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 Table of Contents  
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 172-176

Guided osteotomy: A conservative method for periapical surgery with the aid of cone-beam computed tomography and three-dimensional printing technology

1 Department of Conservative Dentistry and Endodontics, Sardar Patel Post-Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 PDCC, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission10-Apr-2022
Date of Decision01-Jun-2022
Date of Acceptance05-Jun-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Saini Rashmi
MDS, Block 12, MRA92A, SGPGI, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tdj.tdj_8_22

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Cone-beam computed tomography (CBCT), a modern technology in three-dimensional imaging has gained wide acceptance in the field of endodontics. Treatment strategies and surgical guidance have both benefited from this strategy. By the use of conventional periapical radiographs sometime the intraoral localization of root apex is found to be difficult and it is inescapable to prevent significant amount of bone removal. Moreover, the duration of retraction of gingival flap increases and more amount of alveolar bone removal are usually required, leading to prolonged time of surgery. The more intraoperative time, the higher are the chances of postoperative pain, discomfort and even leads to increase risk of infection. The combination of intraoral or extraoral scan and CBCT provides favorable treatment outcomes. Leveraging CBCT, computer-aided design, and three-dimensional printing technology, this case report discusses a method of periapical surgery using a surgical template for guided osteotomy and root resection of the maxillary central incisor.

Keywords: computer-aided design, cone-beam computed tomography, guided osteotomy, three-dimensional printed template

How to cite this article:
Rashmi S, Kr SV. Guided osteotomy: A conservative method for periapical surgery with the aid of cone-beam computed tomography and three-dimensional printing technology. Tanta Dent J 2022;19:172-6

How to cite this URL:
Rashmi S, Kr SV. Guided osteotomy: A conservative method for periapical surgery with the aid of cone-beam computed tomography and three-dimensional printing technology. Tanta Dent J [serial online] 2022 [cited 2023 Jan 30];19:172-6. Available from: http://www.tmj.eg.net/text.asp?2022/19/3/172/356086

  Introduction Top

Endodontic periapical surgeries involves the removal of a periapical lesion and preserving the tooth by performing treatment on the root apices of the infected tooth which cannot be resolved with conventional root canal therapy [1]. According to literature modern endodontic surgeries have a relatively high success rate, ranging from 53 to 98% [2]. In cases of periapical pathologies, the use of conventional radiographs imparts only two-dimensional view by which it is difficult to precisely locate the lesion unless there is a presence of sinus [1]. The new approach of cone-beam computed tomography (CBCT) imaging provides accurate diagnosis, three-dimensional (3D) view of root apex and adjacent surrounding structures [3]. Surgical guide templates using computer-aided design (CAD)/CAM and 3D printing, have been recently introduced in endodontic fields for guided access cavity preparation for calcified canals as well as guided osteotomy in endodontic surgery [4],[5]. It can also be useful in critical cases like mandibular premolars to avoid damage to the sinus. Prognostic factors influencing endodontic surgery outcomes include lesion type, root-end filling material, and coronal restoration, the extent of periapical bone destruction [6],[7]. Furthermore, the extent of the osteotomy has an impact on the severity of postoperative sequelae such pain and swelling [8]. Because it is difficult to detect the root apex in patients with an intact buccal bone plate or no sinus, the amount of osteotomy is substantially larger [9]. This case report described how CBCT, CAD, and a 3D printed surgical template were used to execute guided periapical surgery on the maxillary central incisor.

  Case report Top

A 25-year-old female patient, attended to the Department of Conservative Dentistry and Endodontics, complaining of pain in upper front tooth region since 15 days. Patient recorded a history of trauma on anterior maxillary region 1 year back. The past medical history was irrelevant. Clinical examination revealed that left maxillary central incisor with Elli's II fracture and the tooth was tender to percussion [Figure 1]a. Pulp vitality testing of the affected tooth with heated gutta-percha (Dentsply Maillefer, Switzerland) and Endo Ice (Coltene/Whaledent GmbH+ Co. KG, Langenau, Germany) showed negative response. Intraoral periapical radiograph revealed periapical radiolucency associated with tooth 21 [Figure 1]b. The exact extent of lesion (7.56 mm × 6.36 mm × 6.68 mm) was confirmed using CBCT imaging (Kavo i-CAT FLX V-Series, Australia) with an exposure parameter of 0.25 voxel, 120 kv, 5.0 ma and 7 s [Figure 1]c, [Figure 1]D, [Figure 1]e. The diagnosis of pulpal necrosis with apical periodontitis was made based on clinical and radiographic evaluation. The root canal treatment procedure, guided periapical surgery, root resection with root end filling was explained to the patient. The tooth had an intact buccal cortical bone with absence of sinus and also the patient was apprehensive for the multiple visits for the nonsurgical root canal treatment procedure, therefore guided periapical surgery was suggested to the patient. Patient informed consent was obtained after explaining all the procedure.
Figure 1: (a) Preoperative photograph of the patient. (b) The initial periapical radiograph of tooth 21 exhibiting a periapical radiolucency. (c) A coronal view of CBCT scan revealing a periapical lesion in the root of tooth 21. (d and e) A axial and sagittal view of CBCT scan showed a well-defined periapical lesion of 7.56 mm×6.36 mm×6.68 mm irt 21. (f) The CBCT scan of the cast. (g and h) Frontal and sagittal view revealed virtual planning of metal sleeve position targeted on the tooth 21 in implant surgical planning software. (i) The final design of 3D printed surgical template for endodontic surgery on tooth 21. 3D, three-dimensional; CBCT, cone-beam computed tomography.

