Article Type : Research Article
Authors : Sevil FE and Panahi O
Keywords : Artificial intelligence; Machine learning; Orthognathic surgery; Dental implants; Periodontics; Robotics; Deep learning
The
integration of artificial intelligence (AI) into oral and maxillofacial
surgery, dental implantology, and periodontology represents a paradigm shift in
contemporary dental practice. This comprehensive review synthesizes current
evidence on AI applications across these three interconnected specialties,
drawing from systematic reviews, scoping reviews, and original research
published between 2018 and 2026. In orthognathic surgery, AI demonstrates
diagnostic sensitivity of 75-95.5% for surgical candidate identification and
achieves sub-millimeter accuracy in soft tissue prediction. In implant
dentistry, robotic-assisted systems and AI-enhanced navigation achieve mean
coronal deviations of 0.45 mm and angular deviations of 0.80°, with autonomous
systems demonstrating superior precision. In periodontology, deep learning
models detect radiographic bone loss and classify periodontitis with accuracies
reaching 98.6%, comparable to or exceeding experienced clinicians. Despite
these advances, significant challenges persist, including methodological
heterogeneity, lack of external validation, algorithmic bias, and ethical
concerns regarding data privacy and clinical accountability. This review
critically appraises the current evidence base, identifies knowledge gaps, and
proposes future research priorities to facilitate safe and effective clinical
translation of AI technologies in oral healthcare.
The convergence of artificial intelligence (AI) with clinical dentistry marks one of the most transformative developments in the history of oral healthcare. Across medical disciplines, AI technologies particularly machine learning (ML) and deep learning (DL) have demonstrated capabilities that rival or surpass human performance in image analysis, predictive modeling, and clinical decision support. Dentistry, with its heavy reliance on radiographic interpretation, treatment planning, and precise surgical execution, is uniquely positioned to benefit from these technological advances [1-24]. The scope of AI applications in dentistry has expanded dramatically over the past decade. From automated cephalometric analysis to robotic-assisted implant placement and AI-driven periodontal risk assessment, these technologies promise to enhance diagnostic accuracy, reduce procedural variability, optimize treatment outcomes, and potentially democratize access to specialized dental care. However, the rapid proliferation of AI research has outpaced the establishment of standardized validation protocols, clinical guidelines, and ethical frameworks necessary for responsible implementation [25-45]. This review focuses on three interconnected domains where AI has demonstrated particular promise: orthognathic and maxillofacial surgery, dental implantology, and periodontology. These specialties share common characteristics that make them amenable to AI augmentation: (1) heavy dependence on three-dimensional imaging and spatial reasoning, (2) complex treatment planning requiring integration of multiple data modalities, (3) significant inter-operator variability, and (4) measurable outcomes that can serve as training targets for supervised learning algorithms [46-56].
Objectives
The primary objectives of this review are to
Fundamentals of Artificial Intelligence in Dentistry
Core
AI Architectures
Contemporary
AI applications in dentistry primarily utilize three architectural paradigms:
Convolutional
Neural Networks (CNNs) represent the dominant architecture for image analysis
tasks. CNNs learn hierarchical feature representations through successive
convolutional and pooling layers, enabling automated detection of pathological
features in radiographs, photographs, and three-dimensional scans.
Architectures such as ResNet, U-Net, and VGG have been extensively applied to
dental imaging tasks [57-77]. Artificial Neural Networks (ANNs) and Deep Neural
Networks (DNNs) extend the CNN paradigm to incorporate additional data
modalities, including clinical parameters, demographic information, and genetic
markers. These architectures excel at nonlinear pattern recognition and outcome
prediction tasks [78-90]. Generative Adversarial Networks (GANs) and related
generative models have emerged as powerful tools for image synthesis, data
augmentation, and surgical simulation, enabling realistic prediction of
post-treatment outcomes.
Training
Paradigms and Data Requirements
The
performance of AI models is fundamentally constrained by the quality, quantity,
and representativeness of training data. Supervised learning wherein models
learn to map inputs to labeled outputs remains the predominant paradigm in
dental AI research. This approach requires large, expertly annotated datasets,
which present significant acquisition and annotation challenges. Transfer
learning, wherein models pretrained on large generic datasets (e.g., ImageNet)
are fine-tuned for specific dental tasks, has partially mitigated data
requirements. However, domain shifts between natural images and dental
radiographs limit the generalizability of this approach [91-103].
