Dynamic Navigation System Research Articles

Accuracy of dental implant surgery using dynamic navigation and robotic systems: An in vitro study

ObjectivesTo compare the accuracy of dental implant placement using a dynamic navigation and a robotic system. MethodsEighty three-dimensional (3D) printed phantoms, including edentulous and partially edentulous jaws, were assigned to two groups: a dynamic navigation system (Beidou-SNS) group and a robotic system (Hybrid Robotic System for Dental Implant Surgery, HRS-DIS) group. The entry, exit and angle deviations of the implants in 3D world were measured after pre-operative plans and postoperative cone-beam computed tomography (CBCT) fusion. A linear mixed model with a random intercept was applied, and a p value <.05 was considered statistically significant. ResultsA total of 480 implants were placed in 80 phantoms. The comparison deviation of the dynamic navigation system and robotic system groups showed a mean (± SD) entry deviation of 0.96 ± 0.57 mm vs. 0.83 ± 0.55 mm (p=0.04), a mean exit deviation of 1.06 ± 0.59 mm vs. 0.91 ± 0.56 mm (p=0.04), and a mean angle deviation of 2.41± 1.42° vs. 1 ± 0.48° (p<0.00). ConclusionsThe implant positioning accuracy of the robotic system was superior to that of the dynamic navigation system, suggesting that this prototype robotic system (HRS-DIS) could be a promising tool in dental implant surgery. Clinical significanceThis in vitro study is of clinical interest because it preliminarily shows that a robotic system exhibits lower deviations of dental implants than a dynamic navigation system, in dental implant surgery, in both partially and completely edentulous jaws. Further clinical studies are needed to evaluate the current results.

Dynamic Navigation System for Immediate Implant Placement in the Maxillary Aesthetic Region

(1) Background: The achievement of an optimal implant position is still a critical consideration in implantology, especially in the aesthetic area. Dynamic navigation is a computer-aided procedure that allows the surgeon to follow on a screen the three-dimensional position of instruments in real time during implant site preparation. The aim of this proof-of-concept study was to assess the clinical and radiographical performance and accuracy of the surgical workflow during maxillary immediate implant placement assisted by DTX studio Implant software planning and X-Guide Navigation. (2) Methods: Twelve consecutive patients requiring at least one implant in the maxillary aesthetic region were treated. Clinical outcome measures were biological complications and implant or prosthetic success rate. The accuracy was measured by calculating the deviation between the real implant position obtained from the postoperative cone beam computed tomography (CBCT) scan and the planned implant position. (3) Results: The average deviation at the implant shoulder was 0.77 ± 0.25 mm and at the apical point was 1.2 ± 0.61 mm. The depth error was 0.5 ± 0.21 mm. The axis deviation was 2.5 ± 0.41 degrees. No biological complications or implant and prosthetic failures occurred after mean 6-month follow-up. (4) Conclusions: Within the limitations of this study, it seems that the dynamic navigation system for implant placement in the maxillary aesthetic region is accurate for prosthetically driven implant placement.

Accuracy of 3D dynamic navigation system for fiber post retrival from RC treated teeth

Introduction: Removing fiber posts from root canal–treated teeth is inherent to tooth loss and time consuming. Hence in our study we aim to investigate the accuracy and efficiency of the 3-dimensional dynamic navigation system (DNS) compared with the freehand technique (FH) when removing fiber posts from root canal–treated teeth. Material and Methods: We compared the extracted single rooted teeth prepared with post and build with core. We divided 40 teeth equally as DNS &amp; FH. We compared Global coronal and apical deviations, angular deflection, operation time, and volumetric tooth loss, keeping the p&lt;0.05 as significant. Results: The DNS group showed significantly lower global coronal and apical deviations and angular deflection than the FH group (P &lt; .05). DNS required less operation time than FH. Moreover, the DNS technique had significantly less volumetric loss of tooth structure than the FH technique (P &lt; .05).Conclusions: The DNS was more precise and effective in removing fiber posts from root canal–treated teeth than the FH technique.

