were conducted. Then, implant bed preparation and implant placement were performed under the guidance of the dynamic navigation system (Fig. 1c). To reduce participant bias, all phantom experiments were performed by one surgeon (B.T) who is familiar with dCAIS and has placed hundreds of dental implants in phantoms under guidance of the dynamic navigation system.7
Accuracy evaluation
Postoperative CBCT (Planmeca Oy) was performed with the same parameters as the preoperative CBCT. The pre- and postoperative CBCT images and corresponding planning were imported into Brainlab CMF 3.0.6 (BrainLAB AG, Munich, Germany) software. After image fusion, the global coronal, global apical and angular deviations were calculated by obtaining the coordinates at the center of the coronal and apical planes (Fig. 3). All deviations were measured and calculated by an investigator (Y.S) who was blinded to the group assignment of the phantoms.
Figure 3.
Illustration of deviations between planned and actual implants.
Statistical analysis
Statistical analysis was performed using SAS 9.4 software (SAS Institute Inc., Cary, NC, USA). The normal distribution of data was evaluated by the Shapiro–Wilk test. Descriptive statistical parameters, including the mean, standard deviation, 25th-75th percentile, and minimum–maximum value, were reported. A linear mixed model with a random intercept was used to evaluate the comparative accuracy of the ARDN and DN groups and to analyze potential influencing factors, including tooth position and phantom type (edentulous and partially edentulous). P<.05 was considered to indicate a significant difference.
Results
Sixty-four phantoms were used for dental implant placement, and a total of 242 dental implants were placed. The surgical sites of the dental implants are shown in Table 1. The global coronal, global apical and angular deviations with regard to groups, phantom type and jaws are summarized in Table 2 and Table 3. The three deviations of the ARDN group were 1.31 ± 0.67 mm, 1.36 ± 0.67 mm and 3.72 ± 2.13°, respectively, while those of the DN group were 1.18 ± 0.59 mm, 1.39 ± 0.55 mm and 3.1 ± 1.56°, respectively. Due to the lack of independence of implants, a linear mixed model was applied where the group, phantom type (edentulous and partially edentulous) and tooth position (the universal teeth numbering system was adopted here) were treated as fixed effects, and the intercept was set as the random effect. Because the original deviations were not normally distributed, square root normal transformation was used. The covariance structure was chosen as the unstructured structure (UN). There was no significant difference regarding the global coronal and apical deviations (P = 0.16 and 0.6, respectively), while a significant difference was found in angular deviation (P = 0.02) (Fig. 4). The phantom type and tooth position had no significant effect on the global coronal deviation (P = 0.25 and 0.61, respectively), global apical deviation (P = 0.37 and 0.06, respectively) and angular deviation (P = 0.81 and 0.54, respectively).
Table 1.
Surgical sites for dental implant placement.
| Partially edentulous |
Edentulous |
||||||
|---|---|---|---|---|---|---|---|
| Site | Number | Site | Number | Site | Number | Site | Number |
| 11 | 2 | 32 | 1 | 11 | 2 | 32 | 8 |
| 12 | 2 | 34 | 1 | 12 | 6 | 34 | 8 |
| 14 | 2 | 35 | 2 | 13 | 2 | 36 | 7 |
| 15 | 2 | 36 | 1 | 14 | 8 | 42 | 8 |
| 16 | 3 | 37 | 4 | 16 | 3 | 44 | 8 |
| 17 | 1 | 42 | 1 | 21 | 2 | 46 | 7 |
| 21 | 2 | 44 | 1 | 22 | 6 | ||
| 22 | 2 | 45 | 1 | 23 | 2 | ||
| 24 | 1 | 46 | 2 | 24 | 8 | ||
| 25 | 1 | 47 | 1 | 26 | 3 | ||
Table 2.
Deviations of dental implants in ARDN (AR-based dynamic navigation) and DN (Dynamic navigation) groups.
| Group | Mean (±SD) | Median | P25–P75 | Min-Max | P value | |
|---|---|---|---|---|---|---|
| Global coronal deviation (mm) | ARDN | 1.31 ± 0.67 | 1.23 | 0.84–1.68 | 0.2–4.17 | 0.16 |
| DN | 1.18 ± 0.59 | 1.2 | 0.68–1.6 | 0.14–2.86 | ||
| Global apical deviation (mm) | ARDN | 1.36 ± 0.67 | 1.23 | 0.86–1.76 | 0.12–4.11 | 0.6 |
| DN | 1.39 ± 0.55 | 1.43 | 1.1–1.76 | 0.28–2.91 | ||
| Angular deviation (◦) | ARDN | 3.72 ± 2.13 | 3.53 | 2.44–4.36 | 0.37–12.79 | 0.02∗ |
| DN | 3.1 ± 1.56 | 2.99 | 1.92–4.07 | 0.52–7.9 |
∗P < 0.05; SD, standard deviation; P25, lower quartile; P75, upper quartile; Min, minimum value; Max, Maximum value.
Table 3.
