International Journal of

Environmental Research
and Public Health

Review
Guided Endodontics: A Literature Review
Kateryna Kulinkovych-Levchuk 1 , María Pilar Pecci-Lloret 1, * , Pablo Castelo-Baz 2 ,
Miguel Ramón Pecci-Lloret 1 and Ricardo E. Oñate-Sánchez 1

1 Gerodontology and Special Care Dentistry Unit, Faculty of Medicine, IMIB-Arrixaca, Morales Meseguer
Hospital, University of Murcia, 30008 Murcia, Spain
2 Unit of Dental Pathology and Therapeutics II, School of Medicine and Dentistry, University of Santiago de
Compostela, 15705 Santiago de Compostela, Spain
* Correspondence: mariapilar.pecci@um.es; Tel.: +34-868889518

Abstract: 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 tech-
nique, 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.

Keywords: guided endodontics; canal obliteration; literature review

Citation: Kulinkovych-Levchuk, K.;
Pecci-Lloret, M.P.; Castelo-Baz, P.;
Pecci-Lloret, M.R.; Oñate-Sánchez,
R.E. Guided Endodontics: A
1. Introduction
Literature Review. Int. J. Environ. Res.
Public Health 2022, 19, 13900. Pulp obliteration (PO) is characterized as radiographic evidence of increased dentine
https://doi.org/10.3390/ production, primarily in response to trauma. The result of this process is a calcified canal,
ijerph192113900 which does not necessarily indicate diseased pulp. The term pulp calcification can also be
used to refer to this condition. Parallelly, the term calcific metamorphosis is defined as a
Academic Editors: Alberto De
pulp response to trauma characterized by the rapid deposition of hard tissue in the pulp
Biase, Marco Lollobrigida and
Luca Lamazza
space [1,2]. The entire pulp space may appear radiographically obliterated due to extensive
mineralized tissue deposition, although some portion of the pulp space may remain in
Received: 27 September 2022 histological sections [3]. PO may be total (the pulp chamber and root canals are difficult to
Accepted: 22 October 2022 visualize or not visible) or partial (the pulp chamber is indistinguishable and root canals
Published: 26 October 2022 are significantly narrow but visible) [4].
Publisher’s Note: MDPI stays neutral Although PO is a reparative response indicating the vitality of the tooth, it can lead
with regard to jurisdictional claims in to pulp necrosis (PN), which is closely related to the degree of root development. One
published maps and institutional affil- explanation for this is that the structure obstructing the pulp space contains nutrient vessels
iations. and cells that can be infected through the dentinal tubules [4]. It has also been shown that,
in traumatized teeth, PN is a phenomenon that occurs in most cases [5,6].
Establishing a treatment plan for these teeth is not straightforward. Some authors
have advocated prophylactic-preventive endodontic treatment of these teeth as soon as
Copyright: © 2022 by the authors. PO is diagnosed, since it is believed that the risk of PN increases after new trauma or after
Licensee MDPI, Basel, Switzerland. therapeutic treatments such as orthodontics and dental restorations [7,8]. However, at
This article is an open access article
present, this guideline is not followed. Instead, it is recommended to monitor such teeth
distributed under the terms and
clinically and radiographically and to only perform endodontic treatment when there is
conditions of the Creative Commons
clinical symptomatology or periapical tissue involvement [8].
Attribution (CC BY) license (https://
Before, during, or after endodontic treatment of teeth exhibiting PO, a number of
creativecommons.org/licenses/by/
complications arise that can compromise both the treatment and the prognosis of the
4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 13900. https://doi.org/10.3390/ijerph192113900 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 13900 2 of 17

