International Journal of Applied Dental Sciences 2023; 9(3): 98-101

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2023; 9(3): 98-101 An update on guided endodontics
© 2023 IJADS
www.oraljournal.com
Received: 24-05-2023 Luz Estrella Romero Oliva, Jose Elizondo Elizondo, Sara Saenz Rangel,
Accepted: 27-06-2023
Maricela Ramirez Alvarez, Rosa Alicia Garcia Jau, Efigenia Moreno
Luz Estrella Romero Oliva Terrazas, Fernanda Poblano Izaguirre and Dr. Juan Manuel Solis Soto
Master of Sciences Student, Facultad
de Odontologia, Universidad DOI: https://doi.org/10.22271/oral.2023.v9.i3b.1792
Autonoma de Nuevo Leon,
Monterrey, Nuevo Leon, 64460 ZIP,
Mexico Abstract
Introduction: In 2016, a new approach to endodontics using CAD/CAM printed guides or splints
Jose Elizondo Elizondo
Professor, Facultad de Odontologia,
emerged, mostly in pieces with pulp obliteration.
Universidad Autonoma de Nuevo Objective: To analyze the literature on some current endodontic techniques for the treatment of pulp
Leon, Monterrey, Nuevo Leon, 64460 obliteration, such as static guided endodontics, dynamic guided endodontics, and guided endodontic
ZIP, Mexico microsurgery.
Methodology: PubMed, SCOPUS and Google Scholar databases were reviewed to find recent articles
Sara Saenz Rangel
Professor, Facultad de Odontologia, published on guided endodontics with the following keywords: "pulp obliteration", "CBCT", "static
Universidad Autonoma de Nuevo guided endodontics", "dynamic guided endodontics" and "guided endodontic microsurgery".
Leon, Monterrey, Nuevo Leon, 64460 Results: Pulp obliteration is the narrowing of the dental pulp space, which is caused by extrinsic and
ZIP, Mexico intrinsic factors. CBCT helps to measure the path of the canal in the dental roots, in order to be able to
Maricela Ramirez Alvarez
perform the appropriate accesses in endodontics. Static-guided endodontics, also called Endo Guide, uses
Professor, Facultad de Odontologia, 3D printed directional guides made with CBCT and CAD/CAM. Dynamic guided endodontics combines
Universidad Autonoma de Sinaloa, images that are reproduced in real time, guiding access and angulation. Microsurgery is performed when
Culiacan, Sinaloa, 80013 ZIP, Mexico there is a failure in root canal therapy, its success rate has been increasing thanks to the use of CBCT that
Rosa Alicia Garcia Jau
helps to link the other techniques using templates that predict the procedure.
Professor, Facultad de Odontologia, Conclusions: Pulp obliteration causes pulp sclerosis and necrosis which at some point will require root
Universidad Autonoma de Sinaloa, canal treatment, currently different techniques can be used such as static guided endodontics, dynamic
Culiacan, Sinaloa, 80013 ZIP, Mexico guided endodontics, microsurgery in which they have to go hand in hand with the use of CBCT for
planning, the choice of these depends on the complexity of the case.
Efigenia Moreno Terrazas
Professor, Facultad de Odontologia,
Universidad Autonoma de Sinaloa, Keywords: Guided endodontics, pulp obliteration, CBCT, dynamic endodontics, static endodontics,
Culiacan, Sinaloa, 80013 ZIP, Mexico endodontic microsurgery
Fernanda Poblano Izaguirre
Dentistry Student, Facultad de 1. Introduction
Odontologia, Universidad Autonoma Pulp obliteration (PO) is a typical late sequela after dental trauma. They occur in 15% to 40%
de Nuevo Leon, Monterrey, Nuevo
Leon, 64460 ZIP, Mexico of cases after luxation injuries [1]. Endodontic therapy is indicated in 7% to 27% of OP cases
when apical periodontitis or acute symptoms are present [2]. The combination of dental surgical
Dr. Juan Manuel Solis Soto microscopy and an ultrasonic tip can be used to identify obliterated canals however the
Professor, Facultad de Odontologia,
Universidad Autonoma de Nuevo treatment of teeth with PO is time consuming [3]. Therefore, treatment of teeth with pulp canal
Leon, Monterrey, Nuevo Leon, 64460 obliteration presents a challenge given the high probability of procedural errors and
ZIP, Mexico
complications during their procedure [4]. In 2016, a new approach to endodontics using three-
dimensional (3D) printed guides or splints mostly used in PO teeth emerged [5]. Cone beam
computed tomography (CBCT) devices and software, associated with digital planning and 3D
printing resources, allowed the advent of guided endodontics [6]. Currently, there are different
types of guided endodontics: static guided endodontics (SGE) and dynamic guided
endodontics (DGE) [5]. This 3D information can be combined with tooth surface information
acquired with an intraoral scanner to design and 3D print a treatment guide [7]. Guided
endodontics may be a promising method for endodontic or surgical treatment of complex cases
Corresponding Author: [8]
.
