Accuracy Evaluation of a Stereolithographic Surgical Template for Dental Implant Insertion Using 3D Superimposition Protocol
Identifieur interne : 002E14 ( Pmc/Corpus ); précédent : 002E13; suivant : 002E15Accuracy Evaluation of a Stereolithographic Surgical Template for Dental Implant Insertion Using 3D Superimposition Protocol
Auteurs : Corina Marilena Cristache ; Silviu GurbanescuSource :
- International Journal of Dentistry [ 1687-8728 ] ; 2017.
Abstract
of this study was to evaluate the accuracy of a stereolithographic template, with sleeve structure incorporated into the design, for computer-guided dental implant insertion in partially edentulous patients.
Sixty-five implants were placed in twenty-five consecutive patients with a stereolithographic surgical template. After surgery, digital impression was taken and 3D inaccuracy of implants position at entry point, apex, and angle deviation was measured using an inspection tool software. Mann–Whitney
Mean (and standard deviation) of 3D error at the entry point was 0.798 mm (±0.52), at the implant apex it was 1.17 mm (±0.63), and mean angular deviation was 2.34 (±0.85). A statistically significant reduced 3D error was observed at entry point
The surgical template used has proved high accuracy for implant insertion. Within the limitations of the present study, the protocol for comparing a digital file (treatment plan) with postinsertion digital impression may be considered a useful procedure for assessing surgical template accuracy, avoiding radiation exposure, during postoperative CBCT scanning.
Url:
DOI: 10.1155/2017/4292081
PubMed: 28555157
PubMed Central: 5438863
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PMC:5438863Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Accuracy Evaluation of a Stereolithographic Surgical Template for Dental Implant Insertion Using 3D Superimposition Protocol</title><author><name sortKey="Cristache, Corina Marilena" sort="Cristache, Corina Marilena" uniqKey="Cristache C" first="Corina Marilena" last="Cristache">Corina Marilena Cristache</name><affiliation><nlm:aff id="I1">Faculty of Midwifery and Medical Assisting, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania</nlm:aff></affiliation></author><author><name sortKey="Gurbanescu, Silviu" sort="Gurbanescu, Silviu" uniqKey="Gurbanescu S" first="Silviu" last="Gurbanescu">Silviu Gurbanescu</name><affiliation><nlm:aff id="I2">“Carol Davila” University of Medicine and Pharmacy and Private Practice, Bucharest, Romania</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28555157</idno><idno type="pmc">5438863</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5438863</idno><idno type="RBID">PMC:5438863</idno><idno type="doi">10.1155/2017/4292081</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">002E14</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002E14</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Accuracy Evaluation of a Stereolithographic Surgical Template for Dental Implant Insertion Using 3D Superimposition Protocol</title><author><name sortKey="Cristache, Corina Marilena" sort="Cristache, Corina Marilena" uniqKey="Cristache C" first="Corina Marilena" last="Cristache">Corina Marilena Cristache</name><affiliation><nlm:aff id="I1">Faculty of Midwifery and Medical Assisting, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania</nlm:aff></affiliation></author><author><name sortKey="Gurbanescu, Silviu" sort="Gurbanescu, Silviu" uniqKey="Gurbanescu S" first="Silviu" last="Gurbanescu">Silviu Gurbanescu</name><affiliation><nlm:aff id="I2">“Carol Davila” University of Medicine and Pharmacy and Private Practice, Bucharest, Romania</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Dentistry</title><idno type="ISSN">1687-8728</idno><idno type="eISSN">1687-8736</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>The aim</title><p>of this study was to evaluate the accuracy of a stereolithographic template, with sleeve structure incorporated into the design, for computer-guided dental implant insertion in partially edentulous patients.</p></sec><sec><title> Materials and Methods</title><p> Sixty-five implants were placed in twenty-five consecutive patients with a stereolithographic surgical template. After surgery, digital impression was taken and 3D inaccuracy of implants position at entry point, apex, and angle deviation was measured using an inspection tool software. Mann–Whitney <italic>U</italic> test was used to compare accuracy between maxillary and mandibular surgical guides. A <italic>p</italic> value < .05 was considered significant.</p></sec><sec><title> Results</title><p> Mean (and standard deviation) of 3D error at the entry point was 0.798 mm (±0.52), at the implant apex it was 1.17 mm (±0.63), and mean angular deviation was 2.34 (±0.85). A statistically significant reduced 3D error was observed at entry point <italic>p</italic> = .037, at implant apex <italic>p</italic> = .008, and also in angular deviation <italic>p</italic> = .030 in mandible when comparing to maxilla.</p></sec><sec><title> Conclusions</title><p> The surgical template used has proved high accuracy for implant insertion. Within the limitations of the present study, the protocol for comparing a digital file (treatment plan) with postinsertion digital impression may be considered a useful procedure for assessing surgical template accuracy, avoiding radiation exposure, during postoperative CBCT scanning.