"Use of Dynamic Navigation for Dental Implant Surgery" by Dr. Jan D’haese Ghent University March, 2015
Although osseo-integration of dental implants is predictable1, thorough pre-operative planning is a prerequisite for a successful treatment outcome.2 Anatomic limitations as well as prosthetic considerations encourage the surgeon to obtain a very precise positioning of the implants. Historically, standard radiographic imaging techniques (intra-oral and panoramic) were available for investigation of potential implant sites. Throughout the years, spiral tomography and computed tomography (CT) were often used as a diagnostic tool.3 These techniques provide a 2-dimensional cross section image of the desired implant location and enables a detailed bucco-lingual view of the dimensions of the jawbone. Nowadays, it is well known that 3-dimensional CT scan based pictures allow a more reliable treatment planning than when only 2-dimensional data are available.4 Transforming the CT scan images into a 3D virtual image can be achieved using computer software packages,5 allowing for a 3D viewing using Computer Aided Design (CAD) technology. For years, stereolithographic guided surgery seemed to be the golden standard in computer guided implant surgery. The technique has been well developed over the last years and several scientific reports have been published regarding accuracy, complications, survival and success6. Real-time navigation seems to be a valuable alternative to stereolithographic (static) guided surgery as it offers the clinician some advantages compared to the former technique. Using real-time (dynamic) navigation one can avoid the fabrication of a stereolithographic template resulting in a less expensive treatment. As navigation is considered as a dynamic guided surgery system, changes to the treatment planning (location and size of the implants, number of the implants, flap or flapless…) can be easily made intra-operatively.
The first patient treated was a 59 year-old female consulting the dental office for replacement of two premolars in the maxilla, in locations 15 and 24 (Fig. 1, Fig. 2, Fig. 3). Patient was in good general condition and was a nonsmoker. Intraoral examination revealed numerous amalgam fillings and some metal-porcelain crowns (Fig. 4). Teeth 15 and 24 had to be extracted previously due to cariogenic process. Periodontal screening showed no signs of pathology. Treatment involved placement of 2 osseo-integrated implants in the edentulous regions of the maxilla.
The second patient was a 55 year-old male visiting the office to restore a recently extracted lateral incisor (Fig. 5, Fig. 6). He was a non-smoker, in good general health and not suffering from any systemic disease. Intra-oral examination showed several crowns in the maxilla and a residual root fragment in location 15 (Fig. 7, Fig. 8). Patient suffered from moderate periodontal breakdown. This periodontal condition has been present yet stable for several years.
For both of the patients, impressions of the dental arch were taken prior to implant installation using an irreversible hydrocolloid (Cavex CA37, fast set, Cavex Holland BV, Haarlem, The Netherlands) to fabricate a diagnostic cast (Fig. 9). This cast was used as a model for the molding of theNaviStent in order to have a perfect fit. The NaviStent serves as scanning template and is worn by the patient during the scanning procedure and the surgery. (Fig. 10).
Afterwards, the patient was sent to the CBCT and a scan was made with the NaviStent in place.
A standard CBCT scan was performed according to the procedure outlined in the scanning protocol by Navident (Navident, Toronto, Canada).
The CBCT images were converted into a DICOM image (digital imaging and communications in medicine) and transformed into a 3-D virtual model using the Navident software system. The clinician who placed the virtual implants in the resulting 3-dimensional model also performed the actual surgeries. The potential locations for implant placement, and corresponding implant lengths and widths were planned in a prosthetically driven way. A distance of at least 3 mm from the neck of implant to the gingival zenith was applied, allowing the biological width to create a connective tissue contour around the abutments.
The surgery was performed under local-regional anaesthesia. Appropriate aseptic and sterile conditions prevented post-operative infections. During the operation, the NaviStent was placed over the remaining teeth (Fig. 11). The NaviStent was primarily fixated around the undercuts of the remaining teeth and additionally by application of a denture adhesive (prothese kleefcreme).
The osteotomies were prepared at maximum of 1500 rpm using the Navident navigation system to guide the drilling procedure in real-time by indicating the desired drilling pathway on the computer screen. Prior to the use of each new drill, a calibration process is performed (Fig. 12). No punching of the gingival tissues was performed prior to the preparation of the implant sites.
In the first patient, 2 Xpeed® Anyridge® implants (Megagen, Seoul, South-Korea) were installed. At locus 15; a 10 mm length and a 4 mm wide fixture was inserted whereas at locus 24 a 13 mm length and a 3,5 mm diameter wide implant was installed (Fig. 13, Fig. 14, Fig. 15).
