CLINICAL REPORT

Robotic dental implant placement workflow for edentulous jaws

Wenxue Wang, MDS,a Xin Li, DDS, PhD,b Chenyang Yao, MDS,c and Baodong Zhao, DDSd

Implant-supported prostheses ABSTRACT

provide an optimal solution for
Yakebot, the first autonomous robotic dental implant system, provides a 1-stop solution for
edentulous patients because of implant design, robot operation, real-time navigation, and precision analysis. This report describes
their comfort and efficiency.1 the composition, principles, and implant operation procedures of the Yakebot dental implant
However, placing implants in robotic system in a patient for whom the robotic workflow procedure was used to place implants
edentulous jaws is highly in the edentulous maxilla. The results showed that this workflow was more precise and predictable
2 than traditional methods. (J Prosthet Dent xxxx;xxx:xxx-xxx)
technical and challenging. The
accuracy of the implant placement directly affects the (Fig. 1). The software program (DentalNavi; YakeRobot
definitive restoration and its long-term outcomes.3 With Technology Ltd) includes a patient data management
the development of static computer-assisted implant system, as well as modules for image display, implant
surgery (CAIS) technology, dentists have become reliant planning, creation of guides, design of implantation
upon digital guides to reduce the difficulties associated steps, robotic motion control, and postsurgical evalua­
with edentulous implant placement.2 However, most di­ tion. The processing and manipulation of information
gital guides for edentulous patients are supported by the during surgery are handled by a robotic device. When
mucosa,4 and achieving good stabilization to minimize the vision device obtains the relative position informa­
surgical deviation is problematic.5 Vinci et al6 conducted a tion of the robot and patient, it calculates the position
multicenter study on the accuracy of mucosa-supported change parameters of the robotic arm and converts them
guides with 100 implants in 14 participants, reporting that into the robot’s motion parameters. The robotic arm
the average implant platform and apical and angular then reaches a predetermined position according to the
deviations were 1 mm, 1.6 mm, and 5 degrees respec­ motion parameters. The system combines a design
tively. Guides currently produced by various manu­ software program, an optical tracking and positioning
facturers are commonly inaccurate and suffer from device, and a robotic arm operating platform that com­
problems such as a compromised surgical field of view, plements and augments the surgeon’s brain, eyes, and
insufficient cooling, and the need for excessive patient hands.11
7–10
mouth opening. This report describes the process of edentulous jaw
The use of digital technology could simplify the implantation surgery achieved by the Yakebot autono­
surgical steps and achieve a more precise and con­ mous dental implant robotic system. Although a dental
trollable restoration. The hardware of the Yakebot au­ implant robotic system is complex for initial adopters, it
tonomous dental implant robotic system (Beijing could provide a digital workflow for implant surgery and
YaKebot Technology Co, Ltd) consists of a robotic de­ immediate loading under standardized preparation and
vice, a vision device, and related surgical accessories design. Complex edentulous implant placement could

Supported by the Shandong Municipal Health Commission [project no. 202208050566]; the Qingdao Natural Science Fund [project no. 23–2-1–133-zyyd-jch]; and by
the Qingdao Municipal Health Commission [project no. 2021-WJZD183], PR China.
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.
a
Postgraduate student, Department of Oral Implantology, The Affiliated Hospital of Qingdao University, School of Stomatology of Qingdao University, Qingdao, PR China.
b
Attending, Department of Oral Implantology, The Affiliated Hospital of Qingdao University; School of Stomatology of Qingdao University, Qingdao, PR China.
c
Resident, Department of Stomatology, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, PR China.
d
Professor, Department of Oral Implantology, The Affiliated Hospital of Qingdao University, School of Stomatology of Qingdao University, Qingdao, PR China.
1
W.W. and X.L. contributed equally to this article.

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A B
Figure 2. Data collection. A, Remaining teeth meet data registration
requirements and merge. B, Template with radiopaque markers.