Dr. Juan Manuel Solis Soto
Professor, Facultad de Odontologia, The aim of this research is to analyze the literature on the various current endodontic
Universidad Autonoma de Nuevo techniques for the treatment of pulp obliteration, such as use of CBCT, static guided
Leon, Monterrey, Nuevo Leon, 64460
ZIP, Mexico
endodontics, dynamic guided endodontics, and guided endodontic microsurgery.
~ 98 ~
International Journal of Applied Dental Sciences https://www.oraljournal.com

2. Materials and Methods it plays an important role as it helps to measure the distance
Articles on the subject published through the PubMed, between the cortical plate and the apex, the position of the
SCOPUS and Google Scholar databases were analyzed, with roots within the bone and the proximity of vital structures [22].
emphasis on the last 5 years. The quality of the articles was CBCT imaging allows locating the visible part of the root
evaluated using guidelines, i.e., identification, review, choice, canal and planning the access route to the root canal system
and inclusion. The quality of the reviews was assessed using while preserving the cervical dentin [23]. CBCT applications in
the measurement tool for evaluating systematic reviews. The endodontics involve the shift from analog to digital imaging
search was performed using Boolean logical operators AND, and advances in imaging theory and volume acquisition data,
OR and NOT, with the keywords: pulp obliteration, CBCT, allowing detailed 3D images [24].
static guided endodontics, dynamic guided endodontics, and Cone beam tomography studies have been introduced since
guided endodontic microsurgery. the 1990s in dentistry, being useful for implant procedures,
orthodontics, maxillofacial surgery, and more recently for
3. Results and Discussion guided endodontic treatments. The CBCT helps to improve
3.1 Guided endodontics to treat pulp obliteration predictability in these treatments, in endodontics it helps to
Guided endodontics is a novel approach used in the measure the path of the canal in the dental roots, to be able to
management of obliterated root canals, autotransplantation make the appropriate accesses in an endodontic treatment.
and periradicular surgery, this can be static or dynamic [9].
