CONTINUING EDUCATION 2

DENTAL SURGICAL TECHNOLOGY

Robotic-Assisted Prosthetically
Driven Planning and Immediate
Placement of a Dental Implant
Sundeep Rawal, DMD; Don E. Tillery, Jr, DMD; and Peter Brewer, DDS

LEARNING OBJECTIVES

Abstract: Dental implants arguably have become the preferred treatment Discuss the history of
robotic assistance in
modality for replacing missing teeth. The success of implants, however, depends
medical surgery
on the precision of the implant placement to effectively support prosthetic
Describe the procedure
restorations. With the evolution of static surgical guides, implant dentistry of robotic-assisted
surgery for immediate
science has taken enormous strides toward ensuring accurate placement of single-tooth replacement
dental implant fixtures, yet emerging digital protocols show the potential for List the advantages of
dynamic real-time clinical support to the operator. Robotic-assisted dental robotic guidance over
other digital protocols
surgery (RADS) is a novel form of dynamic surgical guidance that, in addition
to visual navigation, offers haptic guidance for implant treatment planning,
DISCLOSURE: Dr. Brewer is a clinical
osteotomy preparation, and implant placement. This article discusses RADS specialist for Neocis, Inc.; however, the
authors received no financial support or
and includes a case study that, to the authors’knowledge, is the first report of in-kind donation from any company in
relation to this article.
a robotic-assisted dental procedure with quantitative accuracy analysis for
prosthetically driven planning and immediate placement of a single-tooth replacement.

he pursuit of prosthodontic precision continues to available dynamic systems provided “navigation,” characterized by

T
drive the em ergence of increasingly digital protocols real-time visual feedback. W ith navigation, the operator manually
for surgical im plant placement. Indeed, as the accu­ matches the current position of a drill intraorally with the plan model
racy of surgical im plant placem ent has been shown derived from cone-beam com puted tomography (CBCT) scans of
to greatly influence prosthetic results, the precision the patient, and this is viewed on a m onitor .13 Navigation systems
afforded by a range o f digitally based guidance technologies
provide hasinformation on drill deviation with respect to position or
been credited with enabling restoratively optimized dental i mplant depth; however, unlike with static guides, there is no physical preven­
procedures .1 4 Stereolithographic static guides are perhaps the prev­ tion against excursions from the prescribed treatment plan. Therefore,
alent form of surgical guidance for im plants . 5 T heir clinical use, navigation may still be considered an augmented “freehand” approach
however, can be lim ited by both m anufacturing and positioning that is dependent ultimately on the fine motor skill of the operator . 1213
errors, as well as by fracture and fabrication time, thus potentially A new class of surgical dental technology, robotic-assisted dental
increasing tim e to trea t a patient. Moreover, static guides do not surgery (RADS), offers intriguing novel functionalities. One of these
perm it real-time changes to the treatm ent plan in response to surgi­ is the concept that, in addition to providing the auditory and visual
cal conditions while still providing guidance to the clinician .6 10 inputs of navigation, RADS is capable of providing physical guid­
Unlike the fixed protocols dictated by static stereolithographic ance through haptic feedback. Robotic haptics function by providing
resin or laser-sintered metal surgical guides, digital capabilities have directional and proportional guidance forces and constraining instru­
emerged that allow dynamic intraoperative adjustments." 1:1 The first mentation trajectoiy in accordance with the prescribed surgical plan.