The STL data of the template were obtained with digital

scanning.
For data registration, the DICOM data of the patient
A B were imported into the robot design software program
Figure 1. Yakebot autonomous dental implant robotic system. A, (DentalNavi; YakeRobot Technology Ltd), transformed
Robotic device. B, Vision device and display screen. into a 3D model, and matched with the intraoral scan in
the STL format. The coarse 3-point and detailed point-
cloud registrations were combined. By selecting 3 or
be made more straightforward and precise. The surgeon more points with high positional recognition, the soft­
only needs to administer local anesthesia, replace drills ware program calculated the positional relationship
and implants, and suture during the entire procedure. between the 3D model and the intraoral scan image,
realizing 3-point registration. The green color in the
difference plot represents high accuracy; if not obtained,
more regions for registration would have been needed.
CLINICAL REPORT
Crowns were added, the occlusion was adjusted, the
The described treatment of a 61-year-old man with a implants (Straumann Bone Level Tapered; Institut
defective maxillary dentition and residual teeth with Straumann AG) were placed according to the remaining
degree II and III mobility12 who sought an implant- bone volume and restoration, the implant placement
supported fixed prosthesis was approved by the Ethics steps for the robot were planned, and the required at­
Committee of the Affiliated Hospital of Qingdao Uni­ tachments (such as fixator and suction pipes) were
versity. Written informed consent was obtained from the printed (Fig. 3).
patient. For the digital fabrication of the immediately loaded
The process of applying the Yakebot autonomous prosthesis, the implant position and intraoral scan data
robotic system to edentulous jaw implantation involves were imported into a software program (exocad Dental
4 main steps: patient evaluation, data collection, implant CAD 3.0; exocad GmbH), and the interim restoration
design and attachment printing, and robotic surgery. designed. A milling machine (X-MILL 500 Plus Milling
First, the patient’s general systemic and oral conditions, Machine; XTCERA; Shenzhen Xiangtong Co, Ltd) was
including physical health, opening type and degree, used to mill a polymethyl methacrylate resin block
occlusion, vertical distance, and hard and soft tissue (Aidite; Qinhuangdao Technology Co, Ltd).
were assessed. Alternatively, an interim fixed prosthesis could have
Then, an intraoral scan (TRIOS 3 Basic Intraoral been fabricated chairside.
Scanner; 3Shape A/S) was obtained to provide a stan­ Extraction of the remaining teeth was performed
dard tessellation language (STL) file because the number under local anesthesia with minimum trauma. The in­
and distribution of the remaining teeth met the re­ traoral attachment registration was fixed using more
quirements for data registration and merging (Fig. 2A). than 3 cortical bone screws (2.0 ×10 mm; Xi'an
A cone beam computed tomography (CBCT) scan Zhongbang Titanium Biomaterials Co, Ltd) avoiding the
(Dental Imaging Software, CS 9300C; Carestream implant sites, a CBCT scan was obtained, and the
Health, Inc) was converted to the DICOM format. If the DICOM data with intraoral attachment were imported
registration requirements had not been met or if the into the software program (DentalNavi; YakeRobot
patient had had an edentulous jaw, a template with Technology Ltd) and matched with the preoperative
radiopaque markers would have been made (Fig. 2B). plan file (Fig. 4A, B). The registered file was imported
Two DICOM datasets were obtained through CBCT into the software program (DentalNavi; YakeRobot
scans of the template only and of it seated in the patient. Technology Ltd) installed on the robot computer.

THE JOURNAL OF PROSTHETIC DENTISTRY Wang et al

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A B

C D

Figure 3. Project design. A, Data registration and merge. B, Added crowns and adjusted occlusion. C, D, Designed implant position and implantation
steps for robot (red arrows: vertical maxillary first molars).

The patient and robotic device were positioned to prosthesis was attached to the implants using a pick-up
ensure that the robot's eye was approximately 1 m above technique13 and immediately loaded (Fig. 6).
the surgical area and that the extraoral, robot, and probe The STL data of the preoperative design and the
markers were located at the same level and could be DICOM data of the postsurgical CBCT were imported
detected by the stereo visual sensor (green indicated a into the software program (DentalNavi; YakeRobot
good connection). The “calibration probe” option was Technology Ltd) to conduct the deviation analysis.
selected on the software program, the positioning plate Preoperative planning and postoperative CBCT were
registration was completed, and implant calibration was manually matched based on the anatomic structure, and
performed using the calibration probe marker, the entry the deviations between the actual and planned 3D im­
and exit paths of the robot handpiece were recorded, plant positions were measured and recorded. The results
and the spatial mapping relationship between the vision of the accuracy analysis in the patient were platform
and the CBCT image was established (Fig. 4C, D). Fi­ (4.10 ±0.90 mm), apex (0.60 ±0.19 mm), depth (0.49
nally, the entry and exit paths were reconfirmed. ±0.15 mm), and angle (1.43 ±0.78 degrees) (Fig. 7,
The surgeon (B.Z.) replaced and installed the drills Table 1).
according to preset implant procedures and controlled
the robot to complete the osteotomy preparation and
implant placement. The process was displayed in real-
DISCUSSION
time on the DentalNavi screen. The axis, angle, and
depth of the robotic implantation could have been ad­ Precise placement of implants is essential for long-term
justed at any time according to the surgical situation. On esthetic and restorative outcomes.14 The static CAIS
the day of surgery, owing to the patient's concern that facilitated implantation in edentulous patients, with
sinus elevation might lead to maxillary sinus perforation, greater precision and predictability, than freehand. A
bleeding, or infection, the plan was changed to tilt the review of the accuracy analysis of edentulous implants
implants at the maxillary first molar sites (Fig. 5). All 6 using static CAIS, including 2037 implants, showed that
implants achieved sufficient primary stability above 35 the mean deviation of implant platforms and apex was
Ncm. After surgery, a prefabricated computer-aided 1.35 mm and 1.34 mm, respectively and the mean de­
design and computer-aided manufactured interim viation of angle was 3.59 degrees.15 The accuracy of