Review of “Endodontic Microsurgery of Posterior Teeth with the Assistance of Dynamic Navigation Technology: A Report of Three Cases” by Fu and Colleagues in Journal of Endodontics 2022; Article in Press

Implementation of pioneering technologies in surgical specialties is not an easy task and certainly needs a well-described manual. The article of Fu and colleagues is just a manual for the implementation of dynamic navigation-assisted endodontic microsurgery. The publication is prepared by four Chinese co-authors and highlighted on eight pages of precisely illustrated case series. Accordingly to literature there were no previous published cases of the application of dynamic navigation-assisted technology as a companion technology to endodontic microsurgery. The authors are first to report this technology applied to the posterior teeth of the maxilla (one case) and mandible (two cases). A preoperative diagnosis in all the presented cases was a chronic periapical periodontitis. Clinical procedures of the dynamic navigation technique included: (1) preoperative cone-beam computed tomography (CBCT) scanning, (2) a dynamic navigation system (DHC-ENDO1, DCARER Medical Technology, Suzhou, China) was used for the preoperative surgical path designing, (3) calibration and registration, and (4) real-time dynamic navigation. The endodontic microsurgery in all cases was performed using OPMI PICO microscope (Carl Zeiss, Gottingen, Germany) which I`m also using in my practice. In these three molar cases, the authors proved that the novel approach in dynamic navigation–assisted endodontic microsurgery is a feasible, predictable, and timesaving combination of technologies and surgical technique.

Comparison of the accuracy of two different dynamic navigation system registration methods for dental implant placement: A retrospective study.

Dynamic navigation approaches are widely employed in the context of implant placement surgery, with registration being integral to the accuracy of such navigation. Relatively few studies to date, however, have compared different registration approaches, and such a comparison has the potential to guide the development of more accurate and reliable clinical registration methodology. This study was developed to compare the accuracy of dynamic navigation-based dental implant placement conducted using either U-tube or cusp registration methods. Medical records from all patients that had undergone implant surgery between August 2019 and October 2020 in the First Clinical Division of the Peking University Hospital of Stomatology were retrospectively reviewed, with 64 patients and 99 implants ultimately meeting with study inclusion criteria. Implant placement accuracy was gauged via the superimposition of the planned implant position in preoperative cone-beam computed tomography (CBCT) images with the true postoperative implant position in postoperative CBCT images. Accuracy was measured based upon the angular deviation, entry deviation (3-dimensional [3D] deviation in the coronal aspect of the alveolar ridge), and apex deviation (3D deviation in the apical area of the implant) when comparing these two positions. The angular deviation, entry deviation, and apex deviation of all analyzed implants were 3.29 ± 0.17°, 1.29 ± 0.07 mm, and 1.43 ± 0.08 mm, respectively, while in the cusp registration group these respective values were 3.25 ± 1.58°, 1.28 ± 0.60 mm, and 1.34 ± 0.63 mm as compared to 3.35 ± 1.78°, 1.30 ± 0.78 mm, 1.55 ± 0.9 mm in the U-tube group, respectively. No significant differences in accuracy were observed when comparing these two registration techniques. Dynamic computer-assisted surgical systems can facilitate accurate implantation, and both the U-tube and cusp registration methods exhibit similar levels of accuracy. As the cusp registration technique can overcome some of the limitations of the U-tube strategy without the need for an additional registration device, it may be more convenient for clinical use and warrants further research.

Dynamic Navigation in Endodontics: Guided Access Cavity Preparation by Means of a Miniaturized Navigation System.

In the case of teeth with pulp canal calcification (PCC) and apical pathology or pulpitis, root canal treatment can be very challenging. PCC are common sequelae of dental trauma but can also occur with stimuli such as caries, bruxism, or after placing a restoration. In order to access the root canal as minimally invasive as possible in case of a necessary root canal treatment, dynamic navigation has recently been introduced in endodontics in addition to static navigation. The use of a dynamic navigation system (DNS) requires pre-operative cone-beam computed tomography (CBCT) imaging and a digital surface scan. If necessary, reference markers must be placed on the teeth before the CBCT scan; with some systems, these can also be planned and created digitally afterward. By means of a stereo camera connected to the planning software, the drill can now be coordinated with the help of reference markers and virtual planning. As a result, the position of the drill can be displayed on the monitor in real-time during preparation in different planes. In addition, the spatial displacement, the angular deviation, and the depth position are also displayed separately. The few commercially available DNS mostly consist of relatively large camera-marker-systems. Here, the DNS contains miniaturized components: a low-weight camera (97 g) mounted on the micromotor of the electric handpiece utilizing a manufacturer-specific connecting mechanism and a small marker (10 mm x 15 mm), which can be easily attached to an individually manufactured intraoral tray. For research purposes, a post-operative CBCT scan can be matched with the pre-operative one, and the volume of tooth structure removed can be calculated by the software. This work aims to present the technique of guided access cavity preparation by means of a miniaturized navigation system from imaging to clinical implementation.

