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In Vitro Comparison of Surgical Implant Placement Accuracy Using Guides Fabricated by Three Different Additive Technologies

Appl. Sci. 2020, 10(21), 7791; https://doi.org/10.3390/app10217791

by Chuchai Anunmana¹, Chananchida Ueawitthayasuporn², Sirichai Kiattavorncharoen³ and Prakan Thanasrisuebwong^4,*

Reviewer 1: Anonymous

Reviewer 2: Anonymous

Reviewer 3: Anonymous

Appl. Sci. 2020, 10(21), 7791; https://doi.org/10.3390/app10217791

Submission received: 22 September 2020 / Revised: 16 October 2020 / Accepted: 20 October 2020 / Published: 3 November 2020

(This article belongs to the Special Issue Current Trends and Applications of Digital Technology in Dentistry)

Round 1

Reviewer 1 Report

This is a well-written manuscript with the exception of overuse of the word "more over". There is no need for this term. The scientific approach and study design is appropriate however, I have raised some thought provoking questions for authors to consider not to change their minds or conclusions but just to consider their descriptions.

p1. line 19. This sentence could be written: Thus, three printing technologies: Stereolithographic (SLA), Digital light processing (DLP), and Polyjet (PJ) were evaluated in this study.

p.2. line 61. Not certain what the authors are trying to say when they mention "Although the effect of each factor currently remains opaque"?

p.2. line 73. Please explain how data collection, data manipulation, and surgical guide fabrication creates errors?

p.6. line 191. When referring to a reference article (Herschdorfer) please place the appropriate number of this article from the reference list? Herschdorfer's study (16) or was there another study by Herschdorfer?

p.7. line 207. Please list the factors that were minimized and using what techniques to minimise the confounding factors?

p.7. line 211. Yes, but a study using cadavers is also absent of saliva, blood and movement

Author Response

RESPONSES TO REVIEWER

Reviewer 1

Comment: This is a well-written manuscript with the exception of overuse of the word "more over". There is no need for this term. The scientific approach and study design is appropriate however, I have raised some thought provoking questions for authors to consider not to change their minds or conclusions but just to consider their descriptions.

Response: We truly appreciate the kind comment and suggestion.

Text Change: All “moreover” was removed or changed to other words.

p1. line 19

Comment: This sentence could be written: Thus, three printing technologies: Stereolithographic (SLA), Digital light processing (DLP), and Polyjet (PJ) were evaluated in this study.

Response: We appreciate the suggestion.

Text change: The sentence was changed per suggested. Line 19

p.2. line 61

Comment: Not certain what the authors are trying to say when they mention "Although the effect of each factor currently remains opaque”?

Response: We appreciate the insight. There are a limited number of studies that evaluated these factors such as layer thickness, material quality, cast orientation, 3D model shape, and software and hardware capabilities, so the effects of them are still unclear. However, we consider to change the sentence to avoid confusion.

Text change: The sentence is now read

Line 60

“Although the effect of each printing factor currently remains unclear…”

p.2. line 73

Comment: Please explain how data collection, data manipulation, and surgical guide fabrication creates errors?

Response: We truly appreciate the kind comment.

Text change: The following statement was added.

Line 73

“For instance, the data collection of guided surgery may have an error inaccuracy from the superimposition method. The post-surgical CBCT if not superimposed properly can lead to measurement error. These data are often further analyzed statistically in different plans and can be subjected to multiple comparisons. Different guide fabrication methods, 3D printing or milling, along with guide positioning intramurally and experience of surgeons in the placement of drills can also affect the accuracy of implant placement.”

p.6. line 191

Comment: When referring to a reference article (Herschdorfer) please place the appropriate number of this article from the reference list? Herschdorfer's study (16) or was there another study by Herschdorfer?

Response: We appreciate the reviewer for raising the question. The study by Herschdorfer et al published in J Prosthet Dent has concluded that “The different types of 3D printing technology used in this study did not appear to have a significant effect on the accuracy of guided implant surgery.” Their results were consistent with our study. We have corrected already. Thank you for pointing it out.

