CASE REPORT/CLINICAL TECHNIQUES

Xiaoxia Yang, MDS,

Yinchun Zhang, MDS, Limitations and Management
Xuan Chen, MDS, Lei Huang,
MDS, and Xiaoling Qiu, DDS, of Dynamic Navigation System
PhD
for Locating Calcified Canals
Failure

ABSTRACT
SIGNIFICANCE
Nonsurgical endodontic teeth treatment with severe pulp canal obliteration poses challenges,
This work presents the primarily locating canals. By combining 3-dimensional reconstruction and spatial location
manipulation process and registration, the dynamic navigation technique uses an optical tracking system to guide the
clinical outcomes of a dynamic clinician to drill in real time according to the predesigned path until access to the canal is
navigation system that helps in established. Several in vitro studies and case reports have shown that calcified canal location
calcified canal location. We with dynamic navigation system (DNS) is more accurate and efficient, yet the technique has
elucidated the failure to locate limitations. In 4 cases with 7 teeth, this work presents manipulation process and clinical
the canals with the DNS in 2 outcomes of DNS helping in calcified canal location. We performed handpiece adaptation and
teeth, resulting in canal elucidated the failure to locate the canals with DNS in 2 teeth, resulting in canal geometry
geometry alteration and path alteration and canal path deviation. Subsequently, the more experienced endodontist located
deviation. the canals by combining cone-beam computed tomographic imaging and dental operating
microscopy. All patients were completely asymptomatic after treatment. At the 1-year
follow-up visit, the bone healing of periapical lesions progressed well according to the
periapical radiography or cone-beam computed tomographic imaging. These findings
indicate that DNS is a promising technique for locating calcified canals; however, it needs to
be refined before clinical use. (J Endod 2024;50:96–105.)

KEY WORDS
Dynamic navigation; guided endodontics; pulp canal obliteration; root canal treatment

Pulp canal obliteration (PCO), also called pulp canal calcification or calcific metamorphosis, is the
progressive narrowing or complete blockage of the pulp canal space. This process involves secondary
From the Department of Endodontics, dentin or tube-like calcified structure deposits within the canal walls1, associated with dental trauma2, vital
Stomatological Hospital, School of pulp therapy3, revascularization4, caries and restorations5, physiological changes in elderly patients6,
Stomatology, Southern Medical
genetic factors7, and systemic factors8,9.
University, Guangzhou, China
Teeth with PCO that require root canal treatment (RCT) pose a challenge in locating the canal,
Address requests for reprints to Dr which causes iatrogenic complications including perforation, separated instruments, and increased risk
Xiaoling Qiu or Xuan Chen, Department of
Endodontics, Stomatological Hospital, of endodontic treatment failure1. Based on the Endodontic Complexity Assessment Tool, teeth with PCO
School of Stomatology, Southern Medical are considered at high risk of complexity for RCT10.
University, South Jiangnan Road 366, The use of advanced equipment like the cone-beam computed tomographic (CBCT) scanner and
Haizhu District, Guangzhou, 510280, P.R. dental operating microscope (DOM)11, the ultrasonic instrument for removal of obstructions12, and
China.
emerging technology-guided endodontics like the lab-fabricated template13 and dynamic navigation
E-mail addresses: [email protected]
or [email protected] system (DNS)14, has increased the accuracy in planning and treatment of calcified canals, and has
0099-2399 allowed operators to overcome these challenges.
Copyright © 2023 The Authors. Published DNS is an alternative intervention for teeth with calcified canals, described in 3 case reports14-16. In
by Elsevier Inc. on behalf of American 2021, Dianat et al16 located the distobuccal calcified canal of a maxillary molar that could not be located
Association of Endodontists. This is an freehand using the DOM, CBCT, and ultrasonic tip. DNS combines 3-dimensional (3D) CBCT imaging
open access article under the CC BY-NC- reconstruction and spatial location registration technology using an optical tracking system controlled by
ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
a dedicated computerized interface to provide real-time navigation, guiding the operator to drill following
https://doi.org/10.1016/ preoperative planning17. In vitro studies have shown the increased accuracy and efficiency of DNS in
j.joen.2023.10.010 locating calcified canals than the freehand technique18, significantly causing less tooth structure

