THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY
Int J Med Robotics Comput Assist Surg 2008; 4: 95–104.
Published online 17 March 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/rcs.188
Computer-assisted implantology: historical
background and potential outcomes – a review
Abbas Azari1
Sakineh Nikzad2 *
1
Department of Prosthodontics,
Medical Sciences, Faculty of Dentistry,
University of Tehran, Quds Street,
Tehran, Iran
2
Department of Fixed Prosthodontics,
Medical Sciences, Faculty of Dentistry,
University of Tehran, Quds Street,
Tehran, Iran
*Correspondence to:
Sakineh Nikzad, Department of
Fixed Prosthodontics, Medical
Sciences, Faculty of Dentistry,
University of Tehran, Quds Street,
Tehran, Iran.
E-mail: Snikzad@sina.tums.ac.ir
Accepted: 31 January 2008
Copyright  2008 John Wiley & Sons, Ltd.
REVIEW ARTICLE
Abstract
Background The accurate transfer of preoperatively determined implant
positions to the patient mouth is very beneficial to the dental practitioner
as well as patients. The objective of this paper was to review the gradual
development of computer-assisted implant surgery.
Methods All of the major data sources including unpublished data in the
internet are considered
Results and Conclusions Computer-assisted/-guided/-aided implantology
has been founded to overcome the errors encountered during implant
osteotomies and to position the implants more precisely. The protocols
followed by this sophisticated technique are based upon the advocated
concept of prosthetic-driven implantology and CT-scan analysis recently
approved. Although several attempts have been made to improve this
approach more and more, little has been done regarding the patient’s
demands, including cost. The inherent complexity of the techniques and
materials utilized necessitates several degrees of training before attempting
treatment and must be taken into account. Copyright  2008 John Wiley &
Sons, Ltd.
Keywords computer-assisted implantology; dental implants; prosthodontic-
driven implantology
The early days; dental problem-solving approaches
Computer-assisted implantology (CAI) must be considered as a chain of
links related together, each of them having consequences for other links.
Historically, from the introduction of modern implantology in the early
1980s, implant placement has been done based only on available residual
bone. Several studies have clearly demonstrated that implants placed in this
manner often emerge in a buccal or lingual position, ending with difficult
or even impossible aesthetic problems to solve (1,2). On the other hand, it
has been shown that implants that are not working in their long axes were
exposed to detrimental lateral forces, ending with numerous biomechanical
problems and even breakages (3–5). Due to too many associated problems
and the functional compromises of the final prosthesis, at the next step new
concepts were developed and new methods produced by first considering the
prosthesis rather than the surgery.
Hereafter, by introducing the concept of ‘prosthesis-driven implantology’,
not only the bone was considered but also the teeth to be replaced (6,7).
In the early days clinicians who believed in this concept mostly depended
96
on wax-up prostheses and/or surgical templates made on
hard gypsum surfaces of master casts, and to overcome
the problem of transferring the plan to the operative
site, customized radiographic and surgical templates
have become a routine part of treatment (6,8–10). It
was very soon found that the hard surface of casts is
not equal to the soft tissue surface of the oral cavity,
and this method may not be as accurate as necessary
for treatment purposes. Moreover, it was demonstrated
that templates fabricated on the diagnostic cast without
knowledge of the exact anatomy below the surface may
not be considered reliable (11,12). Thus, the general
notion was soon changed compared to when conventional
implantation techniques are used, the clinical outcome
is often unpredictable and, even if the implants are
well placed, the location and deviation of the implants
may not meet the optimal prosthodontic requirements
(11,12). It was demonstrated that this type of template
cannot be used during radiographic pre-evaluation of
bony structures and this precludes ‘show-through’ of
proposed teeth in the radiographs (13,14). Working on
the subject finally led to ‘double-purpose templates’, which
can be used not only for radiographic examination and
evaluation of the patient but also during surgery and
placement of the implants (15–17).
Since that time, conventional dental panoramic
tomography and plain film tomography are usually
performed with the patient wearing a radiographic
template with integrated metal spheres at the position
of the wax-up. Based on the magnification factor and
the known dimensions of the metal sphere, the depth
and dimensions of the implants can be estimated. In
fact, double-purpose templates may somewhat relieve the
problem of directing the implant to a good position, but
using these templates is only confined to the first drilling
sequences and further drilling is not possible without
difficulty. Furthermore, it was soon well established
that all X-ray transmission-based radiographs suffer the
limitation of being two-dimensional (2D) projections of
complex, intrinsically three-dimensional (3D) anatomy.