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Guerrero, M E" uniqKey="Guerrero M">M. E. Guerrero</name></author><author><name sortKey="Jacobs, R" uniqKey="Jacobs R">R. Jacobs</name></author><author><name sortKey="Loubele, M" uniqKey="Loubele M">M. Loubele</name></author><author><name sortKey="Schutyser, F" uniqKey="Schutyser F">F. Schutyser</name></author><author><name sortKey="Suetens, P" uniqKey="Suetens P">P. Suetens</name></author><author><name sortKey="Van Steenberghe, D" uniqKey="Van Steenberghe D">D. van Steenberghe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pauwels, R" uniqKey="Pauwels R">R. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Dent</journal-id><journal-id journal-id-type="iso-abbrev">Int J Dent</journal-id><journal-id journal-id-type="publisher-id">IJD</journal-id><journal-title-group><journal-title>International Journal of Dentistry</journal-title></journal-title-group><issn pub-type="ppub">1687-8728</issn><issn pub-type="epub">1687-8736</issn><publisher><publisher-name>Hindawi</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28555157</article-id><article-id pub-id-type="pmc">5438863</article-id><article-id pub-id-type="doi">10.1155/2017/4292081</article-id><article-categories><subj-group subj-group-type="heading"><subject>Clinical Study</subject></subj-group></article-categories><title-group><article-title>Accuracy Evaluation of a Stereolithographic Surgical Template for Dental Implant Insertion Using 3D Superimposition Protocol</article-title></title-group><contrib-group><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="false">http://orcid.org/0000-0001-6635-6091</contrib-id><name><surname>Cristache</surname><given-names>Corina Marilena</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Gurbanescu</surname><given-names>Silviu</given-names></name><xref ref-type="aff" rid="I2"><sup>2</sup></xref></contrib></contrib-group><aff id="I1"><sup>1</sup>Faculty of Midwifery and Medical Assisting, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania</aff><aff id="I2"><sup>2</sup>“Carol Davila” University of Medicine and Pharmacy and Private Practice, Bucharest, Romania</aff><author-notes><corresp id="cor1">*Corina Marilena Cristache: <email>corinacristache@gmail.com</email></corresp><fn fn-type="other"><p>Academic Editor: Izzet Yavuz</p></fn></author-notes><pub-date pub-type="ppub"><year>2017</year></pub-date><pub-date pub-type="epub"><day>7</day><month>5</month><year>2017</year></pub-date><volume>2017</volume><elocation-id>4292081</elocation-id><history><date date-type="received"><day>31</day><month>12</month><year>2016</year></date><date date-type="rev-recd"><day>4</day><month>4</month><year>2017</year></date><date date-type="accepted"><day>16</day><month>4</month><year>2017</year></date></history><permissions><copyright-statement>Copyright © 2017 Corina Marilena Cristache and Silviu Gurbanescu.</copyright-statement><copyright-year>2017</copyright-year><license xlink:href="https://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec><title>The aim</title><p>of this study was to evaluate the accuracy of a stereolithographic template, with sleeve structure incorporated into the design, for computer-guided dental implant insertion in partially edentulous patients.</p></sec><sec><title> Materials and Methods</title><p> Sixty-five implants were placed in twenty-five consecutive patients with a stereolithographic surgical template. After surgery, digital impression was taken and 3D inaccuracy of implants position at entry point, apex, and angle deviation was measured using an inspection tool software. Mann–Whitney <italic>U</italic> test was used to compare accuracy between maxillary and mandibular surgical guides. A <italic>p</italic> value < .05 was considered significant.</p></sec><sec><title> Results</title><p> Mean (and standard deviation) of 3D error at the entry point was 0.798 mm (±0.52), at the implant apex it was 1.17 mm (±0.63), and mean angular deviation was 2.34 (±0.85). A statistically significant reduced 3D error was observed at entry point <italic>p</italic> = .037, at implant apex <italic>p</italic> = .008, and also in angular deviation <italic>p</italic> = .030 in mandible when comparing to maxilla.</p></sec><sec><title> Conclusions</title><p> The surgical template used has proved high accuracy for implant insertion. Within the limitations of the present study, the protocol for comparing a digital file (treatment plan) with postinsertion digital impression may be considered a useful procedure for assessing surgical template accuracy, avoiding radiation exposure, during postoperative CBCT scanning.</p></sec></abstract></article-meta></front><body><sec id="sec1"><title>1. Introduction</title><p>Nowadays, cone beam computed tomography (CBCT), advanced technology at reasonable costs and low radiation dose [<xref rid="B1" ref-type="bibr">1</xref>, <xref rid="B2" ref-type="bibr">2</xref>], made it possible to better visualize the underlying bone structures for a more precise implant rehabilitation comparing to the standard two-dimensional (2D) radiography.