Dynamic navigation systems in dento-alveolar surgery: advancements and clinical applications

Abstract

Dynamic navigation system (DNS) is an emerging technique providing more accuracy and precise positioning during dental surgical procedures. Studies have shown the application of DNS across several areas of dentistry, including implant surgery, oral and maxillofacial surgery, endodontics, and the treatment of supernumerary teeth. The use of DNS has demonstrated improved accuracy, reduced trauma, and safer approach. Key elements of DNS include a computer, tracking system specialized tracing tools and navigation software. The process of DNS operation begins with obtaining data and reconstructing imaging information. Next calibration of surgical instruments and spatial registration is carried out. The last phase involves executing time guided procedures using the navigation system. DNS applications have seen enhancements, in representation, precision in treatment, efficiency, safety measures and adaptability during procedures. While these advancements offer benefits the adoption of DNS comes with challenges such as high expenses the necessity for thorough training, extended preparation time and heightened exposure to radiation. Despite these hurdles continuous progress, continued advancements in DNS technology are expected to further broaden its applications in dentoalveolar surgery and greatly enhance the field of digital dentistry. Therefore, the application of DNS will be reviewed in dentoalveolar surgery.

Introduction

The use of Dynamic Navigation Systems (DNS) tracked back to framed stereotaxy in 1800 s and it expanded to dentistry in 1995. These telemanipulated medical robots are controlled remotely by image-guided systems and force-feedback by surgeons. Different parts of a DNS are including a position tracking system, and a visual user interface with software for surgical planning and guidance. Also, this system is likened to a GPS or satellite navigation technology. During uncomplicated DNS procedures the surgeon virtually plans the appropriate drill position utilizing preoperative cone-beam computed tomography (CBCT) data submitted to the planning application, firstly. After that, a stereo tracker takes the 3D spatial data from sensors coupled to the handpiece and the patient's teeth. This system uses the CBCT images of the planned surgical site and motion-tracking optical cameras to provide real-time 3D dynamic navigation with visual feedback, allowing the surgeon to control the surgical tool intraoperatively.

DNS is a novel technique derived from the implant dentistry as minimal invasive, more precise surgical procedures, and better localization of adjacent structures compared with traditional surgical methods (Martinho et al. 2023; Tang et al. 2023). Studies showed the utilizing of DNS in implant surgery illustrated higher accuracy compared with the freehand (FH) approach (Cassetta and Bellardini 2017; Wang et al. 2023; Yimarj et al. 2020; Yotpibulwong et al. 2023). Oral and maxillofacial surgery including tooth extraction, repair of maxillofacial fractures, treatment of maxillofacial tumors, removing foreign bodies (FBs), orthognathic surgery, temporomandibular joint ankylosis surgery have intricated and challenging surgical procedures because of complicated network of nerves and blood vessels. Studies showed the application of DNS reduced the trauma in bone by providing accurate localization, faster and safer procedures (Wang et al. 2017; Retana et al. 2019; Zong et al. 2021; Soh et al. 2022; Tzelnick et al. 2023; Azarmehr et al. 2017; Miyazaki et al. 2021; Neuhaus et al. 2021a; Berger et al. 2018; Chen et al. 2021).

The application of DNS in the endodontics tracked back 2019 when primary researches have published and showed DNS increased the precise of endodontics procedures with more safety and accuracy compared to other approach (Chong et al. 2019; Gambarini et al. 2019; Janabi et al. 2021; Tang and Jiang 2023; Wu et al. 2022). So, this review was conducted to systematically evaluate and summarize the advancements and clinical applications of Dynamic Navigation Systems (DNS) in dentoalveolar surgery.

Materials and methods

Search strategy

A literature search was conducted across six databases: PubMed, Scopus, Web of Science, ScienceDirect, SID, and Google Scholar. The search included studies published from January 2000 to January 2025. The following Boolean-based search string was adapted and applied to each database using appropriate syntax:

("dynamic navigation system" OR "DNS") AND ("dentoalveolar surgery" OR "oral surgery" OR "dental implant" OR "tooth extraction" OR "endodontics" OR "digital dentistry")

Where applicable, Medical Subject Headings (MeSH) terms and filters were used to refine the results. The search was limited to English-language articles.

Eligibility criteria

Inclusion criteria:

• English-language articles published in peer-reviewed journals

• Original research studies (randomized controlled trials, prospective and retrospective studies, observational studies, case series, and case reports)

• Systematic reviews and meta-analyses discussing DNS in dental or maxillofacial procedures

• Studies reporting clinical application, accuracy, advantages, limitations, or future integration of DNS

Exclusion criteria:

• Non-English articles

• Abstract-only papers, letters to the editor, opinion pieces, and conference proceedings without full text

• Studies unrelated to DNS or those only covering static navigation

Study selection process

All search results were exported to EndNote for reference management. Duplicates were removed. Two independent reviewers screened the titles and abstracts for relevance. Full-text articles were retrieved for studies meeting the inclusion criteria or when eligibility was unclear. Any disagreements were resolved through discussion or consultation with a third reviewer to minimize selection bias.