Actually, conventional radiography, which is widely used,
has important diagnostic limitations, such as expansion
and distortion, setting errors and position artifacts.
Several studies have shown that these 2D radiographs
do not show lingual anatomy or provide complete three-
dimensional (3D) information about the dental arch
(18–20).
In search of other modalities; medical
solving approach
Perhaps the most important technological advancement
that dramatically enhanced the clinician’s ability to
diagnose and treatment-plan dental implants, with ability
to view 3D anatomy, has been the computed tomography
(CT) scan. Although computerized axial tomography
(CAT) scans have been available for medical use since
Copyright  2008 John Wiley & Sons, Ltd.
A. Azari and S. Nikzad
1973 (21), it was not until 1987 that this innovative
technology became available for dental applications
(22,23). One of the major features that draw the
dentist’s attention to CT technology is the ability to
avoid the superimposition of structures, which makes
them more desirable than conventional radiography
as a morphometric tool. Since its inception, CT has
provided quantitative measurements for many different
biological systems and has been used in pre- and post-
surgical mapping procedures (23), the evaluation of
developmental and regressive dental abnormalities (24),
facial trauma and temporomandibular joint disorders
(25–29).
One of the most promising advantages of CT which
may excite the informed practitioner is its high level of
accuracy in comparison to other modalities. There are
no magnification errors caused by geometric distortions,
whereas such errors are common in conventional dental
radiographs. Some researchers have compared the degree
of accuracy and distortion of conventional radiographs
and CT (30–32). According to these studies, the
least accurate methods were panoramic views (17%),
conventional tomography (39%) and peri-apical views
(53%), whereas the CT has accuracy was as high as 95%
(33). One more feature that has made this modality the
best for diagnostic purposes in implant therapy is its
ability to measure bone density.
From the introduction of modern implantology, it
was proposed that the success rate of dental implant
therapy is influenced by both the quality and the quantity
of bone (34) and clinical reports have indicated that
implant prognosis is significantly affected by bone quality
(35–39). There are several well-documented data in
the literature regarding the vital role of this factor on
the failure rate of implants (40–45). It is important
to note that conventional dental radiographs, including
periapical, panoramic, lateral cephalometric or even
conventional tomographical studies, are less useful for
diagnosing the bone density (46).
A matter of concern; high-dose
radiation
As in many aspects of medicine, there are both benefits
and risks associated with the use of CT. There have been
several reports of dosimetry studies involving CT and
conventional tomography in implant assessment (47–51).
Although it is difficult to compare the results, owing
to the differing experimental parameters, all studies
have demonstrated that the use of CT is associated
with significantly higher absorbed doses compared to
conventional radiography. Despite the many debates
aroused, the American Academy of Oral and Maxillofacial
Radiology (AAOMR) and the European Association for
Osseointegration (EAO) recommend the cross-sectional
imaging modality for patients receiving implants (52–54).
However, they also confirmed that it is the responsibility
Int J Med Robotics Comput Assist Surg 2008; 4: 95–104.
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Computer-assisted implantology
of each diagnostician to use cross-sectional imaging
techniques according to their patients’ special needs.
These evidences among others suggested that, although
the radiation dosage for CT scans is higher, it does not
directly involve adjacent, more radiosensitive tissues; as
such, the many diagnostic benefits outweigh the limited
radiation risk (48,49).
On the other hand, it must be pointed out that CT
scanner systems have been developed to such an extent
that dramatic advances has been achieved during the
developing years. As scanners improved in the speed
of image acquisition, so did their versatility, which
was exploited in clinical practice. The technological
development, first in the spiral/helical type scanners (55)
and latterly in multislice scanners (56), tuned aperture
CT (TACT ;57) and more recently low-dose cone-
beam/digital volume CT technology (58), introduced
enormous power and flexibility. Thus, true multiphase
scanning with well-defined phases can now be achieved,
i.e. larger body volumes may be scanned with little
relevant time penalty, at very low possible dose and
rapid screening in a variety of guises (59).
