Accuracy of Augmented Reality–Assisted Navigation in Dental Implant Surgery: Systematic Review and Meta-analysis

Palumbo A.

In the world reference context, although virtual reality, augmented reality and mixed reality have been emerging methodologies for several years, only today technological and scientific advances have made them suitable to revolutionize clinical care and medical contexts through the provision of enhanced functionalities and improved health services. This systematic review provides the state-of-the-art applications of the Microsoft® HoloLens 2 in a medical and healthcare context. Focusing on the potential that this technology has in providing digitally supported clinical care, also but not only in relation to the COVID-19 pandemic, studies that proved the applicability and feasibility of HoloLens 2 in a medical and healthcare scenario were considered. The review presents a thorough examination of the different studies conducted since 2019, focusing on HoloLens 2 medical sub-field applications, device functionalities provided to users, software/platform/framework used, as well as the study validation. The results provided in this paper could highlight the potential and limitations of the HoloLens 2-based innovative solutions and bring focus to emerging research topics, such as telemedicine, remote control and motor rehabilitation.

Kivovics M., Takács A., Pénzes D., Németh O., Mijiritsky E.

This in vitro study aimed to compare the accuracy of implant placement in model surgeries carried out by implementation of three different methods.An in vitro study was conducted on 3D printed study models randomly assigned to three study groups. In Group 1, model surgeries were assisted by augmented reality (AR)based dynamic navigation (Innooral System, Innoimplant Ltd, Budapest, Hungary). In Group 2, implants were placed with a free-hand method, and in Group 3, static Computer Assisted Implant Surgery (CAIS) was used (coDiagnostiX software, version 10.4 Dental Wings, Montreal, CA, USA). A total of 48 dental implants (Callus Pro, Callus Implant Solutions GmbH, Hamburg, Germany) were placed (16 implants in four models per study group). The primary outcome variables were angular deviation, coronal, and apical global deviation. These were calculated for all implants based on preoperative registration of the surgical plan and postoperative cone beam computed tomography (CBCT) reconstruction.The accuracy of implant placement using AR-based dynamic navigation showed no significant difference compared to static CAIS (angular deviation, 4.09 ± 2.79° and 3.21 ± 1.52°; coronal deviation, 1.27 ± 0.40 mm and 1.31 ± 0.42 mm; and apical global deviation 1.34 ± 0.41 mm and 1.38 ± 0.41 mm). Global deviation results were significantly lower with AR-based dynamic navigation than with the free-hand approach (coronal and apical global deviation of 1.93 ± 0.79 mm and 2.28 ± 0.74 mm, respectively).Implant positioning accuracy of AR-based dynamic navigation was comparable to that of static CAIS and superior to that obtained by the free-hand approach.Implementing Augmented Reality based dynamic Computer Assisted Implant Surgery (CAIS) in model surgeries may allow to obtain an implant positioning accuracy comparable to that provided by static CAIS, and superior to that obtained through the free-hand approach. Further clinical studies are necessary to determine the feasibility of AR-based dynamic navigation.

Chackartchi T., Romanos G.E., Parkanyi L., Schwarz F., Sculean A.

Clinical considerations and treatment criteria in implant placement are constantly evolving. Prosthetically driven implant surgery has become the standard of care to improve short and long-term functional and esthetic outcomes. Therefore, implant position and angulation are planned according to the available bone, anatomical structures, and the requirements of the future prosthetic superstructure. In parallel with these developments, significant progress has been made in data imaging and different software technologies to allow the integration of data within a digital file format. Digitalization in implant surgery enables optimal planning of implant position, as well as the ability to transfer this planning to the surgical field-a process defined as "computer-supported implant planning and guided surgery." The aims of the present review are as follows: (a) to critically appraise the indications and potential "added value" of guided implant surgery, elaborating the main differences between dynamic and static guidance; and (b) to discuss the most important clinical considerations relevant for the different steps of the workflow that might influence the surgical outcome and to offer recommendations on how to avoid or reduce process errors in order to optimize treatment outcomes.

Ramanauskaite A., Sader R.

Esthetic complications in implant dentistry have become a significant consideration for patients and practitioners. This review presents an appraisal on the current knowledge of the physiological peri-implant soft-tissue dimensions and factors that may compromise peri-implant tissue esthetics. Factors such as papilla fill adjacent to the implant and midfacial mucosal height are critical parameters that determine the esthetic success of implant-supported restorations. Papilla fill adjacent to a single dental implant appears to depend upon the clinical attachment level of the neighboring tooth. A horizontal inter-implant distance of at least 3 mm is necessary to ensure optimal interproximal mucosal embrasure between two adjacent implants in the anterior maxilla. In cases where implants cannot be placed at least 3 mm apart, a single implant with a cantilever bridge should be considered. Buccolingual implant positioning plays a major role in midfacial mucosal height. Soft-tissue volume grafting following immediate implant placement in the presence of a thin soft-tissue phenotype or simultaneous to surgical peri-implantitis therapy might help to overcome facial mucosa recession.

