Journal of Dentistry 123 (2022) 104170

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Accuracy of dental implant surgery using dynamic navigation and robotic

systems: An in vitro study
Baoxin Tao a, Yuan Feng b, Xingqi Fan c, Minjie Zhuang a, Xiaojun Chen c, Feng Wang d, *,
Yiqun Wu a, **
a
Department of Second Dental Center, Shanghai Ninth People’s Hospital, College of Stomatology, National Center for Stomatology, National Clinical Research Center for
Oral Diseases, Shanghai Key Laboratory of Stomatology, Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai
Jiao Tong University, Shanghai Jiao Tong University School of Medicine, 280 Mohe Road, Shanghai, China
b
School of Mechanical Engineering, Shanghai Jiao Tong University, Dongchuan Road 800, Minhang District, Shanghai, 200240, China
c
Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering,
Shanghai Jiao Tong University, Room 805, Dongchuan Road 800, Minhang District, Shanghai, 200240, China
d
Department of Oral Implantology, Shanghai Ninth People’s Hospital, College of Stomatology, National Center for Stomatology, National Clinical Research Center for
Oral Diseases, Shanghai Key Laboratory of Stomatology, Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai
Jiao Tong University School of Medicine, Shanghai Jiao Tong University, 639 Zhizaoju Road, Shanghai, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To compare the accuracy of dental implant placement using a dynamic navigation and a robotic
Accuracy system.
Computer-assisted surgery Methods: Eighty three-dimensional (3D) printed phantoms, including edentulous and partially edentulous jaws,
Robot-assisted surgery
were assigned to two groups: a dynamic navigation system (Beidou-SNS) group and a robotic system (Hybrid
Phantom study
Robotic System for Dental Implant Surgery, HRS-DIS) group. The entry, exit and angle deviations of the implants
in 3D world were measured after pre-operative plans and postoperative cone-beam computed tomography
(CBCT) fusion. A linear mixed model with a random intercept was applied, and a p value <.05 was considered
statistically significant.
Results: A total of 480 implants were placed in 80 phantoms. The comparison deviation of the dynamic navi­
gation system and robotic system groups showed a mean (± SD) entry deviation of 0.96 ± 0.57 mm vs. 0.83 ±
0.55 mm (p=0.04), a mean exit deviation of 1.06 ± 0.59 mm vs. 0.91 ± 0.56 mm (p=0.04), and a mean angle
deviation of 2.41± 1.42◦ vs. 1 ± 0.48◦ (p<0.00).
Conclusions: The implant positioning accuracy of the robotic system was superior to that of the dynamic navi­
gation system, suggesting that this prototype robotic system (HRS-DIS) could be a promising tool in dental
implant surgery.
Clinical significance: This in vitro study is of clinical interest because it preliminarily shows that a robotic system
exhibits lower deviations of dental implants than a dynamic navigation system, in dental implant surgery, in both
partially and completely edentulous jaws. Further clinical studies are needed to evaluate the current results.

1. Introduction long-term complications [2]. An optimal implant position can be ach­

A proper three-dimensional (3D) dental implant position is essential
for long-term stability and favorable aesthetic outcomes in implant
prosthodontics [1]. Freehand surgery based on two-dimensional (2D)
radiographic or 3D computer tomographic assessment may lead to
compromised implant positions, which may cause intraoperative- or
ieved virtually using preoperative planning software and then accu­
rately transferred to the surgical field via either static computer–assisted
implant surgery (sCAIS) or dynamic computer–assisted implant surgery
(dCAIS) [3].
Under an sCAIS protocol, a prefabricated surgical guide provides
physical constraint to guide the drill or implant to the planned position

* Corresponding author.
** Corresponding author.
E-mail addresses: diana_wangfeng@aliyun.com (F. Wang), yiqunwu@hotmail.com (Y. Wu).