Printed images vs. screen shots; the
optimal use of images
Despite the many advantages of advanced imaging
techniques, the potential for linking the visualization
on film is limited if there are no indicators for the
ultimate position of the tooth or a final restorative goal.
Review of the literature shows that the earliest scanning
appliances were simple and lacked the necessary detail
required to predict prosthetic outcome. Thus, in order
to address the requirements of the concept of prosthetic-
driven implantology, some type of radio-opaque CT scan
template, incorporating valuable information about the
position, occlusion, form and contour of missing teeth
(usually in the form of radio-opaque markers incorporated
into a patient’s existing denture, or via some type of
barium coating) gave new data that could be viewed in
relationship to the underlying structures (60–67). In this
way it will be possible for prosthodontist to visualize
the location of planned implants from an aesthetic
and biomechanical standpoint. More recent publications
describe three generations of scanning appliance designs
(68) (Table 1).
Table 1. Three generations of radiological guides. These types of
guides are used during CT data acquisition
Generation 1 Generation 2 Generation 3
Barium-coated The hollow portion of the The Tardieu Scannoguide;
silhouette of vacuum-formed template it is a differential
the proposed is completely filled with barium-gradient scanning
final tooth an acrylic resin/barium appliance
positions (30% barium sulphate by
weight), which will
represent a solid
radiopaque tooth
Copyright  2008 John Wiley & Sons, Ltd.
97
It has been indicated that third-generation guides not
only allow the clinician to transfer the prosthetic outcome
but also define the soft tissue boundaries on the CT study.
This offers the potential for fabrication of specialized
surgical drilling guides for flapless implant placement
(68). Beside these, it is always required to have various
degree of expertise to correctly interpret the printed
images, and this is not so easy in routine dental practice.
One must consider that the images obtained from CT
are really 2D printing, requiring a process of mental
integration of multiple sections by the observer to derive
3D information. This problem is discussed in detail in the
literature (69). These 2D views are easier to show on the
computer, but they are basically a digitized version of
printed images. So, it is less predictable for the implant
size needed and poor for anatomical complications (70).
To overcome these obstacles, we need systems that allow
simultaneous visualization of 2D reformatted images as
well as 3D-derived bone surface representations. In this
way we have the opportunity for interactive placement of
implant-like CAD models on the images obtained from CT
data.
The integration of engineering
principles into practice; the last resort
Since the 1990s, many medical research teams have
approached the problem of implant planning with
the assistance of interactive computer applications
(22,23,71). Several techniques have been developed,
together with software and hardware, to represent
the anatomical data in 3D on a 2D screen. In 1988,
Columbia Scientific Inc. (Columbia, MD, USA) developed
3D dental software that worked through standard GE-
CT scanners. The addition of an intermediate computer
workstation, called an Imagemaster101 (introduced in
1990), allowed for further development and refinement
of the diagnostic tools available to CT scans for dental
implants. Interfaces were then developed to process CT
data from most CT scanners available today (72).
Using the first commercialized software program,
SIM/PLANT (Columbia, MD, USA) in 1993 (73),
clinicians had the ability to view and interact with the
CT scan data to presurgically place the implant body and
visualize the prosthodontic implications at the same time,
rather virtually. For the first time since the inception of
osseointegrated implants and CT scans, it was possible
to reformat the CT scans in such a way to provide an
accurate 3D view of the anatomy of the bone, in which
the clinician can interactively introduce implant planning
into the CT images.
Several attempts have been made to improve the
software program in Europe. In this way, by focusing
on the abilities of the software program, SIM/PLANT
(Columbia, MD, USA), the 2D behaviour of the program
was enhanced by smart programming and the so-
called double-scan procedure (74,75). Although these
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98
utilities possessed many advantages, they still faced
the practitioner with a familiar problem – the scanning
appliance became the surgical device. In fact, the result of
virtual survey, by incorporating holes or by removing the
lingual or palatal portion, was transferred to a guide which
could then be used during implant surgery. Actually,
this was more of a visual guide, not a true surgical
guide. Transferring the computer plan into actual patient
treatment seemed to have a missing link, which was
quickly filled by the revolutionary CAD/CAM technique.
