continuing education 2

Dynamic Navigation Surgery

Dynamic Navigation for Surgical Implant

Placement: Overview of Technology,
Key Concepts, and a Case Report
George A. Mandelaris, DDS, MS; Luigi V. Stefanelli, DDS, PhD; and Bradley S. DeGroot, DDS, MS

learning objectives

Abstract: Over the course of several decades implant dentistry has evolved • Acquire an introductory
understanding of the
to include 3-dimensionally (3D) planned and guided surgery. One of the technology that allows for
latest innovations is dynamic navigation, which may allow surgeons to dynamic navigation surgery

place implants with accuracy similar to stereolithographic guides based on • Describe the workflow
and clinical processes
3D, prosthetically directed plans. Benefits of dynamically guided surgery required for dynamic
include real-time feedback, a streamlined digital workflow, improved navigation as it pertains to
dental implant surgery
surgical visualization, and adaptability to intraoperative findings. This
• Identify the clinical
article discusses the technology and workflow of dynamic navigation and its advantages of dynamic

application for guided implant placement. Additionally, a case completed navigation versus either
freehand or statically
using this technology is presented. guided implant surgery

DISCLOSURE: The authors had no

F
disclosures to report.

our key breakthroughs have driven the evolution of negated much of the radiation exposure concerns related to effec-
dental implantology as it is known today: (1) the discov- tive-dose safety for “elective” therapies.11 Today, an emerging stan-
ery of osseointegration by Dr. P-I Branemark1; (2) the dard of care is the use of cross-sectional CBCT imaging for planning
application of computed tomography (CT) imaging and a stereolithographic surgical guide when executing surgery.12,13
technology for “optimal, prosthetically directed implant At their inception, stereolithographic surgical guides were
placement”2-4; (3) computer-generated stereolithographic surgical sequential drilling templates that allowed osteotomy sites to be
guides5-8; and (4) cone-beam CT (CBCT), which reduced radiation enlarged and were used to control the buccolingual and mesio-
exposure and improved access for the private practice sector.9,10 distal planes of space.14 This application has been referred to as
In the late 1980s, 3-dimensional (3D) imaging using medical- “partially guided” implant surgery. The effect of stereolithographic
grade, spiral CT became an important yet controversial tool for surgical guides was significant, improving entry point deviations
implant dentistry. Three-dimensional imaging allowed accurate and angle discrepancies by nearly 50% when compared to conven-
diagnosis of regional anatomy and more personalized planning tional freehand surgery.15 However, it was the production of fully
for surgery via planning software that enabled improved surgical– guided implant surgery that improved accuracy to submillimeter
prosthetic collaboration. However, no methodology was available levels and enabled control in all three planes of space: buccolingual,
to transfer and apply the computer-based surgical plan directly to mesiodistal, and apicocoronal.16 Rotational timing is also possible
the operating field. with fully guided systems, though this is implant- and/or guide-
manufacturer dependent.8,17
Guided Surgery Background Today, the advent of intraoral surface scanners and computer-
In 2000, CBCT became available and allowed for significantly less aided design/computer-aided milling (CAD/CAM) has made
radiation exposure.9,10 In 2002, the ability to generate stereolitho- guided, full-arch, immediate-function treatment for the edentu-
graphic surgical guides from a CBCT-based computer software plan lous and terminally dentate patient simpler and more predictable.18