Real-time 3-dimensional Dynamic Navigation System in Endodontic Microsurgery: A Cadaver Study

This study evaluated the accuracy and efficiency of the 3-dimensional dynamic navigation system (3D-DNS) to perform minimally invasive osteotomy (MIO) and root end resection (RER) in endodontic microsurgery (EMS) and investigated the viability of root end cavity preparation (RECP) and root end fill (REF) in MIO. Forty-eight tooth roots were divided in cadaver heads into 2 groups: 3D-DNS (n=24) and freehand (n=24). Cone-beam computed tomographic scans were taken before and after surgery. First, virtual 3D-DNS accuracy was verified using 3 outcome measures: 2-dimensional and 3-dimensional virtual deviations and angular deflection. Second, the accuracy of 3D-DNS for performing MIO was investigated in 2 outcome measures: osteotomy size and volume. Third, the 3D-DNS accuracy was determined for RER in 3 outcomes: resected root length, root length after resection, and resection angle. The viability of RECP and REF was investigated and REF depth and volume measured as well, and procedural time and the number of mishaps were recorded. Two- and 3-dimensional virtual deviations and the angular deflection were lower in the 3D-DNS group than the freehand group (P<.05). Osteotomy height, length, and volume were all reduced when using 3D-DNS (P<.05). The resection angle was lower for 3D-DNS (P<.05). RECP and REF were completed in 100% of the roots. The REF depth achieved was ∼3mm. Osteotomy time, RER time, and the total procedure time were all significantly shortened using 3D-DNS (P<.05). 3D-DNS enabled our surgeon to perform accurate and efficient EMS with minimally invasive osteotomy and RER. The surgeon was also able to conduct RECP with adequate REF in minimally invasive osteotomy performed using 3D-DNS guidance.

Comparison of Implant Placement Accuracy in Healed and Fresh Extraction Sockets between Static and Dynamic Computer-Assisted Implant Surgery Navigation Systems: A Model-Based Evaluation.

The aim of this model-base study was to compare the accuracy of implant placement between static and dynamic computer-assisted implant surgery (CAIS) systems in a fresh extraction socket and healed ridge. A randomized in vitro study was conducted. Twenty 3D-printed maxillary models and 80 implants were used. One experienced researcher placed the implants using either the static navigation or dynamic navigation system. Accuracy was measured by overlaying the real position in the postoperative CBCT on the virtual presurgical placement of the implant in a CBCT image. Descriptive and bivariate analyses of the data were performed. In the fresh sockets, the mean deviation was 1.24 ± 0.26 mm (entry point), 1.69 ± 0.34 mm (apical point), and 3.44 ± 1.06° (angle discrepancy) in the static CAIS group, and 0.60 ± 0.29 mm, 0.78 ± 0.33 mm, and 2.47 ± 1.09° in the dynamic CIAS group, respectively. In the healed ridge, the mean deviation was 1.09 ± 0.17 mm and 1.40 ± 0.30 mm, and 2.12 ± 1.11° in the static CAIS group, and 0.80 ± 0.29 mm, 0.98 ± 0.37 mm, and 1.69 ± 0.76° in the dynamic CIAS group, respectively. Compared with the static CAIS system, the dynamic CAIS system resulted in significantly lower entry and apical errors in both fresh sockets and healed ridges. Differences in bone morphology therefore seem to have little effect on accuracy in the dynamic CAIS group.

Dynamic Navigation System - A New Era in Endodontics

Dynamic Navigation System - A New Era in Endodontics

Accuracy of a Computer-Aided Dynamic Navigation System in the Placement of Zygomatic Dental Implants: An In Vitro Study.