CAD/CAM techniques; the first
attempt to bring virtual planning
into reality
Early published data regarding the incorporation of
CAD/CAM techniques into implant dentistry were for
eliminating the surgical bone impression phase of the
subperiosteal implant modality (76,77). In this manner
and for the first time, it was possible to physically feel the
area of interest, such as the mandible or maxilla. Physical
models like these are very attractive because they offer
the opportunity to hold the model in the hand and view
it in a natural fashion, thus providing the clinician with
a direct, intuitive understanding of complex anatomical
details which otherwise cannot be obtained from imaging
on screen (78).
Unfortunately, this method has some limitations. One
limitation results from conventional milling machines,
which have restricted motion capability. Practically,
complex geometries are difficult to programme and can
result in tool/work piece collisions, and they are often the
case in medical applications (79). Yet another limitation is
that it usually requires skilful human intervention to help
plan the operations and to operate the equipment (80).
Another limitation lies in the materials used to fabricate
the physical model; the materials employed should be
hard, tough and sterilizable (80). In order to circumvent
these, another revolution was required.
The layer data format of CT scanners quickly prompted
the realization that it may be possible to convert
the data to be compatible with rapid prototyping
(RP) machine requirements (81). By definition, RP
refers to the fabrication of 3D physical models directly
from a computer-aided design (CAD) model. The
model is built layer by layer according to 3D data
(82,83). It was theorized that this type of mechanical
prototyping is capable of quickly fabricating complex-
shaped, 3D parts directly from CAD models. This
may defer from just milling, which has been a
routine procedure in normal CAD technology (81).
The potential transformation was recognized early in
RP development, and accurate anatomical RP models
were fabricated. This physical realization of CT data
has been termed ‘real virtuality’ or ‘virtual reality’
(81). Practical implementations of layered manufacturing
for modern fabricating requirements have been made
Copyright  2008 John Wiley & Sons, Ltd.
A. Azari and S. Nikzad
possible by several enabling technologies, including
CAD-based solid modelling, lasers, ink-jet printing
and high-performance motion controllers, integrated
with more traditional manufacturing processes, such
as powdered metallurgy, extrusion, welding, computer
numerical control (CNC) machining and lithography,
into novel arrangements (81–83). The feasibility and
versatility of this novel technology makes it possible
to utilize it in almost every part of medicine not
limited to dental implantology. Other application fields
were tried jointly with similar success – vertebral screws
(84), transcutaneous stabilization screws for ankles,
implants for reconstruction of the dome of the skull
(85), maxillofacial reconstructions, bone and mucosal
modelling of bone distractions in 3D (86) and many more
(87–91).
Soon after the inception of RP techniques, the notion
of this novel facilitative technology generated intense
governmental interests; primarily in Europe. Actually the
most economical high-tech programmes such as RP have
many potential benefits for governments to convince
them to invest in research in the field. In the first
step, two major studies have been adopted in Europe.
The first was the ‘laser photopolymerization models
based on medical imaging; a development improving
the accuracy of surgery’ (PHIDIAS), which was first
announced in 1993 and targeted the development of
a dedicated system based on laser photopolymerization
for the production of medical models (92). The PHIDIAS
project joined together 40 partners from 11 different
European countries (93). The second was the ‘medical
image-based personalized implants and surgical aids,
manufactured by rapid prototyping techniques’ (PISA),
first announced in 1997, which validated the transfer
of information from the computer to the mouth using
surgical guides (94).
The main objective followed by the PHIDIAS project
was the development of a dedicated system based on
laser photo polymerization for the production of medical
models (called prototypes). This technique, which is
now identified as stereolithography (SL), was originally
described in 1990 (95). On the other hand, within
the framework of the PISA project, several industrial
companies and universities (Materialise, PhilipsMedical,
Ceka, OBL, DuPuy International, Katholieke Universiteit
Leuven, University of Leeds) pooled their knowledge
between 1997 and the beginning of 2001 (96). The
project aims to develop an imaging environment and cost-
effective manufacturing techniques. The generic medical
system called DDOSS (Device Design and Operation
Simulation System) enables presurgical planning, taking
into account aspects such as bone quality, the presence
of soft tissue or the effects of an osteotomy. DDOSS will
integrate biomechanical design principles in the design
and dimensioning process of personalized implants and
surgical aids (94).