96 Yang et al. JOE  Volume 50, Number 1, January 2024

removal19, obtaining 93% success in locating identical dentition to be relatively stationary China). We successively used the #6 file, #8
the canals in 3D printed jaw models with teeth with the targeted tooth (Fig. 1E and F). file, #10 file, #12 file, and #15 file to negotiate
presenting severe PCO20. Therefore, DNS can track the dynamic position the narrow canals from the orifice to the apex.
However, procedural errors might of the handpiece concerning the targeted The working length (WL) was determined using
impede canal location causing adverse events. tooth using the reference device. At least 7 an electronic apex locator (Propex Pixi;
Thus, an optimum alternative is required to fiducial markers in the CBCT imaging were Dentsply Sirona). The crown-down technique
improve DNS for PCO treatment. These case selected in the software for registration, and was used to prepare canals with nickel-
reports aim to describe limitations and the short round bur with the handpiece was titanium rotary instruments (WaveOne Gold;
management of DNS improvement and failure intraorally moved to contact registration points Dentsply Sirona). Three percent sodium
in severely calcified canals. one by one (Fig. 1G). Virtual and intraoral hypochlorite and 17% ethylenediamine
conditions were registered with the pairing tetraacetic acid were used for irrigation using a
INFORMED CONSENT between the fiducial markers in CBCT imaging syringe and #27 needle and activated by
and their actual positions. After calibration and ultrasonic instrument; 2% chlorhexidine was
After informing patients of the treatment registration, the DNS computed the space used as the final irrigating solution. After root
options (freehand, lab-fabricated template, position between the target tooth and canal preparation, calcium hydroxide paste
DNS), and the corresponding advantages and handpiece to guide treatment in real time. was placed in the canal, and the access cavity
disadvantages of PCO, all patients chose the was sealed with glass-ionomer cement for 2
RCT with the help of DNS. Written informed Real-Time Dynamic Navigation weeks. At the revisit, after confirming WL and
consent was then obtained. The pulp chamber opening and canal locating final working width (FWW), root canal
were performed under the DNS. Before tooth obturation was performed via vertical
CLINICAL PROCEDURES OF THE drilling, the short round bur was placed in the compaction technique, using warm gutta-
DYNAMIC NAVIGATION mesial, distal, and central positions of the percha and injectable sealing paste (iRoot SP;
TECHNIQUE target tooth at different angles to confirm the Innovative BioCeramix Inc, Burnaby, Canada),
correct tooth position, calibration, and followed by resin restoration.
Preoperative CBCT Scanning registration (Fig. 1H). Without disrupting the
After managing the tooth undercut in case 1 reference device, the rubber dam was placed
(Fig. 1A) and case 2, the patient was CASE REPORTS
in the targeted tooth (Fig. 1I). DNS constantly
impressed with a U-shape registration device tracked the handpiece wings and reference Case 1
(DCARER, Suzhou, China) containing 9 device, providing visual feedback to the A 27-year-old woman visited the Department
radiopaque fiducial markers. The target teeth operator (Fig. 1J and K). The dynamic of Endodontics on 31 March 2022,
and 1 or more adjacent teeth were covered movement of the actual drill path was complaining about a pustule of her maxillary
with silicone impression material (Silagum- synchronously presented as images on a right anterior tooth for 2 months. She
Putty, DMG, Hamburg, Germany). The patient screen, including the location, angle, and underwent orthodontic treatment for
wore the registration device on the target teeth depth, with CBCT imaging and predesigned 14 months and had suffered dental trauma
area (Fig. 1B) and underwent CBCT scanning drill path (Fig. 1L). The location and angle 10 years earlier. Clinical examination revealed
(i-CAT, Imaging Sciences International, windows displaying "green" revealed that the that teeth #7 and #8 presented physiologic
Hatfield, PA) with the following parameters: actual drill path was clinically within an mobility and no percussion tenderness.
120 kVp, 5.0 mA, 160 ! 60 mm field-of-view, acceptable range. The depth window However, teeth #7 and #8 did not respond to
and 0.25 mm voxel size. displayed "green" to indicate that the bur was thermal (cold and heat) and electrical pulp
within the predesigned depth. Once the bur tests, and a sinus tract was present on tooth
Preoperative Drill Path Designing reached or exceeded the predesigned depth, #8 mucosa (Fig. 2A–C). Periapical radiography
The CBCT data were uploaded to the the depth window showed a "red" warning. revealed that teeth #7 and #8 had calcified
endodontic navigation system software Case 1 and case 2 were performed by pulp chambers and canals, discontinuity
(DHC-ENDO1; DCARER, Suzhou, China) in Endodontist 1, whereas case 3 and case 4 lamina dura of tooth #7 apex, and apical
Digital Imaging and Communications in were performed by Endodontist 2. radiolucency of tooth #8 (Fig. 2D). Tooth #7
Medicine format. According to the laws of was diagnosed with pulp necrosis and PCO,
centrality, concentricity, and cementoenamel and tooth #8 was diagnosed with pulp
junction (CEJ)21, the drill path was designed to
CLINICAL PROCEDURES OF
necrosis, chronic apical abscess, and PCO.
pass through the CEJ center in the coronal, RCT RCT was performed on teeth #7 and #8.
sagittal, and horizontal views of CBCT imaging All patients were treated at the Department of The canal location procedure for teeth
(Fig. 1C). Endodontics, Stomatological Hospital, #7 and #8 was performed with the help of
Southern Medical University. Case 3 received DNS (Fig. 2E–H). Because the handpieces
Calibration and Registration local anesthesia with 4% articaine were not adapted, the low-speed handpiece
The principle of calibration and registration was hydrochloride with epinephrine (1:100,000), and high-speed handpiece were used
based on an optical tracking system that emits whereas cases 1, 2, and 4 were treated alternately to access the cavity (Fig. 2G). The
infrared light. The handpiece and the reference without anesthesia. All the RCT was performed low-speed handpiece with small round bur
devices were calibrated, collecting information under a rubber dam. Under the DNS, Access was used for location, including establishing
on the different planes of the handpiece wings cavity preparation was completed until the position and direction. A high-speed
using long and short round bur, respectively canal was located with a #10 long-shank K file handpiece with a small round bur was used
(Fig. 1D). The reference device was fixed with (Micro-Opener; Dentsply Sirona, Philadelphia, for drilling, with a depth of 1 mm to 2 mm at
bis-acrylic resin (Luxatemp, DMG, Hamburg, PA). Subsequently, the canal was prepared one time. Drilling and locating procedures
Germany) onto the contralateral side of the and obturated under DOM (DentaFilm, Hefei, were repeated several times until the canals