Data extraction

From each included study, the following data were extracted using a standardized form:

• Study design and year of publication

• Sample size and population characteristics

• Surgical intervention type and DNS application

• Outcome measures (e.g., angular deviation, apical deviation, surgical time, success rate)

• Key results and statistical significance

• Duration of follow-up (if applicable)

Data extraction was performed independently by two reviewers and cross-verified for accuracy. Discrepancies were discussed and resolved through consensus.

Result

Application of dynamic navigation system in dental implantology

In a study, Chen et al. (Chen et al. 2023a) investigated the accuracy of two novel robotic methods (THETA) and dynamic dynamics in implant surgery (Yizhimei). The study included 10 partially edentulous jaw models, with each containing 2 implant sites, and were randomly allocated to the robotic group or the DNS group. Preoperative planning was completed with CBCT imaging, and postoperative accuracy was assessed using the planned and actual implant positions for platform, apex, and angular deviations. The robotic system consisted of mechanical arms, with visual tracking and forced feedback, which enabled it to be automatically guided. The DNS system involved uncontrolled surgeon hand movement and ability to conduct the surgery with real-time tracking. The authors found no statistically significant difference for both the platform (robotic = 0.58 ± 0.31 mm; DNS = 0.73 ± 0.20 mm) and apical (robotic = 0.69 ± 0.28 mm; DNS = 0.86 ± 0.33 mm) deviations, but the robotic group had less angular deviation (1.08 ± 0.66°) compared to the DNS group (2.32 ± 0.71°; p < 0.001). The authors concluded that both systems demonstrated similar precision found to be clinically acceptable, but the robotic system was superior for angular control, had significantly less operator movement variability and recommended using the robotic system in more complex implant cases.

Emery et al. (Emery et al. 2016) determined the accuracy of implants obtained from DNS and a virtual computer plan in their study. This study used four dental models: dentate upper jaw, edentulous upper jaw, dentate lower jaw, and edentulous lower jaw. The accuracy of the placed implant was evaluated by measuring the mean and standard deviation of the angle deviation, entry deviation, and apex deviation parameters in the DNS method with the virtual plan. The highest accuracy in the angle was related to the dentate maxillary model (dentate maxillary: 0.78 ± 0.24, dentate mandibular: 1.00 ± 0.40, edentulous mandibular: 1.25 ± 0.65, and edentulous maxillary: 1.26 ± 0.67). The entry (dentate mandibular: 0.35 ± 0.16, dentate maxillary: 0.38 ± 0.25, edentulous mandibular: 0.49 ± 0.16, and edentulous maxillary: 0.58 ± 0.18) and apex (mandibular: 0.31 ± 0.16, dentate maxillary: 0.44 ± 0.23, dentate edentulous mandibular: 0.48 ± 0.13, and edentulous maxillary: 0.63 ± 0.17) deviation were lower in the dentate mandibular model, suggesting higher accuracy of this model compared to others.

In another study by Pellegrino et al. (Pellegrino et al. 2020), implant placement accuracy and surgical time were measured between experienced and novice surgeons. This study randomly assigned 16 dental models, including 112 dental sites, to 4 surgeons with different backgrounds: 1) more than 2000 implant surgeries and familiar with DNS, 2) more than 2000 implant surgeries but unfamiliar with DNS, 3) less than < 50 implants surgeries and familiar with DNS, 4) no prior experience with implants surgeries and unfamiliar to DNS. The accuracy of the surgeries was measured by comparing the angular, apical, and coronal deviation between the implant implanted by each surgeon and the programmed model. Regarding 3D apical (1: 1.44 ± 0.95, 2: 1.47 ± 0.68, 3: 1.59 ± 0.74, and 4: 1.92 ± 0.51) and coronal deviation (1: 1.55 ± 1.08, 2: 1.68 ± 0.69, 1.35 ± 0.67, and 4: 1.74 ± 0.64), no significant difference was observed between 4 surgeons (P > 0.05). However, regarding apical bucco-lingual deviation, surgeon 4 performed significantly weaker than the others (4: 1.26 ± 0.64 vs. 1: 0.73 ± 0.49, 0.53 ± 0.43, 0.58 ± 0.44, P < 0.05). Also, surgeon 4 had more angular deviation than surgeons 1 and 2 (4:5.90 ± 2.38 vs. 1: 2.93 ± 1.50, and 2: 3.54 ± 2.33 with P < 0.001 and P = 0.002, respectively). Regarding drilling time, surgeon number 1 performed considerably better than surgeons’ number 3 and 4 (1: 43.35 ± 14.75 vs. 3: 62.47 ± 16.97, 4: 58.32 ± 24.05 with P = 0.002 and P = 0.014, respectively).