Schwarz F., Ramanauskaite A.

Healthy peri-implant tissues have become synonymous with implant success and a major challenge in contemporary implant dentistry. Numerous local and systemic factors, as well as iatrogenic and other hitherto underappreciated factors of potential clinical relevance may influence the outcome of implant therapy. In this volume of Periodontology 2000, a group of outstanding experts has elaborated on the latest insights on the prevention and management of major surgical, biological and technical complications, to facilitate the establishment and maintenance of peri-implant health. This volume focusses on factors affecting early and late implant loss and the potential role of systemic diseases and local conditions. It comprehensively discusses the implementation of guided implant surgery to facilitate the cleansibility of implant-supported restorations, as well as iatrogenic factors related to bone augmentation/sinus grafting procedures. The challenges associated with soft-tissue grafting and the prevention of esthetic complications are also reviewed as the paradigm of success in implant dentistry shifts from implant survival towards a greater focus on patient-reported outcomes. Prosthetic failures remain a significant challenge and are discussed in light of new evidence, as is the relevance of the structural dimensions of the peri-implant mucosa. The volume closes with detailed and well-illustrated appraisals of the surgical management of peri-implantitis, the management and sequelae of dental implant removal, and the latest evidence for the oral health related quality of life in patients treated with dental implants.

Kotsakis G.A., Romanos G.E.

Implant site preparation is a critical stage of implant surgery that may underpin various complications related to implant surgery. This review discusses the latest available scientific information on risk factors related to implant site preparation. The role of the drilling process in relation to the density of the available alveolar bone, the effects of insertion torque on peri-implant osseous healing, and implant-related variables such as macrodesign and implant-abutment connection are all factors that can influence implant success. Novel information that links osteotomy characteristics (including methods to improve implant initial stability, the impact of drilling speed, and increase of the implant insertion torque modifying the bone-implant interface) with the appropriate instrumentation techniques will be discussed, as well as interactions at the bone-biomaterial interface that may lead to biologic complications mediated by implant dissolution products.

Ochandiano S., García-Mato D., Gonzalez-Alvarez A., Moreta-Martinez R., Tousidonis M., Navarro-Cuellar C., Navarro-Cuellar I., Salmerón J.I., Pascau J.

Image-guided surgery, prosthetic-based virtual planning, 3D printing, and CAD/CAM technology are changing head and neck ablative and reconstructive surgical oncology. Due to quality-of-life improvement, dental implant rehabilitation could be considered in every patient treated with curative intent. Accurate implant placement is mandatory for prosthesis long-term stability and success in oncologic patients. We present a prospective study, with a novel workflow, comprising 11 patients reconstructed with free flaps and 56 osseointegrated implants placed in bone flaps or remnant jaws (iliac crest, fibula, radial forearm, anterolateral thigh). Starting from CT data and jaw plaster model scanning, virtual dental prosthesis was designed. Then prosthetically driven dental implacement was also virtually planned and transferred to the patient by means of intraoperative infrared optical navigation (first four patients), and a combination of conventional static teeth supported 3D-printed acrylic guide stent, intraoperative dynamic navigation, and augmented reality for final intraoperative verification (last 7 patients). Coronal, apical, and angular deviation between virtual surgical planning and final guided intraoperative position was measured on each implant. There is a clear learning curve for surgeons when applying guided methods. Initial only-navigated cases achieved low accuracy but were comparable to non-guided freehand positioning due to jig registration instability. Subsequent dynamic navigation cases combining highly stable acrylic static guides as reference and registration markers result in the highest accuracy with a 1–1.5-mm deviation at the insertion point. Smartphone-based augmented reality visualization is a valuable tool for intraoperative visualization and final verification, although it is still a difficult technique for guiding surgery. A fixed screw-retained ideal dental prosthesis was achieved in every case as virtually planned. Implant placement, the final step in free flap oncological reconstruction, could be accurately planned and placed with image-guided surgery, 3D printing, and CAD/CAM technology. The learning curve could be overcome with preclinical laboratory training, but virtually designed and 3D-printed tracer registration stability is crucial for accurate and predictable results. Applying these concepts to our difficult oncologic patient subgroup with deep anatomic alterations ended in comparable results as those reported in non-oncologic patients.

Guentsch A., Sukhtankar L., An H., Luepke P.G.