Artificial
Intelligence in Maxillofacial and Orthognathic Surgery
Orthognathic
surgery presents unique challenges that make it an ideal application domain for
AI: complex three-dimensional anatomy, aesthetic and functional outcome
considerations, significant surgical variability, and substantial prognostic
uncertainty. Recent systematic reviews have comprehensively mapped AI
applications across the surgical continuum [104-121].
Diagnostic
Applications
Accurate
identification of surgical candidates represents the initial decision point in
orthognathic care. Traditional diagnostic approaches rely on cephalometric
analysis with established normative values, but exhibit significant inter-rater
variability and fail to capture three-dimensional facial aesthetics. Multiple
studies have evaluated AI-based diagnostic classification. Shin and colleagues
developed a CNN model using lateral and posteroanterior cephalograms that
achieved 95.4% accuracy (sensitivity: 84.4%, specificity: 99.3%) in
distinguishing surgical from non-surgical orthodontic cases. Choi et al.
reported a two-layer ANN achieving 96% accuracy for surgery versus non-surgery
classification and 91% overall success across multiple treatment decisions. A
scoping review by Motamedian and colleagues synthesized evidence from 29
studies, reporting diagnostic sensitivities ranging from 75% to 95.5% for
surgical need determination. Notably, AI models demonstrated particular
strength in identifying borderline cases that may benefit from surgical
intervention precisely the scenarios where human judgment exhibits greatest
variability [122-132].
Surgical
Planning and Simulation
AI
applications in surgical planning span automated landmark detection, osteotomy
design, and soft tissue prediction the latter representing perhaps the most
clinically consequential application.
Automated
Landmark Detection: Traditional cephalometric tracing
requires manual identification of 20-30 anatomical landmarks, a time-consuming
process with well-documented inter-operator variability. AI-based systems have
demonstrated comparable or superior accuracy with dramatically reduced
processing time. Reported mean errors for AI landmark detection range from 3.99
to 4.73 mm, representing clinically acceptable precision for most applications.
Soft
Tissue Prediction: Accurate prediction of postoperative
soft tissue changes remains a longstanding challenge in orthognathic planning.
Traditional biomechanical models (e.g., mass tensor modeling) exhibit limited
accuracy, particularly in the lower face and perioral regions. Deep learning
approaches have demonstrated superior performance. Ter Horst and colleagues
compared a DL autoencoder neural network to conventional mass tensor modeling
for predicting soft tissue changes following bilateral sagittal split
osteotomy. The DL model achieved mean absolute errors of 1.0 mm (lower face)
and 1.4 mm (chin) compared to 1.5 mm and 2.0 mm for conventional modeling, with
64.3% of DL predictions falling within 1 mm of ground truth versus 21.4% for
conventional methods [133-145].
Broader
evidence from Motamedian's scoping review indicates soft tissue prediction
success rates ranging from 64.3% to 100% across AI models, with variability
attributable to differences in surgical complexity, prediction targets, and
validation methodologies.
Outcome
Evaluation and Complication Assessment
AI
extends beyond preoperative planning to quantitative outcome assessment.
Studies have applied AI to evaluate postsurgical asymmetry, facial
attractiveness changes, and aesthetic improvements, providing objective metrics
that complement subjective clinical assessment. Complication prediction
represents an emerging application with significant clinical implications.
Published models have achieved 98.7% accuracy for predicting postsurgical
systemic infection and demonstrated mean errors of 7.4 mL for blood loss
estimation. While requiring external validation across diverse populations,
these findings suggest AI may enable personalized risk stratification and
informed consent.
Critical
Appraisal and Evidence Gaps
A
systematic review of AI in oral and maxillofacial cosmetic surgery (14 studies,
n=11,031 initial records) applied the PROBAST-AI risk-of-bias tool and
identified significant methodological limitations. Most studies were
retrospective, single-center, and utilized small or homogeneous datasets.
External validation the critical test of generalizability was largely absent.
The authors concluded that although AI demonstrates strong potential, current
evidence is constrained by methodological weaknesses and limited validation
[146-159].
Specific
deficiencies include: (1) lack of prospective multicenter
studies, (2) absence of standardized outcome metrics, (3) insufficient
attention to model interpretability and clinical explainability, and (4)
failure to report adherence to AI-specific reporting standards (e.g., TRIPOD-AI,
CONSORT-AI).