In their study, Zhan et al. (Zhan et al. 2021) investigated the effect of teaching the DNS technique to dental students compared to the traditional method. Six senior dental students without previous experience in implant placement were randomly divided into two groups of DNS and traditional training, then the results were compared with each other. The DNS group had significantly less apex (1.62 ± 0.43 vs. 2.27 ± 0.40. P < 0.001) and axis (2.89 ± 1.47 vs. 4.34 ± 2.17, P < 0.05) deviation than the traditional group. However, the difference between the platform deviation between the two groups was not substantial (P > 0.05). In general, students under DNS training performed better. So, in addition to the therapeutic application of the DNS technique, its educational application should not be ignored.

In a prospective cohort study by Block et al. (Block et al. 2017), they compared three methods: full-guided DNS, partial-guided DNS, and traditional method. In this study, four surgeons performed 714 implants for 478 patients. The angle deviation for full-guided DNS, partial-guided DNS, and traditional method was 2.97 ± 2.09, 3.43 ± 2.33, and 6.50 ± 4.21, respectively. In addition, platform (full-guided DNS: 1.16 ± 0.59, partial-guided DNS: 1.31 ± 0.68, traditional method: 1.78 ± 0.77) and apical (full-guided DNS: 1.29 ± 0.65, partial-guided DNS: 1.52 ± 0.78, traditional method: 2.27 ± 1.02) deviation were less in full-guided DNS than in partial-guided DNS and traditional method. These results show a significantly better performance of full-guided DNS compared to the other two methods and partial DNS compared to the traditional one (P < 0.05).

An in vivo study to determine implant placement accuracy through DNS was conducted by Stefanelli et al. (Stefanelli et al. 2019). In this study, a total of 231 implants were performed for 89 people by a single surgeon. The average deviation of the angle, entry point, and apex were equal to 2.26 ± 1.62, 0.71 ± 0.40, and 1.00 ± 0.49, respectively. As the study progressed, the accuracy of the implant placement also increased. As a result, the average deviation of the angle, entry, and apex for the last 50 implants was significantly less than first 50 implants and was equal to 1.98 vs. 3.48, 0.59 vs. 0.94, and 0.85 vs. 1.19 (P < 0.01). This shows the effect of the surgeon's skill in reducing deviation and increasing the accuracy of implant placement.

In a study by Guzman et al. (Mediavilla Guzmán et al. 2019), the implant placement accuracy by two dynamic and static navigation methods was compared. In general, 40 implants were placed (20 implants in each group), and the amount of coronal, apical, and angular deviation was calculated for each group. The static group showed significantly less angular deviation than the dynamic group (2.95 ± 1.48 vs. 4.00 ± 1.41, P = 0.02). Similarly, the coronal deviation was lower in the static group than in the dynamic group (0.78 ± 0.43 vs. 0.85 ± 0.48, P = 0.65), although this difference was insignificant. However, the apical deviation in the static group was higher than the dynamic (1.20 ± 0.48 vs. 1.18 ± 0.60, P = 0.90).

Wu et al. (Wu et al. 2023 (compared the accuracy of two active and passive DNS methods in their study. They placed 80 implants in the right or left mandibular missing molar. The deviation angle between the two groups had a significant difference, which included 1.38 ± 1.09 and 1.73 ± 0.82 for active and passive DNS, respectively. Meanwhile, the entry (0.78 ± 0.28 vs. 0.66 ± 0.23) and apex (0.84 ± 0.30 vs. 0.76 ± 0.26) deviations did not differ statistically.

In a retrospective study, Ma et al. (Ma et al. 2023) evaluated the effect of different factors on the accuracy of DNS in the 55 implants placement. The comparison of apex, tip, and angle deviation before and after the operation was used to check the accuracy. The deviation of the tip of the implant was 1.83 ± 1.03, which significantly affected the position of the jaw, the position of the teeth, and the lateral position (P < 0.05). In contrast, the diameter and length of the implant did not affect it. Also, angle and apex deviation were equal to 3.80 ± 2.09 and 1.60 ± 0.94, respectively, which were not influenced by various factors. However, the 27 final implants had significantly less angle deviation than the 28 initial implants.

In another case report study by Dotia et al. (Dotia et al. 2024), a 27-year-old woman was included with a 6 mm alveolar ridge height that required placement of an implant in the mandible. Due to the short alveolar height, the patient needed a direct sinus floor elevation. The path of the implant and lateral window was planned using Navident software. The patient was re-examined one week after surgery to evaluate accuracy. The lateral window showed two-dimensional entry, three-dimensional entry, apex, and angle deviations of 2.83mm, 2.52mm, 0.29mm, and 8.93 degree, respectively. In contrast, the implant that was placed exhibited two-dimensional entry, three-dimensional entry, and apex deviations of 0.03mm, 0.82mm, and 0.83mm, respectively, with no angular deviation observed.

