special topic

Guided endodontics as an alternative for the

treatment of severely calcified root canals

Sônia T. de O. LARA-MENDES1
Camila de Freitas M. BARBOSA2
Vinícius C. MACHADO3
Caroline C. SANTA-ROSA4

DOI: https://doi.org/10.14436/2358-2545.9.1.015-020.sar

ABSTRACT

Introduction: Pulp calcification is one of the factors that make endodontic treatment challenging and capable of compromis-
ing access of instruments and irrigant solutions to the entire extension of the root canal, making it impossible to disinfect it
adequately. Guided endodontics makes the endodontic treatment more predictable and safer in this complex situation.
Materials and Methods: Once severe calcification requiring endodontic intervention has been found, the patient is referred
to the radiology center for the planning of guided endodontics. A 3D model of the arch to be treated is obtained by means of a
bench scanner, afterwards transferred to a virtual implant planning software program. The CBCT is added to this software and
both are superimposed on the basis of radiographically visible structures. The Simplant software is programmed to project a
physical bur used for guided endodontic access, virtually superimposed on the root canal calcification. Once the printed guide
has been obtained, it is positioned in the patient’s arch and the clinical procedure is performed. Conclusion: The guided end-
odontic technique is easy, predictable and clinically feasible to perform. Moreover, it may be performed by less experienced
professionals, and does not require the use of an operating microscope.

Keywords: Calcification. Cone beam computed tomography. Endodontic access. Scanning.

How to cite: Lara-Mendes STO, Barbosa CFM, Machado VC, Santa-Rosa CC. » The authors report no commercial, proprietary or financial interest in the prod-
Guided endodontics as an alternative for the treatment of severely calcified root ucts or companies described in this article.
canals. Dental Press Endod. 2019 Jan-Apr;9(1):15-20.
DOI: https://doi.org/10.14436/2358-2545.9.1.015-020.oar » Patients displayed in this article previously approved the use of their facial and
intraoral photographs.

1
Universidade de Itaúna, Faculdade de Odontologia, Departamento de Endodontia (Itaúna/MG,
Brazil). Submitted: November 28, 2018. Revised and accepted: February 23, 2019.
2
Faculdade de Medicina e Odontologia São Leopoldo Mandic, Programa de Mestrado
Profissional em Odontologia (Endodontia) (Campinas/SP, Brazil).
3
Faculdade de Medicina e Odontologia São Leopoldo Mandic, Departamento de Radiologia
(Belo Horizonte/MG, Brazil). Contact address: Sônia Teresa de Oliveira Lara Mendes
Departamento de Endodontia - Universidade de Itaúna
4
Universidade Federal de Minas Gerais, Faculdade de Odontologia, Departamento de Dentística
Restauradora, (Belo Horizonte/MG, Brazil).
Rodovia MG 431 - Km 45 (Trevo Itaúna/Pará de Minas)
35.680-142 Itaúna/MG, Brasil – E-mail: soniamendes@hotmail.com

© 2019 Dental Press Endodontics 15 Dental Press Endod. 2019 Jan-Apr;9(1):15-20

[ special topic ] Guided endodontics as an alternative for the treatment of severely calcified root canals

Introduction Materials and Methods:

The purpose of adequate cleaning and shaping of Anamnesis, clinical and radiographic exams are
the root canal system is to control and eliminate the performed to evaluate the presence of symptomatol-
resident microorganisms, thus enabling the treatment ogy and/or peri-radicular changes. Once severe cal-
and prevention of apical periodontitis.1,2 One of the cification requiring endodontic intervention has been
factors that make endodontic treatment challenging is found, the patient is referred to the radiology center for
pulp calcification, which is capable of compromising the planning of guided endodontics. A high resolution
access of instruments and irrigant solutions to the CBCT is obtained, by using a lip retractor as aid to al-
entire extension of the root canal, making it impossible low a more detailed view of the dental-gingival unit.
to disinfect it adequately.3 To guide the endodontic access through the calcified
The American Association of Endodontists has tissue, a CAD/CAM approach was used. A 3D model
classified the treatment of root canals with pulp of the arch to be treated is obtained by means of a
calcifications and has included it in the category of bench scanner R700 (3shape, Holmens Kanal, Copen-
procedures with a high level of difficulty.4 Long-necked hagen, Denmark) and the image generated is converted
cutters and ultrasonic inserts are strategies routinely into an STL file, later transferred to a virtual implant
used in this type of procedure, however, they gener- planning software (Simplant, Technologielaan, Leuven,
ate a high risk of failures, even when associated with Belgium Version, 11; Materialise Dental) (Fig 1).
visual magnification with the use of an operating mi- The CBCT is added to this software. Both the
croscope.5-8 Apicectomy is another alternative for the CBCT and scan of the surface of the model are su-
endodontic treatment of calcified canals. Nevertheless, perimposed on the basis of radiographically visible
localization of the obliterated canal and adequate structures, such as the patient’s soft and hard tissues,
cleaning of the region contaminated after root resec- highlighted with the use of the ST-CBCT technique.19
tion is challenging, so that this surgical treatment is The Simplant software is programmed to project a
not the first choice.8 physical bur used for guided endodontic access, vir-
In this panorama, the tridimensional image is an tually superimposed on the root canal calcification
extremely useful tool that opens new ranges of possi- (Fig 2). The bur applied in this technique (Neodent
bility for diagnosis and performing dental procedures.9 Drill for Tempimplants, Ref: 103179; JJGC ind. E Co-
In 2015, the American Association of Endodontists and mércio de Materiais dentários SA, Curitiba, Brazil)
the American Association of Oral and Maxillofacial has a total length of 20 mm, a 12 mm working length,
Radiology,10 met to define clinical situations in which and is 1.3 mm in diameter. The virtual bur is inclined,
cone beam computed tomography (CBCT) must be thus preventing wear of the incisal edge of the tooth
performed. In this context, one of the indications for and conducts the trajectory so that the visible lumen
is its use is the localization of calcified root canals. of the root canal is attained. Using the previously
Recently, tridimensional models were introduced described position of the bur, the software automati-
into Endodontics with promising results for performing cally creates a virtual model by applying its design
guided accesses and localizing the calcified root canal.11-15 tool. With a view to transferring the precision of the
Prototype access guides, generated by means of superim- virtual planning to the surgical procedure, two fixa-
position of the CBCT and intrabucal or bench scanning tion posts are simulated for the purpose of stabilizing
images are used for precisely directing the pathway that the guide (Fig 3). A ring to direct the radicular access
a burr will run through the calcified tissue.16-18 bur (3.0 mm in external diameter, 1.4 mm in internal
Guided endodontics makes endodontic treatment diameter, and 8 mm long) is also virtually customized
more predictable and safer in complex situations, in and incorporated to orient its access to the trajectory
addition to drastically reducing the time of perform- of the visible lumen in the apical third of the root (Fig
ing the procedure, when compared with conventional 4). The model of the guide (Endoguide3D) generated
techniques. Moreover, this does not require a long is exported as an STL file and sent to a 3D printer
learning curve, and facilitates execution even by less (Object Eden 260 V, Material: FullCure 720, Stratasys
experienced professionals. Ltd., Minneapolis, MN, USA).

© 2019 Dental Press Endodontics 16 Dental Press Endod. 2019 Jan-Apr;9(1):15-20

 Lara-Mendes STO, Barbosa CFM, Machado VC, Santa-Rosa CC

Figure 1. 3D Model of the maxillary arch ob-

tained by means of a bench scanner.

Figure 2. Virtual planning of the access guide.

Figure 3. Virtual guide showing the representa-

tion of 3 rings. The yellow arrows pointed out the
virtually planned fixation screws for stabilization.

© 2019 Dental Press Endodontics 17 Dental Press Endod. 2019 Jan-Apr;9(1):15-20

[ special topic ] Guided endodontics as an alternative for the treatment of severely calcified root canals

Figure 4. Virtual guide showing the representa-

tion of 2 rings. The yellow arrow pointed out the
root access canal.

Once the printed guide has been obtained, it is po- the access ring (Fig 6). To perform these procedures,
sitioned in the patient’s arch to check its adaptation. a rotary motor is used at 1200 rpm and 4Ncm, under
Osteotomy (Bone cutting) is performed under local copious irrigation with physiological solution. After
anesthesia, oriented by the fixation rings. After this, this, the guide is removed, and a compression with
the screws are inserted into this trajectory created gauze is made in the area of osteotomy, to promote
by the bur, allowing its stability without any digital hemostasis without the need for sutures. From this
support (Fig 5). Right afterwards, guided radicular time onwards, the endodontic treatment is concluded
access is performed using the same bur oriented by in the conventional manner, under absolute isolation.

Figure 5. Prototyped Guide positioned and screw retained in the maxil- Figure 6. Access guide to the canal.
lary arch.

