Fully versus conventionally guided implant placement by dental students: A randomized controlled trial

The Accuracy of Dental Implant Placement With Different Methods of Computer-Assisted Implant Surgery: A Network Meta-Analysis of Clinical Studies

OBJECTIVE

Computer-assisted implant surgery (CAIS) has been introduced as a tool to aid in reaching a more accurate implant position. The aim of this network meta-analysis was to compare all the available CAIS techniques and obtain collective evidence on the method that offers the highest accuracy compared to freehand implant placement.

MATERIALS AND METHODS

Database search was done in PubMed, Scopus, and Cochrane library in addition to extensive search in the gray literature and related systematic reviews, aiming to find clinical studies that compared any CAIS technique with another, or with freehand implant placement. The outcomes evaluated were angle, platform, and apex deviation. The search process ended on March 18, 2024.

RESULTS

Thirty-three studies were included. All CAIS techniques (static with partial or full guidance, dynamic with partial or full guidance, the combination of static and dynamic CAIS) showed significantly less deviation than freehand implant placement, except for the static CAIS with guidance for the pilot drill only. The combination of static and dynamic CAIS ranked best among all other methods. Based on the GRADE system, the certainty of evidence in the outcomes of the meta-analysis was judged as low or moderate.

CONCLUSIONS

The current study demonstrates that computer-assisted implant surgery provides significantly higher accuracy in implant placement, with the combination of static and dynamic CAIS being the most precise. Nevertheless, future studies are needed, considering the different types, locations, and extents of edentulism in the analyzed investigations, as well as the necessity of obtaining stronger evidence.

TRIAL REGISTRATION

PROSPERIO number: CRD42023482030.

Computer-assisted and robotic implant surgery: Assessing the outcome measures of accuracy and educational implications

OBJECTIVE

This scoping review aimed to (1) critically evaluate the outcomes measures used to assess the accuracy of implant placement with Computer Assisted Implant Surgery (CAIS) and (2) review the evidence supporting the efficient implementation of CAIS in training and education of clinicians.

METHODS

A scoping literature review was conducted aiming to identify (a) clinical trials assessing accuracy of implant placement with CAIS, and (b) clinical trials or simulation/cadaver studies where CAIS was utilised and assessed for the training/education of clinicians. Studies since 1995 were assessed for suitability and data related to the outcomes measures of accuracy and educational efficacy were extracted and synthesised.

RESULTS

Accuracy of CAIS has been mainly assessed through surrogate measures. Individual clinical trials have not shown any difference between static and dynamic CAIS, but recent meta-analyses suggest an advantage of dynamic CAIS in reducing angular deviation. The combination of static and dynamic CAIS might offer higher accuracy than each of the two used alone. Dynamic CAIS is suitable for novice surgeons and might even have added value as an education tool for implant surgery, although mastering the technique requires longer training than static.

CONCLUSION

Meta-analyses of large samples, new and diverse outcomes measures, as well as benchmarking of levels of accuracy with specific clinical outcomes will help to better understand the potential and limitations of CAIS. Dynamic CAIS is suitable for novice operators, but educational interventions distributed over longer periods of time will be required for mastery of the process.

Digital versus conventional prosthetic workflow for dental students providing implant-supported single crowns: A randomized crossover study

STATEMENT OF PROBLEM

Digital scanning has become popular and has been reported to be more comfortable for patients and equally or more accurate than conventional impression techniques. However, clinical evidence to support the advantages of digital scanning is sparse.

PURPOSE

The purpose of this randomized crossover study was to examine and compare the patient and provider perceptions of digital scanning and conventional impression making for implant-supported single crowns (ISSCs) provided by dental students under supervision. Furthermore, the quality and patient-reported outcome of the definitive restorations were compared.

MATERIAL AND METHODS

Forty participants in need of a single tooth replacement were enrolled. Three months after initial implant placement, recordings were made for implant-supported crowns. The participants were randomized into a conventional or a digital group but underwent both procedures. Only the designated impression or scan was sent to the dental laboratory technician to be processed. All participants and students were asked questions concerning which technique they preferred. Furthermore, the participants filled out an oral health impact profile (OHIP-14) questionnaire before and after treatment. The restorations' esthetic and technical quality was evaluated using the Copenhagen Index Score (CIS).

