Outcomes-Based Treatment Planning in Endodontics: Applying the Latest Evidence.

A comprehensive understanding of the factors that influence treatment outcomes is crucial in endodontic diagnosis and treatment planning. Having knowledge that takes into account dental and patient-related conditions when choosing procedures can help clinicians maximize the prognosis of natural teeth and reduce postoperative complications. That being said, the landscape of outcome studies in endodontics is continually evolving, presenting a challenge for many clinicians trying to stay current with the latest literature. This article reviews factors that influence the outcomes of the following endodontic therapies: primary root canal treatment, nonsurgical retreatment, and surgical retreatment. An emphasis is placed on the importance of considering preoperative and treatment-related factors as prognostic indicators before developing a treatment plan, with the ultimate goal of enhancing tooth durability and ensuring patient satisfaction.

Microrobotics in endodontics: A perspective.

Microorganisms are the primary aetiological factor of apical periodontitis. The goal of endodontic treatment is to prevent and eliminate the infection by removing the microorganisms. However, microbial biofilms and the complex root canal anatomy impair the disinfection process. Effective and precise endodontic therapy could potentially be achieved using advanced multifunctional technologies that have the ability to access hard-to-reach surfaces and perform simultaneous biofilm killing, removal, and detection of microorganisms. Advances in microrobotics are providing novel therapeutic and diagnostic opportunities with high precision and efficacy to address current biofilm-related challenges in biomedicine. Concurrently, multifunctional magnetic microrobots have been developed to overcome the disinfection challenges of current approaches to disrupt, kill, and retrieve biofilms with the goal of enhancing the efficacy and precision of endodontic therapy. This article reviews the recent advances of microrobotics in healthcare and particularly advances to overcome disinfection challenges in endodontics, and provides perspectives for future research in the field.

The extended finite element method in endodontics: A scoping review and future directions for cyclic fatigue testing of nickel-titanium instruments.

OBJECTIVES: The present study reviews the current literature regarding the utilization of the extended finite element method (XFEM) in clinical and experimental endodontic studies and the suitability of XFEM in the assessment of cyclic fatigue in rotary endodontic nickel-titanium (NiTi) instruments. MATERIAL AND METHODS: An electronic literature search was conducted using the appropriate search terms, and the titles and abstracts were screened for relevance. The search yielded 13 hits after duplicates were removed, and four studies met the inclusion criteria for review. RESULTS: No studies to date have utilized XFEM to study cyclic fatigue or crack propagation in rotary endodontic NiTi instruments. Challenges such as modelling material inputs and fatigue criteria could explain the lack of utilization of XFEM in the analysis of mechanical behavior in NiTi instruments. CONCLUSIONS: The review showed that XFEM was seldom employed in endodontic literature. Recent work suggests potential promise in using XFEM for modelling NiTi structures.

Systemic Corticosteroid Uses in Endodontics-Part 2: Enhancing the Success of Local Anesthesia.

INTRODUCTION: Chronic inflammation in irreversible pulpitis leads to heightened sensitivity of nociceptive receptors, resulting in persistent hyperalgesia. This poses significant challenges in achieving effective anesthesia for patients with irreversible pulpitis. Various anesthetic techniques and pharmacological approaches have been employed to enhance the success of local anesthesia. Recently, the preemptive use of anti-inflammatory agents, specifically corticosteroids, has gained attention and shown promising results in randomized controlled trials. This systemic review and meta-analysis aimed to evaluate the impact of systemically administered corticosteroids on enhancing anesthetic success in patients undergoing endodontic treatment. METHODS: A comprehensive search was conducted across multiple databases including PubMed, Cochrane Library, Embase, Scopus, Dentistry & Oral Science, and ProQuest. Additionally, the references of primary studies and related systematic reviews were manually searched for additional relevant publications. The primary outcome assessed was the success of anesthesia, and the effect measure was risk ratio using the random-effects inverse variance method. Statistical significance was set at P < .05. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Twelve studies involving 917 participants were analyzed to determine the frequency of successful anesthesia. The corticosteroid group demonstrated a significantly higher number of patients achieving successful anesthesia (risk ratio = 1.66; 95% confidence interval, 1.34-2.06;P < .00001). However, heterogeneity within the pooled data analysis was observed (I2 = 57%, P = .007). CONCLUSIONS: Moderate certainty evidence indicates that preemptive use of systemic corticosteroids enhances the success of local anesthesia, specifically inferior alveolar nerve block, in cases of irreversible pulpitis.

