cad/cam surgical guide - elitedentist.com.t‰‹術模板的臨床應用及精確度.pdf ·...

牙醫最新主流醫學文集

台北市牙醫師公會10-2

摘要

人工植體的成功率己經有充分的研究並得到肯定，臨床上也有廣泛的應用。後早期種植在

有齒槽骨的位置，但現今依美觀及功能來決定植體的位置，植體的使用數目越來越多，植體的

種植位置也就越形重要。如何讓每一顆植體都能植在計劃中的位置，是植牙醫師努力的目標，

也可以減少假牙復的困難度。CAD/CAM手術模板的發明，可以減少手術的時間及困難度，減

少患者在手術前後的時間及𨍥舒服感。本篇是來探討現今使用的CAD/CAM手術模板，應用於

臨床上應注意的事項及其準確度。

▍今日CAD/CAM技術應用於植牙手術的模板設計及其該注意事項牙科植體的骨整合在今日有高度的可靠性 {Pjetursson, 2004 #1027}、{ Jung, 2008 #1028}，甚致在一些

骨量不足（bone atrophy）或一些解剖位置不理想的位置，藉由骨再生技術（bone regeneration technique）

的幫助下，都可以放入植體{Hammerle, 2002 #1025}{Chiapasco, 2006 #1026}，因此植體植入的位置不必在受

限於骨量的考量，而可以從假牙設計（prosthetic driven）的角度來思考，復物的美觀及功能才能達到

患者的須求。

傳統上病患缺牙部份，經復醫師印模（impression）診斷臘型（wax up）利用舊denture或Wax

denture當做X光評估工具（preoperative radiographic template）。現今多是用C T，不論是MSCT或低放射劑

量的CBCT，皆可得到清楚的3D解剖資料，便利與病患溝通及手術醫師和復醫師之間擬定最後治療

計劃，決定植體的位置及最終復物之設計。

CAD/CAM手術模板（Surgical Guide）的臨床應用及精確度

作者：張耿鐘醫師

10 人工植牙

根管治療

人工植牙

口腔診斷與病變

口腔雷射牙醫學

一般牙科

美容牙科

10-3台北市牙醫師公會

手術模板（surgical guide or surgical stent）之製造最早期用CT上定位影像與實際預計植體放入位置，

計算角度再轉移到手術模板上，如圖一。或是利用positon device和computer drill machine製作手術模板，

如圖二{Vercruyssen, 2008 #1018} 現在因為新的軟體與3D列印技術進步，利用Rapid prototyping machine製造

stereolithographic surgical guide，有很高的精確度與可重覆性。依據surgical guide 放置的位置可區分為mucosa

supported ,dental supported ,bone supported 及implant supported surgical guide，如圖3∼圖8。

Implant supported surgical guide 是事先在齒槽骨上植入三隻臨時植體，用以固定診斷用復物，確保

CT 檢查時的位置與之後 surgical guide 放置的是同一位置，並可提供日後臨時復物的支撐，因此準確

度較高{Tahmaseb, 2009 #1024}。

圖一：傳統利用CT影像，轉移到石膏模型圖二

圖3∼圖5：Implant supported surgical guide.

圖6：Ibone supported surgical guide.

圖7：Mucosa support surgical guide. 圖8：Teeth supported surgical guide.



Dental, mucosa, implant supported surgical guide 常用� apless implant surgery，而它的主要好處是減少術後不