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D E F

G H I

J L

FIGURE 1 – Procedures of the dynamic navigation technique. (A ) Tooth undercut management. (B ) Registration device with silicone impression material. (C ) Preoperative drill path
design. (D ) Calibration. (E and F ) Fixation of reference device. (G ) Registration. (H ) Verification of the space position between the target tooth and handpiece. (I ) Placement of rubber
dam. (J–L ) Real-time dynamic navigation.

were determined successfully (Fig. 2H). RCT was performed as previously described master apical files (MAFs) were 25#. The
However, tooth #7 lost excessive tooth (Fig. 2I–K). The initial apical file (IAF) of teeth sinus tract on the buccal side had healed
structure in the mesial to the canal orifice, #7 and #8 was 6# file. The WL of tooth #7 (Fig. 2L–N). One year later, the patient
probably because tooth #7 was microdontia. was 18 mm, and tooth #8 was 21 mm. Both underwent CBCT scanning for orthognathic

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L M N

O P

FIGURE 2 – Clinical examinations and radiographic imaging of case 1. (A– C ) Preoperative photograph. (D ) Preoperative periapical radiography. (E and F ) Preoperative drill path
design. (G ) Alternate performance of low-speed handpiece and high-speed handpiece. (H ) Prepared access cavity; the blue arrow indicates the canal orifice. (I–K ) The steps in RCT.
(L–N ) One-year review of clinical examination. (O and P ) One-year review of CBCT imaging.