Evaluation of a Novel Drilling Approach for Dynamic Navigation-Aided Endodontic Microsurgery: A Surgical Simulation Comparison Study.

INTRODUCTION: This study investigated the feasibility of a novel drilling approach that integrates a pilot trephine into dynamic navigation (DN) for guided osteotomy and root-end resection (RER) with unimanual operation in endodontic microsurgery. METHODS: Two operators with varying levels of DN experience performed guided osteotomy and RER using 2 unimanual drilling methods with DN-aided operation on 3-dimensional printed jaw models. Method 1 (M1) involved drilling with a conventional trephine. Method 2 (M2) involved drilling with a pilot trephine, followed by drilling with a conventional trephine. Accuracy, time, and safety of M1 and M2 were compared. Accuracy measurements included platform deviation (PD), end deviation (ED), angular deviation (AD), resection length deviation (RLD), and resection bevel angle (RBA). Additional parameters included osteotomy and RER time (OT) and bur slippage number (BSN). Statistical analyses were conducted using a 2-sample t-test or Mann-Whitney U test, with the significance level set at .05. RESULTS: The PD, AD, RBA, and BSN in the M2 group were significantly less than in the M1 group (P < .05). For M1, the novice operator (NO) exhibited significantly higher values of PD, ED, OT, and BSN than the experienced operator (EO) (P < .05). For M2, the NO exhibited significantly higher value of ED only (P < .05), and drilling depth >7 mm was significantly associated with a longer OT (P < .05). CONCLUSION: In this surgical simulation comparison study, the incorporation of a pilot drill improved the accuracy and safety of DN-aided endodontic microsurgery.

Comparing accuracy in guided endodontics: dynamic real-time navigation, static guides, and manual approaches for access cavity preparation - an in vitro study using 3D printed teeth.

OBJECTIVES: To assess root canal localization accuracy using a dynamic approach, surgical guides and freehand technique in vitro. MATERIALS AND METHODS: Access cavities were prepared for 4 different 3D printed tooth types by 4 operators (n = 144). Deviations from the planning in angle and bur positioning were compared and operating time as well as tooth substance loss were evaluated (Kruskal-Wallis Test, ANOVA). Operating method, tooth type, and operator effects were analyzed (partial eta-squared statistic). RESULTS: Angle deviation varied significantly between the operating methods (p < .0001): freehand (9.53 ± 6.36°), dynamic (2.82 ± 1.8°) and static navigation (1.12 ± 0.85°). The highest effect size was calculated for operating method (ηP²=0.524), followed by tooth type (0.364), and operator (0.08). Regarding deviation of bur base and tip localization no significant difference was found between the methods. Operating method mainly influenced both parameters (ηP²=0.471, 0.379) with minor effects of tooth type (0.157) and operator. Freehand technique caused most substance loss (p < .001), dynamic navigation least (p < .0001). Operating time was the shortest for freehand followed by static and dynamic navigation. CONCLUSIONS: Guided endodontic access may aid in precise root canal localization and save tooth structure. CLINICAL RELEVANCE: Although guided endodontic access preparation may require more time compared to the freehand technique, the guided navigation is more accurate and saves tooth structure.

Harnessing antimicrobial peptides in endodontics.

Endodontic therapy includes various procedures such as vital pulp therapy, root canal treatment and retreatment, surgical endodontic treatment and regenerative endodontic procedures. Disinfection and tissue repair are crucial for the success of these therapies, necessitating the development of therapeutics that can effectively target microbiota, eliminate biofilms, modulate inflammation and promote tissue repair. However, no current endodontic agents can achieve these goals. Antimicrobial peptides (AMPs), which are sequences of amino acids, have gained attention due to their unique advantages, including reduced susceptibility to drug resistance, broad-spectrum antibacterial properties and the ability to modulate the immune response of the organism effectively. This review systematically discusses the structure, mechanisms of action, novel designs and limitations of AMPs. Additionally, it highlights the efforts made by researchers to overcome peptide shortcomings and emphasizes the potential applications of AMPs in endodontic treatments.