舒服，其他優點如table 1。另外一方面缺乏視野和患者不足的張口度，以及surgical guide本身及放置的誤

差，都可能造成不可挽回的傷害，如table 2，而bone support guide 因為要翻瓣手術，所以與傳統手術相

似，但植體放置時視野較好。

▍手術模板的準確度（acurracy of surgical guide）一般來說，研究手術模板準確度通常利用術前術後的CT

影像，再用電腦軟體去分析術前術後的差異，準確度通常分析

四個數據： deviation of entry （coronal）,deviation of apex, deviation in

height, angular deviation，如圖9。

David Schneider{Schneider，2009 #1}研究2002至2009年發

表的8篇有關computer-guided implant 研究，共有四種系統被使

用（Simplant Surgiguide, NobelGuide, StentCAD, Med3D），其中

{Kalt, 2008 #1029}使用的是laboratory-fabricated surgical guide，利用

定位點，轉移CT資訊經電腦軟體設計植體位置，製作手術

模板。其它三種是用stereolithographically fabricated guide（rapid

prototyping），俗話說的3D列印技術製做的surgical guide，如表3。其中若以bone、implant、mucosa、

teeth，四種不同支撐方式的手術模板，來分析誤差值，在entry deviation上平均誤差為1.08mm，如表4。

TABLE 2 Disadvantages of Flapless Guided Surgery

Lack of visibility and tactile control during surgical procedureInsufficient mouth opening jeopardizes surgical procedureRisk of damaging vital anatomical structures

TABLE 1 Advantages of Flapless Guided Surgery

Facilitated surgical procedureReduced surgical intervention timeReduced postoperative sequalleaTreatment of medically compromised (anticoagulantia,bisfosfonates,etc.) or anxious

patientsAvoiding bone grafting proceduresFacilitated immediate loading protocol

圖9：1, dev ia t ion o f en t r y. 2, deviation of apex. 3, deviation in height. 4, angular deviation.

1

4

2

3

根管治療

人工植牙



一般牙科

美容牙科


表3

表4

在 apex deviation 部份，平均值為1.63mm，如表5。在 angular deviation 部份，平均值為5.26*，如表6。

在 height deviation的部份，只有二個研究，一個平均誤差值為0.28m{Kalt, 2008 #1029}，另一個為 0.6mm

{Ruppin, 2008 #1030}。

0 1 2

author yeartemplatesupport

Mean eatryError in mm(95% CI)

bone

van Steenberghe

Vrielinck

Di Giacomo

Fluppin

Ozan

Subtotal (I-squared=

.

implant

Kalt


.

mucosa

Ozan


.

teeth

Di Giacomo

Van Assche

Ozan


.

Overall (I-squared=

2002

2003

2005

2008

2009

89.1%,

2008

.%, p=

2009

.%, p=

2006

2007

2009

52.6%,

82.9%,

bone

bone

bone

bone

bone

p=0.000)

implant

.)

mucosa

.)

teeth

teeth

teeth

p=0.121)

p=0.000)

0.80(0.65, 0.95)

1.51(1.04, 1.98)

1.95(1.25, 2.65)

1.50(1.25, 1.75)

1.28(1.03, 1.53)

1.35(0.96, 1.73)

0.83(0.69, 0.97)

0.83(0.69, 0.97)

1.06(0.85, 1.27)

1.06(0.85, 1.27)

0.43(-0.07, 0.93)

1.10(0.70, 1.50)

0.87(0.73, 1.01)

0.84(0.57, 1.12)

1.08(0.90, 1.26)

Erro

ratentry

pointandapex

Theover

allmean

errorat

theen

trypoint

(eight

studies,

321

sites)was

1.07mm

(95%

CI:

0.76–1

.22mm)an

dat

theapex

(seven

studies,

281

sites)1.63mm

(95%

CI:1.26–2

mm).

Attheen

trypointthemean

deviatio

n

was

similar

instu

dies

perfo

rmed

inhu-

man

s(th

reestu

dies,

155sites)

(1.16mm,

95%

CI:

0.92–1

.39mm),

cadavers

(four

studies,

116

sites)(1.04mm,95%

CI:

0.74–1

.34mm)an

dmodels

(onestu

dy,50

sites)(0.90mm,95%

CI:

0.76–1

.04mm)

(Fig.

4).

Attheapex

themean

deviatio

n

was

1.96mm

(95%

CI:1.33–2

.58mm)in

studies

perfo

rmed

inhuman

s(th

reestu

-

dies,

155sites),

1.42mm

(95%

CI:

0.59–

2.25mm)in

cadavers

(three

studies,

76

sites)an

d1mm

(95%

CI:0.83–1

.17mm)

inmodels

(onestu

dy,50sites)

(Fig.