This new approach requires more planning time, due to 3.3 Types of guided endodontics
possible inaccuracies of preoperative CBCT and intraoral 3.3.1 Static guided endodontics
scanning [10]. Pulp canal obliteration, is associated with The 3D endodontic guide or Endo Guide is a template made
luxation injuries of teeth or adults, is characterized by a to guide drills in predetermined positions to locate and
gradual, progressive, and excessive deposition of reparative explore root canal orifices or bone trepanation and root end
dentin within the root canal walls [11]. Root canal resection [25], these templates use stereolithography templates
calcifications have several synonyms and etiologies to realize the access cavity [26]. In this guide, a drill hole can
elaborated in the literature, some of which are pulp lumen be designed with a specific diameter and angulation to allow
reduction, dystrophic calcification, pulp calcification, direct access to the calcified canal, then cylinders can be
calcified pulp obliteration, and pulp canal sclerosis [12]. Often, designed, this can be smaller and is made of metal, once the
the affected tooth shows discoloration of the clinical crown designs are finalized, the file is exported from the planning
that becomes darker this is the result of increased dentin software [27]. Directional guides are designed in 3D made with
thickness, leading to reduced crown translucency [13]. PO is CBCT and CAD/CAM allowing the design of the drill with a
seen radiographically as a rapid narrowing of the pulp canal specific diameter and angulation, this benefits the dentist to
space; late development of pulp necrosis and periapical perform the drilling accurately in the original direction of the
disease are rare complications after PO [14]. Local and root canal [27]. Inaccurate endodontic access cavities can lead
systemic factors can contribute to the formation of dental pulp to intraoperative complications, such as overextended access
calcification, excessive forces, presence of restorations, cavity cavities, crown perforation, root perforation, lost root canals,
preparation and caries are common local factors [15]. Within fracture of root canal instruments [28]. This technique in a
the PO, pulpal calculi may exist, which are calcified nodular 2018 study yielded results in which it reduced excessive loss
masses found in the coronal or root portion of the pulp. They of tooth structure and chairside operating times were shorter,
are usually oval or round in shape and can also be irregular in addition, the use of one or two drills ensured the accuracy
[16]
. of the drilling procedure [29]. Static guidance can only be
Pulp obliteration has been described in the literature as the performed on roots or straight parts of curved roots. In
narrowing of the dental pulp space, which is caused by addition, it requires more time for planning and the radiation
various factors that can be extrinsic: restorations, excessive dose is increased due to mandatory CBCT [30]. Static-guided
forces, or intrinsic factors: preparation of the cavity by caries, endodontic technique can provide advantages to the clinician
causing pulp sclerosis and necrosis which at some point will for MTA removal [31]. On the other hand, the disadvantage is
require root canal treatment, which can currently be that it requires the template fabrication step and, therefore,
performed using the guided endodontic approach. patients with severe pain may not be treated quickly [32].
Static guided endodontics allows the design of a directional
3.2 Application of CBCT in guided endodontics guide through software that plans and designs the drilling
CBCT is a radiographic imaging technique that creates a with specific data, in terms of angulation and diameter,
three-dimensional image of the exposure site. Developed in resulting in direct access with less attention time by the
the early 1990s, it is increasingly used in dentistry for a dentist and a high accuracy rate in drilling the template, which
variety of indications [17]. The application of this technology help to reduce risks such as instrument fractures or
ranges from implant design, periodontal defects, endodontics, overextended drillings.
and orthodontics, as well as in maxillofacial practice [18].
Accurate jaw segmentation from CBCT is an important step 3.3.2 Dynamic guided endodontics
in constructing a customized 3D digital jaw model for Dynamic navigation system (DNS) has been used for both
maxillofacial surgery and orthodontic treatment planning due surgical and non-surgical endodontic therapies using an
to the low radiation dose and short scan duration [19]. The optical tracking device managed by a special computer
known limitations of periapical radiographs in clinical interface, DNS combines CBCT and spatial positioning
diagnostics have encouraged practitioners to recommend technologies [33]. There are studies mentioning that dynamic
CBCT imaging examinations [20]. It provides more accurate navigation technology can achieve high positioning accuracy
and detailed information about the anatomical structures of a in the depth range up to 15 mm, but its deviation increases as
root canal system, which has a positive impact on outcomes the depth gets deeper [34]. DNS is based on the use of CBCT
by improving predictability [21]. Within surgical endodontics, images with reference marks that are placed in the patient's
~ 99 ~
International Journal of Applied Dental Sciences https://www.oraljournal.com

mouth on the side opposite to the side to be operated on to preparation and discrimination of angular and linear
position the access path to the pulp chamber and root canal [1]. deviation on canal accessing ability-an ex vivo study.