RESULTS

The participants preferred the digital technique (80%) over the conventional technique (2%), while 18% of the participants had no preference. The participants were bothered significantly more (P<.001), experienced significantly more shortness of breath (P<.001), and were significantly more anxious during the conventional impression than during the digital scan (P<.001). Most students also preferred the digital technique (65%) over the conventional technique (22%), and 13% had no preference. The students found that the conventional impression procedure was less time-consuming but more uncertain in comparison with the digital technique. The digital technique was perceived as significantly more impractical than the conventional technique (P<.05). The results from CIS showed no significant difference in the quality of the restorations. Following treatment, the OHIP-14 scores showed a significant drop, suggesting an increase in oral health-related quality of life (P<.001).

CONCLUSIONS

The perceptions of the participants and students of the digital intraoral scanning were significantly better than those of the conventional technique. No significant differences in the quality of the restorations or OHIP scores were observed using the two recording techniques.

COMPARISONS BETWEEN DIGITAL-GUIDED AND NONDIGITAL PROTOCOL IN IMPLANT PLANNING, PLACEMENT, AND RESTORATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

OBJECTIVES

The present study aimed to systematically review the current randomized clinical trials (RCTs) with respect to computer-aided design/computer-aided manufactured (CAD/CAM) techniques in the process of implant planning, placement, and rehabilitation.

MATERIALS AND METHODS

Four independent reviewers conducted an electronic and manual literature search using several databases, including the National Library of Medicine (MEDLINE-PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE. Articles were included if they were RCTs involving the interventions regarding the computer-guided impression, placement, and manufacturing process. The outcomes of interest include clinical and patient-reported outcomes and time efficiency. A meta-analysis was conducted to evaluate the time efficiency, pain severity, accuracy of implant placement, and postsurgery marginal bone level.

RESULTS

A total of 39 and 25 articles were included in the qualitative and quantitative analysis, respectively. The results of the meta-analysis showed that significantly less time was spent performing the digital impression procedure than the conventional impression (P = .002). In addition, the average adjustment time of the final prosthesis was significantly less than the nondigital fabricated prosthesis (P = .0005). Computer-guided groups reported significantly lower painkiller consumption compared to control groups (P = .03).

CONCLUSIONS

Digital impressions and CAD/CAM procedures are time-saving and provide stable and predictable outcomes. Moreover, computer-guided surgery can effectuate an accurate implant placement and less postsurgery discomfort.

Accuracy and patient-centered results of static and dynamic computer-assisted implant surgery in edentulous jaws: a retrospective cohort study

OBJECTIVES

This study aimed to compare implant positioning accuracy and patient-centered results between static and dynamic computer-assisted implant surgery (s-CAIS and d-CAIS) in edentulous jaws.

MATERIAL AND METHODS

The current study retrospectively evaluated a total of 110 implants placed in 22 fully edentulous patients via s-CAIS or d-CAIS (n = 11). The accuracy of implant positioning was assessed by measuring the implant's angular deviation and deviation at the platform and apex from the preoperative design postoperatively. Patient-centered results, including preoperative and intraoperative patient-reported experiences and postoperative patient-reported outcomes, were extracted from the medical records. The nested t test and chi-square test were used to compare accuracy and patient-centered results between s-CAIS and d-CAIS postoperatively.

RESULTS

The implants in the s-CAIS group showed significantly smaller angular deviation (2.32 ± 1.23°) than those in the d-CAIS group (3.87 ± 2.75°). In contrast, the platform and apical deviation were significantly larger in s-CAIS (1.56 ± 1.19 mm and 1.70 ± 1.09 mm, respectively) than d-CAIS (1.02 ± 0.45 mm and 1.00 ± 0.51 mm, respectively). Furthermore, the implants in the s-CAIS group deviated significantly (p < 0.001) more toward the coronal direction than those in the d-CAIS group. Notably, all patients in the s-CAIS group reported an obvious foreign body sensation during surgery, representing a significant difference from the d-CAIS group.