affected tooth, such as iatrogenic perforations, fractures and/or the inability to remove
instrument fragments within the canals, the excessive removal of tooth tissue, or the
inability to locate and negotiate heavily calcified canals. During a cavitary access in a
tooth with calcified pulp, there is no asymmetric localization of the root canals nor tactile
sensation of “falling into the void” after accessing the pulp chamber as in an endodontic
access in a tooth without PO, so there is a high risk of perforation [8].
Magnifying glasses, microscopes, and CBCT can be used for better guidance, but it
is difficult for the operator—especially a novice—to interpret the CBCT images, create a
mental guide, and at the same time perform the treatment manually. Guided endodontics
(GE), which is based on the use of endodontic treatment planning with the help of computer
technology, emerged to solve these problems. Thus, the risk of perforations and other
iatrogenic problems is reduced by creating a specific pathway for root canal access and
instrumentation [9,10].
In 2016, a new approach to endodontics using 3D-printed guides or splints emerged,
which was based on implant treatments that made use of the aforementioned aids to guide
implant placement. Authors such as Buchgreitz J, Connert T, Krastl G, and Zhender MS,
among others, published the first studies with the aim of evaluating the precision of these
systems for accessing root canals, obtaining very satisfactory results [11,12]. The first case
reports on the application of this technique for the treatment of teeth with OP, and traumatic
antecedents also started to appear in the same year, with favorable results [13].
In addition, endodontic re-treatments can be challenging and sometimes require
microsurgery. A new approach has emerged in which guided endodontics (a printed
surgical guide) is used along with CBCT scans for access to the apical portion of the root
during surgical endodontics. In turn, this results in more precise incisions, both in gum
and bone tissues; accurate root resection; and better postoperative healing. In addition,
the treatments based on this approach are less time consuming in comparison to free-hand
techniques [14–16].
Today, there are different types of guided endodontics: static guided endodontics
(SGE) and dynamic guided endodontics (DGE).
SGE is performed by obtaining a CBCT image of the patient’s upper or lower arch
(depending on where the tooth to be treated is located). At the same time, a registration
of the patient’s arch of interest is performed, which can be performed with an intraoral
scanner or by obtaining an impression that will be scanned later. The two obtained images
are superimposed through the aid of software, whereby a guide can be designed that will
cover the tooth of interest (and some adjacent teeth). In this guide, a drill hole can be
designed with a specific appropriate diameter and angulation to allow direct access to
the calcified canal. Cylinders or “sleeves” can then be designed to allow the stable and
quantified access of a drill to the interior of the root canal through the drill hole. The inner
cylinder is smaller and is made of metal. Once the designs have been completed, the file
is exported from the planning software in an STL (stereolithography) format for the 3D
printing of the guides. If you do not have access to a 3D printer, you can send the file to a
laboratory. To proceed with the use of the guides, rubber dam isolation is performed and
the guide is tried on to ensure that it fits the patient’s teeth in a stable manner. The internal
metal cylinder is what will guide the drill to access and remove the calcified tissue, and
once it is completely removed, the root canal treatment is continued in the conventional
manner [17,18].
DGE is based on the use of CBCT images with reference marks that are placed in the
patient’s mouth on the side opposite to the side to be operated on (before performing the
CBCT). With the help of a stereo camera connected to a dynamic navigation system, the
trajectory of the drills into the pulp chamber and root canal is coordinated in real time. This
way, the operator can follow everything he/she does on a monitor and can correct or adjust
the angulation of the instruments as needed [19].
Guided endodontics is based on the use of endodontic treatment planning with the
aid of computerized technologies. Due to the appearance of these useful techniques to
Int. J. Environ. Res. Public Health 2022, 19, 13900 3 of 17

cover one of the complications in endodontics, pulp obliteration, it is relevant to carry out
a review of the literature to determine the advantages and/or limitations of this technique,
as well as other possible applications.

2. Materials and Methods

A search was performed in the biomedical databases Pubmed, Science Direct, Scopus,
and Web of Science for available literature from 1 January 2017 to 13 May 2022 using the
following keywords and Boolean operators: “guided AND endodontics”.
Duplicates were discarded using Mendeley Desktop reference manager software (El-
sevier, AMS, Asterweg, The Netherlands). Then, the titles and abstracts were manually
reviewed, and those articles that did not meet the inclusion criteria were excluded. Sub-
sequently, the remaining articles were read in full, and those that dealt with a topic other
than that of interest to this literature review were excluded.

2.1. Inclusion Criteria

Articles were included according to the following criteria:
• Keywords: guided AND endodontics;
• Time period: last six years;
• Articles on guided endodontics: its types, uses, advantages, disadvantages, and/or
outcomes of its use.

2.2. Exclusion Criteria

Articles were excluded according to the following criteria:
• Articles in languages other than English or Spanish;
• Animal studies;
• Reviews and systematic reviews;
• Articles that, after reading their title and abstract, did not fit in with the subject of
interest of this paper.

3. Results
Once the bibliographic research was carried out, 6879 articles were obtained from the
different databases (Pubmed, Science Direct, Scopus, and Web of Science), which were
transferred to the Mendeley Desktop reference manager software in order to facilitate their
organization and storage, as well as to discard duplicates and select only those from the
last 6 years. A total of 1047 articles were obtained. Subsequently, their titles and abstracts
were read, and 135 articles were eligible (excluding 912). Finally, the remaining articles
were read entirely, resulting in the 66 studies that were included in this literature review
(Figure 1).

Studies Characteristics
From the 66 selected studies, the two types of guided endodontics were assessed:
53 studies analyzed SGE, and 14 studies tested DGE (Tables 1 and 2).
From the 29 research studies, only 1 study compared SGE with DGE [20], both show-
ing excellent results. Twelve of these studies compared GE (DGE or SGE) with manual
endodontic treatment [14–16,20–30], obtaining better results. Eight of the studies were
performed with 3D replicas instead of natural teeth [21,22,24,28,31–34] and only one with
acrylic dentition [27] (Table 1).
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 4 of 16
Int. J. Environ. Res. Public Health 2022, 19, 13900 4 of 17

Figure
Figure1.1.Study
Studyselection
selectionflowchart.
flowchart.

