Guided Endodontic Treatment of Mandibular Incisor with Pulp Canal Obliteration following Dental Trauma: A Case Report.

Root canal obliteration is caused by hard tissue apposition and is often associated with teeth with a history of trauma, orthodontic movement, caries reaction, restorative procedures near the pulp chamber, and teeth of elderly patients. Preoperative planning of root canal treatment should be thorough and include an assessment of the patient's signs and symptoms in addition to the evaluation of complementary examinations. In a 27-year-old patient with dyschromia of the lower central incisor, a history of dental trauma, and a positive response to vertical percussion, an initial periapical radiograph was obtained that showed calcification of the canal and presence of a periapical lesion. The patient presented with pain on chewing, a positive response to palpation and a vertical percussion test. The diagnosis was symptomatic apical periodontitis. A cone-beam computed tomography scan was requested and a surface scan was performed to establish a static guide. The root canal was accessed in the middle third of the root and the canal was located using a minimally invasive approach. The root canal was treated conventionally. Results obtained showed the success of the treatment after a 3-year clinical and radiographic follow-up. Therefore, the use of an endodontic guide in cases of calcified canals significantly reduces the clinician's working time and offers a more predictable approach to the treatment of these pathologies.

A Global Overview of Guided Endodontics: A Bibliometric Analysis.

INTRODUCTION: This review aimed to analyze the trend and main characteristics of articles related to guided endodontics (GE). METHODS: The search was conducted in May 2023 on Web of Science. GE-related articles were included, and conferences were excluded. Three researchers selected the articles and extracted: the number of citations; year and journal; design and study theme; authorship and institutions; country and continent. Collaborative networks were generated in the Visualization of Similarities Viewer software. The relationship between data was determined by Spearman's correlation. Google Trends was used to investigate the global popularity of GE research. RESULTS: The search resulted in 135 articles, of which 85 were included. The most cited article totaled 116 citations. The studies were published between 2016 and 2023, most frequently in 2022 (n = 22). The most prevalent journal was the Journal of Endodontics (n = 28). Case report (n = 38) was the most frequent study design. The most studied theme was the use of static GE for calcified canals (n = 27). Connert T was the author with the highest number of articles (n = 13). The University of Basel (n = 9) stood out. The most prevalent country was Brazil (n = 13). Europe was the most frequent continent (n = 38). Visualization of Similarities Viewer demonstrated an interaction between authors. There was a moderate positive correlation between citations and the impact factor (rho = .483). According to Google Trends, the United States was the country that most researched GE. CONCLUSIONS: Based on this review, a more significant research interest in GE was observed in Europe, addressing the application of GE in locating severely calcified root canals.

Effectiveness of guided endodontics in locating calcified root canals: a systematic review.

OBJECTIVES: The aim of this study is to answer the question: "Is guided endodontics an effective technique for locating calcified canals?". METHODS: A systematic search was carried out by two independent authors in PubMed, Web of Science, Scopus, and Scielo databases. According to the PIOS criteria, observational studies, ex vivo studies, clinical case reports, and case series were included. The quality of evidence of observational studies, case reports, and case series were assessed using the respective Joanna Briggs Institute critical appraisal tool, and a previous personalized tool was used to assess the quality of the ex vivo studies. RESULTS: Forty-five studies were included. Of them, 21 were clinical case reports, 11 case series, 12 ex vivo studies, and 1 cohort study. Of the 45 studies analyzed, 43 reported that guided endodontics is an effective and precise technique to access the permeable portion of calcified canals. Only 2 studies report accidents or failures related to the use of endodontic guides. CONCLUSIONS: Guided endodontics allows conservative access, minimizes accidents, and is effective in locating calcified canals; however, it is a technique that still presents limitations. CLINICAL RELEVANCE: Guided endodontics has been proposed as a simple and effective technique for the treatment of calcified canals. The expansion of this technique requires knowing its benefits and limitations to ensure success and avoid accidents.

Guided endodontics of calcified canals: The drilling path of rotary systems and intracanal dentin wear.