CONCLUSIONS

Compared to s-CAIS, d-CAIS is a reliable technique for the placement of multiple implants in fully edentulous patients with less linear deviation and less foreign body sensation.

TRIAL REGISTRATION

The retrospective study was registered on the Chinese Clinical Trial Registry on August 8th, 2022, with registration number No. ChiCTR2200062484.

CLINICAL RELEVANCE

Despite the increasing use of computer- assisted implant surgery in fully edentulous patients, clinical evidence comparing implant positioning accuracy and patient-centered results between static and dynamic CAIS systems is scarce. Our study demonstrated that compared to s-CAIS, d-CAIS is a reliable technique for the placement of multiple implants in fully edentulous patients with less linear deviation.

Accuracy assessment of implant placement with versus without a CAD/CAM surgical guide by novices versus specialists via the digital registration method: an in vitro randomized crossover study

BACKGROUND

Many studies demonstrated that surgical guides might reduce discrepancies compared with freehand implant placement. This randomized crossover study aimed to assess the effects of approaches, practitioners' experience and learning sequences on the accuracy of single tooth implantation via digital registration method. No similar study was found.

METHODS

This in vitro randomized crossover study enrolled 60 novice students (Group S) and 10 experienced instructors (Group I). Sixty students were randomly and evenly assigned to two groups (Group SA and SB). In Group SA, 30 students first performed single molar implant on a simulation model freehand (Group SAFH), and then with a CAD/CAM surgical guide (Group SASG). In Group SB, another 30 students first performed guided (Group SBSG) and then freehand (Group SBFH). Ten instructors were also divided into Group IAFH/IASG (n = 5) and IBSG/IBFH (n = 5) following the same rules. The accuracy of implant placement was assessed by the coronal and apical distance (mm) and angular (°) deviations using the digital registration method. T tests and nonparametric tests were used to compare the results among different groups of approaches, experience and sequences.

RESULTS

For students, the coronal and apical distance and the angular deviations were significantly lower in surgical guide group than freehand group in total and in learning freehand first subgroup, but for learning surgical guide first subgroup the apical distance deviation showed no significant difference between two approaches. For students, the angular deviation of freehand group was significantly lower in learning surgical guide first group than learning freehand first group. For instructors, the coronal and apical distance and angular deviations showed no significant difference between two approaches and two sequences. For freehand approach, the coronal and apical distance and the angular deviations were significantly higher in student group than instructor group, while not significantly different between two groups for surgical guide approach.

CONCLUSIONS

For novices, using a surgical guide for the first implant placement may reduce the potential deviations compared with freehand surgery, and may reach a comparable accuracy with that of specialists. For simple single molar implantation, the surgical guide may not be significantly helpful for experienced specialists.

Efficacy of CAD/CAM technology in dental procedures performed by students: A systematic scoping review of randomized clinical trials

To assess the efficacy of computer-aided design/computer-aided manufacturing (CAD/CAM) in dental procedures performed by dental students.

METHODS

A systematic scoping review was performed. MeSH terms and keywords were specified to assess randomized clinical trials (RCTs) in all idioms.

RESULTS

Nine RCTs that include 520 students were selected. Two RCTs studied implant placement, and the rest of the trials explored implant impressions, intraoral scans, canal obturation, head positioning errors in panoramic images, deep caries and pulp exposure, diagnosis of temporomandibular disorders, and a tooth for restorations. Considering efficacy, variable results were found. The RCTs that explored implant impressions, deep caries and pulp exposure, and diagnosis of temporomandibular disorders showed better results when CAD/CAM technology was performed by students. Two RCTs that investigated implant placement presented contradictory outcomes; one showed better results when CAD/CAM systems were used while the other described similar results to conventional methods. The remaining RCTs did not find differences with conventional procedures. Considering the time spent during the procedures, two studies showed no differences between groups, while another indicated that the time spent was less for digital impressions (p < 0.001). A continuous decrease in scanning time was also perceived for all groups as skills in intraoral scanning augmented (p = 0.0005). Students indicated an interest in utilizing the CAD/CAM systems and recognized that their abilities were enhanced.