JOE  Volume 50, Number 1, January 2024 DN-Assisted Treatment of PCO: A Case Series 99
surgery, which confirmed the healing of teeth anterior teeth were abraded (Fig. 4A–C). hence RCT with the assistance of DNS was
#7 and #8, with apical radiolucency Mobility of teeth #23, #24, and #26 was within performed.
disappearance (Fig. 2O and P). normal limits. Tooth #23 had percussion and In the first time of drilling tooth #9, the
cold pulp test pain without response to heat endpoint of the drill path was designed at the
and electric pulp tests. Teeth #24 and #26 had CEJ level (Fig. 5E); however, the operator did
Case 2
no percussion pain or sinus tract, whereas not locate the canal when the bur reached the
A 59-year-old man was referred from the
they did not respond to the thermal (cold and predesigned depth. After redesigning the path
Department of Periodontology for endodontic
heat) and electric pulp tests. Periapical (Fig. 5F), the operator drilled the tooth again
treatment on 24 June 2022, resulting from
radiography revealed an apical radiolucency in without a fresh calibration and registration; the
periapical radiolucency of tooth #9. The patient
teeth #24 and #26, and calcified pulp chamber location and angle window displayed "green,"
complained of abnormal left upper front teeth
and narrowed canal in teeth #23, #24, and #26 which seemed to be the “correct path”.
mobility for several months. Clinical
(Fig. 4D). Tooth #23 was diagnosed with However, the canal could still not be located
examination revealed deep overbite (Fig. 3A). A
symptomatic irreversible pulpitis and PCO; (Fig. 5G). The drill path deviated severely
premature contact of tooth #9 was noted in
teeth #24 and #26 were diagnosed with pulp mesially from the cervical one-third to the
protrusive movement. Tooth #9 had
necrosis, asymptomatic apical periodontitis, middle one-third of the root canal (Fig. 5H).
discoloration (Fig. 3B) with grade 1 mobility.
and PCO. RCT with the assistance of DNS was CBCT scanning was performed to establish
Tooth #9 experienced pain to vertical
performed on teeth #23, #24, and #26. the deviation. We observed that the drill path
percussion but no response to thermal (cold
The drill paths of teeth #23, #24, and deviated similarly to the designed path during
and heat) and electrical pulp tests. The
#26 were designed (Fig. 4E–G). The the initial attempt (Fig. 5I). Endodontist 1
periodontal pocket of tooth #9 was 5 mm to
radiographic imaging features of the periapical revised the drilling direction and located the
7 mm in probing depth, with gingival bleeding
radiography revealed that tooth #23 might canal at the CEJ level, with the direction of
upon probing and discharge of pus (Fig. 3C).
present 2 canals. However, this could not be distal and labial sides from wrong access,
Periapical radiography revealed calcified pulp
confirmed by CBCT imaging because the under the DOM (Fig. 5J). RCT was performed
chambers and narrowing in the canal; tooth #9
canal space was completely calcified as previously described (Fig. 5K). The IAF was
had apical radiolucency and half of the alveolar
obliterative, hence it was difficult to design the an 8# file and prepared to 0.45 mm of FWW,
bone loss (Fig. 3D). CBCT images showed that
drill path. Therefore, the endpoint of the drilling with a WL of 21 mm. With a 1-year follow-up
alveolar bone loss and apical bone defects
path of tooth #23 was designed at the CEJ (Fig. 5L–O), periapical radiography revealed
were not through-and-through (Fig. 3E). Tooth
level (Fig. 4E). Canals of teeth #23 and #24 that periapical bone had healed around the
#9 was diagnosed with symptomatic apical
were finally located under DNS, and tooth #23 overfilled sealer (Fig. 5L).
periodontitis (SAP), PCO, and chronic
single canal was confirmed. However, the
periodontitis. The therapeutic schedule was
