SYSTEMATIC REVIEW

Artificial intelligence applications in implant dentistry:

A systematic review
Marta Revilla-León, DDS, MSD,a Miguel Gómez-Polo, DDS, PhD,b Shantanu Vyas,c
Basir A. Barmak, MD, MSc, EdD,d German O. Galluci, DMD, PhD,e Wael Att, DDS, Dr Med Dent, PhD,f and
Vinayak R. Krishnamurthy, PhDg
Several domains of science ABSTRACT
and engineering have been Statement of problem. Artificial intelligence (AI) applications are growing in dental implant
influenced by artificial intelli- procedures. The current expansion and performance of AI models in implant dentistry
gence (AI) and machine applications have not yet been systematically documented and analyzed.
learning. While AI is a general Purpose. Thepurposeofthissystematicreview wasto assess theperformanceofAImodelsinimplantdentistry
term that is used for the study, for implant type recognition, implant success prediction by using patient risk factors and ontology criteria, and
development, and investiga- implant design optimization combining finite element analysis (FEA) calculations and AI models.
tion of any computer system Material and methods. An electronic systematic review was completed in 5 databases: MEDLINE/
that exhibits “intelligent PubMed, EMBASE, World of Science, Cochrane, and Scopus. A manual search was also conducted. Peer-
behavior,”1,2 machine learning reviewed studies that developed AI models for implant type recognition, implant success prediction,
is a special branch of AI where and implant design optimization were included. The search strategy included articles published until
February 21, 2021. Two investigators independently evaluated the quality of the studies by applying
the system learns specific sta- the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies
tistical patterns in a given data (nonrandomized experimental studies). A third investigator was consulted to resolve lack of consensus.
set to predict the behavior of
Results. Seventeen articles were included: 7 investigations analyzed AI models for implant type
new data samples. In AI, recognition, 7 studies included AI prediction models for implant success forecast, and 3 studies
typically, one is concerned evaluated AI models for optimization of implant designs. The AI models developed to recognize
with “intelligent agents” or implant type by using periapical and panoramic images obtained an overall accuracy outcome
agents that have both flexi- ranging from 93.8% to 98%. The models to predict osteointegration success or implant success by
bility and autonomy of action.3 using different input data varied among the studies, ranging from 62.4% to 80.5%. Finally, the
Examples of AI systems such studies that developed AI models to optimize implant designs seem to agree on the applicability of
AI models to improve the design of dental implants. This improvement includes minimizing the
as expert systems, methods for
stress at the implant-bone interface by 36.6% compared with the finite element model; optimizing
dimensionality reduction, and the implant design porosity, length, and diameter to improve the finite element calculations; or
probabilistic models capture accurately determining the elastic modulus of the implant-bone interface.
some important aspect of the
Conclusions. AI models for implant type recognition, implant success prediction, and implant design
data set. Of those, machine
optimization have demonstrated great potential but are still in development. Additional studies are
learning systems offer a rich indispensable to the further development and assessment of the clinical performance of AI models
variety of algorithms and for those implant dentistry applications reviewed. (J Prosthet Dent 2021;-:---)

a
Assistant Professor and Assistant Program Director AEGD Residency, Department of Comprehensive Dentistry, College of Dentistry, Texas A&M University, Dallas, Texas;
and Affiliate Faculty Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash; and Researcher at Revilla
Research Center, Madrid, Spain.
b
Associate Professor Department of Conservative Dentistry and Prosthodontics, School of Dentistry, Complutense University of Madrid, Madrid, Spain.
c
Graduate Research Assistant, J. Mike Walker ’66 Department of Mechanical Engineering, Texas A&M University, College Station, Texas.
d
Assistant Professor Clinical Research and Biostatistics, Eastman Institute of Oral Health, University of Rochester Medical Center, Rochester, NY.
e
Raymond J. and Elva Pomfret Nagle Associate Professor of Restorative Dentistry and Biomaterials Sciences and Chair of the Department of Restorative Dentistry and
Biomaterials Science, Harvard School of Dental Medicine, Boston, Mass.
f
Professor and Chair Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, Mass.
g
Assistant Professor, J. Mike Walker ’66 Department of Mechanical Engineering, Texas A&M University, College Station, Texas.