The accuracy of three DNS calibration methods was compared in Pei et al.'s (Pei et al. 2024) study. They used 11 standard mandibular models with 33 tooth locations, including 11 left first molars, 11 left second molars, and 11 s premolars. they randomly employed one of the three calibration methods: U-shaped tube, dental cusp, and bone marker. There was no significant angular deviation between the three methods (U-shaped tube:1.36 ± 0.54, dental cusp: 2.95 ± 2.07, and bone marker: 2.92 ± 2.45, P = 0.92). However, the deviation of the platform (U-shaped tube: 0.78 ± 0.34, dental cusp: 1.86 ± 0.91, and bone marker:1.44 ± 0.57, P < 0.01) and apex (U-shaped tube: 0.79 ± 0.35, dental cusp: 2.19 ± 1.01, and bone marker: 1.49 ± 0.50, P < 0.01) was significantly different. As a result of this study, the U-shaped tube method was more accurate than the bone marker and the dental cusp. Table 1 shows, summary of application of DNS in dental Implantology.

Table 1.

Summary of application of dynamic navigation system in dental Implantology

Study	Aim	Method	Advancement	Application	Result
Chen et al. (Chen et al. 2023a)	Compare accuracy of robotic vs. DNS in implant surgery	• In vitro • 10 models • 20 implants • randomized groups	Robotic arm with visual tracking and force feedback	Dental implant placement	• Robotic group had significantly lower angular deviation (1.08° vs. 2.32°, p < 0.001) • no difference in apex/platform
Emery et al. (Emery et al. 2016)	Evaluate accuracy of DNS in different jaw models	• In vitro • 4 jaw models • deviation analysis	Jaw type-specific analysis of DNS precision	Implant placement in various anatomic sites	• Dentate mandible had lowest deviation • Angle: 1.00° • Entry: 0.35mm • Apex: 0.31mm
Pellegrino et al. (Pellegrino et al. 2020)	Compare DNS accuracy based on surgeon experience	• 16 models • 4 surgeons with varying experience	DNS accuracy varies with training and experience	Dental implant training and placement	• Experienced users had better angular accuracy and faster drilling time (p < 0.05)
Zhan et al. (Zhan et al. 2021)	Assess educational effect of DNS training	• Randomized controlled trial with 6 students	DNS as training aid for implantology	Dental education	• DNS group had lower apex and axis deviation (p < 0.001, p < 0.05)
Block et al. (Block et al. 2017)	Compare full/partial DNS with traditional technique	• Prospective cohort • 714 implants • 478 patients	Large-scale clinical comparison of guidance techniques	Implant surgery	• Full-guided DNS most accurate (angle: 2.97° vs 6.5°) • Reduced platform/apex deviation
Stefanelli et al. (Stefanelli et al. 2019)	Evaluate accuracy improvement over time	• 231 implants by one surgeon	Shows learning curve effect in DNS	Implantology	• Accuracy improved significantly in last 50 cases vs. first 50 (p < 0.01)
Guzman et al. (Mediavilla Guzmán et al. 2019)	Compare static vs. dynamic navigation	• 40 implants • Two groups	Static better angular accuracy	Dental implant placement	• Static group had lower angular deviation (2.95° vs. 4.00°, p = 0.02)
Wu et al. (Wu et al. 2023)	Compare active vs. passive DNS accuracy	• 80 implants in molar sites	Active DNS slightly more accurate	Implant surgery	• Active DNS had lower angular deviation (1.38° vs. 1.73°, p < 0.05)
Ma et al. (Ma et al. 2023)	Assess factors affecting DNS accuracy	• Retrospective • 55 implants analyzed	Correlation between jaw/position and deviation	Dental implants	• Jaw position affects tip deviation • Accuracy improved over time
Dotia et al. (Dotia et al. 2024)	Evaluate DNS-guided implant placement with simultaneous sinus elevation	• Case report of a 27-year-old woman requiring implant with 6 mm alveolar ridge height	Use of Navident for precise planning of implant path and sinus window	Implant placement with sinus floor elevation	• Implant showed minimal deviation (2D: 0.03 mm; 3D: 0.82 mm; apex: 0.83 mm; no angular deviation) • Lateral window deviation was higher (angle: 8.93°, apex: 0.29 mm)
Pei et al. (Pei et al. 2024)	Compare DNS calibration methods	• In vitro • 33 sites • 3 calibration protocols	U-shaped frame more accurate calibration	Implant planning	• U-shape tube had least deviation (p < 0.01)

Figure 1 shows impacted maxillary supernumerary teeth and immediate implantation at the same time.