AbstractStatement of problem Malpositioning of implants is one of the main factors leading to hard- and soft-tissue deficiencies. Whether static computer-guided implant placement increases accuracy and prevents malpositioning is unclear. Purpose The purpose of this in vitro study was to determine accuracy defined by trueness and precision (according to International Organization for Standardization 5725) of computer-assisted implant surgery (fully guided and partially guided) in comparison with freehand single implant placement. Material and methods Implants (n=20) were placed fully guided (sleeve-bone distance of 2, 4, or 6 mm), partially guided (guide used for pilot drill), or free hand in identical replicas produced from a cone beam computed tomography (CBCT) scan of a partially edentulous patient. The achieved implant position was digitized by using a laboratory scanner and compared with the planned position. Trueness (planned versus actual position) and precision (difference among implants) were determined. The 3D-offset at the crest of the implant (root mean square between virtual preoperative planning and postoperative standard tessellation language file) was defined as the primary outcome parameter. The means, standard deviation, and 95% confidence intervals were analyzed statistically with 1-way ANOVA and the Scheffé procedure. Results Fully guided implant surgery achieved significantly lower 3D deviations between the planned and actual implant position with 0.22 ±0.07 mm (2-mm sleeve-bone distance) than partially guided 0.69 ±0.15 mm and freehand placement 0.80 ±0.35 mm at the crest (P

Pellegrino G., Ferri A., Del Fabbro M., Prati C., Gandolfi M., Marchetti C.

PURPOSE Dynamic navigation is a technique that allows for the placement of dental implants using a computer-guided approach according to preoperative planning. Its accuracy has been assessed in several previous studies. The purpose of this study was to summarize data on implant placement accuracy using dynamic navigation, to synthesize the frequency of intraoperative complications and implant failures, and to compare this technique with static computer-guided surgery and a freehand approach. MATERIALS AND METHODS Electronic and manual literature searches until December 2019 were performed. The outcome variables were implant placement accuracy using dynamic navigation, accuracy differences between dynamic and static techniques and between dynamic and freehand techniques, intraoperative complications, and implant failures. Random-effects meta-analyses were performed. RESULTS A total of 32 studies were included; 29 reported accuracy values (2,756 implants), and 10 focused on complications and implant failures (1,039 implants). The pooled mean implant placement errors were 0.81 (95% CI: 0.677 to 0.943) mm at the entry point and 0.910 (95% CI: 0.770 to 1.049) mm at the apical point. The pooled mean vertical and angular deviations were 0.899 (95% CI: 0.721 to 1.078) mm and 3.807 (95% CI: 3.083 to 4.530) degrees. The navigation group showed significantly lower implant placement errors with respect to the freehand technique (P < .01) and similar accuracy values (P ≥ .05) compared with the static technique. The pooled prevalence of failures was 1% (95% CI: 0.00% to 2%). CONCLUSION Dynamic navigation provided small implant placement errors, comparable with those obtained using static computer-guided surgery, and can be considered a more accurate technique than conventional freehand surgery.

Rigamonti L., Secchi M., Lawrence J.B., Labianca L., Wolfarth B., Peters H., Bonaventura K., Back D.A.

Background Support for long-distance research and clinical collaborations is in high demand and has increased owing to COVID-19–related restrictions on travel and social contact. New digital approaches are required for remote scientific exchange. Objective This study aims to analyze the options of using an augmented reality device for remote supervision of exercise science examinations. Methods A mobile ultrasound examination of the diameter and intima-media thickness of the femoral and carotid arteries was remotely supervised using a head-mounted augmented reality device. All participants were provided with a link to a YouTube video of the technique in advance. In part 1, 8 international experts from the fields of engineering and sports science were remotely connected to the study setting. Internet connection speed was noted, and a structured interview was conducted. In part 2, 2 remote supervisors evaluated 8 physicians performing an examination on a healthy human subject. The results were recorded, and an evaluation was conducted using a 25-item questionnaire. Results In part 1, the remote experts were connected over a mean distance of 1587 km to the examination site. Overall transmission quality was good (mean upload speed: 28.7 Mbps, mean download speed: 97.3 Mbps, mean ping: 21.6 milliseconds). In the interview, participants indicated that the main potential benefits would be to the fields of education, movement analysis, and supervision. Challenges regarding internet connection stability and previous training with the devices used were reported. In part 2, physicians’ examinations showed good interrater correlation (interclass correlation coefficient: 0.84). Participants valued the experienced setting as highly positive. Conclusions The study showed the good feasibility of the chosen design and a highly positive attitude of all participants toward this digital approach. Head-mounted augmented reality devices are generally recommended for collaborative research projects with physical examination–based research questions.

Jorba-García A., González-Barnadas A., Camps-Font O., Figueiredo R., Valmaseda-Castellón E.