https://doi.org/10.1016/j.jdent.2022.104170
Received 16 January 2022; Received in revised form 21 April 2022; Accepted 31 May 2022
Available online 7 June 2022
0300-5712/© 2022 Elsevier Ltd. All rights reserved.
B. Tao et al.
[4]. The dynamic navigation system offers real-time visualization and
guidance of the drills. Tracking cameras are used to track the reference
frames attached to the patient and handpiece. Registration between
cone-beam computed tomography (CBCT) and the patient and drill
calibration are performed, and then the movement of the patient and
drill can be displayed in real time on a computer as the movement be­
tween the corresponding CBCT and calibrated virtual drill [5, 6]. The
transformation accuracy from the virtual plan to the surgical field using
sCAIS and dCAIS is clinically acceptable in recent systematic reviews
[7–9]. However, drawbacks exist in the two approaches. Extra time and
effort are needed for surgeons to become familiar with the two systems
and understand any potential errors before clinical application [3,
10–12]. Using static guides has disadvantages, such as the intra­
operative broken static guide, reduced water cooling, intolerance of
simultaneous grafting procedures and absence of real-time feedback
[13]. Additional manufacturing time is needed for the surgical guide,
and once the static guide is fabricated, the planned implant paths cannot
be changed intraoperatively [14]. Finally, when implant placement is
required in the posterior region where access is limited, using static
guides may be difficult [14]. Although some studies have modified the
template using open holes for the posterior region with limited
inter-arches space, the accuracy is reduced [15]. In dCAIS, a steep
learning curve has been described [16]. The surgery procedure may
become discontinuous and prolonged because the surgeon must
frequently shift attention between the computer screen and surgical field
[16]. Additionally, because of the lack of physical guidance, the position
and axis of the drill are not constrained during drilling. Therefore, under
a dCAIS protocol, the result highly depends on the experience and per­
formance of surgeons [17,18].
The robotic system has been applied in dental implant surgery,
combining the benefits of physical constraint of the surgical guide and
real-time feedback of the dynamic navigation system [19]. In 2017,
Yomi became the first FDA-approved robot for dental implant surgery
[20]. As a semiactive robot assistance system [21], Yomi actively con­
strains the direction and location of the drill according to the selected
planned path. Surgeons perform the drilling and implant placement and
encounter no restriction if the drill is in the correct orientation and
location. The virtual drill and patient’s CBCT are also displayed on the
computer in real time. The robot developed by Zhao can perform dental
implant surgery automatically and can be classified as a semiactive and
task autonomy robot [22]. The patient is asked to remain static, and the
robot arm reaches the entry point of the planned position following a
prerecorded path. After that, the implant bed preparation and implant
placement are automatically performed. Surgeons only monitor the
robot and intervene when necessary. Using robotic systems in dental
implant surgery can eliminate deviations from fatigue-induced tremors
and the slow response of the surgeon. Surgeons can perform implant
surgery based on physical constraints and real-time feedback or only
monitor the performance of robots during surgery.
As a new computer-assisted surgery method, its accuracy has been
reported in previous studies [19,20,23–27]. However, no study has
compared the accuracy of dental implant placement between dynamic