Fig. 1.

a) preoperative planning phase using CBCT (Cone Beam Computed Tomography) scans and software for dental implant placement (including 3D reconstruction of the jaw, virtual implant positioning, and panoramic radiographs). b) Positioning parallel bone fenestrations, gradually expand the bone window after drilling. c) Supernumerary teeth sticking out, to erect the supernumerary teeth on the palatal side using dental thrusters. d) Implant placement under navigation guidance. e) Planting preparation Navigation guides downward planting preparation. f) Bone grafting. g) Cover barrier film. h) Closely suture the wound after tension reduction. i) Immediate evaluation by postoperative CBCT scans of the final position of the implants in different views (axial, coronal, sagittal)

Application of dynamic navigation system in complex teeth extraction

In Pellegrino et al.'s (Pellegrino et al. 2021) study, 3 mandibular third molar surgery cases were treated with the DNS technique. This study used a flapless approach, which minimizes the need for bone harvesting. These patients were followed up one month after surgery. The patients reported no swelling, pain, or complications during this period. Also, there was no need to prescribe any medication to control the pain.

According to Wang et al.'s (Wang et al. 2021) study, the use of navigation helps to accurately determine the location of impacted supernumerary teeth and reduce surgical bone damage. In this study, 32 supernumerary impacted teeth in 24 people were studied. Access to the supernumerary tooth at the initial planned point was more in the navigation group than in the control group (100% vs. 68.75%, P = 0.015). Also, futile length (0.0 [0.0, 4.0] mm vs. 3.0 [0.0, 8.0] mm, P = 0.028) and width (0.0 [0.0, 2.0] mm vs. 2.0 [0.0, 4.0] mm, P = 0.018) in challenging cases (bone thickness > 0.5 mm) in the navigation group were significantly lower than in control. This indicates that the navigation method is more efficient than the traditional method.

In a study conducted by Xu et al. (Xu et al. 2024), the effectiveness of the DNS technique in extracting the impacted mandibular third molar tooth was evaluated compared to the traditional method. A total of 160 patients aged 18 to 37 who had impacted mandibular third molars were included in this study. Patients were randomly divided into two groups, DNS and control. The surgery time in the DNS group was significantly shorter than in the control group (22 ± 3 vs. 36 ± 3, P = 0.005). However, the DNS technique needed 15 ± 2 min before starting surgery; 11 ± 1 min for preoperative design time and 4 ± 1 for navigation installation time. Moreover, patients in the DNS group did not report any complications. While in the control group, 3 cases of damage to adjacent teeth and 4 cases of lower lip discomfort due to damage to the lower alveolar nerve were reported. Table 2 shows summary of application of DNS in complex teeth extraction.

Table 2.

Summary of application of dynamic navigation system in tooth extraction

Study	Aim		Method	Advancement	Application	Result
Pellegrino et al. (Pellegrino et al. 2021)		Assess DNS in third molar flapless surgery	• 3 mandibular molar cases • DNS guided • Flapless	Minimally invasive DNS-guided extractions	Third molar extraction	• No post-op pain • Swelling or complications • No medication needed
Wang et al. (Wang et al. 2021)	Evaluate DNS for supernumerary tooth location		• 32 teeth in 24 patients • Control vs. DNS	Reduced surgical trauma and futile bone cutting	Supernumerary extraction	• Improved accuracy • Less bone removal in DNS group (P < 0.05)
Xu et al. (Xu et al. 2024)	Compare DNS and traditional for impacted molars		• RCT • 160 patients • 18–37 yrs • 2 groups	Faster, safer DNS-guided extraction	Impacted molar removal	• Surgery time reduced (22 vs 36 min) • DNS had no complications

Figure 2 shows a complex tooth extraction with DNS to ensures minimally invasive procedures by accurately navigating around the nerves.

Fig. 2.

a) Real-time navigation. b-f) Procedure of extraction with the usage of DNS

Application of dynamic navigation system in cyst removal

In a case report by Hong et al. (Hong and Kim 2019), they operated a cystic lesion in the left mandibular ramus and coronoid process suspected to be an odontogenic keratocyst using the DNS technique. In this study, navigation was performed under CT guidance. The DNS method led to easier access to the cyst. After the cyst removal, the remaining structures were curetted. No complications or recurrence were reported up to 24 months after surgery. Table 3 shows summary of application of DNS in cyst removal.

Table 3.

Summary of application of dynamic navigation system in cyst removal

Study	Aim	Method	Advancement	Application	Result
Hong et al. (Hong and Kim 2019)	Remove cyst with DNS guidance	• Case report • DNS with CT imaging	Improved lesion access with DNS	Cystic lesion removal	• Successful access • No recurrence up to 24 months

Figure 3 shows an odontoma removal using DNS.

Fig. 3.

a) Combined odontoma of the right mandible. Determination the safety boundary of adjacent teeth to avoid iatrogenic root damage of adjacent teeth. b) Step-by-step surgical procedures with the help of the real-time Dynamic Navigation System result in smaller incisions, less postoperative pain, and quicker recovery times for patients

Application of dynamic navigation system in supernumerary teeth treatment

Supernumerary teeth (ST), extra teeth, are a common dental condition, and patients suffering encounter several complications, including gaps between teeth (diastema), tooth eruption, root resorption, incorrectly positioned teeth or rotated teeth, poor bite alignment (malocclusion), and fistulas or cysts formation (dentigerous cysts). The need for orthodontic treatment, pathological conditions, and abnormal eruption of the dentition are reasons for removing supernumerary teeth. Despite the suggestion of surgical extraction as the primary recommended treatment for ST, the inconsistent ST extraction methods are challenging and dangerous to localize and extract ST (Retana et al. 2019; Liu et al. 2022) accurately. Therefore, DNS could provide advantages in diagnosing, localizing, and planning surgical interventions to extract ST (Retana et al. 2019; Liu et al. 2022).

