applied

sciences
Article
Accuracy of Guided Endodontics in Posterior Teeth
Benjamin Haarmann 1,† , Wadim Leontiev 1,† , Eva Magni 1, * , Sebastian Kühl 2 , Dorothea Dagassan-Berndt 3 ,
Roland Weiger 1 and Thomas Connert 1

1 Department of Periodontology, Endodontology and Cariology, University Center for Dental Medicine Basel
UZB, University of Basel, Mattenstrasse 40, 4058 Basel, Switzerland
2 Department of Oral Surgery, University Center for Dental Medicine Basel UZB, University of Basel,
Mattenstrasse 40, 4058 Basel, Switzerland
3 Center for Dental Imaging, University Center for Dental Medicine Basel UZB, University of Basel,
Mattenstrasse 40, 4058 Basel, Switzerland
* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: The purpose of this ex vivo study was to determine the accuracy of template-based guided
endodontics for access cavity preparation and root canal detection in posterior teeth. First, three
maxillary and four mandibular models were constructed using 67 premolars and molars, with a total
number of 135 main root canals. Cone beam computed tomography (CBCT) and three-dimensional 3D
surface scans of each model were performed and matched in order to plan access cavity preparation
and design templates virtually. Template-guided access cavity preparation was then performed for
each tooth, followed by postoperative CBCT scanning. Deviations between planned and prepared
access cavities were measured after superimposition of the pre- and postoperative CBCT scans, and
they were analyzed using descriptive and multivariate statistics. All root canals (135/135) were
detected utilizing guided endodontics. The mean angle deviation was 1.4 degrees, and the mean
deviations at the tip and base of the bur were 0.24–0.31 mm and 0.26–0.29 mm, respectively. This
study demonstrated that guided endodontics is an accurate and predictable method for endodontic
access cavity preparation in posterior teeth.

Keywords: guided endodontics; cone beam computed tomography; access cavity preparation
Citation: Haarmann, B.; Leontiev, W.;
Magni, E.; Kühl, S.; Dagassan-Berndt,
D.; Weiger, R.; Connert, T. Accuracy
of Guided Endodontics in Posterior 1. Introduction
Teeth. Appl. Sci. 2023, 13, 2321.
The aim of any root canal treatment is to cure or prevent apical periodontitis [1]. This
https://doi.org/10.3390/
is mainly achieved by disinfecting the root canal system [2,3].
app13042321
In teeth with severe pulp canal calcification (PCC), endodontic access cavity prepa-
Academic Editor: Andrea Scribante ration and identification of the root canal orifice can be very difficult, time-consuming
Received: 13 January 2023
and prone to a higher risk of iatrogenic damage (e.g., tooth structure loss and root per-
Revised: 3 February 2023
foration) [4]. An increased loss of enamel and dentin may result in an increased risk of
Accepted: 9 February 2023
fractures, ultimately worsening the prognosis of the tooth [4,5]. Guided endodontics (GE)
Published: 10 February 2023 is an innovative method that uses 3D imaging (cone beam computed tomography, CBCT)
and surface scans for virtual preoperative planning of minimally invasive access cavity
preparation. A bur is guided through a template sleeve system to the planned position,
similarly to the technique of guided implantology [6]. Guided endodontics enables the
Copyright: © 2023 by the authors. operator to locate the root canal orifice even in teeth with severe PCC [7,8], and is less
Licensee MDPI, Basel, Switzerland. invasive than conventional endodontic techniques [9].
This article is an open access article Since CBCT was introduced into dentistry, it has been widely used for diagnostics
distributed under the terms and and treatment planning [10]. It is extremely important to adhere to the ALARA principle
conditions of the Creative Commons (as low as reasonably achievable) in order to keep the radiation exposure for patients as
Attribution (CC BY) license (https://
low as possible [11]. A CBCT in endodontics may be considered when the conventional
creativecommons.org/licenses/by/
radiograph is insufficient for diagnosis, and the additional information from the CBCT
4.0/).

