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applied
sciences
Article
Digital Evaluation of the Accuracy of
Computer-Guided Dental Implant Placement:
An In Vitro Study
Seong-Min Kim 1,2, Keunbada Son 2,3 , Duk-Yeon Kim 2and Kyu-Bok Lee 1,2,*
1
Department of Prosthodontics, School of Dentistry, Kyungpook National University, 2177 Dalgubeol-daero,
Jung-gu, Daegu 41940, Korea
2Advanced Dental Device Development Institute, Kyungpook National University, 2177 Dalgubeol-daero,
Jung-gu, Daegu 41940, Korea
3Department of Dental Science, Graduate School, Kyungpook National University, 2177 Dalgubeol-daero,
Jung-gu, Daegu 41940, Korea
*Correspondence: kblee@knu.ac.kr; Tel.: +82-053-600-7674
Received: 19 July 2019; Accepted: 13 August 2019; Published: 16 August 2019
Abstract:
Compared to traditional implant surgical guides, computer-assisted implant surgical
guides can be considered for positioning implants in the final prosthesis. These computer-assisted
implant surgical guides can be easily fabricated with personal 3D printers after being designed
with implant planning CAD software. Although the accuracy of computer-assisted implant surgical
guides fabricated using personal 3D printers is an important factor in their clinical use, there is
still a lack of research examining their accuracy. Therefore, this study evaluated the accuracy of
computer-assisted implant surgical guides, which were designed using two implant planning CAD
software programs (Deltanine and R2gate software) and fabricated with personal 3D printers using
a non-radiographic method. Amongst the patients who visited Kyungpook National University
Dental Hospital, one patient scheduled to undergo surgery of the left mandibular second premolar
was randomly selected. Twenty partially edentulous resin study models were produced using a
3D printer. Using the Deltanine and R2gate implant planning CAD software, 10 implant surgical
guides per software were designed and produced using a personal 3D printer. The implants (SIII
SA (Ø 4.0,
L=10 mm
), Osstem, Busan, Korea) were placed by one skilled investigator using the
computer-assisted implant surgical guides. To confirm the position of the actual implant fixture,
the study models with the implant fixtures were scanned with a connected scan body to extract the
STL files, and then overlapped with the scanned file by connecting the scan body-implant fixture
complex. As a result, the mean apical deviation of the Deltanine and R2gate software was 0.603
±
0.19 mm and 0.609
±
0.18 mm, while the mean angular deviation was 1.97
±
0.84
◦
and 1.92
±
0.52
◦
,
respectively. There was no significant difference between the two software programs (p>0.05). Thus,
the accuracy of the personal 3D printing implant surgical guides is in the average range allowed by
the dental clinician.
Keywords:
dental implant; computer-aided design; implant surgical guide; additive manufacturing
1. Introduction
Digital dentistry has evolved from cone-beam computed tomography (CBCT), intra-oral scanners,
computer-aided design (CAD) software, and computer-aided manufacturing (CAM), which has had a
profound impact on dental implantology [
1
–
3
]. In particular, additive manufacturing (AM) technology,
known as 3D printing, has contributed to the successful implementation of computer-guided implant
surgery [
1
,
3
]. Traditional implant surgical guides with modified radiographic templates require
Appl. Sci. 2019,9, 3373; doi:10.3390/app9163373 www.mdpi.com/journal/applsci
Appl. Sci. 2019,9, 3373 2 of 8
complex laboratory procedures which can be inaccurate, making it somewhat difficult to accurately
position implants in their planned locations [
4
–
9
]. On the other hand, computer-assisted implant
surgical guides can consider important anatomical structures, save time, and aid implant placement by
drawing the pre-planned final prosthesis design [10–12].
Accurate computer-assisted implant surgical guides are designed with implant planning CAD
software to process the information obtained from CBCT, intra-oral scanners, and diagnostic casts [
13
].