navigation and robotic systems. Therefore, this in vitro study aimed to
compare the accuracy of dental implant surgery in terms of deviations
between virtual plans and real dental implants using dynamic system
and robotic systems in both partially edentulous and edentulous ster­
eolithographic phantoms.
2. Materials and methods
This study was approved by the ethics committee of the Shanghai
Ninth People’s Hospital, Shanghai, China (NO. SH9H-2020-T6-2) and
was conducted according to the Helsinki Declaration of 1964, as revised
in 2008.
2
Journal of Dentistry 123 (2022) 104170
2.1. Phantom preparation and virtual planning
The cone-beam computed tomography (CBCT) (Planmeca ProMax,
Planmeca Oy, Helsinki, Finland) data of a patient who had complete
dentition were selected as the source for phantom preparation. The
edentulous and partially edentulous phantoms were created after CBCT
three-dimensional reconstruction in Geomagic Studio, version 2013 (3D
Systems Inc., Rock Hill, South Carolina, USA). All the teeth were trim­
med in edentulous phantoms. The right second molar, right second
premolar, right canine and left canine remained in the maxilla, while the
left second molar, left canine, right canine and the right second premolar
remained in the mandible in partially edentulous phantoms. The middle
of the alveolar ridge of the model was hollowed out and then filled with
mesh to simulate the structure of cortical and cancellous bone. The
models were exported in the STereoLithography (STL) format and
manufactured (Zhixi Biomedical Technology Co., Ltd, Shanghai, China)
using stereolithography with 0.1 mm tolerance and Somos® EvoLVe 128
resin (Covestro AG, Leverkusen, Germany) (Fig. 1). Soft tissue was not
considered according to previous studies [27,28]. The phantoms were
mounted on a stereolithographic platform (Zhixi Biomedical Technol­
ogy Co., Ltd, Shanghai, China) to simulate conditions for normal mouth
opening (Fig. 2), and a face mask (Liyue Dental Model Co., Ltd, Dong­
guan, China) was fixed on the phantoms.
Eight carbon steel mini-screws (φ1.7 mm × 10 mm) (Jianwei Co.,
Ltd, Shenzhen, China) were inserted into both the maxilla and mandible
phantoms as fiducial markers. In the maxilla phantoms, mini-screws
were placed according to a previous study [29] in which four
mini-screws were placed on the anterior region, two were placed on the
midline palatine suture and two on both sides of the maxilla tuberosity.
In the mandible phantoms, they were dispersedly distributed on the
buccal side. The phantom received a CBCT scan with the following pa­
rameters: 96 kV; 7.1 mA; voxel size of 0.4 mm; field of view of 23 cm (D)
× 26 cm (H); scanning time of 18 s. The image data in the DICOM
(Digital Imaging and Communications in Medicine) format were im­
ported into Dental-Helper planning software V1.0.0 (Shanghai, China).
The planned surgical sites for dental implants are listed for each type in
Table 1. The image data and virtual plans were then imported into the
navigation software in BeiDou-SNS navigation system V1.0.0 (Shanghai,
China) [30]. The fiducial markers were then marked in the software.
Phantoms were assigned to the following two groups: the dynamic
navigation system group (n=40) and robotic system group (n=40). Each
group included 20 edentulous jaws (10 maxilla and 10 mandible) and 20
partially edentulous jaws. This is the first study comparing the accuracy
between dynamic navigation and robotic systems in dental implant
placement, so it is not possible to calculate a sample size for the study.
Fig. 1. Occlusal view of edentulous and partially edentulous phantom models.
(a and b: edentulous maxilla and mandible models; c and d: partially edentulous
maxilla and mandible models).
B. Tao et al. Journal of Dentistry 123 (2022) 104170