Appl. Sci. 2023, 13, 2321. https://doi.org/10.3390/app13042321 https://www.mdpi.com/journal/applsci

Appl. Sci. 2023, 13, 2321 2 of 8

is likely to facilitate diagnosis and further treatment. The current guidelines explicitly
state that implementation of a CBCT may be justified for the planning of GE in teeth with
PCC [12].
Appl. Sci. 2023, 13, 2321 Guided endodontics is already being implemented in the clinical setting. 2 of 8 However, it
is mainly used in anterior teeth [8,13], and only a few publications have provided details
regarding the accuracy of GE in posterior teeth [14,15]. Therefore, the aim of this study
was to determine
diagnosis and furtherthe general
treatment. accuracy
The of template-guided
current guidelines endodontics
explicitly state that for access cavity
implementation
of a CBCT may be justified for the planning of GE in teeth with PCC [12].
preparation in posterior teeth, and to evaluate variables that might affect the accuracy of
Guided endodontics is already being implemented in the clinical setting. However,
access cavity preparation, such as the type of tooth (molar vs. premolar), location of the
it is mainly used in anterior teeth [8,13], and only a few publications have provided details
posterior teeth (maxilla vs. mandible) and the number of root canals per tooth.
regarding the accuracy of GE in posterior teeth [14,15]. Therefore, the aim of this study
was to determine the general accuracy of template-guided endodontics for access cavity
2.preparation
Materialsinand Methods
posterior teeth, and to evaluate variables that might affect the accuracy of
Sixty-seven
access premolars
cavity preparation, such and
as themolars
type of extracted forvs.reasons
tooth (molar unrelated
premolar), location to this study were
of the
posterior teeth (maxilla vs. mandible) and the number of root canals per tooth.
used to construct three maxillary and four mandibular models. Only premolars and molars
with complete root formation and without resorptions or restorations were included. Teeth
2. Materials and Methods
with profound caries extending to the pulp were excluded. The extracted teeth were
Sixty-seven premolars and molars extracted for reasons unrelated to this study were used
placed in their anatomically correct arch positions and fixed onto a permanent methyl
to construct three maxillary and four mandibular models. Only premolars and molars with
methacrylate copolymer
complete root formation and base.
withoutAfterwards,
resorptions oroptical surface
restorations werescans of the
included. models
Teeth with were made
using
profound caries extending to the pulp were excluded. The extracted teeth were placed in their Switzerland)
an intraoral scanner (3Shape TRIOS 3; Institut Straumann AG, Basel,
and saved in
anatomically surface
correct tessellation
arch positions language
and fixed (STL) format.
onto a permanent Additionally,
methyl methacrylate CBCT scans of
copoly-
each model were made with a voxel size of 0.16 mm, 90 kV, 6 mA and an 8 × 8 cm field
mer base. Afterwards, optical surface scans of the models were made using an intraoral scan-
nerview
of (3Shape(3DTRIOS 3; Institut Straumann
Accuitomo 170; Morita AG,Manufacturing
Basel, Switzerland)Corp.,
and saved in surface
Kyoto, tessel-and saved in
Japan)
lation language (STL) format. Additionally, CBCT scans of each model were made with a
digital imaging and communications in medicine (DICOM) format. The STL and DICOM
voxel size of 0.16 mm, 90 kV, 6 mA and an 8 × 8 cm field of view (3D Accuitomo 170; Morita
data sets wereCorp.,
Manufacturing then Kyoto,
imported into
Japan) and3D planning
saved software
in digital imaging (coDiagnostiX;
and communications Dental
in Wings Inc,
Montreal,
medicine (DICOM) format. The STL and DICOM data sets were then imported into 3D plan- tool without
Canada) and virtually matched based on the available matching
further corrections.
ning software For each
(coDiagnostiX; main
Dental root Inc,
Wings canal of the 67
Montreal, posterior
Canada) teeth, a matched
and virtually guided access cavity
basedplanned
was on the available
in thematching tool without
3D planning furtherby
software corrections.
virtually Forpositioning
each main rootacanal of
true-to-dimension
the 67 posterior teeth, a guided access cavity was planned in the 3D planning software
bur to allow straight-line access to the root canal orifice, followed by the construction of by
virtually positioning a true-to-dimension bur to allow straight-line access to the root canal or-
templates (Figure 1).
ifice, followed by the construction of templates (Figure 1).

Figure 1. Digital workflow: (A) virtually planned straight-line access cavity, (B) multiple access cav-
Figure 1. Digital workflow: (A) virtually planned straight-line access cavity, (B) multiple access
ities planned for posterior teeth in a maxillary model, (C) virtually designed template, (D) 3D ren-
cavities
dered viewplanned for posterior
of accuracy evaluation teeth in athemaxillary
revealing model, planned
deviation between (C) virtually designed
and performed template, (D) 3D
access
cavity preparation.
rendered view of accuracy evaluation revealing the deviation between planned and performed access
cavity preparation.
A total of 11 templates were virtually designed with computer-aided design/computer-
aided manufacturing (CAD/CAM) and manufactured from polymethyl methacrylate discs
A total of 11 templates were virtually designed with computer-aided design/computer-
(98.5 mm; Yamahachi Dental, Gamagori, Japan) in a 3D milling machine (Motion 2; Amann
aided manufacturing
Girrbach (CAD/CAM)
AG, Koblach, Austria) and manufactured
[16]. The fabricated from
templates were polymethyl
checked for propermethacrylate
fit on discs
(98.5 mm; Yamahachi Dental, Gamagori, Japan) in a 3D milling machine (Motion
the models and adjusted as needed. Afterwards, the tip of the guided endodontics bur was 2; Amann
Girrbach AG,
stained with Koblach,
caries Austria)
marker solution [16].
(Karies The VOCO
Marker, fabricated
GmbH,templates were checked
Cuxhaven, Germany). The for proper
fit on the models and adjusted as needed. Afterwards, the tip of the guided endodontics
bur was stained with caries marker solution (Karies Marker, VOCO GmbH, Cuxhaven,
Appl. Sci. 2023, 13, 2321 3 of 8