</p><p>Proper implant position, “prosthetically driven,” is fundamental in order to achieve an aesthetic and functional implant-supported restoration [<xref rid="B3" ref-type="bibr">3</xref>] and can be analyzed and planned with the assistance of numerous types of dedicated software [<xref rid="B4" ref-type="bibr">4</xref>].</p><p>In order to transfer the planned implant position information to the clinical situation, Jung and coworkers [<xref rid="B5" ref-type="bibr">5</xref>] defined two types of techniques: “static,” applying surgical templates, and “dynamic,” transferring the selected implant position to the surgical area via visual imaging tools on a monitor. Dynamic guided implant surgery allows the surgeon to adjust the implant position in real time but is not frequently used, mostly due to the initial high costs of the equipment requested [<xref rid="B6" ref-type="bibr">6</xref>].</p><p>Static guided implant surgery is preferred due to increased predictability, reduced invasiveness of surgical procedures [<xref rid="B7" ref-type="bibr">7</xref>], less healing period required, decreasing treatment time, and increasing patient satisfaction [<xref rid="B8" ref-type="bibr">8</xref>].</p><p>The accuracy of a guided implant surgery system is defined as the deviation between the planned and placed position of an implant [<xref rid="B4" ref-type="bibr">4</xref>].</p><p>Implant positioning accuracy is crucial especially when immediate restoration is intended and limited space is available and to avoid damaging the vital structures [<xref rid="B9" ref-type="bibr">9</xref>–<xref rid="B11" ref-type="bibr">11</xref>].</p><p>The protocol of static surgical guidance involves several steps from data collection, to planning, surgical template manufacturing, and effective surgical placement of the implants [<xref rid="B12" ref-type="bibr">12</xref>]. Errors can occur at each individual step and the final inaccuracy is the sum of all mistakes.</p><p>Assessing the overall errors with a static guided implant protocol is mandatory in order to<list list-type="roman-lower"><list-item><p>improve the design and manufacturing of the surgical template and the overall protocol of implant insertion,</p></list-item><list-item><p>plan the implant position at a convenient distance, considering the occurrence of insertion inaccuracy, to elude complications and also to avoid damage of vital structures,</p></list-item><list-item><p>provide precise prosthetic reconstructions prior to surgery, resulting in reduced treatment time.</p></list-item></list>The accuracy assessment between planned and placed implant position was, in most of the studies published, based on matching preoperative and postoperative CBCT over the treatment plan [<xref rid="B13" ref-type="bibr">13</xref>–<xref rid="B16" ref-type="bibr">16</xref>], requiring radiological investigation with higher irradiation dose, not in accordance with ALARA principles.</p><p>A method of surgical template accuracy assessment avoiding a second CBCT investigation is needed [<xref rid="B17" ref-type="bibr">17</xref>].</p><p>Therefore, the aim of this study was to evaluate, by superimposition of 3D digital files, the accuracy of computer-guided dental implant insertion in partially edentulous patients using a stereolithographic template with sleeve structure incorporated into the design.</p><p>The null hypotheses of the present study were formulated as follows:<list list-type="order"><list-item><p>Neither angular nor 3D deviations would be found between the planned and placed implant position with the proposed computer-guided surgery protocol.</p></list-item><list-item><p>If present, no statistically significant deviations would be found in all directions between maxillary and mandibular implants inserted.</p></list-item></list></p></sec><sec id="sec2"><title>2. Materials and Methods</title><p>Twenty-five consecutive partially edentulous patients (20 women and 5 men, age ranged between 32 and 66, mean 51 years), included in Classes I and II, according to the American College of Prosthodontists classification [<xref rid="B18" ref-type="bibr">18</xref>], requiring dental implant placement, were enrolled in this prospective clinical study (ClinicalTrials.gov Identifier: <ext-link ext-link-type="uri" xlink:href="https://clinicaltrials.gov/ct2/show/NCT02418117">NCT02418117</ext-link>) conducted, between April 2015 and December 2016, in accordance with ethical principles including the World Medical Association Declaration of Helsinki and approved by the Bioethics Committee of “Carol Davila” University of Medicine and Pharmacy (70/04.06.2015). Written consent of each subject was also obtained.</p><p>Patients with limited bone volume requiring staged bone graft, limited mouth opening (impossibility of using a surgical template), or history of Parkinson disease (impossibility of performing an accurate CBCT) were excluded from the present study.</p><sec id="sec2.1"><title>2.1. Patient Data Collection</title><p>After initial examination, an accurate impression of the surgical site and the opposite arch, for stone casts, was taken to all patients. For perfect 3D matching of the scanned models with the CBCT files, a radiopaque datum tray (R2Tray®, Megagen Implant, Gyeongbuk, Korea) was customized with silicone (Registrado Clear®, VOCO, GmbH, Cuxhaven, Germany) on the dental arch to be restored with implants. Same silicone was utilized for bite registration.