Several studies have previously measured the accuracy of computer-assisted implant surgical guides
designed using various implant planning CAD software [
14
]. According to a systemic review of the
accuracy of the implant surgical guides, the mean apical deviation between the planned position and
placed position was 1.4 mm, and the angle deviation was 3.5
◦
[
15
]. However, the deviations may vary
in different studies [16].
Son’s study shows that the positioning accuracy of computer-guided implants can vary depending
on experimental conditions, and that the accuracy of a cone beam computed tomogram (CBCT) or
intraoral scanning of the patient, and the accuracy of 3D printing or milling, have been reported to have
a significant effect on the positioning of implants [
17
]. If the positioning accuracy of computer-guided
implants is inaccurate, it can lead to an unintended position, which may be the biggest cause of
implant failure.
The positioning accuracy of the placed implants is measured by superimposing the pre- and
post-operative CBCT images. However, CBCT can be inaccurate due to resolution and distortion, and
errors may occur during the superposition of the CBCT images. In addition, the presence of metal
artifacts in the oral cavity may lower the resolution of the CBCT images [
18
,
19
]. A non-radiographic
method has been recently introduced to obtain the implant position and measure the placed implant
position, by using an intraoral scanner and superimposing it on the previously obtained implant fixture
scan data [
20
]. This allows for evaluation of the accuracy of the placed implant without post-operative
CBCT imaging.
In the 1980s, Charles Hull developed an early 3D printing device called the stereolithography
apparatus (SLA) that could create 3D models from digital data [
21
]. Since the important patents of AM
technology have recently expired, the 3D-printer market is further developing [
22
]. As a result, smaller
3D printers are being introduced into dental clinics quicker and with lower costs [
23
,
24
]. These 3D
printers are called in-office or personal 3D printers [
25
,
26
]. Computer-assisted implant surgical guides
can be easily produced with personal 3D printers after being designed with implant planning CAD
software [27].
Although the accuracy of computer-assisted implant surgical guides produced by personal 3D
printers is an important factor in their clinical use, there is still a lack of research examining their
accuracy. Therefore, this study evaluated the accuracy of computer-assisted implant surgical guides,
which were designed using implant planning CAD software (Deltanine and R2gate software) and
fabricated with personal 3D printers using a non-radiographic method. The null hypothesis of this
study is that there is no difference in the accuracy of surgical guides fabricated by both types of software.
2. Materials and Methods
Amongst the patients who visited Kyungpook National University Dental Hospital, one patient
who was scheduled to undergo surgery of the left mandibular second premolar with an identifiable
inferior alveolar nerve was randomly selected. Before placing the implant, we took a preliminary
impression and created a diagnostic cast using hard plaster. A 3D model scanner (Freedom HD, Degree
of Freedom, Seoul, Korea) was used to scan the diagnostic model and save the patient’s intraoral
soft tissue surface information in a Surface Tesselation Language (STL) file. The patient’s hard-tissue
information was obtained using CBCT (Alphard-3030, ASAHI Rogentgen, Kyoto, Japan) and stored as
a Digital Imaging and Communication in Medicine (DICOM) file. Twenty partially edentulous resin
study models were produced using a 3D printer (ZENITH, Dentis, Daegu, Korea). To replicate the
cancellous bone on the mandibular second premolar alveolar bone, the resin on the opposite side of
Appl. Sci. 2019,9, 3373 3 of 8
the study models was removed from the surface of the alveolar bone, and the removed portion was
hardened by filling it with orthodontic resin (Dentsply Sirona, York, PA, USA) and sawdust. Twenty
partially edentulous resin study models were scanned (CS3600, Carestream Dental LLC, Atlanta, GA,
USA) and the results were saved as standard tessellation language (STL) files.
Pilot experiments were conducted 2 times to determine the sample size, and 8 samples per
software were calculated using a power analysis software (G*Power v3.1.9.2, Heinrich Heine University,
Düsseldorf, Germany) (actual power =95.05%; power =95%;
α
=0.05). To increase power, the number
of samples presented in this study was determined to be 10 per software.