StudiesThe
Characteristics
objectives of the different studies were to perform endodontic access cavity
procedures,
From theevaluate the technique
66 selected studies, the with
tworespect
types ofto guided
the fracture strength were
endodontics of theassessed:
teeth, guide
53
apical access during endodontic microsurgery, perform an
studies analyzed SGE, and 14 studies tested DGE (Table 1 and Table 2). osteotomy and/or apicoectomy,
locate the the
From greater palatinestudies,
29 research artery to prevent
only 1 studyitscompared
damage, remove
SGE withfiberglass
DGE [20],posts,
bothcompare
show-
3D printers for the manufacture of SGE splints, and evaluate
ing excellent results. Twelve of these studies compared GE (DGE or SGE) with the results of endodontic
manual
microsurgery.
endodontic treatment [14–16,20–30], obtaining better results. Eight of the studies were
The most
performed withfrequently
3D replicas assessed
insteadparameters from[21,22,24,28,31–34]
of natural teeth the application of SGE and DGE
and only were
one with
effectiveness,
acrylic dentitionaccuracy, amount
[27] (Table 1). of tooth tissue removed, and speed during treatment.
Table 1 provides further details on the content
The objectives of the different studies wereoftothese studies.
perform endodontic access cavity pro-
From the 37 selected case reports (Table
cedures, evaluate the technique with respect to the fracture2), 25 of them had atofleast
strength one year
the teeth, guideof
apical access during endodontic microsurgery, perform an osteotomy and/orof
follow-up with excellent results in terms of the absence of symptomatology or evidence
bone regeneration [35–60]. Eighteen of them were performed with only single-rooted te-
apicoectomy, locate the greater palatine artery to prevent its damage, remove fiberglass
eth [3,9,38,40,44,46,50–53,55,58,60–65]. In twenty-five of them, GE was used for the treat-
posts, compare 3D printers for the manufacture of SGE splints, and evaluate the results of
ment of pulp obliteration [3,9,35–52,54,58,60,63–65], eight for osteotomy and apicoec-
endodontic microsurgery.
tomy [57,59,61,66–70], two for re-treatment or removal of fiberglass posts [43,56], and
The most frequently assessed parameters from the application of SGE and DGE were
one for the treatment of a dens evaginatus [55].
effectiveness, accuracy, amount of tooth tissue removed, and speed during treatment. Ta-
ble 1 provides further details on the content of these studies.
From the 37 selected case reports (Table 2), 25 of them had at least one year of follow-
up with excellent results in terms of the absence of symptomatology or evidence of bone
regeneration [35–60]. Eighteen of them were performed with only single-rooted teeth
Int. J. Environ. Res. Public Health 2022, 19, 13900 5 of 17

Table 1. Research articles included in review information.

Authors Object of Study and Type of EG Nature of Teeth and Type Operator and Practice Conclusions

Ultra-conservative AC precision - R3D DGE more precise, removes less tissue, reduces risk of
Gambarini G et al. 2020 [21] - type 2.6 operator with experience in both groups
(DGE vs. MAN) iatrogenic coronary weakening

- NAT SGE is accurate, fast, and operator-independent in terms of

SGE accuracy with miniaturized - I and C
Connert T et al. 2017 [71] 2 operators preparing apically extensive access cavities in teeth with
instruments - mandibular narrow roots.

Loss of tooth tissue in AC in teeth with - R3D with simulated OP DGE removes less tissue and is more accurate in locating
Jain SD et al. 2020 [22] - 2.1 y 4.1 1 EST (with microscope for MAN access)
OP (DGE vs. MAN) ducts with OP

- NAT - SGE preserves more tissue in molars

Amount of tooth tissue removed in CA - I central and lateral mandibular - No significant differences in terms of tissue removed
Loureiro MAZ et al. 2020 [23] 1 ESP (with magnifying glasses)
(SGE vs. MAN) - M (1st and 2nd) jaws from incisors

- Miniaturized DGE results in a more precise CA and less

- R3D 1 operator with 12 years’ experience, 1 OP tissue is removed.
Time and tooth loss in AC
Connert T et al. 2021 [24] - I (central and lateral) and C maxillae with 12 years’ experience, 1 OP with 12 years’ - Less experienced operators achieved comparable results
(miniaturized DGE vs. MAN)
experience, 1 OP with 12 years’ experience. to more experienced ones.

- There are significant differences between printers

- R3D
Koch GK et al. 2022 [31] Compare 3D printers (for SGE) 1 EST - All produced very accurate guides for the AC to the
- All types
ducts.

SGE accuracy (in teeth with OP, apical - NAT - SGE implementation is accurate in locating canals with
Buchgreitz J et al. 2019 [72] - I (central and lateral) and C No data OP in uniradicular teeth
periodontitis, and in need of post)

- R3D - EGS was accurate in performing AC on teeth with OP

- I (central and lateral), C and PM maxillary 1 EST, - The technique requires a certain degree of dexterity,
Accuracy and potential for use of DGE in
Torres A et al. 2021 [32] and mandibular (with OP 1 ESP manual-visual coordination
AC teeth with simulated OP
- simulated) Yes - Practice is needed before treatment

Laser precision and predictability in - NAT

- Laser integration in DGE is suitable for efficient cutting
Simon JC et al. 2021 [73] minimally invasive CA - PM and M No data of hard dental tissues.
(with DGE) - Subsequent
Int. J. Environ. Res. Public Health 2022, 19, 13900 6 of 17

Table 1. Cont.