To assess the accuracy of dynamic computer–aided implant surgery (dCAIS) systems when used to place dental implants and to compare its accuracy with static computer–aided implant surgery (sCAIS) systems and freehand implant placement. An electronic search was made to identify all relevant studies reporting on the accuracy of dCAIS systems for dental implant placement. The following PICO question was developed: “In patients or artificial models, is dental implant placement accuracy higher when dCAIS systems are used in comparison with sCAIS systems or with freehand placement? The main outcome variable was angular deviation between the central axes of the planned and final position of the implant. The data were extracted in descriptive tables, and a meta-analysis of single means was performed in order to estimate the deviations for each variable using a random-effects model. Out of 904 potential articles, the 24 selected assessed 9 different dynamic navigation systems. The mean angular and entry 3D global deviations for clinical studies were 3.68° (95% CI: 3.61 to 3.74; I2 = 99.4%) and 1.03 mm (95% CI: 1.01 to 1.04; I2 = 82.4%), respectively. Lower deviation values were reported in in vitro studies (mean angular deviation of 2.01° (95% CI: 1.95 to 2.07; I2 = 99.1%) and mean entry 3D global deviation of 0.46 mm (95% CI: 0.44 to 0.48 ; I2 = 98.5%). No significant differences were found between the different dCAIS systems. These systems were significantly more accurate than sCAIS systems (mean difference (MD): −0.86°; 95% CI: −1.35 to −0.36) and freehand implant placement (MD: −4.33°; 95% CI: −5.40 to −3.25). dCAIS systems allow highly accurate implant placement with a mean angular of less than 4°. However, a 2-mm safety margin should be applied, since deviations of more than 1 mm were observed. dCAIS systems increase the implant placement accuracy when compared with freehand implant placement and also seem to slightly decrease the angular deviation in comparison with sCAIS systems. The use of dCAIS could reduce the rate of complications since it allows a highly accurate implant placement.

Wei S., Zhu Y., Wei J., Zhang C., Shi J., Lai H.

Objective To assess the accuracy of dynamic computer-assisted implant surgery. Materials and methods An electronic search up to March 2020 was conducted using PubMed, Embase, and the Cochrane Central Register of Controlled Trial to identify studies using dynamic navigation in implant surgery, and additional manual search was performed as well. Clinical trials and model studies were selected. The primary outcome was accuracy. A single-arm meta-analysis of continuous data was conducted. Meta-regression was utilized for comparison on study design, guidance method, jaw and systems. Results Ten studies, four randomized controlled trials (RCT) and six prospective studies, met the inclusion criteria. A total of 1298 drillings and implants were evaluated. The meta-analysis of the accuracy (five clinical trials and five model studies) revealed average global platform deviation, global apex deviation and angular deviation were 1.02 mm, CI: 95% [0.83, 1.21], 1.33 mm, CI: 95% [0.98, 1.67], and 3.59°, CI: 95% [2.09, 5.09]. Meta-regression shown no difference between model studies and clinical trials (p=0.295, 0.336, 0.185), drilling holes and implant (p =0.36, 0.279, 0.695), maxilla and mandible (p =0.875, 0.632, 0.281) and five different systems (p =0.762, 0.342, 0.336). Conclusion Accuracy of dynamic computer-aided implant surgery reaches a clinically acceptable range and has potential in clinical usage, but more patient-centered outcomes and socio-economic benefits should be reported.

Schnutenhaus S., Edelmann C., Knipper A., Luthardt R.G.

The aim of this systematic review and meta-analysis is to analyze the accuracy of implant placement using computer-assisted dynamic navigation procedures. An electronic literature search was carried out, supplemented by a manual search. The literature search was completed in June 2020. The results of in vitro and clinical studies were recorded separately from each other. For inclusion in the review, the studies had to examine at least the prosthetically relevant parameters for angle deviation, as well as global deviation or lateral deviation at the platform of the implant. Sixteen of 320 articles were included in the investigation: nine in vitro and seven clinical studies. The meta-analysis showed values of 4.1° for the clinical studies (95% CI, 3.12–5.10) and 3.7° for the in vitro studies (95% CI, 2.31–5.10) in terms of the angle deviation. The global deviation at the implant apex of the implant was 1.00 mm for the clinical studies (95% CI, 0.83–1.16) and 0.91 mm for the in vitro studies (95% CI, 0.60–1.12). These values indicate no significant difference between the clinical and in vitro studies. The results of this systematic review show a clinical accuracy of dynamic computer-assisted navigation that is comparable to that of static navigation. However, the dynamic navigation systems show a great heterogeneity that must be taken into account. Moreover, currently there are few clinical data available. Therefore, further investigations into the practicability of dynamic navigation seem necessary.

Yeung A.W., Tosevska A., Klager E., Eibensteiner F., Laxar D., Stoyanov J., Glisic M., Zeiner S., Kulnik S.T., Crutzen R., Kimberger O., Kletecka-Pulker M., Atanasov A.G., Willschke H.