In the second patient, a solitaire Xpeed® Anyridge® implant with a length of 10 mm and a diameter of 3,5 mm was placed at locus 22 (Fig. 16, Fig. 17). An Xpeed® Anyridge® implant consists of a nanolayer of calcium ions incorporated on the sandblasted, large-grit, acid-etched (SLA) implant surface. All the implants were inserted into the maxilla with a maximum insertion torque of 35 Ncm.
As the implant fixtures were also calibrated for use with the navigation system (Fig. 18), their exact position could also be tracked during insertion. This means that both implant preparation drilling and the implant placement process are tracked in real time. Depth of drilling and placement are guided by Navident using on screen visual representation and auditory cues to aid the clinician. Immediately after implantation, cover screws were placed onto the implants and hand torqued (Fig. 19, Fig. 20).
Postoperatively, patient received a prescription for antibiotics (amoxicilline 1000 mg, 2x/d, 4 days), for non-steroidal anti-inflammatory drugs (ibuprofen 600mg, 3x/d) and for a mouthwash (chlorhexidine 0,12%, 2x/d). After 1 week, a post-operative visit was scheduled. No signs of infection or inflammation were present as the healing went on uneventfully (Fig. 21, Fig. 22, Fig. 23).
In a one week postoperative follow up the patients reported no pain or swelling associated with the dental implant procedure. Further postoperative results are being tracked and reported as part of a qualitative study being done in cooperation with the University of Ghent. The potential of the Navident dynamic navigation system with regard to minimally invasive and accurate implant surgeries will be evaluated during this study.
1. Albrektsson T, Dahl E, Enbom L, et al. Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. J Periodontol 1988; 59:287–296.
2. Jacobs R, Adriansens A, Naert I, Quirynen M, Hermans R, van Steenberghe D. Predictability of reformatted computed tomography for preoperative planning of endosseous implants. Dentomaxillofacial Radiology 1999; 28,37–41.
3. Rothman SL, Chaftez N, Rhodes ML, Schwarz MS. CT in the preoperative assessment of the mandible and maxilla for endosseous implant surgery. Work in progress. Radiology 1988; 168:171–175.
4. Jacobs, R., Adriansens, A., Verstreken, K., Suetens, P. & van Steenberghe, D. Predictability of a three-dimensional planning system for oral implant surgery. Dentomaxillofacial Radiology 1999; 28:105–111.
5. Israelson H, Plemons JM, Watkins P, Sory C. Barium-coated surgical stents and computer- assisted tomography in the preoperative assessment of dental implant patients. Int J Periodontics Restorative Dent 1992; 12:52–61.
6. D’haese J, Van De Velde T, Komiyama A, Hultin M, De Bruyn H. Accuracy and Complications Using Computer-Designed Stereolithographic Surgical Guides for Oral Rehabilitation by Means of Dental Implants: A Review of the Literature Clin Impl Dent Rel Res 2012; 14: 321–335
Navident is cleared by the FDA for sale in the United States. Navident is approved for commercial sales and distribution in Canada by Health Canada. It has also received the CE mark; please contact ClaroNav.
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"Dynamic navigation for precise Implantation in cases of critical anatomy" by Dr David Burgess, United Kingdom 2017
Using the CBCT image as a map, dynamic navigation guides surgeons just like a GPS guides drivers. The clinician virtually plans where implants should be placed. During surgery, the navigation system dynamically tracks the drill and the patient’s jaw, providing guidance and visual feedback to ensure the implants are placed according to plan.
There are several advantages with dynamic navigation. The technology allows clinicians to place implants more accurately than free-hand. This results in improved safety and aesthetics, as it helps the clinician to anticipate and to avoid potential complications. Other advantages are the ability to have more minimal invasive treatments, which means less chair time, less patient discomfort and less recovery time. This treatment option has generally been seen as a ‘blind’ procedure in the past, but the ability to avoid delicate anatomical structures due to the real-time surgical feedback makes so-called flapless surgery a valuable option.
In the following case report, Dr David Burgess describes how using computer-guided dynamic navigation helped him overcome clinical challenges for dental implant placement in the lower posterior region.
A 75-year-old male patient had endured a gap for five years, following removal of his lower left second molar, due to an acute apical infection. He was finding mastication increasingly difficult and sought advice about the treatment options available.