Authors Object of Study and Type of EG Nature of Teeth and Type Operator and Practice Conclusions

Accuracy in AC - Acceptable accuracy of SGE during AC

- NAT
Su Y et al. 2021 [74] Linear and angular deviation during AC No data - Larger linear and angular deviations in M
- I, C, PM and M
(with SGE) - Angular deviation best discriminates AC ability

- Both software packages enabled fast planning of the

- R3D with simulated OP
Accuracy and effort of 2 AC software milling guide.
Krug R et al. 2020 [33] - I (central and lateral) jaws 1 operator
(with SGE) - SGE treatment is predictable
- I (central) mandibular
- Root canal localization is safe in teeth with OP

- Reduction in preparation time by 75.9% in PM and 81%

Effectiveness in CA with guidelines to in M when students used the AOG-3DP guide.
prevent excessive tooth loss - NAT 1 EST
Choi Y et al. 2021 [75] - More conservative approaches using such guidance.
(student-oriented) - PM and M pre-doctoral - Time is needed for design and manufacture
(with SGE) - The guide can be used for help in more difficult cases.

- Effectiveness of SGE for CA through

MTAs - NAT - SGE results in faster and less error-prone MTA removal.
Ali A et al. 2021 [25] - Effect of technique on fracture - PM Same operator (with magnifiers for MAN) - With SGE, greater resistance to tooth fracture is
strength - mandibular preserved.

(SGE vs. MAN)

- NAT - DGE is more accurate and efficient in locating ducts

Accuracy and efficiency when locating - I, C, PM 1ESP AND 1 EST with OP
Dianat O et al. 2020 [26]
ducts with OP (DGE vs. MAN) - maxillary and mandibular with OP (2 per group) - DGE can help prevent accidents during CA

- NAT
- Great potential for using dynamic computerized
(simulating OP) navigation in endodontics to guide and facilitate CA
Chong BS et al. 2019 [76] Use of DGE for guided endodontics No data
and canal location.
- All types

Success rate and tissue removal required - The use of guided endodontics on calcified teeth allows
- Acrylic dentition with root canals
Kostunov J et al. 2021 [27] for CA 1 ESP for both groups for a considerable amount of tooth tissue to be
- 1.1, 1.4, 1.7
(SGE vs. MAN in teeth with OP) preserved.

- DGE together with high-speed drills achieves minimally

Minimally invasive AC and channel invasive CA in canal localization with OP with an
- R3D
Jain SD et al. 2020 [34] localisation with simulated OP 1 ESP average 2D horizontal deviation of 0.9mm, 3D of
(in DGE) All types 1.3mm, and 3D angular deviation of 1.7◦ .
Int. J. Environ. Res. Public Health 2022, 19, 13900 7 of 17

Table 1. Cont.

Authors Object of Study and Type of EG Nature of Teeth and Type Operator and Practice Conclusions
SGE entails:
- Tissue loss in CA - R3D
- Duration of treatment - I central maxillary 1 ESP
Connert T et al. 2019 [28] - Pipeline location and negotiation 1 DG - more predictable results
- I maxillary lateral - reduced loss of tooth tissue by locating calcified canals
- Influence of operator experience - I central mandibular 1 recent graduate
- no influence on operator experience
(SGE vs. MAN in teeth with OP)

Accuracy of SGE and DGE for AC - NAT SGE and DGE enable more accurate CAs than conventional
Zubizarreta Macho A et al. 2020 [20] - I central mandibular 1 same operator for both
(SGE vs. DGE vs. MAN) techniques.

Compare accuracy of OT and AP - NAT The use of prefabricated grids in guided endodontic surgery
Fan Y et al. 2019 [15] (with SGE using a grid as a guide vs. - All types 1 ESP
proved to be more accurate than using no guide at all.
MAN)

Implications of the location of the greater

- Endodontic (palatal root) surgery with a 2mm safety
palatine artery in relation to the molars
- With CBCT images of 1st and 2nd margin is possible in 47% of upper 1st molars and 52%
for the performance of OT and AP.
Smith BG et al. 2021 [77] maxillary molar teeth of real patients. 2 ESP of upper 2nd molars.
Feasibility of a flapless palatal access
technique A flapless palatal access can be a viable option for almost
(with SGE) half of the maxillary 1st and 2nd molars.

- With CBCT images of pre-treated teeth - This study assumes that endodontic surgery using SGE
Galino Buniag A et al. 2021 [78] OT and PA results after 1 year (with SGE) (made by the Faculty of Dental Medicine). 2 ESP has similar success rates to those using the conventional
- endodontics and residents) MAN technique.