This study evaluated the drilling path (mm) and the dentin wear (mm3 ) of two instruments used during guided endodontic access. Twenty mandibular incisors with calcified canals were selected using cone-beam computed tomography (CBCT) and fixed in articulated models. Preoperative CBCT scans were performed in combination with intraoral scanning, and the images were reconstructed in the Blue Sky Bio software for access planning and printing the guides. The access cavity was drilled with 1.0-mm-diameter bur (DSP) and 0.8-mm-diameter bur (Munce). Postoperative CBCT was performed, and the images obtained preoperative and postoperative were superimposed for the analyses. Data were analysed by a t-test and linear regression (α = 0.05). No difference was found in the drilling path (p = 0.422). However, the Munce bur had higher dentin wear than the DSP bur (p = 0.011). A positive linear correlation (R2  = 0.859) was found between the factors.

Guided endodontic treatment in a region of limited mouth opening: a case report of mandibular molar mesial root canals with dystrophic calcification.

BACKGROUND: The endodontic treatment of calcified root canals in molars is a challenging and time-consuming procedure. Even with the aid of a surgical microscope, the risk of root perforation is high, especially in the furcation area. The purpose of this study is to report the Computer-Aided-Design and Manufacturing (CAD-CAM) workflow, the innovative strategies for the template ideation, and the guided endodontic treatment of a mandibular molar with dystrophic calcification in the mesial root canals. CASE PRESENTATION: A 58-year-old female patient, ASA I, was referred to endodontic treatment in the right first mandibular molar for prosthetic reasons. The mesiobuccal and mesiolingual canals appeared obliterated in the radiographic images. The absence of dental crown, tooth inclination, and the limited mouth opening of the region contributed to a poor visual reference of the tooth in the dental arch and the direction of the remaining lumens of the canals. Despite using surgical microscopy, the conventional technique led to the deviation of the mesiobuccal canal towards the furcation area. The obliteration of both mesial root canals was confirmed using the Cone Beam Computer Tomography. The clinical history associated with the tomography diagnosis was compatible with dystrophic calcifications in the pulp canals. The patient was submitted to an intra-oral scanning as well. The Digital Imaging and Communications in Medicine data (DICOM) were segmented. The Standard Tessellation Language (STL) files were processed following the CAD-CAM workflow, aiming to create two different endodontic templates with a new open design concept. The templates with open design allowed direct visualization of the operative field, irrigation, and dentin debris removal. The strategy of the guidance sleeves niche as half-cylinders allowed the drill insertion in a limited mouth opening region. CONCLUSIONS: The digital planning and guided access permitted to overcome the case limitations and then re-establish the glide path following the original anatomy of the root canals. The guided endodontic represents a personalized technique that provides security, reduced risks of root perforation, and a significant decrease of the working time to access obliterated root canals even in the mesial root canal of mandibular molars, a region of limited mouth opening.

Guided Endodontic Approach in Teeth with Pulp Canal Obliteration and Previous Iatrogenic Deviation: A Case Series.

Pulp canal obliteration (PCO) is a challenging clinical scenario in which canals must be located in progressively narrowing roots. Recently, proof of concept papers have, in parallel, introduced the combination of cone-beam computed tomography and surface scans for the construction of guides to pilot the negotiation and preparation of partially or completely obliterated pulp chambers and canals in anterior and posterior teeth. Authors' purpose is to describe the treatment approach for teeth with PCO and previous iatrogenic deviation using guided endodontic technique. The clinical cases reported here show that technological evolutions should make guided endodontic procedures more widespread because their execution is relatively fast and safe even in the cases of root canal deviation. Treatment of teeth with pulp canal obliteration with deviations or perforation may be more effective with designed 3D printed access guides that seems to be a safe and clinically feasible method to locate root canals.

Limitations and Management of Static-guided Endodontics Failure.