Guo et al. successfully applied DNS to extract mandibular third molars (Guo et al. 2016). Emery et al. conducted a retrospective study of in-office extraction of complex mandibular third molars using a dynamic image navigation system (DINS). Despite the limitations, they showed that using DINS to improve visualization and localization of anatomical structures, enhance surgical control, and decrease morbidity was a helpful instrument during complex mandibular third molar surgery in an office setting (Emery et al. 2017). In a case report by Wang et al., the importance of a navigation-guided system for accurate tooth location and minimal invasion was highlighted (Wang et al. 2017). In a case report, Retana et al.'s (Retana et al. 2019) case report study used DNS to treat maxillary left and right third molars, supernumerary maxillary second premolar, and supernumerary maxillary central incisor teeth. This case was complicated due to the proximity of the supernumerary maxillary second premolar and the supernumerary maxillary central incisor tooth to the maxillary sinus and the nasal cavity. A dynamic image navigation was programmed to guide the surgeon on the entry angle, osteotomy depth, and safe access location. The surgical procedures were performed according to the plan. In the surgery, no mouth-to-sinus or nasal cavity fistula was created. Also, the patient did not mention any fever or discomfort until one week after the surgery. Table 4 shows summary of application of DNS in extracting a supernumerary tooth.

Table 4.

Summary of application of dynamic navigation systems in extracting a supernumerary tooth

Study	Aim	Method	Advancement	Application	Result
Guo et al. (Guo et al. 2016)	DNS-guided third molar removal	• Case report • DNS navigation used	DNS improves control and visualization	Supernumerary extraction	• Effective visualization, minimized morbidity
Retana et al. (Retana et al. 2019)	Evaluate DNS in complex ST cases	• Case report • Sinus/nasal proximity	Guided osteotomy planning and entry path	Supernumerary teeth near critical anatomy	• No fistula, fever, or discomfort post-surgery
Wang et al. (Wang et al. 2017)	Demonstrate DNS for minimal invasion	• Case report with guided access plan	Precise positioning with minimal trauma	Complex ST extraction	• DNS enabled accurate and safe procedure

The application of dynamic navigation systems in extracting a supernumerary tooth is collectively illustrated in Fig. 4.

Fig. 4.

a) DNS application, indicating the precise location and orientation of the buried supernumerary tooth in the right maxilla. b, c) Crown bone removal of supernumerary tooth; intraoperative dynamic navigation operation showcasing real-time feedback on the position of the surgical instruments. d-f) step-by-step process of the tooth extraction, from the initial incision to the removal of the tooth, placing the CGF and suturing of the surgical site

Application of dynamic navigation system in auto-transplantation

Auto-transplantation is an approach to replacement missing teeth. long-term success rate of this technique is dependent on the recipient site condition (alveolar bone volume and local inflammation), surgery technique (intraoperative medications and technique used for stabilization), lack of surgical trauma, and stage of root formation, and healthy periodontal tissue (Algubeal et al. 2022; Boschini et al. 2024). In other hand, as shown by Chang et al., the application of medical image-processing software and real-time navigation technology could help to accurately preparation the recipient site for the auto-transplantation of teeth. Their findings illustrated good clinical outcomes over the short-term duration (Chang et al. 2024). Table 5 shows summary of application of DNS in Auto-transplantation and a step-by-step Auto-transplantation is shown in Fig. 5.

Table 5.

Summary of application of dynamic navigation system in Auto-transplantation

Study	Aim	Method	Advancement	Application	Result
Chang et al. (Chang et al. 2024)	Use DNS in site preparation for auto-transplant	Image software + real-time navigation	Accurate recipient site prep	Tooth auto-transplantation	Good clinical outcomes in short-term

Fig. 5.

a) Auto-transplantation. Based on the root length and width of 38 teeth, design the length and width of 36 tooth preparations. b) The extraction of the decayed tooth, and then removing the debris and irrigating the site accurately, and in the next step, preparation the site for transplanting the new tooth 38 according to its morphology were shown. c) The site was cleaned and was ready to receive the wisdom tooth. Then, the site was checked according to the morphology of the wisdom tooth and make sure if it fits or not. d) Tooth 38 has been extracted Successfully. e) Placing the CGF. the tooth was transplanted, and the site was sutured. f) The occlusion (occlusal bite) was checked. g) Radiographic picture was taken from patient after operation and after one month