- Accuracy and efficiency of DGE in

- DGE allowed the operator to perform minimally
minimally invasive OT and AP - NAT 1 ESP (with microscope for MAN)
Aldahmash SA et al. 2022 [29] invasive OT, AP, and endodontic surgery as well as
- Feasibility of retrograde sealing Yes
All types adequate retrograde obturation.
- (DGE vs. MAN)

- DGE is more accurate than the MAN technique.

Accuracy and efficiency of DGE for OT - NAT - The distance of the roots from the cortical bone
Dianat O et al. 2021 [16] - All types 1 ESP (with microscope for MAN) negatively influences the accuracy and efficiency of the
and AP (DGE vs. MAN)
MAN technique.

Gaffuri S et al. 2021 [79] Accuracy of minimally invasive guides - NAT 1 ESP - Non-operator-dependent technique
for OT and AP (with SGE) - All types 1 EST - SGE is considered an accurate method for apex access.

Guide accuracy in OT and AP - NAT - The use of 3D guides for endodontic surgery is more
Ackerman S et al. 2019 [14] - All types No data accurate.
(with SGE vs. MAN)
Int. J. Environ. Res. Public Health 2022, 19, 13900 8 of 17

Table 1. Cont.

Authors Object of Study and Type of EG Nature of Teeth and Type Operator and Practice Conclusions

Suitability of IMR instead of CBCT for - NAT

1 operator with 2 years of professional - MRI has an accuracy comparable to CBCT for
Leontiev W et al. 2021 [80] CA - I, C, and PM
experience performing CA.
(with SGE) - maxillae and mandibles

Accuracy and efficiency for PR towards - NAT

Janabi A et al. 2021 [30] pre-treated teeth 1ESP (with microscope for MAN) - More accurate and efficient DGE for PR
- Maxillary I & C with glass fiber posts
(with DGE vs. MAN)

- NAT - SGE is safe and reliable for root canal retreatment,

Reliability for RP when artefacts are - PM and M preserving tooth structure.
Perez C et al. 2021 [81] 2 operators
present on CBCT(with SGE) - maxillae and mandibles - Can be used by most operators

EG: guided endodontics, VS: versus, DGE: dynamic guided endodontics, SGE: static guided endodontics, MAN: manually, OP: pulp obliteration, AC: cavity opening, NAT: natural,
R3D: 3D replicas, ESP: endodontic specialist, EST: student, DG: general dentist, I: incisors, C: canines, PM: premolars, M: molars, OT: osteotomy, AP: apicoectomy, RP: post (fiberglass)
removal, CBCT: cone beam computed tomography, and IMR: magnetic resonance imaging.

Table 2. Other types of articles included in the review.

Previous
Author Tooth Diagnosis Trauma Problem Type of EG Results
Treatment
NP
Todd R et al. 2021 [60] 2.1 No No OP SGE Tooth without symptomatology after 24 h.
PAS
Buchgreitz J et al. 2019 [35] 1.6 PAS Yes No OP SGE Tooth without symptomatology after 2 years.
NP
Torres A et al. 2021 [36] 1.4 No No OP SGE Bone regeneration at one year
PAS
Lara Mendes STO et al. 2018 [37] 2.7, 2.8 PAS No No OP SGE No symptoms and bone regeneration after one year
(a) NP
(a) 1.1 (a) No (a) At 15 days, there was no symptomatology.
Fonseca Tavares WL et al. 2018 [3] PAS Yes OP SGE
(b) 1.1 (b) Yes (b) Tooth asymptomatic at 30 days.
(b) PAS
Lara Mendes STO et al. 2018 [38] 2.1 PAS No Yes OP SGE Tooth without symptomatology after 1 year.
(a) PAS
(a) 2.6 (a) No
(b) NP
Maia LM et al. 2019 [39] (b) 2.5 (b) Yes No OP SGE Complete healing after 1 year
Bruxismo
(c) 1.5 (c) Yes
(c) PAS
OP, complex root SGE and photo-dynamic
Fonseca Tavares WL et al. 2020 [40] 2.3 PAS No No Asymptomatic tooth at 12 months.
anatomy dynamics
(a) At one year, the size of the apical lesion was reduced and
(a) 2.3 (a) No OP
Fernandes Goncalves W. 2021 [41] PAS No SGE there was no symptomatology.
(b) 4.6 (b) Yes RP
(b) No signs or symptoms at one-year review.
Int. J. Environ. Res. Public Health 2022, 19, 13900 9 of 17

Table 2. Cont.