DNS requires an optical triangulation tracking system that BMC Oral Health. 2021 Nov 23;21(1):606.
uses real-time stereoscopic motion tracking cameras to guide 4. Llaquet Pujol M, Vidal C, Mercadé M, Muñoz M,
the drilling process according to the planned angle, path, and Ortolani-Seltenerich S. Guided Endodontics for
depth of the endodontic access cavities [35]. Managing Severely Calcified Canals. J Endod. 2021
The technique of dynamically guided endodontics is Feb;47(2):315-321.
combined with the use of CBCT using images that are 5. Kulinkovych-Levchuk K, Pecci-Lloret MP, Castelo-Baz
reproduced in real time, which are followed in motion P, Pecci-Lloret MR, Oñate-Sánchez RE. Guided
cameras in a stereoscope that guide the access, angulation and Endodontics: A Literature Review. Int J Environ Res
depth, which in studies mentioned that has a high accuracy at Public Health. 2022 Oct 26;19(21):13900.
a depth of 15mm, one of its advantages unlike static guided 6. Decurcio DA, Bueno MR, Silva JA, Loureiro MAZ,
endodontics is that no templates are required so that the Damião Sousa-Neto M, Estrela C. Digital Planning on
patient can be treated in a faster way. Guided Endodontics Technology. Braz Dent J. 2021 Sep-
Dec;32(5):23-33.
3.3.3 Guided endodontic microsurgery 7. Moreno-Rabié C, Torres A, Lambrechts P, Jacobs R.
Endodontic microsurgery is defined as treatment performed Clinical applications, accuracy and limitations of guided
on the root apices of an infected tooth that did not resolve endodontics: a systematic review. Int Endod J. 2020
with conventional root canal therapy [36]. Surgical endodontic Feb;53(2):214-231.
procedures include removal of necrotic and infected 8. Zhang C, Zhao X, Chen C, Wang J, Gu P, Ma J, et al.
periapical tissues, resection of the apical part of the tooth The accuracy of using guided endodontics in access
(apicoectomy), and preparation of the root-end cavity for cavity preparation and the temperature changes of root
insertion of retrograde filling material [37]. Endodontic surface: An in vitro study. BMC Oral Health. 2022 Nov
microsurgery in the mandibular molar area can be more 16;22(1):504.
challenging due to limited access, thickness of buccal cortical 9. Vasudevan A, Santosh SS, Selvakumar RJ, Sampath DT,
bone, complex root morphology, and proximity to the Natanasabapathy V. Dynamic Navigation in Guided
mandibular canal [38]. Endodontics - A Systematic Review. Eur Endod J. 2022
The success rate of endodontic microsurgery has increased Jun;7(2):81-91.
from 44.2 to 53.5% to 90.5 to 91.1% with the advancement of 10. Jonaityte EM, Bilvinaite G, Drukteinis S, Torres A.
CBCT and surgical instruments and materials [39]. Accuracy of Dynamic Navigation for Non-Surgical
Microsurgery is performed when there is a failure in canal Endodontic Treatment: A Systematic Review. J Clin
therapy in a conventional way, so it is opted to perform an Med. 2022 Jun 15;11(12):3441.
apicoectomy and retrograde obturation, its success rate has 11. Spinas E, Deias M, Mameli A, Giannetti L. Pulp canal
been increasing thanks to the use of CBCT that help to link obliteration after extrusive and lateral luxation in young
the other techniques using templates that predict the permanent teeth: A scoping review. Eur J Paediatr Dent.
procedure. There are not many studies describing the 2021;22(1):55-60.
application of this technique. 12. Hegde SG, Tawani G, Warhadpande M, Raut A,
Dakshindas D, Wankhade S. Guided endodontic therapy:
4. Conclusions Management of pulp canal obliteration in the maxillary
Pulp obliteration has been described as the narrowing of the central incisor. J Conserv Dent. 2020 Nov-
dental pulp space, causing pulp sclerosis and necrosis which Dec;22(6):607-611.
at some point will require a root canal treatment, currently 13. Vinagre A, Castanheira C, Messias A, Palma PJ, Ramos
different techniques can be used as static guided endodontics JC. Management of Pulp Canal Obliteration-Systematic
that requires templates, dynamic guided endodontics that is Review of Case Reports. Medicina (Kaunas). 2021 Nov
performed in real time cameras, also microsurgery in which 12;57(11):1237.
they have to go hand in hand with the use of CBCT for 14. Bastos JV, Côrtes MIS. Pulp canal obliteration after
planning, the choice of these depends on the complexity of traumatic injuries in permanent teeth - scientific fact or
the case. fiction? Braz Oral Res. 2018 Oct 18;32(suppl 1):e75.