614 compendium October 2018 Volume 39, Number 9

Computer-generated stereolithographic guides used for all modalities
of partially or totally guided surgery are referred to as “static” guides,
because once they are constructed there is no opportunity to change
the treatment plan and remain “guided.” Despite their improvements
over previous methods, the use of stereolithographic guides can be
hampered by inaccurate planning and fit, movement of the guide
during the surgical operation, and bone density difficulties that may
require angulation changes during placement.8 Unfortunately, inac-
curacies in the guides typically are not discovered until the time of
surgery or, worse, after the implants have been placed.
Dynamic navigation (or “virtual”) surgery is relatively common
in various areas of medicine such as craniomaxillofacial surgery,
Fig 1.
neurosurgery, and orthopedic/spine surgery.19,20 Surgical navi-
gation systems are made possible by motion tracking technology,
commonly referred to as a micron tracker camera.19,20 This technol-
ogy is now also available in dentistry.
In dentistry, implant placement is possible using dynamic naviga-
tion because the micron tracker camera is able to relate the position
of the patient’s jaw to the position of the implant drill tip in real time.
The relationship of the drill to the jaw is displayed instantaneously,
allowing for continuous, immediate feedback on the mesiodis-
tal, buccolingual, and apicocoronal positions of the implant drill
(Figure 1). The three fundamental steps, which together enable the
real-time mapping of the drill tip to the patient’s planned CBCT
image volume, are called registration, calibration, and tracking.
(Figure 2). The surgeon is thus able to prepare the osteotomy and
Fig 2.
place the implant based on the pre-planned, prosthetically directed
implant position.
There are several advantages of this approach compared to the Fig 1. The dynamic navigation system described consists of a note-
book computer (1) and an optical position sensor (4) carried by
use of static guides: changes can be made during the surgery, the the foldable boom arm extending from a compact mobile cart (not
technology can be used with a standard surgical kit for any implant shown). The stereoscopic optical position sensor (micron tracker) (4)
system, surgical navigation can be accomplished in 1 day (if circum- detects and triangulates checkerboard targets marked on the drill tag
(2) and jaw tag (3), providing instant feedback during the opera-
stances permit), and the cost for constructing a static guide is elim- tion. Fig 2. The three coordinate mapping steps that, when chained
inated. Further, when compared to freehand approaches, guid- together, map the drill tip to the planning CBCT image volume.
ance enables a significant reduction in damage to soft tissue with
a resultant decrease in infection risk, patient discomfort, and soft-
tissue healing time. For dental implant surgery, dynamic naviga- x-navtech.com), Image Guided Implant (IGI) Dentistry System
tion technology allows for real-time verification and validation of (Image Navigation, image-navigation.com), YOMI® (Neocis, neocis.
positional accuracy. The purpose of this article is to introduce read- com), and Inliant® (Navigate Surgical, navigatesurgical.com). The
ers to dynamic navigation and present a case using the technology. Navident, X-Guide, IGI, and YOMI systems are US Food and
Drug Administration approved. The Navident dynamic navigation
Overview of Navigation System system consists of five main components (Figure 1)2: (1) A notebook
Dynamic navigation systems track the position of the tip of the computer runs the system software and provides integrated plan-
implant drill and map it to a pre-acquired CBCT scan of the patient’s ning and navigation functionalities. (2) A handpiece attachment
jaw to provide real-time drilling and placement guidance/feed- consists of a universal handpiece-hugging adapter and an optically
back.21 When the drill approaches a pre-planned implant location, marked plastic component, referred to as the “drill tag.” (3) A patient
the system provides a “cross-hair” or “bulls-eye” display to help the jaw attachment consists of a moldable thermoplastic stent that is
surgeon navigate precisely to the planned drill entry point position, situated directly on the patient’s natural dentition (ie, the retainer)
adjust the drill orientation to the planned angle, and navigate the with a retainer arm extending from the retainer body. A fiducial
osteotomy site along the planned trajectory to the planned depth.22 marker attached to the retainer acts as a CT marker and allows for
Once the osteotomy preparation is complete, the same approach spatial registration of the patient relative to the jaw attachment. This
can be used to guide the insertion of the implant itself. same retainer is used during the implant surgery, thus maintaining
The dynamic navigation system described here is the Navident the same relationship to the CBCT image that was obtained and
system (ClaroNav, claronav.com). Other similar dynamic navi- used for case planning. (4) An optical positioning sensor (ie, micron
gation systems include X-Guide Dynamic 3D Navigation (X-Nav, tracker camera) detects the patterns printed on the handpiece and

www.compendiumlive.com October 2018 compendium 615

continuing education 2 | Dynamic Navigation Surgery

jaw attachments and constantly reports their relative positions to the same thermoplastic material and includes a fix plate at its end,
the dynamic system software. This allows the surgeon to intraop- which is joined to the CT marker via a thumbscrew. The CT marker
eratively reference and, in real time, verify and validate positional contains an aluminum fiduciary marker within it that can be iden-
accuracy. (5) A compact, mobile cart (not shown in Figure 1) holds tified in the CBCT. The fix plate is the common reference position
the laptop and positions the optical sensor above the patient. between the CBCT scan and the surgery to which mathematical
algorithms can be calculated so that spatial positioning is known
Workflow: Stent, Scan, Plan, and Place to the system. When attached via the thumbscrew, the CT marker
The navigation system described here has a digital workflow that is rigidly locked with the retainer. The thermoplastic retainer and
involves four major steps: arm are attached via adhesive glue (Figure 3).
Stent—A thermoplastic retainer is molded over the dentition, Scan—The CT marker, thermoplastic stent, and retainer arm
left to harden, and then removed and trimmed to provide access with fix-plate apparatus are secured and seating accuracy is verified.
to the intended implantation region. The retainer arm is made of Thereafter, a single jaw is scanned using a CBCT scanner (Figure 3).