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This systematic review aimed to analyze the perfor-

Clinical Implications mance of AI models in implant dentistry to identify
Artificial intelligence algorithms can provide a implant type by using periapical and panoramic radio-
graphs, to develop prediction models for osteointegration
powerful diagnostic tool to identify dental implants
and forecast implant success, and to optimize implant
by using radiographical images, predict implant
designs.
survival, or assist and optimize dental implant
designs.
MATERIAL AND METHODS
A population or problem, intervention, comparison,
methods particularly suited for complex prediction tasks outcome (PICO) question was formulated. The popula-
by training the algorithms to recognize and capture sta- tion included the clinical applications in implant dentistry
tistical patterns in a given data set (that is, the training for implant type recognition, osteointegration success or
data set).4 The primary goal of machine learning is to be implant success prediction by using patient risk factors
able to recognize similar patterns in new data (test data) and ontology criteria, and implant designs optimization
for various applications, including classification, regres- by combining FEA calculations and AI models. The
sion, and clustering.5 intervention included artificial intelligence models. The
Two distinct types of training are used in machine comparison was determined as nonapplicable.
learning algorithms: supervised and unsupervised.5 Tasks The outcome was the AI model performance for recog-
such as classification (determining the category of a given nition of the implant type, forecast of the implant success
data point) and regression (finding a numerical rela- by using patient risk factors and ontology criteria, and
tionship between a set of independent and dependent optimization of implant designs by combining FEA cal-
variables) are typically achieved through supervised culations and AI models.
training where the learning model is fed a set of input- Five databases were accessed without any date re-
output pairs of training data. Tasks such as clustering striction: MEDLINE/PubMed, Embase, World of Science,
and dimensionality reduction, however, are usually Cochrane, and Scopus. Additionally, a manual search
accomplished through unsupervised training where the was completed (Table 1). The search strategy included
objective is simply to capture the important features in a articles published until February 21, 2021. All titles and
given data set.6 A special class of machine learning that abstracts were evaluated for criteria which included
has become popular recently is deep learning, which is an clinical or in vitro studies that assessed the performance
advanced methodology based on artificial neural net- of the AI models for implant type recognition, models to
works.7,8 Deep learning has found applications in many determine osteointegration success or implant success
domains of engineering, health care, and data analytics in prediction by using patient risk factors and ontology
general because of its exceptional ability for generaliza- criteria, and implant design optimization by combining
tion.6,9 In this article, a detailed review of a wide variety FEA calculations and AI models. This systematic review
of machine learning methods is provided as applied to conformed to the Preferred Reporting Items for Sys-
implant dentistry. tematic Reviews and Meta-Analyses (PRISMA)
In 2003, a systematic search found over 2000 types of guidelines.25
dental implants.10 The broad variability of dental implant The full text of the articles was evaluated according to
types presents a challenging problem for dental pro- the previously defined inclusion criteria. Studies not
fessionals.10,11 Different AI models have been developed related to AI models; articles that evaluated AI applica-
for image recognition of the implant type by using peri- tions but not for dental disciplines; investigations that
apical and panoramic radiographs.12,13 Furthermore, AI examined AI models but not related with implant
models have also used dental radiographs to diagnose dentistry, such as radiology, periodontics, endodontics,
different lesions such as periodontal disease14-17 or pediatric dentistry, maxillofacial surgery, and orthodon-
dental caries.18-23 Similarly, AI applications have been tics; review articles of AI applications; letters to editors;
reported for developing prediction models to determine posters; AI models for tooth segmentation purposes;
osteointegration success or implant prognosis by using studies associated with dental robotics; age estimation
patient risk factors and ontology criteria, as well as model studies; and augmented reality applications were
optimizing dental implant designs by combining finite considered ineligible.
element analysis (FEA) calculations and AI models.24 Two calibrated reviewers (M.R.-L., M.G.-P.) gathered
However, an analysis of the development performance the data from the included articles into tables. Dis-
of AI methodology and its potential influence on implant agreements were resolved by consensus with a third
dentistry is lacking. examiner (V.R.K.). The quality of the investigations was