© 2019 Dental Press Endodontics 18 Dental Press Endod. 2019 Jan-Apr;9(1):15-20

 Lara-Mendes STO, Barbosa CFM, Machado VC, Santa-Rosa CC

Discussion way the bur is directed was created by virtual planning,

The root canal system (RCS) may be partially or com- oriented by the access ring in the surgical guide.14
pletely obliterated as a result of the occurrence of several For adequate precision of access, the position of the
factors.20,21 Due to dentin apposition over the course of guide on the tooth surface must be checked to guarantee
life, elderly patients may present with severe calcification correct fit.2 In addition, the bur used must penetrate the
of the root canals.22-26 The number of elderly patients ring walls side by side to guarantee stability. Therefore,
and their endodontic treatment needs is increasing due the burs used must have cylindrical stems, because if the
to the fact that teeth remain in the oral cavity for a longer stem were conical, it would lose stability in the guide. Be-
time. Orthodontic treatment as well as dental traumatism cause this technique was reported recently, kits of burs
may also generate the onset of accelerated dentin de- with characteristics advantageous to endodontics must
position.27-28 Pulp obliteration may be considered a sign be developed. However, accesses to roots without orien-
of pulp cure, irrespective of the result of pulp sensitivity tation of the bur may generate more extensive structural
testing, and in this case, there is no need for endodontic wear when compared with accesses made with the burs
treatment.29-30 However, there is a risk ranging from 7 to used at present.
27% that the pulp of these teeth may become necrot- The rings and fixation screws stabilize the guide so
ic,29,31,32 so that endodontic treatment is indispensable, that no digital support will be necessary. These were re-
particularly when there are symptoms of the develop- ported for the first time by Lara-Mendes et al.14 in guides
ment of apical periodontitis.13,33 for endodontic access.
The remaining canals of severely calcified teeth are After removal of the guide, it is not necessary to
localized in the more apical portions of progressively suture the region where osteotomy was performed for
straighter roots, making it difficult to gain access to their the purpose of this fixation, because only compression
entire extension.8,27 Because this concerns a challenging with gauze will be sufficient to promote hemostasis. In
stage of endodontic treatment, the localization and ne- the post-operative period, patients reported absence
gotiation of calcified root canals has been related to an of discomfort in the region, and no need to consume
increase in the rate of technical failures and an unfavor- analgesics.
able prognosis, even when the procedures have been per- Krastl et al and Connert et al,12,13 affirmed that the
formed by experienced professionals.34,35 This procedure guided endodontic technique could be restricted to the
is commonly performed in a long period of time, and de- anterior teeth due to the accessibility to and presence of
mands caution and professional experience, in addition curvatures. However, Lara-Mendes et al,14 demonstrated
to the need to have different radiographs taken for check- that it was possible to performing the guided root ac-
ing the root canal trajectory and the use of an operating cess procedure in molars, as in the cited study the access
microscope. Nevertheless, loss of orientation of the bur guide was used in the second and third molars. There-
or ultrasonic insert may generate excessive loss of dentin fore, the guided endodontic technique is feasible for use
structure and high risk of perforation.2,12 in posterior teeth, provided that the patient presents no
Although CBCT is known to be helpful in the treat- limitations in mouth opening.
ment of severely calcified canals, it is necessary to the Curvature of the canal may be a limiting factor for the
professional to have knowledge of dental anatomy and a use of this technique, however, taking into account that
precise mental map of the root canal system at the time the majority of root calcifications are found in the cervi-
of performing conventional access.2 cal and middle root thirds and the curvatures, in the api-
Superimposition of the images of intraoral scanning cal third of canals, guided endodontics have been widely
and CBCT by means of a software, allows precise plan- used.
ning of penetration of the access bur. Guided endodon- After performing this technique in endodontic
tics may be an excellent option for the resolution of these treatment of teeth with severe calcifications, new
challenging situations such as calcifications, because it is possibilities have arisen for other challenging cases,
a simple, precise technique that does not demand exten- such as those of deviations/perforation of the origi-
sive experience of the operator.13,14,15 Furthermore, there nal trajectory of the canal, in removal of glass fiber
is no need to use the operating microscope, because the intraradicular posts, among others.

© 2019 Dental Press Endodontics 19 Dental Press Endod. 2019 Jan-Apr;9(1):15-20

[ special topic ] Guided endodontics as an alternative for the treatment of severely calcified root canals

14. Lara-Mendes STO, Barbosa CFM, Santa-Rosa CC, Machado VC.

Conclusion Guided Endodontic Access in Maxillary Molars Using Cone-beam
Computed Tomography and Computer-aided Design/Computer-
The guided endodontic technique is easy, predict- aided Manufacturing System: A Case Report. J Endod. 2018
able and clinically feasible to perform. Moreover, it May;44(5):875-9.
15. Lara-Mendes STO, Barbosa CFM, Machado VC, Santa-Rosa CC.
may be performed by less experienced professionals, A new approach for minimally invasive access to severely calcified
and does not require the use of an operating micro- anterior teeth using the guided endodontics technique. J Endod.
2018 Oct;44(10):1578-82.
scope. Knowing about the high risk of iatrogenic er- 16. Strbac GD, Schnappauf A, Giannis K, Moritz A, Ulm C. Guided
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technique has become an important and excellent An evaluation of the periapical status of teeth with necrotic pulps
using periapical radiography and cone-beam computed tomography.
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