Artificial
Intelligence in Implant Dentistry
Dental
implantology has emerged as a leading application domain for AI, driven by the
critical importance of precise three-dimensional positioning and the
availability of high-resolution imaging data. AI applications span preoperative
planning, intraoperative navigation, robotic-assisted placement, and long-term
outcome prediction [160-173].
Preoperative
Planning and Diagnostic Support
Traditional
implant planning requires manual segmentation of osseous anatomy,
identification of critical neurovascular structures, and determination of
optimal implant position a process requiring significant expertise and time.
AI-based automation offers substantial efficiency and accuracy gains.
Automated
Segmentation: Convolutional neural networks
demonstrate high accuracy in segmenting alveolar bone from cone-beam computed
tomography (CBCT) data. One study reported 96.4% accuracy for AI-based bone
segmentation, compared to 85% concordance for human experts, with planning time
reduced from 45 minutes to approximately 8 minutes. AI systems also detect
subtle bone defects, including buccal plate deficiencies, with 94% specificity.
Implant
Position Optimization: AI algorithms integrate bone density
mapping, anatomical constraint identification, and prosthetic requirements to
propose optimal implant trajectories. Reported alignment with optimal
trajectories reaches 95%. A systematic review by Vázquez-Sebrango and
colleagues (120 studies) found that 89.2% of AI applications in implant
dentistry utilized deep learning algorithms, predominantly processing image
data (72.0% two-dimensional, 28.0% three-dimensional) [174-185].
Intraoperative
Navigation and Robotics
Perhaps
the most clinically visible AI application in implant dentistry is
robotic-assisted and AI-enhanced navigation systems. These technologies address
limitations of static surgical guides (rigidity, inability to adjust for
intraoperative changes) and traditional dynamic navigation (manual calibration,
susceptibility to movement).
Robotic-Assisted Systems: A comprehensive scoping review of AI-enhanced robotics for dental implant placement identified 27 eligible studies. Pooled analysis demonstrated:
Subgroup analyses indicated that fully autonomous robotic systems achieved the lowest deviation values. Mandibular implant placement demonstrated greater accuracy compared to maxillary and zygomatic sites. When compared to dynamic navigation systems, robotic approaches showed comparable linear deviations but superior angular precision.
AI-Enhanced
Dynamic Navigation: Beyond full robotics, AI integration
into dynamic navigation systems enables real-time adaptive guidance. AI-powered
systems adjust drill paths instantaneously in response to patient movement or
tissue deformation, achieving angular errors as low as 1.2° compared to 3.8° in
traditional dynamic navigation. Tip errors as low as 0.4 mm have been reported,
even in challenging scenarios involving metallic restorations that distort
imaging.
The
Yomi system (Neocis), FDA-cleared in 2017, represents the first commercially
available robotic dental implant system. It provides haptic guidance physical
resistance that constrains drill position and orientation without requiring
surgical guides. Subsequent developments have achieved fully autonomous implant
placement, marking a major advance toward automated implant surgery.
Impact
on Surgical Efficiency: Limited evidence suggests
AI-enhanced navigation may improve procedural efficiency, particularly in
multi-implant cases. Reported time savings include 20-40 minutes reduction in
chair time, enabling higher patient throughput. However, these findings require
confirmation in larger, controlled trials [186-190].
Outcome Prediction and Long-term
Follow-up
AI
extends beyond the surgical episode to prognostic assessment. Predictive models
analyze imaging, biomechanical, and patient-specific data to forecast implant
survival and complications. One study reported 92% accuracy for 5-year implant
survival prediction, outperforming traditional bone density assessments.
Another analysis of 312 implants identified stress patterns associated with
marginal bone loss with 88% sensitivity, enabling targeted follow-up and
preventive intervention.
Critical Appraisal and Limitations
Despite impressive accuracy metrics, the evidence base for AI in implant dentistry has significant limitations. The scoping review by participants reported statistical heterogeneity exceeding 97% (I²) across outcomes, indicating substantial variation that complicates meta-analytic synthesis. This heterogeneity reflects variability in:
Moreover, most evidence derives from in vitro and single-center studies. Long-term clinical data with patient-centered outcomes remain sparse. The systematic review by Vázquez-Sebrango found that 11 of 120 included studies had high risk of bias according to PROBAST assessment.