The objective of this in vitro study was to evaluate and compare the accuracy of zygomatic dental implant (ZI) placement carried out using a dynamic navigation system. Materials and Methods: Forty (40) ZIs were randomly distributed into one of two study groups: (A) ZI placement via a computer-aided dynamic navigation system (n = 20) (navigation implant (NI)); and (B) ZI placement using a conventional free-hand technique (n = 20) (free-hand implant (FHI)). A cone-beam computed tomography (CBCT) scan of the existing situation was performed preoperatively to plan the surgical approach for the computer-aided study group. Four zygomatic dental implants were placed in anatomically based polyurethane models (n = 10) manufactured by stereolithography, and a postoperative CBCT scan was performed. Subsequently, the preoperative planning and postoperative CBCT scans were added to dental implant software to analyze the coronal entry point, apical end point, and angular deviations. Results were analyzed using the Student’s t-test. Results: The results showed statistically significant differences in the apical end-point deviations between FHI and NI (p = 0.0018); however, no statistically significant differences were shown in the coronal entry point (p = 0.2617) or in the angular deviations (p = 0.3132). Furthermore, ZIs placed in the posterior region showed more deviations than the anterior region at the coronal entry point, apical end point, and angular level. Conclusions: The conventional free-hand technique enabled more accurate placement of ZIs than the computer-assisted surgical technique. In addition, placement of ZIs in the anterior region was more accurate than that in the posterior region.

Major indications and current clinical findings of zygomatic implant: a systematic review

Introduction: The lack of bone in the alveolar crest represents a major problem in aesthetic recovery in patients who have suffered dentoalveolar trauma, traumatic extractions, congenital tooth absence pathologies involving maxilla and mandible, and the possibility of deformity. In this sense, the zygomatic implant (ZI) is an alternative when there is bone loss. Objective: It was to carry out a systematic review of the main clinical outcomes of ZI, emphasizing the main indications. Methods: The present study followed the PRISMA rules. The search strategy was performed in the PubMed, Scielo, Cochrane Library, Web of Science and Scopus, and Google Scholar databases, following the rules of the word PICOS (Patient; Intervention; Control; Outcomes; Study Design). The Cochrane Instrument was used to assess the risk of bias of the included studies. Results and Conclusion: A total of 82 articles were found involving zygomatic implantation and the evolution of the technique. Initially, the duplication of articles was excluded. A total of 54 articles were fully evaluated and 33 were included in this study. Based on the clinical results of the last five years, some studies have broadened clinical understanding based on comparative studies to show the success rate of ZI. Even if more complications were reported for ZI that resolved spontaneously or could be handled, ZI proved to be a better modality of rehabilitation for severely atrophic jaws. Furthermore, zygomatic surgery proved to be a viable and safe alternative to conventional treatment modalities for oral rehabilitation of patients with ectodermal dysplasia syndrome. Also, there was greater accuracy and drastically reduced risk of perioperative/postoperative complications using the dynamic navigation system compared to the freehand placement of implants. Finally, guided surgery for the placement of ZI using specially designed metal jigs that must be supported by bone showed the placement of a made-to-measure provisional prosthesis, reducing surgery time, simplifying the procedure, and optimizing the result.

Reliability and accuracy of dynamic navigation for zygomatic implant placement.

ObjectivesTo assess the accuracy of a real‐time dynamic navigation system applied in zygomatic implant (ZI) surgery and summarize device‐related negative events and their management.Material and methodsPatients who presented with severely maxillary atrophy or maxillary defects and received dynamic navigation‐supported ZI surgery were included. The deviations of entry, exit, and angle were measured after image data fusion. A linear mixed‐effects model was used. Statistical significance was defined as p < .05. Device‐related negative events and their management were also recorded and analyzed.ResultsTwo hundred and thirty‐one zygomatic implants (ZIs) with navigation‐guided placement were planned in 74 consecutive patients between Jan 2015 and Aug 2020. Among them, 71 patients with 221 ZIs received navigation‐guided surgery finally. The deviations in entry, exit, and angle were 1.57 ± 0.71 mm, 2.1 ± 0.94 mm and 2.68 ± 1.25 degrees, respectively. Significant differences were found in entry and exit deviation according to the number of ZIs in the zygomata (p = .03 and .00, respectively). Patients with atrophic maxillary or maxillary defects showed a significant difference in exit deviation (p = .01). A total of 28 device‐related negative events occurred, and one resulted in 2 ZI failures due to implant malposition. The overall survival rate of ZIs was 98.64%, and the mean follow‐up time was 24.11 months (Standard Deviation [SD]: 12.62).ConclusionsThe navigation‐supported ZI implantation is an accurate and reliable surgical approach. However, relevant technical negative events in the navigation process are worthy of attention.