8).

Table 1. Accuracy studies

No. Author (year) System Template

production

Study

design

Posi-

tioning

method

Template

support

Number

of sites

Error

entry mean

(mm)

Error

entry

SD (mm)

Error

entry

max (mm)

Error

apex mean

(mm)

Error

apex SD

(mm)

Error

apex max

(mm)

Error

angle

mean (1)

Error

angle

SD (1)

Error

angle

max (1)

Error

height

mean (mm)

Error

height

SD (mm)

Error

height

max (mm)

1 Di Giacomoet al. (2005)

SimPlant Rapid prototyping Human Implant Bone and/orteeth

21 1.45 1.42 4.5 2.99 1.77 7.1 7.25 2.67 12.2 – – –

2 Sarment et al.(2003)

SimPlant Rapid prototyping Model Bore Model 50 0.9 0.5 1.2 1 0.6 1.6 4.5 2 5.4 – – –

3 Vrielinck et al.(2003)

SurgiGuide,Materialise

Rapid prototyping Human Implant Bone/pins 24 1.51 – 4.7 3.07 – 6.4 10.46 – 21 – – –

4 Van Asscheet al. (2007)

Nobel Rapid prototyping Cadaver Implant Teeth ormucosa and/orpins

12 1.1 0.7 2.3 1.2 0.7 2.4 1.8 0.8 4 – – –

5 van Steenbergheet al. (2002)

Nobel Rapid prototyping Cadaver Implant Bone/pins 16 0.8 0.3 – 0.9 0.3 – 1.8 1 – – – 1.1

6 Ozan et al. (2009) Stent CAD Rapid prototyping Human Implant Bone 50 1.28 0.9 2.9 1.57 0.9 3.6 4.63 2.6 9.9 – – –Human Implant Teeth 30 0.87 0.4 1.8 0.95 0.6 2.2 2.91 1.3 5.6 – – –Human Implant Mucosa 30 1.06 0.6 2.6 1.6 1 4.1 4.51 2.1 9 – – –

7 Kalt & Gehrke(2008)

med3D Dental laboratory Cadaver Implant Implant 48 0.83 0.49 1.69 2.17 1.02 3.79 8.44 3.98 15.98 0.28 0.51 1.94

8 Ruppin et al.(2008)

SimPlant Rapid prototyping Cadaver Implant Bone 40 1.5 0.8 3.5 – – – 7.9 5 18.5 0.6 0.4 1.4

.. .Overall (I-squared =

79.4%, p =

0.000)

author

Sarm

ent

model

Vrielinck

human

Van A

ssche

Subtotal (I-squared =

.%, p =

.)

Di G

iacomo

Ozan

Ozan


88.5%, p =

0.000)

Ozan

Kalt

Ruppin


72.6%, p =

0.006)

van Steenberghe

cadaver

year

2003

2003

2007

2005

2009

2009

2009

2008

2008

2002

design

model

human

cadaver

human

human

human

human

cadaver

cadaver

cadaver

study

1.07 (0.92, 1.22)

Error in m

m (95%

CI)

0.90 (0.76, 1.04)

1.51 (1.04, 1.98)

1.10 (0.70, 1.50)

0.90 (0.76, 1.04)

1.45 (0.84, 2.06)

1.28 (1.03, 1.53)

1.06 (0.85, 1.27)

1.04 (0.74, 1.34)

0.87 (0.73, 1.01)

0.83 (0.69, 0.97)

1.50 (1.25, 1.75)

1.16 (0.92, 1.39)

0.80 (0.65, 0.95)

Mean entry

1.07 (0.92, 1.22)

Error in m

m (95%

CI)

0.90 (0.76, 1.04)

1.51 (1.04, 1.98)

1.10 (0.70, 1.50)

0.90 (0.76, 1.04)

1.45 (0.84, 2.06)

1.28 (1.03, 1.53)

1.06 (0.85, 1.27)

1.04 (0.74, 1.34)

0.87 (0.73, 1.01)

0.83 (0.69, 0.97)

1.50 (1.25, 1.75)

1.16 (0.92, 1.39)

0.80 (0.65, 0.95)

Mean entry

01

2

Fig.4

.Deviatio

nat

entry

point,stratifi

edbystu

dydesign

(human

,cad

aver

orin

vitro

study).