Appl. Sci. 2023, 13, 2321 Germany). The template, with the sleeve inserted, was placed on the model 3 of 8 in the end
position and the stained bur was inserted in the sleeve, leaving a mark indicating the
occlusal position of the access cavity. The enamel at the access cavity site was then removed
template, with the sleeve inserted, was placed on the model in the end position and the stained
using a diamond bur in a contra-angle handpiece without using the template. With dentin
bur was inserted in the sleeve, leaving a mark indicating the occlusal position of the access
exposed, the endodontic bur (ATEC Endoseal, steco-system-technik GmbH & Co KG,
cavity. The enamel at the access cavity site was then removed using a diamond bur in a contra-
Hamburg, Germany)
angle handpiece was set
without using the to a speed
template. of dentin
With 10,000exposed,
rpm and the guided
endodonticthrough the sleeve of the
bur (ATEC
template using slow and short
Endoseal, steco-system-technik GmbH up-and-down
& Co KG, Hamburg,movements
Germany)while
was setregularly
to a speed clearing
of debris
from
10,000the
rpmbur
and and
guidedaccess
throughcavity. Guided
the sleeve of theaccess
templatecavity preparation
using slow was completed once the
and short up-and-down
movements
bur reached while
theregularly
definedclearing debris
bur stop. from the bur and
Endodontic handaccess
filescavity.
wereGuided access cav-to confirm the
then utilized
ity preparation was completed once the bur reached the defined bur stop.
root canal location (Figure 2). After access cavity preparation for each tooth, Endodontic hand the bur was
files were then utilized to confirm the root canal location (Figure 2). After access cavity prep-
inspected for deformation or damage, and was replaced after completing all teeth on a
aration for each tooth, the bur was inspected for deformation or damage, and was replaced
model or beforehand
after completing if any
all teeth on damage
a model was observed.
or beforehand if any damage was observed.

Figure 2. Access cavity preparation: (A) CAD/CAM-fabricated template placed on a model, (B)
Figure 2. Access cavity preparation: (A) CAD/CAM-fabricated template placed on a model,
sleeve inserted for static navigation of the bur, (C) access cavity preparations in maxillary premolars
(B)
andsleeve
molar, inserted forthree
(D) locating static navigation
main root canalsofwith
the endodontic
bur, (C) access cavity preparations in maxillary premo-
hand files.
lars and molar, (D) locating three main root canals with endodontic hand files.
After all access cavities were prepared, postoperative CBCT scans of each model were
After
created usingalltheaccess cavities
same CBCT weresettings
machine prepared, postoperative
as those CBCTUsing
used preoperatively. scanstheofplan-
each model were
ning software, the pre- and postoperative CBCT data were matched
created using the same CBCT machine settings as those used preoperatively. in the 3D planning soft- Using the
ware. The software,
planning treatment evaluation tool integrated
the pre- and into theCBCT
postoperative software
datawaswere
usedmatched
to determine the 3D planning
in the
accuracy of the prepared vs. virtually planned access cavities. Because the direction of each
software. The treatment evaluation tool integrated into the software was used to determine
access cavity could be derived from the postoperative CBCT data, virtual bur placement was
the accuracy
possible for each ofprepared
the prepared vs. virtually
access cavity. planned
The software access cavities.
then automatically Because
calculated the an- the direction
of each access cavity could be derived from the postoperative CBCT
gular and spatial deviation in different planes at the tip and base of the bur. Descriptive anal- data, virtual bur
placement was possible
ysis was performed for each
for all access prepared
cavities (Table 1).access cavity.
The results for The software
posterior then automatically
tooth location
(maxilla vs. mandible),
calculated the angular typeand
(molar vs. premolar)
spatial deviationand in
number of main
different root canals
planes at thepertip
tooth
and base of the
(one, two or three) were calculated as mean values with 95% confidence intervals.
bur. Descriptive analysis was performed for all access cavities (Table 1). The results for In addition,
a multivariate analysis of variance (MANOVA), followed by Bonferroni post hoc tests for the
posterior tooth location (maxilla vs. mandible), type (molar vs. premolar) and number of
variable “number of main root canals”, were performed using SPSS V. 28.0.1 (IBM Corp, Ar-
main root
monk, NY) in canals per
order to tooth
assess the(one, twoof or
influence three)variables
different were calculated
with regard as mean
to the values with 95%
accuracy
confidence intervals. In addition, a multivariate analysis of variance (MANOVA),
of the prepared access cavities in different and angular spatial dimensions. The level of signif- followed
by Bonferroni
icance was set atpost hoc tests for the variable “number of main root canals”, were performed
α = 0.05.
using SPSS V. 28.0.1 (IBM Corp, Armonk, NY, USA) in order to assess the influence of
3. Results variables with regard to the accuracy of the prepared access cavities in different
different
All of thespatial
and angular 135 rootdimensions.
canals (100%)The
werelevel
detected after GE access
of significance wascavity preparation.
set at α = 0.05.
No root perforations were observed. The overall mean angular deviation between the
planned
Table 1. and prepared
Deviation access cavities
between planned was 1.39
and degrees (details
prepared are shown
access cavities in Table 1).
regarding The deviation and
angle
distribution of angular deviation for all models is presented in Figure 3.
mesio-distal and bucco-oral deviation at the tip and base of the bur.