Background Virtual reality (VR) and augmented reality (AR) have recently become popular research themes. However, there are no published bibliometric reports that have analyzed the corresponding scientific literature in relation to the application of these technologies in medicine. Objective We used a bibliometric approach to identify and analyze the scientific literature on VR and AR research in medicine, revealing the popular research topics, key authors, scientific institutions, countries, and journals. We further aimed to capture and describe the themes and medical conditions most commonly investigated by VR and AR research. Methods The Web of Science electronic database was searched to identify relevant papers on VR research in medicine. Basic publication and citation data were acquired using the “Analyze” and “Create Citation Report” functions of the database. Complete bibliographic data were exported to VOSviewer and Bibliometrix, dedicated bibliometric software packages, for further analyses. Visualization maps were generated to illustrate the recurring keywords and words mentioned in the titles and abstracts. Results The analysis was based on data from 8399 papers. Major research themes were diagnostic and surgical procedures, as well as rehabilitation. Commonly studied medical conditions were pain, stroke, anxiety, depression, fear, cancer, and neurodegenerative disorders. Overall, contributions to the literature were globally distributed with heaviest contributions from the United States and United Kingdom. Studies from more clinically related research areas such as surgery, psychology, neurosciences, and rehabilitation had higher average numbers of citations than studies from computer sciences and engineering. Conclusions The conducted bibliometric analysis unequivocally reveals the versatile emerging applications of VR and AR in medicine. With the further maturation of the technology and improved accessibility in countries where VR and AR research is strong, we expect it to have a marked impact on clinical practice and in the life of patients.

Xue J., Hu R., Zhang W., Zhao Y., Zhang B., Liu N., Li S., Logan J.

Background To provide participants with a more real and immersive intervening experience, virtual reality (VR) and/or augmented reality (AR) technologies have been integrated into some bystander intervention training programs and studies measuring bystander behaviors. Objective We focused on whether VR or AR can be used as a tool to enhance training bystanders. We reviewed the evidence from empirical studies that used VR and/or AR as a tool for examining bystander behaviors in the domain of interpersonal violence research. Methods Two librarians searched for articles in databases, including APA PsycInfo (Ovid), Criminal Justice Abstracts (EBSCO), Medline (Ovid), Applied Social Sciences Index & Abstracts (ProQuest), Sociological Abstracts (ProQuest), and Scopus till April 15, 2020. Studies focusing on bystander behaviors in conflict situations were included. All study types (except reviews) written in English in any discipline were included. Results The search resulted in 12,972 articles from six databases, and the articles were imported into Covidence. Eleven studies met the inclusion and exclusion criteria. All 11 articles examined the use of VR as a tool for studying bystander behaviors. Most of the studies were conducted in US young adults. The types of interpersonal violence were school bullying, dating violence, sexual violence/assault, and soccer-associated violence. VR technology was used as an observational measure and bystander intervention program. We evaluated the different uses of VR for bystander behaviors and noted a lack of empirical evidence for AR as a tool. We also discuss the empirical evidence regarding the design, effectiveness, and limitations of implementing VR as a tool in the reviewed studies. Conclusions The reviewed results have implications and recommendations for future research in designing and implementing VR/AR technology in the area of interpersonal violence. Future studies in this area may further contribute to the use of VR as an observational measure and explore the potential use of AR to study bystander behaviors.

Demeco A., Renzi F., Frizziero A., Palermi S., Salerno A., Foresti R., Martini C., Costantino C.

Background Mixed reality (MR) is an emerging technology that has been employed in medicine, providing a holographic representation of patient anatomy. Purpose The aim of this review is to examine the use of imaging-derived holograms in the management of musculoskeletal conditions. Research Desing A literature search was performed on PubMed, Embase, Web of Science, Scopus, and Google Scholar up to June 2023, a total of 31 studies were included. A random-effects model was employed for the meta-analysis. Results MR has been extensively used in orthopedic surgery, spinal surgery, and interventional procedures for pain management. A 3D model is derived from DICOM images and superimposed on the surgical field. The procedure’s accuracy has yielded remarkable results, especially for operators with less surgical experience. Furthermore, this technology minimises the need for intra-procedure imaging, thus reducing radiation exposure. Conclusion The meta-analysis showed an impact of MR in reducing operatory time and improving inexperienced surgeons’ accuracy.

Angilov V.I., Osmanova N.D., Vakhitova S.R., Ugolkova M.S., Chnavayan L.E., Arutyunyan E.P., Gukezheva D.V., Pesnya A.S., Rybakova T.A., Lupenko E.D., Latypova L.I., Efimova S.K., Zakaraya S.D.