The major advantage of the system was the integration
of CAD and medical imaging. This integration overcomes
the limitations of the inevitable link between medical
Int J Med Robotics Comput Assist Surg 2008; 4: 95–104.
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Computer-assisted implantology 99

imaging and CAD which is usually obtained by segmenting programmes in Japan and Australia have concentrated on
the data, resulting in the preservation of the outer object the application of RP models for diagnostics and surgical
shape data only. With this system, both custom implants planning.
and custom surgical aids will be designed (94). Custom Today, many programmes have been developed and
surgical aids fit perfectly on an internal structure of are commercially available. Some of the commercially
the patient and guide (e.g. with a hole) the surgeon available software packages that allow 3D planning of
during the operation, helping the surgeon in the exact implants and use the protocol of RP technology for
positioning of his instruments or bone cuts. They enable providing surgical templates are presented in Table 2.
the operation to be performed exactly as planned and are
essential for the optimal use of personalized implants.
By optimization of these processes, one can convert Attempting to incorporate the robotics
prototyping techniques into reliable, cost-effective and
fast one-of-a-kind production methodology for medical
principles for implant planning
devices (94).
In addition to using RP technology, a different method-
One of the most prominent research projects carried out
ological approach has also been carried out for evaluating
within the frame of the PISA project was one which took
other methods for placing implants accurately and within
place through the cooperation of Leeds University and the
the concept of mamimum precision. This methodology,
Catholic University of Leuven in 2001. In this study, for
which gained a place in recent 10 years in implant den-
the first time, based upon images achieved by CT data and
tistry, was the image-guided solution/navigation system
the principles of rapid prototyping, a personalized drilling
(IGS) or image-guided navigational implantology (IGI).
guide was developed and utilized for the placement of
The primary work in this field was mainly promoted in
spinal drills (97).
Germany, and some of the most famous company studies
Yet another glorious published study in 2001 promoted
using this principle are presented in Table 3.
the usen of RP templates in the surgical placement of
These systems were principally designed for relieving
implants (98). The work of Philips Medical Systems within
the common drawbacks of RP technology; if the proposed
the PISA project, which focused on clinical pre-operative
jaw is severely atrophied, it is difficult to handle the
planning for the placement of dental implants, and on
templates without dislodgement. Moreover, it is always a
the design of surgical aids in the form of drill guides
matter of concern to best control the distance of the drill
to transfer the planning to the patient, have resulted
tip from critical structures, such as the inferior alveolar
in an interactive manipulation of computer-generated
nerve, the floor of the nasal cavity or the maxillary sinus,
implant models which could simulate the placement of
during precise surgery (99). It must be noted that this
implants, and an automatic procedure to generate a
problem has been addressed recently by introducing
surgical aid at later stages. This company, in cooperation
new techniques in RP technology, such as the SAFE
with Materialise (Leuven) and the ESAT department of
system (Materialise, Belgium), Facilitate (Astra Tech,
the University of Leuven developed an interface between
the medical workstation and the CAD/CAM-orientated
environment, which may be used for producing actual Table 3. Some of the well-known companies involved in
image-guided implantology
implants and surgical tools (98).
In this manner, a new therapeutic protocol was Company Name Internet address
developed that included not only case planning based
on 2D and 3D scanner data, but also the transfer of Artma Medical Technologies http://www.medlibre.org/
Inc. Munich, Germany mission.html
implant planning into the mouth of the patient, through RoboDent, Gmbh, Berlin, Germany http://www.robodent.com
the use of custom-made stereolithographic drill guides Vector Vision 2, BrainLAB, Gmbh http://www.brainlab.com
(96). In addition to Europe, there are also some similar Munich, Germany
IVS Soloutions AG, Chemnitz, http://www.ivs-solutions.com
significant efforts in Japan, Australia and USA in applying Germany
RP models for surgical planning. The medical modelling

Table 2. Manufacturers, registered names of the programmes and their internet addresses, currently involved in CT-based modelling
and RP-made surgical templates

Name of Company Name of Software Package Internet Address

Materialise, Leuven, Belgium Simplant http://www.materialise.com

MediaLabSoftware, Germany Implant3D http://www.implant3d.com
Smitech(Asia)Pte Ltd., South Korea Vimplant http://www.smitechasia.com.sg/product.php
Nobel Biocare, Yorba Linda, CA NobelGuide http://www.nobelbiocare.se
I-Dent Ltd., Hod Hasharon, Israel Implant Master http://www.ident-surgical.com
CADImplant, Praxim Le Grand Sablon, 4, La Tronche, France CADImplant http://www.cadimplant.com
Sirona Dental Systems GmbH, Germany Galileos http://www.sirona.com
SDS Amount Corporation, Osaka Japan 10DR http://www.10dr.co.jp
Allo Vision Europe GmbH Germany DDent/DDent plus I http://www.allovision.com

Copyright  2008 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2008; 4: 95–104.
