The integration of robotics in medicine and surgery marks a pivotal shift in the way modern health care delivers care. Robotics technology is not only capable of augmenting human capabilities but also improving the quality of surgical interventions. Initially designed to enhance precision in complex surgeries, robotics has made significant advancements in orthopedics, soft tissue surgery, and, more recently, implant dentistry.
Key points
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The development of robotics in surgery has been implemented in 3 phases: orthopedics, soft tissue surgery, and, finally, its more recent application in dentistry.
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Each phase represents a significant technological leap in the ability of surgeons to perform complex procedures with heightened precision and control.
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Using haptic robotics to plan and place dental implants results in significantly higher accuracy and precision compared to all other guidance technologies.
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Robotic technology enables more minimally invasive procedures, such as flapless surgery.
Introduction: robotics in medicine and surgery
The integration of robotics in medicine and surgery marks a pivotal shift in the way modern health care delivers care. Robotics technology is not only capable of augmenting human capabilities but also improving the quality of surgical interventions and subsequently the clinical outcomes. Initially designed to enhance precision in complex surgeries, robotics has made significant advancements in orthopedics, soft tissue surgery, and, more recently, implant dentistry. In these fields, robotics has been used to reduce human error, optimize outcomes, and enhance surgeon control during critical surgical moments. Dentistry is now embracing robotics to solve some of the inherent challenges of implant placement, particularly accuracy and control in both routine and difficult anatomic cases. The promise of robotics lies in its ability to blend preoperative planning with real-time intraoperative flexibility, setting the stage for what is likely to become a new standard in dental surgeries. This chapter explores the evolution of robotics in medicine and its eventual integration into dental surgery, focusing on the advancements in implant placement using robotic assistance.
A brief history of robotics in medicine and surgery
The development of robotics in surgery can be categorized into 3 phases: orthopedics, soft tissue surgery, and, finally, its more recent application in dentistry. Each phase represents a significant technological leap in the ability of surgeons to perform complex procedures with heightened precision and control.
Robotics in Orthopedics
Orthopedics is where robotics first demonstrated its potential to revolutionize surgery. The ROBODOC system (Integrated Surgical Systems, Davis, CA) was designed in the early 1990s to assist in hip replacement surgery by preparing the femur with greater precision than human surgeons could consistently achieve. , ROBODOC’s breakthrough came from its ability to create precise cavities for prosthetic implants, resulting in better fitting and longer lasting prosthetics ( Fig. 1 ).
Following this, MAKO (MAKO Surgical Corporation, Davie, FL)—another robotic platform—was introduced, allowing surgeons to perform minimally invasive partial knee replacements with exacting precision, significantly reducing recovery times. MAKO continues to be used today in total knee and total hip replacement surgeries. MAKO’s precision ensures that bone preparation is optimized, reducing postoperative complications and improving recovery times. As of 2023, over 1 million surgeries have been performed using the MAKO robotic system globally. Following the clinical adoption of the MAKO system, a variety of other robotic systems have been introduced into the market with similar technical and clinical goals ( Fig. 2 ).
Robotics in Soft Tissue Surgery
The introduction of robotics in soft tissue surgery came with the advent of the da Vinci Surgical System, (Intuitive Surgical, Inc, Sunnyvale, CA) which was approved by the Food and Drug Administration (FDA) in 2000 for general laparoscopic surgery. This system revolutionized minimally invasive procedures by providing surgeons with enhanced dexterity and control, allowing them to operate through small incisions while viewing the surgical field in 3 dimension (3D). It found applications in several specialties, including urology, gynecology, and thoracic surgery ( Fig. 3 ).
The system’s robotic arms can mimic a surgeon’s hand movements with greater precision, allowing for delicate tissue dissections and suturing in hard-to-reach areas. Soft tissue surgery is inherently more complex due to the nature of the tissues involved, but robotic assistance reduces the risk of human error and improves outcomes for procedures such as prostatectomies and hysterectomies. As of 2024, more than 12 million surgeries have been performed worldwide using the da Vinci Surgical System and, as in orthopedics, numerous now robotic platforms are being introduced with the same goals of improving outcomes and making surgeries easier and safer.
Robotics in Dentistry
Dentistry was slower to adopt robotic technology, largely due to the unique challenges of operating in the confined space of the oral cavity. However, advances in imaging technology, coupled with the increasing demand for precise implant placement, led to the development of robotic systems for dental surgery. In 2017, Yomi (Neocis, Inc., Miami, FL), the first FDA-approved robotic system for dental surgery, was introduced by Neocis Inc. Yomi was designed specifically to assist in the precise placement of dental implants ( Fig. 4 ).
Its key benefits include providing haptic feedback during surgery, ensuring that the surgeon follows the preoperative plan while allowing for intraoperative adjustments. This marked the beginning of robotics as an essential tool for achieving superior outcomes in dental implantology.
