Accuracy of 3-dimensional–printed Endodontic Surgical Guide: A Human Cadaver Study

doi:10.1016/j.joen.2019.02.005

Journal of Endodontics

Volume 45, Issue 5, May 2019, Pages 615-618

https://doi.org/10.1016/j.joen.2019.02.005 Get rights and content

Highlights

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The accuracy of cone-beam computed tomographic (CBCT)-designed surgical guides for use during endodontic surgery was evaluated using human cadaver jaws.
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CBCT-designed surgical guides facilitate access to the apices of the roots for endodontic surgery.
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Using a CBCT-designed printed surgical guide is a more accurate method for access to the apical portion of the root during surgical endodontics compared with a “freehand” CBCT-approximated method.

Abstract

Introduction

Cone-beam computed tomographic (CBCT)-based 3-dimensional–printed surgical guides, such as those used in implant placement and orofacial surgery, allow for accurate planning and performance of surgical procedures. The objective of this study was to evaluate the accuracy of CBCT-designed surgical guides for use during endodontic surgery.

Methods

A split-mouth design was conducted using 48 roots in a cadaver model. In the experimental group, using information from the preoperative CBCT scans and digital impressions, surgical guides were designed using Blue Sky Bio (Grayslake, IL) planning software and printed using a Form 2 3-dimensional printer (Formlabs, Somerville, MA). The guides were designed to allow for surgical access at 3 mm from the apex of each root with depth control to the lingual or palatal surface of the root. In the control group, surgical access was completed “freehand” by visually approximating measurements from the CBCT scan only. The planned and postoperative CBCT images were superimposed, and the deviation of the surgical access point from the planned target was measured using Invivo software (Anatomage, San Jose, CA). A 2-tailed t test and the Fisher exact test were conducted to compare the deviation in the experimental CBCT-guided group versus the control CBCT-approximated freehand group.

Results

The mean deviation for the guided group (1.743 mm) was significantly less than that of the approximated freehand group (2.638 mm, P < .001). Only in 11 of the 24 samples of the control group was surgical access considered clinically successful (within the apical area of the root), whereas all 24 of the experimental samples were considered clinically successful.

Conclusions

Using a CBCT-designed printed surgical guide is a more accurate method for access to the apical portion of the root during surgical endodontics compared with a “freehand” CBCT-approximated method.

Section snippets

Materials and Methods

Two embalmed cadaver heads were obtained from the Willed Body Program, University of Texas Southwestern Medical Center, Dallas, TX. The use of cadaveric materials follows the regulations of the Anatomical Board of the State of Texas. From these specimens, 48 roots were included in the study (24 roots/group). In a split-mouth design, right or left sides of cadaver maxillae or mandibles were randomly selected as control versus experimental specimens. Palatal roots of the maxillary molars were

Results

The distance (in millimeters) between the root apex and the nearest point of the drill path was collected as the outcome. The mean and standard deviations for the control and treatment groups are presented in Table 1. The following group comparison was performed using a 2-tailed t test with unequal variances. The resulting statistic was t_35.407 = −3.6212 and P = .0009. Thus, the mean distances between the planned and the actual paths in the control and treatment groups were statistically

Discussion

Accuracy in endodontic surgery is important, especially when roots approximate vital structures. In a prospective clinical study by Song et al (17), they found that anterior, premolar, and molar teeth had significantly different success rates after microsurgery. They also found a significant difference between the maxillary and mandibular teeth groups. They concluded that the decreased success rates in the mandibular anterior and molar teeth compared with the maxillary anterior teeth may be

Acknowledgments

We would like to thank Chris Gonzales, prosthodontic resident from the prosthodontic department at Texas A&M College of Dentistry for his help with photography; Jennifer M. Gonzalez, Vanessa Martinez, and Roxanne R. Edwards from the radiology department at Texas A&M College of Dentistry for their help with the iCAT scans; Bethany S. Wright from the Department of Biomedical Sciences at Texas A&M College of Dentistry for her help in preparing the specimens; and Anatomage (San Jose, CA) for

