Conservative management of Type II dens invaginatus with guided endodontic approach: A case series

Application of personalized templates in minimally invasive management of coronal dens invaginatus: a report of two cases

BACKGROUND

Treating the coronal dens invaginatus (CDI) with pulp infection commonly involves the removal of invagination, which increases the risk of perforation and fracture, and compromises the tooth structure. Minimally invasive endodontic management of CDI is highly recommended. This report describes two cases of type II CDI with the application of personalized templates.

CASE PRESENTATION

Two cases of type II CDI, affecting the main root canal in a maxillary canine and a lateral incisor, were diagnosed. A guided endodontics (GE) approach was applied. Cone-beam computed tomography and intraoral scans were imported and aligned in a virtual planning software to design debridement routes and templates. The MICRO principle (which involves the aspects of Mechanical (M) debridement, Irrigation (I), Access cavities (C), Rectilinear routes (R), and Obstruction (O)) was proposed for designing optimal debridement routes for future applications. The templates were innovatively personalized and designed to preserve the tooth structure maximally while effectively debriding the root canal. Root canal treatment with supplementary disinfection was then performed. The follow-up of the two patients revealed favorable clinical and radiographic outcomes.

CONCLUSIONS

The GE approach could be a feasible method for preserving healthy dental structure while effectively debriding the root canal, thereby achieving successful and minimally invasive endodontic treatment for CDI.

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.

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.

Evaluation of volumetric substance loss and precision in targeted endodontic re-treatment with guided versus conventional access cavity preparations: An in vitro study

Introduction

Root canal retreatment is typically viewed as an "all or nothing" approach. Whether there is periapical pathosis or not, it is advised that all restorative and obturation materials be removed from all roots. Selective root retreatment, a new therapeutic strategy, allows retreatment to be restricted to a single root or multiple roots exhibiting periapical pathosis. To address the issues, "guided endodontics," a unique guided technique for the preparation of apically extended access cavities, was introduced.

Materials and Methods

In this in vitro experimental study, 22 freshly extracted two-rooted maxillary first premolars were selected and divided into two groups (n = 11). Pretreatment cone-beam computed tomography imaging of all teeth was performed. Root canal treatment was performed for all samples followed by postendodontic composite restorations with the occlusal stamp technique. Then targeted endodontic retreatment (TER) was done with the conventional method and guided method respectively. The tooth substance loss was measured and evaluated using Ez3D-i-3D-software (VATECH) and work precision was determined by calculating the dentinal loss. Statistical data analysis was done by Independent t-test for substance loss measurement and Chi-square test was used to measure the dentinal loss.

Results

TER with conventional method showed significantly higher substance loss with t = 4.591 (P < 0.05) and significantly higher dentinal loss measured in conventional method (P < 0.05).

Conclusion

In comparison to traditional TER, TER using a customized bur and three dimensions (3D)-guide results in much less substance loss. The dentinal loss was much lower in 3D-guided approach.

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.

Non-surgical management of dens invaginatus type IIIB in maxillary lateral incisor with three root canals and 6-year follow-up: A case report and review of literature

BACKGROUND

The presence of dens invaginatus (DI) complicates treatment of any tooth, from diagnosis to access cavity and biomechanical preparation and obturation. Reports of successful non-surgical management of DI type IIIB in maxillary lateral incisor are rare. Here, we report such a case, with three root canals and a long follow-up.

CASE SUMMARY

A 13-year-old female patient presented with mild pain in the maxillary right lateral incisor (#7) for 10-15 d. On examination, the tooth was slightly rotated, with slight tenderness on percussion and grade I mobility but with no caries, pockets or restorations and non-vital pulp (via vitality tests). Radiographic examination revealed unusual configuration of the tooth’s root canals, with an enamel-lined invagination extending to the apex, suggesting the possibility of DI Oehler’s type IIIB and a periapical radiolucency. Widening the access cavity lingually revealed one distinct buccal orifice and two distinct palatal orifices; under higher magnification of a dental operating microscope (DOM), the mesio-palatal and disto-palatal orifices were observed as connected by a C-shaped groove. The root canals were prepared with hand K-files following a step-back technique, and obturated using a combination technique of lateral condensation and vertical compaction. At the 6-year follow-up, the patient was asymptomatic, and the periapical radiography displayed significant healing around the apical end of the root.