ABSTRACT Dynamic navigation (DN) provides for tracking the position of instruments in real time through a computerized system. Through the use of video tracking systems, DN displays the location of instruments on a computer monitor, enabling doctors to manage them with a high degree of accuracy and control. This technology is especially useful when performing complex and demanding procedures such as endodontic microsurgery, sinus lifting and orthognathic surgery. The purpose of the review is to analyze the literature data on the use of DN technology in dentistry with a special focus on oral implantology, endodontics and maxillofacial surgery, as well as to identify the main disadvantages and advantages of this technique and to propose recommendations for its introduction into widespread clinical practice. As a result of the search, 6,755 publications were extracted from PubMed/MEDLINE, Google Scholar, and eLibrary databases.En, after the selection procedure, 88 articles were included in the review. DN allows doctors to visualize the patient's anatomy before surgery, plan the intervention with high accuracy, and monitor the course of the procedure in real time. This is especially important during complex operations such as dental implantation, where the accuracy of the implant placement is crucial for the success of the treatment. The use of digital technologies also reduces the risk of complications and shortens the duration of the rehabilitation period after surgery. Thus, the introduction of DN into dental practice represents a significant step forward in the development of medicine. These technologies not only improve the quality of medical services, but also make the treatment process safer and more comfortable for patients. In the future, we can expect further development and integration of digital technologies into dentistry, which will lead to the creation of new diagnostic and treatment methods, as well as to an increase in the level of professionalism of doctors. Keywords: Dynamic navigation; endodontics; root canals; implantology; maxillofacial surgery; dentistry; cone beam tomography.

Farronato M., Crispino R., Fabbro M.D., Tartaglia G.M., Cenzato N.

Schneider B., Ströbele D.A., Grün P., Mosch R., Turhani D., See C.V.

Precise implant placement is essential for optimal functional and aesthetic outcomes. Digital technologies, such as computer-assisted implant surgery (CAIS), have improved implant outcomes. However, conventional methods such as static and dynamic CAIS (dCAIS) require complex equipment. This study examined the usefulness of smartphone-based augmented reality (AR) for CAIS based on the value addition regarding angulation and positioning of pilot drillings and the potential for training dental students. An in vitro model was created to mimic dental scenarios using three-dimensional datasets. Smartphone technology and AR application (app)-based intraoral tracking were used for dCAIS. The app allowed real-time visualization of implant planning, superimposition of three-dimensional models, and alignment of surgical instruments. Forty dental students performed four pilot drillings each; two were performed freehand, whereas two were performed using the app. The angulation and position of the prepared implant bed preparation were statistically analyzed. Implant angulation was significantly better in the AR-guided group than in the unguided group; however, no significant difference was observed in the implant position. Smartphone-based AR techniques for dCAIS are easily accessible in dental implantology. This may be advantageous for training dental students and potentially improving clinical outcomes, particularly the angulation of dental implants.

Van den Bempt M., Nahles S., Heiland M., Flügge T.

In den letzten Jahren hat die digitale Implantatplanung in der dentalen Implantologie einen signifikanten Wandel durchlaufen, wobei dreidimensionale Bildgebungstechnologien wie die digitale Volumentomographie (DVT) und der Intraoralscan (IOS) eine zentrale Rolle spielen. Diese Technologien haben nicht nur die Diagnostik und Behandlungsplanung verbessert, sondern auch die konventionellen Methoden abgelöst. Der nächste Schritt in dieser Entwicklung ist die Integration von künstlicher Intelligenz (KI), die Implantolog:innen dabei unterstützt, präzisere Diagnosen zu stellen, Behandlungspläne zu erstellen und den Erfolg von Implantaten vorherzusagen. Anwendungen der KI helfen bei der Analyse von 3‑D-Bilddaten, der Identifikation anatomischer Strukturen, der automatisierten Implantatplanung und der Vorhersage von periimplantären Komplikationen. Die Effizienz und Genauigkeit dieser Systeme werden in der klinischen Praxis zunehmend untersucht. Trotz der Fortschritte bleiben Einschränkungen, insbesondere in Bezug auf vollständig automatisierte Arbeitsabläufe und die Validierung kommerzieller Softwarepakete. Die Zukunft der Implantologie wird durch die Weiterentwicklung von KI-gestützten Tools geprägt sein, die eine optimierte Behandlungsplanung und eine verbesserte Implantatprognose ermöglichen.

Wang F., Cai X., Sun W., Chen C., Meng L.