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Apical root resection pattern affects the stress distribution behavior in the apical region of the resected tooth. The purpose of the study was to compare the biomechanical responses of resected teeth between endodontic microsurgery (horizontal resection) and targeted endodontic microsurgery (round resection).
Five different models were developed. The basic model without resection (NR) was regarded as the control model, and the others involved: horizontal resection without bone grafting (HN), horizontal resection with bone grafting (HG), round resection without bone grafting (RN), and round resection with bone grafting (RG) models. A static load of 100 N was applied to the buccal and palatal cusps of all the teeth in a 30° oblique direction. The maximum von-Mises stress and tooth displacement values were analyzed and compared.
Both the HN and RN models exhibited lower stress distribution values on bone compared with the NR (control) model. Regarding maximum stress distribution at the root apex, the stress value of the RN model was slightly higher compared to the HN model, whereas the RG model displayed a slightly lower stress value in comparison with the HG model. For maximum tooth displacement value, there were no significant differences between the HN and RN models, as well as the HG and RG models.
The round resection pattern had comparable stress distribution behaviors at the root apex and tooth displacement values with the horizontal resection pattern. Targeted endodontic microsurgery might provide better biomechanical response of the resected tooth after root-end resection.
Accuracy of CAD-CAM Surgically Guided Tooth Autotransplantation Using Guided Templates and Custom-designed Osteotomes in Human Cadaver Mandibles
2023, Journal of Endodontics
A major challenge in dentistry is the replacement of teeth lost prematurely due to trauma, caries, or malformations; especially in growing patients. The aim of this study was to assess the accuracy of CAD-CAM surgically guided tooth autotransplantation in cryopreserved cadaver mandibles using guided templates and custom-designed osteotomes.
Cryopreserved human cadaver heads were digitized and scanned using an intraoral optical scanner and a large-volume cone beam computed tomography device. First, virtual surgical planning was performed to create a 3D tooth replica, 2 surgical guides, and a custom-made osteotome for each single-rooted tooth autotransplantation procedure/case. Surgical sockets were created in the selected mandibles using guided tooling consisting of an initial guided osteotomy with implant burs and a final guided osteotomy using custom osteotomes. After tooth autotransplantation, second large-volume cone beam computed tomography images of the 5 cadaver mandibles were obtained. The discrepancy in mm within the 3D space (apical and mesiodistal deviations) between the final position of the autotransplanted teeth and their digitally planned 3D initial position was calculated and analyzed statistically (P < .05).
All donor teeth were placed without incident within their newly created sockets in the real mandibles. The mean difference between the digitally planned root apex position and the final tooth position was 2.46 ± 1.25 mm. The mesiodistal deviation of the autotransplanted teeth was 1.63 ± 0.96 mm.
The autotransplantation of single-rooted teeth with custom-designed and 3D-printed surgical tooling provided promising results. The technique was able to create surgically prepared sockets that could accommodate transplanted teeth in mandibles.
Stress Distribution on Trephine-Resected Root-end in Targeted Endodontic Microsurgery: A Finite Element Analysis
2022, Journal of Endodontics
This study aimed to determine if stress distribution from occlusal loads after targeted endodontic microsurgery (TEMS) differed for trephine-resected flat and curved root-ends, with and without bone graft.
Finite element analysis models were constructed from cone-beam computed tomography data of a TEMS-treated maxillary central incisor. Models included flat and curved resected root-ends, with and without apical bone graft, and normal or root canal filled controls. In centric occlusion, axial force was directed on mesial and distal lingual marginal ridges at 120° angle. For lateral excursion, additional mesiodistal forces were applied from centric occlusion. For edge biting, axial force was directed on the incisal edge. Under occlusal loads, stress distribution patterns on tooth and root-end circumference were analyzed.
In normal and root filled controls, occlusal stress was distributed on labial and palatal root surfaces, concentrated in the labial cervical area, and maximized at the apex. For resected root-ends, occlusal loads concentrated stress on the labial cervical area. With bone graft, maximum stress concentration shifted to the apex, which implied stress relief and dispersion from the cervical root area. Stress patterns on the root-end were more widely spread in models with apical bone graft, whereas curved root-end showed stress concentrating arc especially when without apical bone support. The mean stress values on root-end circumference were significantly higher in curved than flat root-end (P < .05), especially with apical bone support (P < .05).
Occlusal stress patterns on a maxillary central incisor were markedly affected by root-end resection configuration and apical bone support. Trephine-resected curved root-end had stress pattern concentrated on its circumference. Curved and flat root-ends had labial cervical stress that was relieved by bone graft. TEMS resected root-ends should be flattened and bone grafted to disperse stress from occlusal loads.