Fig. 3. Illustration of the tip-to-tip calibration procedure.

computer screen. Next, a sequence drilling procedure was performed by

the surgeon according to the relative position of the planned path and
Fig. 2. The edentulous phantom was mounted on the 3D-printed platform and
drill. The dental implants (Course Material SP; φ4.1 mm × 10 mm;
a patient reference frame was fixed on the mandible using a mini-screw.
Institut Straumann AG, Basel, Switzerland) were placed under the
guidance of the navigation system. All the procedures were performed
Table 1 by a surgeon (Tao) with experience in dCAIS (Fig. 4a).
Surgical sites for dental implant placement.
Edentulous Partially edentulous 2.3. Robotic-assisted dental implant surgery protocol

Maxilla Mandible Maxilla Mandible

Tooth number 17 37 16 36
(FDI two-digit system) 14 34 14 34
13 33 21 41
11 31 25 44
22 42 27 47
25 45
26 46
2.2. Dynamic CAIS protocol
The patient reference frame (Zhihang Medical Technology Co., Ltd,
Jiaxing, China) with three reflective spheres (NDI Passive Sphere™,
Northern Digital Inc., Waterloo, Canada) was fixed on the residual crest
in the middle line using a mini-screw (φ3 mm × 10 mm; Dcarer Medical
Technology Co., Ltd, Suzhou, China). The reference frame has two joints
designed for reference adjustment to the best tracking position, and the
right-angled bend beside the anchored hole is designed to avoid
oppressing lips (Fig. 2). The handpiece reference frame (Zhihang Med­
ical Technology Co., Ltd, Jiaxing, China) was also secured firmly on the
surgical micromotor (SGL70M LED Micromotor; NSK, Nakanishi Inc,
Tochigi, Japan). A fixator (Peituo Mechanical Equipment Co., Ltd,
Shanghai, China) was mounted to eliminate micromovement between
the handpiece (X-DSG20L Optic Handpiece (20:1 Reduction); NSK,
Nakanishi Inc, Tochigi, Japan) and surgical micromotor. Next, the
infrared tracker (Polaris Vega, Northern Digital Inc., Waterloo, Canada)
was set at a proper position to track all the devices mentioned above.
The registration procedure was accomplished using a probe (Zhihang
Medical Technology Co., Ltd, Jiaxing, China) to contact each fiducial
screw in the predetermined sequence in the navigation software. After
that, a tip-to-tip drill calibration procedure was performed by inserting
the drill (φ2.2 mm; Institut Straumann AG, Basel, Switzerland) into the
hole with the same diameter as that of the calibration block (Zhihang
Medical Technology Co., Ltd, Jiaxing, China). The probe was inserted
into the opposite side (Fig. 3), and the tips contacted each other along
the same axis [31]. This procedure defines the apex point and axis of the
drill so that the drill can be tracked in real time. When the drill is
changed, a virtual calibration is initiated by inputting the corresponding
length of the selected drill in the software. The position of the drill,
alveolar bone and virtually planned implant were displayed on the
The robotic system was the Hybrid Robotic System for Dental
Implant Surgery (HRS-DIS; Shanghai, China) (Fig. 4b) [25]. The robot
has 11◦ of freedom (DOF), including a 5-DOF serial manipulator (Peituo
Mechanical Equipment Co., Ltd, Shanghai, China), which is responsible
for enlarging the workspace, and a 6-DOF Stewart manipulator (Peituo
Mechanical Equipment Co., Ltd, Shanghai, China), which is used to
ensure the positioning accuracy and stiffness (Fig. 5). The handpiece (CA
20:1; Bien-Air Dental SA, Bienne, Suisse) was attached to the Stewart
manipulator. Human-robot interactive dragging, instead of automatic
movement, was also adopted using a six-dimensional force transducer
(OnRobot Hex-H, Onrobot Inc., Odense, Denmark) so that the surgeon
could drag the handpiece to the target positions, preventing the patient
from any harm associated with the automatic movement of the robot
arm in the initialization procedure. The navigation system (BeiDou-SNS
navigation system V1.0.0; Shanghai, China) integrated into HRS-DIS
was used to track the phantom and drill and then interchange data
with the robot. After the reference frame fixation, registration and
calibration process, an initial axis adjustment to position the drill par­
allel to the axis of the target trajectory was conducted using the Stewart
manipulator and two revolute joints. Next, the handpiece end-effector
was dragged close to the entry point of the target implant trajectory
by the surgeon via human-robot interactive dragging. A second fine axis
adjustment was then initiated using the Stewart manipulator, and the
drill then reached 2 mm above the entry point. Osteotomies were
automatically performed by the robot, after the drilling was finished, it
returned to the starting point. The handpiece end-effector was then
dragged out of the mouth, and the next drill was changed manually.
After the osteotomies were accomplished, the dental implants were
placed by the robot.
2.4. Accuracy assessment
After all the implants were placed in the two groups, postoperative
CBCT was performed using the same parameters The preoperative im­
ages and plan paths were imported to Brainlab CMF 3.0.6 (BrainLAB AG,
Munich, Germany), and then the postoperative images were imported
and fused based on the reference of the preoperative images using a
semiautomatic surface-based fusion method [32]. The center of the
entry and exit points of the planned path and actual implant were
marked using the “Measure Hounsfield Unites” function, which provides

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B. Tao et al. Journal of Dentistry 123 (2022) 104170

Fig. 4. Overview of the experimental setup. (a) Setup of the dynamic navigation system group. (b) Setup of the robotic system group.