..Overall (I-squared =

79.4%, p =

0.000)


81.4%, p =

0.000)

Vrielinck

Ruppin

Ozan


.%, p =

.)

Ozan

Ozan

van Steenberghe

Sarm

ent

bore

Kalt

Van A

ssche

Di G

iacomo

implant

author

2003

2008

2009

2009

2009

2002

2003

2008

2007

2005

year

implant

implant

positioning

implant

implant

implant

implant

bore

implant

implant

implant

method

1.07 (0.92, 1.22)

1.10 (0.92, 1.28)

1.51 (1.04, 1.98)

1.50 (1.25, 1.75)

Mean entry

0.87 (0.73, 1.01)

0.90 (0.76, 1.04)

1.28 (1.03, 1.53)

1.06 (0.85, 1.27)

0.80 (0.65, 0.95)

0.90 (0.76, 1.04)

0.83 (0.69, 0.97)

1.10 (0.70, 1.50)

1.45 (0.84, 2.06)

Error in m

m (95%

CI)

1.07 (0.92, 1.22)

1.10 (0.92, 1.28)

1.51 (1.04, 1.98)

1.50 (1.25, 1.75)

Mean entry

0.87 (0.73, 1.01)

0.90 (0.76, 1.04)

1.28 (1.03, 1.53)

1.06 (0.85, 1.27)

0.80 (0.65, 0.95)

0.90 (0.76, 1.04)

0.83 (0.69, 0.97)

1.10 (0.70, 1.50)

1.45 (0.84, 2.06)

Error in m

m (95%

CI)

01

2

Fig.5

.Deviatio

nat

entry

point,stratifi

edbypositio

ningmeth

od(im

plan

tsorbore

holes).

Sch

neid

eret

al�Accu

racyan

dclin

icaloutco

meofcomputer-gu

ided

template-b

asedim

plan

tden

tistry

76

|Clin

.OralIm

pl.Res.

20(Suppl.4),2009/73–8

6c�

2009JohnW

iley&

SonsA/S



●

●

0 1 2

bonevan SteenbergheVrielincxDi GiacomoOzanSubtotal {I-squared = 95.7%, p=0.000)

2002200320052009

bonebonebonebone

2008

2009

200620072009

mucosa

implant

.implantKaltSubtotal {I-squared = .%, p=.)

.mucosaOzanSubtotal {I-squared = .%, p=.)

.teethDi GiacomoVan AsscheOzanSubtotal {I-squared = 64.3%, p=0.061)

.Overall {I-squared = 93.6%, p=0.000)

teethteethteeth

yeartemplatesupportauthor

Mean apexError in mm (95%CI)

0.80 {0.75, 1.05}3.70 {2.43, 3.71}3.19 {2.11, 4.27}1.57 {1.32, 1.82}2.06 {1.24, 2.87}

2.17 {1.88, 2.48}2.17 {1.88, 2.46}

1.60 {1.24, 1.96}1.60 {1.24, 1.98}

1.95 {1.09, 2.81}1.20 {0.80, 1.60}0.95 {0.74, 1.16}1.20 {0.79, 1.61}

1.74 {1.32, 2.15}

●

●

●

●

●

●

●

●

●

0 5 10

→●

bonevan SteenbergheVrielincxDi GiacomoAuppinOzanSubtotal {I-squared = 97.4%, p=0.000)

20022003200520082009

bonebonebonebonebone

2008

2009

200620072009

mucosa

implant

.implantKaltSubtotal {I-squared = .%, p=.).mucosaOzanSubtotal {I-squared = .%, p=.).teethDi GiacomoVan AsscheOzanSubtotal {I-squared = 86.9%, p=0.000).Overall {I-squared = 96.9%, p=0.000)

teethteethteeth

yeartemplatesupportauthor

Mean angleError in mm (95%CI)