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Table 1. Boolean search strategy formulated on 5 databases investigated

Database MeSH Terms and Search Terms
MEDLINE/PubMed (“dental implants” [MeSH] OR “dental prostheses, implant-supported" [MeSH] or “Dental implant, single tooth” [MeSH] OR “Alveolar bone loss”
[MeSH] or “alveolar bone” or “dental implant” OR “dental prostheses implant-supported”) AND (“Artificial intelligence" [MeSH] OR
“Computational Intelligence"OR “Machine Intelligence” OR “Computer Reasoning” OR “AI-based” OR “Computer Vision Systems” OR
“Knowledge Acquisition” OR “Knowledge Representation” OR “Machine learning" [MeSH] OR “Deep learning" [MeSH] OR “Supervised machine
learning" [MeSH] OR “Unsupervised Machine Learning" [MeSH] OR “Expert systems" [MeSH] OR “Fuzzy Logic" [MeSH] OR “Natural Language
Processing" [MeSH] OR “Neural Networks, Computer" [MeSH])
Embase, World of (“dental implants” OR “dental prostheses implant-supported” OR “Dental implant, single tooth” OR “Alveolar bone loss” OR “alveolar bone” OR
Science, Cochrane, and “dental implant” OR “dental prostheses implant-supported”) AND (“Artificial intelligence” OR “Computational Intelligence” OR “Machine
Scopus Intelligence” OR “Computer Reasoning” OR “AI-based” OR “Computer Vision Systems” OR “Knowledge Acquisition” OR “Knowledge
Representation” OR “Machine learning” OR “Deep learning” OR “Supervised machine learning” OR “Unsupervised Machine Learning” OR “Expert
systems” OR “Fuzzy Logic” OR “Natural Language Processing” OR “Neural Networks, Computer”) NOT (MEDLINE)

Table 2. Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies (nonrandomized experimental studies)
Question Answer
1 Is it clear in the study what is the ‘cause’ and what Yes, No, Unclear, or Not
is the ‘effect’ (that is, there is no confusion about which variable comes first)? applicable
2 Were the participants included in any similar comparisons?
3 Were the participants included in any comparisons receiving similar treatment/care other than the exposure or intervention of
interest?
4 Was there a control group?
5 Were there multiple measurements of the outcome both before and after the intervention/exposure?
6 Was follow-up complete and, if not, were differences between groups in terms of their follow-up adequately described and
analyzed?
7 Were the outcomes of participants included in any comparisons measured in the same way?
8 Were outcomes measured in a reliable way?
9 Was appropriate statistical analysis used?