Fig. 5. Structure of the hybrid robotic system of HRS-DIS.

the Hounsfield units and X-Y-Z coordinates of the points. The co­
ordinates of the entry and exit points of the planned path can be
expressed as Pen and Pex , while those of the actual implant are Aen and
Aex . The entry deviation (Den ), exit deviation (Dex ) and angle deviation
(Dan ) can be calculated as follows (Fig. 6):
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
Den = ‖ Pen − Aen ‖2 (1)
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
Dex = ‖ Pex − Aex ‖2 (2)

(Pex − Pen )⋅(Aex − Aen )

Dan = cos− 1 √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅ √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅ (3)
‖ Pex − Pen ‖2 ⋅ ‖ Aex − Aen ‖2

All the deviations were measured by a blinded surgeon (Zhuang)

who did not participate in the phantom surgery.

2.5. Statistical analysis

SAS 9.4 computer software (SAS Institute Inc., SAS Campus Drive,
Cary, North Carolina, USA) was applied to analyze the data. The
descriptive statistical parameters of the two groups were measured as
the mean, standard deviation, interquartile range (25th-75th percentile)
and minimum–maximum value according to the different groups and
phantom types. The normality distribution of the data was evaluated
using the Shapiro–Wilk test. Because of the implants lacked indepen­
dence, a linear mixed model with a random intercept was applied to
Fig. 6. Illustration of deviations (entry, exit and angle deviations) between
compare the three deviations of the dynamic navigation and robotic virtually planned and actually placed dental implants.
system groups and analyze the possible influencing factors, including
the jaw types, phantom types and implant positions. A significant dif­
ference was defined as p<0.05.

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B. Tao et al. Journal of Dentistry 123 (2022) 104170