26 COMPENDIUM Jan u a ry 2020 Volume 41, N um ber 1

Historic Perspective: Robotic Assistance in implant on a monitorwith respeettothe surgical plan on the patient’s
Medical Surgery CBCT image. In addition, by avoiding fixed (static) guidance, dynamic
Digital surgery in the hospital setting has a long history, beginning systems facilitate same-day treatm ent, avert the risks of broken or
with diagnostic imaging innovations that enabled the development inaccurate guides, allow for identification of keratinized tissue at the
of minimally invasive surgical techniques, including endoscopic, time of implant osteotomy preparation, and enable irrigation at the
laparoscopic, and arthroscopic surgery,14and osteotomy surgical surgical site during preparation of the implant osteotomy.
guides for orthopedic procedures. Digital technology also facili­ Furthermore, dynamic navigation allows the surgeon to change the
tated intraoperative navigation, and eventually robotic-assisted plan during the surgery should unexpected intraoperative conditions
surgery em erged.15Robotic surgery gathered significant m om en­ arise.12-13Flowevcr, camera navigation does not physically prevent the
tum in 2000 with the Food and Drug Administration clearance of surgeon from deviating from the proposed surgical plan or moving
the da Vinci robotic system (Intuitive Surgical, davincisurgery. beyond the planned depth. Accordingly, the surgeon m ust watch
com) in the United States.16As of today, more than 5,000 surgical the m onitor rather than the surgical field to ensure the osteotomy
robots are in use at hospitals around the world.16Millions of robotic- and implant placement is proceeding according to plan. Moreover,
assisted surgeries have been performed, across the fields of urology, because camera navigation systems typically use infrared or visible
gynecology, general surgery, orthopedics, neurology, otolaryngol­ light to track the drill relative to the patient, each aspect of the proce­
ogy, thoracic surgery, bariatric surgery, and colorectal surgery.15'22 dure must remain within the line of sight of the stereoscopic camera,
Surgical robotics addressing different clinical needs utilize vari­ and communication errors may occur during the procedure.1213
ous approaches to augmenting surgical technique. Robotic systems Dynamic surgical guidance arrived in dental implant surgery with
addressing hard-tissue procedures, such as hip and knee arth ro ­ the clearance of the first robotic-assisted dental surgery system in
plasty and placem ent of spine pedicle screws, tend to function as 2016.25As with orthopedic robotic assistance, RADS provides physi­
assistive guides, ensuring that surgeon-initiated actions conform to cal haptic guidance that inhibits the surgeon from deviating from the
the preoperative digital plan.21'23 In these systems, robotic haptics planned implant angulation, location, and depth. Robotic assistance
provide real-tim e guidance via soft or firm resistance th a t physi­ in dental implant surgery potentially offers the promise of combining
cally prevents deviation from the plan. Robotic haptic guidance the advantage of the physical security of static guides with the flex­
of orthopedic procedures has been reported to enable minimally ibility and spontaneity of image-based dynamic navigation. A digital
invasive techniques and has been associated with greater surgical robotic-assisted workflow may mitigate the potential for inaccura­
accuracy, minimal tissue trauma, and early functional recovery.1718-23 cies introduced during the production and fitting of a physical guide
and allow patients to be treated with same-day guided surgery, while
Introduction of Robotics Into Dental Surgery permitting pi an modifications during the procedure. At the same time,
Digital dental implant surgery likewise has developed to improve patient RADS haptic guidance potentially lets the surgical team focus on the
outcomes through the use of enhanced diagnostic imaging, treatment surgical site duringthe procedure instead of a computer monitor.
planning software, and assistive surgical systems. Utilization of CBCT In the RADS system used by the authors, the robotic haptic feedback
has enabled clinical use of static surgical guides and dynamic camera has been designed such that unintentional movement that deviates
navigation with the goal of attaining accurate, precise, minimally inva­ from the CBCT-based plan is either met with a feeling of resistance
sive treatment through surgical insights and intraoperative control. or prevented, depending on the stage of the procedure. The system
W ith respect to static surgical guides. CAD/CAM is the means restricts handpiece movement once the handpiece is in the appropriate
through which the physical guide is generated for use during the drill- position in terms ofboth bodily position and angulation, and prohibits
ing sequence and, depending on the manufacturer, to guide the place­ further deeper movement or penetration when the operator drills to
ment of the implants. However, production of surgical guides, whether depth. The digital nature of RADS haptic guidance allows for same-
in-house or by outside laboratories, can delay surgery, and produc­ day guided surgery when indicated and for adjustments to the plan in
tion may need to be repeated if an error
or poor fit results. Additionally, guides
can break in use, do not perm it intraop­
erative adjustments or allow the operator
to assess the soft-tissue type beneath the
guide, and may impede irrigation during
the osteotom y preparation.6-24 Finally,
static guides maybe difficult to use in situ­
ations when patients cannot open their
mouths wide enough to prevent drill head
interference on opposing teeth.
C am era navigation system s, also
known as dynamic navigation, provide
real-time visual information via a visual
display of the position of the drill or

www.compenclitinilive.com J an uary 2020 COMPENDIUM 27

CONTINUING EDUCATION 2 | DENTAL SURGICAL TECHNOLOGY

Fig 2. Virtual placement of the implant in RADS p'anning software. Fig 3. Robotic guidance arm positioned over the patient. Fig 4 and Fig 5.
Osteotomy into the extraction socket under robotic guidance. Fig 6 and Fig 7. Implant placement into the extraction socket under robotic guidance.

