Journal Pre-proof

Guided endodontics for managing severely calcified canals.

M. Llaquet, C. Vidal, M. Mercadé, M. Muñoz, P.S. Ortolani-Seltenerich

PII: S0099-2399(20)30932-8
DOI: https://doi.org/10.1016/j.joen.2020.11.026
Reference: JOEN 4747

To appear in: Journal of Endodontics

Received Date: 13 July 2020

Revised Date: 19 November 2020
Accepted Date: 24 November 2020

Please cite this article as: Llaquet M, Vidal C, Mercadé M, Muñoz M, Ortolani-Seltenerich PS, Guided
endodontics for managing severely calcified canals., Journal of Endodontics (2021), doi: https://
doi.org/10.1016/j.joen.2020.11.026.

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Copyright © 2020 Published by Elsevier Inc. on behalf of American Association of Endodontists.

 1. Title:
Guided endodontics for managing severely calcified canals.

2. Running title:
Guided endodontics.

3. Authors:
Llaquet M 1; Vidal C 2; Mercadé M 3,4; Muñoz M 5, P. S. Ortolani-Seltenerich 6.

4. Affiliations:

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1
Department of Restorative Dentistry and Endodontics, Universitat Internacional de

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Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
2
Private practice, Dubai, United Arab Emirates.
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3
Department of Dentistry, Universitat de Barcelona, Barcelona, Spain.
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4
IDIBELL Institute, Barcelona, Spain.
5
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Private practice, Liège, Belgium.

6
Department of Dental Pathology and Therapeutics, Universidad Católica San
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Antonio de Murcia, Murcia, Spain.

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5. Acknowledgements:
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The authors thank the staff members of Autrán Dental for its logistic contribution and
Jesús Muñoz for his assistance with the digital planning.

The authors deny any conflicts of interest

6. Corresponding author:
Marc Llaquet Pujol
Universitat Internacional de Catalunya
Dentistry Faculty
C/Josep Trueta s/n
08195 Sant Cugat del Vallès
Barcelona, Spain
Email: [email protected]

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Title

Guided endodontics for managing severely calcified canals

Abstract

Introduction: Endodontic treatment of teeth with pulp canal obliteration presents a

challenge given the high likelihood of procedural errors and complications during

treatment. These drawbacks can be avoided by using a personalized 3D guide,

designed by overlaying a cone beam computed tomography scan with an intraoral

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scan of the patient. This 3D guide enables the clinician to obtain a straight access to

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the obliterated root canal. Case report: This paper described guided endodontics in
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managing seven severely obliterated teeth using both virtually designed 3D guides
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and a customized 1 mm-diameter cylindrical bur. Conclusions: This treatment
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approach was demonstrated to be safe and fast and can be considered as a predictable
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technique for the location of calcified canals, thus minimizing complications.

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Keywords

Root canal treatment; Pulp canal obliteration; cone beam computed tomography;

intraoral scan; surgical planning software; guided endodontics.

Introduction

Pulp canal obliteration (PCO) associated with traumatic injury in anterior teeth results

from accelerated deposition of dentin within the root canal space (1). This reparative

process develops as a pulpal response to severed neurovascular supply during the

trauma (2, 3). Jacobsen & Kerekes (3) observed, during a period of 10 to 22 years,

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that 78 (63.9%) of 122 teeth injured by trauma were completely obliterated, and 44

(36%) were partially obliterated. Oginni et al. (4) reported similar results, with 56.9%

and 43.1% of partial and complete cases of PCO, respectively. The most frequent

clinical sign of PCO, found in approximately 70-80% of teeth, is tooth discoloration,

caused by loss of translucency due to dentin calcification within the pulp chamber (3,

5). Given that teeth most affected by PCO are in the esthetic zone (2, 6), different

treatments have been described for the restoration of discolored PCO teeth: external

or vital bleaching (7), internal and external bleaching without root canal treatment (8),

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internal bleaching with root canal treatment, and a prosthetic approach (9). Among

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these options, internal bleaching has been demonstrated to be esthetically predictable
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and stable (10), conservative and inexpensive (11, 12). Therefore, root canal treatment
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is considered an indication for the treatment of discolored PCO teeth when internal
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bleaching is required.
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Another indication for root canal treatment in PCO teeth is in cases with acute
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symptoms or apical lesions. Although PCO is considered a sign of pulp vitality (13),
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which does not require endodontic treatment, pulp necrosis with a periapical lesion

may develop unpredictably after several years (3, 5) in up to 38.2% of cases (3, 4, 14).

