An advanced navigational surgery system for dental implants completed in a single visit: An in vitro study Sung-Goo Kim a, 1 , Woo-Jin Lee b, 1 , Sam-Sun Lee c , Min-Suk Heo c , Kyung-Hoe Huh c , Soon-Chul Choi c , Tae-Il Kim d, ** , Won-Jin Yi c, * a Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Republic of Korea b Interdisciplinary Program in Radiation, Applied Life Science Major, College of Medicine, and Dental Research Institute, Seoul National University, Republic of Korea c Department of Oral and Maxillofacial Radiology, BK21, and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea d Department of Periodontology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea article info Article history: Paper received 2 May 2014 Accepted 22 October 2014 Available online 5 November 2014 Keywords: Image-guided surgery Navigational implant surgery Cone-beam computed tomography Improvised splint Reusable registration body All-in-one visit surgery abstract In this study, we have developed an advanced navigational implant surgery system to overcome some disadvantages of the conventional method and have evaluated the accuracy of the system under in vitro environment. The patient splint for registration and tracking was improvised using a bite splint without laboratory work and the offset of an exchanged drill was calibrated directly without pivoting during surgery. The mean target registration errors (TRE) were 0.35 ± 0.11 mm using the registration body, 0.34 ± 0.18 mm for the registration method with prerecorded fiducials, and 0.35 ± 0.16 mm for the direct calibration of a drill offset. The mean positional deviations between the planned and placed implants in 110 implant surgeries were 0.41 ± 0.12 mm at the center point of the platform and 0.56 ± 0.14 mm at the center point of the apex. The mean angular deviation was 2.64  ± 1.31 for the long axis of the implant. In conclusion, the developed system exhibited high accuracy, and the improved tools and simplified pro- cedures increased the convenience and availability. With this advanced approach, it will be possible to complete dental implant surgery during a single visit at local clinics using a navigational guidance involving cone-beam computed tomographic images. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. 1. Introduction As an increasing number of edentulous patients are treated with implants, the surgical complications are also increasing because of the limitations of the operator's experience and the patient's anatomical variations (Chee and Jivraj, 2007; Zoghbi et al., 2011). Damages to the inferior alveolar nerve or perforation into the maxillary sinus are common complications during implant surgery (Greenstein et al., 2008). An implant has to be precisely placed at locations of the planned position, angle, and depth to reduce complications and to increase the long-term success of an implant- supported prosthesis (Becker and Kaiser, 2000; Buser et al., 2004). Recently, cone-beam computed tomography (CBCT) has been widely used to obtain a 3-dimensional (3D) image of the jaw in local dental clinics because of its lower installation cost, smaller occupied space, and lower radiation dose than general computed tomography (CT) (Benavides et al., 2012; Quereshy et al., 2008). The 3D images can help a surgeon transfer the implant surgical plan to the patient's jaw bone more exactly, with a better understanding of the anatomical structures. Nonetheless, great experience is required to place an implant exactly at the planned location without surgical complications (Van de Velde et al., 2008). Currently, the most actively studied method for the precise placement of dental implants is the surgical guide template. The implant position is determined preoperatively by planning soft- ware using a 3D CT image, and the surgical guide template is generally fabricated by a rapid prototyping machine (Di Giacomo et al., 2012; Nickenig and Eitner, 2010; Nickenig et al., 2010; * Corresponding author. Tel.: þ82 2 2072 3049; fax: þ82 2 744 3919. ** Corresponding author. Tel.: þ82 2 2072 2642; fax: þ82 2 744 0051. E-mail addresses: periopf@snu.ac.kr (T.-I. Kim), wjyi@snu.ac.kr (W.-J. Yi). 1 Sung-Goo Kim and Woo-Jin Lee contributed equally to this study as the co-first author. Contents lists available at ScienceDirect Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com http://dx.doi.org/10.1016/j.jcms.2014.10.022 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 117e125