1.80 {1.31, 2.99}10.46 {8.36, 12.56}7.72 {8.05, 9.39}7.90 {8.35, 9.45}4.83 {3.81, 5.35}6.39 {3.81, 9.17}

8.44 {7.31, 9.57}8.44 {7.31, 9.57}

4.51 {3.76, 5.26}4.51 {3.76, 5.26}

6.93 {3.47, 10.39}1.80 {1.35, 2.25}2.81 {2.44, 3.36}2.82 {1.57, 4.07}

5.50 {4.07, 6.92}

表5

表6

根管治療

人工植牙



一般牙科

美容牙科


▍CAD/CAM surgical guide誤差的產生原因手術模板放置的位置與一開始診斷設計的位置不一致，是造成誤差的主要原因。Mucosa supported

surgical guide 因為是軟組織支撐，在診斷階段的CT檢查及手術階段的手術模板放置，可能會因為軟組

織的 translation 及 rotation 而位移，{Casse� a, 2013 #38}，尤其是maxilla mucosa較mandible 厚，產生的誤差更

大。因此{Van Assche, 2012 #13}建議mucosa supported surgical guide要使用bite index及� xation screw 來減少擺放位

置的誤差。

Bone supported surgical guide 的誤差值較其它三種大，它是根據CT 的檢查數據來製作手術模板，但

因為較小的骨在CT voxel 成像時被乎略，而使手術模板無法放置定位，須要將尖銳的骨移除{Yong,

2008 #25}，才能使手術模板貼合。Teeth, implant supported surgical guide 因為有較穩定的支撐，誤差值理論

上較小。但因為金屬造成CT metal artifact，及移動造成的motion artifact，仍會造成誤差。Implant supported

surgical guide 通常植入三隻 mini-implant，除了可之以支撐手術模板，也可用來支撐臨時復物{Cassetta,

2013 #36}。

另外CAD/CAM手術模板須要較長的drill，通常後牙區在 initial drill 使用後，因為病人的開口度及

interocclusal distance不足的情况下，移除surgical guide 做freehand drilling，也增加了entry deviation 0.3mm及apex

deviation 0.6mm{Behneke, 2012 #31}。若先移除 surgical guide，再置入Implant時，也會產生較大誤差，尤其是

較軟的骨頭，或是有bone dehiscence或fenestration的部位{Park, 2009 #1006}。

▍The intrinsic error of surgical guide主見現今常用的surgical guide分為surgical sleeve及internal tube二個部份，如圖11。surgical sleeve 4 mm長，

internal tube 5mm，為了套筒與套筒之間及drill與套筒之間可自由移動，留有0.15-0.2mm的空間，這會造成

angular deviation, drill越長，側方的apex deviation越大，所以drilling過程中，僅量保持drill在正中央的位置，

主要因開口度不足，而偏向近心側，drill apex會往遠心側偏移，如圖12。而surgical sleeve距bone越近，

apex deviation越小。Internal tube越長，apex deviation越小，{Van Assche, 2012 #13}。Cassetta et al.{Cassetta, 2013

#33}，發現若 mucosa厚度是 3mm, implant長度為13mm，就會在mucosa及teeth supported guide產生 1.88mm的

apical deviation，如表7。所以Casse� a et al.建議使用 surgical guide 最好距重要的解剖位置保留2-3 mm的安全

距離。



▍結論Guided implant surgery是一項日漸普遍的手術方式，但並不是有了CAD/CAM手術模板，就可以達到

零誤差。使用這項技術時，須了解可能發生之誤差，在手術過程中小心避免可能的失誤，與重要的

神經血管及組織保留安全間距，才能達到良好的效果。

▍參考文獻1. Pjetursson BE, Tan K, Lang NP, Bragger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of � xed

partial dentures (FPDs) a� er an observation period of at least 5 years. Clinical oral implants research 2004;15:667-76.

2. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clinical oral implants research 2008;19:119-30.