15. Jiandong B, Yunxiao Z, Zuhua W, Yan H, Shuangshuang
4.1 Conflict of Interest G, Junke L, et al. Generalized pulp canal obliteration in a
Not available patient on long-term glucocorticoids: a case report and
literature review. BMC Oral Health. 2022 Aug
4.2 Financial Support 15;22(1):352.
Not available 16. Ravichandran K, Dinesh K, Nagaraja S, Srinivasan B,
Shetty N, Ramesh P. Comparative evaluation of
5. References decalcifying agents for dissolution of pulp stones: An in
1. Connert T, Weiger R, Krastl G. Present status and future vitro study. J Conserv Dent. 2022 Jul-Aug;25(4):356-
directions - Guided endodontics. Int Endod J. 2022 362.
Oct;55 Suppl 4(Suppl 4):995-1002. 17. Gallichan N, Albadri S, Dixon C, Jorgenson K. Trends in
2. Ribeiro D, Reis E, Marques JA, Falacho RI, Palma PJ. CBCT current practice within three UK paediatric dental
Guided Endodontics: Static vs. Dynamic Computer- departments. Eur Arch Paediatr Dent. 2020
Aided Techniques-A Literature Review. J Pers Med. Aug;21(4):537-542.
2022 Sep 15;12(9):1516. 18. Verykokou S, Ioannidis C, Angelopoulos C. Evaluation
3. Su Y, Chen C, Lin C, Lee H, Chen K, Lin Y, et al. of 3D Modeling Workflows Using Dental CBCT Data for
Guided endodontics: accuracy of access cavity Periodontal Regenerative Treatment. J Pers Med. 2022
~ 100 ~
International Journal of Applied Dental Sciences https://www.oraljournal.com

Aug 23;12(9):1355. vitro evaluation of positioning accuracy of trephine bur at

19. Qiu B, Van Der Wel H, Kraeima J, Glas HH, Guo J, different depths by dynamic navigation]. Beijing Da Xue
Borra RJH, et al. Mandible Segmentation of Dental Xue Bao Yi Xue Ban. 2022 Feb 18;54(1):146-152.
CBCT Scans Affected by Metal Artifacts Using Coarse- 35. Palma PJ, Marques JA, Casau M, Santos A, Caramelo F,
to-Fine Learning Model. J Pers Med. 2021 Jun Falacho RI, et al. Evaluation of Root-End Preparation
16;11(6):560. with Two Different Endodontic Microsurgery Ultrasonic
20. Bueno MR, Azevedo BC, Estrela C. A Critical Review of Tips. Biomedicines. 2020 Sep 28;8(10):383.
the Differential Diagnosis of Root Fracture Line in 36. Kim JE, Shim JS, Shin Y. A new minimally invasive
CBCT scans. Braz Dent J. 2021 Dec 6;32(5):114-128. guided endodontic microsurgery by cone beam computed
21. Bueno MR, Estrela C. A computational modeling method tomography and 3-dimensional printing technology.
for root canal endoscopy using a specific CBCT filter: A Restor Dent Endod. 2019 Jul 25;44(3):e29.
new era in the metaverse of endodontics begins. Braz 37. Zubizarreta-Macho Á, Tosin R, Tosin F, Velasco
Dent J. 2022 Jul-Aug;33(4):21-30. Bohórquez P, San Hipólito Marín L, Montiel-Company
22. Reddy S, Gadhiraju S, Quraishi A, Kamishetty S. JM, et al. Influence of Guided Tissue Regeneration
Targeted Endodontic Microsurgery: A Guided Approach Techniques on the Success Rate of Healing of Surgical
- A Report of Two Cases. Contemp Clin Dent. 2022 Jul- Endodontic Treatment: A Systematic Review and
Sep;13(3):280-283. Network Meta-Analysis. J Clin Med. 2022 Feb
23. Dąbrowski W, Puchalska W, Ziemlewski A, Ordyniec- 18;11(4):1062.
Kwaśnica I. Guided Endodontics as a Personalized Tool 38. Lu YJ, Chiu LH, Tsai LY, Fang CY. Dynamic navigation
for Complicated Clinical Cases. Int J Environ Res Public optimizes endodontic microsurgery in an anatomically
Health. 2022 Aug 12;19(16):9958. challenging area. J Dent Sci. 2022 Jan;17(1):580-582.