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Presurgical planning for surgical template

A diagnostic cast was created after an impression was taken with additional silicon rubber base material. CBCT images of the cast were generated [Figure 1]f. For virtual surgical planning, the acquired Digital Imaging and Communications in Medicine (DICOM) files from the CBCT pictures of the patient and cast were uploaded and superimposed on each other in the software (AIS software, ACETON Group North America). In virtual surgical planning, an anchor sleeve with a diameter (2.3 mm inner and 4.3 mm outer) and 5 mm in length was incorporated to target the root apex of tooth 21 [Figure 1]g. A stereolithography file format was used to export the surgical template [Figure 1]h. This file was sent for 3D printing using next dent surgical guide resin (Vertex Global Holding, The Netherlands). A metal sleeve was placed after the printing was finished [Figure 1]i.

Root canal procedure

An access cavity was prepared under rubber dam after administration of local anesthetic with 2% lidocaine combined with epinephrine (1: 100 000). With the help of an apex locator (Root ZX; J Morita, Kyoto, Japan) and the radiography approach, the working length was confirmed. Biomechanical preparation was completed using Stepback technique. Irrigation was performed using 5.25% sodium hypochlorite solution and normal saline. The canals were wiped with sterile paper tips. Obturation was performed using AH 26 (Dentsply, Maillefer) root canal sealer with the combination of lateral and vertical condensation technique.

Surgical procedure

A surgical operating microscope was used for all surgical procedures. On the day of the procedure, a 3D printed surgical template was checked on tooth 21 to ensure that it fit correctly [Figure 2]a. The patient was anesthetized with 2% lidocaine and epinephrine (1: 80 000), then a full thickness rectangular flap reflection was performed with a periosteal elevator [Figure 2]b. Guided osteotomy was conducted using a 1.5-mm-diameter, 20-mm-long anchor drill after the surgical template was positioned on tooth 21 [Figure 2]c and [Figure 2]d. The surgical site was punctured to a depth of 4 mm using a guide [Figure 2]e. After removing the surgical template, the punctured buccal bone was examined. Additional osteotomy was performed with a No. 4 round carbide bur (No. 4; Prima Classic Prima Dental Group, Gloucester, UK) at a low speed of 1200 rpm under distilled irrigation until sufficient space for the manipulation of ultrasonic instruments was gained [Figure 2]f. A KIS ultrasonic tip (No. 1 ProUltra, Dentsply) was used to accomplish periapical curettage and 3-mm root tip excision. Using KIS ultrasonic tips, root-end preparation was made 3 mm into the canal space along the long axis [Figure 2]g. The prepared root-end cavity was dried and Biodentin (Septodent, India) was used to fill it. A postoperative radiograph was done to ensure that the root end filling was complete and that the bone crypt was free of surplus material [Figure 2]h. The flap was closed and sutured with 3–0 monofilament sutures after the wound area was disinfected [Figure 2]i. The patient was given oral analgesics (ibuprofen 400 mg three times a day), antibiotics (1 g amoxicillin and clavulanic acid, twice daily), and chlorhexidine mouth rinse (0.2%, three times a day) for 5 days after the procedure. The sutures were removed 7 days after the procedure. No complications were discovered after a week of follow-up. Clinical symptoms were fully alleviated after one month of follow-up. There were no further indicators of negative consequences in the vicinity of the soft tissues. The PRICE 2020 Guidelines were used to prepare this case report [Figure 3] [10].
Figure 2: (a) The surgical template was positioned on tooth 21. (b) After retraction of flap no fenestration is seen. (c) Placement of surgical template after retraction of flap. (d) Drilling through surgical template using an anchor drill of 1.5 mm diameter. (e) The bony punch made through surgical template (black arrow). (f) The bone crypt was enlarged to enable instrument manipulation. (f) Intraoral periapical radiograph showing root end preparation. (g and h) Intraoral periapical radiograph showing root end preparation and filled with Biodentin. (i) Postoperative image after suture placement.