direction of tooth #26 distally deviated at the
RCT combined with periodontal treatment.
cervical one-third, and failed to locate the canal
DISCUSSION
The drilling equipment was adapted as a
with DNS (Fig. 4H). CBCT imaging confirmed Guided endodontics using a prefabricated
high-speed handpiece (Fig. 3F). A round bur
that the drilled path distally deviated in the guide template or dynamic navigation is a safe
was used to drill the enamel, and a long-shank
coronal plane (Fig. 4I). Endodontist 1 revised and minimally invasive method for calcified
fissure bur was used to drill the dentin
the drill direction and located the canal under canal location17. However, existing
(Fig. 3G). The canal was located without
the DOM. RCT was performed as previously studies17,22,23 and our unpublished case
excessive loss of tooth structure (Fig. 3H). RCT
described (Fig. 4J). The IAF of teeth #23, #24, series indicate that a prefabricated guide
was performed as previously described (Fig. 3I
and #26 was 8# file, with WL of 21.5 mm, template has limitations. First, the low-speed
and J). The IAF was 8# and prepared to MAF of
20 mm, and 21.5 mm, respectively. After handpiece is used for drilling dentin structure,
35# with a WL of 23 mm. After RCT, the
preparation, the FWW was 0.25 mm, and which is inefficient. Second, template insertion
patient accepted periodontal treatment at the
tooth #26 canal geometry altered mildly. After increases the difficulty of placing the rubber
periodontology department. After 3 months,
6 months and 1 year of follow-up, the apical dam, rinsing dentin debris in the cavity, and
the patient was asymptomatic, and the tooth
radiolucency had resolved, with periapical lack of vision. Third, patients with restricted
mobility had normalized. However, periapical
bone healing (Fig. 4K and L). The treated teeth mouth opening associated with treating
radiography revealed overfilled sealer
and mucosa were normal (Fig. 4M–O). posterior teeth might exert this technique as a
movements (Fig. 3K). Oral examination and
counter indication. Importantly, the drill path
radiographic monitoring were recommended.
was predetermined and guided by a template,
After 1 year, the periapical radiography
Case 4 which could not be changed during operation.
revealed that apical radiolucency and sealer
A 45-year-old man visited the Department of DNS resolves these challenges.
extrusion decreased in size (Fig. 3L). The
Endodontics on 27 June 2022, complaining of Unlike prefabricated guide templates,
periodontal condition of the patient improved
discomfort in his upper left front teeth while DNS has operational benefits in calcified canal
(Fig. 3M–O).
chewing for the previous 2 weeks. The patient location, including rubber dam placement,
had suffered dental trauma for more than cavity rinse, operating space, and vision.
Case 3 20 years. Tooth #9 mobility and probing Without template manufacturing, the process
A 29-year-old man was referred from the depths were within normal limits (Fig. 5A–C); can be completed chair-side in a single visit,
Department of Orthodontics on 27 June 2022; however, it had percussion tenderness and did including canal locating and preparatory work,
he was diagnosed with apical radiolucency in not respond to thermal (cold and heat) and suited for patients with acute pain17. It is also
the mandibular anterior teeth. The patient had electrical pulp tests. Periapical radiography advantageous for patients undergoing
received adequate endodontic treatment for revealed an apical radiolucency with a calcified orthodontic treatment, described in case 1.
tooth #25 3 months earlier. Clinical pulp chamber and narrowed canal (Fig. 5D). Orthodontic brackets can alter tooth position,
examination showed that the mandibular Tooth #9 was diagnosed with SAP and PCO, making it impossible to use the prefabricated