Robot-Assisted and Haptic-Guided Endodontic Surgery: A Case Report.

There has been a significant increase in robot-assisted dental procedures in the past decade, particularly in the area of robot-assisted implant placement. The objective of this case report was to assess the initial use of the Yomi Robot's assistance and haptic guidance during endodontic microsurgery. The robot was used during the osteotomy and root-end resection of the first and second upper left premolars. The report aims to inform clinicians of the initial implementation of this cutting-edge technology in endodontics and its potential to enhance endodontic microsurgery. The Yomi Robot was used in performing osteotomy and root-end resection during apical surgery in a patient presenting with symptomatic upper left first and second premolars. The treatment procedure was decided after clinical examination, chart data, and radiographic examinations, which showed periapical lesions on both premolars, taking into consideration the failed endodontic retreatment on the first premolar, the post and ceramic coronal restorations on both teeth, and the desire of the patient to save them. The Yomi Robot system provides auditory, visual, and physical guidance to clinicians during surgery while using a cone-beam computed tomography scan for precision planning with greater accuracy and minimized potential for human error. Further studies are needed to prepare a protocol for robotic-guided procedures in endodontics.

Expert consensus on digital guided therapy for endodontic diseases.

Digital guided therapy (DGT) has been advocated as a contemporary computer-aided technique for treating endodontic diseases in recent decades. The concept of DGT for endodontic diseases is categorized into static guided endodontics (SGE), necessitating a meticulously designed template, and dynamic guided endodontics (DGE), which utilizes an optical triangulation tracking system. Based on cone-beam computed tomography (CBCT) images superimposed with or without oral scan (OS) data, a virtual template is crafted through software and subsequently translated into a 3-dimensional (3D) printing for SGE, while the system guides the drilling path with a real-time navigation in DGE. DGT was reported to resolve a series of challenging endodontic cases, including teeth with pulp obliteration, teeth with anatomical abnormalities, teeth requiring retreatment, posterior teeth needing endodontic microsurgery, and tooth autotransplantation. Case reports and basic researches all demonstrate that DGT stand as a precise, time-saving, and minimally invasive approach in contrast to conventional freehand method. This expert consensus mainly introduces the case selection, general workflow, evaluation, and impact factor of DGT, which could provide an alternative working strategy in endodontic treatment.

Resistencia a la fractura de premolares superiores con tratamientos de endodoncia por accesos conservador y tradicional / Resistance to Fracture of Upper Premolars with Endodontic Treatment by Conservative and Traditional Access

Introducción: Las piezas dentarias luego de tratamiento de endodoncia aumentan su susceptibilidad a la fractura, lo que está asociado, principalmente, con la pérdida de la estructura dental. Objetivo: Evaluar in vitro, la resistencia a la fractura de premolares superiores con tratamientos de endodoncia mediante acceso tradicional, conservador y conservador Ninja, con restauración provisoria y final. Métodos: Estudio prospectivo de diseño experimental longitudinal con 42 premolares superiores donados, separados en 3 grupos según el tipo de acceso de endodoncia a aplicarse y luego cada uno en dos subgrupos según el tipo de restauración, y un grupo control, al cual no se le realiza endodoncia. Luego de realizar el tratamiento y la restauración, se evaluó la resistencia a la fractura mediante carga compresiva oblicua (45°), en una máquina de carga universal. Las cargas requeridas para la fractura se registraron en newtons y fueron comparadas estadísticamente. Resultados: Las piezas tratadas mediante acceso conservador Ninja con restauración provisoria y final, requirieron una carga promedio para la fractura de 513,45 N y 638,13 N, respectivamente. Fuerzas significativamente mayores a las resistencias ofrecidas por los otros tratamientos con p 0,05. Conclusiones: En la endodoncia in vitro, el diseño del acceso a la cavidad, tipo conservador Ninja, afectó significativamente la resistencia a la fractura de los premolares superiores, adquiriendo un comportamiento biomecánico similar al de las piezas control(AU)