Fig 3. Stent prepared for CBCT imaging and that leads to dy-
namic navigation surgery capability. A customized, well-fitting,
stable thermoplastic retainer; thermoplastic retainer arm and fix
plate; and CT marker secured by a thumbscrew are shown. Fig 4.
Planning software is shown. STL file of the maxillary arch has been
imported from optical scanning and matched to regional anatomy
for soft-tissue visualization. The aluminum fiduciary of the CT
marker can be observed in the axial view. Virtual teeth have been
constructed for Nos. 8 and 9, and the case has been planned for
prosthetically directed implant placement on a dynamic naviga-
tion platform.

Fig 3.

Fig 4.

616 compendium October 2018 Volume 39, Number 9

 Plan—The image data in Digital Imaging Fig 5. Implant drill tip
Communication in Medicine (DICOM) being calibrated prior to
osteotomy site prepara-
format is imported to the navigation system tion by placing it in a
by a direct transfer using the local network. dimple in the jaw tag.
Registration of the fiducial image in the CT Fig 6. The target view
used during dynamic
scan is performed (automatically) and veri- navigation surgery,
fied by the user at this point. STL files of which contains all the
either the dentition or prosthetic wax-ups information the clinician
needs to guide the os-
can be imported from optical scanning for teotomy and implant.
prosthetically directed treatment planning
(Figure 4). Virtual teeth are placed and
adjusted to simulate the desired restora-
Fig 5.
tion, and supporting implants are placed in
consideration of the prosthetic plan. While
considerable time is spent in the planning figure 6

phase, the surgeon has the opportunity to

0.5mm A Patient’s anterior
modify the plan during the operation if the Distance between drill
surgical environment warrants change. tip and central axis of
planned osteotomy
Place—The laptop displaying the plan is
positioned over the patient. The customized 12.4°
thermoplastic stent is now attached to an Angle between drill Drill
and central axis of
optical marker tag (ie, jaw tag), which replaces planned osteotomy
the CT marker. The jaw tag is secured to the
12.9mm
fix plate of the retainer arm with the use of Distance between
Fig 6.
a thumbscrew. The second optical marker drill tip and
component (ie, drill tag) is mounted to the apical end of
planned osteotomy
handpiece, the drill’s axis is calibrated, and R Patient’s right
then the first drill in the sequence is installed
Drill tip
in the handpiece and its length (tip) is cali-
brated (Figure 5). Each drill tip for osteotomy 2mm 1mm
site preparation is independently calibrated
just prior to its use, followed by an accuracy
check prior to drilling. Osteotomy site prepa-
ration is performed using the dynamic naviga-
tion technology. The motion of the handpiece
is tracked against patient position. During
drilling the operator can see axial, panoramic, P Patient’s posterior
and cross-sectional views in real time as the
case progresses. A real-time “cross-hair” or
“bulls-eye” target view provides distance in millimeters between the position entry point, angulation, and depth, which can be ensured for
drill tip and the central axis, the angle of the drill in relation to the instantaneous transparency (ie, surgical accountability).
central length axis, and the distance (mm) between the tip of the drill
and the apical end of the planned osteotomy (Figure 6). Sources of Guidance Errors
While the surgeon is watching the computer monitor rather than Errors in the drill tip to CT image mapping may appear at any step in
focusing on patient anatomy, the surgical field is open for better treat- the workflow due to slight inaccuracies within the dynamic naviga-
ment visibility compared to static guides. The drill tip calibration and tion system or associated with using the technology (eg, manufac-
accuracy checks are repeated after each drill size change. The surgeon turing tolerances, stent distortion, inaccurate calibration, patient
conducts intrasurgical accuracy checks by touching rigid anatomical motion during the CT scanning process, unstable seating of the
landmarks such as the surfaces of nearby teeth with the drill tip of oste- jaw attachment, bending of arms or connectors during surgery).
otomy burs. If the indicated accuracy demonstrated by the software Operators must pay close attention throughout the process to mini-
is insufficient, the surgeon can troubleshoot to find and eliminate mize errors that could ultimately compromise accuracy.
the source of the inaccuracy by following a systematic procedure. If Despite the navigation system’s extraordinary detection accu-
the issue cannot be resolved, the surgery can be aborted or the CBCT racy, the surgeon’s control (or ability to direct the handpiece) is
imaging and planning phases can be repeated. The advantage of this inherently imperfect. Challenges with regard to his or her hand-
technology is the real-time verification and validation of implant eye coordination and personal fine motor control under stressful