24. Antony DP, Thomas T, Nivedhitha MS. Two- 39. Peng L, Zhao J, Wang ZH, Sun YC, Liang YH. Accuracy
dimensional Periapical, Panoramic Radiography Versus of root-end resection using a digital guide in endodontic
Three-dimensional Cone-beam Computed Tomography surgery: An in vitro study. J Dent Sci. 2021 Jan;16(1):45-
in the Detection of Periapical Lesion After Endodontic 50.
Treatment: A Systematic Review. Cureus. 2020 Apr
19;12(4):e7736.
25. DGT, Saxena P, Gupta S. Static vs. dynamic navigation How to Cite This Article
Oliva LER, Elizondo JE, Rangel SS, Alvarez MR, Jau RAG, Terrazas
for endodontic microsurgery - A comparative review. J EM, et al. An update on guided endodontics. International Journal of
Oral Biol Craniofac Res. 2022 Jul-Aug;12(4):410-412. Applied Dental Sciences. 2023;9(3):98-101.
26. Zubizarreta-Macho Á, Muñoz AP, Deglow ER, Agustín-
Panadero R, Álvarez JM. Accuracy of Computer-Aided
Creative Commons (CC) License
Dynamic Navigation Compared to Computer-Aided This is an open access journal, and articles are distributed under the
Static Procedure for Endodontic Access Cavities: An in terms of the Creative Commons Attribution-Non Commercial-Share
vitro Study. J Clin Med. 2020 Jan 2;9(1):129. Alike 4.0 International (CC BY-NC-SA 4.0) License, which allows
27. Kim BN, Son SA, Park JK. Endodontic retreatment of a others to remix, tweak, and build upon the work non-commercially, as
long as appropriate credit is given and the new creations are licensed
calcified anterior tooth using a 3D-printed endodontic under the identical terms.
guide. Int J Comput Dent. 2021 Dec 21;24(4):419-427.
28. Zubizarreta-Macho Á, Valle Castaño S, Montiel-
Company JM, Mena-Álvarez J. Effect of Computer-
Aided Navigation Techniques on the Accuracy of
Endodontic Access Cavities: A Systematic Review and
Meta-Analysis. Biology (Basel). 2021 Mar 10;10(3):212
29. Shah P, Chong BS. 3D imaging, 3D printing and 3D
virtual planning in endodontics. Clin Oral Investig. 2018
Mar;22(2):641-654.
30. Zhang T, Chen D, Miao LY, Xie SJ, Tang XN. [Guided
endodontic access of calcified root canal by laser melting
templates]. Hua Xi Kou Qiang Yi Xue Za Zhi. Chinese.
2020 Oct 1;38(5):525-531.
31. Ali A, Arslan H. Effectiveness of the static-guided
endodontic technique for accessing the root canal through
MTA and its effect on fracture strength. Clin Oral
Investig. 2021 Apr;25(4):1989-1995.
32. Gambarini G, Galli M, Morese A, Stefanelli LV,
Abduljabbar F, Giovarruscio M, et al. Precision of
Dynamic Navigation to Perform Endodontic
Ultraconservative Access Cavities: A Preliminary In vitro
Analysis. J Endod. 2020 Sep;46(9):1286-1290.
33. Panithini DB, Sajjan GS, Kinariwala N, Medicharla UD,
Varma KM, Kallepalli M. Real-time guided endodontics:
A case report of maxillary central incisor with calcific
metamorphosis. J Conserv Dent. 2023 Jan-
Feb;26(1):113-117.
34. Liu SM, Zhao YJ, Wang XY, Wang ZH. [In
~ 101 ~