Introduction: Tooth pieces, after endodontic treatment, increase their susceptibility to fracture, a phenomenon mainly associated with loss of tooth structure. Objective: To evaluate, in vitro, the resistance to fracture of upper premolars with endodontic treatment by traditional, conservative and conservative ninja access, with temporary and final restoration. Methods: A prospective study of longitudinal experimental design was carried out with 42 donated upper premolars, separated into three groups, according to the type of endodontic access to be applied; in turn, each was then divided into two subgroups, according to the type of restoration, and a control group, not performed endodontic treatment. After treatment and restoration, fracture resistance was evaluated using oblique compressive loading (45°) in a universal loading machine. The loads required for fracture were recorded in newtons and statistically compared. Results: The parts treated by conservative ninja access with provisional and final restoration required an average fracture load of 513.45 N and 638.13 N, respectively; this forces were significantly higher than the resistance values offered by the other treatments, with p < 0.05. Likewise, there were no significant differences in the resistance values obtained between the cases of conservative access and traditional access, nor when comparing the types of applied restoration, with P<0.05. Conclusions: In in vitro endodontics, the design of the access to the cavity of conservative ninja type significantly affected the resistance to fracture of the upper premolars, acquiring a biomechanical behavior similar to that of the control pieces(AU)

Guided Endodontic Surgery: A Narrative Review.

Background and objectives: Endodontic surgery has evolved over the last two decades. The use of state-of-the-art guided endodontic surgical procedures produces a predictable outcome in the healing of lesions of endodontic origin. The main objective of this review paper is to define and characterize guided surgical endodontics as well as its benefits and drawbacks by reviewing the most recent relevant scientific literature. Methods: A literature search was conducted using multiple databases comprising of MEDLINE (via PubMed), EMBASE, and Web of Science. The terms used for the search were 'guided endodontics', 'surgical endodontics', and 'endodontic microsurgery'. Results: In total, 1152 articles were obtained from the analysis of the databases. Unrelated articles from the available full text of 388 articles were excluded. A total of 45 studies were finally included in the review. Conclusions: Surgical-guided endodontics is a relatively new area of study that is still maturing. It has many applications such as root canal access and localization, microsurgical endodontics, endodontic retreatment, and glass fiber post removal. Additionally, it does not matter how experienced the operator is; the procedure can be completed for the patient in less time and provides greater accuracy and safety than conventional endodontics.

Pain Management and Endodontics: Rapidly Evolving Science Benefits Patient Care.

Pain management and endodontics represent two separate but very much interrelated disciplines. Advances in both fields have resulted in significant improvements in the predictable and comfortable delivery of patient care. From the utilization of cone-beam computed tomography (CBCT) imaging, the use of biomaterials, and enhanced irrigation in endodontics, to greater understanding of pain physiology and treatment, providers and patients alike are benefiting from rapidly evolving science. These two interrelated disciplines are among the most exciting in dentistry for both clinicians and researchers. The science and practice of clinical endodontics progresses quickly. Resultantly, virtually every clinician providing endodontic care gets to experience real changes in methodologies and technologies during their career. These advances have enhanced outcomes in both nonsurgical and surgical endodontics. Similarly, seismic shifts in pain management continue to occur, and significant advances in the understanding of pain physiology, as well as drugs and devices for the prevention and treatment of pain, have greatly improved patient care.

Novel method for augmented reality guided endodontics: An in vitro study.