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D
Figure 4. Preoperative preparation. A, Fixing registration of intraoral attachment. B, Cone beam computed tomography scan data matched with
preoperative plan. C, D, Preoperative registration to detect extraoral, robot, and probe markers.

C E
Figure 5. Surgical procedure. A, Robotic surgery overview. B, Osteotomy preparation. C, Implant placement. D, E, Real-time monitoring on
DentalNavi (changed plan during surgery, red arrows: tilted maxillary first molar).

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A B C

D E
Figure 6. Immediate loading. A-C, Digital fabrication (red arrow: palatal extension for guide positioning). D, Composite resin abutments and
protector caps placed. E, Immediate loading completed.

A B C D
Figure 7. Deviation analysis on DentalNavi. A, Three-dimensional model. B, Cross-sectional view. C, Sagittal view. D, Coronal view.

Table 1. Deviations of implant position (mean ±standard deviation) This technology has a complete intelligent decision-
Deviation making system that could make reasonable decisions
Platform (mm) 0.49 ±0.21 based on the intraoperative force and positional feedback.
Apex (mm) 0.60 ±0.19
Depth (mm) 0.49 ±0.15
The robotic arm completes the autonomous operations
Angular (degree) 1.43 ±0.78 under system control, which should reduce the operating
difficulty and the learning cycle for the surgery. Surgeons
are not required to keep their heads down all the time to
implant placement with static CAIS is affected by factors operate; they only needed to observe and make timely
that include image acquisition, data processing, software adjustments, which was beneficial to their health, espe­
design, guide template printing, template fixation, and cially for the cervical spine. The stability of the robotic arm
template types.16–18 However, an implant template is was higher than that of the human hand. If needed,
not needed for robotic surgery, which avoids associated custom suction tubes could be designed using a software
errors. The results of accuracy analysis in the present program for automatic intraoperative suction.
patient were platform (0.49 ±0.21 mm), apex (0.60 The surgical plan, including the type, position, and
±0.19 mm), depth (0.49 ±0.15 mm), and angle (1.43 direction of the implant, could be flexibly adjusted
±0.78 degrees), more accurate than CAIS, and consistent during surgery without any attachment replacement. For
with a previous study on the accuracy analysis of the presented patient, 6 implants were planned with 2
edentulous jaws.19 treatment options involving the maxillary first molar:

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whether to perform sinus floor elevation or tilt the im­ 3. Siqueira R, Chen Z, Galli M, et al. Does a fully digital workflow improve the
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phisticated, mature, and smaller with improvements in
technology. Corresponding author:
Dr Baodong Zhao
Department of Oral Implantology
The Affiliated Hospital of Qingdao University
PATIENT CONSENT School of Stomatology of Qingdao University
No. 59 Haier Road
Written informed consent was obtained from the patient. Qingdao, Shandong 26600
PR CHINA
Email: [email protected]

CRediT authorship contribution statement

REFERENCES Wenxue Wang: Writing- original draft preparation, Writing- reviewing and
editing, Software, Validation, Formal analysis. Xin Li: Methodology, Writing-
1. Messias A, Nicolau P, Guerra F. Different interventions for rehabilitation of reviewing and editing, Visualization, Investigation, Validation, Data curation.
the edentulous maxilla with implant-supported prostheses: An overview of Chenyang Yao: Software, Investigation, Formal analysis. Baodong Zhao:
systematic reviews. Int J Prosthodont. 2021;34:s63–s84. Conceptualization, Methodology, Resources, Writing- reviewing and editing,
2. Siqueira R, Chen Z, Galli M, et al. Does a fully digital workflow improve the Supervision, Project administration.
accuracy of computer-assisted implant surgery in partially edentulous
patients? A systematic review of clinical trials. Clin Implant Dent Relat Res. Copyright © 2024 Published by Elsevier Inc.
2020;22:660–671. https://doi.org/10.1016/j.prosdent.2024.04.030

THE JOURNAL OF PROSTHETIC DENTISTRY Wang et al