response to intraoperative decisions. The haptic-basecfguidance is also (DICOM) files from a CBCT scan of the patient. An intraoral splint
designed to allow the surgeon to retain visualization on the anatomy, was mechanically retained on the patient’s stable dentition using
as opposed to die monitor-based guidance of navigation-only systems. hard-locking dental m aterial and m onitored for proper fixation.
The following case study outlines a RADS procedure for the pros- A fiducial array was affixed to the in trao ral splint during CBCT
thetically driven planning and im m ediate placem ent of a single- scanning to allow for eventual registration of the patient location
tooth replacement. It includes an analysis of accuracy to the plan. (Figure 1). Using 3D graphics and 2D cross-sections in the RADS
planning software (Yomi -Enabled Surgery, Neoeis, Inc., neocis.
Case Report emn), the surgeon virtually optimized the depth and future inser­
A 64-year-old man presented with a nonrestorable lower left bicus­ tion axis of the 4.1-nun x 10-rnni dental im plant (SLA Bone Level,
pid (tooth No. 21) w hose apex was in proxim ity to the p atien t’s Straumann, straumann.com). The existing tooth was used as a rela­
m ental nerve. W hen assessing' w hether or not this p atien t was a tive guide for restorative-driven planning (Figure 2).
candidate for im plant placem ent immediately after extraction, the 'file surgical procedure proceeded w ith the p atien t receiving
risk to the mental nerve from the drills tracking down the root socket intravenous sedation. Local anesthesia was then administered to the
was a consideration. A RADS approach was recommended to the surgical area. Tooth No. 21 was atraumatically extracted. A robotic
patient, which would allow for same-day guided surgery to mitigate guidance arm, which held the drill, was th en positioned over the
risk of drill deviation while perm itting adjust m ents to the plan as patient (Figure 3). A patient tracker arm of the surgery system was
•needed subsequent to the extraction. attached to the intraoral splint to provide real-time updates on the
The surgical intervention was planned on the same day as the patient’s position throughout the procedure. If the patient moved
su rg ery using digital im aging and com m unication in m edicine during the surgical procedure, the RADS system w-ould respond by

28 COMPENDIUM January 2020 Volume 41, Number 1

altering the prescribed surgical cutting angle and position to accom­ fields.20*22 Specific to orthopedics, haptics-based robotic guidance
modate the movement. has been shown to provide enhanced and augm ented surgical
Prior to drilling the osteotomy, a landmark poi nt on the patient scan precision, tissue preservation, and functional recovery.17-18’23 Only
was verified against direct visualization by placingthe drill tip on the recently has robotic assistance become available in dental im plant
chosen anatomical landmark. Surgery proceeded under RADS guid­ surgery. This case study is, to the authors’ knowledge, the first to
ance, in the form of auditory feedback (ie, mode-change and warning outline a robotic-assisted dental surgery procedure and to report
beeps) and haptic feedback (ic, resistance to drill motion) as well as on quantitative accuracy for prosthetic-ally driven planning and
visual guidance via a monitor (ie, navigation). To initiate the osteot­ imm ediate placem ent of a single-tooth replacement.
omy, a 2.3-mm round drill was placed in the robotic guidance arm. As In this immediate implant placement case with minimal residual
per the implant manufacturer’s recommendations, three subsequent buccal bone, the surgeon utilized RADS haptics, which enabled
drills were used to perform the osteotomy in the prescribed location steady control of the handpiece to prevent deviation of the o ste­
and angulation (Figure 4 and Figure 5). Implant placement was also otomy into the extraction socket. The quantitative results from this
achieved with the RADS system (Figure 6 and Figure 7). case study suggest that the robotic guidance resulted in an accurate
The im plant was hand-torqued to secure prim ary stability. A osteotomy, which may not be as readily and predictably allowed
6-m m x 4-mm healing abutm ent (Regular C ro ssF it, Straumann) using freehand protocols. While static guides also provide a high
was placed and the site grafted with particulate cancellous dem in­ measure of control, their usage may prevent direct visualization of
eralized bovine xenograft material (Bio-Oss', Geistlich Biomaterials, the surgical site, and they cannot be dynamically adjusted if m odi­
dental.geistlich-na.com). The flap was reapproximated around the fications are necessary post-extraction. Furtherm ore, the RADS
healing abutment with 3-0 plain chromic gut suture in an interrupted system in this case allowed for system verification via a landm ark
manner, and the splint was removed from the patient’s dentition. point before preparation of the osteotomy, an asset not available
A mathematical algorithm was implemented to analyze the devia­ with stereolithographic surgical guides.
tion between the planned (Figure 2) and actual implant placement Navigation systems also would have allowed for intraoperative
(Figure 8). Im plant placement versus the plan was evaluated using changes to the plan but without the haptic guidance of the RADS
an autom ated superim position of the preoperative plan and the system to assist in overcoming the tendency of the drill to follow
postoperative CBCT plan. In line with methodologies advised in the path of the extraction socket. Additionally, the surgeon was
the International Team for Implantology (ITI) consensus reports,s able to retain visualization of the surgical site with RADS, receiving
the algorithm assessed deviation between the planned and actual guidance through the sense of touch rather than relying on visual
im plant placem ent in term s of coronal and apical depth, lateral, directions on a monitor.
and global deviations, as well as angular deviation. Results from It is im portant to note th a t the robotic guidance arm does not
this RADS case (Table 1) were com parable to those calculated in move unless the surgeon manually applies a force to it, and motion
the ITI consensus meta-analysis of surgical guide accuracy, which in guidance mode is constrained within the plan. Otherwise, the
reported m ean global coronal deviations of 0.9 mm (Cl: 95% [0.8-1 robotic guidance arm is able to resist any motion, including inciden­
mm]), global apical deviations of 1.2 mm (Cl: 95% [1.1-1.2 mm]), tal bumps or other contact. In this case the surgeon was in control
and angular deviations of 3.3 degrees (Cl: 95% [2.1-4.6 degrees]).’’ of initiating and pausing drilling and had the ability to modify the
At the tim e of this writing the patient was healing and awaiting plan or switch to freehand operation at any time.
osseointegration of the bone to the implant. A single-tooth, screw-
retained prosthesis constructed of porcelain fused to zirconia is Conclusion
planned, and all postoperative signs point to ideal positioning of With prosthetically driven implant dentistry now widely considered
the im plant to support the prosthetic tooth. the ideal approach to offering dental implant therapy, clinicians must
execute the virtual plan with as much integrity as possible. The authors’
Discussion application of a robotic-assisted dental surgery system to this single­
Since 1999, use of robotic assistance has been rapidly adopted and tooth immediate implantplacementdemonstrated accuracy in accor­
has assumed an im portant position across a broad range of medical dance with publ ished precepts and provided real-time verification of