In addition, Oginni et al. (4) observed a periapical index (PAI) score ≥ 3 (percussion

tenderness, swelling, and/or sinus tract) in 27.1% of the teeth diagnosed with PCO.

The American Association of Endodontists (15) classifies the endodontic treatment of

obliterated root canals as a high level of difficulty. Root canal location and

preparation represent a challenge to manage teeth with PCO, even when using an

operating microscope (16, 17). Potential procedural errors include access cavity

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overextension, iatrogenic perforation, missed root canals, file separation, and root

canal deviation from the original path, all of which prevent the clinician from

reaching working length (18, 19).

To improve treatment planning and simplify the technical treatment procedure, digital

technology is being increasingly applied to endodontics (20). Overlaying a patient’s

cone beam computed tomography (CBCT) images with digital impressions allows for

the design a 3D guide to access the drill through the tooth (21). Similar to 3D

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planning of dental implants, the proper rotation, angulation, and positioning of the

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drill can be virtually predefined. This method allows the clinician to locate the root
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canals by minimizing those procedural complications (22).
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This clinical report describes the endodontic management of seven teeth with PCO by
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means of digitally guided endodontics using both a virtually designed 3D guide and a

customized 1 mm-diameter cylindrical bur.

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Case report

Seven consecutive adult patients (aged 27 to 53 years, mean age 40.5 years) with a

previous history of dental trauma experiencing tooth discomfort in the anterior region

were referred to the dental office (endodontic referral clinic in Barcelona, Spain)

between 2015 and 2017. No teeth responded to thermal or electric pulp testing,

although sensitivity to palpation was observed in four cases, and to percussion in two

cases (Table 1). Radiographic examination, which included a periapical radiograph

(Kodak RVG 6100; Carestream Health, Rochester, NY) and a selective CBCT scan

(Newtom 5GXL, Newtom, Verona, Italy), revealed an apical lesion in six of the

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seven, and advanced PCO in all the teeth (Figs. 1b – 1e). Informed consent was

obtained from each patient prior to guided root canal treatment.

In all cases, clinical and digital protocols were followed according to the method

reported by Zehnder et al. (23) and Connert et al. (24). A surgical planning software

(BlueskyPlan, Libertyville, IL, USA) was used to design 3D guides as follows: first,

an intra-oral scan (Trios3, 3Shape, København, Denmark) taken of each patient’s

anterior tooth and the CBCT DICOM files were imported into the software, in which

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they were matched using the alignment tool by selecting six common reference

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points. The tooth guiding access was then designed virtually by customizing an
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implant according to both length (21mm) and diameter (1mm) of the access bur.
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Thereafter, drill angulation and position were determined following a straight line
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from the visible root canal axis (Figs. 1f, 1g). Each 3D guide was digitally designed
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according to the predefined position and dimensions of the drill guided access, and

exported as an STL file (Figs. 1h, 1i). Four 3D guides were 3D-printed using
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biocompatible fused deposition modeling (FDM) or stereolithography (SLA) resins,

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while three others were milled using a biocompatible poly (methyl methacrylate)

PMMA disc (Polident, Volčja Draga, Slovenia) (Fig. 1j).

After 3D guide fitting was checked (Fig. 1l), endodontic treatment was initiated under

rubber dam isolation (Fig. 1m). A customized (length, 21 mm; diameter, 1 mm)

cylindrical diamond bur was used at 10000 rpm in a pecking movement to penetrate

both the enamel and the dentin (Figs. 1k, 1n). Both the bur and access cavities were

copiously rinsed with saline every 3-4 mm in order to prevent tooth overheating. This

procedure was repeated until the root canal could be negotiated with manual files

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(Fig. 1o). Working length was determined using an apex locator (Raypex 5, VDW,

Munich, Germany) and digital radiography (Figs. 1p - 1r). Chemo-mechanical

preparation was performed using either ProTaper Next system (Dentsply-Maillefer,

Baillagues, Switzerland) or WaveOne Gold instruments (Dentsply-Maillefer,

Baillagues, Switzerland) under 5.25% sodium hypochlorite irrigation. In 2 teeth

calcium hydroxide was left for three weeks, since suppuration could not be controlled

in the first visit. All root canals were sealed with warm gutta-percha using

the continuous wave technique (Figs. 1s, 1t). No patients reported discomfort upon

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percussion or palpation at least one year after the treatment, when periapical healing