Using the Deltanine (Daesung, Seoul, Republic of Korea) and R2gate (Megagen, Daegu, Republic
of Korea) implant planning CAD software; the CBCT DICOM file taken before placement, and the
intraoral scanning STL file were retrieved and overlapped (Figure 1A), the implant position was
planned (Figure 1B), and a computer-assisted implant surgical guide was produced (Figure 1C). Ten
implant surgical guides per software were designed and fabricated using a personal 3D printer (n=10)
(Figure 1D).
Appl. Sci. 2019, 9, x FOR PEER REVIEW 3 of 8
Dental LLC, Atlanta, GA, USA) and the results were saved as standard tessellation language (STL)
files.
Pilot experiments were conducted 2 times to determine the sample size, and 8 samples per
software were calculated using a power analysis software (G*Power v3.1.9.2, Heinrich Heine
University, Düsseldorf, Germany) (actual power = 95.05%; power = 95%; α = 0.05). To increase power,
the number of samples presented in this study was determined to be 10 per software.
Using the Deltanine (Daesung, Seoul, Republic of Korea) and R2gate (Megagen, Daegu, Republic
of Korea) implant planning CAD software; the CBCT DICOM file taken before placement, and the
intraoral scanning STL file were retrieved and overlapped (Figure 1A), the implant position was
planned (Figure 1B), and a computer-assisted implant surgical guide was produced (Figure 1C). Ten
implant surgical guides per software were designed and fabricated using a personal 3D printer (n =
10) (Figure 1D).
Figure 1. Process of surgical guide production. (A) Overlap between data. (B) Implant position plan.
(C) Virtual surgical guide production. (D) Surgical guide production through a 3D printer.
The implants (TSIII SA (Ø 4.0, L = 10 mm), Osstem, Busan, Korea) were placed by one skilled
investigator using the computer-assisted implant surgical guides and one guide surgical kit (Osstem,
Busan, Korea). All implant fixture placement procedures were conducted by one skilled investigator.
The accuracy of the implant fixture placement angle was evaluated by measuring the angle of
the straight line connecting the top and bottom of each implant fixture (Figure 2A). Accuracy of the
implant fixture placement depth was confirmed by measuring the length of the straight line
connecting the planned implant fixture apex and the placed implant fixture apex (Figure 2B).
Figure 1.
Process of surgical guide production. (
A
) Overlap between data. (
B
) Implant position plan.
(C) Virtual surgical guide production. (D) Surgical guide production through a 3D printer.
The implants (TSIII SA (Ø 4.0, L =10 mm), Osstem, Busan, Korea) were placed by one skilled
investigator using the computer-assisted implant surgical guides and one guide surgical kit (Osstem,
Busan, Korea). All implant fixture placement procedures were conducted by one skilled investigator.
The accuracy of the implant fixture placement angle was evaluated by measuring the angle of
the straight line connecting the top and bottom of each implant fixture (Figure 2A). Accuracy of the
implant fixture placement depth was confirmed by measuring the length of the straight line connecting
the planned implant fixture apex and the placed implant fixture apex (Figure 2B).
Appl. Sci. 2019,9, 3373 4 of 8
Appl. Sci. 2019, 9, x FOR PEER REVIEW 3 of 8
Dental LLC, Atlanta, GA, USA) and the results were saved as standard tessellation language (STL)
files.
Pilot experiments were conducted 2 times to determine the sample size, and 8 samples per
software were calculated using a power analysis software (G*Power v3.1.9.2, Heinrich Heine
University, Düsseldorf, Germany) (actual power = 95.05%; power = 95%; α = 0.05). To increase power,
the number of samples presented in this study was determined to be 10 per software.
Using the Deltanine (Daesung, Seoul, Republic of Korea) and R2gate (Megagen, Daegu, Republic
of Korea) implant planning CAD software; the CBCT DICOM file taken before placement, and the
intraoral scanning STL file were retrieved and overlapped (Figure 1A), the implant position was
planned (Figure 1B), and a computer-assisted implant surgical guide was produced (Figure 1C). Ten
implant surgical guides per software were designed and fabricated using a personal 3D printer (n =
10) (Figure 1D).
