ISSN No: 2582-0559

COMPUTER ASSISTED DYNAMIC NAVIGATION SYSTEMS

-CURRENT SCENARIO

Dr. V. R. Balaji, Dr. D. Manikandan, Dr, Dr. G. Rohini, Dr. M. Nivethitha

Department of Periodontology and Implantology, CSI College of Dental Sciences and Research, Madurai, Tamilnadu, India

Address for Correspondence

Dr. M. Nivethitha,

Postgraduate student,

Department of Periodontology and Implantology,

CSI College of Dental Sciences and Research,

Madurai. Tamilnadu, India

E-mail id: dpmnivi@gmail.com

REVIEW ARTICLE

ABSTRACT

One  of  the  techniques  available  for  prosthetic  rehabilitation
of  lost  teeth  are  implants.  Earlier  implants  were  placed  in  a
surgically  driven  treatment  approach.  Later  the  idea  of
placing  implants  on  the  basis  of  prosthetically  driven
treatment approach  was derived by introduction of computer
assisted  surgery.  Dynamic  navigation  is  a  technique  of
computer  assisted  surgery  where  the  operator  can  perform
accurate,  easy  and  flapless  implant  insertion  surgeries  even
within  a  single  day.  These  navigation  systems  are
continuously evolving to achieve even better ways of implant
placement. This review will briefly highlight on the details of
this navigation implant surgery.

KEY WORDS:

Dynamic navigation, Static system, Trace

registration, Evalunav.

Received:

14.08.2021

First Published:

07.09.2021

Accepted:

02.09.2021

Published:

27.09.2021

Volume No: 8, Issue No: 3

108

DOI: 1.37841/jidam_2021_V8_I3_03

Balaji et al:

Computer Assisted Dynamic Navigation Systems-Current Scenario

ISSN No: 2582-0559

INTRODUCTION

The treatment modalities available for replacement of

missing teeth have evolved over the last centuries. Earlier,
implants were intended to be placed in areas with greatest
amount  of  bone  within  the  arch,  with  less  regards  to  the
placement  of  final  definitive  restoration  thus  causing
failures.  In  order  to  cater  to  this  requirement,  CGIS-
Computer  Guided  Implant  Surgery  and  CNIS-  Computer
Navigated  Implant  Surgery  were  introduced.  Dynamic
navigation  (DN)  seems  to  be  a  tool  for  navigation  thus
improving the accuracy of implant placement.

HISTORICAL PERSPECTIVE

Various software using Computerized tomography

were  available  in  late  1980’s.  Initially  in  1988,  the
Columbia  scientific  INC.,  developed  a  software  to
convert  the  axial  slices  of  CBCT  into  cross  –  sectional
images  (2D)  thus  favoring  diagnosis  and  evaluation.
Utilizing  this  software,  D’haese  et  al  stressed  the
importance  of  evaluating  the  alveolar  ridges  to  analyze
computerized tomography axial slices

In 1992 “viewing wand” a frameless system was

developed for neurosurgery which served as an adjunct to
CT

. Three dimensional imaging was used for pre-

surgical planning and guiding surgeries

3,4,5

In the late 1997 dynamic navigation was introduced

for oral maxilla-facial surgical procedures on the basis of
contribution done by Enisilidis G, Wagner G and Ploder
O

. In 2000 VISIT a new dynamic implant navigation

system was introduced for implant placement

COMPUTER-ASSISTED SURGERY

It involves either a static or a dynamic system. The

static  system  utilizes  pre-fabricated  stent  by  using
computer  aided  approaches  which  can’t  make  real  time
changes  during  the  implant  surgery.  Deviations  from  the
pre-determined plan can be carried out using the dynamic
systems

. The operator need not withdraw from the pre-

determined plan if they desire to change it during mid-
surgery in navigation surgery

(Fig 1).

STEPS INVOLVED IN A COMPUTER AIDED

SURGERY:

●

Cone Beam Computed Tomography Scanning-
CBCT scanning,

●

Software program execution

●

Fabrication of surgical drilling guides in case of static
approach or a computerized virtual plan in dynamic
approach.

●

Surgical execution

Fig 1: Flow Chart depicting Computer Assisted

Implant Surgery

CONVENTIONAL VS COMPUTED AIDED

APPROACH:

The implant placement in a free-handed approach is

done based on the adjacent and opposing teeth as a
reference. In case of computer- assisted surgery, in a
static system, CT-generated CAD/CAM stents with metal
tubes are used.