www.compendiumlive.com October 2018 compendium 617

continuing education 2 | Dynamic Navigation Surgery

surgical conditions may influence individual results. Thus, oper- implant fixtures (Astra Tech EV, Dentsply Sirona, dentsplysirona.
ating with a freehand, standard implant handpiece without static com) were placed. SmartPegs (Osstell, osstell.com) were attached
guide control, as with the dynamic navigation system, does add an to the implants to show the trajectory of the fixture positioning.
element of operator-dependent error. After implant placement, anorganic bovine bone matrix (Bio-Oss®,
Geistlich Pharma, geistlich-na.com) was used to graft the implant
Case Report alveolus “gap,” and healing abutments were placed (Figure 9 and
A 29-year-old Caucasian woman presented to the author’s (GAM) Figure 10). The patient was provided with an interim removable
practice for evaluation of teeth Nos. 8 and 9. The teeth were fractured appliance for tooth replacement.
at the free gingival margin and had sclerosed dental pulps (Figure 7 A post-placement CBCT scan was secured and compared to the
and Figure 8). The patient’s medical history was significant for gastro- preoperative CBCT plan using software inherent to the dynamic
esophageal reflux disorder (GERD), migraines, narcolepsy, attention navigation system (Figure 11). Accuracy results from this case
deficit hyperactivity disorder (ADHD), and depression. She had no (preoperative plan compared to post-implant placement) were as
known drug allergies or drug idiosyncrasies and was determined to follows: entry point deviation was 0.13 mm for tooth position No.
have an American Society of Anesthesiologists (ASA) II physical status. 8 and 0.41 mm for No. 9; angle discrepancy was 4.3 degrees for No.
A comprehensive periodontal examination was performed. A 8 and 6.76 degrees for No. 9; implant apex depth deviation was 1.10
thermoplastic retainer and arm were fabricated for the patient mm for No. 8 and 1.37 mm for No. 9.
with the fiduciary marker (CT marker) attached to the fix plate. At 3 months, osseointegration was confirmed and screw-retained
Great care was taken regarding the fit of the thermoplastic stent to provisionals were used for soft-tissue grooming. Final prosthetic
ensure proper seating. A CBCT scan (CS 9300, Carestream Dental, phase completion occurred at 6 months (Figure 12).
carestreamdental.com) of the maxilla was secured, and the DICOM
data were registered into the planning software. Discussion
The surgery was performed under local-regional anesthesia. The Imaging technology has transformed the field of implant dentistry
thermoplastic retainer was placed over the remaining teeth and its and has led to significant improvements in accuracy and greater
fit/stability verified. Atraumatic extractions of teeth Nos. 8 and 9 predictability in prosthetic outcomes.23 A systematic review demon-
were performed, and intact buccal bone was verified. Osteotomy strated that, on average, CT-guided implant surgery with static guides
site preparation and immediate implant placement were performed has around 1 mm entry point deviation and around 5 degrees of angle
using the dynamic surgical navigation system. Two 3.6 mm x 9 mm discrepancy when compared to treatment plans.23 However, that and

Fig 7.

Fig 9. Fig 8.

Fig 7. Initial examination of nonrestorable maxillary central incisors, clinical presentation. Fig 8. Radiograph of nonrestorable maxillary central
incisors. Fig 9. Dynamic surgical navigation, demonstrating flapless immediate implant placement. “Smart pegs” were placed to show the trajec-
tory of the fixture positioning.