OBJECTIVE: The aim of this study is to evaluate the accuracy in endodontics of a novel augmented reality (AR) method for guided access cavity preparation in 3D-printed jaws. METHODS: Two operators with different levels of experience in endodontics performed pre-planned virtually guided access cavities through a novel markerless AR system on three sets of 3D-printed jaw models (Objet Connex 350, Stratasys) mounted on a phantom. After the treatment, a post-operative high-resolution CBCT scan (NewTom VGI Evo, Cefla) was taken for each model and registered to the pre-operative model. All the access cavities were then digitally reconstructed by filling the cavity area using 3D medical software (3-Matic 15.0, materialize). For the anterior teeth and the premolars, the deviation at the coronal and apical entry points as well as the angular deviation of the access cavity were compared to the virtual plan. For the molars, the deviation at the coronal entry point was compared to the virtual plan. Additionally, the surface area of all access cavities at the entry point was measured and compared to the virtual plan. Descriptive statistics for each parameter were performed. A 95% confidence interval was calculated. RESULTS: A total of 90 access cavities were drilled up to a depth of 4 mm inside the tooth. The mean deviation in the frontal teeth and in the premolars at the entry point was 0.51 mm and 0.77 mm at the apical point, with a mean angular deviation of 8.5° and a mean surface overlap of 57%. The mean deviation for the molars at the entry point was 0.63 mm, with a mean surface overlap of 82%. CONCLUSION: The use of AR as a digital guide for endodontic access cavity drilling on different teeth showed promising results and might have potential for clinical use. However, further development and research might be needed before in vivo validation.

In vitro study on the accuracy of sleeveless guided endodontics and treatment of a complex upper lateral incisor.

PURPOSE: The present study aims to assess the accuracy of sleeveless guided endodontics for root canal treatment of severe pulp canal obliteration (PCO) in 3D printed jaws. Additionally, the treatment of a complex lateral incisor is presented to illustrate the use of sleeveless guides in a clinical situation. METHODS: Two cone-beam computed tomography (CBCT) volumes of an upper and lower jaw were selected to design 3D printed models with PCO. Virtual planning of the access cavities was performed from right to left second premolar. Then, the models were mounted into a phantom head to simulate an actual patient. Two operators with different levels of experience in endodontics performed guided access cavities. The handpiece was guided by guiding rails placed against each other on the sides of the tooth. A post-operative CBCT scan was taken for analysis. RESULTS: Eighty-eight guided access cavities (44 per operator) were drilled on eight 3D printed models. The mean length of the access cavities was 15.3 mm, with a mean coronal and apical deviation of 0.5 mm and 0.7 mm respectively. The mean angular deviation was 1.5°. No statistically significant difference was found between operators for the three measured parameters. CONCLUSIONS: This study demonstrates, within its limitations, that sleveless guides represent an accurate method for guided endodontic treatment. No statistically significant difference between operators was found when using the guide. CLINICAL SIGNIFICANCE: This method offers a valuable alternative to conventional endodontic guides with similar accuracy results.

A computational modeling method for root canal endoscopy using a specific CBCT filter: A new era in the metaverse of endodontics begins.

A contemporary technological revolution has started a new era in the metaverse of Endodontics, a world of virtual operational possibilities that use an exact replica of the natural structures of the maxillofacial complex. This study describes a modeling method for root canal endoscopy using modern cone-beam CT (CBCT) software in a series of clinical cases. The method consists in acquiring thin CBCT slices (0.10mm) in the coronal, sagittal, and axial planes. A specific 3D volume filter, the pulp cavity filter of the e-Vol DX CBCT software, was used to navigate anatomical root canal microstructures, and to scan them using root canal endoscopy. The pulp cavity filter should be set to synchronize CBCT scans from 2D mode - multiplanar reformations (MPR) - to 3D mode - volumetric reconstruction. This filter, when adopting the option of volumetric reconstruction, the developed algorithm leaves the dentin density in transparent mode so that the pulp cavity may be visualized. The algorithm applied performs the suppression (visual) of areas with dentin density. This ensures 3D visualization of the slices and the microanatomy of the root canal, as well as a dynamic navigation throughout the pulp cavity. This computational modeling method adds new resources to Endodontics, which may impact the predictability of root canal treatments positively. The virtual visualization of the internal anatomy of an exact replica of the canal ensures better communications, reliability, and clinical operationalization. Root canal endoscopy using this novel CBCT filter may be used for clinical applications together with innovative digital and virtual-reality resources that will be naturally incorporated into the principles of Endodontics.