Planning for optimum implant positioning
As there was no tooth distal to the space, conventional fixed bridgework was not possible. The treatment options were either a unilateral single saddle lower partial denture or restoration of the space with two dental implants. The patient chose to have dental implant treatment as he did not wish to have any form of removable prosthesis.
What makes Navident dynamic navigation stand out is it precisely guides the surgeon to prepare and place the implant in a pre-determined position (Figure 1). This allows me to achieve greater accuracy and certainty than I have previously been able to, using conventional protocols. Whilst there is no physical guide, a simple scanning template (NaviStent) is used to hold the fiducial in place whilst taking the CT scan, and secure the jaw reference (JawTag) for the navigated osteotomy.
In this case, the Navistent was fabricated, the fiducial marker attached and a CBCT scan taken two weeks prior to surgery (Figure 2). The treatment plan was created immediately after the scan (Figure 3), with the patient present. He was able to see the proposed treatment displayed by the Navident software and appreciated that great care was being taken to achieve the optimum implant positioning, with minimal risk of potential complications (Figure 4). The patient was extremely impressed with, and reassured by, the state-of-the-art technology.
Confidence from continuous feedback Treatment was carried out under local anaesthesia. Prior to preparation of the implant sites, the simple Navident protocol for calibration and verification of the drill axis and drill tip was carried out. A crestal incision was made, with a minimal flap reflected. The software shows the drill position on the scan in real time, as it enters the jaw. This allows adjustments to be made, if necessary, whilst the site is being drilled. Two DENTSPLY ANKYLOS® CX 3.5mm diameter dental implants were placed sub-crestally in the lower left first and second molar sites, with implant lengths of 11mm and 9.5mm respectively.
Avoiding damage to the inferior alveolar nerve was a crucial factor in the treatment planning of this case. Access was difficult, due to the limited opening of the patient’s mouth. The issue was compounded by the plan to place an implant as distal as the second molar. These challenges were overcome using Navident’s continuous internal visual feedback, which gave me the confidence to use the optimum length of implant, whilst staying within a safe distance from the inferior alveolar nerve and avoiding post-surgical complications, such as paraesthesia.
Navident provided guidance for accurate implant location, even with restricted visibility and the drill being impeded by opposing teeth. Tactile feedback can often be reduced when using a physical drill guide. Dynamic navigation removes this obstacle. I was able to achieve the best buccal and lingual position of the implants, and their relation to each other and to adjacent teeth (Figure 5). This would allow for optimal shape, position and occlusal function of the final restorations.
ANKYLOS® Balance posterior sulcus formers were fitted and the incision was closed with simple interrupted sutures. There was no need for bone augmentation. Two to three months after surgery, the implants will be restored with ATLANTIS® custom-made CAD/CAM titanium abutments and screw-retained linked zirconia crowns.
The clinical outcome was excellent. The planned placement was restoratively driven and the implants were well positioned, with good primary stability. Having used the Navident dynamic navigation system for more than a year, I would not want to go back to preparing and placing dental implants without its 3D visual guidance. The patient was comfortable and reassured, with no post-operative pain, swelling, bruising or paraesthesia. He was delighted and, if he needed any implant treatment in the future, would insist on dynamic navigation.
About Dr David Burgess BDS DPDS MScConSed
David Burgess has been principal of Carbis Bay Dental Care in Cornwall since 1988 and has placed over 2,000 implants. Throughout his career, David has striven to combine clinical perfection with the ultimate in patient care. He has been a willing pioneer of new technology, particularly in the field of digital dentistry. David was the first UK clinician to introduce the Navident dynamic navigation system into his implant treatment workflow, with the objective of achieving a higher degree of precision and greater patient comfort.
David Burgess is also a member of the Dynamic Navigation Society as a Master Clinical Trainer, providing courses for implantologists who wish to experience how dynamic navigation can help to simplify their digital workflow. More information can be found on http://dns.claronav.com
"FLAPLESS IMPLANT PLACEMENT WITH AN INTERNAL SINUS LIFT USING DYNAMIC GUIDED NAVIGATION" by Naheed Mohamed, DMD 2017
Today implant surgery is focused on being minimally invasive with an emphasis on prosthetically guided implant placement. Implants which are not placed in a prosthetically favorable position are at risk for future complications involving the prosthetic components or peri-implant tissues. Successful implant placement is not only judged by osseointegration but also the esthetics. In a climate where implant therapy is held to the highest of standards; using advanced tools to simplify surgical dental implant placement is a requisite for success.