Endodontic treatment in severely calcified canals is always a challenging task because it can result in accidents such as deviations or perforations. Recently, guided endodontics has become an alternative approach for pulp canal calcification, facilitating the location of root canals more predictably through the combined use of cone-beam computed tomographic imaging, oral scanning, and endodontic access guides. Although several reports have shown that guided endodontics is safer, faster and can be performed without an operating microscope and by less experienced operators, the technique has limitations, and iatrogenesis may occur. This article describes the limitations of static-guided endodontics and possible causes of failures. In the present case, not fixing the guide to the bone and inaccuracies generated by manually performing mesh merger software led to root perforation. Endodontic microsurgery was effective in resolving this case and should be considered the treatment of choice when guided endodontics cannot be used safely or when it fails.

Guided endodontic access of severe calcified tooth without incisal edge ­ case report / Acesso endodôntico guiado de dente calcificado severamente sem borda incisal ­ relato de caso

Pulp tissue may suffer calcification because of trauma, operative procedures or carious lesions. This paper aimed to report and discuss the guided endodontic access as an alternative treatment. A 52 years old female patient had severe root canal calcification of tooth #11 associated with a radiolucent periapical lesion. Firstly, the crown and metal post and core were removed. A digital impression and cone-beam computed tomography "CBCT" scans were performed and imported to implant planning software (SimPlant Version 11; Materialise Dental, Leuven, Belgium).The guided endodontic access template was designed to allow the drill to reach a distance of 2 mm short of the apical foramen, once printed, it was tested in the mouth to evaluate its insertion and stability in the dental arch. The calcified root canal was penetrated using the access drill rotating by a low-speed hand-piece (10,000 rpm) under saline solution irrigation through advancing movements. Then, the apical foramen was negotiated with C-Pilot files #10 and #15. The working length was measured using the iPex-II apex locator. The instrumentation was carried out with Reciproc R50 and 2.5% sodium hypochlorite. One week later, a full-ceramic crown preparation was performed, and polyvinyl siloxane impression was carried out. A total of three follow-up sessions were performed after one week, one and twelve months. Bone neoformation was observed in the site of the periapical lesion and the patient had no signs or symptoms of any discomfort. Therefore, guided endodontics is indicated for severe calcified root canals.(AU)

O tecido pulpar pode sofrer calcificação por trauma, procedimentos cirúrgicos ou como resposta a lesões cariosas. Este trabalho teve como objetivo relatar e discutir o acesso endodôntico guiado como opção de tratamento. Paciente do sexo feminino, 52 anos, com calcificação severa do canal radicular do dente 11 associada a lesão periapical radiolucida. Na primeira intervenção clínica, a coroa e o pino de metal foram removidos. Uma impressão digital e imagens de CBCT foram realizadas e importadas para o software de planejamento de implante (SimPlant Versão 11; Materialize Dental, Leuven, Bélgica) tentando projetar um modelo de acesso endodôntico guiado para permitir que a broca alcance uma distância de 2 mm antes do forame apical, uma vez impresso, foi testado na boca para avaliar sua inserção e estabilidade na arcada dentária. O canal radicular calcificado foi penetrado com broca de acesso girando por peça de mão de baixa velocidade (10.000 rpm) sob irrigação com solução salina por meio de movimentos de avanço. Em seguida, o forame apical foi negociado com as limas C-Pilot nº 10 e nº 15. O comprimento de trabalho foi determinado usando o localizador de ápice iPex-II. A instrumentação foi realizada com Reciproc R50 e hipoclorito de sódio 2,5%. Uma semana depois, foi realizado o preparo da coroa total em cerâmica e a moldagem com polivinilsiloxano. Um total de três sessões de acompanhamento foram realizadas após uma semana, um e doze meses. A neoformação óssea foi observada no local da lesão periapical e a paciente não apresentava sinais ou sintomas de qualquer desconforto. Portanto, o acesso endodôntico guiado é indicado para canais radiculares calcificados severamente.(AU)