618 compendium October 2018 Volume 39, Number 9

another systematic review also demonstrated that large standard
deviations exist (ranging up to 7.5 mm for entry point deviation and
more than 15 degrees angle discrepancy).23,24 Static guided surgery
has many challenges, most of which involve either planning errors
or iatrogenic errors that occur during surgery. Certain clinical situ-
ations, such as limited mouth opening or interdental space limita-
tions, may preclude the use of stereolithographic surgical guides.
These types of limitations do not apply to dynamic navigation surgery.
Because static stereolithographic guides provide no reference of
tooth position, most inaccuracies are realized after surgery. Dynamic
Fig 10
navigation provides the ability to verify and validate, in real time,
positional accuracy of oste-
otomy site preparation and
implant placement. In addi-
tion, real-time navigation
affords an opportunity to Real-time
edit the plan during surgery.
Because the operating field
navigation affords
is fully visualized and unre- an opportunity to
stricted, changes to implant edit the plan during
positioning or dimension surgery. Because
can be implemented when
regional anatomy warrants
the operating field is
modification unforeseen fully visualized and
during the planning phase. unrestricted, changes
Improper implant placement to implant positioning
has repeatedly been found to Fig 11.
be a factor in esthetic failures
or dimension can
and/or marginal bone loss.25,26 be implemented
In the present case report, when regional
where the surgery was anatomy warrants
per­formed while the authors
were still in a learning curve
modification
with dynamic navigation, the unforeseen during
entry point deviations for planning.
tooth position Nos. 8 and 9
were 0.13 mm and 0.41 mm,
respectively, and the respec-
tive angle discrepancies were 4.3 and 6.76 degrees. Block et al has Fig 12.

demonstrated that dynamic navigation has the potential to further

improve accuracy measurements compared to static guides but that, Fig 10. Healing abutments were placed, and implant/alveoli gaps were
managed with placement of anorganic bovine bone. Fig 11. Pre- and
on average, the clinician must perform at least 20 cases using the post-placement CBCT scan matched with DICOM data and accuracy
technology before the learning curve is mastered.27 This is encour- evaluation for site No. 8. Yellow outlines of implant represent the
aging considering that other medical disciplines have reported a planned implant position, while red outlines show the actual implant
position outcome. Fig 12. Final prosthetic outcome.
proficiency curve ranging from 60 to 500 cases depending on the
surgical subspecialty.27,28 Like the introduction of guided surgery
in 2002, accuracy and outcome success are largely proportional to (1.62 degrees) from actual versus planned implant positions. The
planning and experience. accuracy measurements for partially edentulous patients using a ther-
In a recent publication by Stefanelli et al, data were obtained on moplastic stent attachment and for fully edentulous patients using a
231 implants placed in healed ridges using a flapless or minimal flap mini-implant-based attachment were nearly identical. No significant
approach under dynamic guidance by a single surgeon using the same accuracy differences were found between implant positions within the
navigation system described here. Of the 89 arches operated on, 28 different sextants. Guided insertion of the implant itself reduced angu-
(125 implants) were fully edentulous. For all implants, the mean devia- lar and apex location deviations. Most interestingly, the accuracy of
tions (SD) were: 0.71 (0.40) mm for entry point (lateral) and 1 (0.49) implant placement improved during the study period, with the mean
mm at the apex (3D). The mean angle discrepancy was 2.26 degrees entry point, apex deviation, and overall angle discrepancy measured

www.compendiumlive.com October 2018 compendium 619

continuing education 2 | Dynamic Navigation Surgery

for the last 50 implants (0.59 mm, 0.85 mm, and 1.98 degrees, respec- ACKNOWLEDGMENT
tively) being better when compared to the first 50 implants (0.94 mm,
1.19 mm, and 3.48 degrees, respectively).29 The authors would like to acknowledge and thank Christopher K.
While the present case report demonstrates the use of a fiduciary Ching, DDS, of Glenview, Illinois, for his collaboration and pros-
marker and thermoplastic stent, future applications of dynamic thetic expertise on this case.
navigation surgery plan to involve the use of trace registration (TR)
mapping technology. With TR, existing structures that are rigidly ABOUT THE AUTHORS
affixed to the patient’s jaw (such as the natural dentition or existing
George A. Mandelaris, DDS, MS
implants) can serve as a natural fiduciary for the registration of the Adjunct Clinical Assistant Professor, Department of Graduate Periodontics,
CBCT imaging to the patient by the navigation software. This elimi- University of Illinois, College of Dentistry, Chicago, Illinois; Private Practice, Chicago,
nates the need for a thermoplastic stent or specialized CBCT scan Oakbrook Terrace, and Park Ridge, Illinois

