CLINICAL REPORT

Implant placement with an autonomous dental implant robot:

A clinical report
Zhiwen Li, DDS, PhD,a Rui Xie, MSD,b Shizhu Bai, DDS, PhD,c and Yimin Zhao, DDS, PhDd

Proper placement of the ABSTRACT

implant is a prerequisite for Ideal implant placement is the basis for long-term implant survival and satisfactory restoration
immediate postoperative outcomes. Static and dynamic computer-assisted guidance have been used to improve the
restoration and esthetic out- accuracy of implant placement, but both have shortcomings that robots can overcome. This
comes, as well as to ensure the clinical report describes the use of an autonomous implant robot to complete the placement of
optimal occlusion and loading 2 adjacent implants with immediate postoperative restoration. (J Prosthet Dent 2023;-:---)
of the prosthesis.1 A significant
deviation from the planned position of the implant limitations, and the implant surgery is carried out by a
placement may lead to complications,2 hence the hand-held handpiece, affecting the operator’s surgical
importance of accurate implant placement. Freehand accuracy.10
implant surgery relies on the experience of the surgeons, Robots have been used to assist in implant place-
which makes the accuracy of implant placement ment.11-13 An autonomous dental implant robot (ADIR)
uncertain.3 was developed, and its feasibility and safety were
Static guides and dynamic navigation have been established with an animal experiment.14 The placement
applied to dental implant surgery and reported to of 2 implants with an autonomous dental implant robot
improve the accuracy of implant placement compared is described in this clinical report. The robot performed
with freehand.4 However, the static guide technology the entire surgical procedure autonomously under the
does not allow intraoperative adjustment of the position surgeon’s instruction and supervision.
and angle of the implant placement, and the presence of
the guide plate may affect the cooling efficiency of the
CLINICAL REPORT
surgery.5 In addition, the surgeon’s experience impacts
the accuracy of dental implant surgery guided by a A 61-year-old woman presented to the Digital Dentistry
template.6-8 Dynamic navigation technology can provide Center, School of Stomatology, the Fourth Military
the position, angle, and depth of the drill in real-time Medical University, with a chief complaint of decreased
during the surgery, but it requires the surgeon to focus masticatory function because of the loss of her mandib-
continuously on a screen instead of directly observing the ular right second premolar and first molar. A preopera-
operation area, requiring practice to build confidence.9 tive evaluation, including general examination and oral
Moreover, dynamic navigation lacks physical examination, was performed by dentists (R.X., S.Z.B.) for

Funding: Supported by the National Natural Science Foundation of China [Program No. 81970987]. Z.W.L. and R.X. contributed equally to this article.
a
Resident, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Key Laboratory of Stomatology, Digital Dentistry
Center, School of Stomatology, The Fourth Military Medical University, Xi’an, PR China.
b
Resident, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Key Laboratory of Stomatology, Digital Dentistry
Center, School of Stomatology, The Fourth Military Medical University, Xi’an, PR China.
c
Associate Professor, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Key Laboratory of Stomatology, Digital
Dentistry Center, School of Stomatology, The Fourth Military Medical University, Xi’an, PR China.
d
Professor, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Key Laboratory of Stomatology, Digital Dentistry
Center, School of Stomatology, The Fourth Military Medical University, Xi’an, PR China.

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Preoperative Procedure
2. Preoperative 3. Accessories
1. Data Acquisition
Planning Fabrication

Intraoperative Procedure
6. Osteotomies and
5. Path Recording 4. Registration
Implant Placement

7. Accuracy 8. Immediate 9. Definitive

Assessment Restoration Restoration

Postoperative Procedure

Figure 1. Clinical workflow of implant placement by ADIR system. ADIR, autonomous dental implant robot.