assessed by applying the Joanna Briggs Institute (JBI) risk factors and ontology criteria (Supplementary Table 2,
Critical Appraisal Checklist for Quasi-Experimental available online),33-39 and implant design optimization by
Studies (nonrandomized experimental studies) combining FEA calculations and AI models
(Table 2).26 Similarly, the third examiner (V.R.K.) was (Supplementary Table 2, available online).40-42
consulted to resolve lack of consensus. The overall accuracy outcome of the AI models
developed in the different reviewed studies ranged
RESULTS from 93.8% to 98%.13,27-32 The AI models to predict
osteointegration or implant success by using different
The search strategies yielded 207 studies. A total of 21 input data varied among the studies ranging from
duplicates were found. The 186 remaining articles were 62.4% to 80.5%.33-39 Finally, the studies that developed
evaluated by the titles and abstracts. Twenty-six articles AI models to optimize implant designs seem to agree
were identified for full-text revision. Nine articles were on the applicability of AI models to improve implant
excluded after full-text review, 2 excluded articles designs, minimizing the stress at the implant-bone
exposed a conceptual methodology, 1 applied AI models interface by 36.6% compared with the FEA model,40
for implant placement accuracy improvement evaluation optimizing the implant design porosity, length, and
by using robotics, 2 articles did not describe the AI diameter, improving the FEA calculations,41 or accu-
model, 1 study applied AI models to improve the data rately determining the elastic modulus of the implant-
search on systematic reviews, 2 studies used an AI model bone interface.42
to predict future developments by clustering patents and With respect to the selection of articles by reviewing
clinical implant studies, and 1 investigation was not their titles and abstracts, there was significant agreement
related to AI (Fig. 1). between the 2 investigators for the articles that were
Seventeen articles published between 2005 and 2020 selected (Cohen Kappa value=0.97, P<.001) and the ar-
were included in the present investigation (Fig. 2). The AI ticles that were not selected (Cohen Kappa value=0.97,
models used among the different studies are presented in P<.001). With respect to the selection of articles by
Table 3. The selected articles were distributed into 3 reviewing their full text, there was a significant agree-
groups depending on the application of the AI model: ment between the 2 investigators for the articles that
implant type recognition (Supplementary Table 1, avail- were selected (Cohen Kappa value=1, P<.001) and the
able online),13,27-32 models to determine osteointegration articles that were not selected (Cohen Kappa value=1,
success or implant success prediction by using patient P<.001).

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Identification
207 studies identified data base searching
Pubmed: 43
Embase: 48
21 duplicated eliminated:
Web of science: 48
- Pubmed: 0
Scopus: 61
- Embase: 0
Cochrane: 5
- Web of science: 16
Hand search: 2
- Scopus: 5
- Cochrane: 0
- Hand search: 0
Screening
185 studies identified data base searching 160 studies excluded due to the following:
Pubmed: 43 - 11 AI studies related to another disciplines,
Embase: 48 not dentistry related.
Web of science: 32 - 49 AI studies related to another dental
Scopus: 56 disciplines, not following the inclusive criteria.
Cochrane: 5 Such as endodontics, maxillofacial surgery,
Hand search: 1 radiology, orthodontics, pediatric dentistry,
Periodontology, and restorative dentistry.
- 8 AI for enhancement of radiographic images
Eligibility
- 9 robotics in dentistry
26 studies of full text assessed for eligibility - 19 AI for segmentation
Pubmed: 6 - 2 age estimation models
Embase: 1 - 1 augmented reality
Web of science: 5 - 59 dental studies, not related with AI.
Scopus: 12 - 1 poster
Cochrane: 0 - 1 letter to editor
Hand search: 2
9 studies were excluded due to the following
criteria:
Included - 4 AI model not described
- 1 AI model for robotics
- 2 conceptual description of AI method
- 1 AI model to improve systematic reviews
17 studies included in systematic review search
- 1 AI not for implant recognition, prediction
of implant success or optimization of implant
designs

Figure 1. PRISMA flow diagram with information through phases of study selection.

Article Year
7
6
6

5
Num. Articles

3
2 2
2
1 1 1 1 1 1 1
1

0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Implant prediction Optimization implant design Implant type recognition

Figure 2. Number of included articles by year and purpose of artificial intelligence model.

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Table 3. Artificial intelligence models used in articles included in systematic review

Classical Machine Learning Artificial Neural Networks
Regression analysis: Estimates the relationship among variables. Artificial neural networks or neural networks: Linked units named
 Support Vector Machine (SVM) (classification)33-39 artificial neurons which receives and processes a signal. The connections
 Support Vector Regression (SVR)40 are called edges. Neurons are usually collected into layers.
 k-Nearest Neighbors (k-NN) (supervised learning, classification)13,36,37,39  Naïve Bayes37
 k-Means clustering (clustering)36  Deep Convolutional Neural Networks (CNN)27-32
Decision tree learning: Prediction model using classification tree34,35  Residual Neural Network30,32
 Random forest33  Artificial Neural Networks (ANN)33,37-39,41,42