The history of dental implants and the evolution of technology
Dental implants, as a form of tooth replacement, have a long history dating back to ancient civilizations, where rudimentary materials like seashells and ivory were used to replace missing teeth. Modern implantology began with the study of Per-Ingvar Brånemark in the 1960s. His discovery of osseointegration, the process by which titanium bonds with bone tissue, revolutionized the field of prosthetics and laid the foundation for today’s dental implant practices. However, the placement of dental implants has always required a high degree of precision to ensure proper osseointegration, avoid complications, and achieve optimal esthetic outcomes.
Modern Dental Implants
Modern implantology was revolutionized in the 1960s when Per-Ingvar Brånemark, a Swedish orthopedic surgeon, discovered osseointegration—the ability of titanium to fuse with bone. This discovery allowed for the development of stable and long-lasting dental implants, which could integrate seamlessly with the patient’s jawbone. Brånemark’s titanium dental implants quickly became the gold standard in tooth replacement and have remained so ever since ( Fig. 5 ).
These implants provide a foundation for prosthetic teeth that function much like natural teeth, but their successful placement requires a high degree of precision to ensure proper integration, avoid complications, and achieve both functional and esthetic outcomes.
Freehand Implant Placement
Initially, the placement of dental implants relied on freehand techniques, with surgeons using their clinical judgment and experience to determine the correct angulation, depth, and placement of the implant. While many skilled surgeons achieved successful outcomes, freehand placement was prone to errors. Deviations in angulation could lead to poor esthetics, implant failure, or damage to critical structures such as the inferior alveolar nerve or adjacent teeth.
Static Guides
To address the limitations of freehand placement, static guides were introduced. These guides are based on preoperative 3D cone-beam computed tomography (CBCT) scans and are fabricated to fit over the patient’s teeth or gums, providing a preplanned path for the surgical drill ( Fig. 6 ).
Static guides improve accuracy by eliminating guesswork, but they are rigid in their design. Once the guide is fabricated, no adjustments can be made during the surgery to account for differences in bone quality or unforeseen changes in the patient’s anatomy. Static computer-guided systems rely on a preplanned 3D model to create physical guides that assist with osteotomy preparation and, in some designs, with the placement of the actual implant. These systems have demonstrated better accuracy compared to freehand or drill-guided techniques. , However, several sources of potential error exist in static systems, including inaccuracies in the initial scan, deviations in the 3D-printed guide, the fit of the guide within the patient’s mouth, and the tolerance between the drill bit and the guide. While static guides are consistently more accurate than freehand placement, tooth-supported templates have shown superior precision over mucosa-supported or bone-supported guides. , Despite their accuracy, static guides come with limitations such as the time needed to fabricate the guide, the risk of guide breakage or shifting during surgery, and the inability to make intraoperative adjustments. Additionally, these guides often include stacked sleeves, which can limit access to posterior regions of the mouth and restrict visibility and irrigation during the procedure.
Dynamic Navigation
The next evolution in implant technology was dynamic navigation, which provides real-time feedback to the surgeon during the implant placement process. Using advanced 3D imaging and a computer interface, dynamic navigation systems track the position of the drill relative to the patient’s anatomy, allowing for greater flexibility than static guides. These systems have demonstrated accuracy comparable to static guides but offer several advantages ( Fig. 7 ).
By allowing direct access to the surgical site and enabling intraoperative adjustments, dynamic computer-guided systems overcome many of the limitations of static guides. However, unlike static systems that physically guide the surgical tools, dynamic systems only provide visual feedback on deviations from the plan, rather than actively preventing them. Additionally, a key limitation of camera-based dynamic systems is the need for an unobstructed line of sight between the stereoscopic camera and the tracked tools to maintain accuracy.
The rise of robotics in implant dentistry
The introduction of robotics in dental implantology has combined the best aspects of static guides and dynamic navigation while introducing new benefits like haptic feedback and real-time adaptability. This combination offers unparalleled precision and accuracy in implant placement and minimizes the risks associated with traditional methods.
How Robotics Works in Implant Dentistry
Robotic systems like Yomi operate by guiding the surgeon’s hand during the procedure, ensuring the implant is placed according to the preoperative plan. Before surgery, the robotic workflow is similar to other 3D-guided procedures, such as those utilizing dynamic optical navigation or preprinted static guides. The process begins with a preoperative CBCT scan to generate a 3D virtual plan. However, on the day of surgery, the robotic workflow diverges from these conventional guided approaches. In robotic-assisted surgery, a disposable, single-use splint is mounted on the patient’s teeth (for partially edentulous cases) or on the bone (for fully edentulous cases) at the anterior maxilla or mandible ( Figs. 8 and 9 ).