Previous
Author Tooth Diagnosis Trauma Problem Type of EG Results
Treatment
(a) 4.7 (a) Yes (a) Tooth asymptomatic at 12 months.
Fonseca Tavares WL et al. 2020 [42] (b) 4.6 PAS (b) Yes No OP SGE (b) No data.
(c) 1.6 (c) Yes (c) No symptoms at 12 months.
NP
Maia LM, et al. 2020 [43] 4.6 Yes No OP SGE Complete healing after 24 months of revision.
PAS
NP
Freire BB et al. 2021 [44] 1.1 No Yes OP SGE Complete healing and absence of symptomatology after 2 years.
PAS
NP
Doranala S et al. 2020 [63] 1.1 No Yes OP SGE Signs of healing at 3 months and absence of symptomatology.
PAS
Absence of symptomatology at one year together with a
Casadei BDA et al. 2020 [45] 1.5 AAC Yes No OP SGE
decrease in the size of the apical lesion.
Loureiro MAZ et al. 2021 [9] 2.1 PAA Yes Yes OP SGE Satisfactory results at the 6-month checkup.
NP
Villa Machado PA et al. 2022 [46] 3.1 No Yes OP DGE Asymptomatic at 12 months.
PAS
There was no
Connert T et al. 2018 [64] 3.1, 4.1 PAS No Yes OP SGE
symptomatology at 2 weeks.
Torres A et al. 2019 [65] 2.2 PAS No No OP SGE Apical lesion healing at 6 months.
Silva AS et al. 2020 [53] 2.1 NP Yes No OP SGE. Successful results after 1 year.
Coelho Santiago M et al. 2022 [48] 4.6 NP Yes No OP SGE Asymptomatic tooth at one year.
PAS
1.5, 1.2, 2.6, 3.6, At one year, there was complete healing of 1.5, 2.6, 3.1, and 4.6,
Krug R et al. 2020 [49] Dysplasia Yes, en 3.6 No. OP SGE
3.2, 3.1 and 4.6 as well as reduction of apical lesion size by 3.6, 3.2, and 1.2.
dentinaria
Kaur G et al. 2021 [50] 2.2 PAS No Yes OP SGE Tooth asymptomatic at 2 weeks.
(a) 4.4 (a) No (a) No
NP At one year, there was absence of signs and symptoms in all
Ali A et al. 2022 [51] (b) 1.1, 1.2, 2.2. (b) No (b) Yes OP SGE
PAS cases.
(c) 1.2, 2.1 (c) No (c) Yes
(a) 2.1 (a) PAS
(b) 1.3 (b) AAC
(c) 2.1 (c) AAA
Llaquet Pujol M et al. 2021 [52] (d) 1.1 (d) PAS No Yes OP SGE No symptoms at one year.
(e) 1.1 (e) AAA
(f) 2.1 (f) PAA
(g) 1.1 (g) PAA
SGE
Yan YQ et al. 2021 [54] 2.7 PAS Yes No OP No symptoms at two years.
(mediate inlay unitario)
Mena Álvarez J et al. 2017 [55] 2.1 AAC No No Dens evagina-tus SGE No symptoms at one year.
Int. J. Environ. Res. Public Health 2022, 19, 13900 10 of 17

Table 2. Cont.

Previous
Author Tooth Diagnosis Trauma Problem Type of EG Results
Treatment
RT
Moreira Maia L et al. 2020 [62] 2.1 PAS Yes Yes SGE Injury healing at 18 months.
RP
RT
Perez C et al. 2020 [56] 1.6 PAS Yes No SGE Healing of the periapical area at one year.
RP
OT
Strbac G et al. 2017 [57] 1.5 y 1.6 PAS Yes No SGE Healing of the periapical area at one year.
AP
(a) 1.7 (a) AAC (a) Yes (a) No OT (a) No symptoms at 12 weeks.
Giacomino CM et al. 2018 [70] (b) 2.6 (b) PAA (b) No (b) Yes AP SGE (b) Asymptomatic at one month.
(c) 3.5 (c) PAS (c) Yes (c) No (c) Asymptomatic at one month.
a) PAS
(a) 2.5 (a) Yes (a) No OT (a) No symptoms at 7 months.
Popowicz W et al. 2019 [69] b) NP SGE
(b) 2.5 (b) Yes (b) No AP (b) No symptoms at 8 months.
PAS
(a) 2.6
Benjamin G et al. 2021 [68] OT (a) No symptoms after 10 days.
(b) 3.6 PAS YES No SGE
AP (b,c) No symptoms at 1 week.
(c) 2.6
OP
Gómez Meda R et al. 2022 [58] 2.3 Impacted No No AT SGE Complete bone integration at 2 years.
AUT
OT
Gambarini G et al. 2019 [61] 1.2 PAS Yes No DGE Successful healing after 1, 3, and 6 months of control.
AP
NP: pulp necrosis, PAS: symptomatic apical periodontitis, PAA: asymptomatic apical periodontitis, OP: pulp obliteration, AAA: acute apical abscess, AAC: chronic apical abscess,
RT: retreatment, RP: removal of post (fiberglass), OT: osteotomy, AP: apicoectomy; ERR: external root resorption, IRR: internal root resorption; AUT: auto-transplantation.
Int. J. Environ. Res. Public Health 2022, 19, 13900 11 of 17