Dynamic navigation (DN) technology has ushered in a paradigm shift in dentistry, revolutionizing the precision of diverse procedures in oral and craniofacial surgery. This comprehensive review aims to review the manifold applications of DN, including implantology, endodontics, oral and dental surgeries, and other dental disciplines. A thorough search of the online databases PubMed and Google Scholar was conducted up to March 2024. Publications associated with DN in the field of oral and maxillofacial surgery were sourced. Narrative literature review. DN harnesses cone beam computerized tomography imaging, virtual design software, and motion tracking technology to construct a virtual model of the patient’s oral cavity, affording real-time instrument tracking during procedures. Notably, in implantology, DN facilitates implant placement, enhances safety measures, and augments procedural efficiency. The application of DN in sinus lift procedures contributes to improved surgical outcomes and reduced complications. Within endodontics, DN guides root canal treatment (RCT), retreatment of failed RCT, and endodontic microsurgery, ensuring conservative access cavities and precise canal location. Beyond these, the versatility of DN extends to encompass maxillomandibular and orthognathic surgeries, tooth extraction, removal of foreign bodies, and facial reconstruction. However, it is crucial to acknowledge potential disadvantages and error-prone scenarios as DN technologies advance. DN technology empowers dentists with high accuracy, heightened safety protocols, and increased procedural efficiency, culminating in enhanced patient outcomes across various dental procedures. As DN technology further expands, its pivotal role will advance in the future of oral and maxillofacial surgery.

Tabernée Heijtmeijer S., Glas H., Janssen N., Vosselman N., de Visscher S., Spijkervet F., Raghoebar G., de Bree R., Rosenberg A., Witjes M., Kraeima J.

Purpose Placement of zygomatic implants in the most optimal prosthetic position is considered challenging due to limited bone mass of the zygoma, limited visibility, length of the drilling path and proximity to critical anatomical structures. Augmented reality (AR) navigation can eliminate some of the disadvantages of surgical guides and conventional surgical navigation, while potentially improving accuracy. In this human cadaver study, we evaluated a developed AR navigation approach for placement of zygomatic implants after total maxillectomy. Methods The developed AR navigation interface connects a commercial navigation system with the Microsoft HoloLens. AR navigated surgery was performed to place 20 zygomatic implants using five human cadaver skulls after total maxillectomy. To determine accuracy, postoperative scans were virtually matched with preoperative three-dimensional virtual surgical planning, and distances in mm from entry-exit points and angular deviations were calculated as outcome measures. Results were compared with a previously conducted study in which zygomatic implants were positioned with 3D printed surgical guides. Results The mean entry point deviation was 2.43 ± 1.33 mm and a 3D angle deviation of 5.80 ± 4.12° (range 1.39–19.16°). The mean exit point deviation was 3.28 mm (±2.17). The abutment height deviation was on average 2.20 ± 1.35 mm. The accuracy of the abutment in the occlusal plane was 4.13 ± 2.53 mm. Surgical guides perform significantly better for the entry-point (P = 0.012) and 3D angle (P = 0.05); however, there is no significant difference in accuracy for the exit-point (P = 0.143) when using 3D printed drill guides or AR navigated surgery. Conclusion Despite the higher precision of surgical guides, AR navigation demonstrated acceptable accuracy, with potential for improvement and specialized applications. The study highlights the feasibility of AR navigation for zygomatic implant placement, offering an alternative to conventional methods.

Liu C., Wang Y., Sun T.

Challenges with hand-eye coordination limit display-based navigation systems, while augmented reality (AR) offers a promising alternative. However, achieving accurate and stable alignment between virtual space and real space remains a challenge. Developing a fast, accurate, and robust virtual-real calibration method is crucial for advancing the application of AR in the medical field. We propose an automatic online calibration method for Microsoft Hololens2. First, a calibration module containing identifier image and optical spheres is designed for the automatic acquisition of the virtual-real space transformation. Then, real-time calibration combined with window sliding filtering updates and smooths the calibration results, providing the operator with a continuous, accurate, and smooth navigation screen. Finally, an AR-based surgical navigation system is developed and experimental validation is carried out. Experiments using a 3D printed spine model were conducted to assess calibration accuracy. Results showed that the point distance error was 1.34 ± 0.43 mm, and the accuracy of the virtual-real fusion did not drift significantly over time. Two ex vivo porcine spines were used to evaluate the drilling accuracy of the AR navigation system. At the 25 planned drilling positions, the nail placement success rate was 96% (Gertzbein-Robbins grades A and B). The average placement point deviation and angular deviation were 1.09 ± 0.35 mm and 1.45 ± 0.64°, respectively. Our calibration method helps surgeons achieve accurate and efficient virtual-real alignment through simple operations. The results of model and ex vivo animal experiments demonstrate the accuracy, efficiency, and feasibility of the proposed system.

Kantor T., Mahajan P., Murthi S., Stegink C., Brawn B., Varshney A., Reddy R.M.

Gao L., Zhang H., Xu Y., Dong Y., Sheng L., Fan Y., Qin C., Gu W.