DOI: 10.1002/rcs
100
AstraZeneca Group, Sweden), Compu-Guide (Implant
Logic Systems, Cedarhurst, NY, USA) and Nobelguide
(Nobel Biocare, Yorba Linda, CA, USA).
The IGS/IGI systems provide sensors as well as
software programs to transfer the pre-surgical plan to the
patient. They also provide automated monitoring of the
surgical procedure. The process is limited by the physical
navigation control of the dental practitioner placing the
implants and the fact that the sensing device is sensitive
to the line of sight (100). Basically, the system produced
by this concept uses marker-based referencing methods
(called registration points, fiducial markers, etc.) to
establish the transference of the tool coordinate system to
the patient. The markers are principally devices designed
to act as reliable surrogates for imaging anatomical
structures of interest. Fiducial marker techniques were
originally developed in the pre-conformal radiotherapy
era for positional verification of tissues that were not easily
visualized using portal X-ray film imaging for patient
alignment (101). By incorporating the light or sound
generator markers, the clinician is able to be guided,
audially and/or visually, to set the implant by simply
moving the drill in the appropriate position with the
support of the navigation system (102). The system tries
to assist the surgeon during the preoperative planning
and also during the intra-operative procedure, while the
optimal treatment plan is applied directly to the patient.
This procedure, like RP technology, was first utilized in
neurosurgical surgery (103) and is being implemented
in various surgical fields (104). It has been argued
that the use of intra-operative navigation systems in
implant dentistry allows the surgeon to precisely transfer
a detailed pre-surgical implant plan to the patient and
intra-operative modification of the plan and accuracy can
be verified during surgery (105).
In contrast to the ‘virtual reality’ concept, which
was explained above for RP–CT technology, IGS/IGI
introduced a new concept called ‘augmented reality’, i.e.
the technique does not rely solely on artificially generated
environments but expands the real world with additional
elements (information content) (106,107). The basic
principle for application of augmented reality and IGS/IGI
in cranio-maxillofacial surgery is the visualization of 2D
and 3D views of the surgical site superimposed on the
real image of interest, which is called ‘overlay-graphics’
(108). This protocol was very recently used by Materialise
(Leuven, Belgium) for a process called ‘Photo-Mapping’
(109).
According to the literature, Basic research on IGS/IGI
technology has been carried out since 1992 in Germany
and software development has been accomplished in
cooperation with Artma Medical Technologies, Vienna.
Moreover, some types of navigation software (Virtual
Vision , MedScanII and Virtual Implant , Artma
Medical Technologies, Vienna; and VISIT, by Birkfellner
et al. at the Department of Biomedical Engineering and
Physics, Vienna General Hospital) have been used for the
navigational tracking of surgical burrs (108,110).
Copyright  2008 John Wiley & Sons, Ltd.
A. Azari and S. Nikzad
It must be noted that, similar to the RP–CT method,
intra-operative computerized navigation also mandates
that an interfacing template be firmly attached to the
operated jaw (usually by bone screws) throughout the
surgery.
Other computerized methods used for
implant planning
In addition to the systems described above, several
research teams have attempted to adopt other systems
to precisely position the implants. One of the most
brilliant studies done in this regard is one which
initially coordinated by a European programme called
VISIMPLANT. This project ran for 3 years and ended
in December 2000 (111). The main objective of the
VISIMPLANT project and its partners (Ecole des Mines
de Paris, Umeå University, Techdent, SFO, Imperial
College) was to develop a new protocol for dental
implantology through robotic methodology (111–114).