3. Results of dental implant placement between dynamic navigation and robotic

systems. The robotic system group exhibited significantly lower de­
In total, four hundred eighty dental implants were placed unevent­ viations in the entry point, exit point and angle than the dynamic nav­
fully in 80 phantoms. The deviations in the entry and exit points, angle igation group, suggesting that the robotic system could gain a higher
of the two groups and types of jaws are summarized in Tables 2 and 3. accuracy than the dynamic navigation system in dental implant surgery.
The means of the entry deviations of the dynamic navigation system and The reason could be attributed to the following factors. First, dCAIS is
robotic system groups were 0.96 ± 0.57 mm and 0.83 ± 0.55 mm, still highly dependent on the manipulation and experience of the sur­
respectively. The mean exit deviations of the two groups were 1.06 ± geon. A clear learning curve was described in which the inexperienced
0.59 mm and 0.91 ± 0.56 mm, and the mean angle deviations were 2.41 surgeon requires three to five attempts with these systems to reach a
± 1.42◦ and 1 ± 0.48◦ , respectively. Because the data were not normally plateau [17,18]. Hand tremors and an inaccurate perception have been
distributed, square root normal transformation was first applied. The demonstrated to cause 0.25 mm of lateral deviation and 0.5◦ of angle
independence of each implant was lacking because the implants were deviation [36]. Additionally, frequent view shifting between the com­
clustered on the same phantom; thus, a linear mixed model was adopted. puter screens and surgical sites may cause surgeons to miss critical de­
The group variables (dynamic navigation and robotic systems), phantom tails or become fatigued [24]. Second, the robotic system can constrain
and jaw types, and implant position were treated as fixed effects, and the and stabilize the location and axis of drills without human tremors.
intercept was included as the random effect. Significant differences were Furthermore, compared with computer-assisted dynamic navigation
found in the entry, exit and angle deviation between the groups (p=0.04, methods, robotic systems have a higher accuracy and reproducibility
p=0.04 and p<0.00, respectively) (Fig. 7). The phantom type (edentu­ because of their repeated task performance and a lower need for surgical
lous and partially edentulous), jaw type (maxilla and mandible) and experience or skills, although time and practice are needed to master the
implant position showed no significant effect on the entry deviation standard operation procedure of robotic systems [41]. Interestingly, the
(p=0.74, 0.49 and 0.35, respectively) or exit deviation (p=0.9, 0.05 and phantom type (edentulous or partially edentulous) and tooth position
0.61, respectively). Regarding angle deviation, the phantom type and did not significantly affect the accuracy, which could be regarded as a
implant position presented no significant effect (p=0.91 and 0.5, benefit for both robotic and navigation systems that they could adapt to
respectively), but the jaw type showed a significant effect on the accu­ different scenarios. The result also agrees with two systematic reviews
racy (p=0.02). that found no significant differences between edentulous and partially
edentulous patients [37] or between the maxilla and mandible [42]
4. Discussion regarding the deviations of implants placed by dynamic navigation
systems. However, the mandible phantom presented a slightly higher
The precise transformation of virtual plans to surgical sites is a angle deviation than the maxilla phantom (1.81 ±1.28◦ vs. 1.6 ± 1.27◦ ;
prerequisite for the final outcomes of dental implant restoration, such as p=0.02), particularly in the robotic system group (1.14 ±0.49◦ vs. 0.87
functional performance, aesthetics, and peri-implant tissue health [2]; ± 0.44◦ ). The reason may be related to the mandible phantom, which