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FIGURE 3 – Clinical examinations and radiographic imaging of case 2. (A– C ) Preoperative photograph. (D ) Preoperative periapical radiography. (E ) Preoperative drill path design. (F )
Handpiece adaptation as high-speed handpiece. (G ) Drill bur of preparing access cavity. (H ) Prepared access cavity; the blue arrow indicates canal orifice. (I and J ) The steps in RCT.
(K and L ) Three-month and 1-year review of periapical radiography. (M–O ) One-year review of clinical examination.

guide template. After oral scanning and CBCT also, a learning curve and training are required causing severe deviation of the drill path from
imaging, the patient must stop orthodontic for operators, including operating by looking at proper canal access.
treatment for prefabricated guided endodontic a monitor and not the patient20. Moreover, Because the canal space cannot be
treatment23. New restorations after therapy information regarding safety and adverse distinguished in CBCT imaging, the drill path
must be avoided to preserve the original teeth events is lacking. Operators should be design of severely calcified canals is not
configuration. As an adaptation from case 1 to cautious about possible failures and observe effective in DNS software. In case 3, the
case 2, DNS is furnished with a high-speed preventive measures to prevent iatrogenic primary failure factor was inaccuracy of path
handpiece that can match smaller diameter complications. Based on DNS workflow, design. This was because of the planning path
and diversiform burs and optimizes time. calibration and registration were performed in the CBCT coronal viewer, which could not
Although several case reports and after path design. If the path is redesigned show the whole tooth shape. Consequently,
in vitro studies have shown comprehensive during operation, it must be re-calibrated and the "center" path could likely be designed
operating procedures and success with re-registered for the DNS to update the spatial offset. Besides, although the drill path was
DNS14-16,18-20, there are disadvantages, position of the actual drill and designed paths. designed to pass near the center of the tooth
including an unaffordable navigation system17; However, this step was omitted in case 4, CEJ21, subjective errors exist in human

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FIGURE 4 – Clinical examinations and radiographic imaging of case 3. (A–C ) Preoperative photograph. (D ) Preoperative periapical radiography. (E–G ) Preoperative drill path design.
(H ) Periapical radiography after preparing access cavity of tooth #26. (I ) CBCT imaging after preparing access cavity of tooth #26. (J ) Immediate radiography of root canal obturation.
(K and L ) Six-month and 1-year review of periapical radiography. (M–O ) One-year review of clinical examination.

observation, and manual annotations are time- Augmented reality (AR) is a technology can see both the operative field and 3D
consuming and tedious efforts. Dentistry could that overlays virtual information, including digital navigation images without looking at a monitor.
be transformed by adoption of artificial images, videos, or 3D models, onto the real- This case series presents some
intelligence tools24. Deep learning and world environment. The AR approach is applied limitations of DNS for locating calcified canals
automated image analysis have emerged in in dental implant surgery with clinically and the need for more technology research
endodontic radiology25-28, which is expected acceptable accuracy30,31. In 2023, Martinho could improve endodontic procedures in the
to improve calcified canal drill path design. et al32 combined the AR technique and DNS to future.
Wang et al29 used DentalNet and PulpNet to perform osteotomy and root-end resection in
perform automatic tooth and root canal 3D-printed surgical jaw models, revealing that
segmentation in 2 minutes, from the CBCT AR improved accuracy and time efficiency. AR
ACKNOWLEDGMENTS
imaging of the left upper anterior tooth with techniques may be integrated into DNS and
severe PCO, based on which efficiently DOM for future treatment of teeth with PCO. XiaoXia Yang and Yinchun Zhang are co-first
designed drill path with a personalized The AR technique superimposes CBCT 3D authors.
access opening guide and located the imaging and a navigation path onto a DOM view Xuan Chen and Xiaoling Qiu are co-
canal. of the operative field. Therefore, the operator corresponding authors.

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FIGURE 5 – Clinical examinations and radiographic imaging of case 4. (A–C ) Preoperative photograph. (D ) Preoperative periapical radiography. (E ) Preoperative drill path design first
time. (F ) Redesign of drill path. (G ) Failure of locating canal orifice. (H ) Periapical radiography after preparing access cavity. (I ) CBCT imaging after preparing access cavity. (J ) The
success of locating canal under DOM. (K ) Immediate radiography of root canal obturation. (L ) One-year review of periapical radiography. (M–O ) One-year review of clinical
examination.

The authors would like to thank the University (grant number: KQIIT2021005), NTP20220110703), and the Research and
patients who consented to the publication of Personnel Training Plan of Stomatological Cultivation Project of Stomatological Hospital,
this case report. Hospital, Southern Medical University (grant Southern Medical University (grant number:
This study was supported by the Clinical number: RC202204), New Technology New PY2020029).
Research Initiation Plan Project of Projects of Stomatological Hospital, Southern The authors deny any conflicts of
Stomatological Hospital, Southern Medical Medical University (grant number: interest related to this study.

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