Application of dynamic navigation system in treatment of temporomandibular joint

A vital part of orofacial system is temporomandibular joint (TMJ) and participates in all movements of the lower jaw with an amazing range of motion in all three dimensions. Temporomandibular disorders or TMDs are a large group of disorders which affect TMJ and surrounding structures and associated with pain, limited ability to open the mouth, sounds in the joint, and headaches (Knezevic et al. 2023). Treatment approaches include physical therapy, medications (Wright and North 2009), alloplastic replacement (total joint replacement, TJR) (Neuhaus et al. 2021b), and injections, such as sodium hyaluronate (Sequeira et al. 2019; Bertolami et al. 1993), but precise injection delivery is challenging and DNS could use to localize the exact site of injection.

A kind of TMD is TMJ ankylosis (TMJa) and characterized by immobilized join due to a bony fibro osseous mass fused to the skull base. Trauma, infections or certain systemic diseases such as spondylitis, rheumatoid arthritis or psoriasis could cause of TMJa. This condition could lead to jaw and facial deformities, during growth stages (Miyazaki et al. 2021). DNS was utilized to TMJa treatment for the first time in 2002 (Schmelzeisen et al. 2002). He et al., during gap arthroplasty to treat TMJa, maintaining a safety distance of at least 3 mm from the middle cranial fossa and bony external auditory canal is vital to prevent injury and the use of DNS helped the surgeon to achieve more extensive removal of the ankylosed bone, particularly in the direction of the skull base, while still preserving the necessary safety distance (He et al. 2017). Neuhaus et al. showed similar outcomes (Neuhaus et al. 2021b). Miyazaki et al., reported a case control and illustrated the application of DNS was benefit to accurately target positioning and safe surgical procedures in a 7-year-old child (Miyazaki et al. 2021). Table 6 summarize application of DNS in treatment of TMJ.

Table 6.

Summary of application of dynamic navigation system in treatment of temporomandibular joint

Study	Aim	Method	Advancement	Application	Result
He et al. (He et al. 2017)	Use DNS during gap arthroplasty for TMJa	• Surgical navigation for safe bone removal	Safe margin preservation near skull base	TMJ ankylosis treatment	• Effective removal with safety margin
Miyazaki et al. (Miyazaki et al. 2021)	Assess DNS in pediatric TMJ case	• Case–control study • 7-year-old child	DNS enables safer targeting	Pediatric TMJ surgery	• Accurate surgical targeting, improved outcomes
Neuhaus et al. (Neuhaus et al. 2021b)	Evaluate DNS in TMJ ankylosis	• Case series or report	Precision and safety in TMJ surgery	TMJ ankylosis treatment	• Positive surgical results with DNS

An step-by-step TMJ surgery using DNS is shown in Fig. 6.

Fig. 6.

a) Restricted mouth opening (approximately 2 cm) accompanied by pain in front of the left ear for 1 week. b) CT Findings: Left TMJ: Visible bone resorption, irregular joint surface, asymmetrical condyle shape; Both Sides: Irregular morphology. MRI Findings, Right TMJ: Reduced condylar mobility; Both Sides: Irreversible anterior disc displacement, Left TMJ: Joint deformation, right side joint effusion. c) Treatment: Bilateral TMJ cavity lavage and injection of sodium hyaluronate

Discussion

DNS is an emerging technology in modern dentistry that can increase accuracy and safety and improve clinical results compared to traditional methods and static guidance (Tang et al. 2024). In this study, we intend to provide a comprehensive understanding of the current state of this method by reviewing the existing literature on the use of DNS, its clinical application, and its advantages and challenges.

Guidance systems in dentistry were initially static and were planned based on pre-operative imaging. However, these systems could not adapt to changes during surgery, which was one of the most significant limitations of these systems (Gargallo-Albiol et al. 2019). To compensate for this limitation, dynamic navigation systems were created to adapt to the conditions and guide the surgeon even during surgery by imaging and tracking in real-time. Cone beam computer imaging is often used in this technology. As a result, DNS can increase accuracy and safety in dental procedures by offering real-time guidance. (Jorba-García et al. 2019).

DNS has had a fantastic effect on oral and dental surgery and implant placement. It enables more precise implant placement by reducing the angular (Emery et al. 2016; Block et al. 2017; Wu et al. 2023), apical (Emery et al. 2016; Zhan et al. 2021; Block et al. 2017; Mediavilla Guzmán et al. 2019), and entry (Emery et al. 2016) deviation. For example, Younis et al. (Younis et al. 2024), reported that a fully guided DNS had an average angular error of 5.82° using freehand placement, as well as approximately 3.66° difference in DNS group. These improvements in accuracy will ultimately result in improved initial stability and integration of implants. (Younis et al. 2024). Furthermore, these factors lead to improved integration and excellent stability of implants. Also, this system reduces the damage caused to the patient by using less invasive methods. Consequently, patients experience less pain, discomfort, and post-operative complications. Moreover, patients recover faster than usual, as mentioned in the study by Pellegrino et al. (Pellegrino et al. 2021).