3. Hammerle CH, Jung RE, Feloutzis A. A systematic review of the survival of implants in bone sites augmented with barrier membranes (guided bone regeneration) in partially edentulous patients. Journal of clinical periodontology 2002;29 Suppl 3:226-31; discussion 32-3.

4. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral

圖12

表7

Total angular error = 5.15’ Mucosa (teeth) supported guide Bone supported guide

Global curenal devition (entry point)

Laieral devition

Global apical devition

0.72 mm (mucosa thickness 3 mm)

1.9 mm (mucosa thickness 3 mm and implant length 14 mm)

1.53 mm (mucosa thickness 3 mm and implant length 14 mm)

0.45 mm

1.62 mm (implant length 14 mm)

1.6 mm (implant length 14 mm)

圖11

根管治療

人工植牙



一般牙科

美容牙科


張耿鐘醫師 ◆ 中山醫學大學牙醫學系

◆ 台大義齒復專科訓練

◆ 中華民國復牙科學會專科醫師

◆ 中華民國口腔植體學會專科醫師

Profile

implants. Clinical oral implants research 2006;17 Suppl 2:136-59.

5. Vercruyssen M, Jacobs R, Van Assche N, van Steenberghe D. � e use of CT scan based planning for oral rehabilitation by means of implants and its transfer to the surgical � eld: a critical review on accuracy. Journal of oral rehabilitation 2008;35:454-74.

6. Tahmaseb A, De Clerck R, Wismeijer D. Computer-guided implant placement: 3D planning so� ware, � xed intraoral reference points, and CAD/CAM technology. A case report. � e International journal of oral & maxillofacial implants 2009;24:541-6.

7. D'Haese J, Van De Velde T, Komiyama A, Hultin M, De Bruyn H. Accuracy and complications using computer-designed stereolithographic surgical guides for oral rehabilitation by means of dental implants: a review of the literature. Clinical implant dentistry and related research 2012;14:321-35.

8. Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the clinical outcome of computer-guided template-based implant dentistry. Clinical oral implants research 2009;20 Suppl 4:73-86.

9. Kalt G, Gehrke P. Transfer precision of three-dimensional implant planning with CT assisted offline navigation. International journal of computerized dentistry 2008;11:213-25.

10. Ruppin J, Popovic A, Strauss M, Spuntrup E, Steiner A, Stoll C. Evaluation of the accuracy of three di� erent computer-aided surgery systems in dental implantology: optical tracking vs. stereolithographic splint systems. Clinical oral implants research 2008;19:709-16.

11. Casse� a M, Di Mambro A, Giansanti M, Stefanelli LV, Barbato E. How does an error in positioning the template a� ect the accuracy of implants inserted using a single fixed mucosa-supported stereolithographic surgical guide? International journal of oral and maxillofacial surgery 2013.

12. Van Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer-aided implant placement. Clinical oral implants research 2012;23 Suppl 6:112-23.

13. Yo ng LT, Moy PK. Complications of computer-aided-design/computer-aided-machining-guided (NobelGuide) surgical implant placement: an evaluation of early clinical results. Clinical implant dentistry and related research 2008;10:123-7.

14. Tahmaseb A, De Clerck R, Aartman I, Wismeijer D. Digital protocol for reference-based guided surgery and immediate loading: a prospective clinical study. � e International journal of oral & maxillofacial implants 2012;27:1258-70.

15. Behneke A, Burwinkel M, Behneke N. Factors influencing transfer accuracy of cone beam CT-derived template-based implant placement. Clinical oral implants research 2012;23:416-23.

16. Park C, Raigrodski AJ, Rosen J, Spiekerman C, London RM. Accuracy of implant placement using precision surgical guides with varying occlusogingival heights: an in vitro study. J Prosthet Dent 2009;101:372-81.

17. Casse� a M, Di Mambro A, Giansanti M, Stefanelli LV, Cavallini C. � e intrinsic error of a stereolithographic surgical template in implant guided surgery. International journal of oral and maxillofacial surgery 2013;42:264-75.

cad/cam surgical guide - elitedentist.com.t‰‹術模板的臨床應用及精確度.pdf ·...

Documents