Angle Mesio-Distal, at Base Bucco-Oral, at Base of Mesio-Distal, at Tip of Bucco-Oral, at Tip

Deviation
[Degrees] of the Bur [mm] the Bur [mm] the Bur [mm] of the Bur [mm]
Mean 1.39 0.26 0.29 0.24 0.31
Median 1.10 0.20 0.21 0.18 0.21
Minimum 0.0 0.0 0.0 0.0 0.0
Maximum 7.8 1.19 1.96 1.61 1.36
 Appl. Sci. 2023, 13, 2321 4 of 8

Appl. Sci. 2023, 13, 2321 4 of 8

3. Results
All of the 135 root canals (100%) were detected after GE access cavity preparation.
Appl. Sci. 2023, 13, 2321 No root perforations were observed. The overall mean angular deviation between
4 of 8 the
planned and prepared access cavities was 1.39 degrees (details are shown in Table 1). The
distribution of angular deviation for all models is presented in Figure 3.

Figure 3. Angle deviation between the planned and prepared access cavities on the three maxillary
and four mandibular models.

Table 1. Deviation between planned and prepared access cavities regarding angle deviation and
mesio-distal and bucco-oral deviation at the tip and base of the bur.

Angle Mesio-Distal, at Base Bucco-Oral, at Base Mesio-Distal, at Tip Bucco-Oral, at Tip

Deviation
[degrees] of the Bur [mm] of the Bur [mm] of the Bur [mm] of the Bur [mm]
Mean 1.39 0.26 0.29 0.24 0.31
Median 1.10 0.20 0.21 0.18 0.21
Minimum 0.0 Figure Angle
Figure3.3.Angle deviation
0.0 between the planned
0.0 and prepared access
0.0 cavities on the three maxillary
0.0
deviation between the planned and prepared access cavities on the three maxillary
Maximum 7.8 and
andfour
four 1.19
mandibular models.
mandibular models. 1.96 1.61 1.36

The
Table 1. Themean
Deviation angular
meanbetween and
angularplannedspatial deviations
and prepared
and spatial inin
access
deviations the different
cavities
the regarding
different dimensions, inand
angle deviation
dimensions, addition
in addition to
mesio-distal
to their
their95% and
95% bucco-oral deviation at the tip and base of the bur.
confidence intervals for maxillary vs. mandibular teeth and for molars vs. pre- vs.
confidence intervals for maxillary vs. mandibular teeth and for molars
Angle
premolars, areshown
molars, are
Mesio-Distal,
shown in Figure
at Basein Bucco-Oral,
Figure 4. at
Regarding
4. Regarding angular
Base angular
deviation,
deviation,
Mesio-Distal,
the MANOVA
the MANOVA
at Tip Bucco-Oral,
revealed
revealed
at Tip that
Deviation that access
access cavity preparation was significantly less accurate in maxillary teeth compared
[degrees] of the cavity
Bur [mm]preparation wasBur
of the significantly
[mm] less accurate
of the in maxillary
Bur [mm] teeth
of the Burcompared
[mm] to
to mandibular
mandibular teeth (1.70◦vs.
teeth(1.70° vs. 1.04p◦ ;=p0.03).
1.04°; = 0.03).
TheThe results
results are presented
are presented in Table
in Table 2. 2.
Mean 1.39 0.26 0.29 0.24 0.31
Median 1.10 0.20 0.21 0.18 0.21
Minimum 0.0 0.0 0.0 0.0 0.0
Maximum 7.8 1.19 1.96 1.61 1.36

