A Novel Method for Periapical Microsurgery With the Aid of 3D Technology

A Case Report

Shangzhu Ye; Shiyong Zhao; Weidong Wang; Qianzhou Jiang; Xuechao Yang


BMC Oral Health. 2018;18(85) 

In This Article

Discussion and Conclusions

Endodontic surgery is needed for the treatment of a large, cyst-like periapical lesion.[1,2] Sometimes it is challenging to locate root-end for resection.[4] The length of resection of root-end (3 mm) is not easy to control for inexperienced surgeons. Here, a novel method was used to solve these problems with the guide of a 3D-printed template. This template was fabricated following data acquisition, image processing and manufacturing, through which the combined information obtained from CBCT and digital surface scans could be integrated into a physical template.

In a conventional periapical surgical process, searching for root-end and the need for adequate operative visual field usually leave a large bone defect which seems unnecessary now.[19] With the aid of the 3D printed template, the diameter of the lesion caused by surgery could be restricted to 3–4 mm, only slightly larger than the length of resection (3 mm). This minimal invasive surgical procedure maximally limits injury to osseous tissues. Less damage to osseous tissues results in less haemorrhage during surgery, less postoperative complications, shorter healing time and better prognosis.

The template served as a carrier, carrying the information of the location of the root-end and the 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. With the aid of the template, the trephine was navigated into the exact location, and the surgeons did not have to mentally transfer the information to the clinical situation. This procedure enabled the surgeons to precisely remove the overlying bone and the root-end using the trephine. This method not only simplified the surgical procedure but also considerably improved the treatment efficiency. More time was needed preoperatively to virtually design the template. However, the time will surely be reduced in the future once a workflow is established.

Adjacent teeth and bone were saved from accidental damage with the restriction of the template. This procedure eliminated the unpredictability of osteotomy and root end resection, rendering a challenging clinical procedure relatively simple to manage. The 3D technology described has the potential to substitute for the specialized training and/or clinical experience necessary to treat these difficult cases, which would enable many dentists to achieve predictable results without needing extensive surgical skills.

A slight mismatch between planning and execution may be expected if we consider the accuracy of this 3D planning technology. Further studies need to be carried out to confirm the accuracy of the 3D-printed template-aided periapical surgery procedure. The uniformity can be checked by comparing pre and postoperative virtual images.

This procedure still has some limitations. When the lesion is in a posterior region, the template can still be fabricated and positioned, but insufficient space will be available for the trephine. The costs of such 3D planning and the production of the directional template are considered high; however, such costs will be reduced in the future given the fast-paced development of digital technology in dentistry. There is a promising chance that a reasonable therapy workflow will be established and this treatment approach will be applied in daily routine practice, benefiting more patients.

The digitally designed directional template fabricated using CBCT, CAD and 3D printing technology worked in all aspects to facilitate the periapical surgery as anticipated. The root-ends were accurately located using the template and resected with the trephine. The surgical procedure was simplified, and the treatment efficiency was improved. This technique minimized the damage to soft and hard tissues and reduced iatrogenic injury.