Deviations regarding the maxilla and mandible of the ARDN (AR-based dynamic navigation) and DN (Dynamic navigation) groups.
| ARDN group |
DN group |
||||||
|---|---|---|---|---|---|---|---|
| Global coronal deviation (mm) | Global apical deviation (mm) | Angular deviation (°) | Global coronal deviation (mm) | Global apical deviation (mm) | Angular deviation (°) | ||
| Edentulous | Maxilla | 1.25 ± 0.56 | 1.23 ± 0.6 | 3.98 ± 1.94 | 1.29 ± 0.65 | 1.49 ± 0.61 | 3 ± 1.38 |
| Mandible | 1.43 ± 0.72 | 1.52 ± 0.74 | 3.26 ± 1.61 | 1.15 ± 0.6 | 1.32 ± 0.49 | 3.16 ± 1.66 | |
| Partially edentulous | Maxilla | 1.2 ± 0.73 | 1.3 ± 0.59 | 4.41 ± 3.46 | 1.05 ± 0.47 | 1.38 ± 0.55 | 3.11 ± 1.92 |
| Mandible | 1.25 ± 0.7 | 1.29 ± 0.69 | 3.6 ± 1.88 | 1.09 ± 0.55 | 1.35 ± 0.59 | 3.21 ± 1.36 | |
Figure 4.
Comparison of the deviations between ARDN (AR-based dynamic navigation) and DN (Dynamic navigation) groups.
Discussion
The present study demonstrated that AR-based dynamic navigation yields a comparable accuracy to the conventional dynamic navigation system regarding coronal and apical deviations, but a significantly higher angular deviation was detected in the AR-based dynamic navigation group.
In the present study, an AR-based dynamic navigation system was developed and achieved high accuracy with global coronal, apical and angular deviations of 1.31 ± 0.67 mm, 1.36 ± 0.67 mm and 3.72 ± 2.13°, respectively, which were similar to previous studies.9,13,19 For the comparison of AR-based and conventional dynamic navigation methods, AR-based navigation had a smaller lateral deviation at coronal, depth and angle deviations but a higher global coronal deviation compared with dynamic navigation.9 However, there are only two studies included in this systematic review, and the referred dynamic navigation modalities are not the same as normal dynamic navigation, which provides axial, sagittal and coronal perspectives. The guidance of the drill to the target was realized by matching two crosshairs in one study,21 and the other used a monitor to display the 3D relationship between the drill and path instead of offering coronal, sagittal and axial interfaces.19 Therefore, to the best of our knowledge, the current study is the first to compare AR-based dynamic navigation and dynamic navigation approaches. A significant difference was found with regard to angular deviation of dental implants placed by the ARDN and DN groups. The potential explanations were as follows. First, surgeons have to shift perspectives to review and confirm the angle between the drill and planned path because the 3D relationship between the drills and virtual implants is not easy to observe from one perspective, and the angular deviation is hard to detect without axial observation, especially in the maxilla. The maximum angular deviation (12.79°) was found at the right first molar in the maxilla. However, a dynamic navigation system can provide three separated interfaces, which enables surgeons to visualize three directions at the same time. This result is consistent with a previous study showing that the angular deviation of the AR-based dynamic CAIS was slightly higher than that of static CAIS.13 In addition, the virtual implants, which are the same size as real objects, are projected onto phantoms. Therefore, small deviations may not be found by surgeons in time. However, dynamic navigation systems can enlarge virtual implants and drills on computer screens, so any deviations can be detected easily. To further improve its accuracy with regards to the angle, a combination of static guide and AR-based dynamic navigation approach could be a choice, where the angular deviation in the mandible phantom was 2.7 ± 1.55° and that was 3.33 ± 1.42° in the maxilla.20 Moreover, a display of navigation system screens or real-time deviations in the perspective of HoloLens 2 may be another choice.12,16,17
The limitation of the present study is that no auxiliary information for guidance was added to the AR system, so the surgeon had to perceive deviations based on the surgical and manipulation experience. Moreover, the result should be restricted to the modality of the AR-based navigation used in the current study. The comparative accuracy of other AR modalities should be further investigated. The time and investment needed for setup and training may slow its speed in clinical application. Then, the bulky headset may evoke a feeling of refusal, especially for surgeons who have an illness of the cervical spine. An adjustable AR headset is a potential solution. Finally, the results of the current in vitro study with a small sample size should be carefully extended to a real clinical environment, and its feasibility, accuracy and reliability must be further evaluated in clinical studies.
In summary, this in vitro study demonstrated that the AR-based dynamic navigation approach had a comparable accuracy to the conventional dynamic navigation system in global coronal and apical deviation but had a higher angular deviation. This AR-based navigation system provides in situ AR navigation and facilitates precise and convenient dental implant navigation surgery. However, the angle of implant site preparation and implant placement should be reconfirmed when the AR-based dynamic navigation system is implemented in dental implant surgery.
Declaration of competing interest
The authors have no conflicts of interest relevant to this article.
Acknowledgments
This work was supported by the grants/awards of Clinical Research Plan of SHDC (SHDC2020CR3049B), Medical Engineering Cross Research Fund of “Jiao Tong University Star” Program of Shanghai Jiao Tong University (YG2021QN72), CAMS Innovation Fund for Medical Sciences (CIFMS) (2019-I2M-5-037), Research Discipline fund from Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine (KQYJXK2020); Huangpu District Industrial Support Fund (XK2020014).
Contributor Information
Xiaojun Chen, Email: xiaojunchen@sjtu.edu.cn.
Yihan Shen, Email: 1413313536@qq.com.
Yiqun Wu, Email: yiqunwu@hotmail.com.
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