Text change: None.

p.7. line 207

Comment: Please list the factors that were minimized and using what techniques to minimise the confounding factors?

Response: We appreciate the opportunity to give the readers clarity on this issue.

Text change: The following clarification statement was added.

Line 221

“To minimize confounding factors, we utilized that same guide design, drill protocol, surgeon, and the same type of surgical models. The implant placement using different printed guides was also done at random to minimize the drilling memorization of the surgeon.”

p.7. line 211

Comment: Yes, but a study using cadavers is also absent of saliva, blood and movement.

Response: We agree.

Text change: Additional information was added and the sentence was amended as following.

Line 226

“Besides, the advantage of an in vitro study compared to an in vivo one was the absence of patient movement, saliva, or blood.”

Author Response File: Author Response.docx

Reviewer 2 Report

Dear Authors ,

your manuscript deals with a very interesting and actual topic for dental implant surgeons.

The aim of your in vitro research is well defined, and the research design is clearly described.

Regarding the methods, you analyzed the following parameters: central deviation at implant entry point and apex, and mean angulation deviation. Could you explain in method section why depth deviation is not considered?

Results are clearly described and easy to read.

Discussion and conclusion are supported by the results

Moreover I suggest:

a) to improve english language and style, especially in the Introduction section.

b) to add the following references:

Kernen F, Kramer J, Wanner L, Wismeijer D, Nelson K, Flügge T. A review of virtual planning software for guided implant surgery - data import and visualization, drill guide design and manufacturing.BMC Oral Health. 2020 Sep 10;20(1):251. doi: 10.1186/s12903-020-01208-1.

Bencharit S, Staffen A, Yeung M, Whitley D 3rd, Laskin DM, Deeb GR.In Vivo Tooth-Supported Implant Surgical Guides Fabricated With Desktop Stereolithographic Printers: Fully Guided Surgery Is More Accurate Than Partially Guided Surgery.J Oral Maxillofac Surg. 2018 Jul;76(7):1431-1439. doi: 10.1016/j.joms.2018.02.010.

Derksen W, Wismeijer D, Flügge T, Hassan B, Tahmaseb A.The accuracy of computer-guided implant surgery with tooth-supported, digitally designed drill guides based on CBCT and intraoral scanning. Clin Oral Implants Res. 2019 Oct;30(10):1005-1015. doi: 10.1111/clr.13514.

After these changes I'll suggest the Editor to consider your manuscript suitable for publication.

Kind Regards

Author Response

RESPONSES TO REVIEWER

Reviewer 2

Comment:

Your manuscript deals with a very interesting and actual topic for dental implant surgeons.

The aim of your in vitro research is well defined, and the research design is clearly described.

Response: We appreciate this important insight. We also agree with the reviewer that implant vertical displacement or deviation can be an important factor. However, we chose not to examine the vertical dimension because of the nature of model we used. The model used here had no soft tissue. The soft tissue in humans would allow the seating of the vertical placement of implants slightly further than solid model. We feel that vertical displacement may not reflective of vertical displacement in humans.

Text change: None.

Comment:

Results are clearly described and easy to read.

Discussion and conclusion are supported by the results

Response: We appreciate the comment.

Text change: None.

Moreover I suggest:

Comment:

a) to improve English language and style, especially in the Introduction section.

Response: We truly appreciate the comments. English editing was performed throughout the manuscript.

Text change: English editing.

Comment:

b) to add the following references:

Response: We appreciate this comment and important references.

Text change: The references were added according to the suggestion. The reference numbering was also revised.