Guided Endodontics in Root Canals with Complex Access: Two Case Reports

Abstract This article reported two clinical cases in which the guided endodontics was used to perform the access to the root canals. The first case presents a 40-year-old female with a history of pain related to the left maxillary canine. After radiographic examination, the presence of severe calcification up to the apical third of the root canal, associated with a periapical radiolucency, was noted. In the second case, an 85-year-old male was referred to our service with pain upon palpation, at the right mandibular first molar. The radiographic images revealed the presence of endodontic treatment and a fiberglass post in the distal root canal, which was associated with extrusion of the filling material and a periapical lesion. The 3D-guides were planned based on cone beam computed tomography and intraoral digital scanning, which were aligned using a specific software. Therefore, implant drills could be guided up to the root canal length required for each case. In the first case, a surgical root canal was created and the patient was free of signs and symptoms after the treatment was completed. In the second case, it was observed that the fiber post was worn by the drill, allowing free access to the filling material. It was possible to perform the endodontic reintervention in a more predictable way and in less time. In both cases, the use of the guided endodontics allowed the preservation of a large part of the dental structure. The procedures were performed faster, without the occurrence of fractures and perforations.

Resumo Este artigo relatou dois casos clínicos em que a endodontia guiada foi utilizada para realizar o acesso aos canais radiculares. O primeiro caso apresenta uma mulher de 40 anos com história de dor relacionada ao canino superior esquerdo. Após exame radiográfico, notou-se a presença de calcificação acentuada até o terço apical do canal radicular, associada a radioluscência periapical. No segundo caso, um homem de 85 anos foi encaminhado ao nosso serviço com dor à palpação no primeiro molar inferior direito. As imagens radiográficas revelaram a presença de tratamento endodôntico e pino de fibra de vidro no canal radicular distal, que estava associado à extrusão do material obturador e lesão periapical. Os guias-3D foram planejados com base em tomografia computadorizada de feixe cônico e escaneamento intraoral digital, os quais foram alinhados por meio de um software específico. Desta forma, brocas de implante puderam ser guiadas até o comprimento necessário do canal radicular para cada caso. No primeiro caso, foi confeccionado um canal radicular cirúrgico e o paciente ficou sem sinais e sintomas após o término do tratamento. No segundo caso, observou-se que o pino de fibra foi desgastado pela broca, permitindo o livre acesso ao material obturador. Foi possível realizar a reintervenção endodôntica de forma mais previsível e em menos tempo. Em ambos os casos, o uso da endodôntica guiada permitiu a preservação de grande parte da estrutura dentária. Os procedimentos foram realizados com maior agilidade, sem a ocorrência de fraturas e perfurações.

Digital Planning on Guided Endodontics Technology

Abstract The aim of this review is to discuss the digital planning and the use of guided technology in Endodontics. The complexity of the root canals anatomy and the challenges in the microorganism's control represent risk factors for failure after the infected root canal's treatment. Scientific improvements associated with technological advances have enabled better predictability of therapeutic procedures results. The development of efficient and modern devices provided safer root canal treatments, with shorter clinical visits and greater patient comfort. Digital endodontics incorporated different tools and developed its own, advancing even further in resolving complex cases. The faithful copy of the internal anatomy provided by the advancement of CBCT devices and software's, associated with the digital resources of 3D planning and printing, enabled the advent of guided endodontics. This technique is used at different stages of endodontic treatment, with specific indications and greater result predictability. Therefore, this study critically reviewed the potential clinical application of this guided access technique, and the operative steps for its safe performance in managing complex endodontic cases. The main indications are accessing calcified root canals, performing endodontic surgeries in difficult access areas, removing fiberglass posts, and accessing teeth with developmental anomalies. In summary, guided endodontics has been a precise strategy, effective, safe, and clinically applicable. This procedure represents incorporating technological resources and digital planning in the Endodontist clinical practice, increasing predictability to complex cases.