4. Discussion
After identifying and describing the available studies, the different applications of
guided endodontics would be towards:
Endodontic access cavities. Many of the available studies are based on performing
an endodontic access cavity, which is the first step in performing non-surgical root canal
treatment. Three of the studies [21,22,73] focused on ultra-conservative [21] and minimally
invasive [22,73] approaches.
In the study by Gambarini G et al. [21], ultra-conservative access (comparing DGE and
manual) consisting of linear access to the teeth was performed with the aim of minimizing
tooth weakness, preserving as much tooth tissue as possible, and reducing instrument stress
during treatment. Endodontic access cavities are a controversial subject; the terminology is
inconsistent [82], and there are multiple classifications for these accesses [47]. They could
be broadly classified as: traditional (the pulp chamber roof is removed, and the coronal
third of the canals are accessed directly), conservative (the access is made in the central
fossa and expanded just enough to locate the canals), ultra-conservative (minimal access in
the deepest center of the tooth), and truss access cavities (oval cavities guided by micro-CT
imaging where the pulp chamber roof is preserved between the accesses and depending
on the diameter of the rotary instruments subsequently used) [83]. However, a linear and
direct access in the coronal third would be helpful in reducing the chances of perforations,
false passages, or transported canals [21]. Generally, minimally invasive cavities generate a
trajectory towards the canal that causes the endodontic instruments to bend and generate
stress on the canal. This can lead to iatrogenic accidents such as fractures or steps [83].
However, by means of DGE, this did not occur since the access is direct, linear, and parallel
to the axis of the canal [21]. Regarding the loss of dental tissue, it is evident that it is lower in
more conservative access cavities than in traditional ones (which is also corroborated in the
study). It has been shown that fracture resistance in anterior teeth is not related to the type
of endodontic access, in contrast to posterior teeth, where there are certain discrepancies.
Some studies show no differences and others state that as long as marginal ridges are
preserved, the endodontic access does not negatively influence the tooth’s stiffness [83,84].
The study by Simon GC et al. is an adaptation of the dynamic guided navigation
system [73]. In this study, both traditional and minimally invasive, multiple access cavities
were performed using CO2 laser ablation, providing an alternative method to the use of
drills. Using lasers, in this case, means that the infected tissues and toxins are heated to
high temperatures, which reduces contamination of the most apical layers of soft or hard
tissues. It also produces hemostasis, which may be a treatment option for pulpotomies [73].
However, although the laser used in pulpotomies has a similar clinical and radiographic
success rate to other techniques such as MTA and formocresol, it should be taken into
account that its use can produce pulp hyperemia due to the heat generated, which can
be avoided by removing the affected pulp tissue with manual instruments [85]. Another
advantage of its use is that it is possible to perform laser surgery without using CBCT data,
since the dynamic navigation system has an integrated digital image of the occlusal surface.
This way, the operator can design the access, and it will be performed automatically by the
laser, which is controlled by a computer [73].
Concerning other possible applications, starting from the premise that guided en-
dodontics can be applied in difficult cases with calcifications, it is pertinent to think that it
could also be used in cases of abnormal dental morphologies that make conventional en-
dodontic treatments difficult. Although there are no studies in this regard, several authors
such as Ali A et al. [86], Mena Álvarez J et al. [55], and Zubizarreta Macho A et al. [87] have
reported several cases in the literature where 3D splints were used to treat cases of dens
invagintus and dens evaginatus with successful results.
Pulp calcifications. The most common treatment performed with GE was the treatment
of pulp calcifications [3,9,35–52,54,58,60,63–65]. Jain SD et al. [22] aimed to locate calcified
canals by performing minimally invasive cavities using high-speed drills and DGE. It was
found that the group that located these canals manually accumulated several errors that
Int. J. Environ. Res. Public Health 2022, 19, 13900 12 of 17