with an artificial metal fiduciary marker captured in space during Luigi V. Stefanelli, DDS, PhD
the CBCT imaging. The diagnostic CBCT imaging can be used for Professor, master of second level in implant surgery and master of second level of
the planning and navigation surgery, thus simplifying the workflow prosthesis, Sapienza University of Rome, Rome, Italy; Private Practice, prosthetics
and dental implant surgery, Rome, Italy
process. However, because the micron tracker camera needs to be
able to track the patient during the operation, a tag referred to as the Bradley S. DeGroot, DDS, MS
“jaw tracker” must be connected to the jaw being operated on. Because Private Practice, Chicago, Oakbrook Terrace, and Park Ridge, Illinois

the maxilla is a static/nonmovable bone in relation to the cranium,

the patient may wear specialized glasses that lean against the nose- Queries to the author regarding this course may be submitted to
bridge and ears, carrying that tag. In the mandible, however, which is [email protected].
a movable/dynamic bone, a jaw tracker tag reference must be fixed to
the dentition (or the jaw itself ) as a method to track its position. TR REFERENCES

technology in the mandible is accomplished with the use of a dual- 1. Brånemark PI, Adell R, Breine U, et al. Intra-osseous anchorage of
cure composite resin bonding of the jaw tracker assembly (consist- dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg.
ing of the jaw tag and bendable stainless-steel wire) to a natural tooth, 1969;3(2):81-100.
crown, or abutment. The future use of TR technology is expected to 2. Mecall RA, Rosenfeld AL. Influence of residual ridge resorption
patterns on fixture placement and tooth position. 1. Int J Periodontics
simplify and streamline the dynamic navigation workflow process
Restorative Dent. 1991;11(1):8-23.
and facilitate adoption of navigation technology to the private prac- 3. Mecall RA, Rosenfeld AL. The influence of residual ridge resorption
tice armamentarium involving surgical implant placement. patterns on implant fixture placement and tooth position. 2. Presurgi-
Dynamic navigation for dental implants is in its infancy but cal determination of prosthesis type and design. Int J Periodontics
provides some distinct advantages to freehand surgery or static Restorative Dent. 1992;12(1):32-51.
4. Mecall RA, Rosenfeld AL. Influence of residual ridge resorption
guidance. As any technology application generally improves with
patterns on fixture placement and tooth position, Part III: Presurgical
time and innovation, dynamic navigation has a promising future. assessment of ridge augmentation requirements. Int J Periodontics
Further research with a variety of clinical applications is needed, Restorative Dent. 1996;16(4):322-337.
and validated, controlled, blinded, and randomized studies are 5. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed
required to demonstrate efficacy of patient care. implant placement using computer software to ensure precise place-
ment and predictable prosthetic outcomes. Part 1: diagnostics, imag-
Lastly, dynamic navigation technology provides a modality of
ing, and collaborative accountability. Int J Periodontics Restorative
medico-legal documentation and an unprecedented level of surgi- Dent. 2006;26(3):215-221.
cal accountability to ensure that prosthetically directed surgical 6. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed im-
outcomes are achieved. This is largely due to the navigation system’s plant placement using computer software to ensure precise placement
ability to record and save the surgical images and video. This approach and predictable prosthetic outcomes. Part 2. rapid prototype medical
modeling and stereolithographic drilling guides requiring bone expo-
can also ensure the concept of “collaborative accountability.”5 As with
sure. Int J Periodontics Restorative Dent. 2006;26(4)347-353.
any treatment modality that advances patient care, however, technol- 7. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed im-
ogy is not a substitute for sound judgment and experience, nor can it plant placement using computer software to ensure precise placement
or should it undermine biologic principles of surgery and/or proper and predictable prosthetic outcomes. Part 3. stereolithographic drilling
decision-making for predictable wound-healing dynamics. guides that do not require bone exposure and the immediate delivery
of teeth. Int J Periodontics Restorative Dent. 2006;26(5):493-499.
8. Mandelaris GA, Rosenfeld AL, King S, Nevins ML. Computer-
Conclusion guided implant dentistry for precise implant placement: combining
Many factors contribute to implant success, with 3D implant posi- specialized stereolithographically generated drilling guides and
tioning emerging as perhaps the most critical. Dynamic navigation surgical implant instrumentation. Int J Periodontics Restorative Dent.
is a promising advance in CBCT-guided surgery to help improve 2010;30(3):275-281.
9. Mallaya SM, White SC. The nature of ionizing radiation and risks
placement accuracy. The ability to attain real-time verification
from maxillofacial cone beam computed tomography. In: Sarment
and validation of position accuracy holds great potential and may D, ed. Cone Beam Computed Tomography: Oral and Maxillofacial
enhance surgical transparency and accountability to optimize Diagnosis and Applications. Hoboken, NJ: John Wiley & Sons, Inc;
patient outcomes. 2014:25-41.