According to the study of Xu et al. (Xu et al. 2024), it was found that the DNS method resulted in significantly shorter surgical duration compared to the traditional method. Although this study did not consider the time required to prepare the program, the reduction in surgery duration could be crucial for the patient's comfort. As with all complex procedures, DNS clinical results depend on operator ability and experience. Inexperience will lead to greater variability, suggesting that the operator may still be in the learning phase. An in vitro study found that novice surgeons had a much larger angular deviation (± 3°) in DNS implant placement than experienced surgeons (± 2.5°) (Younis et al. 2024). Clinicians involved in the placement of dental implants using the dynamic navigation could benefit from ongoing DNS training and practice to fully leverage what the system has to offer and to ensure that they can be performed with as much accuracy as possible.

Also, the necessity for three-dimensional imaging such as CBCT for obtaining a DNS raises the challenge of delivering radiation to a person. While a dental CBCT is an important source of detailed anatomy for guidance with generally low doses of radiation, the effective dose can range from the equivalent of only a few to dozens of panoramic radiographs, depending on the device as well as the exposure settings (Jacobs et al. 2018). Therefore, we need to maintain radiation safety principles (ALARA: "As Low As Reasonably Achievable"), using the smallest field of view when the devices allows it and low-dose protocols, just as we would with any form of imaging. In practice, a single preoperative CBCT is generally sufficient for a DNS, and avoiding any extra or subsequent exposure to scanning or utilizing newer lower-dose CBCT will allow us to limit dose while also getting value from dynamic guidance (Jacobs et al. 2018).

While there are many benefits to DNS several limitations exist. These include high up-front costs for the hardware and software (Tang et al. 2024), a shortage of specialized training and/or calibration, the need for more time to prepare for preoperative planning (Ma et al. 2023), errors incurred while using DNS systems (most notably tracking or navigation errors during real time usage) (Pellegrino et al. 2020), risk of radiation injury to the patient from repeated imaging exposures when utilizing DNS, and outcomes were always subject to operator experience and technical capacity. Future directions of DNS with some newer technologies from industry may help to address some of these limitations. For example, artificial intelligence may support better preoperative planning and lower human error. Robotics may allow for surgical instruments to be controlled with greater precision and stability. New technologies—augmented reality (for intraoperative real time visualization), machine learning (for predictive analytics), and cloud-based platforms (for interprofessional collaboration)—may all positively impact the ways we can expand the clinical reach and improve access of DNS possibilities. These advancements are expected to improve clinical outcomes and drive the next generation of minimally invasive digital dentistry.

In conclusion, DNS demonstrate an important advancement in dentoalveolar surgery by facilitating increased accuracy and safety across a variety of clinical settings. For example, in guided implant placement, minimally invasive impacted tooth extractions, and minimally invasive endodontic procedures, DNS has improved the accuracy of surgical procedures and reduced the potential for harm to critical orthodontic structures. Benefits of DNS include improved positioning of implants with successful outcomes, shorter operative times than comparable conventional procedures, an ability to perform surgeries that are less invasive with a lesser degree of morbidity and patient pain (e.g., improved recovery time), an ability to adjust and adapt in real-time, amongst others; these advantages in combination, provided improved treatment outcomes and greater patient satisfaction. Despite this, there are limitations of the technology. Presently limitations—with respect to the cost of the equipment, the reality that there is a learning curve which requires specialized training, and the fact that DNS may require radiation-based imaging (CBCT)—have presented barriers to widespread adoption of the technology. As improvements in technology continue and improved training associated with DNS becomes more widely accepted, fundamentally these barriers will likely decrease over time. All in all, DNS has already made meaningful improvements to modern dental surgery and it is poised to become a key element of digital dentistry. No doubt dynamic navigation will continue to improve and expand clinical versatility and efficacy driving safer and more efficient surgical care far into the future.

Author contributions

Conceptualization: Sina Ahmadi, Sijia Na; Methodology: Sina Ahmadi, Xiang Liang, Sijia Na; Literature Search and Data Curation: Xiang Liang, Fangfang Xu, Linyang Xie; Writing - original draft preparation: Sina Ahmadi; Writing - review and editing: Xiang Liang, Fangfang Xu, Chunyan Wang, Ming Yu, Sijia Na; Resources: Linyang Xie; Supervision: Junbo Tu, Sijia Na.

Funding

This work was supported by the National Natural Science Foundation of China (Grant No. 81960194), the Natural Science Foundation of Shaanxi Province (Grant No. 2020JQ563), and the Fundamental Research Funds for the Central Universities, China (Grant No. xzy012020048).

Data availability

The datasets generated and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors have no conflicts of interest relevant to this article.

Clinical trial number

Not applicable.

Competing interest

The authors have no conflicts of interest relevant to this article.