thus, computer-assisted methods such as sCAIS and dCAIS have been was secured on the slope of the stereolithographic platform. The occlusal
developed to meet this requirement. Several studies have compared the plane is not perpendicular or parallel to the ground, which may cause
accuracy of sCAIS and dCAIS in dental implant surgery, and most have the drill to slip. A small slip of the drill at the entry point could cause
demonstrated that sCAIS and dCAIS have met the clinical requirements. deviation accumulation in the exit point and angle. However, the angle
No statistically significant difference was found between the approaches deviation of mandible phantoms in the robotic system group was smaller
regarding the entry, exit and angle deviations [2,33–36], and this result than that of the dynamic navigation system group and other in vitro
was also strongly supported by recent systematic reviews [9,37,38]. studies of robotic systems in dental implant surgery [24,26]. Some sig­
However, both sCAIS and dCAIS still have disadvantages [39]. Robotic nificant outliners exist in both groups. In the robotic system group, one
systems have recently been introduced in dental implant surgery, and implant had entry and exit deviations up to 2.96 mm and 3.06 mm,
several reports have shown that implants placed by the robotic system respectively. The deviations resulted from malposition of the robot
were more accurate than those placed by the sCAIS system [23,40]. during implant site location because of the loosening of the model after
However, few studies have compared the accuracy of implant placement prior drilling procedure, which was not compensated by HRS-DIS
between dynamic navigation and robotic systems. instantly because of the lack of rapid following movement function
To our best knowledge, this study is the first to compare the accuracy currently, which will be developed and added further. The maximum
deviation of the navigation system group showed that one implant had
entry and exit deviations of 2.93 mm and 3.09 mm, respectively, and
Table 2 another implant had an angle deviation of 8.13◦ . The deviations could
Deviations between the planned and placed dental implants of the dynamic be attributed to the undiscovered loosening of the patient reference
navigation system group and robotic system group (dynamic navigation implant
frame or handpiece fixator. The patient reference frame is fixed by a
(DI): dynamic navigation system group; robotic system implant (RI): robotic
single mini-screw (φ3 mm × 10 mm) that may become loose when a
system group).
large force is placed on the end of the reference frame. The loosening of
Group Mean ( Median P25- Min- p value the handpiece fixator affects the pre-calibrated relationship between the
± SD) P75 Max
drill tip and handpiece reference, resulting in error accumulation.
Entry DI 0.96 ± 0.84 0.48- 0.14- 0.04* Therefore, an anti-rotation screw or two screws with small diameters are
deviation 0.57 1.39 2.93
recommended to fix the reference. The handpiece reference frame
(mm) RI 0.83 ± 0.7 0.11-1 0.06-
0.55 2.96 should be designed to be directly secured on the handpiece. Addition­
Exit deviation DI 1.06 ± 1.03 0.54- 0.12- 0.04* ally, a routine stability check of the references must be performed.
(mm) 0.59 1.46 3.09 The accuracy results of the dynamic navigation and robotic systems
RI 0.91 ± 0.83 0.48- 0.04- in the study are consistent with those in other studies and systematic
0.56 1.21 3.06
Angle DI 2.41± 1.97 1.36- 0.02- 0.00****
reviews. In the present study, the three deviations of the dynamic nav­
deviation 1.42 3.32 8.13 igation system were 0.96 ± 0.57 mm, 1.06 ± 0.59 mm and 2.41± 1.42◦ ,
(degrees) RI 1 ± 0.48 0.93 0.63- 0.06- which were similar to those of Somogyi-Ganss et al. (1.14± 0.55 mm,
1.32 2.57 1.71 ± 0.61 mm and 2.99± 1.68◦ ) [43] and Chen et al. (1.07± 0.48 mm,
*
p<0.05 1.35 ± 0.55 mm and 4.45± 1.97◦ ) [44]. Three recent systematic reviews
****
p<0.0001 [9,37,42] reported that the mean entry deviations were 0.91 mm, 0.91