Resumo O objetivo desta revisão é discutir o planejamento digital e o uso da tecnologia guiada em Endodontia. A complexidade e variabilidade da anatomia dos canais radiculares, em conjunto com o desafio no processo de sanificação e controle de micro-organismos representam fatores de risco ao fracasso após o tratamento dos canais radiculares infectados. O aprimoramento técnico-científico e os avanços tecnológicos tem possibilitado uma melhor previsibilidade de resultados nos procedimentos terapêuticos. O desenvolvimento de ferramentas de trabalho eficientes e modernas proporcionou tratamentos endodônticos seguros, com menor tempo clínico operacional e maior conforto ao paciente. A endodontia digital incorporou diferentes ferramentas e desenvolveu suas próprias, avançando ainda mais na resolução de casos complexos. A cópia fiel da anatomia interna proporcionada pelo avanço dos aparelhos e softwares de TCFC, associada aos recursos digitais de planejamento e impressão 3D possibilitaram o surgimento da endodontia guiada. Esta técnica é utilizada em diferentes etapas do tratamento endodôntico, com indicações específicas e maior previsibilidade de resultados. Este estudo revisou criticamente o potencial de aplicação clínica da técnica de acesso guiado, e os passos operatórios para sua realização de forma segura no manejo de casos endodônticos complexos. As principais indicações da Endodontia Guiada incluem o acesso a canais radiculares calcificados; as cirurgias parendodônticas em áreas de difícil acesso; a remoção de pinos de fibra de vidro; e o acesso a dentes com anomalias de desenvolvimento. Em síntese, a endodontia guiada é uma técnica precisa, eficaz e de fácil aplicação clínica. Esta técnica representa a incorporação dos recursos tecnológicos e planejamentos digitais do Endodontista, dando maior previsibilidade aos casos em que é aplicada na prática clínica.

Guided endodontics: The impact of new technologies on complex case solution.

Discuss the impact of new diagnostic and planning technologies on the resolution of a clinical case of an upper central incisor with lateral perforation, root canal calcification and apical periodontitis. A 44-year-old woman sought treatment because of a colour change in an anterior tooth. The tooth had already been endodontically accessed, and she reported that two different clinicians had failed to locate the root canal. A Cone Beam Computed Tomography scan showed excessive wear and root perforation in the middle third, as well as pulp canal obliteration in the apical third. The perforation was treated using a biomaterial, and the root canal was located using guided endodontics. This treatment protocol was used to access, prepare, medicate with calcium hydroxide for 21 days and fill the root canal. Treatment results were satisfactory at 6-month follow-up.

Guided Endodontics: Volume of Dental Tissue Removed by Guided Access Cavity Preparation-An Ex Vivo Study.

INTRODUCTION: Guided endodontics emerged as an alternative method capable of providing greater precision and accuracy to endodontic treatments. The aim of the present study was to compare the volume of dental tissue removed after guided endodontic access (GEA) and conventional endodontic access (CEA) to mandibular incisors and upper molars. METHODS: Twenty extracted human mandibular incisors and upper molars were selected and submitted to cone-beam computed tomographic (CBCT) examination. They were divided into 2 groups, G1 (mandibular incisors) and G2 (maxillary molars), and subdivided into G1a (CEA), G1b (GEA), G2a (CEA), and G2b (GEA). The Digital Imaging and Communications in Medicine files obtained by examining the CBCT scans were transferred to InVesalius software (Renato Archer Information Technology Center, Campinas, SP, Brazil) to calculate the initial volume of each tooth. G1b and G2b teeth were scanned with a device to plan and print the guides. After gaining endodontic access, new CBCT examinations were performed to calculate the final volume of each sample unit. The Student t test for independent samples compared the volumes among the groups. RESULTS: G1 group had an average volume reduction of 31.667 mm3 (10.62%) using CEA and 26.523 mm3 (10.65%) using GEA with no significant difference among the groups (P = .960). There was an average volume reduction of 62.526 mm3 (5.86%) in the G2 group using CEA and 45.677 mm3 (4.11%) using GEA with a significant difference among the groups (P = .004). CONCLUSIONS: GEA preserved a greater volume of dental tissue in extracted upper human molars than CEA; however, there was no significant difference between CEA and GEA in the volume of dental tissue removed from mandibular incisors.

Adaptable fiberglass post after 3D guided endodontic treatment: Novel approaches in restorative dentistry.