620 compendium October 2018 Volume 39, Number 9

10. Jacobson MW. Technology and principles of cone beam computed patient. Compend Contin Educ Dent. 2015;36(2):116-128.
tomography. In: Sarment D, ed. Cone Beam Computed Tomography: 19. Luebbers HT, Messmer P, Obwegeser JA, et al. Comparison of dif-
Oral and Maxillofacial Diagnosis and Applications. Hoboken, NJ: John ferent registration methods for surgical navigation in cranio-maxillofa-
Wiley & Sons, Inc; 2014:1-24. cial surgery. J Craniomaxillofac Surg. 2008;36(2):109-116.
11. Tyndall DA, Brooks SL. Selection criteria for dental implant site 20. Jayaratne YS, Zwahlen RA, Lo J, et al. Computer-aided maxillofa-
imaging: a position paper of the American Academy of Oral and Maxil- cial surgery: an update. Surg Innov. 2010;17(3):217-225.
lofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 21. Block MS. Static and dynamic navigation for dental implant place-
2000;89(5):630-637. ment. J Oral Maxillofac Surg. 2016;74(2):231-233.
12. Rios HF, Borgnakke WS, Benavides E. The use of cone-beam 22. Somogyi-Ganss E, Holmes HI, Jokstad A. Accuracy of a novel pro-
computed tomography in management of patients requiring dental totype dynamic computer-assisted surgery system. Clin Oral Implants
implants: an American Academy of Periodontology best evidence Res. 2015;26(8):882-890.
review. J Periodontol. 2017;88(10):946-959. 23. Jung RE, Schneider D, Ganeles J, et al. Computer technology ap-
13. Mandelaris GA, Scheyer ET, Evans M, et al. American Acadmey of plications in surgical implant dentistry: a systematic review. Int J Oral
Periodontology best evidence consensus statement on selected oral Maxillofac Implants. 2009;24 suppl:92-109.
applications for cone-beam computed tomography. J Periodontol. 24. Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review
2017;88(10):939-945. on the accuracy and the clinical outcome of computer-guided template-
14. Sarment DP, Al-Shammari K, Kazor CE. Stereolithographic surgical based implant dentistry. Clin Oral Implants Res. 2009;20 suppl 4:73-86.
templates for placement of dental implants in complex cases. Int J 25. Monje A, Galindo-Moreno P, Tözüm TF, et al. Into the paradigm of
Periodontics Restorative Dent. 2003;23(3):287-295. local factors as contributors for peri-implant disease: short communi-
15. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant place- cation. Int J Oral Maxillofac Implants. 2016;31(2):288-292.
ment with a stereolithographic surgical guide. Int J Oral Maxillofac 26. Cosyn J, Hooghe N, De Bruyn H. A systematic review on the
Implants. 2003;18(4):571-577. frequency of advanced recession following single immediate implant
16. Tardieu P, Vrielinck L. Implantologie assistée par ordinateur: le treatment. J Clin Periodontol. 2012;39(6):582-589.
programme SimPlantSurgiCase™ et le SAFE System™. Cas clinique: 27. Block MS, Emery RW, Cullum DR, Sheikh A. Implant placement
Mise en charge immédiate d’un bridge mandibulaire avec des implants is more accurate using dynamic navigation. J Oral Maxillofac Surg.
transmuqueux. Implant. 2003;19:15-28. 2017;75(7):1377-1386.
17. Testori T, Robiony M, Parenti A, et al. Evaluation of accuracy and 28. Block MS, Emery RW, Lank K, Ryan J. Implant placement accuracy us-
precision of a new guided surgery system: a multicenter clinical study. ing dynamic navigation. Int J Oral Maxillofac Implants. 2017;32(1):92-99.
Int J Periodontics Restorative Dent. 2014;34(suppl 3):s59-s69. 29. Stefanelli VL, DeGroot BS, Lipton DI, Mandelaris GA. Accuracy of
18. Pikos MA, Magyar CW, Llop DR. Guided full-arch immediate- a dynamic dental implant navigation system in a private practice. Int J
function treatment modality for the edentulous and terminal dentition Oral Maxillofac Implants. In press.