The mean angular and spatial deviations in the different dimensions, in addition to
their 95% confidence intervals for maxillary vs. mandibular teeth and for molars vs. pre-
molars, are shown in Figure 4. Regarding angular deviation, the MANOVA revealed that
access cavity preparation was significantly less accurate in maxillary teeth compared to
mandibular teeth (1.70° vs. 1.04°; p = 0.03). The results are presented in Table 2.

Figure
Figure 4. 4.Mean
Meanangle
angle deviation
deviation(°)(◦and mean
) and deviation
mean at theatbase
deviation the and
basethe tip of
and thethe bur
tip ofinthe
thebur
mesio-
in the
distal and bucco-oral dimensions (mm) by tooth location (maxilla vs. mandible) and type (premolar
mesio-distal and bucco-oral dimensions (mm) by tooth location (maxilla vs. mandible) and type
(pm) vs. molar (m)).
(premolar (pm) vs. molar (m)).

MANOVA revealed that the number of root canals per tooth had a significant effect
on the angular and spatial deviation at the tip of the bur in the bucco-oral direction
(p < 0.05). The results for accuracy with regard to mean deviation, according to the number
of main roots canals per tooth, are shown in Figure 5. Teeth with one canal had significantly
higher mean angle deviation than those with two canals (2.08 vs. 0.96 degrees; p = 0.006).
Figuredeviation
The in deviation
4. Mean angle bucco-oral dimension
(°) and at theattip
mean deviation theof theand
base burthewas
tip ofalso significantly
the bur in the mesio-greater
distal and bucco-oral dimensions (mm) by tooth location (maxilla vs. mandible) and type (premolar
(pm) vs. molar (m)).
 Appl. Sci. 2023, 13, 2321 5

Table 2. Mean angle deviation (°) and deviation in the mesio-distal and bucco-oral direction (m
Appl. Sci. 2023, 13, 2321 at the base and tip of the bur between maxillary vs. mandibular and premolar vs.5 molar
of 8 teeth.

Mean
Deviation Type
Maxilla Mandible p-Value Premolar Molar p-Value
in teeth
Angle [°]with one canal compared
1.70 to those
1.04 with two canals
0.03 (0.42 vs.
1.52 0.27 mm; p
1.34= 0.04). 0.89
Further
Mesiodistal, details
Base [mm]are shown0.31 in Tables 3 and
0.274. 0.99 0.29 0.29 0.11
Buccolingual, Base [mm] 0.29 0.23 0.78 0.22 0.28 0.77
Table 2. Mean angle deviation (◦ ) and deviation in the mesio-distal and bucco-oral direction (mm) at
Mesiodistal, Apex [mm] 0.34 0.28 0.46 0.35 0.30 0.14
the base and tip of the bur between maxillary vs. mandibular and premolar vs. molar teeth.
Buccolingual, Apex [mm] 0.26 0.21 0.97 0.16 0.27 0.77
Mean
Deviation Type MANOVA revealed that the number of root canals per tooth had a significant eff
Maxilla Mandible p-Value Premolar Molar p-Value
on the angular and spatial deviation at the tip of the bur in the bucco-oral direction (
Angle [◦ ] 1.70 1.04
0.05). The 0.03 with regard
results for accuracy 1.52 to mean deviation,
1.34 0.89 to the numbe
according
Mesiodistal, Base [mm] 0.31 main roots
0.27canals per tooth,
0.99 are shown0.29
in Figure 5. Teeth
0.29 with one canal
0.11 had significan
higher mean angle deviation than those with two canals (2.08 vs. 0.96 degrees; p = 0.00
Buccolingual, Base [mm] 0.29 0.23 0.78 0.22 0.28 0.77
The deviation in bucco-oral dimension at the tip of the bur was also significantly grea
Mesiodistal, Apex [mm] 0.34 in teeth0.28
with one canal 0.46 0.35 with two0.30
compared to those 0.14
canals (0.42 vs. 0.27 mm; p = 0.0
Buccolingual, Apex [mm] 0.26 Further 0.21
details are shown in Tables 3 and
0.97 0.164. 0.27 0.77

Figure 5. Mean angle

Figuredeviation (◦ ) and
5. Mean angle mean (°)
deviation deviation
and meanatdeviation
the tip of thetip
at the bur
of in
thethe
burbucco-oral
in the bucco-oral dim
dimension (mm) for teeth
sion with
(mm) forone,
teethtwo orone,
with three main
two root main
or three canals, respectively.
root canals, respectively.