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Figure 3: PRICE 2020 flow chart.

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  Discussion Top

Endodontic microsurgery using the guide template has demonstrated high accuracy over a free hand operation [1]. After endodontic surgery, the diameter of a bone defect affects the healing success. Extensive bone damage is associated with uncertain or poor healing, healing delays and a higher risk of surgical morbidity [7],[11]. Surgical trauma, including osteotomy, triggers the inflammatory response, which results in postoperative problems such as pain and swelling [8]. Reducing the size of the osteotomy can aid with surgical problems and recuperation. Therefore, 3D guided template functioned as a carrier, conveying information about the root-end location and size of the periapical lesion, the orientation and angle of the root and its apex, and the thickness of the cortical bone into the surgical procedure. Using the trephine, the surgeons were able to precisely remove the overlaying bone and the root-end. The surgical method was simplified, and the effectiveness of the treatment was increased. This method lowered iatrogenic injury while minimizing soft and hard tissue damage provides more favorable postoperative healing and better prognosis [12]. In comparison to traditional processes, 3D planning for the construction of surgical templates is definitely expensive and time-consuming. Because our guided endodontic surgical approach for osteotomy and root resection employs a customized software program similar to that used in guided implant surgery, planning time and production costs should be comparable to those of guided implant treatment. However, as stated in the guidelines for state-of-the-art endodontic surgery, the preservation of the cortical bone and dental structures could be credited as prospective benefits, justifying additional planning time and expenditures [13],[14]. Although 3D fabrication of surgical templates is a time-consuming process but it reduces time taken during the surgical procedure. Pinsky et al. [5] confirmed in their in vitro study that the greater accuracy and consistency was achieved during endodontic surgery with surgical guidance without damaging vital structures. An error greater than 3 mm occurred over 22% of the time with freehand surgery whereas none of errors occurred with surgical guidance [5]. Proper case selection and delicate design are necessary for the success of the procedure. Further clinical studies may be required regarding surgical procedure for endodontic periapical surgery using the guide template to improve the accuracy or to reduce the surgical time.

  Conclusion Top

Introducing a CBCT, CAD and 3D printing technology, helps to minimize the extent of osteotomy and facilitates locating the root apex by using surgical template. This surgical procedure using guided templates, required lesser surgical time, reduced bone removal and also provides favorable postoperative healing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kim JE, Shim JS, Shin Y. A new minimally invasive guided endodontic microsurgery by cone beam computed tomography and 3-dimensional printing technology. Restor Dent Endod 2019; 44:3.  Back to cited text no. 1
Kim S. Modern endodontic surgery concepts and practice: a review. J Endod 2006; 32:7.  Back to cited text no. 2
Fan Y, Glickman GN, Umorin M, Nair MK, Jalali P. A novel prefabricated grid for guided endodontic microsurgery. J Endod 2019; 45:606–610.  Back to cited text no. 3
Zehnder MS, 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.  Back to cited text no. 4
Pinsky HM, Champleboux G, Sarment DP. Periapical surgery using CAD/CAM guidance: preclinical results. J Endod 2007; 33:148–151.  Back to cited text no. 5
Song M, Kim SG, Lee SJ, Kim B, Kim E. Prognostic factors of clinical outcomes in endodontic microsurgery: a prospective study. J Endod 2013; 39:1491–1497. Epub 2013 Oct 15.  Back to cited text no. 6
von Arx T, Hänni S, Jensen SS. Correlation of bone defect dimensions with healing outcome one year after apical surgery. J Endod 2007; 33:1044–1048.  Back to cited text no. 7
Sisk AL, Hammer WB, Shelton DW, Joy ED Jr. Complications following removal of impacted third molars: the role of the experience of the surgeon. J Oral Maxillofac Surg 1986;44:855–859.  Back to cited text no. 8
Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations and clinical techniques. Int Endod J 1985; 18:8–34.  Back to cited text no. 9
Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020 guidelines for reporting case reports in endodontics: a consensus-based development. Int Endod J 2020; 53:619–626.  Back to cited text no. 10
Song M, Kim SG, Shin SJ, Kim HC, Kim E. The influence of bone tissue deficiency on the outcome of endodontic microsurgery: a prospective study. J Endod 2013; 39:1341–1345.  Back to cited text no. 11
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod 2006; 32:601–623.  Back to cited text no. 12
Krastl G, Zehnder MS, Connert T, Weiger R, Kühl S. Guided Endodontics: a novel treatment approach for teeth with pulp canal calcification and apical pathology. Dent Traumatol 2016; 32:240–246.  Back to cited text no. 13
Zehnder MS, 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.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]


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