Artificial Intelligence in
Periodontology
Periodontal
disease affects approximately 50% of adults globally, representing a major
public health burden. Traditional diagnostic approaches periodontal probing,
radiographic assessment, and clinical examination are time-consuming, exhibit
significant inter-examiner variability, and detect disease only after
substantial tissue destruction has occurred. AI offers potential solutions
across the diagnostic and therapeutic continuum
Radiographic Bone Loss Detection
Radiographic
bone loss (RBL) assessment represents the most extensively studied AI
application in periodontology. Deep learning models, particularly CNNs,
demonstrate high accuracy in detecting, quantifying, and classifying alveolar
bone loss from periapical and panoramic radiographs. A
systematic review of deep learning applications in periodontal diagnosis
synthesized evidence from multiple studies. Reported diagnostic accuracies
ranged from 73.0% for alveolar bone loss detection to 98.6% for periodontitis
staging using clinical data. For binary classification of mild (<15%) versus
severe (?15%) bone loss, one study reported average accuracy of
0.87±0.01[191-195]. Lee and colleagues found higher diagnostic
accuracy for premolars (81.0%) compared to molars (76.7%), while Chang and
collaborators reported that classification performance was highest for canines
and premolars and lower for incisors and molars. These tooth-specific
variations highlight the importance of anatomic considerations in model
development and validation.
Disease Classification and Staging
Beyond
simple bone loss detection, AI models have been developed for complete
periodontal classification according to established staging and grading systems
(e.g., AAP/EFP 2017 classification). These models integrate radiographic
findings with clinical attachment loss, probing depth, bleeding on probing, and
patient risk factors. Krois and colleagues demonstrated the
feasibility of cross-center model generalization, while also highlighting
challenges: performance degrades when models are applied to populations or
imaging protocols different from training data. This limitation underscores the
need for diverse, multi-institutional training datasets.
Risk Assessment and Treatment
Planning
AI-enabled risk assessment represents a paradigm shift from reactive to proactive periodontal care. By integrating clinical, radiographic, demographic, behavioral (e.g., smoking), and systemic health data, ML models can identify patients at elevated risk for disease progression before significant tissue destruction occurs. Treatment outcome prediction remains an active research area. AI models have demonstrated potential in forecasting responses to non-surgical periodontal therapy, potentially enabling personalized treatment selection. However, accurate prediction of individual treatment outcomes particularly in complex cases with multiple risk factors or systemic conditions remains challenging [196-204].
Integration with Clinical Workflow
The
practical implementation of AI in periodontal practice raises important
workflow considerations. Automated periodontal charting real-time, chairside AI
analysis of probing depths, bleeding, and recession represents an underexplored
but promising application. Such systems could standardize data collection,
reduce documentation burden, and enable longitudinal disease monitoring.
Critical Appraisal
As
with other domains, periodontal AI research exhibits significant methodological
heterogeneity. A systematic review identified several limitations: (1)
predominance of cross-sectional rather than longitudinal study designs, (2)
lack of standardized data collection and preprocessing protocols, (3)
insufficient attention to model interpretability ("black box"
problem), and (4) limited external validation across diverse populations.
Challenges, Limitations, and
Ethical Considerations
Methodological Challenges
The
current evidence base for AI in dentistry suffers from several interconnected
methodological limitations that complicate clinical translation and evidence
synthesis.
Lack
of External Validation: Most published studies report performance on
convenience samples from the same institution where models were developed.
External validation testing on independent datasets from different populations,
imaging equipment, and clinical protocols is rarely performed. When attempted,
performance typically degrades, revealing limited generalizability [205].
Risk
of Bias: Systematic reviews have consistently identified high risk of bias
across dental AI studies. Common issues include inadequate sample size
justification, lack of blinding between AI predictions and reference standards,
selective outcome reporting, and failure to account for data leakage between
training and test sets.
Heterogeneity:
Marked heterogeneity in study design, outcome definitions, and reporting
standards precludes meaningful meta-analysis for most applications. I²
statistics exceeding 95% are common, reflecting true variation rather than
sampling error.
Algorithmic
Bias: Models trained on homogeneous populations may perform poorly and
potentially cause harm when applied to underrepresented groups. This concern is
particularly acute for AI applications in dentistry, given global variations in
anatomy, disease presentation, and treatment norms.
Clinical Integration Barriers
Several
practical barriers impede clinical adoption:
Interpretability
and Trust: Deep learning models operate as "black
boxes," producing predictions without explanatory mechanisms. This opacity
creates barriers to clinician trust, regulatory approval, and medicolegal
accountability. Explainable AI (XAI) approaches that provide visual
explanations (e.g., saliency maps, attention mechanisms) represent an active
research priority.