Currently computer guided surgery involves the use of a CBCT (cone beam computer tomography) scan and possibly an intra-oral scan to allow personalized digital surgical planning. This plan is then transferred to the patient in the form of a surgical guides to aid in accurate implant placement. These guides however are static and do have some drawbacks. They are not always stable depending on whether they are supported by teeth, mucosa, or bone. Limited mouth opening does become an issue when surgical guides are used to place implants for posterior dentition. And lastly if there is any error in the digital planning, segmentation of the anatomy, or data transfer to the guide fabrication, the error is passed down onto the guide’s implant position. If errors are noted during surgery, then the guide becomes essentially useless.
The next evolution in guided dental implant surgery comes from neurosurgery and orthopedic spine surgery where it has been used for quite some time. Claronav Inc has developed a live navigation system using optical tracking cameras (Fig 1) during implant surgery to provide the surgeon with CBCT based real-time three dimensional drill guidance during implant surgery. One of the main advantages of this Navident system (Fig1) is that dynamic navigation allows intra-operative changes to implant position in real time if any errors or anatomical complexities are noted during the surgery. The flexibility of having a guided implant placement in a digitally planned ideal location without the need for a static surgical stent and having the osteotomies live navigated on CBCT data using optical tracking is a game changer for implant dentistry. This open system also has the flexibility of using any implant system and any drill to guide placement. The case presented below showcases the flexibility of real time navigation where Straumann implant drills are used for placement of an implant with a simultaneous internal sinus lift using the Hiossen CAS-KIT drills with the Navident system.
The patient was 57 year old healthy female that was referred to our clinic to replace the missing maxillary second premolar at the 2.5(13) site with a dental implant. The Navident workflow consists of four main sequential steps: stent fabrication, CT(computer tomography) scan with the stent and affixed CT marker in the patient’s mouth, digitally planning the implant surgery in the Navident software, and lastly completing the live guided implant surgery. One of the biggest advantages of the Navident system is that these four sequential steps can all be completed in one appointment provided the clinic has an available CBCT scanner.
The NaviStent functions as a retainer onto which the CT marker is affixed to while the patient undergoes her CBCT scan. The NaviStent is a custom single use retainer made of a thermoplastic material called Naviplast than can be heated in hot water and molded to the patient’s dentition. The stent was trimmed and the planned implant site was cut open to expose the ridge. The CT marker was then fixed to the stent by way of a thumb screw. The NaviStent with the attached CT Marker was placed into the patient’s mouth. The stent was checked for stability in the patient’s mouth. A CBCT scan was completed for the entire maxillary arch being sure to include the arm of the CT marker which contains the aluminum fiducial.
The CBCT scan was then imported into the Navident software. The Navident software automatically registers the fiducial and asks you to inspect the registration to ensure there is no malalignment. Our implant position is prosthetically determined, so our first step was to place a virtual crown at the 2.5 (13) site. The vertical height of bone from the ridge to the sinus floor was measured using the software measuring tool and found to be 7.4mm (Fig 2).
Our treatment plan involved placing a Straumann Bone Level Tapered SLActive Roxolid 4.1mm x 10mm implant as a single stage flapless approach with an internal sinus elevation. Taking advantage of the freedom of the Navident system, we were able to plan our surgery to place a Straumann dental implant and complete our internal sinus lift using the HIOSSEN CAS-KIT (Crestal Approach Sinus Kit). To control our drilling depth and use the live navigation to guide us to the sinus, a digital implant was placed in the ideal location with respect to the digital crown. This digital plan would guide us to the sinus floor for the sinus elevation and allow ideal implant placement.
Live Navigation Implant Surgery and Internal Sinus Elevation.
The patient was seated for the implant surgery. Local anesthetic was given. The single use JawTag was fixated to the NaviStent with the provided thumb screw. The tag adapter was mounted onto the surgical handpiece and fastened in place according to the company’s instructions. The single use DrillTag was attached to the tag adapter on the surgical handpiece. The NaviStent was placed into the patient’s mouth with the JawTag visible for the Navident camera to detect. Once the CT markers are visible by the camera, they become visible on the side panel on the monitor. The next step was to calibrate the drill axis by placing the handpiece head onto the calibration peg present on top of the JawTag. The handpiece was then rotated back and forth around the peg to register and calibrate the drill axis. The system then prompts us to calibrate the drill. The initial precision point drill was then placed onto the handpiece and calibrated by placing the drill tip into the dimple present at the center of the target on the JawTag (Fig 3). Once the drill tip was calibrated, it then became visible on the monitor against the CT image when it is placed into the surgical field. Our next step was to verify the drill tip position. This was done easily by placing the tip of the bur on a landmark in the jaw to verify accuracy of its positioning. In our case the tip of the drill was verified by placing it on the cusp tip of the neighboring tooth 2.4 (13). The drill was then brought to the surgical site (Fig 4) and the navigated drilling screen comes up which shows a Target view and cross sectional views of the CT images with the drill image visualized in its real-time position (Fig 5). The target and cross sectional views allow you to position the drill into the ideal digitally planned implant position based on the live view of the drill over the CT images.