Present status and future directions: Surgical endodontics.

Endodontic surgery encompasses several procedures for the treatment of teeth with a history of failed root canal treatment, such as root-end surgery, crown and root resections, surgical perforation repair and intentional replantation. Endodontic microsurgery is the evolution of the traditional apicoectomy techniques and incorporates high magnification, ultrasonic root-end preparation and root-end filling with biocompatible filling materials. Modern endodontic surgery uses the dental operating microscope, incorporates cone-beam computed tomography (CBCT) for preoperative diagnosis and treatment planning, and has adopted piezoelectric approaches to osteotomy and root manipulation. Crown and root resection techniques have benefitted from the same technological advances. This review focuses on the current state of root-end surgery by comparing the techniques and materials applied during endodontic microsurgery to the most widely used earlier methods and materials. The most recent additions to the clinical protocol and technical improvements are discussed, and an outlook on future directions is given. Whilst nonsurgical retreatment remains the first choice to address most cases with a history of endodontic failure, modern endodontic microsurgery has become a predictable and minimally invasive alternative for the retention of natural teeth.

Can the method of cbct interpretation influence endodontic diagnosis? / O método de interpretação da tcfc pode influenciar o diagnóstico endodôntico?

Objetivo: Este estudo avaliou a influência do método de visualização e análise do exame de tomografia computa-dorizada de feixe cônico (TCFC) no diagnóstico de afecções endodônticas. Materiais e métodos: Vinte casos clínicos contendo doze diferentes afecções endodônticas foram ana-lisados por dois especialistas em radiologia odontológica e um especialista em endodontia. Inicialmente, os avaliadores visualizaram os casos em Portable Document Format (PDF) contendo uma seleção de imagens digitais e, por consenso, descreveram suas hipóteses diagnósticas para cada caso. Após uma semana, os avaliadores reavaliaram os casos, desta vez utilizando reconstrução multiplanar em um visualizador de imagens no formato Digital Imaging and Communications in Medicine (DICOM). Novamente, por consenso, eles indicaram suas hipóteses diagnósticas. Resultados: Em 10% dos casos, houve discrepância entre os diagnósticos realizados utili-zando as seleções de imagens digitais em PDF e utilizando a reconstrução multiplanar. A visualização das imagens em PDF obteve sensibilidade de 0.714, especificidade de 0.966, e acurácia de 90%. Discussão: Na maioria destes casos, as afecções endodônticas identificadas utilizando o visuali-zador de imagens DICOM (reconstrução multiplanar) não foram detectadas quando visualizados os PDF de imagens pré-selecionadas. Conclusão: Embora mais estudos sejam necessários, os autores reiteram que a utilização de recons-truções multiplanares sempre são preferíveis comparadas à outras formas de análise da TCFC, para que se atinja o máximo potencial diagnóstico do exame de imagem.

Aim: This study evaluated the influence of the method used for visualization and analysis of cone-beam com-puted tomography (CBCT) on the diagnosis of endodontic conditions. Materials and methods: Twenty clinical cases containing twelve different endodontic conditions were analyzed by two specialists in dental radiology and one specialist in endodontics. Initially, the evaluators viewed the cases in Portable Document Format (PDF) containing a selection of digital images and, by consensus, described their diagnostic hypotheses for each case. One week la-ter, the evaluators reassessed the cases, this time using multiplanar reconstructions with a Digital Imaging and Communications in Medicine (DICOM) format image viewer. Once more, by consensus, they recorded their diagnostic hypotheses. Results: In 10% of the cases there was a discrepancy between the diagnoses made using preselected digital images in PDFs and by viewing multiplanar reconstructions. The visualization of the PDF images obtained a sensitivity of 0.714, specificity of 0.966, and 90% accuracy. Discussion: In the majority of these cases, endodontic conditions identified using the DICOM image viewer (multiplanar reconstruction) were not detected using the PDFs of preselected images. Conclusion: Although more studies are needed, the au-thors reiterate that using multiplanar reconstructions should always be preferred to other forms of analysis for CBCT, so that the maximum diagnostic potential of the imaging exam can be achieved.