</p><p>A larger volume CBCT was performed for each patient with the customized datum tray, using ProMax 3D (Planmeca®, Helsinki, Finland) with a rotation of 360°, for data acquisition. All CBCTs were performed with the following characteristics: field of view (FOV: height and diameter) was 160 mm and 160 mm, voxel size was 0.3 mm, and the exposure factors were 110 kV, 6.0 mA, and 13.779 s exposure time, patient's Camper plan (Ala-Tragus) parallel to horizontal plane.</p><p>A series of axially sliced image data were obtained and exported to a personal computer in DICOM (Digital Imaging and Communications in Medicine) format. Stone models, individually and in centric occlusion and datum trays, were scanned using a D 700 3D scanner (3Shape®, Copenhagen, Denmark) and imported as stl (standard tessellation language) files.</p></sec><sec id="sec2.2"><title>2.2. Treatment Plan</title><p>DICOM files obtained from CBCT and stl files were imported in a treatment plan software R2GATE version 1.0.0 (Megagen, Gyeongbuk, Korea) and R2Tray was used as landmark for superimposition of the scanned model and underlying bone image. Implants length and diameter were selected and drilling protocol was planned according to the final restoration and bone anatomy (<xref ref-type="fig" rid="fig1">Figure 1</xref>).</p><p>A surgical template was designed and fabricated, for each treatment plan, using Clear Guide M, a light curing material to be used in an additive manufacturing technology (Stereolithography) with EnvisonTEC Perfactory®3D printer (Gladbeck, Germany). The surgical template used is sleeve incorporated (<xref ref-type="fig" rid="fig2">Figure 2</xref>), requiring shank-modified drills for minimizing mechanical tolerance of the instruments and increasing accuracy, as described by Lee and coworkers [<xref rid="B19" ref-type="bibr">19</xref>].</p></sec><sec id="sec2.3"><title>2.3. Implant Surgery</title><p>All 65 implants inserted were AnyRidge® (Megagen Implant, Gyeongbuk, Korea) and all surgeries were performed according to the manufacturer's instructions, by one experienced surgeon, under local anesthesia, using flapless, minimally invasive technique.</p><p>Perfect fit of the template was assessed prior to surgery (on the diagnostic gypsum cast) and intraorally, on adjacent teeth. Adequate mouth opening after surgical template insertion was also verified in order to avoid displacement of the surgical instruments during site preparation.</p><p>The tooth-supported surgical template was applied over the edentulous area and adjacent teeth and the corresponding shank-modified drills were used (Figures <xref ref-type="fig" rid="fig3">3(a)</xref> and <xref ref-type="fig" rid="fig3">3(b)</xref>).</p><p>A fully guided site preparation and implant insertion was performed. Implants were inserted using a hand ratchet up to the required landmark in order to reproduce the planned insertion depth (<xref ref-type="fig" rid="fig4">Figure 4</xref>).</p></sec><sec id="sec2.4"><title>2.4. Accuracy Assessment</title><p>After implant insertion, digital impression was performed using the intraoral scanner CS 3500 (Carestream Health, Inc., Rochester, NY, USA). Standard scan abutment was screwed onto each implant prior to impression (<xref ref-type="fig" rid="fig5">Figure 5</xref>) and the obtained stl file was imported in Geomagic Qualify 2013 software (Rock Hill, SC, USA). The stl file of the corresponding inserted implant (length and diameter) was then attached to each implant by perfect matching of the scan abutment, using<italic> best fit algorithm</italic>.</p><p>Treatment plan exported from R2GATE software, as stl file as well, with scan abutment included was also imported in Geomagic Qualify 2013 software and the corresponding implant stl file was added for each fixture.</p><p>For examining the deviation between the planned and placed position of each implant, treatment plan data set and digital impression with scan abutments were superimposed.</p><p>Treatment plan was set as reference, the 3D coordinate axes were defined (<italic>x</italic>: buccolingual, <italic>y</italic>: mesiodistal, and <italic>z</italic>: apicocoronal), and the digital impression was aligned to the reference using the best fit algorithm [<xref rid="B20" ref-type="bibr">20</xref>]. Alignment was performed for perfect matching of the neighboring teeth.</p><p>To facilitate an accurate evaluation, irrelevant areas, beyond the field of interest, were removed.</p><p>The entire work flow is presented in <xref ref-type="fig" rid="fig6">Figure 6</xref>.</p><p>For accuracy analysis the following parameters were assessed [<xref rid="B17" ref-type="bibr">17</xref>] using Geomagic Qualify 2013 software (<xref ref-type="fig" rid="fig7">Figure 7</xref>):<list list-type="roman-lower"><list-item><p>3D error at the entry point measured at the center of the implant (in mm),</p></list-item><list-item><p>3D error at the apex measured at the center of the implant apex (in mm),</p></list-item><list-item><p>angular deviation,</p></list-item><list-item><p>vertical deviation at entry point measured at the center of the implant (on <italic>z</italic>-axis).