Regulatory
Hurdles: AI-based medical devices require regulatory
clearance (FDA, CE mark, etc.) before clinical deployment, a process demanding
rigorous evidence of safety and efficacy. The rapid pace of AI development
creates challenges for traditional regulatory frameworks designed for static
technologies.
Cost
and Accessibility: High implementation costs including
hardware, software licensing, training, and maintenance may exacerbate existing
disparities in access to advanced dental care. AI adoption is concentrated in
wealthy regions and large institutional practices, potentially widening the
oral health gap.
Workflow
Integration: Effective AI implementation requires
seamless integration with existing electronic health records, imaging systems,
and clinical workflows. Poorly designed interfaces may increase rather than
decrease clinical burden.
Ethical
and Legal Considerations
Data
Privacy: AI model training requires large datasets of patient
information, including identifiable images and clinical data. Ensuring
de-identification, secure storage, and appropriate consent presents ongoing
challenges.
Medicolegal
Accountability: When AI systems contribute to clinical
decisions, liability for adverse outcomes becomes ambiguous. Is the clinician
who relied on AI advice responsible? The AI developer? The institution? Current
legal frameworks provide limited guidance.
Informed
Consent: Patients should understand AI's role in their care,
including its capabilities, limitations, and alternatives. What constitutes
adequate disclosure for AI-assisted diagnosis or robotic surgery?
Professional Autonomy: The increasing role of AI in clinical decision-making raises questions about the erosion of professional judgment and the potential deskilling of clinicians who over-rely on automated systems.
Future Directions and Research Priorities
Methodological Recommendations
To advance the evidence base, future research should adhere to established reporting standards:
Multicenter prospective validation studies with diverse populations are urgently needed. Researchers should prioritize external validation before claiming clinical utility.
Technical Priorities
Explainable
AI:
Development of inherently interpretable models or post-hoc explanation methods
that provide clinically meaningful insights into model decision-making.
Multimodal
Integration: Models that integrate radiographic,
clinical, genomic, and patient-reported data for comprehensive assessment
rather than isolated tasks.
Longitudinal
Learning: AI systems capable of learning from sequential patient
data to monitor disease progression and treatment response over time.
Federated
Learning: Training paradigms that enable model development
across institutions without centralized data sharing, addressing privacy
concerns while enabling diverse training data.
Clinical Translation Priorities
Prospective
Clinical Trials: Randomized controlled trials comparing
AI-assisted care to standard care across relevant outcomes (accuracy,
efficiency, patient-reported outcomes, cost-effectiveness).
Implementation
Science: Research on effective strategies for integrating AI
into clinical workflows, including user interface design, training
requirements, and change management.
Health
Economics: Rigorous cost-effectiveness analyses to
guide resource allocation and reimbursement policy.
Surveillance Systems: Post-market monitoring of AI system performance in real-world clinical settings, including detection of performance degradation or emergent biases.
Artificial
intelligence has demonstrated remarkable capabilities across maxillofacial
surgery, implant dentistry, and periodontology. In orthognathic surgery, AI
achieves diagnostic accuracy exceeding 95% and sub-millimeter soft tissue
prediction. In implantology, robotic systems and AI-enhanced navigation achieve
placement deviations below 0.5 mm and 0.8°, exceeding typical freehand
accuracy. In periodontology, deep learning models detect bone loss and classify
disease with accuracy rivaling experienced clinicians. However, the current
evidence base is constrained by significant methodological limitations:
predominance of retrospective single-center studies, lack of external
validation, substantial heterogeneity, and high risk of bias. Claims of AI
superiority over human clinicians are rarely supported by rigorous comparative
trials. The
path forward requires methodological rigor, clinical validation, and regulatory
oversight commensurate with the potential risks of AI deployment. Clinicians
should approach AI adoption with informed skepticism, seeking evidence of
external validation, prospective evaluation, and demonstrated clinical benefit
for their specific patient populations. When responsibly implemented, AI holds
genuine promise to enhance diagnostic accuracy, reduce procedural variability,
optimize outcomes, and expand access to specialized dental care. The
convergence of clinical expertise and artificial intelligence not replacement
of one by the other represents the optimal trajectory for advancing oral
healthcare.