Figure 1. Process of surgical guide production. (A) Overlap between data. (B) Implant position plan.
(C) Virtual surgical guide production. (D) Surgical guide production through a 3D printer.
The implants (TSIII SA (Ø 4.0, L = 10 mm), Osstem, Busan, Korea) were placed by one skilled
investigator using the computer-assisted implant surgical guides and one guide surgical kit (Osstem,
Busan, Korea). All implant fixture placement procedures were conducted by one skilled investigator.
The accuracy of the implant fixture placement angle was evaluated by measuring the angle of
the straight line connecting the top and bottom of each implant fixture (Figure 2A). Accuracy of the
implant fixture placement depth was confirmed by measuring the length of the straight line
connecting the planned implant fixture apex and the placed implant fixture apex (Figure 2B).
Figure 2.
Measuring deviations between planned (red) and placed (gray) implants. (
A
) Angular
deviation at the central axis of the implant. (B) Linear deviation at implant apex.
To evaluate the apical deviation and angular deviation, 3D inspection software (Geomagic control
X, 3D system, Morrisville, NY, USA) was used, and the scan, design, and sleeve indicator STL files
were extracted from the implant planning CAD software and overlapped to show the position of the
planned implant fixture (Figure 3A). To confirm the position of the actual implant fixture, the study
models with implant fixtures were scanned with a connected scan body (Osstem, Busan, Korea) to
extract STL files, and were overlapped with the scanned file by connecting the scan body-implant
fixture complex (Figure 3B). Precise scan data was obtained by calibration of the 3D scanner, and the
operator performed the evaluation by confirming the exact overlapping in the 3D inspection software.
A virtual cylinder was created for each implant fixture placed after planning with a 3D inspection
software, and the angular deviation was assessed by evaluating the angle difference. Virtual points
were created on the sleeve indicator and the tip of the placed implant fixture, and the apical deviation
was assessed by measuring the distance between the two points (Figure 3D).
Appl. Sci. 2019, 9, x FOR PEER REVIEW 4 of 8
Figure 2. Measuring deviations between planned (red) and placed (gray) implants. (A) Angular
deviation at the central axis of the implant. (B) Linear deviation at implant apex.
To evaluate the apical deviation and angular deviation, 3D inspection software (Geomagic
control X, 3D system, Morrisville, NY, USA) was used, and the scan, design, and sleeve indicator STL
files were extracted from the implant planning CAD software and overlapped to show the position
of the planned implant fixture (Figure 3A). To confirm the position of the actual implant fixture, the
study models with implant fixtures were scanned with a connected scan body (Osstem, Busan, Korea)
to extract STL files, and were overlapped with the scanned file by connecting the scan body-implant
fixture complex (Figure 3B). Precise scan data was obtained by calibration of the 3D scanner, and the
operator performed the evaluation by confirming the exact overlapping in the 3D inspection
software. A virtual cylinder was created for each implant fixture placed after planning with a 3D
inspection software, and the angular deviation was assessed by evaluating the angle difference.
Virtual points were created on the sleeve indicator and the tip of the placed implant fixture, and the
apical deviation was assessed by measuring the distance between the two points (Figure 3D).
All data were analyzed using the Statistical Package for the Social Sciences (version 25.0, IBM,
Chicago, IL, USA) (α = 0.05). First, the normal distribution of data was investigated using a Shapiro–
Wilk test. Equality of variance was evaluated using the Levene test for normal distribution. To
compare the accuracy of the surgical guide fabricated according to software, the difference was
analyzed using an independent t-test.
Figure 3. Digital evaluation method through 3D inspection software. (A) Planned implant position
through an overlap between the data extracted from computer-guided implant software. (B) Placed
implant position through scan body overlap. (C) Overlap between the data of the planned implants
and the placed implants. (D) Deviation measurement through a virtual cylinder.