Use of dynamic navigation system in endodontics: A literature review

Over the years, traditional endodontic approaches performed have caused significant loss of healthy tooth structure. Clinical approach became relatively predictable following the introduction of cone-beam computed tomography, Digital Imaging and Communications files, and dental operating microscopes. Despite these advances, mishaps such as excessive dentin loss and/or perforations may still occur during freehand preparations affecting the tooth's prognosis. Following the developments in surface scanning and three-dimensional printing, static guidance systems were introduced. However, they too had multiple drawbacks. Dynamic navigation systems (DNSs) were introduced following to overcome them. DNS is based on computer-aided navigation technology analogous to the Global Positioning System (GPS) navigation. New minimally invasive preparations have been put forward claiming to be the future of endodontics which can be achieved with the help of DNS. The review thus aims at evaluating the possible use of DNS in planning and executing these minimally invasive preparations without unnecessary loss of healthy tooth structure.

Endodontic retreatment: significance and a systematic review of te major protocols

Introduction: In the endodontic treatment scenario, despite the emergence of techniques and instruments that facilitate the treatment, there are still cases that require retreatment of the treated root canals. Non-surgical endodontic retreatment (NSER) can be performed in one or several visits. Endodontic pain has been the main reason for patient consultations after therapy and affects patient comfort. A condition for successful endodontic retreatment is proper cleaning of the root canals, therefore, special attention must be given to the technique used to remove the filling material, with the most commonly used cement, pastes, and gutta-percha cones. Objective: This systematic review aimed to evaluate the main protocols and techniques for endodontic retreatment. Methods: The present study was followed by a systematic literature review model. Clinical studies were included as case reports, retrospective, prospective and randomized trials with qualitative and/or quantitative analysis. The quality of the studies was based on the GRADE instrument. The risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: The results showed that cleaning and the presence of debris at a speed of 1500 rpm provided greater agility with a smaller number of fractured instruments. Furthermore, the dynamic navigation system enabled the minimally invasive removal of the fiber post with a high degree of precision, without unnecessary removal of the root structure. One visit NSER had lower postoperative pain than multiple visits only for 1 and 30 days. Ultrasonic tips should be considered a good option for endodontic retreatment, especially for cases of bioceramics. Finally, there is a predominance of E. faecalis and P. gingivalis in all phases of endodontic retreatment.

Real-Time Image-Guided Navigation in the Management of Alveolar Cleft Repair.

Objectives: To present the use of dynamic navigation system in the repair of alveolar cleft. Patients and Participants: A total of three non-syndromic patients with unilateral alveolar cleft were involved in this study. Real-time computer-aided navigation were used to achieve restoration and reconstruction with standardized surgical technique. Methods: With the individual virtual 3-dimensional (3-D) modeling based on computed tomography (CT) data, preoperative planning and surgical simulation were carried out with the navigation system. During preoperative virtual planning, the defect volume or the quantity of graft is directly assessed at the surgical region. With the use of this system, the gingival periosteum flap incision can be tracked in real-time, and the bone graft can be navigated under the guidance of the 3-D views until it matches the preoperatively planned position. Results: Three patients with alveolar cleft were successfully performed under navigation guidance. Through the model alignment procedure, accurate matches between the actual intraoperative position and the CT images were achieved within the systematic error of 0.3 mm. The grafted bone was implanted according to the preoperative plan with the aid of instrument- and probe-based navigation. All the patients were healed well without serious complications. Conclusions: These findings suggest that image-guided surgical navigation, including preoperative planning, surgical simulation, postoperative assessment, and computer-assisted navigation was feasible and yielded good clinical outcomes. Clinical relevance: This dynamic navigation could be proved to be a valuable option for this complicated surgical procedure in the management of alveolar cleft repair.

RETRACTED: Setoguchi et al. Accuracy Assessment of Implant Placement in a Newly Developed Dynamic Navigation System: A Pilot Study. Appl. Sci. 2021, 11, 6593

The published article [...]