2 implants placed with the ADIR. The treatment had and a suction tray to evacuate blood and saline during
been approved by the Medical Ethics Committee of the drilling. Registration holes were designed in the marker
School of Stomatology (Approval No. IRB-REV- holder and suction tray for intraoperative registration
2020050). Informed consent had been obtained, and (Fig. 3A).
the principle of privacy protection was observed. The The interim prosthesis, marker holder, prop, and
clinical workflow for implant surgery using ADIR is suction tray were fabricated preoperatively by 3-dimen-
shown in Figure 1. sional printing (Pro S95; SprintRay Co). Their support
Jaw information was obtained from a cone beam removal, cleaning, and postpolymerization were per-
computed tomography (CBCT) scan (HiRes3D; LargeV formed according to the manufacturer’s instructions.
Instrument Corp) and stored in digital imaging and On the day of surgery, the edentulous area was
communications in medicine (DICOM) format. The teeth anesthetized with 4% articaine with epinephrine 1/
and soft tissues were scanned with an intraoral scanner 100 000 (Primacaine Adrenaline; ACTEON Group) after
(CS 3600; Carestream Dental) and exported in standard disinfection (5.0 g/L iodophor; ShanDong LIRCON
tessellation language (STL) format. The DICOM and STL Medical Technology Inc Co) of the patient’s mouth. The
data were imported into the preoperative planning soft- patient was in a sitting position during the procedure
ware program (DentalNavi; YakeRobot Technology Ltd) (Fig. 4). The surgical accessories were fixed in her mouth,
for 3-dimensional reconstruction and alignment. The supported by the teeth (Video 1, available online). The
height and width of the alveolar ridge of the mandibular surgical marker was assembled into the holder, and the
right second premolar were 19.0 mm and 5.8 mm, and intraoral registration was completed by inserting the
the height and width of the alveolar ridge of the registration probe into the 5 registration holes one by one
mandibular right first molar were 17.8 mm and 5.4 mm, (Fig. 3B).
which were sufficient for implant placement (TX 4.0×9 The handpiece connected to the robot’s end-effector
mm, TX 4.0×11 mm, AstraTech OsseoSpeed; Dentsply was manually positioned in the mouth of the patient by
Sirona). the surgeon (R.X.) and reached the planned starting po-
An interim prosthesis was designed with 2 wings to sition of the drill. Then the handpiece was removed from
be placed on the occlusal surface of the adjacent teeth. the mouth, and the path was recorded into the robot’s
The position of 2 implants was planned following the computer by identifying the marker of the robot’s end-
prosthesis-driven principle, with a safe distance of at effector by using an active optical pose-tracking system
least 2 mm from the inferior alveolar nerve (Fig. 2A). Two (fusionTrack 250; Atracsys LLC). During the surgery, the
channels were reserved in the interim prosthesis along ADIR autonomously followed this path to safely enter and
the long axis of the planned implant position, Ø0.6-mm exit the mouth without touching teeth or soft tissues.
larger than that of the interim abutment. The drill Then, the ADIR autonomously performed osteoto-
sequence of osteotomies was determined following the mies step-by-step and implant insertion without lifting a
surgical guidelines and according to the bone quality of flap along the recorded paths according to the preoper-
the edentulous area. The depth, rotational speed (lower ative planning. The drills were changed by the surgeon
than 1200 rpm), and feed rate (slower than 0.5 mm/s) outside the mouth. The depth and angle of the drill
were set for each drill (Fig. 2B). Surgical accessories were compared with the planned position of the implant were
also designed before surgery, including a holder to con- displayed in real-time on the screen. The surgeon
nect the surgical marker, a prop to assist mouth opening, continuously supervised the procedure through the

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Figure 2. Preoperative planning. A, Prosthesis and implant position. B, Osteotomy steps.