OBJECTIVE: The rehabilitation of extensively damaged teeth with great structural loss and calcified root canals represents a challenge for dentistry. Classically, this restorative procedure of endodontically treated teeth involves intraradicular post placement. Retentive function post that can closely adapt to the root canal without the excessive wear of intraradicular dentin has a fundamental importance to ensure the longevity of the restoration. CLINICAL CONSIDERATIONS: This report presents a clinical case of 3D guided access to a severely calcified pulp canal followed by the cementation of a fiberglass post that is adaptable to the root canal and prosthetic rehabilitation with full ceramic crown. CONCLUSIONS: 3D guided access allowed conservative and safe root canal treatment. The adaptable fiberglass post meets the specific needs of the described case and has a simple technique and low cost. CLINICAL SIGNIFICANCE: Guided endodontics is a minimally invasive approach for teeth with calcified root canals. The post used in this study meets the demands of teeth endodontically treated with conservative techniques. The professional should not need to adapt the anatomy of the root canal to the anatomical reality of the post. This one adapts itself to the shape of the canal.

Guided Endodontics in Complex Scenarios of Calcified Molars.

This study aimed to report a case series and describe the use of guided endodontics in complex symptomatic cases of mandibular and maxillary molars; presenting calcification of all three root canals. The arches of the referred patients were scanned, and high-resolution cone-beam computed tomography (CBCT) imaging was performed. Then, the taken CBCT and tooth scans were aligned and processed using software. A virtual copy of a drill was superimposed onto the scans and evaluated in 3 dimensions. Subsequently, a 3-dimensional (3D) template was designed and printed. Drilling was performed and a radiograph was taken to confirm its position. The canals were reached and endodontic treatment was performed. At the 12-month follow-up, the teeth were completely asymptomatic. The use of guided endodontics in cases of calcification in molars was demonstrated to be a viable and reliable alternative treatment. The technique was based on 3D planning.

Guided Endodontics in Nonsurgical Retreatment of a Mandibular First Molar: A New Approach and Case Report.

This case report describes the use of the guided endodontics for a non-surgical endodontic retreatment of the mandibular molar. A 38-year-old female reported apical swelling and localized pain on the tooth #30, exacerbated when chewing hard food. Periapical radiographic examination showed pulp canal obliteration in the apical third associated with extensive radiolucent area. Cone-beam computed tomography (CBCT) images were requested to support the diagnosis and enable preparation of a surgical guide, used to direct access to the canals that were obliterated and incompletely filled. The follow-up at 24 months radiographically showed completely healed apical area in the involved tooth. This non-surgical technique demonstrated efficacy in case resolution.

Case Reports in Maxillary Posterior Teeth by Guided Endodontic Access.

The localization of partial or completed root canal obliteration is a challenging task in endodontic practice. Recently, guided endodontics has become an alternative solution for those cases. Although this technique has already been used clinically in managing anterior teeth, in this report, we describe 3 complex clinical scenarios of calcified root canals of 1 molar and 2 premolars using guided endodontics. The clinical cases reported here show that technological evolutions should make guided endodontic procedures more widespread because their execution is relatively fast and safe even in the case of the upper molar. Additionally, 12-month clinical follow-up visits showed the effectiveness of the guided endodontic procedures.

Clinical Approach to Pulp Canal Obliteration: A Case Series.

This article describes four cases with safe and feasible clinical treatment strategies for anterior teeth with pulp canal obliteration (PCO) using cone-beam computed tomography (CBCT), digital radiography (DR), dental operating microscopy (DOM) and ultrasonic tips (US). Four anterior teeth with PCO were chosen. DR was taken with different angulations and analyzed with different filters. Subsequently, the access cavity was performed with the aid of DOM. If the canal was not identified, CBCT was requested. Sagittal and axial slices guided the direction of the ultrasonic tips. After identification of the canal, it was then negotiated and instrumented with the rotary instruments. All four canals were successfully identified, with no complications. In case 1, the canal was identified using DR, DOM and US tips. In cases 2, 3 and 4, the canals were identified with DR, DOM, US tips and CBCT. Complete root canal obliteration identified in radiography did not necessarily mean that pulp tissue was not visible clinically, either. The clinical evaluation of the access cavity with the aid of MO was crucial. If the canal was not identified, CBCT was mandatory in order to show more detailed view of the precise position of the canals, their directions, degrees of obstruction and dimensions. It served as a guide for the direction of the ultrasonic tips to keep them within the pulp chamber safely, with a low risk of iatrogenic injury.