</p></list-item></list>The 3D deviation was calculated by the software taking into consideration the deviation on each direction set as follows: <italic>x</italic> = buccolingual error, <italic>y</italic> = mesiodistal error, and <italic>z</italic> = apicocoronal error, using Pythagorean Theorem [<xref rid="B17" ref-type="bibr">17</xref>]:<disp-formula id="eq1"><label>(1)</label><mml:math id="M1"><mml:mtable style="T1"><mml:mtr><mml:mtd><mml:mn mathvariant="normal">3</mml:mn><mml:mi mathvariant="normal">D</mml:mi><mml:mo> </mml:mo><mml:mo> </mml:mo><mml:mi mathvariant="normal">d</mml:mi><mml:mi mathvariant="normal">e</mml:mi><mml:mi mathvariant="normal">v</mml:mi><mml:mo>.</mml:mo><mml:mo>=</mml:mo><mml:msqrt><mml:msup><mml:mrow><mml:mi>x</mml:mi></mml:mrow><mml:mrow><mml:mn mathvariant="normal">2</mml:mn></mml:mrow></mml:msup><mml:mo>+</mml:mo><mml:msup><mml:mrow><mml:mi>y</mml:mi></mml:mrow><mml:mrow><mml:mn mathvariant="normal">2</mml:mn></mml:mrow></mml:msup><mml:mo>+</mml:mo><mml:msup><mml:mrow><mml:mi>z</mml:mi></mml:mrow><mml:mrow><mml:mn mathvariant="normal">2</mml:mn></mml:mrow></mml:msup></mml:msqrt><mml:mo>.</mml:mo></mml:mtd></mml:mtr></mml:mtable></mml:math></disp-formula>The three-dimensional differences between planned (reference) and placed implants (test) are also illustrated in a color-coded map after setting ±2 mm as accuracy limit. The significance of color code is: green, perfectly matching surface (error ± 0.0995 mm), yellow, test model positively positioned relative to reference, error between +0.0996 and +0.7297 mm, orange, error between +0.7298 and +1.3598, red, error between +1.3599 mm and +2.0000 mm, blue, test model surface negatively positioned relative to reference surface, from – 0.0996 mm (light blue) to −2.0000 mm (dark blue), and gray, test model surface positioned outside the accuracy limit being set (<xref ref-type="fig" rid="fig8">Figure 8</xref>).</p><p>Immediate or conventional loading of implants was planned according to the CBCT presurgical evaluation and performed after measurements of insertion torque value (ITV) and implant stability quotient (ISQ) with Osstell Mentor® (Gothenburg, Sweden) and the corresponding SmartPeg [<xref rid="B21" ref-type="bibr">21</xref>].</p><p>Statistical analyses were performed using XLSTAT 2016 (Addinsoft, New York, NY, USA). Mann–Whitney <italic>U</italic> test was used to compare accuracy between maxillary and mandibular surgical templates. A <italic>p</italic> value < .05 was considered significant.</p></sec></sec><sec id="sec3"><title>3. Results</title><p>A total of sixty-five implants were inserted in twenty-five partially edentulous patients: thirty-two in the maxilla and thirty-three in the mandible using tooth-supported surgical templates and a flapless technique. Neither complications nor unexpected events occurred during implants insertion.</p><p>Loading protocol was performed as follows: eleven implants were immediately loaded with screw-retained acrylic crowns manufactured prior to surgery, fourty-four implants were early loaded (after 6 weeks' healing period), and ten implants were conventionally loaded due to additional bone graft requirements of the specific sites [<xref rid="B22" ref-type="bibr">22</xref>]. No implant was lost at 12 months' follow-up, meaning a 100% survival rate.</p><p>The mean length and diameter of the AnyRidge (Megagen Implant, Gyeongbuk, Korea) implants inserted were 9.74 mm (±1.48) and 4.03 mm (±0.40), respectively.</p><p>The mean (and standard deviation) of 3D error at the entry point was 0.798 mm (±0.52) and at the implant apex was 1.17 mm (±0.63) and most of the superimposed surfaces were green mapped (error ± 0.0995 mm), indicating a high accuracy level between model (treatment plan) and test (implants placed).</p><p>However, differences in accuracy were noticed when analyzing implants inserted in maxilla and mandible (Figures <xref ref-type="fig" rid="fig9">9</xref><xref ref-type="fig" rid="fig10"></xref>–<xref ref-type="fig" rid="fig11">11</xref> and <xref ref-type="table" rid="tab1">Table 1</xref>). For the mandible, a significantly lower 3D error was observed at entry point <italic>p</italic> = .037, at implant apex <italic>p</italic> = .008, and also in angular deviation <italic>p</italic> = .030 when comparing the 3D error of the implants inserted in the maxilla. No significant difference in accuracy between maxilla and mandible was noticed regarding vertical deviation at entry point (<italic>p</italic> = .314).</p></sec><sec id="sec4"><title>4. Discussion</title><p>To our knowledge, this is the first study assessing in vivo accuracy of computer-guided (static) implant insertion by comparing a digital file (treatment plan) with postinsertion digital impression, without using a postoperative CBCT for this purpose.</p><p>The protocol proposed for evaluating planned and performed implants insertion was designed in accordance with the recommendations stated by Bornstein and coworkers [<xref rid="B23" ref-type="bibr">23</xref>] regarding the use of new methods such as digital impressions for studies on accuracy of guided implant placement.</p><p>In order to compare two virtual objects (treatment plan and scanned implant position), the stl files were imported in Geomagic Qualify software (Rock Hill, SC, USA), recommended as a powerful industrial inspection tool, previously used in dental research to assess conventional impression technique and digital impression [<xref rid="B20" ref-type="bibr">20</xref>] and also intraoral and extraoral scanners [<xref rid="B24" ref-type="bibr">24</xref>].