Figure 3. A, Design of surgical accessories with registration holes. B, intraoral registration with probe.

screen and controlled all robot movements with a pedal,

including entry into the mouth, osteotomies, and exit.
The surgical plan could have been modified during the
surgery, and the movement of the robot could have been
terminated at any time, if needed. Eventually, 2 implants
were successfully placed by the ADIR in the planned
positions without any intraoperative complications
(Fig. 5, Video 2, available online).
The scan bodies were connected to the 2 implants for
intraoral scanning to evaluate the accuracy of implant
placement (Fig. 6A). Deviations between the actual and
planned position of the 2 implants were calculated in the
software program (Fig. 6B). The results showed that the
coronal deviation was 0.26 mm, the apical deviation was
Figure 4. Surgical scenario of dental implant placement surgery with
0.28 mm, and the angular deviation was 0.40 degrees for
autonomous dental implant robot.
the mandibular right second premolar implant, and 0.32
mm, 0.44 mm, 1.16 degrees for the mandibular right first
molar implant (Table 1). The immediate postoperative
radiograph showed that the 2 implants were well posi- ISQ; Osstell AB org). Interim abutments were connected
tioned and parallel (Fig. 7A). to the implants, and the interim prosthesis fabricated
The initial implant stability of the mandibular right before implant placement was seated without any
second premolar and first molar was 74 and 72 (Osstell adjustment (Fig. 7B).

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Figure 5. A, Implant inserted by ADIR system autonomously. B, Position and angle of implant displayed on screen in real-time. ADIR, autonomous
dental implant robot.

Figure 6. A, Scan bodies connected for intraoral scanning. B, Accuracy assessment of implant placement.

Radiographs after 3 months showed no bone Table 1. Describe of implant deviations

resorption around the 2 implants (Fig. 8A), and the Coronal Apical Angular
definitive prosthesis was fabricated (Fig. 8B). No post- Implant Position Deviation (mm) Deviation (mm) Deviation (deg)
operative complications occurred. The patient was satis- Second premolar 0.26 0.28 0.40
fied with the surgery and the definitive restoration. First molar 0.32 0.44 1.16

DISCUSSION
The authors are unaware of a previous report on the surgeon’s inexperience on accuracy and can effectively
clinical application of an autonomous robot in dental reduce fatigue. The lack of grasping is also the main
implant surgery. In this report, the autonomous dental difference between an autonomous robot and the robots
implant robot performed implant placement with high used to assist dental implant placement. As with free-
accuracy. Implant placement with an ADIR has the ad- hand implant surgery, there is no guide plate at the
vantages of static guides and dynamic navigation while surgical site, which does not affect the cooling of drills. In
overcoming the shortcomings of each. During the pro- addition, the prop can help the patient open the mouth
cedure, the surgeon only needs to focus on the position for a long time, and the suction tray will prevent the
and angle of the drill displayed in real-time on the screen patient from aspirating liquid in the sitting position. An
without observing the surgical area, and the target po- assistant is not needed for cheek retraction and saliva
sition of the implant can be changed according to the evacuation during the procedure, making the osteoto-
surgical situation. The handpiece is controlled and mies more efficient.
physically limited by the robotic arm without the need for Safety is an essential principle for implant placement
the surgeon to grasp it, eliminating the impact of the with the ADIR system. The entire process is under the

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Figure 7. A, Immediate postoperative radiograph. B, Immediate restorations.

Figure 8. A, Radiograph after 3 months. B, Definitive restorations.

surgeon’s supervision, and the robot’s movement is future. Robot calibration and spatial registration before
controlled by the instructions issued by the pedal. The surgery need to be further simplified. The robot devices
surgeon can quickly stop all activities of the robot in also take up space in the operating room. For the present
response to possible emergencies, such as sudden patient, the accuracy of implant placement using ADIR
movement of the patient. The safe distance of the was satisfactory. However, whether the accuracy of the
implant from vital structures and the slow feed rate ADIR is better than with static guides and dynamic
ensured sufficient time for the surgeon to react. navigation is unclear. Clinical studies and additional case
Furthermore, the recording of the path ensures that the reports on the accuracy of the ADIR are needed.
surgical instruments will not damage the patient’s soft
tissues and remaining teeth when the handpiece enters
SUMMARY
and exits the patient’s mouth autonomously.
Disadvantages of the procedure include the need for An autonomous dental implant robot achieved accurate
several personalized surgical accessories to be designed implant placement and satisfactory patient outcomes.
before surgery, reducing the planning efficiency. General However, the efficiency of the process needs to be further
accessories may be used to address this problem in the improved.

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