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B. Tao et al. Journal of Dentistry 123 (2022) 104170

Table 3
Deviations regarding the maxilla and mandible of the dynamic navigation system and robotic system groups.
Dynamic navigation system group Robotic system group

Entry deviation (mm) Exit deviation (mm) Angle deviation ( )

◦
Entry deviation (mm) Exit deviation (mm) Angle deviation (◦ )

Edentulous Maxilla 1±0.52 1.07±0.57 2.44±1.34 0.74±0.51 0.81±0.75 0.83±0.46

Mandible 0.88±0.52 1.07±0.62 2.44±1.65 0.95±0.59 1.05±0.56 1.19±0.54
Partially edentulous Maxilla 1.02±0.68 1±0.59 2.2±1.46 0.74±0.5 0.8±0.5 0.92±0.42
Mandible 0.95±0.58 1.09±0.6 2.55±1.15 0.89±0.59 0.99±0.59 1.07±0.4

Fig. 7. Boxen plot of the distribution of the entry, exit and angle deviations of the dynamic navigation system (Navigation) and robotic system (Robot) groups. The
statistically significant differences were demonstrated using a mixed effect model. *p<0.05, **** p<0.0001

mm and 1.07 mm, and the results were similar to our data (0.96 mm).
The mean exit deviations were reported as 1.04 mm, 1.21 mm and 1.36
mm, which agreed with our result of 1.06 mm. Regarding the angle
deviation, the 3.7◦ , 2.78◦ and 3.47◦ , reported in the three reviews were
also similar to our result of 2.41◦ . The results demonstrate that our
dynamic navigation system can gain the same accuracy as that of the
systems in other studies. In the current study, a novel dental implant
robotic system named HRS-DIS was developed. The hybrid robot, which
was first applied in dental implant surgery, possessed serial and parallel
parts, in which the serial part adopted 3 decoupling translation joints as
well as 2 revolute joints to expand the work space to cover all tooth
positions, and the parallel part adopted the Stewart platform to avoid
cumulative joint error and low stiffness of the serial manipulator [45,
46]. Additionally, the robot also meets the requirement of high input
force in hard cortical bone. The accuracy results showed that the entry,
exit and angle deviations of dental implants placed by HRS-DIS were
0.83 ± 0.55 mm, 0.91 ± 0.56 mm and 1 ± 0.48◦ , respectively. Ac­
cording to other studies, the robotic system accuracy values were 0.79 ±
0.17 mm, 1.26 ± 0.27 mm, and 3.77 ± 1.57◦ for the three deviations in
an in vitro study [24] and 0.269 (0.152) mm, 0.254 (0.218) mm and
0.989◦ (0.517◦ ) in an in vivo study [40]. The clinical application of the
Yomi dental implant robotic system exhibited accuracy values of 1.04 ±
0.47 mm, 0.95± 0.73 mm and 2.56 ± 1.48◦ for entry, exit and angle
deviations of 38 implants, respectively, placed in edentulous patients
[20].
Regarding the limitations of the two approaches, the registration and
reference fixation screws in both dynamic navigation and robotic sys­
tems were all invasive in the current study. However, some types of
static guides, particularly tooth support, is exempt from additional
trauma from anchored pins or references. Therefore, in conventional
dental implant surgery, noninvasive registration [47] and tracking ap­
proaches [48] are needed. Additionally, the prohibitive cost of dynamic
navigation or robotic systems may limit their widespread use, particu­
larly in regular dental practices [12], but static guides have been widely
used because of many open-source planning software and low
manufacturing fees [49]. Furthermore, sufficient hands-on and clinical
practice are required to establish confidence and proficiency of clini­
cians to perform surgery using a dynamic navigation system [49]. These
approaches are the same for robotic systems that require additional
training concerning the standard operation procedure. Comparing the
two approaches, static guides agree more with the operating habits of a
dental surgeon, and a typical learning curve was not identified [50].
However, the possibilities of the future employment of robotic systems
in dentistry still exist, and robotic systems will become cost-effective and
easy to use by introducing affordable systems and establishing a simple
operation workflow [51].
However, the present study has some limitations. A prediction al­
gorithm will be adopted to compensate for any possible deviations from
the deformation of silica gel, which is used to detect the external force in
the force sensor. Additionally, rapid following movement of the robot
should be developed and added to the system. Finally, the accuracy
comparison was conducted in phantoms, which may not completely
simulate real clinical situations; thus, cadavers or clinical studies should
be conducted in the future.
5. Conclusions
In this study, the comparative accuracy of dental implant surgery in
phantoms between a dynamic navigation system and a robotic system
was evaluated. The robotic system yielded significantly lower entry, exit
and angle deviations than those in the dynamic navigation system,
suggesting that the prototype robotic system (HRS-DIS) could be a
promising tool in dental implant surgery. However, its accuracy, reli­
ability and feasibility should be further evaluated in clinical situations.
CRediT authorship contribution statement
Baoxin Tao: Investigation, Data curation, Writing – original draft.
Yuan Feng: Software, Investigation. Xingqi Fan: Software, Formal
analysis, Visualization. Minjie Zhuang: Validation, Data curation.
Xiaojun Chen: Conceptualization, Methodology, Software. Feng Wang:
Methodology, Writing – review & editing. Yiqun Wu: Conceptualiza­
tion, Funding acquisition, Supervision, Writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.

6
B. Tao et al.
Acknowledgments
This work was supported by the grants/ awards of Clinical Research
Plan of SHDC (SHDC2020CR3049B), CAMS Innovation Fund for Medi­
cal Sciences (CIFMS) (Project No. 2019-I2M-5-037), Research Discipline
fund from Ninth People’s Hospital, Shanghai Jiao Tong University
School of Medicine, and College of Stomatology, Shanghai Jiao Tong
University, Grant/Award Number: KQYJXK2020; Huangpu District In­
dustrial Support Fund, Grant/Award Number: XK2020014. We also
acknowledge the statistic support of Dr. Wentao Shi.
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