</p><p>The superimposition of the two stl files (treatment plan and digital impression of the implants placed) was performed with point registration, by setting the landmark points on the neighboring teeth. The software then calculated the matrix for the best fit between surfaces (stl files), treatment plan was set as reference, and the locations of the placed implants were compared to the virtually planned implants. A similar superimposition protocol, but for comparing pre- and postoperative CBCT files, was used by Turbush and Turkyilmaz [<xref rid="B25" ref-type="bibr">25</xref>] in an in vitro study on acrylic resin mandible for assessing the accuracy of implant placement by using 3 different types of surgical guide: bone-supported, tooth-supported, and mucosa-supported.</p><p>The point (or marker) based registration used to match the stl files is considered an accurate and fast method for superimposition, but depending on the number and the location of the markers (remaining teeth) [<xref rid="B26" ref-type="bibr">26</xref>]. Therefore, the heterogeneous distribution of the remaining teeth could be considered one of the limitations of the present study.</p><p>The performance of computer-guided implant systems and their accuracy relies on all the cumulative and interactive errors involved, from examination, impression, CBCT data acquisition, and guide manufacturing to the surgical procedure and improvements of templates design should be performed to reduce inaccuracy [<xref rid="B12" ref-type="bibr">12</xref>].</p><p>The aim of this study was to evaluate the accuracy of computer-guided dental implant insertion in partially edentulous patients with the use of a stereolithographic template with sleeve structure incorporated into the design. The drilling system used allowed a higher accuracy of implant placement comparing to the dates recently reported in the literature. From the 65 consecutive implants inserted with the direct drill-guiding system, the placement errors measured were 0.79 (max. 2.30 mm) [<xref rid="B27" ref-type="bibr">27</xref>] at the entry point and 1.17 (max. 3.22 mm) at the apex, within the acceptable lower range of error in the literature. Tahmaseb and coworkers [<xref rid="B17" ref-type="bibr">17</xref>] in a systematic review analyzing data retrieved from 24 studies reported an inaccuracy at the implant entry point of 1.12 mm with maximum of 4.5 mm on 1,530 implants, respectively, and an inaccuracy of 1.39 mm at the apex of implants with maximum of 7.1 mm when measured on 1,465 implants [<xref rid="B17" ref-type="bibr">17</xref>].</p><p>The maximum inaccuracy registered (3.22 mm) was measured for 11.5 mm length implant inserted in the posterior maxilla. The length of the implant, the softer bone in maxilla allowing slightly deviation during hand ratchet insertion, and also the limited access with surgical instruments in the posterior area [<xref rid="B6" ref-type="bibr">6</xref>] could cause this high placement error.</p><p>A significantly better 3D overall positional accuracy was noticed in the mandible comparing to the maxilla, results similar to Ozan et al. [<xref rid="B28" ref-type="bibr">28</xref>] findings. Other studies reported no difference [<xref rid="B17" ref-type="bibr">17</xref>, <xref rid="B29" ref-type="bibr">29</xref>] or lower accuracy [<xref rid="B30" ref-type="bibr">30</xref>, <xref rid="B31" ref-type="bibr">31</xref>] when the guide was used in mandible.</p><p>The most notable error with guided surgery was expected to occur in vertical direction (too superficial implant position) due to the presence of debris in the implant cavity [<xref rid="B12" ref-type="bibr">12</xref>] or to the blockage of the implant holders in the sleeves of the guide during surgery [<xref rid="B32" ref-type="bibr">32</xref>]. However, the use of a guide sleeve incorporated in the design with no need for additional metal sleeves and also the presence of the additional buccal window allowed debris removal during drilling and irrigation results in a reduced vertical deviation 0.50 (±0.38) when compared to Farley and coworkers findings (1.24 mm ± 0.78 mm). The obtained values were also lower comparing to the findings of Lee and coworkers [<xref rid="B19" ref-type="bibr">19</xref>] on 21 consecutive implants. The authors reported a 0.925 (±0.376) depth inaccuracy using the same type of surgical template but a different implant (AnyOne, Megagen Implant, Gyeongbuk, Korea), involving different drilling sequences.</p><p>The angle deviation value 2.34 (±0.85) from the present study was lower than the mean rate (3.89) reported in the systematic review conducted by Tahmaseb and coworkers [<xref rid="B17" ref-type="bibr">17</xref>] but similar to the deviations reported by Lee and coworkers [<xref rid="B19" ref-type="bibr">19</xref>] utilizing the same guided implant system. The sleeve incorporated stereolithographic surgical template for flapless implant insertion is designed to lower mechanical tolerance of surgical instruments [<xref rid="B19" ref-type="bibr">19</xref>], considered by Vercruyssen and coworkers [<xref rid="B12" ref-type="bibr">12</xref>] a source of error occurring during execution phase, leading to improper implant positioning.