We added the reference to line 33. “Over the last few decades, computer-aided design (CAD) and computer-aided manufacturing (CAM) has been improved significantly for dental applications”

We added the reference to line 231. “When there are sufficient bone and keratinized mucosa, fully-guided surgery is the most precise approach for flapless surgery, which can decrease chair time, comparing to a free-handed approach or pilot-drill, half-guided surgery”

We added the reference to line 228. “Additionally, for surgical guide design, this experiment used tooth-support surgical guides, which showed less deviation of implant position

Author Response File: Author Response.docx

Reviewer 3 Report

The authors conducted an in vitro study to evaluate the deviation of implant position between surgical guides fabricated with three different additive procedures: SLA, DLP, and PolyJet, as well as the total processing time of these 3D printers.

The study design is very simple and manageable. The manuscript is well written and scientifically sound and the results are very intersecting for the digital community of the dental implantology. I have some minor points to be added/changed as following:

Title: be concise and add that the study conducted to test three different technologies.

Abstract: Li 56-26 its not clear which system was accurate please revise the sentences.

Introduction: Li 77-79: add more rationals for conducting this study and the differences between the published studies and yours. what is the clinical relevance by conducting this study?

Materials and Methods: Sample calculation has not been demonstrated.

Results: do you find any statistical significant regarding the printing time

Discussion: Add the limitations and the future step of this research.

Author Response

RESPONSES TO REVIEWER

Reviewer 3

Comment:

Title: be concise and add that the study conducted to test three different technologies.

Response: We appreciate the insight.

Text change: The tile is now read.

Line 2

“In vitro comparison of surgical implant placement accuracy using guides fabricated by three different additive technologies”

Comment:

Abstract: Li 56-26 its not clear which system was accurate please revise the sentences.

Response: We agreed with the reviewer.

Text change: The text is now read.

Line 25

“For the 3D deviation, PolyJet was statistically more accurate than DLP (p = 0.002) and SLA (p = 0.017) at the entry point. PolyJet is also statistically more accurate than DLP (p = 0.007) in regards to 3D deviation at the apex.”

Comment:

Introduction: Li 77-79: add more rationals for conducting this study and the differences between the published studies and yours. what is the clinical relevance by conducting this study?

Response: We appreciate the insight.

Text change: Additional sentence on clinical relevancy was added.

Line 83

“Clinicians currently have no idea if these printers would produce the same accuracy for their implant guides and often choose a printer without knowing the accuracy of printed products. Thus, the study aimed to evaluate the deviation of implant position among SLA, DLP, and PolyJet 3D printer as well as the total processing time of these 3D printers. The outcome would assist in 3D printer selection among these common printing technologies”

Comment:

Materials and Methods: Sample calculation has not been demonstrated.

Response: In general, the in vitro study sample size of n=10 was used similar to previous studies such as Deeb et al 2017.

Deeb GR, Allen RK, Hall VP, Whitley D 3rd, Laskin DM, Bencharit S. How Accurate Are Implant Surgical Guides Produced With Desktop Stereolithographic 3-Dimentional Printers? J Oral Maxillofac Surg. 2017 Dec;75(12):2559.e1-2559.e8. doi: 10.1016/j.joms.2017.08.001. Epub 2017 Aug 5. PMID: 28863884.

Text change:

Line 92

“The sample size was chosen based on a previous study [17] that used 10 samples per study group. For this study, the entire 30 samples were made by using a standard maxillary dentoform as a template”

Comment:

Results: do you find any statistical significant regarding the printing time

Response: We appreciate your kind concern. The printing time cannot be tested for statistical significance. The models were printed altogether at once for each printer. Thus, there is no distribution of printing time and cannot be used to compute p-values.

Text change: None

Comment:

Discussion: Add the limitations and the future step of this research.

Response: We truly appreciate the comments. We added limitations along with the future step regarding the scope of the type of 3D printers.

Text change:

Line 255

“Apart from the surgical procedure, due to the roughness surface of the sleeve or resin interface as well as the offset setting, placing of the guide sleeve into the surgical guide probably contribute to another aspect affecting the implant deviation. Also, differences in post-processing recommendations and instruments may influence on the surface of the surgical guide [37].”

Author Response File: Author Response.docx

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In Vitro Comparison of Surgical Implant Placement Accuracy Using Guides Fabricated by Three Different Additive Technologies

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