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was evident.
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Discussion
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McCabe & Dummer (18) used a treatment decision flowchart to determine that
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procedures on PCO teeth should be limited to cases with symptomatic and/or

radiographic signs of periapical pathosis. They also suggested that endodontic

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treatment should be considered for discolored teeth that were unresponsive to vital
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bleaching techniques. However, in their flowchart, radiographic assessment was

limited to intraoral radiographs, which may be insufficient for proper visualization of

the root canal configuration (25). In this context, CBCT is widely recommended as a

diagnostic tool in PCO teeth, since it provides a three-dimensional representation of

the root canal configuration, increasing the accuracy of evaluating the degree of

obliteration (26). Therefore, CBCT image should be used in PCO cases in order to

allow clinicians to decide whether to use guided endodontics or a conventional

approach, depending on the severity of obliteration throughout the root.

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Apical surgery and intentional replantation have been suggested as treatment options

when root canals are not accessible, since both treatments ensure a direct approach to

the apical third of the root (27, 28). However, canal identification and root end-

preparation might be jeopardized in teeth with advanced PCO, even when methylene

blue and magnification are used (18). The incomplete disinfection of the root apex

and necrotic tissue remnants of the unprepared root canal has been considered as the

main cause of post-treatment disease (29). Guided endodontics ensures precise and

safe location of the root canal (22, 30), with significantly less dentine removal

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compared with the traditional approach, as demonstrated by some ex-vivo studies (31,

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32). Thus, guided endodontics should be considered in PCO cases, since avoids both
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the chair-time and post-operative inconveniences of endodontic microsurgery without
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damaging soft and hard tissues.
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Full crown coverage has been described as an alternative to non-vital techniques for
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severely obliterated, discolored teeth (9) because of the high frequency of

complications associated with root canal therapy in teeth with PCO (18, 19). Guided
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endodontics allows the clinician to easily locate the root canals, without the need for
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excessive tooth preparation (32). Thus, given that PCO teeth are often intact, guided

endodontics should be considered, along with the non-vital bleaching, as an

alternative to full crown restoration.

Although guided endodontics is a straightforward, time-saving technique, it still

presents limitations. In this report, two printed 3D guides required minimal

adjustment of the inner part to allow correct seating, owing to the presence of the 3D

printing support structures in the inner part of the guide, which were cleaned and

polished. In contrast, all milled 3D guides fit adequately without adjustment. The

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authors highly recommend orientating the supports of the 3D model in the outer

model surface, in order to avoid it interfering with the guide fitting, as stated by many

authors (33, 34).

Previous studies confirmed that resolution and dimensional accuracy of 3D printing

mainly depends on the 3D printing system (33, 35-38). Comparing 3 types of 3D

printers, Kim et al. demonstrated that, although the PolyJet system (photopolymer

jetting) is more expensive, had better accuracy and reduced printing time than both

the SLA and the MJP (multitjet printing). The authors concluded that the PolyJet and

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SLA 3D printing systems met the required accuracy for clinical applications in

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dentistry(33). Similar results were found by Salmi et al., who reported that the PolyJet
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achieved higher accuracy compared to 3DP (binder jetting), and SLS (selective laser
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sintering) by printing a skull replica (39).
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This report describes the application of endodontic 3D guides manufactured with 3

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different materials and CAD-CAM techniques: an extrusion-based 3D printer (FDM),

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a photopolymerization-based 3D printer (SLA) and milling process. Nestler et al.

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compared the dimensional accuracy of 5 different manufacture technologies: 2

extrusion-based 3D printers (FDM) and 3 photopolymerization-based 3D printers

(SLA and DLP). Although DLP displayed the highest accuracy, no significant

differences were found. Therefore, expensive printers (photopolymerization-based 3D

printers) were no more accurate than less expensive ones (36). Jin et al. showed that

the PolyJet technology appeared to have better trueness than that of the FDM, but was

not significant (40). This could be explained by the smaller molecules that uses

Polyjet liquid photopolymers which enables to reproduce complex shapes (41).

Furthermore, FDM models display thicker layers and rougher surfaces than PolyJet

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models, which could hamper dental treatment effectiveness, according to Lee et al.

(42).

Shrinkage and warpage can also affect dimensional accuracy of both

photopolymerization and extrusion-based systems (36, 42, 43). This is a potential

disadvantage compared to CAD-CAM milled technology, which have been

demonstrated to be significantly more precise than 3D-printed technology (44, 45).