www.compendiumlive.com October 2018 compendium 621

 continuing education 2
quiz

Dynamic Navigation for Surgical Implant Placement:

Overview of Technology, Key Concepts, and a Case Report
George A. Mandelaris, DDS, MS; Luigi V. Stefanelli, DDS, PhD; and Bradley S. DeGroot, DDS, MS

This article provides 2 hours of CE credit from AEGIS Publications, LLC. Record your answers on the enclosed Answer Form or submit them on a sepa-
rate sheet of paper. You may also phone your answers in to 877-423-4471 or fax them to 215-504-1502 or log on to compendiumce.com/go/1821. Be sure
to include your name, address, telephone number, and last 4 digits of your Social Security number.

Please complete Answer Form on page 624, including your name and payment information.
You can also take this course online at compendiumce.com/go/1821.

1. Which of following improved implant surgery accuracy to 6. In the “place” workflow step, during drilling the operator can see:
submillimeter levels and enabled control in all three planes of space?
A. an axial view in real time.
A. cross-sectional CBCT imaging B. a panoramic view in real time.
B. partially guided implant surgery C. a cross-sectional view in real time.
C. fully guided implant surgery D. All of the above
D. sequential drilling guides
7. With the dynamic navigation system, challenges regarding
2. Stereolithographic guides that do not allow the opportunity to the operator’s hand-eye coordination and fine motor control
change the treatment plan and remain “guided” are called: under stress:

A. dynamic navigation systems. A. may influence individual results.

B. static guides. B. will not impact the outcome.
C. jaw tags. C. are eliminated.
D. micron trackers. D. All of the above

3. With dynamic navigation, the position of the patient’s jaw is 8. Clinical situations such as limited mouth opening or interdental
related to the position of which of the following in real time? space limitations may preclude the use of:

A. the checkerboard target A. stereolithographic surgical guides.

B. the handpiece attachment B. dynamic navigation surgery.
C. the CT marker C. CBCT imaging.
D. the implant drill tip D. image data in DICOM format.

4. In the dynamic navigation system, what detects the patterns 9. Block et al found that, on average, a clinician must perform
printed on the handpiece and jaw attachments and reports their how many dynamic navigation cases before mastering the
relative positions to the system software? learning curve?

A. the notebook computer A. 5

B. the drill tag B. at least 20
C. the moldable plastic stent C. more than 60
D. the micron tracker camera D. 100

5. In which workflow step are the CT marker, thermoplastic stent, 10. The navigation system’s ability to record and save surgical
and retainer arm with fix-plate apparatus secured and seating images helps ensure:
accuracy verified?
A. collaborative accountability.
A. stent C. proper decision-making by the operator.
B. scan D. that biologic principles of surgery will be followed.
C. plan B. that future research will further validate dynamic
D. place navigation technology.

Course is valid from October 1, 2018, to October 31, 2021.

Participants must attain a score of 70% on each quiz to receive
AEGIS Publications, LLC, is an ADA CERP Recognized Approved PACE Program Provider
credit. Participants receiving a failing grade on any exam will be FAGD/MAGD Credit
Provider. ADA CERP is a service of the American Dental
notified and permitted to take one re-examination. Participants Association to assist dental professionals in identifying quality Approval does not imply acceptance
providers of continuing dental education. ADA CERP does not by a state or provincial board of
will receive an annual report documenting their accumulated approve or endorse individual courses or instructors, nor does
dentistry or AGD endorsement
credits, and are urged to contact their own state registry boards it imply acceptance of credit hours by boards of dentistry.
Program Approval for 1/1/2017 to 12/31/2022
Concerns or complaints about a CE provider may be directed Continuing Education
for special CE requirements. to the provider or to ADA CERP at www.ada.org/cerp. Provider ID# 209722

622 compendium October 2018 Volume 39, Number 9