Fig 8. C om pa rison be tw e e n th e a ctu a l im p la n t p la c e m e n t (sho w n here) and th e planned p o s itio n (F ig 2 ) was analyzed.

www.compendiumlive.com January 2020 COMPENDIUM 29

C O N T IN U I N G E D U C A T I O N 2 | D E N T A L SU R G IC A L T E C H N O L O G Y

TABLE 1

Robotic-Assisted Immediate Dental Implant Placement, Deviation From Plan

Coronal Coronal Global Apical Apical Global Angular
Depth Lateral Coronal Lateral Depth Apical Deviation
Deviation Deviation Deviation Deviation Deviation Deviation (degrees)
(mm) (mm) (mm) (mm) (mm) (mm)
0.80 0.41 0.90 0.30 0.80 0.85 0.53

the execution of the plan. This initial experience indicates potential co m p u te r-a ssiste d im p la n t plan ning and g u id e d s u rg e ry in th e a n te rio r
benefits of robotic guidance in comparison with other available digi­ region. I n t J C o m p u t D ent. 2018;21(2):147-162.
10. Kola MZ, Shah AH, Khalil HS, e t al. S urgical te m p la te s fo r d e n ta l im ­
tal protocols for prosthetically driven dental implant therapy. It is
p la n t p o sitio n in g ; c u rre n t k n o w le d g e and clinical pe rspectives. N ig e r J
the authors’ intention to follow this RADS system case study with an
Surg. 2015;2l(l):1-5.
in-depth multiple case analysis and future prospective studies. 11. Block MS, Emery RW, Lank K, Ryan J. Im p lant placem ent accuracy us­
ing dynam ic navigation. In t J O ral M axillofac Im plants. 2017;32(1):92-99.
ACKNOWLEDGMENT 12. S tefanelli LV, D eG root BS, Lip to n Dl, Mandelaris GA. A ccura cy o f a
dyn a m ic dental im p la n t n a vig ation system in a priva te practice. In t J
The authors thank Robin Grandl, PhD, and Joanne M. Balshi for Oral M a xillo fac Im plants. 2019;34(1):205-213.
13. Mandelaris GA, Stefanelli LV, D eG root BS. D ynam ic na vig ation fo r
editorial support.
surgical im p la n t placem ent: ove rview o f tech nolog y, key concepts, and
a case re p o rt. C o m p end C ontin E duc Dent. 2018;39(9):614-621.
ABOUT THE AUTHORS 14. Spaner SJ, W arnock GL. A brie f history o f endoscopy, laparoscopy, and
laparoscopic surgery. J Laparoendosc A d v Surg Tech A. 1997;7(6):369-373.
Sundeep Rawal, DMD
15. M edical A d v is o ry S ecretatiat. C om p uter-assiste d h ip and knee a r­
Private Practice, Merritt Island, Melbourne/Suntree, Lake Nona, and Winter Park,
throplasty. N aviga tion and a ctive ro b o tic system s: an evidence-based
Florida; Cofounder, Digital Dentistry Institute
analysis. O n t H ealth Technoi Assess Ser. 2004;4(2):1-39.
DonE. Tillery, Jr, DMD 16. S m ith R. R o b o tic surgery: th e fu tu re is alre ady here. Linke dln Pulse.
Private Practice, Winter Park, Florida May 2, 2019. h ttp s ://w w w .lin k e d in .c o m /p u ls e /ro b o tic -s u rg e ry -fu tu re -
a lre a d y -h e re -ro g e r-s m ith /. A ccessed N ovem ber 4, 2019.
Peter Brewer, DDS 17. Kayani B, Konan S, P ietrzak JRT, H addad FS. Ia tro g e n ic bo ne and
Clinical Specialist, Neocis, Inc., Miami, Florida s o ft tissue tra um a in ro b o tic -a rm assisted to ta l knee a rth ro p la s ty
co m pare d w ith co n vention al jig -b a se d to ta l knee a rth ro p la sty: a p ro ­