Accuracy of digitally planned, guided apicoectomy with a conventional trephine and a custom-made endodontic trephine: An in vitro comparative study
2022, Journal of Stomatology, Oral and Maxillofacial Surgery
Static guided trephine apicoectomy has been developed as a less invasive and more accurate alternative to conventional freehand apicoectomy with drills. Overpenetration is a frequent issue with this procedure, which deteriorates accuracy and raises safety concerns. A safety improvement to address this problem is presented.
Guided apicoectomies were performed in porcine mandibles with either a conventional bone trephine or a custom-made endo-trephine with built-in depth control. The deviation of the apical endpoint of the trephine from the digital surgical plan was analyzed. Overpenetration frequency was recorded.
Procedures performed with the custom trephine were significantly more accurate both along the x-axis and globally, but no significant difference was found for the y and z axes. Overpenetration frequency was 70% in the conventional trephine group versus 38% in the stop trephine group.
The results indicate that the lack of physical depth control can interfere with the accuracy (and safety) of these procedures to a significant extent, as visual cues (such as the depth markings on a conventional trephine) are insufficient to prevent overpenetration. Our results show that custom-made trephines with a built-in stop offer an optimal solution for this problem.
A Novel Simplified Workflow for Guided Endodontic Surgery in Mandibular Molars With a Thick Buccal Bone Plate: A Case Report
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Citation Excerpt :
Three-dimensional–printed guides have been widely applied in endodontics, and several studies regarding this issue are currently available20. Many authors18,19,21,22 reported the applications of these prototyped guides in different apical surgery situations. Specifically, regarding mandibular molars, different authors demonstrated the advantages of using a 3D-printed guide in patients with a thick buccal bone plate, allowing both precision and safety for accessing the apex15,23,24.
One of the challenges in apical surgery in mandibular molars is the thick buccal cortical bone plate, which might lead to access errors, damage to neighboring teeth, and injury to healthy tissue. Surgical guide templates with 3-dimensional (3D) impressions have been suggested for use in such cases, allowing greater precision. Usually, this technique involves a cone-beam computed tomography (CBCT) examination related to a 3D oral scanning to generate surgical templates printed from 3D imaging data. This study reports a novel workflow possibility in which apical surgery is performed with the aid of a surgical guide planned only with CBCT, excluding the need for 3D oral scanning. A 32-year-old woman presented with asymptomatic apical periodontitis and external root resorption on the mesial root of tooth #19. A surgical template was planned using only the patient's CBCT scan to provide precise access to the lesion and remove a mandibular cortical bone block. The procedure was carried out with apicoectomy, root-end preparation, and retrograde filling, and the bone block was repositioned before suture. No postoperative complications were reported. After 1 year, the patient presented asymptomatic, and a CBCT scan confirmed bone healing. The current 3D-printed guides may be planned and printed through a novel simplified workflow with a CBCT scan only, which allows its application in apical surgery for precise apex and surgical site location.
Non-Hodgkin Lymphoma Mimicking Endodontic Lesion: A Case Report with 3-dimensional Analysis, Segmentation, and Printing
2021, Journal of Endodontics
Citation Excerpt :
Over the past few years, CBCT imaging has become an integral part of modern endodontic practice. CBCT imaging is now used as a complementary tool to better diagnose endodontic disease and to plan for nonsurgical root canal treatments16, retreatments17, and endodontic surgeries18. CBCT imaging improves our understanding about the internal and external anatomy of the teeth16,19,20, the location and extension of resorptions and perforations21, and the location and extension of radiolucent lesions22,23.
Non-Hodgkin lymphoma (NHL) of the oral cavity can present with pain, swelling and radiolucent lesion mimicking endodontic diseases. This article reports on a case of diffuse large B-cell lymphoma initially diagnosed and treated as periodontal disease and then endodontic disease in the maxillary anterior and premolar area of a 40-year old female. A cone beam computed tomography (CBCT) image of the lesion was taken. The lesion was segmented using Mimics software (Materialise NV, Lueven, Belgium). Three-dimensional models of the tumor were printed. During the surgical phase teeth #4, 6, and 7 were extracted and biopsy samples were obtained. Histopathologic examination showed invasive sheets of large, atypical, basophilic cells strongly and diffusely positive for CD20. Three-dimensional analysis, segmentation, and printing of radiolucent lesions of the jaws assists with differential diagnosis and efficient treatment. Oral health professionals can play a crucial role in the early detection and diagnosis of oral NHL, thereby preventing extensive loss of function and esthetics, and even saving lives.

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Basic ResearchAccuracy of 3-dimensional–printed Endodontic Surgical Guide: A Human Cadaver Study

Highlights

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Oral Surg Oral Med Oral Pathol

J Endod

J Endod

J Oral Maxillofac Surg

J Endod

J Endod

J Endod

J Endod

J Endod

J Endod

J Evid Base Dent Pract

Basic Research
Accuracy of 3-dimensional–printed Endodontic Surgical Guide: A Human Cadaver Study