The drilling process was started with a precision drill to punch a dimple into the bone and give us a soft tissue bleeding point. The bleeding point was then used as a marker to remove a 4mm diameter of crestal gingiva with a tissue punch. The Straumann pilot drill was then calibrated and verified on the handpiece. The 2.2 mm pilot drill was then used to drill at 800rpm to about 7mm into the osteotomy using the live navigation to guide us into the digitally planned position. The second 2.8mm drill in the Straumann Bone Level Tapered implant protocol was calibrated, verified and live navigated to the desired position at a depth of 7mm into the osteotomy.
The drills were now switched to the Hiossen CAS-KIT drills to allow removal of the cortical bone at the floor of the sinus without damaging the Schneiderian membrane. The CAS-Drill tip has an inverse conical shape that forms conical bone chip as it drills to allow it to safely elevate the sinus membrane without perforating it. The bone particles formed when drilling discharge upwards producing a membrane auto-lift function. The Hiossen CAS 3.3mm drill was used with an 8mm stopper as a back up to prevent us from forcefully pushing too deep into the sinus. The CAS drill was calibrated and verified and then live navigated to access the sinus membrane.
Once the membrane was exposed through the osteotomy, it was elevated using hydraulic pressure with the CAS-Kit Membrane Lifter and sterile saline. Cortical allograft chips were then gentled pushed into the void created from the membrane elevation. The jaw stent was removed and the implant was placed through the osteotomy with direct vision. The Straumann Bone Level Tapered 4.1mm x 10mm implant was placed with 50Ncm of primary stability. A healing abutment was then hand torqued in place (Fig 6). A post-operative peri-apical radiograph (Fig 7) was taken to assess the implant placement. The implant can also be live navigated into place, however it needs to be calibrated by touching the tip of the implant over the JawTag dimple, and due to the risk of contamination we chose to place it with direct vision. The company recommends placing a sterile piece of nylon over the dimple when calibrating the implant to keep the conditions of the implant sterile.
Due to the flapless live guided Navident protocol, we were able to release the patient, with no sutures required and minimal trauma to the site. The patient was prescribed anti-inflammatory analgesics and placed on a 7 day antiobiotic course. Her healing was uneventful with minimal discomfort to the area.
Computer guided placement of dental implants is significantly more accurate than free hand surgery. In areas of complex anatomy, computer guided navigational surgery is superior to conventional implant surgery when it comes to preventing iatrogenic injuries. This technology can contribute to considerable improvement in quality and accuracy of dental implant placement. The live real-time view of the exact position of the drill minimizes the potential risk of damage to critical anatomic structures. The optical tracking system seems to be more accurate and have more flexibility during surgery but does require more training to develop hand eye coordination for using the system. However once mastered, this new system can improve on accuracy of surgery, reduce surgeon anxiety, improve patient confidence, and work as a powerful marketing tool for your practice.
About Naheed Mohamad
Dr. Naheed Mohamed received his Honours Bachelor of Science degree from the University of Toronto. After a year of periodontal research at Mount Sinai Hospital, he attended dental school at Boston University and completed his Doctor of Dental Medicine degree. Graduating from dental school with magna cum laude and the American Academy of Periodontology Dental Student of the Year Award for achievement in Periodontics, Dr. Mohamed further pursued his studies at Case Western Reserve University in Cleveland to complete his specialty training in Periodontics. During his residency he pioneered research in an autologous blood derived material called platelet-rich fibrin and its numerous clinical applications; earning his Masters Degree. Dr. Mohamed is a board certified specialist in the United States and Canada attaining his Diplomate status by the American Board of Periodontology and Fellow of the Royal College of Dentists of Canada. Dr. Mohamed currently maintains a private practice and actively lectures about innovations in Periodontics and Implant surgery.
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