全導引植牙手術對植牙手感診斷骨質能力之影響

Abstract

實驗目的:有經驗的手術醫師常以鑽骨時的手感來診斷骨質(bone quality)的軟硬以決定手術步驟與癒合時間。全導引植牙手術導板(fully guided stent)的使用可以讓植牙位置更精準並減少手術時間，然而植牙導板上的手術套筒與植牙鑽針緊密貼合會產生摩擦力，可能會影響到手感的判斷。因此本實驗的目的為探討使用全導引手術導板是否會影響到手術醫師對骨質的判斷，而可能影響手術的預後，並藉此探討全導引式手術導板的優缺點以及對於人工植牙手術的助益。虛無假設為使用全導引手術導板不會影響到骨質的判斷與骨頭密度正確率之判斷。本實驗欲探討之結果為在同一個骨塊密度下，使用全導引手術導板所判斷的骨頭密度與沒有使用導板的骨頭密度判斷分類是否有差異，其次為使用全導引手術導板對於骨頭密度判斷的正確率是否有影響。實驗材料與方法:實驗納入三十位受試者，納入標準為執業未滿10年之牙醫師，臨床植牙經驗少於10支，年齡為24~40歲。排除條件為無法配合全程受測試時程者。實驗設計共有兩輪，一輪有七個標準模型，標準模型由3 Shape E4桌掃機(Lab scanner)掃描模擬病人的實體模型合併dicom檔（錐狀射束電腦斷層掃描檔案），設計虛擬補綴物的位置，將模型透過Meshmixure(Autodesk 123D)編輯使欲植牙位置有一凹槽可放置不同硬度的模擬骨塊，列印出14個標準模型，並產出7個相對應牙位的全導引手術導板。模型凹槽處放置四種密度骨塊(saw bone test block)(5pcf、5pcf、10pcf、10pcf、15pcf、15pcf、30pcf)隨機順序測試，進行每輪測試前請受試者對一個50pcf骨塊鑽孔並告知此為最硬的骨塊。接著依序開始實驗，第一輪對7個模型上進行徒手鑽孔測試(free hand drilling)，第二輪則使用另外7個模型進行全導引手術導板鑽孔測試(fully guided drilling with stent)，每個模型鑽骨完成，即在問卷上評估硬度，以VAS數值表示。評估標準以VAS 數值為評量工具，長度為10cm。統計分析:將實驗中每位受試者每次鑽骨的VAS 數據以及模擬骨塊相對應之密度以 MicrosofT EXCEL(V14.1)以及SPSS(IBM SPSS Statistics V19.0)建檔，記錄受試者在傳統鑽骨及使用全導引手術導板輔助之下對於不同密度模擬骨塊的VAS 值及敘述性統計分析。以paired t test來評估同密度下VAS平均值是否有顯著差異。所有統計分析 p value 設定在p <0.05 表示在統計學上具有差異。並以McNemer test分析模擬骨塊密度排序的正確率。實驗結果:實驗數據分佈皆成常態分佈。使用全導引手術導板與未使用全導引手術導板進行鑽骨時，對於模擬骨塊密度之判斷有顯著差異，且使用全導引手術導板的骨質密度判斷皆大於未使用全導引手術導板的數值。使用全導引手術導板對於模擬骨塊密度排序正確率之判斷並未有統計學上的顯著意義。結論:使用全導引手術導板將顯著影響對於骨頭密度之判斷，且容易高估骨密度數值。然而使用全導引手術導板對於骨密度排序正確率並無影響。

Objective:Experienced surgeons often diagnose bone quality through the tactile feedback when drilling bones to determine surgical steps and healing time. The use of fully guided stents in dental implant surgery can make implant positioning more precise and reduce surgery time. However, the space between the surgical sleeve on the implant guide and the implant drill can create friction, potentially affecting the tactile sensation. Therefore, this experiment aims to evaluate whether the use of a fully guided surgical stent affects the surgeon's tactile sensation of bone quality, which could impact surgical outcomes. Additionally, it explores the advantages and disadvantages of fully guided stents and their benefits for dental implant surgery. The null hypothesis is that the use of fully guided surgical stents does not affect the classification of bone quality and the accuracy of bone density order assessment. The results to be investigated are whether there is a difference in bone density classification using fully guided stents compared to freehand drilling under the same bone density, and whether the use of fully guided stents affects the correct rate of bone density sequence assessment.Materials and Methods:The experiment included thirty subjects, with the inclusion criteria being dentists practicing for less than 10 years, with clinical implant experience of fewer than 10 implants, and aged 24-40 years. Exclusion criteria included those unable to comply with the entire testing schedule. The experiment design consisted of two rounds, each with seven standard models. The standard models were scanned using a 3 Shape E4 lab scanner, simulating the patient's physical model combined with DICOM files (cone-beam computed tomography scans), designing the virtual prosthetic positions, and editing the models using Meshmixer (Autodesk 123D) to create a box at the intended implant site for placing test blocks of different density. Fourteen standard models were printed, and seven corresponding fully guided stents were produced. Test blocks of four different densities (saw bone test blocks) (5 pcf, 5 pcf, 10 pcf, 10 pcf, 15 pcf, 15 pcf, 30 pcf) were randomly placed in the box for testing. Before each round of testing, subjects drilled in a 50 pcf block and were informed that it was the hardest block. The experiment then proceeded sequentially, with the first round involving free-hand drilling on seven models, and the second round using the other seven models for fully guided drilling with a stent. After completing each drilling, subjects evaluated the density using a Visual Analog Scale (VAS), represented by a 10 cm line.Statistical Analysis:The VAS data for each drilling and the corresponding density of the test blocks were recorded using Microsoft EXCEL (V14.1) and SPSS (IBM SPSS Statistics V19.0). Descriptive statistical analysis was performed on the VAS values for freehand drilling and fully guided drilling. A paired t-test was used to assess whether there was a significant difference in the average VAS values for the same density. And the accuracy of the bone block density order was analyzed by using the McNemar test. All statistical analyses were considered significant at p < 0.05.Results:The experimental data were normally distributed. There was a significant difference in the classification of bone block density when using fully guided stents compared to freehand drilling, with the VAS values for fully guided stents being higher than those without stents. However, there was no statistically significant difference in the correct rate of bone density sequence with the use of fully guided surgical stents.Conclusion:Using fully guided stents significantly affects the classification of bone density, often leading to an overestimation of bone density values. However, the use of fully guided stents does not affect the correct rate of bone density order.