3. Results
For the 20 study models in which implant fixtures were placed, the depth and angle of the
planned implant fixture and the placed implant fixture were compared and, as a result, the mean
apical deviation of Deltanine and R2gate software was 0.603 ± 0.19 mm and 0.609 ± 0.18 mm, while
the mean angular deviation of Deltanine and R2gate software was 1.97 ± 0.84° and 1.92 ± 0.52°,
respectively (Tables 1 and 2). There was no significant difference between the mean apical deviation
of the two software programs (p = 0.948), and there was no significant difference between the mean
angular deviation of the two software programs (p = 0.884).
Figure 3.
Digital evaluation method through 3D inspection software. (
A
) Planned implant position
through an overlap between the data extracted from computer-guided implant software. (
B
) Placed
implant position through scan body overlap. (
C
) Overlap between the data of the planned implants
and the placed implants. (D) Deviation measurement through a virtual cylinder.
Appl. Sci. 2019,9, 3373 5 of 8
All data were analyzed using the Statistical Package for the Social Sciences (version 25.0, IBM,
Chicago, IL, USA) (
α
=0.05). First, the normal distribution of data was investigated using a Shapiro–Wilk
test. Equality of variance was evaluated using the Levene test for normal distribution. To compare the
accuracy of the surgical guide fabricated according to software, the difference was analyzed using an
independent t-test.
3. Results
For the 20 study models in which implant fixtures were placed, the depth and angle of the
planned implant fixture and the placed implant fixture were compared and, as a result, the mean apical
deviation of Deltanine and R2gate software was 0.603
±
0.19 mm and 0.609
±
0.18 mm, while the mean
angular deviation of Deltanine and R2gate software was 1.97
±
0.84
◦
and 1.92
±
0.52
◦
, respectively
(Tables 1and 2). There was no significant difference between the mean apical deviation of the two
software programs (p=0.948), and there was no significant difference between the mean angular
deviation of the two software programs (p=0.884).
Table 1.
Apical and angular deviations between the planned implant fixture and the placed implant
fixture of the surgical guides fabricated with the Deltanine software.
No. Apical Deviation (mm) Angular Deviation (◦)
10.4264 1.378
20.9347 2.8391
30.8911 2.3762
40.4799 3.213
50.6554 1.102
60.6141 3.0092
70.3532 1.4332
80.6747 2.1232
90.4748 1.2342
10 0.5325 0.9968
Mean 0.60368 1.9704
Standard Deviation 0.19182 0.8465
Table 2.
Apical and angular deviations between the planned implant fixture and the placed implant
fixture of the surgical guides fabricated with the R2gate software.
No. Apical Deviation (mm) Angular Deviation (◦)
10.6219 1.9113
20.4728 1.3134
30.9832 2.983
40.7261 2.0142
50.6281 1.8602
60.3729 1.4312
70.5812 1.9786
80.4981 1.6823
90.3827 1.4821
10 0.8273 2.5829
Mean 0.6094 1.9239
Standard Deviation 0.1845 0.5207
4. Discussion
The location of the planned implants and placed implants have traditionally been evaluated by
comparing the pre- and post-operative CBCT images. In addition, the image artifacts and patient
movements can affect the quality of the CBCT images and limit their accuracy. This study evaluated
the accuracy of computer-assisted implant surgical guides made with personal 3D printers using a
Appl. Sci. 2019,9, 3373 6 of 8
non-radiographic method that overlapped the scan image of the study model with the scan body and
the scan body-implant fixture complex, respectively. In 2019, Tang et al. compared the traditional
radiographic method of evaluating the implant position using CBCT, with the non-radiographic
method of overlapping the scan data and inferring the implant position, and reported that there were
no statistically significant differences between these methods [
20
]. Therefore, the evaluation of the
implant position in this study is acceptable.