Table 3.
Table 3. Mean difference inMean
angledifference
deviation in angle deviation
between planned between planned
and prepared and cavities
access preparedaccording
access cavities acco
ing to the number of main root canals per tooth (CPT).
to the number of main root canals per tooth (CPT).
Angle Deviation [°]
Angle Deviation ◦
Group [1 ] Group 2 Mean Difference: Group 1 vs. Group 2 [°] p-Value
Group 1 ◦ p-Value
1 CPT Group 2 2 CPTMean Difference: Group 1 vs. Group 2[ ]
1.12 0.006
1 CPT 2 CPT 3 CPT 1.12 0.55 0.006 0.36
2 CPT 3 CPT 1 CPT 0.55 −1.12 0.36 0.006
2 CPT 1 CPT 3 CPT −1.12 −0.56 0.006 0.13
3 CPT 3 CPT 1 CPT −0.56 −0.55 0.13 0.36
3 CPT 1 CPT
2 CPT − 0.55
0.56 0.36
0.13
2 CPT 0.56 0.13
Appl. Sci. 2023, 13, 2321 6 of 8

Table 4. Mean difference in bucco-oral deviation at the tip of the bur between planned and prepared
access cavities according to the number of main root canals per tooth (CPT).

Bucco-Oral Deviation at Tip of the Bur [mm]

Mean Difference: Group 1 vs. Group 2 [mm] p-Value
Group 1 Group 2
1 CPT 2 CPT 0.16 0.04
3 CPT 0.12 0.21
2 CPT 1 CPT −0.16 0.04
3 CPT −0.04 1.00
3 CPT 1 CPT −0.12 0.21
2 CPT 0.04 1.00

4. Discussion
This ex vivo proof-of-principle study demonstrates that GE allows for precise and
predictable access cavity preparation in posterior teeth. Other ex vivo studies showing
that GE is a viable, fast and accurate method for the preparation of endodontic access
cavities in anterior teeth already exist [7,8,16], and there are clinical case reports showing
the feasibility of guided endodontic treatment of the upper second and third molars [14] as
well as the first lower molar [17].
The evidence indicates that GE is operator-independent and allows less experienced
operators to reliably access calcified root canals. The overall accuracy (mean angular
deviation for all access cavities) measured in this study (1.39 degrees) is comparable to that
reported in previous studies [7,18].
One interesting new finding of this study is that the number of main root canals per
tooth had a significant effect on angular deviation and spatial deviation at the tip of the
bur in the bucco-lingual dimension. Access cavity preparation was less accurate in teeth
with one main root canal than in multi-canal teeth. This could be explained by the fact that
the teeth used in this study did not have severe calcification, and that the teeth with one
root canal had a larger, possibly oval root canal lumen. Since there was a certain looseness
of fit between the utilized burs and sleeves, the bur might have been able to center itself
in smaller and rounder root canals once the root canal orifice was reached. This would
explain the smaller deviation in teeth with two or three main root canals per tooth.
However, operator-related sources of error (e.g., manual positioning during certain
steps) may have led to inaccuracies in access cavity preparation as well. Semi-automatic
registration of CBCT and surface scan data by the planning software could be another
source of inaccuracy, as there is some evidence suggesting that full arch surface scans
may be subject to local deviation [16]. Other sources of inaccuracy described in previous
studies also apply to the present study (e.g., CAD/CAM processing of templates or loose
fit between the bur and sleeve) [19].
There are limiting factors to consider before performing GE in the posterior region [7].
A limited mouth-opening ability and, therefore, limited space for the GE template may
complicate the application of GE in posterior regions. However, it should be noted that the
templates used in clinical practice can be designed with a lower height than the ones used
in this study.
For GE, the root canal orifice must be located in a position that can be reached by a
straight and rigid bur [7]. Therefore, root curvature is considered a contraindication if the
root canal orifice is located far apically. In contrast to anterior teeth, molars often have roots
with greater curvature. Fortunately, curvatures most commonly occur in the apical third of
molar roots, resulting in a generally promising prognosis for guided endodontics treatment
in molars, since root canal calcifications rarely occur up to the apical third of the root canal
of these teeth [15].
Even though complex canal morphologies can be a limiting factor for the application
of GE, on the other hand, GE may be advantageous in teeth with root variations. GE could
be aid in the identification of a calcified radix entomolaris or a middle mesial canal.
Appl. Sci. 2023, 13, 2321 7 of 8