Real-Time Dynamic Navigation System for the Precise Quad-Zygomatic Implant Placement in a Patient with a Severely Atrophic Maxilla.

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive bone augmentation and shorten the treatment cycle. However, there are risks associated with the placement of ZIs, such as penetration of the orbital cavity or infra-temporal fossa. Furthermore, the placement of multiple ZIs makes this surgery risky and more difficult to perform. Potential intraoperative complications are extremely dangerous and may cause irreparable losses. Here, we describe a practical, feasible, and reproducible protocol for a real-time surgical navigation system for precisely placing quad-zygomatic implants in the severely atrophic maxilla of patients with residual bone that does not meet the requirements of conventional implants. Hundreds of patients have received ZIs at our department based on this protocol. The clinical outcomes have been satisfactory, the intraoperative and postoperative complications have been low, and the accuracy indicated by infusion of the designed image and postoperative three-dimensional image has been high. This method should be utilized during the entire surgical procedure to ensure ZI placement safety.

Real-Time Dynamic Navigation System for the Precise Quad-Zygomatic Implant Placement in a Patient with a Severely Atrophic Maxilla

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive bone augmentation and shorten the treatment cycle. However, there are risks associated with the placement of ZIs, such as penetration of the orbital cavity or infra-temporal fossa. Furthermore, the placement of multiple ZIs makes this surgery risky and more difficult to perform. Potential intraoperative complications are extremely dangerous and may cause irreparable losses. Here, we describe a practical, feasible, and reproducible protocol for a real-time surgical navigation system for precisely placing quad-zygomatic implants in the severely atrophic maxilla of patients with residual bone that does not meet the requirements of conventional implants. Hundreds of patients have received ZIs at our department based on this protocol. The clinical outcomes have been satisfactory, the intraoperative and postoperative complications have been low, and the accuracy indicated by infusion of the designed image and postoperative three-dimensional image has been high. This method should be utilized during the entire surgical procedure to ensure ZI placement safety.

Accuracy of intentionally tilted implant placement in the maxilla using dynamic navigation: a retrospective clinical analysis

The aim of this retrospective study was to investigate the accuracy of dynamic navigation for the placement of intentionally tilted implants in the posterior maxilla. The study included 12 patients with edentulism or continuous multiple tooth loss, who had 48 implants inserted under dynamic navigation guidance in the posterior maxilla. Twenty-four implants near maxillary sinuses were intentionally tilted. The average platform deviation was 1.3 ± 0.4 mm (range 0.8–2.3 mm), apex deviation was 1.1 ± 0.5 mm (range 0.2–2.3 mm), and axis deviation was 3.1 ± 1.0° (range 1.8–6.7°). The other 24 implants were axially positioned. The average platform deviation was 1.5 ± 0.5 mm (range 0.7–3.1 mm), apex deviation was 1.3 ± 0.7 mm (range 0.5–3.1 mm), and axis deviation was 3.2 ± 1.5° (range 1.5–7.7°). There was no significant difference in platform deviation, apex deviation, or axis deviation between the tilted implants and implants in the axial position (P > 0.05). This analysis indicates that a dynamic navigation system can be used as a method of guidance to place intentionally tilted implants as accurately as axially positioned implants in the posterior maxilla, thereby preventing damage to the maxillary sinuses and the need to graft bone.

Dynamic navigation and technical improvements in zygomatic surgery

The rehabilitation of the severely atrophied edentulous maxilla poses a great challenge to surgeons and prosthodontics that work on this particular area. The classic approach implies bone augmentation techniques by means of bone grafting, bone distraction techniques, tilted and short implants. All of these require major surgery, sometimes associated with morbidity at donor and receptor sites and functional rehabilitation of the patient must occur in two surgical stages. Since the development of the zygomatic implants by Per-Ingvar Branemark, there’s an alternative to bone grafting techniques, using the body of the zygomatic bone as major point of anchorage to an intraoral osteointegrated implant. This procedure allows the patient to regain orofacial function in only one surgical stage, with high predictability, less morbidity, time spend and costs. In this scientific article the authors present a set of technical improvements in the zygomatic implant (S.I.N. - Implant System, São Paulo, Brazil) in combination with a new dynamic navigation system called StealthStation™ (Medtronic, Dublin, Irland) used for the first time in this type of surgery.