The positioning accuracy of the implant surgical guides can be determined by evaluating the
deviation between the planned implant position and placed implant position [
28
]. These deviations
represent different values in various papers [
14
]. However, a 1
◦
deviation of the insertion angle makes
an apical deviation of 0.34 mm based on a 10 mm implant fixture. In other words, a 5
◦
deviation of
the insertion angle represents an apical deviation of 1.7 mm. If the space between the implant and
the adjacent tooth root is 1.5 mm, an angular deviation of 5
◦
implies that it can invade the adjacent
tooth root [
29
]. When considering important anatomical structures such as the inferior alveolar
nerve, implant surgical guides have an allowable vertical and angle deviation of up to 1.5 mm and
3
◦
, respectively [
30
]. Therefore, the vertical deviation and angle deviation in this study are within
clinical tolerance.
As a result of placing implant fixtures in each of the 20 study models, there was no surgical guide
fabricated with the two software programs outside the vertical deviation of 1.5 mm, and there was no
statistically significant difference between the two software programs (p=0.948). One surgical guide
fabricated with the Deltanine software was out of tolerance of the 3
◦
angle deviation, but there was
no statistically significant difference between the two software programs (p=0.884). In light of these
results, it can be concluded that the surgical guide fabricated according to the software showed no
difference in the positioning accuracy of the implants. The Deltanine software used in this study was
compared to the R2gate software, which has been verified in the accuracy of implant placement in
a previous study [
17
]. Although not compared to traditional implant surgical guides, the Deltanine
software has been verified in comparison to the R2gate software and verified in a previous study.
The 20 resin study models used in this study had a rigid cortical bone. The inside surface was
removed and filled with a mixture of orthodontic resin and sawdust, which had a lower physical
property, thereby forming the cancellous bone. Since the thickness of the cortical bone varies in the
clinical setting, this study also arbitrarily set the thickness of the cortical bone. In the case of a rigid
personal 3D printer resin, the drill and fixture got stuck in the hard resin during the drilling process
resulting in an error. In addition, fabrication of the implant surgical guides with personal 3D printers
was thought to cause internal errors due to the removal of undercuts and nodules and the proficiency
of the surgeon who placed the implants. Given that this was an in-vitro study measuring the accuracy
of implant surgical guides made with personal 3D printers, errors above the mean can be fatal in the
clinical setting. However, since the cortical bone has lower strength and higher elasticity compared to
hard resin, errors due to the drill would be smaller when the implant is placed. Although the study
model was fabricated in consideration of the actual clinical environment, further studies are needed to
apply it to patients in actual clinical trials.
5. Conclusions
Based on the findings of this in-vitro study, the following conclusions were drawn:
1.
The surgical guide fabricated according to the two software programs shows no difference in the
positioning accuracy of the implants.
2.
The accuracy of the personal 3D printed implant surgical guides is in the average range allowed
by the dental clinician.
3.
The surgical guide fabricated by the method presented in this study can be utilized in dental
clinical practice.
Appl. Sci. 2019,9, 3373 7 of 8
Author Contributions:
Conceptualization, S.-M.K.; methodology, K.S. and D.-Y.K.; validation, K.-B.L.; formal
analysis, D.-Y.K.; investigation, K.S.; data curation, S.-M.K.; writing—original draft, S.-M.K.; visualization, K.S.;
supervision, K.-B.L.; project administration, K.-B.L.
Funding:
This research was supported by the Ministry of Trade, Industry & Energy (MOTIE, Korea) under the
Industrial Technology Innovation Program (No. 10062635); and the Institute for Information & Communications
Technology Promotion (IITP) for a grant funded by the Korea government (MSIP) (B0101-19-1081); and Korea
Institute for Advancement of Technology (KIAT) through the National Innovation Cluster R&D program (P0006691);
the Technology Innovation Program (10077743, Development of handpiece design for air turbine and root canal
treatment) funded By the Ministry of Trade, Industry & Energy(MOTIE, Korea).
Acknowledgments:
The authors thank the researchers of the Advanced Dental Device Development Institute,
Kyungpook National University for their time and contributions to the study.
Conflicts of Interest:
The authors declare no conflicts of interest. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of the data; in the writing of the manuscript, or in the decision
to publish the results.
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