</p><p>Generally, the inaccuracy of the implants insertion expressed by the four parameters recommended being assessed [<xref rid="B33" ref-type="bibr">33</xref>]: deviation at the entry point; deviation at the apex; deviation of the long axis (angular deviation); and deviation in height/depth registered in our study lower values than the mean obtained from other studies confirming that the use of shank-modified drills and sleeve incorporated stereolithographic templates is an effective way to improve the accuracy of implant placement.</p><p>The results of this study support the rejection of the null hypothesis, both regarding the inaccuracy between planned and inserted implants and also regarding 3D deviation in maxilla and mandible implants.</p></sec><sec id="sec5"><title>5. Conclusions</title><p>The surgical template with sleeve incorporated, designed to reduce mechanical tolerance of surgical instruments, used in the present study has proved high accuracy for dental implants insertion.</p><p>By comparing the treatment plan digital file with postinsertion digital impression, without requiring postoperative CBCT for assessing implant placement accuracy, a further radiation exposure may be avoided. However, a validation study comparing error analysis using postoperative CBCT versus intraoral optical scans should be performed in order to evaluate the potential errors arising from impression taking (error of the optical scanner), superimposition of the surfaces, segmentation of implants in the software, error calculation algorithm, and so forth.</p><p>Within the limits of the present study, assessment of insertion accuracy by comparing treatment plan stl file and optical impression of implants placed may be considered a promising protocol for guided surgery evaluation in larger prospective clinical trials.</p></sec></body><back><ack><title>Acknowledgments</title><p>The authors thank Megagen Dental Implant Romania for providing all the required AnyRidge implants, Dr. Roen Boiangiu and FM Medident Dental X-Ray Institute, Bucharest, Romania, for performing CBCT according to the established protocol, and Mr. Eugen Stanciu and Mr. Cristian Butnarasu, M.S. degree students at University Politehnica of Bucharest, for assisting with data collection, files superimposition, and statistical analysis.</p></ack><sec><title>Conflicts of Interest</title><p>The authors declare that there are no conflicts of interest regarding the publication of this paper.</p></sec><ref-list><ref id="B1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Guerrero</surname><given-names>M. 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J.</given-names></name><name><surname>Mercelis</surname><given-names>P.</given-names></name><name><surname>De Clerck</surname><given-names>R.</given-names></name><name><surname>Wismeijer</surname><given-names>D.</given-names></name></person-group><article-title>Parameters of passive fit using a new technique to mill implant-supported superstructures: an in vitro study of a novel three-dimensional force measurement-misfit method</article-title><source><italic>The International Journal of Oral & Maxillofacial Implants</italic></source><year>2010</year><volume>25</volume><issue>2</issue><fpage>247</fpage><lpage>257</lpage><pub-id pub-id-type="pmid">20369082</pub-id></element-citation></ref><ref id="B33"><label>33</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vercruyssen</surname><given-names>M.</given-names></name><name><surname>Hultin</surname><given-names>M.</given-names></name><name><surname>Van Assche</surname><given-names>N.</given-names></name><name><surname>Svensson</surname><given-names>K.</given-names></name><name><surname>Naert</surname><given-names>I.</given-names></name><name><surname>Quirynen</surname><given-names>M.</given-names></name></person-group><article-title>Guided surgery: accuracy and efficacy</article-title><source><italic>Periodontology 2000</italic></source><year>2014</year><volume>66</volume><issue>1</issue><fpage>228</fpage><lpage>246</lpage><pub-id pub-id-type="doi">10.1111/prd.12046</pub-id><pub-id pub-id-type="other">2-s2.0-84902541292</pub-id><pub-id pub-id-type="pmid">25123771</pub-id></element-citation></ref></ref-list></back><floats-group><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Planned implant insertion in R2GATE® software.</p></caption><graphic xlink:href="IJD2017-4292081.001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>The stereolithographic surgical guide utilized in all cases had the guide sleeve incorporated in the design, eliminating the need for additional insertion of metal guide sleeves. All surgical drills used had 3 parts: the stopper part, the guide part, and the drilling part [<xref rid="B19" ref-type="bibr">19</xref>]. Stopper and guide parts are identical for all drills and especially designed for R2Gate® surgical template. Drilling part varies in length and diameter according to the drilling protocol.</p></caption><graphic xlink:href="IJD2017-4292081.002"></graphic></fig><fig id="fig3" orientation="portrait" position="float"><label>Figure 3</label><caption><p>(a) Surgical template applied over the edentulous area and adjacent teeth. (b) Second drill used for flapless implant site preparation.