Performing spinal anesthesia in elderly patients with spine degeneration is challenging for novice practitioners. This stratified randomized controlled trial aims to compare the effectiveness of mixed reality-assisted spinal puncture (MRasp) with that of landmark-guided spinal puncture (LGsp) performed by novice practitioners in elderly patients. This prospective, single-center, stratified, blocked, parallel randomized controlled trial will include 168 patients (aged ≥ 65 years) scheduled for elective surgery involving spinal anesthesia. All spinal punctures will be performed by anesthesiology interns and residents trained at Huadong Hospital. Patients will be randomly assigned to the MRasp group (n = 84) or the LGsp group (n = 84). Based on each intern/resident’s experience in spinal puncture, participants will be stratified into three clusters: the primary group, intermediate group, and advanced group. The primary outcome will be the comparison of the rate of successful first-attempt needle insertion between the MRasp group and the LGsp group. Secondary outcomes will include the number of needle insertion attempts, the number of redirection attempts, the number of passes, the rate of successful first needle pass, the spinal puncture time, the total procedure time, and the incidence of perioperative complications. A stratified subgroup analysis will also be conducted for interns/residents at different experience levels. The findings from this trial establish the effectiveness of MRasp by novice practitioners in elderly patients. This trial may provide experimental evidence for exploring an effective visualization technology to assist in spinal puncture. Chinese Clinical Trials Registry ChiCTR2300075291. Registered on August 31, 2023. https://www.chictr.org.cn/bin/project/edit?pid=189622 .

Li Y., Drobinsky S., Becker P., Xie K., Lipprandt M., Mueller C.A., Egger J., Hölzle F., Röhrig R., Radermacher K., de la Fuente M., Puladi B.

AbstractConventional navigation systems (CNS) in surgery require strong spatial cognitive abilities and hand-eye coordination. Augmented Reality Navigation Systems (ARNS) provide 3D guidance and may overcome these challenges, but their accuracy and efficiency compared to CNS have not been systematically evaluated. In this randomized crossover study with 36 participants from different professional backgrounds (surgeons, students, engineers), drilling accuracy, time and perceived workload were evaluated using ARNS and CNS. For the first time, this study provides compelling evidence that ARNS and CNS have comparable accuracy in translational error. Differences in angle and depth error with ARNS were likely due to limited stereoscopic vision, hardware limitations, and design. Despite this, ARNS was preferred by most participants, including surgeons with prior navigation experience, and demonstrated a significantly better overall user experience. Depending on accuracy requirements, ARNS could serve as a viable alternative to CNS for guided drilling, with potential for future optimization.

Xue F., Zhang R., Dai J., Zhang Y., Luan Q.

To demonstrate the potential application of mixed reality (MR) holographic imaging technology in subgingival scaling and root planing (SRP) for patient with advanced periodontitis.

Shusterman A., Nashef R., Tecco S., Mangano C., Mangano F.

To present the first clinical application of a novel mixed reality-based dynamic navigation (MR-DN) system in the rehabilitation of a single tooth gap.

Kihara T., Keller A., Ogawa T., Armand M., Martin-Gomez A.

Tooth preparation is complicated because it requires the preparation of an abutment while simultaneously predicting the ideal shape of the tooth. This study aimed to develop and evaluate a system using augmented reality (AR) head-mounted displays (HMDs) that provide dynamic navigation capabilities for tooth preparation.

Shusterman A., Nashef R., Tecco S., Mangano C., Lerner H., Mangano F.G.

This in vitro study aimed to compare the accuracy of dental implant placement in partially edentulous maxillary models using a mixed reality-based dynamic navigation (MR-DN) system to conventional static computer-assisted implant surgery (s-CAIS) and a freehand (FH) method. Forty-five partially edentulous models (with teeth missing in positions #15, #16 and #25) were assigned to three groups (15 per group). The same experienced operator performed the model surgeries using an MR-DN system (group 1), s-CAIS (group 2) and FH (group 3). In total, 135 dental implants were placed (45 per group). The primary outcomes were the linear coronal deviation (entry error; En), apical deviation (apex error; Ap), XY and Z deviations, and angular deviation (An) between the implants' planned and actual (post-surgery) positions in the models. These deviations were computed as the distances between the stereolithographic (STL) files for the planned implants and placed implants captured with an intraoral scanner. Across the three implant sites, the MR-DN system was significantly more accurate than the FH method (in XY, Z, En, Ap and An) and s-CAIS (in Z, Ap and An), respectively. However, S-CAIS was more accurate than MR-DN in XY, and no difference was found between MR-DN and s-CAIS in En. Within the limits of this study (in vitro design, only partially edentulous models), implant placement accuracy with MR-DN was superior to that of FH and similar to that of s-CAIS. In vitro, MR-DN showed greater accuracy in implant positioning than FH, and similar accuracy to s-CAIS: it could, therefore, represent a new option for the surgeon. However, clinical studies are needed to determine the feasibility of MR-DN.