Queries to the author regarding this course may be submitted to spe ctive c o h o rt s tu d y and v a lid a tio n o f a new classificatio n system . J
[email protected]. A rth ro p la s ty . 2018;33(8):2496-2501.
18. Kayani B, Konan S, Tahmassebi J, et al. Robotic-arm assisted total knee ar­
throplasty is associated w ith improved early functional recovery and reduced
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6. Sigcho Lopez DA, Garcia I, Da Silva Salomao G, Cruz Lagana D. Po­ Technoi Int. 2017;30:441-446.
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30 COMPENDIUM January 2020 Volume 41, Number 1

 CONTINUING EDUCATION 2
QUIZ

Robotic-Assisted Prosthetically Driven Planning and Immediate

Placement of a Dental Implant
Sundeep Rawal, DMD; Don E. Tillery, Jr, DMD; and Peter Brewer, DDS

This article provides 2 hours of CE credit from AEGIS Publications, LLC. Record your answers on the enclosed Answer Form or submit them on a separate
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1. Use of stereolithographic static guides for implant guidance 6. Static surgical guides:
can be limited by:
A. enhance the flow of irrigation during osteotomy preparation.
A. positioning errors. B. are ideal for use when patients have limited mouth opening.
B. fracture. C. do not permit intraoperative adjustments.
C. fabrication time. D. All of the above
D. All of the above
7. Dynamic surgical guidance arrived in dental implant
2. Characterized by real-time visual feedback, the first available surgery with the clearance of the first robotic-assisted
dynamic systems provided: dental surgery system in:
A. navigation. A. 1999.
B. robotic assistance. B. 2000.
C. haptic guidance. C. 2011.
D. physical prevention against excursions from the prescribed D. 2016.
treatment plan.
8. Haptic-based guidance is designed to allow the surgeon to
3. Which of the following is capable of providing physical retain visualization:
guidance through haptic feedback?
A. on the computer monitor only.
A. robotic-assisted dental surgery (RADS) B. on the anatomy.
B. static navigation C. strictly on the patient’s CBCT image.
C. guided surgery D. that is focused on the motion of the robotic arm.
D. freehand implant placement
9. In the case presented, prior to drilling the osteotomy, what
4. Currently, how many surgical robots are in use at hospitals was verified against direct visualization?
around the world?
A. a fiducial array
A. less than 500 B. 2D cross-sections in the planning software
B. approximately 1,000 C. a landmark point on the patient scan
C. nearly 2,500 D. primary implant stability
D. more than 5,000
10. In the RADS system used by the authors, the robotic guidance
5. Robotic haptics provide real-time guidance via soft or firm arm does not move unless:
resistance that:
A. intraoperative changes to the plan are implemented.
A. relies solely on audible interaction with the operator. B. the surgeon manually applies a force to it.
B. gives only visual warnings of deviation from the plan. C. the patient experiences discomfort.
C. physically prevents deviation from the plan. D. it detects incidental contact.
D. is hardly noticeable by the operator.

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