CONCLUSION

Proper knowledge of unusual root canal anatomy is required in treating DI. Conventional methods of root canal treatment can successfully resolve such complex cases, facilitated by DOM and cone-beam computed tomography.

Guided Endodontics: A Literature Review

The main objective of this paper is to perform an updated literature review of guided endodontics based on the available up-to-date scientific literature to identify and describe the technique, its benefits, and its limitations. Four electronic databases (PubMed, Scopus, Science Direct, and Web of Science) were used to perform a literature search from 1 January 2017 to 13 May 2022. After discarding duplicates, out of 1047 results, a total of 29 articles were eligible for review. Guided endodontics is a novel technique that is currently evolving. It is applied in multiple treatments, especially in accessing and locating root canals in teeth with pulp canal obliteration, microsurgical endodontics, and removing glass fiber posts in endodontic retreatments. In addition, it is independent of an operator's experience, requires less treatment time for the patient, and is more accurate and safer than conventional endodontics.

Present status and future directions - Guided endodontics

Luxation injuries and other stimuli may lead to a pulp canal obliteration (PCO). Even though the apposition of tertiary dentine is a sign of a vital pulp, in some cases root canal treatment is indicated in the long term due to apical periodontitis or pulpitis. Depending on the extent of PCO, root canal treatment may be challenging even for experienced and well-equipped endodontic specialists. The 'guided endodontics' (GE) technique was introduced 6 years ago as an alternative to conventional access cavity preparation for teeth with PCO and apical pathosis or irreversible pulpitis. Using three-dimensional radiological imaging such as cone-beam computed tomography and a digital surface scan, an optimal access to the orifice of the calcified root canal can be planned virtually with appropriate software. GE is implemented either with the help of templates analogous to guided implantology (= static navigation) or by means of dynamic navigation based on a camera-marker system. GE has emerged as a field of research in the last 6 years with very promising laboratory-based results regarding the accuracy of guided endodontic access cavities for both static and dynamic navigation. Clinical implementation seems to provide favourable results, but the evidence is mainly based on numerous case reports and a few case series. This narrative review aims to provide an update on the present status of GE and to identify relevant research areas that could contribute to further improvements of this technique.

Guided Endodontics: Static vs. Dynamic Computer-Aided Techniques—A Literature Review

(1) Background: access cavity preparation is the first stage of non-surgical endodontic treatment. The inaccuracy of this step may lead to numerous intraoperative complications, which impair the root canal treatment’s prognosis and therefore the tooth’s survival. Guided endodontics, meaning computer-aided static (SN) and dynamic navigation (DN) techniques, has recently emerged as a new approach for root canal location in complex cases. This review aims to compare SN and DN guided endodontics’ techniques in non-surgical endodontic treatment. (2) Methods: an electronic search was performed on PubMed, Scopus, and Cochrane Library databases until October 2021. Studies were restricted by language (English, Spanish and Portuguese) and year of publication (from 2011 to 2021). (3) Results: a total of 449, 168 and 32 articles were identified in PubMed, Scopus, and Cochrane Library databases, respectively, after the initial search. Of the 649 articles, 134 duplicates were discarded. In this case, 67 articles were selected after title and abstract screening, of which 60 were assessed for eligibility through full-text analysis, with one article being excluded. Four cross-references were added. Thus, 63 studies were included. (4) Conclusions: guided endodontics procedures present minimally invasive and accurate techniques which allow for highly predictable root canal location, greater tooth structure preservation and lower risk of iatrogenic damage, mainly when performed by less experienced operators. Both SN and DN approaches exhibit different advantages and disadvantages that make them useful in distinct clinical scenarios.

Digital Planning on Guided Endodontics Technology

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.