The planning effort has surely increased with the application of GE; however, the
effective treatment time for the patient is probably reduced, as the tedious search for
PCC is omitted. Therefore, GE may possibly improve the patient’s comfort, even though
additional treatment steps such as intraoral scanning are necessary. In addition, numerous
case reports and studies regarding GE have already been published, focusing mainly on
anterior teeth [20].
CBCT has become an important tool for preoperative planning in dentistry. In en-
dodontics, CBCT aids in identifying resorptions, calcifications, root canal morphologies
and apical pathologies [21]. However, CBCT results in higher radiation doses than con-
ventional radiography techniques. Therefore, the indication for CBCT must be carefully
evaluated. According to a joint statement of the American Association of Endodontists and
the American Academy of Oral and Maxillofacial Radiology, the use of limited field-of-view
(FOV) is indicated to help identify and locate calcified canals and depict complex canal
morphology [22].
A limitation of this ex vivo study is related to the fact that none of the treated teeth
were severely calcified. Severe calcification could have negative implications for virtual
access cavity planning and may result in lower overall accuracy. However, it is difficult
to find extracted teeth that are severely calcified, yet caries- and restoration-free, at the
same time. In recent years, 3D-printed teeth have also been used in the field of endodontic
teaching and research. The major advantage of these teeth over extracted teeth is the
possibility to digitally create root canal calcification as needed. However, studies have also
shown that various types of 3D-printed teeth cannot fully reproduce the optical and haptic
properties of human dentin [23].
In GE, additional time is required to perform CBCT and intraoral scanning, to complete
the virtual planning and to fabricate the guide template. Further studies are needed to
address aspects such as the differences between conventional freehand and GE access cavity
preparation in posterior teeth with regard to time, operator experience, possible additional
costs and the amount of tooth substance loss that is associated with the techniques.

5. Conclusions
Guided endodontics is an accurate and predictable technique for access cavity prepa-
ration and root canal detection in posterior teeth. All root canals were successfully detected
due to a low deviation in angle (1.4◦ ) and a low mean deviation at the tip of the bur
(0.24–0.31 mm). GE was even more accurate in teeth with multiple root canals than in teeth
with only one root canal.

Author Contributions: Conceptualization, T.C. and R.W.; methodology, T.C.; software, S.K. and
W.L.; formal analysis, W.L.; investigation, B.H.; data curation, B.H. and W.L.; writing—original
draft preparation, B.H.; writing—review and editing, B.H., W.L., T.C., E.M., R.W., D.D.-B. and S.K.;
visualization, B.H. and W.L.; supervision, T.C.; funding acquisition. All authors have read and agreed
to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical approval was obtained from the local Research Ethics
Committee (EKNZ UBE-15/111).
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: This article was supported by the following dentists, who provided access to
the necessary infrastructure: Sabine Teubner, Eckart Teubner, and Stefanie Hirt.
Conflicts of Interest: The authors declare that they have no conflict of interest.
Appl. Sci. 2023, 13, 2321 8 of 8