The idea has now been commercialized by MED3D
(MediaLabSoftware, Germany), CADImplant (Praxim ‘Le
Grand Sablon’ 4, La Tronche, France) and DDent
(Allovision Euroup, Germany), which uses a robotic
drilling machine for preparing a specially designed
mechanical drilling template for implant surgery (115).
More recently, a novel approach with a different
concept was introduced. This new methodology, named
the ‘tactile imaging and registration concept’ (116),
uses an electronically-driven intraoral device to which
tactile sensors containing needle arrays are affixed (116).
Principally, the penetration of these needles to the soft
tissue coverage of the proposed jaw make analogue data
which can then be retrieved and translated by a computer
to a digital 3D image. This process is repeated several
times until the surface acquired data are completely
recorded, transposed and matched (registered) to CT
scan data. A specially designed machine is then required
for making the required templates at the prescribed
coordinates of optimal axis (116).
Other systems, including magnetic tracking systems
(117) and a robot with a mechanical arm (118) have also
been tried but never commercialized.
The major differences and/or
similarities between two methods
of guided implantology
In spite of the different methodology used by each tech-
nique, as presented in Tables 4 and 5, there are similar
accuracy data reports for both burr tracking, image-guided
templates and RP–CT-based surgical guides, and it has
been shown that each method allows precise position-
ing of oral implants in the same manner (107,119).
Some studies indicated that the overall accuracy of a
computer-aided intra-operative navigation system (IGS)
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Computer-assisted implantology
during implant surgery depends on the precision of the
surgical navigation system and the skill of the surgeon to
interpret positional data displayed on the computer screen
during the drilling of the implant socket. Additionally, it
was argued that several cycles of drilling and widening
are required to prepare the socket, thus increasing the
deviation each time (120). In contrast, it has also been
pointed out that navigation-controlled techniques are less
influenced by human error than standard implantation
methods (12).
General shortcomings and
outstanding features provided
by computer-assisted implantology
Despite the many opportunities attained by using
CAI compared to the conventional techniques, this
sophisticated technology requires substantially more cost
Table 4. Treatment protocol in RP–CT technology used in
implantology (modified from Materialise NV, Leuven, Belgium)
Table 5. Treatment flowchart followed by IGS/IGI technology (modified from IVS Solutions AG, Chemnitz, Germany)
Copyright  2008 John Wiley & Sons, Ltd.
101
expenditure, meticulous effort (CT imaging, fabrication of
a registration template, etc.) and a high level of training.
Although there are no reference data in the literature
regarding the exact costs of the two methods, but it is a
reality that the patient is forced to pay a higher price than
is usual for conventional implantology, and this is true
for both techniques. Moreover, the high complexity of
both techniques necessitates that the clinician expends
more time in training at different level courses. The
kind of support also rendered by each company must
be carefully considered and weighed – the better the
support and service, the better the clinician achieves the
benefits. Unfortunately, the serviceability of companies is
not equal for all countries and hence many opportunities
for developing concepts may be affected in a reverse
manner.
One must consider the superiority and cost : benefit
ratio of CAI in relation to its potential to eliminate
possible manual placement errors and to categorize
reproducible treatment success. The potential for the
protection of critical anatomical structures, such as nerve
or sinus, and the aesthetic and biomechanical outcomes
of prosthodontic-driven implant positioning, must also
be taking into consideration. Based on clinical data,
computer-assisted implantology is not so cheap or even
required for easy cases of sufficient anatomical orientation
and bone height, but whenever a CT scan is recommended
as a diagnostic means, when prosthodontic-driven implant
positioning is taking into consideration, and when safe
positioning of implants at optimal length and accurate
estimation of bone density is desired, the clinician and
patient can similarly fully benefit from the advantages
of CAI. It is also necessary to note that the dedicated
software programs included in both techniques can be
used efficiently for inter-/intra-office communication and
the treatment plan can be discussed in detail with the
patient. This type of communication may be even more
helpful if every partner of a treatment group, including the
Int J Med Robotics Comput Assist Surg 2008; 4: 95–104.
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102
laboratory technicians, can be invited for consultation. In
the case of more complex patients, this opportunity may
be used to send the treatment plan to experts via the
internet, and this is more demanding, especially for the
beginners in the field.
With further development of these methods, it may be
accessible in the near future to incorporate the benefits of
the two methods merged together, and the whole process
to be truly implemented by robotic systems without
manual intervention.
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