Logistic regression (LR): Used as a classification model33,35

Multidimensional unfolding analysis (MDU)36
Ensemble-based models: Combination of different models to improve
accuracy (such as, Bagging, Adaboost)35,37

The JBI Critical Appraisal Checklist for Quasi- with the prosthetic part was visible on the radiographical
Experimental results showed a 100% low risk of bias images; therefore, comparisons among the different
in all included articles for question 8. For question 1, all studies are difficult.
the studies obtained a low risk of bias except for that of All the reviewed studies that developed AI models for
Morais et al13 that obtained a high risk of bias. For implant type recognition used 2-dimensional (2D) radi-
question 4, all the investigations attained a low risk of ography as the input data set. A diversity of deep CNN
bias except for those of Hadj Saïd et al,27 Papantono- architectures has been dedicated and trained by using 3-
poulos et al,36 Zaw et al,42 Sukegawa et al,29 Ha et al,34 dimensional (3D) computed tomographic images.43,44
Morais et al,13 Takahashi et al,32 and Kim et al30 that Two-dimensional images including periapical and
showed a high risk of bias. For question 9, all the panoramic radiographs are more distorted than 3D scans.
studies displayed a low risk of bias except for that of Even though clinicians normally obtain periapical radio-
Zaw et al42 that did not have statistical analysis. As no graphs for the radiographic evaluation of dental implants,
specific in vitro study quality assessment tool has been the inclusion of cone beam computed tomography
developed, questions 2 and 6 of the JBI were not (CBCT) images might aid in the AI development for the
applicable in this systematic review. Questions 3, 5, and recognition of dental implant types. All the included
7 were not applicable for any of the included studies studies used CBCT images to develop the AI model.
(Fig. 3). Considering the broad implant types available in
the market,10 limited implant types were analyzed in
different reviewed studies. Furthermore, implant de-
DISCUSSION
signs can be different from each other, facilitating AI
The number of publications that use AI models for recognition among the different implant types analyzed
implant dentistry applications has risen notably since in a study, while other implant designs are similar,
2018. The year ranged from 2005 to 2020, with very few which may require a data base large enough to train
publications before 2005. the AI model to differentiate them. However, the
A total of 7 included studies developed AI models for overall accuracy outcome of the AI models developed
implant type recognition. Except 1 study that used in the different reviewed studies ranged from 93.8% to
regression analysis k-nearest neighbors (k-NN), all the 98%.13,27-32
studies selected developed a convolutional neural Lee and Jeong28 used a data set of 10 770 radio-
network (CNN) d a deep neural network algorithm for graphic images from 3 different implant types to train a
image recognition and classification by using as an input deep CNN model. The authors compared the implant
radiographical data such as periapical27,28,30,31 and recognition capabilities of the examiners (board-certified
panoramic images -,27-29,31,32 or the type of radio- periodontists and the AI model) and of the radio-
graphical data was not provided.13 The efficacy compar- graphical image used: periapical, panoramic, or both
isons among the different AI models used are difficult images. Implant recognition accuracy varied among the
because of the data input or methods used on the studies 3 types of implants tested, but higher specificity and
reviewed. While each study attempted to standardize the sensitivity were found when both periapical and pano-
collection of the radiographical data set, differences ramic images were used for both the AI model and the
among the studies were identified, including projection periodontists.
geometry, exposure factors, film contrast, and film speed. While in other medicine specialties different regis-
Furthermore, variations on the radiographic information tering strategies have developed orthopedic records,45
differed among the reviewed studies where the implant one of the current limitations in implant dentistry is the
by itself (with a cover screw or a healing abutment) or absence of available data records which can facilitate AI