In dynamic navigation, a computerized system is

used to visualize implant site development while the drills
are in function. “Real-time” changes to the plan can be
made at the time of surgery

DYNAMIC NAVIGATION:

The navigation system consists of stereovision with

natural  light  cameras  which  utilizes  active  or  passive
arrays of optical technologies. Active system utilizes their
own  light  system  while  the  passive  systems  utilize  the
light  from stereo cameras and the reflected light in order
to get tracked for viewing the surgical procedure.

INDICATIONS:

(i)

It is indicated in patients having limited mouth

opening with no accessibility.

(ii)

It is useful at regions of tight interdental spaces

where static guides can’t be used owing to the tube size

(iii)

(iii) in regions adjacent to the natural teeth, in

situations where static guide tubes will interfere with
ideal implant placement

10,11,12

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COMPONENTS:

Hand piece attachment: It consists of the drill or the
handpiece with the drill tag. The drill tag helps to
locate the drill position.

Patient jaw attachment: It consist of the stent, handle,
fiducial marker, fiducial clip an array and a tag. The
fiducial marker is the one that enables the whole jaw
attachment to be tracked through their identification
in CBCT images and clip will help it to be attached
to the tag.

System cart: It consists of a computer with dynamic
navigation software, the stereo cameras with the light
source

. (Fig 2)

Fig 2: Components of Dynamic navigation (11)

GENERATIONS OF DYNAMIC NAVIGATION

SYSTEM:

Based on literature evidence there are two different

generations  of  dynamic  navigation.  The  first  generation
involved four distinct workflow steps such as stent, scan,
plan  and  place.  Commercially  available  system  includes
NAVIDENT,  X-Guide,  Image  Yomi,  Inliant,  X-NAV.
The  drawbacks  of  first  generation  system  included  high
system  price,  immaturity  of  design  and  limited  access  to
CT  scanner  (Block  2016,  Vercruyssen  2014).  With  the
various  improvements  in  the  computing  and  optical
tracking  technology  evolved  with  elimination  of  the
fiducial clip preparation

and implementation of simpler

workflow called TAP – Trace and Place. Commercially
available second generation system include NAVIDENT
2.0.

DYNAMIC WORKFLOW

FIRST GENERATION SYSTEM

Stent:

A thermoplastic retainer molded over the dentition,

cured, removed and finished to give guidance to the
planned implant placement. Utilizing this, positional
approximation is verified and surgery is performed

Scan

CT marker, thermoplastic stent, retainer arm with fix

plate apparatus are secured. Thereafter a single jaw is
scanned using a CBCT scanner and the procedure is
carried out.

Plan:

Utilizing the scanned jaw image the implant planning

is virtually done through placing a computerized implant
simulation onto the intended site and alterations can be
done.

Place:

The jaw tag is utilized in relation to thermoplastic

stent  and  drill  tag.  Osteotomy  is  then  performed.  A  real
time  “cross-hair”  or  “bulls-eye”  target  view  is  used  and
osteotomy  is  completed  and  implant  placement  is  done
under simultaneous tracking likewise.

Steps involved in drill navigation:

●

Initially the procedure starts with mapping of fiducial
and extra-oral clip to the CT-image. By doing this the
patient and his jaw position are fed to the navigation
software.

●

Similarly, the drill attachment and its information are
further fed to the computer.

●

Then the drill tip calibration and drill axis calibration
are done. Initially the go plate is registered and
calibrated and following that the drill tip is placed for
its calibration.

●

Following  these  procedures,  the  position  of  the
patient’s  jaw  and  the  drill  attachment  relative
position to each other are constantly tracked through
the  stereo  cameras  and  fed  onto  the  navigation
software.

SECOND GENERATION SYSTEM

The implant placement protocol is further simplified

with the introduction of trace registration. So, the recent
protocol is, Trace and Place.

Trace registration:

In an attempt to achieve ease of operation in the

whole

dynamic

navigation

procedure,

various

technologies  have  been  utilized  to  carry  out  implant
surgery.  Trece  registration  will  eliminate  the  need  for
stent fabrication or even a fiducial clip preparation is not
needed.  Trace  registration  will  trace  the  recognizable
structures  naturally  present  in  the  scan  like  teeth,
implants,  abutments,  bony  ridge  and  bone  screws  as
fiducials

Trace and Place – TAP:

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ISSN No: 2582-0559

It is mainly introduced with NAVIDENT 2.0

systems. The CBCT image in DICOM format is installed
into  dynamic  navigation  system  software  (NAVIDENT
software).  The  intra  oral  scanner  image  with  the  virtual
wax-up  prosthesis  is  installed  and  these  two  images  are
superimposed  and  landmarks  we  marked.  Then  the
trackers  have  to  be  attached  onto  the  patient  firmly
without  movements.  Then  the  tracing  begins  by  moving
the ball tip of stylus on each tooth for a distance of atleast
15cms.  The  progression  of  tracing  is  indicated  audibly
and registration completed. For placing implants then drill
axis  and  drill  tip  calibration  are  done.  The  drilling  is
carried  out  following  the  target  view  on  the  monitor.  It
eliminates  the  need  for  multiple  scans.  The  implant
planning,  trace  registration  and  placement  all  can  be
completed in single visit.  Provided, the implant itself was
inserted  under  guidance  EvaluNav,  a  software  evaluates
the  accuracy  and  enables  to  further  separate  guidance
deviation  (system  error)  from  drilling  deviation  (user
error)

. (Fig 3)

Fig 3: Workflow of trace registration

ADVANTAGES OF DYNAMIC NAVIGATION

In  case  of  complex  cases  with  challenging  bone
topography  and  critical  anatomic  situation  dynamic
navigation provides its assistance. Wittwer et al in his
study  supported  the  accuracy,  safer  and  immediate
implant placement in smoother and wide bone areas.
In  patients  with  physiological  and  psychological
problems,  Vercruyssen  et  al  pointed  out  that  sleeves
used as the guide for static approach has rigidity and
control in drilling in irregular bony areas.

Navigation  technology  exhibits  greater  accuracy  in
recording  the  coronal  and  apical  portion  of  implants
as  cited  by  few  studies  which  indicated  a  negligible
error of 0.4mm of linear deviation and 4° of angular
deviation.  This  system  reported  higher  precision
between planned and finally placed implants

DISADVANTAGES OF DYNAMIC

NAVIGATION:

(i)

Using dynamic navigation systems, when

problems arise due to asymmetric bone density may
create problems they cannot be avoided.

(ii)

Array positions can affect the operation of

surgeons’ dominant hand in certain cases.

(iii)

The reclined or sitting position of patient might

affect the cameras’ ability to track drill arrays.

(iv)

Surgeon’s ability to hold the instrument and the

rigidity of the instrumentation can interfere with the
results. To avoid such short coming the inherent level of
tremor of every operator’s hand has to be managed with
double finger rests

3,10,12,14

ERRORS IN DYNAMIC NAVIGATION

The following errors may arise during dynamic

navigation such as stent distortion, inaccurate calibration,
patient movement, unstable seating of the jaw attachment,
operators’ eye coordination and lack of personal fine
motor control and operators’ awareness of the computer
technology and systems. Few studies reported accuracy of
implants with a mean error of 0.35mm

9,15,16

APPLICATIONS IN OTHER MEDICAL FIELDS

It is basically used in surgical decision making and

also  in  execution  of  surgeries.  It  locates  the  anatomic
landmarks  with  precision  and  ease.  It  is  employed  in
various  neurosurgeries  for  precise  localization  and
avoidance  of  areas  of  risk.  It  is  also  used  in  spinal
surgeries  and  in  orthopaedic  surgeries  as  a  precise
measurement tool

APPLICATIONS IN OTHER DENTAL FIELDS

In endodontic, dynamic navigation systems can be

used in preparation of minimally invasive access cavity
preparations in endodontic. They are also called as
conservative/contracted

endodontic

cavities

ultraconservative “ninja” endodontic cavities and Point
endodontic access cavity (PEAC) preparation.

They can be used in identifying and exactly locating

calcified canals while performing procedures like root
canal treatments

19,20

. It can be utilized to perform

endodontic  microsurgeries  and  will  greatly  help  us  to
create  bone  cavities  and  do  root  end  resections  and
various  other  procedures.  In  maxillofacial  surgeries
computer guided navigation of bone segments are utilized
and  employed  in  surgical  procedures  of  TMJ,
orthognathic  and  implant  procedures

. In maxillo-facial

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surgery,

also

employed

surgery,

Temporomandibular

joint

surgeries,

orthognathic

surgeries and Implantology.

CONCLUSION:

The 3-D diagnostic and therapeutic modalities allow

us to overcome various difficulties encountered in case of
conventional  approaches.  It  allows  the  implant  team  to
overcome the difficulties and limitations of human stereo
vision and increase the accuracy and precision of implant
placement.  CAS  has  its  own  difficulties  like  in
performing  surgery  in  cost  effective  fashion.  The
recurring  cost  after  the  initial  setting  up  of  these
instrument  is  however  low.  The  learning  curve  is  also
another  difficulty  in  performing  such  procedures.    The
benefits of these systems also have to be further evaluated
to  arrive  at  confirming  results.  Very  few  studies  are
available  using  this  dynamic  approach.  In  future,
longitudinal  studies  are  needed  in  using  dynamic
navigation system.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil

CONFLICTS OF INTEREST

There are no conflicts of interest.

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