References
1. European Society of Endodontology. Quality guidelines for endodontic treatment: Consensus report of the European Society of
Endodontology. Int. Endod. J. 2006, 39, 921–930. [CrossRef] [PubMed]
2. Schilder, H. Cleaning and shaping the root canal. Dent. Clin. N. Am. 1974, 18, 269–296. [CrossRef] [PubMed]
3. Kakehashi, S.; Stanley, R.; Fitzgerald, R.J. The effects of surgical exposures of dental pulps in germ-free and conventional
laboratory rats. Oral. Surg. Oral. Med. Oral. Pathol. 1965, 20, 340–349. [CrossRef] [PubMed]
4. Cvek M, G.L.; Lundberg, M. Failures and healing in endodontically treated non-vital anterior teeth with posttraumatically
reduced pulpal lumen. Acta Odontol. Scand. 1982, 40, 223–228. [CrossRef] [PubMed]
5. Lang, H.; Korkmanz, Y.; Schneider, K.; Raab, W.H. Impact of Endodontic Treatments on the Rigidity of the Root. J. Dent. Res.
2006, 85, 364–368. [CrossRef] [PubMed]
6. Kühl, S.; Payer, M.; Zitzmann, N.U.; Lambrecht, J.T.; Filippi, A. Technical accuracy of printed surgical templates for guided
implant surgery with the coDiagnostiX software. Clin. Implant Dent. Relat. Res. 2015, 17, 177–182. [CrossRef]
7. Connert, T.; Zehnder, M.S.; Weiger, R.; Kühl, S.; Krastl, G. Microguided Endodontics: Accuracy of a Miniaturized Technique for
Apically Extended Access Cavity Preparation in Anterior Teeth. Int. Endod. J. 2017, 43, 787–790. [CrossRef] [PubMed]
8. Krastl, G.; Zehnder, M.S.; Connert, T.; Weiger, R.; Kuhl, S. Guided Endodontics: A novel treatment approach for teeth with pulp
canal calcification and apical pathology. Dent. Traumatol. 2015, 32, 240–246. [CrossRef]
9. Connert, T.; Krug, R.; Eggmann, F.; Emsermann, I.; ElAyouti, A.; Weiger, R.; Kuhl, S.; Krastl, G. Guided Endodontics versus
Conventional Access Cavity Preparation: A Comparative Study on Substance Loss Using 3-dimensional-printed Teeth. J. Endod.
2019, 45, 327–331. [CrossRef]
10. Mozzo, P.; Procacci, C.; Tacconi, A.; Martini, P.T.; Andreis, I.A. A new volumetric CT machine for dental imaging based on the
cone-beam technique: Preliminary results. Eur. Radiol. 1998, 8, 1558–1564. [CrossRef]
11. Farman, A.G. ALARA still applies. Oral. Surg. Oral. Med. Oral. Pathol. Oral. Radiol. Endod. 2005, 4, 395–397. [CrossRef] [PubMed]
12. Patel, S.; Brown, J.; Semper, M.; Abella, F.; Mannocci, F. European Society of Endodontology position statement: Use of cone beam
computed tomography in Endodontics. Int. Endod. J. 2019, 52, 1675–1678. [CrossRef] [PubMed]
13. van der Meer, W.J.; Vissink, A.; Ng, Y.L.; Gulabivala, K. 3D Computer aided treatment planning in endodontics. J. Dent. 2016, 45,
67–72. [CrossRef] [PubMed]
14. Lara-Mendes, S.T.O.; Barbosa, C.F.M.; Santa-Rosa, C.C.; Machado, V.C. Guided Endodontic Access in Maxillary Molars Using
Cone-beam Computed Tomography and Computer-aided Design/Computer-aided Manufacturing System: A Case Report. J.
Endod. 2018, 44, 875–879. [CrossRef]
15. Lee, J.K.; Ha, B.H.; Choi, J.H.; Heo, S.M.; Perinpanayagam, H. Quantitative three-dimensional analysis of root canal curvature in
maxillary first molars using micro-computed tomography. J. Endod. 2006, 32, 941–945. [CrossRef] [PubMed]
16. Leontiev, W.; Bieri, O.; Madorin, P.; Dagassan-Berndt, D.; Kuhl, S.; Krastl, G.; Krug, R.; Weiger, R.; Connert, T. Suitability of
Magnetic Resonance Imaging for Guided Endodontics: Proof of Principle. J. Endod. 2021, 47, 954–960. [CrossRef]
17. Shi, X.; Zhao, S.; Wang, W.; Jiang, Q.; Yang, X. Novel navigation technique for the endodontic treatment of a molar with pulp
canal calcification and apical pathology. Aust. Endod. J. 2018, 44, 66–70. [CrossRef]
18. Zehnder, M.S.; Connert, T.; Weiger, R.; Krastl, G.; Kühl, S. Guided endodontics: Accuracy of a novel method for guided access
cavity preparation and root canal location. Int. Endod. J. 2016, 49, 966–972. [CrossRef]
19. Krug, R.; Reich, S.; Connert, T.; Kess, S.; Soliman, S.; Reymus, M.; Krastl, G. Guided endodontics: A comparative in vitro study on
the accuracy and effort of two different planning workflows. Int. J. Comput. Dent. 2020, 23, 119–128.
20. Connert, T.; Weiger, R.; Krastl, G. Present status and future directions—Guided endodontics. Int. Endod. J. 2022, 10, 995–1002.
[CrossRef] [PubMed]
21. Patel, S.; Durack, C.; Abella, F.; Shemesh, H.; Roig, M.; Lemberg, K. Cone beam computed tomography in Endodontics—A review.
Int. Endod. J. 2015, 48, 3–15. [CrossRef] [PubMed]
22. Endodontics, A.A.O. AAE and AAOMR Joint Position Statement—Use of Cone Beam Computed Tomography in Endodontics.
Available online: https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/conebeamstatement.pdf (accessed on
12 December 2022).
23. Reymus, M.; Fabritius, R.; Keßler, A.; Hickel, R.; Edelhoff, D.; Stawarczyk, B. Fracture load of 3D-printed fixed dental prostheses
compared with milled and conventionally fabricated ones: The impact of resin material, build direction, post-curing, and artificial
aging-an in vitro study. Clin. Oral. Investig. 2020, 24, 701–710. [CrossRef] [PubMed]

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