</p></caption><graphic xlink:href="IJD2017-4292081.003"></graphic></fig><fig id="fig4" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Implant insertion with hand ratchet. The ratchet connector has six green vertical landmarks (corresponding to implant hex) and a horizontal reference line. In order to reproduce the planned implant position, the horizontal reference line should match with the upper border and the green vertical landmark with the window of the surgical template.</p></caption><graphic xlink:href="IJD2017-4292081.004"></graphic></fig><fig id="fig5" orientation="portrait" position="float"><label>Figure 5</label><caption><p>Digital impression of the implants after screwing the scan abutment.</p></caption><graphic xlink:href="IJD2017-4292081.005"></graphic></fig><fig id="fig6" orientation="portrait" position="float"><label>Figure 6</label><caption><p>Study workflow.</p></caption><graphic xlink:href="IJD2017-4292081.006"></graphic></fig><fig id="fig7" orientation="portrait" position="float"><label>Figure 7</label><caption><p>Measurement of 3D accuracy of the planned (reference) and effective implant insertion (test), <italic>∗</italic> represents degree symbol (°) as it measures an angle.</p></caption><graphic xlink:href="IJD2017-4292081.007"></graphic></fig><fig id="fig8" orientation="portrait" position="float"><label>Figure 8</label><caption><p>Qualitative color-codded graphical analysis of implants planned (reference) and placed (test) in Geomagic Qualify® software.</p></caption><graphic xlink:href="IJD2017-4292081.008"></graphic></fig><fig id="fig9" orientation="portrait" position="float"><label>Figure 9</label><caption><p>Mean 3D error at entry point, measured at the center of the implant in mandible and maxilla.</p></caption><graphic xlink:href="IJD2017-4292081.009"></graphic></fig><fig id="fig10" orientation="portrait" position="float"><label>Figure 10</label><caption><p>Mean 3D error at the apex measured at the center of the implant in mandible and maxilla.</p></caption><graphic xlink:href="IJD2017-4292081.010"></graphic></fig><fig id="fig11" orientation="portrait" position="float"><label>Figure 11</label><caption><p>Mean angular deviation for implants inserted in mandible and maxilla.</p></caption><graphic xlink:href="IJD2017-4292081.011"></graphic></fig><table-wrap id="tab1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Discrepancy values at entry point, apex, angular deviation, and vertical deviation.</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2" align="left" colspan="1"> </th><th rowspan="2" align="center" colspan="1">Overall (<italic>n</italic> = 65) implants <break></break>Mean (SD)</th><th colspan="3" align="center" rowspan="1"> Mandible (<italic>n</italic> = 33 implants)</th><th colspan="3" align="center" rowspan="1"> Maxilla (<italic>n</italic> = 32 implants)</th></tr><tr><th align="center" rowspan="1" colspan="1">Mean (SD)</th><th align="center" rowspan="1" colspan="1">Max.</th><th align="center" rowspan="1" colspan="1">Min.</th><th align="center" rowspan="1" colspan="1">Mean (SD)</th><th align="center" rowspan="1" colspan="1">Max.</th><th align="center" rowspan="1" colspan="1">Min.</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">3D error entry point (mm)</td><td align="center" rowspan="1" colspan="1">0.79 (±0.52)</td><td align="center" rowspan="1" colspan="1">0.65 (±0.43)</td><td align="center" rowspan="1" colspan="1">1.59</td><td align="center" rowspan="1" colspan="1">0.11</td><td align="center" rowspan="1" colspan="1">0.94 (±0.56)</td><td align="center" rowspan="1" colspan="1">2.30</td><td align="center" rowspan="1" colspan="1">0.04</td></tr><tr><td align="left" rowspan="1" colspan="1">3D error apex (mm)</td><td align="center" rowspan="1" colspan="1">1.17 (±0.63)</td><td align="center" rowspan="1" colspan="1">0.96 (±0.49)</td><td align="center" rowspan="1" colspan="1">2.00</td><td align="center" rowspan="1" colspan="1">0.32</td><td align="center" rowspan="1" colspan="1">1.38 (±0.69)</td><td align="center" rowspan="1" colspan="1">3.22</td><td align="center" rowspan="1" colspan="1">0.18</td></tr><tr><td align="left" rowspan="1" colspan="1">Angular deviation (degree)</td><td align="center" rowspan="1" colspan="1">2.34 (±0.85)</td><td align="center" rowspan="1" colspan="1">2.11 (±0.88)</td><td align="center" rowspan="1" colspan="1">3.90</td><td align="center" rowspan="1" colspan="1">0.50</td><td align="center" rowspan="1" colspan="1">2.58 (±0.75)</td><td align="center" rowspan="1" colspan="1">4.22</td><td align="center" rowspan="1" colspan="1">1.08</td></tr><tr><td align="left" rowspan="1" colspan="1">Vertical deviation at entry point (<italic>z</italic>-axis, mm)</td><td align="center" rowspan="1" colspan="1">0.50 (±0.38)</td><td align="center" rowspan="1" colspan="1">0.46 (±0.34)</td><td align="center" rowspan="1" colspan="1">1.54</td><td align="center" rowspan="1" colspan="1">0.00</td><td align="center" rowspan="1" colspan="1">0.55 (±0.42)</td><td align="center" rowspan="1" colspan="1">1.96</td><td align="center" rowspan="1" colspan="1">0.02</td></tr></tbody></table></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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