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D1 D4 D8 D9 Overall
Hadj Saïd et al, 2020 + × + + –
Lee et al, 202028 + + + + +
Li et al, 2019 + + + + +
Papantonopoulos et al, 2017 + × + + –
Zaw et al, 2009 + × + ? –
Zhang et al, 2020 + + + + +
Q1
Sukegawa et al, 2020 + × + + – Q4
Q8
Ha et al, 2018 + × + + – Q9
Overall
Roy et al, 2018 + + + + + 0% 25% 50% 75% 100%
Morais et al, 2015 × × + + – Low Unclear High No information
Oliveira et al, 200538 + + + + +
Oliveira et al, 200539 + + + + +
Moayeri et al, 2016 + + + + +
Lee et al, 202031 + + + + + Judgement
D1: Q1 + Low
Takahashiet al, 2020 + × + + –
D4: Q4 – Unclear
Kim et al, 2020 + × + + – D8: Q8 × High
Liu et al, 2018 + + + + + D9: Q9

Figure 3. Joanna Briggs Institute JBI Critical Appraisal Checklist for Quasi-Experimental evaluation.

model development and training on implant recognition. not include the implant type used, a definition of implant
However, the clinical applicability of such an AI appli- success, implant prosthesis design, and genetic, immu-
cation would help clinicians trying to restore an unknown nological, or microbiological variables, which might have
implant. Furthermore, clinicians that have less clinical impacted the results. Because of methodological dis-
experience in implant dentistry may obtain assistance by crepancies, comparisons among the different studies
using an implant recognition software program. were not feasible.
A total of 7 included studies aimed to develop AI Papantonopoulos at al36 aimed to cluster de-
models to predict implant success by using a broader mographic, clinical, and radiographic data from 72 pa-
variety of AI models compared with the implant recog- tients with 237 implants and recognize potential implant
nition AI application. The main AI models used were “phenotypes” and forecasters of bone levels around
regression analysis (support vector machine classifica- implants. The AI model produced an implant map
tion), decision tree learning, logistic regression, and establishing the existence of 2 distinct implant clusters,
classifier neural network.33-39 However, because of a high which the authors identified as 2 possible types of
variation in the methodologies among the different implant “phenotypes,” namely implant phenotype with
studies, comparisons among the obtained results are susceptibility or resistance to peri-implantitis. The inter-
difficult. pretation of the data is interesting, as the AI model was
Prediction models are based on clustering data and developed by using the data obtained from 1 private
investigating the structural properties of the data network practice which might not represent the general popula-
generated by intricate relations of demographic, radio- tion. The limited data and measurements collected by 1
graphical, and clinical variables. Therefore, the prediction periodontist, the restricted patient follow-up period of 2
AI algorithm is assembled based on the input data pro- years, or implants placed with bone grafting procedures
vided. Most of the included studies used demographic were excluded. The difficulty of obtaining data to develop
data, physical and intraoral conditions, lifestyle, anatomic and train AI models is a challenge for researchers,
condition of the area receiving the implant, implant limiting the faster development of AI models in implant
placement with or without bone grafting procedures, dentistry.
bone levels around the implant measured by using per- Three included studies applied AI models for implant
iapical radiographs, or characteristics of the prosthesis as design optimization by using finite element analysis
an input. Furthermore, most of the reviewed studies did (FEA) methods.40-42 Li et al40 replaced the FEA model

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with an AI algorithm to compute the stress at the 4. The studies that developed AI models to optimize
implant-bone interface by considering 3 implant design implant designs seem to agree on the applicability of
variables, namely the implant length, thread length, and AI models to improve implant designs, minimizing
thread pitch. The AI model sought to optimize the the stress at the implant-bone interface by 36.6%
implant design variables to minimize the stress at the compared with the FEA model, optimizing the
implant-bone interface. The results of this study showed implant design porosity, length, and diameter,
a reduction of 36.6% of the stress at the implant-bone improving the FEA calculations, or accurately
interface compared with the FEA model. Roy et al41 determining the elastic modulus of the implant-
aimed to optimize the implant design porosity, length, bone interface.
and diameter by using an artificial neural network
(ANN) combined with genetic algorithms by substitut- REFERENCES
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