CONCLUSIONS

Considering the limitations of this review and the limited number of RCTs evaluated, students recognized that their skills improved using CAD/CAM systems; however, only in some specific procedures greater efficacy and less time spent were observed when this technology was used. Dental students also showed great interest in using these techniques.

Digital versus radiographic accuracy evaluation of guided implant surgery: an in vitro study

Background

Cone-beam computed tomography (CBCT) is the most widely used method for postsurgical evaluation of the accuracy of guided implant surgery. However, the disadvantages of CBCT include radiation exposure, artifacts caused by metal implants, and high cost. Few studies have introduced a digital registration method to replace CBCT for evaluating the accuracy of guided surgery. The purpose of this study was to compare digital registration to conventional CBCT in terms of the capacity to evaluate the implant positioning accuracy of guided surgery.

Materials and methods

This in vitro study included 40 acrylic resin models with posterior single mandibular tooth loss. Guided surgery software was used to determine the optimal implant position; 40 tooth-supported fully guided drilling templates were designed and milled accordingly. After the guided surgery, the accuracies of the surgical templates were evaluated by conventional CBCT and digital registration. For evaluation by conventional CBCT, postsurgical CBCT scans of the resin models were performed. The CBCT data were reconstructed and superimposed on the implant planning data. For digital registration, we constructed a virtual registration unit that consisted of an implant replica and a scan body. Next, we obtained postsurgical optical scans of resin models with the scan body. The postsurgical implant position was identified by superimposition of the registration unit and optical scan data. The implant planning data and postsurgical implant position data were superimposed; deviations were reported in terms of distance for implant entry/apex point and in terms of angle for the implant axis. Interclass correlation coefficients (ICCs) and Bland–Altman plots were used to analyze the agreement between the two evaluation methods.

Results

The ICCs between the two methods were 0.986, 0.993, and 0.968 for the entry point, apex point, and angle, respectively; all were significantly greater than 0.75 (p < 0.001). Bland–Altman plots showed that the 95% limits of agreement of the differences were − 0.144 to + 0.081 mm, − 0.135 to + 0.147 mm, and − 0.451° to + 0.729° for the entry point, apex point, and angle, respectively; all values were within the maximum tolerated difference.

Conclusion

Conventional CBCT and digital registration showed good agreement in terms of evaluating the accuracy of implant positioning using tooth-supported surgical templates.

Can computer-assisted implant surgery improve clinical outcomes and reduce the frequency and intensity of complications in implant dentistry? A critical review

Computer-assisted implant surgery (CAIS), either static or dynamic, is well documented to significantly improve the accuracy of implant placement. Whether the increased accuracy leads to a corresponding improvement in clinical outcomes has not yet been systematically investigated. The aim of this critical review was to investigate whether the use of CAIS can lead to reduction of complications as well as improved clinical and patient-reported outcomes (PROs) when compared with conventional freehand implant surgery. A comprehensive online search was conducted to identify studies where implants were installed with static computer-assisted implant surgery (s-CAIS)or dynamic computer-assisted implant surgery(d-CAIS) or combinations of the two, either compared with conventional free-hand implant placement or not. Seventy-seven studies were finally included in qualitative analysis, while data from three studies assessing postsurgical pain were suitable for a meta-analysis. Only a small number of the available studies were comparative. The current evidence does not suggest any difference with regard to intraoperative complications, immediate postsurgical healing, osseointegration success, and survival of implants placed with CAIS or freehand protocols. Intraoperative and early healing events as reported by patients in randomized clinical trials (RCTs) did not differ significantly between CAIS used with flap elevation and conventional implant placement. There is limited evidence that increased accuracy of placement with CAIS is correlated with superior esthetic outcomes. Use of CAIS does not significantly reduce the length of surgeries in cases of single implants and partially edentulous patients, although there appears to be a more favorable impact in fully edentulous patients. Although CAIS alone does not seem to improve healing and the clinical and PRO, to the extent that it can increase the utilization of flapless surgery and predictability of immediacy protocols, its use may indirectly lead to substantial improvements in all of the above parameters.