Kalberer et al. analyzed the differences in the trueness of milled versus 3D-printed

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complete dentures, from different surfaces of a reference maxillary edentulous model.

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The authors observed a significant better trueness of the milled protheses compared to

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that of the 3D-printed ones in almost all the analyzed surfaces (44), which was
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confirmed by Marcel et al. (45). In addition, an accuracy error can occur as a
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consequence of variations in the CBCT settings, as demonstrated by Choi et al., who

recommend a 1-mm section thickness, a high-quality of CBCT images and a correct

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threshold value (46). In our report, 3 guides were milled in clear PMMA, which
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allowed the clinician to check both the correct guide fitting and the drill.
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This technique may not be applicable in all posterior teeth, since it requires an

additional working space for the 3D guide and the bur. Furthermore, the straight

shape and stiffness of the bur presents an anatomical limitation in curved canals. In

this report, 1-mm diameter, cylindrical, diamond burs were successfully used in upper

anterior teeth. However, this bur could be unsuitable when treating lower incisors,

which might lead to an excessive removal of radicular dentine, as a result of these

teeth having thin roots (31). In an ex vivo study, Connert et al. reported the successful

treatment of mandibular anterior teeth by guided endodontics using a 0.85-mm

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diameter bur (24, 32). Another drawback of this technique is the difficulty in cooling

below the drill path. In this report the cavity was constantly irrigated with saline to

avoid the tooth overheating. For its part, Buchgretiz et al. recommended the use of a

low-speed bur at 250 rpm (22), in contrast to a high-speed bur at 10.000 rpm, used in

this report. The authors strongly feel that an additional irrigation system crossing the

sleeve or the tube would overcome that problem.

Conclusion:

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Within the limitations of the present report, guided endodontics were demonstrated to

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be a safe, accurate, and conservative approach for the endodontic management of
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severely anterior obliterated canals when precise virtual planning is used. CBCT
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should be used to determine the need for guided endodontic access, depending on the
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degree of tooth obliteration. Additional research should focus on comparing different

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planning software, materials and designs for both 3D guides and burs.
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Table 1. Age, gender, tooth diagnosis, template material and obliterated root third/s of

each case.

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Case Age Tooth Diagnosis Template material Oblitered third/s

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1 27 #21 SAP PMMA CM

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35 #13 CAA SLA C
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3 AAA
39 #21 FDM C
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4 42 #11 SAP FDM CMA

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5 33 #11 AAA SLA CMA

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6 51 #21 AAP PMMA CM

7 29 #11 AAP PMMA CM

SAP: symptomatic apical periodontitis, AAP: asymptomatic apical periodontitis,

AAA: acute apical abscess, CAA: chronic apical abscess. C: coronal, M: medium, A:

apical.

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Figures:

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Figure 1. Guided endodontics in an upper left central incisor with obliteration of more

than two thirds of the root canal. (a - e) Intraoral photograph and radiographic

examination. (f, g) Tooth guiding access following a straight line from the visible root

canal axis. (h, i) Template design. (j) A PMMA-milled template. (k) Fit verification of

the customized bur through the template guiding access orifice. (l) Template oral

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seating verification. (m) Rubber dam isolation before endodontic treatment. (n - r)

Guided drilling and drilling verification radiographs. (s) Final radiograph. Note the

bur shape in the coronal and middle third of the root canal. (t) Root canal sealing.

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Figure 2. Guided endodontics in an upper right canine. (a, b) Radiographic

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examination revealing pulp canal obliteration until the middle third of the root and

-p
apical lesion. (c) Virtual planning and 3D guiding template design using surgical

planning software. (d) SLA template oral seating verification. (e) Guided open access.
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(f) Final radiograph.
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Figure 3. Guided endodontics in an upper left central incisor with the calcified pulp

chamber and an internal root resorption. (a) Clinical aspect of the discolored tooth. (b

– d) Radiographic examination. Note the root resorption and the large periapical

lesion leading to buccal bone fenestration. (e) FDM template oral seating verification.

(f) Guided access cavity. (g, h) Root canal obturation using a bioceramic sealer. (i)

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Clinical aspect of the treated tooth after internal bleaching.

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Figure 4. Guided endodontics in an upper right central incisor. (a, b) Radiographic

examination showing complete root obliteration. (c, d) Virtual treatment planning and
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guiding template design with surgical planning software. (d) SLA template seating
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and bur drilling through the guided access. (e) Drilling verification radiograph. (f, g)

Canal location and the final radiograph. (h) Root canal sealing with gutta-percha.

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