resulted in perforations and a greater amount of dental tissue removal. Using high-speed
drills entails less operation time compared to low-speed drills used in conjunction with 3D
guides in static guided endodontics. This study also showed that using DGE requires some
time to learn the technique as manual and visual coordination is required at all times. This
makes the results of DGE treatment dependent on the experience of the operator, which is not
influenced by DGE, as was also concluded in the study by Connert T et al. [28].
In the study by Connert T et al. [28], as mentioned above, it was confirmed that even an
inexperienced operator could have similar success to an endodontic specialist with respect
to locating calcified canals, removing a minimal amount of tooth tissue, and completing
the treatment in a similar time.
The access cavities made with guided endodontics, especially SGE, are limited to a
linear access, which means that they cannot be performed in curved canals or in teeth with
an unusual morphology. In the case of straight canals in the same tooth (such as a molars),
several guides would have to be designed in the case of DGE (one per root or depending
on where the canals are located). A single guide with several accesses could be considered
in cases of multiple root canals in adjacent teeth, e.g., several incisors, or a DGE treatment
could be planned to perform these root canals in one session [28].
For cases of teeth with OP and canals that are not very curved or with some curvature
in the apical third, several management modalities could be combined, such as using
SGE or DGE as far as possible and instrumenting the curved part in a conventional way
and/or using some treatment such as photodynamic therapy as performed by Fonseca WL
et al. [40]. Thus, further studies covering different clinical situations are suggested.
Osteotomy and apicectomy. Apicoectomy and osteotomy were the second most
common treatment performed with GE [57,59,61,66–70]. A retrospective study by Galino
Buniag A et al. [78] is the only one that presents the follow-up of patients who underwent
SGE treatment after at least 1 year, showing that it is as valid a treatment option as the
conventional one (performing a full-thickness flap and using drills and reamers). However,
it does not report the process of the SGE performed. More studies similar to this one with
longer follow-ups of patients treated with both types of guided endodontics are needed.
In the studies by Ackerman S et al. [14] and Fan Y et al. [15], direct access to the
apex was made by drilling through the bone. In the study by Ackerman S et al. [14], a
flap was also made (as well as in the studies by Aldamash SA et al. [29] and Gaffuri S
et al. [79]) to simulate the clinical conditions of endodontic microsurgery. In other studies,
however, such as that of Smith GB et al. [77], it was proposed to forego performing a flap
and to use a biopsy at the site where the osteotomy would be performed to remove the
masticatory palatal mucosa (which will then be sutured after the completion of treatment).
This represents a new approach to minimally invasive endodontic microsurgery with the
advantage of being more comfortable for the patient in the postoperative process and
avoiding damage to compromised structures such as the greater palatal artery in the case
of apicoectomies of palatal roots of maxillary molars. This is reported by authors such as
Shcmid C et al. [88], Benjamin G et al. [68], and Giacomino CM et al. [70].
Glass fiber posts’ removal. The re-treatment of teeth that require fiberglass posts’
removal was the third most common treatment performed with GE [43,56]. The studies by
Perez C et al. [81] and Janabi A et al. [30] cover this topic using SGE and DGE, respectively.
The removal of fiberglass posts is mainly carried out after a previously failed treatment [81]
and it can be performed with the help of ultrasound tips [89]. Still, it involves a risk of
the perforation of the tooth [30]. In addition, the color of the post, which blends in with
the adjacent dentine, is an added difficulty [90]. Even so, the practitioner’s experience
performing this treatment influences the amount of extra dentine removed around the post,
which is greater and leads to a widening of the radicular canal after the removal of the
post [91]. For these reasons, guided endodontics is suggested as a treatment alternative.
In the study by Perez C et al. [81], which was carried out with SGE, the apical gutta-
percha could be accessed in 87.5% of the treated teeth, and those that could not be fully
accessed were due to root curvature. Furthermore, this study is interesting because it
Int. J. Environ. Res. Public Health 2022, 19, 13900 13 of 17

simulates artifacts in the CBCT images, which makes access design and guidance difficult,
as they are not as accurate. Even so, the results were satisfactory and require less time than
ultrasonic tips or long-stem drills. Once again, it was confirmed that this procedure could
be performed by any operator.
Similarly, the study by Janabi A et al. [30] also had satisfactory results and faster
results compared to removing the post by milling and using a microscope. Still, the
operator needed to adapt to this new system to work comfortably and quickly.
The limitations of the present work are based on the type of studies covered in the
literature since guided endodontics is a new topic that is only beginning to be developed,
expanded, and applied. Therefore, more and higher quality studies are needed in the
future, such as randomized clinical trials, to compare the results of all—and other future—
applications of SGE and DGE in real patients and with long-term clinical and radiological
follow-ups. Even so, one of the risks of bias presented by the selected articles is that not all
the procedures were performed with extracted teeth; some were 3D-printed, in which case
the tooth’s characteristics are not the same as in a real tooth. In addition, in other types
of articles, the follow-up periods were short, some even of days or weeks, which is not
enough time to evaluate the outcome of the use of the technique.

5. Conclusions
EG applications encompass not only endodontic cavity access and canal location with
PO but can also be applied in cases of osteotomy and apicoectomy as well as retrograde
fillings, the removal of fiberglass posts, and treating teeth with morphological asymmetries.
• The advantages of SGE are as follows: it is independent of the operator’s experience,
requires less treatment time for the patient, and is more accurate and safer than
conventional endodontics.
• The disadvantages of SGE are as follows: more time is needed for the design and
production of 3D guides, it involves linear access that only works for straight canals,
and it is not very stable in the mouth in partially edentulous patients.
• The benefits of DGE are as follows: it is more ergonomic (in terms of having to look at
the monitor during treatment), it allows for the real-time adjustment and repositioning
of the working instruments, it is more accurate as it does not accumulate design errors,
and it is useful in cases of multi-rooted teeth.
• The disadvantages of DGE are as follows: it is highly dependent on the operator’s
experience and requires deeper learning for its mastery, and it requires simultaneous
hand–eye coordination.

Author Contributions: Conceptualization, K.K.-L. and M.P.P.-L.; methodology, M.R.P.-L. and P.C.-B.;
data curation, K.K.-L.; writing—original draft preparation, K.K.-L.; writing—review and editing
M.P.P.-L. supervision, R.E.O.-S. All authors have read and agreed to the published version of the
manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2022, 19, 13900 14 of 17

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